Treatment of prolactinoma based on the results of transsphenoidal operations

Ninety-eight patients (16 male, 82 female) with prolactinomas were treated by transsphenoidal operation. The postoperative course was closely related to the tumor size and the preoperative levels of serum prolactin. In 37 (74%) of 50 patients with microadenomas, the levels of serum prolactin returned to normal postoperatively. There were 48 patients with macroadenomas; 27 of these were expansive and 21 were invasive. In 9 (33%) of the 27 patients with expansive macroadenomas, the postoperative levels of prolactin returned to normal; this was not the case in any of the 21 patients with invasive macroadenomas. Of 81 premenopausal women, 35 (43%) resumed normal menstruation postoperatively. All patients with preoperative deficits in the visual field experienced postoperative improvement. There were no postoperative deaths or serious complications in this series. Our data indicate that microprolactinomas are highly curable by transsphenoidal operation alone. In women who plan to have children, prolactinomas should be removed immediately. On the other hand, in patients with macroprolactinomas who manifest high levels of serum prolactin, initial treatment with bromocriptine should be considered because there is little hope for surgical cure and postoperative bromocriptine treatment might be necessary.

Juvenile angiofibroma: imaging by magnetic resonance, CT and conventional techniques

Thirty patients with histologically verified angiofibromata have been investigated over a period of 14 years. They have been examined by conventional radiographic techniques and computerized tomography, and more recently 4 patients have been scanned by magnetic resonance. CT studies of patients with small tumours have shown that the point of origin is at the sphenopalatine foramen. The tumour enlarges the foramen and erodes bone locally giving rise to characteristic signs both on plain X-ray and on CT scan. The value of magnetic resonance imaging is assessed and it is concluded that in the presence of the characteristic 'antral sign' on plain X-ray, 3-plane magnetic resonance is now the method of choice to show the extent of the tumour pre-operatively. Magnetic resonance can also show the vascular nature of the angiofibroma by the demonstration of large vessels, shown as dark areas of negative signal within the tumour mass. With this new method of investigation available, angiography should now only be performed if embolization is deemed necessary prior to surgical removal of the angiofibroma.

Early normalization of luteinizing hormone pulsatility after successful transsphenoidal surgery in women with microprolactinomas

In eight hyperprolactinemic amenorrheic women who had a microprolactinoma, LH secretion was examined by measuring its concentration in blood samples collected every 15 min for 6 h before and 8 days after successful selective adenomectomy. Computer analysis was used for LH peak evaluation. In both circumstances, serum PRL and basal estradiol (E2) levels were also determined. Before operation, the number of LH peaks ranged from zero to one per 6 h in seven patients and was two per 6 h in the eighth patient. In all patients, serum PRL was normal on the eighth postoperative day, while E2 levels remained low, similar to the values usually found in the early follicular phase of the cycle in normal women. Postoperatively, mean LH levels were similar to preoperative levels, but there was a dramatic increase in the number of LH peaks (three to five per 6 h) in five of the eight patients. These observations confirm the impairment of LH pulsatility in hyperprolactinemia and demonstrate that normalization of PRL levels by surgery can restore LH pulsatile secretion in certain women as early as the eighth day after operation in the absence of a significant change in serum E2 levels. Thus, the preoperative impaired pulsatility of LH secretion was probably a central effect of hyperprolactinemia.

[A case of clival chordoma without bone destruction]

A case of clival chordoma without bone destruction is reported. A 28-year-old man was admitted to Kagoshima University Hospital on April 8, 1983 with the complaints of headache, displopia and gait disturbance. Neurological examination revealed the right eighth, ninth, tenth nerve palsy and gait disturbance. Plain skull firms showed no abnormality and left vertebral arteriography revealed a displacement of basilar artery to the left side. The CT scanning showed a low density area at the retroclival region, and enhancement was acquired slightly. Metrizamide cisternography, CT cisternography showed retroclival round tumor and no destruction of the bone. The tumor which invaded intradurally was removed totally. Histological examination confilmed the chordoma. In this report, it will be stressed that when clival chordoma invades intradually, subtemporal approach will be most favorable, and metrizamide CT cisternography is one of the useful diagnostic procedures of retroclival mass.

Study of hypotonic polyuria after trans-sphenoidal pituitary adenomectomy

We have studied the postoperative diuresis patterns in 116 patients following the removal of a pituitary adenoma using the trans-sphenoidal approach. We observed a normal diuresis (ND) in 55 patients and a hypotonic polyuria (HP) in 61 patients, consisting of water elimination (WE = 45 cases) and transient diabetes insipidus (DI = 16 cases). We investigated the problem of predicting these patterns from eight pre-operative factors by applying stepwise logistic discriminant analysis. We demonstrated that DI was significantly associated with a posterior localization of the adenoma in the pituitary gland and that WE was more frequently observed in cases of suprasellar expansion, in young patients, and in prolactin secreting tumors. Finally, we discuss the pathogenic role of these factors in the occurrence of HP, taking into account inhibition of vasopressin secretion and possible fluid overload.

Techniques and applications of sphenoidal recording

Sphenoidal electrodes were introduced in the late 1940s and early 1950s to record EEG activity from the inferior mesial temporal region. They are inserted percutaneously beneath the zygomatic arch to rest in the vicinity of the foramen ovale. They are safe, easy to insert, and well tolerated for up to 3 weeks. Artifacts are less prominent than with other types of basal electrodes. Complications are rare. Sphenoidal electrodes are superior to scalp electrodes in detecting interictal epileptiform discharges and ictal EEG patterns from the inferior mesial temporal lobe. Clinical indications include: documentation of epileptiform activity in patients with partial complex seizures in whom scalp recording has been inconclusive; diagnosis of episodes of uncertain mechanism; and localization of an epileptogenic focus in patients being evaluated for temporal lobectomy.

Surgical management of tumours invading the skull base

The author describes four different approaches to clival tumours, and reviews his experience with 33 chordomas of the clivus. He also reviews his large experience with tumours invading the floor of the anterior and middle cranial fossae, and describes various surgical approaches for the removal of these tumours, followed by reconstruction of the bony floor with bone grafts, and dural reconstruction.

Fronto-orbito-sphenoidal fibrous dysplasia

Eight patients with fronto-orbito-sphenoidal fibrous dysplasia, aged between 9 and 37 years, half of them male, were radically or nearly radically excised with immediate autogenous bone graft reconstruction. They had had frontal bulging and proptosis on the affected sides for 3 to 20 years. Four had decreased vision on the diseased side, and among them 1 had corneal ulceration due to proptosis and lower lid intropion. Optic nerve decompression was used with the other 3 patients who had narrowed optic canals. Cosmetic improvement was achieved after surgery. The vision of the normal and blind eyes was not changed after optic nerve decompression. The progression of visual loss stopped after surgery. One eye with decreased vision improved after optic nerve decompression.

Direct surgical approach to infraclinoidal aneurysms

A loose connective tissue layer covering the intracavernous portion of the internal carotid artery makes the exposure of the anterior syphon knee possible without opening the cavernous sinus. The approach leads by a fronto-latero-basal craniotomy to the anterior part of the cavernous sinus roof (transversal plate). The anatomical relationships are discussed. By means of surgical cases, both the ipsilateral and the contralateral approach to infraclinoidal aneurysms are demonstrated.

Retraction system for transsphenoidal surgery. Technical note

A retraction system has been developed for transsphenoidal surgery to use together with a conventional self-retaining speculum. The system comprises an attachment to the speculum, a self-retaining retractor, and a slim tapered brain spatula and pronged hook. The spatula or hook is secured with the self-retaining retractor and the attachment. The retractor can also be fixed to the Sugita multipurpose head frame. The system may be used to retract the bulging diaphragma sellae and tumor tissues, and to stop bleeding from the dural venous sinus or tumor bed, so the surgeon can continue the procedure with both hands.

Clinical observations concerning choroidal folds

This paper deals with 6 patients who suffer from choroidal folds. Special emphasis will be laid on several aspects of differential diagnostics. In our 6 cases discussed here, we found a retrobulbar tumor in 3 patients, hypotony in 1, and a marked hyperopia in another as causes. In the 6th patient no pathological condition was found, and, therefore, we characterized the choroidal folds in this case as idiopathic.

Transsphenoidal microsurgery for Cushing's disease

Nineteen patients thought to have Cushing's disease were treated by transsphenoidal microsurgery; the type of operation performed depended upon the findings in the individual patient. Seventeen patients remitted. Failures occurred in a patient with an invasive macroadenoma and in a patient who was subsequently found to have a thymic carcinoid tumour secreting ACTH. One patient who remitted suffered a recurrence during pregnancy, 30 months after operation. The ten patients (Group I) who had a selective removal of a microadenoma or a limited resection of the gland were often GH deficient, but seven regained cortisol reserve and all ten regained normal pituitary-thyroid and pituitary-gonadal responses. By contrast abnormalities of pituitary function were common in nine patients who had a radical or total hypophysectomy. We conclude that transsphenoidal microsurgery is the best treatment for Cushing's disease and that, when feasible, a selective microadenomectomy is the most appropriate operation.

Usefulness of the orbitofrontomalar approach associated with bone reconstruction for frontotemporosphenoid meningiomas

Seven cases of frontotemporosphenoid meningioma are reported. The principles of the orbitofrontomalar approach and of reconstruction of the orbital cone and of the frontomalar region with an orbitotemporal prop are discussed.

Computed tomography-guided aspiration cytologic examination in head and neck lesions

Aspiration cytologic examination, as distinguished from needle biopsy, may be performed with 22- to 25-gauge needles with an extremely low complication rate. For deep-seated lesions, computed tomography guidance is helpful to ensure that the needle tip is correctly within the tumor mass and that vital structures have been avoided. Lesions of the skull base, nasopharyngeal region, and infratemporal fossae are readily accessible with this approach.

Transsphenoidal approach to the sella: the Johns Hopkins experience

The transsphenoidal hypophysectomy has become a relatively frequent procedure in recent years, with the otolaryngologist playing a major role in its renewed popularity. This paper reviews the evolution of pituitary surgery, discusses the surgical technique currently used, and reviews the results and complications of 114 cases over a 13-year period. Of the 129 procedures performed at Johns Hopkins Hospital between 1970 and 1983, 114 charts were available for review. Twelve of these were palliative hypophysectomies and 102 were for sella tumors. Sixty-eight patients were treated with surgery alone, and 34 received surgery and postoperative irradiation. Significant complications such as CSF rhinorrhea, diabetes insipidus, meningitis, septal perforation, anosmia, and visual field defects are discussed. The mortality rate for the series was 1.7%. These results are compared with those of previously published series and the differences are discussed in detail. In analyzing these data we feel that the transseptal, transsphenoidal hypophysectomy has become a safe and effective therapy for sella lesions.

Sphenoid wing meningioma occurring as a lateral orbital mass

The differential diagnosis of a mass presenting in the lateral aspect of the orbit with bony erosion and involving the skin includes many malignancies, predominantly sarcomas. A total evaluation of the mass to include histopathologic characteristics and the true extent of the disease is critical to proper management of the patient. A 68-year-old man was referred for therapy with a diagnosis of fibrosarcoma. Evaluation of the disease revealed contiguous tumor from the right temporal region into the posterior orbit, with displacement of the globe and extension intracranially. During operation a frozen section analysis of the tumor was also interpreted as fibrosarcoma. A craniofacial resection was performed, including orbital exenteration and resection of a large 10 X 12 cm segment of attached dura. There was no evidence of extension into the brain. Final pathologic evaluation of the tumor was meningioma rather than fibrosarcoma. This unusual presentation of a meningioma has never been reported in the medical literature. The difficulty with interpretation of the original biopsies will be discussed, as well as the management of this case