Delayed Complications After Transsphenoidal Surgery for Pituitary Adenomas

The nomogram for predicting nasal bleeding after endoscopic transsphenoidal resection of pituitary adenomas: a retrospective study

Objective

This study aimed to develop and validate a dynamic nomogram to assess the risk of nasal bleeding after endoscopic transnasal transsphenoidal pituitary tumor resection.

Methods

A retrospective analysis was conducted on patients who underwent endoscopic transnasal transsphenoidal pituitary tumor resection from June 2019 to June 2021. Univariate and multivariate logistic regression analyses were used to screen for independent risk factors for nasal bleeding from the training set. A multivariate logistic regression model was established, a nomogram was plotted, and it was validated in an internal validation set. The performance of the nomogram was evaluated based on the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

The nomogram indicators included anticoagulant use, sphenoid sinus artery injury, nasal irrigation, platelet count (PLT), and constipation. The predictive model had an area under the ROC curve of 0.932 (95% CI: 0.873-0.990) and 0.969 (95% CI: 0.940-0.997) for the training and validation sets, respectively, indicating good discrimination. The calibration curve showed good consistency between the actual and predicted incidence of nasal bleeding (p > 0.05). DCA indicated that the nomogram had good clinical net benefit in predicting postoperative nasal bleeding in patients.

Conclusion

In summary, this study explored the incidence and influencing factors of nasal bleeding after endoscopic transnasal transsphenoidal pituitary tumor resection and established a predictive model to assist clinical decision-making.

Cerebral vasospasm occurring immediately after endoscopic transsphenoidal resection of a pituitary adenoma: A case report

Background

Cerebral vasospasm is a rare postoperative complication of transsphenoidal pituitary adenoma surgery with potentially severe consequences. These vasospasms generally have a delayed presentation at a mean of 8 postoperative days. We report an unusual case of hyperacute onset of cerebral vasospasm that occurred immediately after surgery.

Case Description

A 38-year-old man underwent endoscopic transsphenoidal surgery for a nonfunctioning pituitary adenoma. The patient experienced mild subarachnoid hematoma during surgery. Three hours after surgery, he developed rightward conjugate eye deviation and complete paralysis of the left upper and lower extremities. Diagnostic imaging revealed cerebral vasospasm in both middle cerebral arteries, and symptoms improved after intra-arterial administration of fasudil hydrochloride.

Conclusion

There is a need for prompt diagnosis and therapeutic intervention when typical symptoms of cerebral vasospasm, such as paralysis, occur at any time during the postoperative course.

Delayed epistaxis after endoscopic transnasal pituitary tumor resection: clinical characteristics, risk factors, treatment and prevention

BACKGROUND

Delayed epistaxis after endoscopic transnasal pituitary tumor resection (ETPTR) is a critical complication, tending to cause aspiration or hemorrhagic shock. This study assessed clinical characteristics, risk factors, and provide treatment and prevention advice of this complication.

METHODS

This was a retrospective monocentric analysis of 862 patients who underwent ETPTR. Statistical analyses of clinical data revealed the incidence, sources and onset time of delayed epistaxis. Univariate analysis and binary logistic regression were used to identify risk factors.

RESULTS

The incidence of delayed epistaxis was 2.78% (24/862), with an average onset time of 20.71 ± 7.39 days. The bleeding sources were: posterior nasal septal artery branch of sphenopalatine artery (12/24), multiple inflammatory mucosae (8/24), sphenopalatine artery trunk (3/24) and sphenoid sinus bone (1/24). Univariate analysis and binary logistic regression analysis confirmed that hypertension, nasal septum deviation, chronic rhinosinusitis and growth hormone pituitary tumor subtype were independent risk factors for delayed epistaxis. Sex, age, history of diabetes, tumor size, tumor invasion and operation time were not associated with delayed epistaxis. All patients with delayed epistaxis were successfully managed through endoscopic transnasal hemostasis without recurrence.

CONCLUSIONS

Delayed epistaxis after ETPTR tends to have specific onset periods and risk factors. Prevention of these characteristics may reduce the occurrence of delayed epistaxis. Endoscopic transnasal hemostasis is recommended as the preferred treatment for delayed epistaxis.

Endocrinopathies in a Pediatric Patient Post-anatomical Hemispherectomy for Rasmussen's Encephalitis Treatment: A Case Report

Hemispherectomy is a neurosurgical procedure that is frequently performed in pediatric patients diagnosed with Rasmussen's encephalitis. Postoperative complications include immediate complications such as hydrocephalus and hemorrhage and behavioral complications such as language impairments and contralateral weakness. However, there are limited studies or case reports that address the potential endocrinopathies associated with this and other pediatric epileptic surgeries. This case report describes the endocrinopathies following an anatomical hemispherectomy procedure. A four-year-old African-American female had a right anatomical hemispherectomy for the treatment of Rasmussen's encephalitis in 2020. The postoperative course was immediately complicated by central diabetes insipidus which was stabilized with desmopressin. The patient's labs in 2021 were consistent with central precocious puberty with elevated luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Additionally, the patient was found to have secondary adrenal insufficiency in which she failed a low-dose adrenocorticotropic hormone (ACTH) stimulation test. Oral hydrocortisone therapy was initiated for secondary adrenal insufficiency in addition to initiating leuprolide injections for central precocious puberty. Furthermore, at the age of seven years, the patient had her first menarche. This case report emphasizes the need for closer and long-term surveillance for endocrine issues in postepileptic surgical pediatric patients as well as a surveillance plan for the development of other potential endocrine abnormalities throughout the patient's life.

Incidence, risk factors, management and prevention of severe postoperative epistaxis after endoscopic endonasal transsphenoidal surgery: a single center experience

Objective

Postoperative epistaxis is a very rare but severe complication after endoscopic endonasal transsphenoidal surgery (EETS) that can lead to catastrophic consequences. However, the incidence, risk factors, management and prevention of postoperative epistaxis remain unclear.

Patients and methods

Consecutive patients with pituitary adenoma (PA), Rathke's cleft cyst, craniopharyngioma, or clival chordoma who received EETS in our department between September 2020 and November 2022 were retrospectively analyzed. The incidence, risk factors, management and prevention of postoperative epistaxis were investigated and analyzed.

Results

A total of 557 consecutive patients who received EETS were included in this study. Eight patients (1.4%) (7 PAs and 1 Rathke's cleft cyst) experienced severe postoperative epistaxis. The size of the PAs was 9.6 mm-46.2 mm, with a median size of 22.1 mm. Epistaxis occurred 4 h to 30 days (median 14.5 days) postoperatively. Bleeding was stopped in 3 patients after nasal packing with iodoform gauze. The remaining 5 patients for whom nasal packing was insufficient were all sent to the operating room, and posterior nasal septal artery (PNSA) bleeding was identified and successfully treated with endoscopic bleeding artery electrocauterization under general anesthesia. In the EETS, all 8 patients had downward extension of the septal mucosal incision, in which 6 had intraoperative bleeding of PNSA that were cauterized by bipolar diathermy. Four patients had causative factors, including administration of antiplatelet agents, Valsalva-like manoeuvre, nose blowing and removal of nasal packing, respectively. No patients had recurrent epistaxis during the follow-up period.

Conclusion

Post-EETS epistaxis is a rare but severe complication that could lead to catastrophic consequences, and one of the most common bleeding sources is the PNSA. Endoscopic bleeding artery electrocauterization under general anesthesia may be a safe, economic and effective measure for epistaxis refractory to nasal packing. Avoiding excessive downward extension of the septal mucosal incision could contribute to the prevention of postoperative epistaxis.

Otolaryngology Considerations of Pituitary Surgery: What an Endocrinologist Should Know

Endoscopic endonasal skull base surgery is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.

Remission, complications, and overall survival in transsphenoidal pituitary surgery-a Swedish single-center experience of 578 patients

BACKGROUND

Surgical treatment of pituitary lesions causing hormonal overproduction or mass effect is standard procedure. There are few reports on the results and complications related to these surgeries from Northern Europe. Our aim was to evaluate the outcome and complications of a single tertiary surgical center over more than a decade.

METHODS

This was a retrospective study on all patients that underwent pituitary surgery from 1st of January 2005 to 31st of December 2017. The analysis included type of lesion, surgical method, pre- and postoperative need for hormonal substitution, hormonal outcome, complications to surgery, survival, need for revision surgery, or stereotactic radiation. Appropriate statistical analyses were made to evaluate surgical results, complications, and survival.

RESULTS

Five hundred seventy-eight patients were included in the study. Remission was achieved in 58% of patients with GH-producing and 94% of ACTH-releasing adenomas. Sixty-six percent had no preoperative hormonal substitution compared to 39% postoperatively. Rhinosinusitis (10%) was the most commonly reported postoperative complication followed by leakage of cerebrospinal fluid (8%) and meningitis (4%). Standardized mortality rate for the study population was higher (p = 0.18) when compared to the general population.

CONCLUSION

Our results regarding remission rates and complications are in comparison with previous studies. Surgery of pituitary lesion can be considered a safe and efficient surgery. We noted lower rates of CSF leakage in the later part of the study period and believe that this, in part, was an effect by the introduction of a multidisciplinary surgical skull base team and increased surgical experience.

Surgical treatment of a ruptured internal carotid artery pseudoaneurysm following transsphenoidal surgery

Development of Internal Carotid Artery pseudoaneurysms (ICAp) after transsphenoidal surgery is extremely rare, occurring only in 0.4% of cases. Surgical treatment of ICAp poses a real challenge to the neurosurgeon as treatment may require parent vessel sacrifice or artery reconstruction with bypass grafting. Furthermore, surgical resolution of these lesions is rarely reported in the literature. The internal carotid artery is prone to iatrogenic injury in transsphenoidal surgery due to its frequent involvement in pituitary adenomas. Intracranial pseudoaneurysms may be at high risk for rupture and increased morbidity and mortality. Here we present a case of a patient with an ICAp rupture two months after transsphenoidal surgery for a pituitary adenoma.

Effect of pituitary adenoma consistency on surgical outcomes in patients undergoing endonasal endoscopic transsphenoidal surgery

BACKGROUND

Most pituitary adenomas (PAs) are considered to have a soft tumor consistency. However, there is a non-negligible percentage (5-13%) of tumors presenting or exhibiting a fibrous consistency that would entail a more difficult and complicated surgical excision with higher surgical morbidity and mortality rates.

PURPOSE

To analyze the clinical consequences of PA tumor consistency on the surgical outcomes in patients undergoing endonasal endoscopic transsphenoidal (EET) pituitary surgery.

METHODS

An ambispective study of patients with PAs operated on through an EET approach in two Spanish tertiary hospitals over the last 12 years. A total of 226 consecutive interventions were carried out in the Neurosurgery Departments of the Hospital Universitario Ramón y Cajal (HURC) and the Hospital Universitario Puerta del Sur by the same neurosurgeon. PAs were grouped into soft (n = 150) and fibrous (n = 76). All patients underwent hormonal and magnetic resonance imaging (MRI) studies before and after surgery. In addition, neurosurgical complications were recorded in each patient.

RESULTS

Fibrous adenomas were independently associated with lower resection rates compared to soft adenomas (fibrous gross total resection [GTR] rate 48.7% vs. 76.3%, p < 0.001), even in those adenomas without invasion of the cavernous sinus (Knosp grades 0, I, and II). There were more intraoperative cerebrospinal fluid (CSF) leaks in patients with fibrous PAs. Moreover, fibrous PAs showed higher rates of postoperative hypopituitarism, permanent diabetes insipidus (DI) and postoperative treatments (hormonal treatment and radiotherapy). The excision of a fibrous PA required a longer surgical time (22.5 min more than soft PAs, p = 0.014), regardless of other factors.

CONCLUSION

The consistency of the PAs significantly conditions both the results of surgery (lower resections rates), complications (higher incidence of postoperative hypopituitarism, permanent DI), and the prognosis (higher incidence of postoperative treatments) of the patient undergoing EET.

Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care

Background  Thirty-day unplanned readmission following endoscopic transsphenoidal pituitary surgery (ETPS) occurs in up to 14% of patients. Delayed hyponatremia is one of the most common causes, accounting for 30% of readmissions and often occurs within 1 week of surgery. The authors' prior retrospective review identified endocrinology follow-up as protective factor. Objectives  Implementation of a multidisciplinary postoperative care (POC) pathway: (1) to reduce 30-day hospital readmissions following ETPS and (2) improve inpatient and outpatient coordination of care with endocrinologist. Methods  This study is a single institution temporal cohort study of patients prior to (control cohort) and after implementation of the POC pathway (intervention cohort). The POC pathway utilized postdischarge 1 to 1.5 L/d fluid restriction, postoperative days 5 to 7 serum sodium, and endocrinology follow-up within 1 week of discharge to stratify patients into tiered hyponatremia regimens. Results  A total of 542 patients were included in the study, 409 (75%) in the control cohort and 133 (25%) in the intervention cohort. All-cause readmission was significantly reduced following implementation of the POC pathway (14 vs. 6%, p  = 0.015). Coordination with endocrinologist significantly increased in the inpatient (96 vs. 83%, p  < 0.001) and outpatient (77 vs. 68%, p  = 0.042) settings. Patients who were not in the POC pathway had the highest risk of readmission (odds ratio: 2.5; 95% confidence interval: 1.1-5.5). Conclusion  A multidisciplinary POC pathway incorporating endocrinologist in conjunction with postdischarge weight-based fluid restriction and postoperative serum sodium levels can safely be used to reduce 30-day readmissions following ETPS.

Moderate Delayed Middle Cerebral Artery Vasospasm With Clinical Repercussions After the Resection of a Giant Pituitary Adenoma Using an Endonasal Endoscopic Approach: A Case Report

Endoscopic endonasal approach (EEA) techniques have evolved significantly in recent years, with better techniques guaranteeing better surgical results in the treatment of sellar and parasellar region pathologies. Although the complications associated with the EEA have been widely described, with cerebrospinal fluid fistulas being the most commonly reported, some rare complications, such as vasospasm after surgery in extended approaches, turn out to be poorly understood. Here, we describe a case of middle cerebral artery delayed vasospasm associated with the resection of a non-functional pituitary adenoma via an EEA.

Prevention of Hyponatremia After Transsphenoidal Surgery: A Systematic Review

Context: Pituitary adenomas are amongst the most common tumors with a low mortality rate compared to other intracranial malignancies. Delayed hyponatremia (DH) is a common finding after transsphenoidal resection (TSS), which is the basis for the management of these tumors. Although DH is one of the leading causes of readmission after TSS, no unified guidelines exist with regard to the prevention of this electrolyte disturbance. Objectives: This study aims to evaluate and compare existing preventive protocols for DH in order to identify and signify their common grounds. Methods: After a search in electronic databases, including PubMed (NCBI), Embase, Scopus, and Google Scholar with the keywords of “pituitary adenoma,” “hyponatremia,” “transsphenoid surgery”, “water electrolyte balance,” “patient readmission", six original articles were included in the study. Results: We found that a protocol that both identifies groups susceptible to DH (males, older individuals, and those with a lower BMI) and consists of fluid restriction, sodium supplementation, and regular serum sodium monitoring could be utilized to prevent DH in patients with pituitary adenomas after TSS. Conclusions: Further studies with a larger sample size must be conducted to compare existing protocols for preventing DH and also investigate post-surgery optimal fluid-restricted diets and corticosteroid therapy in these patients.

Effect of vasopressin V2-receptor antagonist tolvaptan on syndrome of inappropriate antidiuresis (SIAD) after transsphenoidal pituitary surgery: recovery of measured osmolality

Background

Delayed hyponatremia after pituitary surgery can be treated with the V2-receptor antagonist, oral tolvaptan. We investigated the pharmacological effect of oral tolvaptan against SIAD in patients with hyponatremia after pituitary surgery.

Methods

Thirty-nine patients with pituitary adenoma treated by endoscopic transsphenoidal surgery developed SIAD according to the major guidelines, and 7 patients (17.9%) were treated with tolvaptan. Tolvaptan was administrated orally half a tablet (3.75 mg) once in the first two cases, and half a tablet twice in the other five cases. Serum osmolality, urinary osmolality, urinary sodium concentration, urinary volume, and serum sodium and potassium concentration were evaluated before administration, and after the last oral administration of tolvaptan. Serum osmolality and urine osmolality were physically measured.

Results

Serum sodium concentration was significantly increased from 132.1 ± 4.0 to 143.0 ± 2.9 mmol/L (mean ± standard deviation, n = 7, P < 0.001). Serum osmolality was significantly increased from 266.3 ± 7.7 to 289.6 ± 6.7 mOsm/kg (n = 7, P < 0.001). Urine osmolality was significantly reduced from 607.1 ± 240.4 to 262.7 ± 115.6 mOsm/kg (n = 7, P = 0.01). Urinary sodium concentration was significantly decreased from 121.3 ± 48.4 to 36.9 ± 35.0 mOsm/kg (n = 7, P = 0.001). Urine output (24-hour including the first administration) was significantly increased from 1384.2 ± 550.7 to 3291.3 ± 1710.9 mL/day (n = 6, P = 0.026).

Conclusions

Oral tolvaptan administration corrects SIAD after pituitary surgery. Hyponatremia after pituitary surgery was confirmed to be due to SIAD.

Incidence and risk factors of delayed postoperative hyponatremia after endoscopic endonasal surgery for Rathke’s cleft cyst: A single-center study

Backgroud

Delayed postoperative hyponatremia (DPH) is common for sellar lesions. However, the true prevalence and associated factors of DPH after endoscopic endonasal surgery (EES) for Rathke’s cleft cyst (RCC) have not been studied in a large patient cohort.

Methods

A retrospective analysis was conducted over 6 years at our institution, and patients with RCC treated by EES were enrolled according to our inclusion criteria. Patient demographics, clinical characteristics, images, and surgical procedures were documented. Serum sodium was routinely measured before surgery, on postoperative day 1, and every 2 days thereafter until discharge. For patients with DPH, electrolyte, hematocrit, serum protein levels, and plasma and urinary osmolality were daily measured to explore potential etiology.

Results

Of the 149 eligible patients, 25 (16.8%) developed DPH, which was similar to other sellar lesions, except craniopharyngioma, in the same period in our institution. Significant risk factors suggested by univariate analysis were cyst location, requirement of postoperative hydrocortisone therapy, postoperative meningitis, intraoperative cerebrospinal fluid (CSF) leakage, and subtotal resection (STR) of the cyst wall (all p &lt; 0.05). In addition, other supplementary 11 cases of suprasellar RCC with different surgical strategies (aggressive resection) and relevant factors were enrolled into multivariate analysis. Suprasellar location [odds ratio (OR) 8.387, 95% confidence interval (CI) 1.014–69.365, p = 0.049], requirement of postoperative hydrocortisone therapy (OR 4.208, 95%CI 1.246–14.209, p = 0.021), and intraoperative CSF leakage (OR 6.631, 95%CI 1.728–25.440, p = 0.006) were found to be the independent predictors of DPH.

Conclusion

DPH is a common complication after EES for RCC. Suprasellar location, requirement of postoperative hydrocortisone therapy, and intraoperative CSF leakage are the most reliable risk factors. Cortisol deficiency and syndrome of inappropriate antidiuretic hormone (SIADH) are considered as the main etiologies of DPH in RCC. Conservative excision of the cyst wall may reduce DPH occurrence.

Clinical analysis of delayed epistaxis following endoscopic sinus surgery

OBJECTIVE

To investigate the clinical characteristics and treatment methods associated with delayed epistaxis following endoscopic sinus surgery.

METHODS

The clinical data of 46 patients with delayed epistaxis following endoscopic sinus surgery were retrospectively analyzed. To explore the clinical features, pathogenesis, and treatment plan for delayed epistaxis, the postoperative bleeding time, bleeding inducements, systemic complications, surgical approach, the hemorrhage locations and responsible vessels, and treatment methods were analyzed.

RESULTS

The average bleeding time was 16.34 ± 9.05 days after the operation, and 76.6% of the cases occurred 6-20 days after the operation. Sphenopalatal artery hemorrhage accounted for 69.6% (32/46), the most common of which was a posterior nasal septal artery hemorrhage (17/32). A total of 45 patients received endoscopic low-temperature plasma hemostasis following ineffective nasal packing, and no rebleeding in the ipsilateral nasal cavity was observed during the postoperative follow-up for 3 to 6 months.

CONCLUSIONS

The peak of hemorrhaging in delayed epistaxis following endoscopic sinus surgery occurred at 6-20 days post-operatively. Bleeding of the posterior nasal septal artery from the sphenopalatine artery was the most common. Surgical methods were closely related to delayed postoperative hemorrhage. Treatment with low temperature plasma hemostasis under nasal endoscope was found to be effective.

Impact of patient-reported nasal symptoms on quality of life after endoscopic pituitary surgery: a prospective cohort study

PURPOSE

Endoscopic transsphenoidal surgery causes nasal morbidity and negatively affects health-related quality of life (HRQoL). Knowledge on actionable symptoms that could improve postoperative HRQoL is therefore important. This study assessed the impact of nasal symptoms on postoperative HRQoL.

METHODS

This perioperative cohort study included 103 adult patients undergoing endoscopic pituitary adenoma resection (August 2016-December 2018), with measurements preoperatively, and 5 days, 6 weeks and 6 months after surgery. Nasal symptoms were measured with the Anterior Skull base nasal inventory-12, and HRQoL with the Short Form-36 (SF-36) physical (PCS) and mental component scores (MCS). Linear regression analysis was used to assess (1) determinants of postoperative nasal morbidity, (2) associations between number of symptoms or (3) individual symptoms and HRQoL, and (4) the percentage of variance of HRQoL explained by nasal symptoms.

RESULTS

The number of nasal symptoms transiently increased after surgery. No significant treatment- or disease-related determinants of nasal morbidity were identified. The number of nasal symptoms was significantly associated with a lower PCS (β = - 1.0; 95%CI - 1.5, - 0.4), but not with MCS at 6 weeks. Similar results were observed at 6 months. Headaches (42.2%), problems with smell (42.0%), and taste (36.0%) were the most prevalent symptoms, while sense of smell and taste, and nasal discharge showed the strongest associations with HRQoL.

CONCLUSIONS

Postoperative nasal symptoms, in particular problems with smell and taste, significantly affect pituitary patients' physical HRQoL. Monitoring of these symptoms may aid in determining which patients may benefit from intensified follow-up and treatment, aiming to optimize HRQoL.

Imaging of the Postoperative Skull Base and Cerebellopontine Angle

For pathologic conditions affecting the skull base and cerebellopontine angle, imaging techniques have advanced to assess for residual disease, disease progression, and postoperative complications. Knowledge regarding various surgical approaches of skull base tumor resection, expected postoperative appearance, and common postsurgical complications guides radiologic interpretation. Complexity of skull base anatomy, small size of the relevant structures, lack of familiarity with surgical techniques, and postsurgical changes confound radiologic evaluation. This article discusses the imaging techniques, surgical approaches, expected postoperative changes, and complications after surgery of the skull base, with emphasis on the cerebellopontine angle, anterior cranial fossa, and central skull base regions.

What is the current clinical practice in pituitary adenoma surgery in Europe? European Pituitary Adenoma Surgery Survey (EU-PASS) results-technical part

Pituitary adenoma surgery has evolved rapidly in recent decades, changing clinical practice markedly and raising new challenges. There is no current consensus or guidelines for perioperative care that includes possible complication management. This study aims to determine current practice across European neurosurgical centres. We created a list of eligible departments performing pituitary adenoma surgery based on cooperation with EANS, national neurosurgical societies, and personal communication with local neurosurgeons. We contacted the chairpersons from each department and asked them (or another responsible neurosurgeon) to fill out the survey. The survey consisted of 58 questions. For further analysis, departments were divided into subgroups: "academic"/ "non-academic centre", "high-volume"/"low-volume", "mainly endoscopic"/ "mainly microscopic"/ "mixed practise", and by geographical regions. Data from 254 departments from 34 countries were obtained. The average time to complete the survey was 18 min. Notably, the endoscopic approach is the predominant surgical approach in Europe, used in 56.8% of the centres. In routine cases without intraoperative cerebrospinal fluid leak, high-volume centres are less pedantic with sellar closure when compared with low-volume centres (p < 0.001). On the other hand, when a postoperative cerebrospinal fluid leak occurs, high-volume centres are more active and indicate early reoperation (p = 0.013). Less than 15% of the participating centres perform early postoperative MRI scans. Marked variation was noted among different groups of respondents and some contentious issues are discussed. Such information can encourage useful debate about the reasons for the variations seen and perhaps help develop standardised protocols to improve patient outcomes. A future research focus is to compare European results with other regions.

Fluid Restriction After Transsphenoidal Surgery for the Prevention of Delayed Hyponatremia: A Systematic Review and Meta-Analysis

OBJECTIVE

Delayed hyponatremia is the primary cause of readmission after transsphenoidal surgery, with a reported incidence of 9% to 30.7%. Studies have failed to identify consistent predictive factors for postoperative hyponatremia; thus, it is difficult to determine patients that are at a high risk. Fluid restriction is one approach for the prevention of hyponatremia. We have performed a meta-analysis and systematic review of the literature to evaluate the impact of fluid restriction on hyponatremia and hospital readmissions.

METHODS

Ovid EMBASE, PubMed, Scopus, and Cochrane were searched from inception to May 2021, using the Population, Intervention, Comparison, Outcome, and Study question format: Do patients who underwent transsphenoidal surgery and followed a postoperative fluid restriction regimen differ in terms of hyponatremia and readmission rates? Studies that implemented fluid restriction and reported hyponatremia and/or readmission rates were included for analysis. Data were pooled by meta-analysis and analyzed using fixed effect and random effect models.

RESULTS

A total of 143 manuscripts representing 103 unique studies were identified, with 5 studies included for analysis, yielding a pooled cohort of 1586 patients: 594 on fluid restriction protocols and 992 control patients. Fluid restriction protocols ranged from 1.0 to 2.5 L and varied in the length time between postoperative days 1 to 15. Patients on fluid restriction had a decreased risk of hyponatremia (risk ratio: 0.34; 95% CI, 0.21-0.57; P < .00001) and readmission due to hyponatremia (risk ratio: 0.24; 95% CI, 0.09-0.63; P = .0038).

CONCLUSION

Postoperative fluid restriction after transsphenoidal surgery represents an effective method for the prevention of hyponatremia and hospital readmission and has the potential to decrease health care costs.

Outcome of pituitary hormone deficits after surgical treatment of nonfunctioning pituitary macroadenomas

OBJECTIVES

Nonfunctionning pituitary macroadenomas (NFPMA) are benign tumors that cause symptoms of mass effects including hypopituitarism. Their primary treatment is transsphenoidal surgery. We aimed to determine the outcome of pituitary hormone deficits after surgical treatment of NFPMA and to identify factors predicting hormonal recovery.

DESIGN

We retrospectively included 246 patients with NFPMA diagnosed and operated in one of the two participating centers. All hormonal axes were evaluated except growth hormone (GH). Postoperative improvement of pituitary endocrine function was considered if at least one hormonal deficit had recovered and a lower total number of deficits was observed 1 year after surgery.

RESULTS

80% (n = 197) of patients had one or more pituitary deficits and 28% had complete anterior hypopituitarism. Besides GH, the gonadotropic and thyrotropic axes were the most commonly affected (68% and 62%, respectively). The number of hypopituitary patients dropped significantly to 61% at 1 year (p < 0.001) and a significant improvement was observed for all hormonal axes, except central diabetes insipidus. Among patients with preoperative hypopituitarism, 88/175 (50%) showed improved pituitary function at 1 year. Both hyperprolactinemia at diagnosis and a lower tumor diameter independently predicted favorable endocrine outcome.

CONCLUSIONS

Hypopituitarism is present in 80% of patients with NFPMA and nearly half of them will benefit from sustained improvement after surgery. Hyperprolactinaemia at diagnosis and lower tumor dimensions are associated with favorable endocrine prognosis. This supports the option of early surgery in NFPMA patients with pituitary deficits independent of the presence of visual disturbances.

Optimizing pre-, intra-, and postoperative management of patients with sellar pathology undergoing transsphenoidal surgery

OBJECTIVE

Perioperative management of patients with sellar lesions is complex, requiring input from a multidisciplinary team of specialists for ongoing management of both endocrinological and neurosurgical issues. Here, the authors reviewed the experience of a single multidisciplinary center over 10 years to identify key postoperative practices that ensure positive outcomes for patients with sellar lesions who undergo transsphenoidal surgery.

METHODS

The authors performed a retrospective review of all transsphenoidal operations carried out by the senior author at a single center from April 2008 through November 2018. They included only adult patients and recorded perioperative management. They also reviewed the evolution of clinical practices for perioperative care at their institution to identify strategies for ensuring positive patient outcomes, and they reviewed the literature on select related topics.

RESULTS

In total, 1023 operations in 928 patients were reviewed. Of these, 712 operations were for pituitary adenomas (69.6%), and 122 were for Rathke cleft cysts (11.9%). The remainder included operations for craniopharyngiomas (3.6%), arachnoid cysts (1.7%), pituitary tumor apoplexy (1.0%), and other sellar pathologies (12.2%). Among the reviewed operations, the median hospital stay was 3 days (IQR 2-3). Patient management details during the pre-, intra-, and postoperative periods were identified, including both shared characteristics of all patients undergoing transsphenoidal surgery and unique characteristics that are specific to certain lesion types or patient populations.

CONCLUSIONS

Patients with sellar lesions who undergo transsphenoidal surgery require complex, multidisciplinary perioperative care to monitor for common adverse events and to improve outcomes, but there is a dearth of high-quality evidence guiding most perioperative practices. Here, the authors reviewed practices at their institution across more than 1000 transsphenoidal operations that may help ensure successful patient outcomes.

Recurrent epistaxis from inflamed granulated tissue and an associated pseudoaneurysm of the internal carotid artery: case report

BACKGROUND

Chronic inflamed tissue in nasal cavity is a rare complication of transsphenoidal approach (TSA). Inflamed tissue is rich in blood vessels, which can lead to frequent nosebleeds. In addition, chronic inflammation can cause pseudoaneurysm, whose rupture results in massive epistaxis. There have been few reported cases of pseudoaneurysm of ICA occurring more than 10 years after TSA surgery.

CASE PRESENTATION

We report a case of a patient who had recurrent epistaxis for over a decade after TSA surgery, and analyzed the causes of the nosebleeds. The aspect of occurrence of the nosebleeds and the result of biopsy and imaging tests suggest that the nosebleeds were due to chronic inflamed tissue and an associated pseudoaneurysm. The rupture of pseudoaneurysm recurred after treatment with stent placement, and brain abscess was developed. After removing the inflamed tissue by endoscopic resection, the patient no longer had recurrence of ruptured pseudoaneurysm or nosebleeds.

CONCLUSIONS

In patients with recurrent nosebleeds, the possibility of intranasal inflammation and subsequent pseudoaneurysm should be considered. Therefore, people who consistently have epistaxis after TSA, even if the bleeding is not in large amount, should be actively screened and treated for nasal chronic inflammation.

30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients

Objective The study aimed to (1) quantify readmission rates and common causes of readmission following endoscopic transsphenoidal pituitary surgery (ETPS); (2) identify risk factors that may predict readmission within 30 days; (3) assess postoperative care coordination with endocrinology follow-up; and (4) identify patients for whom targeted interventions may reduce 30-day readmissions.

Methods Retrospective quality improvement review of patients with pituitary adenoma who underwent ETPS from December 2010 to 2018 at a single tertiary care center.

Results A total of 409 patients were included in the study, of which 57 (13.9%) were readmitted within 30 days. Hyponatremia was the most common cause of readmission (4.2%) followed by pain/headache (3.9%), cerebrospinal fluid leak (3.4%), epistaxis (2.7%), hypernatremia (1.2%), and adrenal insufficiency (1.2%). Patients with hyponatremia were readmitted significantly earlier than other causes (4.3 ± 2.2 vs. 10.6 ± 10.9 days from discharge, p = 0.032). Readmitted patients had significantly less frequent outpatient follow-up with an endocrinologist than the nonreadmitted cohort (56.1 vs. 70.5%, p = 0.031). Patients who had outpatient follow-up with an endocrinologist were at lower risk of readmission compared with those without (odds ratio: 0.46; 95% confidence interval: 0.24–0.88).

Conclusion Delayed hyponatremia is one of the most common causes of 30-day readmission following ETPS. Postoperative follow-up with an endocrinologist may reduce risk of 30-day readmission following ETPS.

Implications for Clinical Practice A multidisciplinary team incorporating otolaryngologist, neurosurgeons, and endocrinologist may identify patients at risk of 30-day readmissions. Protocols checking serum sodium within 1 week of surgery in conjunction with endocrinologist to tailor fluid restriction may reduce readmissions from delayed hyponatremia.

Prediction of Readmission and Complications After Pituitary Adenoma Resection via the National Surgical Quality Improvement Program (NSQIP) Database

Introduction Pituitary adenomas are common intracranial tumors (incidence 4:100,000 people) with good surgical outcomes; however, a subset of patients show higher rates of perioperative morbidity. Our goal was to identify risk factors for postoperative complications or readmission after pituitary adenoma resection. Methods We undertook a retrospective cohort study of patients who underwent surgery for pituitary adenoma in 2006-2018 by using the National Surgical Quality Improvement Program database. The main outcome measures were patient complications and the 30-day readmission rate. Results Among the 2,292 patients (mean age 53.3±15.9 years), there were 491 complications in 188 patients (8.2%). Complications and 30-day readmission have remained stable over time rather than declined. Unplanned readmission was seen in 141 patients (6.2%). Multivariable analysis demonstrated that hypertension (OR=1.6; 95% CI= 1.1, 2.1; p=0.005) and high white blood cell count (OR=1.08; 95% CI=1.03, 1.1; p=0.0001) were independent predictors of complications. Return to the operating room (OR=5.9, 95% CI=1.7, 20.2, p=0.0005); complications (OR=4.1, 95% CI=1.6, 10.6, p=0.004); and blood urea nitrogen (OR=1.08, 95% CI=1.02, 1.2, p=0.02) were independent predictors of 30-day readmission. Conclusion Using one of the largest datasets of pituitary adenoma patients, we identified perioperative factors most critical for patient outcome. One strength of this study is adjusting for cofactors that predict outcomes, which has not been done previously. Several patient biomarkers, namely white blood cell count and blood urea nitrogen, may serve as preoperative markers that might identify patients at higher risk. Control of blood pressure and renal disease may be perioperative management strategies that can impact the outcome.

Internal carotid artery false aneurysm as a fatal complication of transsphenoidal surgery

False aneurysm of internal carotid artery (ICA) is a rare but serious vascular complication observed after transsphenoidal pituitary surgery. Here, we present a 41-year-old woman with a pseudoaneurysm in the ophthalmic¹ segment of the left ICA after exoscopic transsphenoidal pituitary surgery. The initially uneventful procedure was complicated by a subarachnoidal hemorrhage 10 days after the surgery, which was confirmed by cranial computed tomography scan. The emergency angiography revealed a pseudoaneurysm of the ophthalmic¹ part of the left ICA. Despite repeated endovascular treatments with a flow diverter and coiling, the patient experienced a re-bleeding with consecutive vasospasms, occlusion hydrocephalus and finally bifrontal intracerebral hemorrhage with fatal outcome. As a conclusion in irregular post-operative courses with for example headache, a post-operative magnetic resonance imaging with vessel presentation using TOF sequence and contrast-enhanced MRA might be recommended in order to detect a possible pseudoaneurysm in an early stage.

An Effective and Practical Fluid Restriction Protocol to Decrease the Risk of Hyponatremia and Readmissions After Transsphenoidal Surgery

BACKGROUND

Delayed hyponatremia is a common complication following transsphenoidal surgery (TSS) of pituitary lesions, which leads to significant patient morbidity, as well as increased hospital costs associated with readmission.

OBJECTIVE

To report the effects of fluid restriction, during a postoperative period of 4 d, to decrease rates and readmissions for hyponatremia in a cohort of patients undergoing TSS.

METHODS

Because of our observed postoperative rates of hyponatremia, we implemented 1000-mL fluid restriction limited to postoperative days (POD) 4 to 8 in consecutive patients undergoing surgery at our center between March 2018 and January 2019. Patients were monitored for the development of hyponatremia and readmissions. We compared outcomes with those of patients who had undergone TSS prior to fluid restriction.

RESULTS

Data from 57 patients who underwent TSS following implementation of fluid restriction were compared to prior patients who underwent TSS without restriction. The rate of hyponatremia in patients (n = 57) prior to fluid restriction was 12.3%. Following implementation of fluid restriction, we had zero cases of hyponatremia or readmissions. We found body mass index to be inversely related to the risk of hyponatremia and readmissions. Furthermore, male gender, follicle stimulating hormone and/or luteinizing hormone staining on pathology, and administration of preoperative and intraoperative glucocorticoids were associated with decreased risk of hyponatremia readmissions.

CONCLUSION

The implementation of 1000-mL fluid restriction between POD 4 and 8 is a highly successful and simple approach to decrease the risk of delayed hyponatremia after TSS.

Retrospective Analytic Study of Neurosurgical Patients Who Developed Postoperative Hydrocephalus

Objective This article discusses the causes, primary pathologies, management, and prognosis of patients who did not have hydrocephalus in preoperative stage, underwent definitive surgical procedure, and developed postoperative hydrocephalus requiring cerebrospinal fluid (CSF) diversion procedures.

Methods Retrospective data collection was done from operation theatre (OT) department database and patient records were obtained for the patients after, related literature was searched, all possible risk factors were analyzed, and our results were compared with other studies.

Results A total of 80 cases were found eligible for the study. Decompressive craniectomy was the most common cause followed by aneurysmal subarachnoid hemorrhage (SAH), intraventricular, and cerebellopontine angle (CPA) tumors. Rate of postsurgical hydrocephalus was 15 to 16%. Cases of decompressive craniectomy presented late, only few cases required diversion procedures during the immediate postop period, mostly aneurysm cases and tumors bed bleed. Out of total 6 mortalities, none of them were directly attributable to hydrocephalus. Since most patient presented after initial stabilization, permanent ventriculoperitoneal shunting was found to be the best option.

Conclusion Cases of decompression surgery should be under vigilant follow-up after discharge and even after cranioplasty for risk of development of hydrocephalus and requirement of permanent shunting. Cases with intraventricular hemorrhage or SAH should be considered as future candidate with risk of developing hydrocephalus. Lamina terminalis opening whenever possible results in favorable outcome in cases of anterior circulation aneurysms. CSF protein analysis in cases of intraventricular and CPA tumors should be done whenever possible, preferably routinely.

Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas

INTRODUCTION

Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas.

AREAS COVERED

We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019.

EXPERT OPINION

Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.

Lost to Follow-Up: Complications of an Invasive Giant Prolactinoma

Invasive giant prolactinomas are a rare type of prolactin-secreting tumors. Most lactotroph adenomas, including giant prolactinomas, consist of the sparsely granulated subtype and respond well to medical therapy with dopamine agonists. Proptosis due to intra-orbital tumor extension and ischemic infarction are two rare complications associated with these tumors.

We report a case of a 51-year-old woman with a 30-year history of a macroprolactinoma who was lost to follow-up and returned with severe proptosis, a 10-cm invasive sellar mass on imaging, and markedly elevated serum prolactin levels, consistent with invasive giant prolactinoma. She was initially managed with dopamine agonists followed by palliative debulking of the tumor, which microscopically demonstrated a highly proliferative neoplasm predominantly consisting of sparsely granulated lactotroph adenoma with a minor component of the rare and aggressive acidophil stem cell adenoma subtype. Postoperatively, she developed a large left middle cerebral artery infarct and ultimately died.

This case is notable in that it demonstrates the aggressive nature of invasive giant prolactinomas when not treated and highlights two rare findings in patients with this tumor: orbital invasion and ischemic infarct.

An advanced protocol for intraoperative visualization of sinunasal structures: experiences from pituitary surgery

OBJECTIVE

The transsphenoidal route to pituitary adenomas challenges surgeons because of the highly variable sinunasal anatomy. Orientation may be improved if the appropriate information is provided intraoperatively by image guidance. The authors developed an advanced image guidance protocol dedicated to sinunasal surgery that extracts information from multiple modalities and forms it into a single image that includes fine sinunasal structures and arteries.The aim of this study was to compare the advantages of this novel image guidance protocol with the authors' previous series, with emphasis on anatomical structures visualized and complication rate.

METHODS

This retrospective analysis comprised 200 patients who underwent surgery for pituitary adenoma via a transnasal transsphenoidal endoscopic approach. The authors' standard image guidance protocol consisting of CT for solid bone, T1CEMRI for soft tissues, and MRA for the carotid artery was applied in 100 consecutive cases. The advanced image guidance protocol added a first-hit ray casting of the CT scan for visualization of fine sinunasal structures, and adjustments to the MRA to visualize the sphenopalatine artery (SPA) were applied in a subsequent 100 consecutive cases.

RESULTS

A patent sphenoid ostium-i.e., an ostium not covered by a mucosal layer-was visualized significantly more often by the advanced protocol than the standard protocol (89% vs 40%, p < 0.001) in primary surgeries. The SPA and its branches were only visualized by the advanced protocol (87% and 91% of cases in primary surgeries and reoperations, respectively) and not once by the standard protocol. The number of visualized complete and incomplete sphenoid septations matched significantly more commonly with the surgical view when using the advanced protocol than the standard protocol at primary operation (mean 1.9 vs 1.6, p < 0.001). However, in 25% of all cases a complex and not a simple sinus anatomy was present. In comparison with the intraoperative results, a complex sphenoid sinus anatomy was always detected by the advanced but not by the standard protocol (25% vs 8.5%, p = 0.001).Furthermore, application of the advanced protocol reduced the cumulative rate of complications (25% vs 18% [standard vs advanced group]). Although an overall significant difference could not be determined (p = 0.228), a subgroup analysis of reoperations (35/200) revealed a significantly lower rate of complications in the advanced group (5% vs 30%, p = 0.028).

CONCLUSIONS

The data show that the advanced image guidance protocol could intraoperatively visualize the fine sinunasal sinus structures and small arteries with a high degree of detail. By improving intraoperative orientation, this may help to reduce the rate of complications in endoscopic transsphenoidal surgery, especially in reoperations.

Enhanced recovery and accelerated discharge after endoscopic transsphenoidal pituitary surgery: safety, patient feedback, and cost implications

BACKGROUND

Enhanced recovery after surgery (ERAS) is a constant motivation. There is growing evidence that an endoscopic (rather than microscopic) transsphenoidal approach to pituitary tumours can play a role, facilitating faster recovery and a commensurate reduction in length of stay (LOS). Reducing LOS is beneficial to both patients and healthcare systems. We sought to assess the safety, patient feedback, and resource implications of adopting an enhanced recovery and accelerated discharge policy for elective pituitary surgery.

METHODS

We retrospectively assessed two consecutive cohorts of patients undergoing elective surgery for pituitary adenoma in a single UK centre between July 2016 and November 2019. The pre-ERAS cohort included 52 sequential patients operated prior to protocol change. The ERAS cohort included 55 sequential patients operated after a protocol change. Patient demographic data, tumour characteristics, intra- and post-operative CSF leak, the rate and cause of readmission (within 30 days), and the mean and median LOS were recorded. Patient feedback was collected from a subset of patients (n = 23) in the ERAS group.

RESULTS

The two cohorts were well-matched with respect to their demographic, pathological, and operative characteristics. The rates of readmission within 30 days of discharge were similar between the two groups (8% pre-ERAS cohort, 9% ERAS cohort, p = 0.75). In the pre-ERAS cohort, the mean LOS was 4.5 days and median LOS was 3 days. This compares with significant reduction in LOS for the ERAS group: mean of 1.7 days and median of 1 day (p < 0.05). Thirty-nine of 55 patients in the ERAS group were discharged on post-operative day 1. Patient feedback was very positive in the ERAS group (mean patient satisfaction score of 9.7/10 using a Likert scale).

CONCLUSIONS

An enhanced recovery protocol after elective endoscopic pituitary surgery is safe, reduces length of stay, and is associated with high patient satisfaction.

Symptomatic Cerebral Vasospasm After Transsphenoidal Tumor Resection: Two Case Reports and Systematic Literature Review

Cerebral vasospasm is a rare life-threatening complication of transsphenoidal surgery (TSS). We report our experience with two cases of symptomatic vasospasm after endoscopic TSS, alongside a systematic review of published cases. Two patients who underwent endoscopic TSS for resection of a tuberculum sella meningioma (case 1) and pituitary adenoma (case 2) developed symptomatic vasospasm. Clinical variables, including demographics, histopathology, the extent of subarachnoid hemorrhage (SAH), diabetes insipidus (DI), day of vasospasm, vasospasm symptoms, vessels involved, management, and clinical outcome, were retrospectively extracted. We subsequently reviewed published cases of symptomatic post-TSS vasospasm. Including our two cases, we identified 34 reported cases of TSS complicated by symptomatic vasospasm. Female patients accounted for 20 (58.8%) of 34 cases. The average age was 48.1 ± 12.9 years. The majority of patients exhibited postoperative SAH (70.6%). The average delay to vasospasm presentation was 8.5 ± 3.6 days. The majority of patients exhibited vasospasm in multiple vessels, typically involving the anterior circulation. Hemodynamic augmentation with hemodilution, hypertension, and hypervolemia was the most common treatment. Death occurred in six (17.6%) of 34 patients. Common deficits included residual extremity weakness (17.6%), pituitary insufficiency (8.8%), and cognitive deficits (8.8%). Symptomatic vasospasm is a rare, potentially fatal complication of TSS. The most consistent risk factor is SAH. Early diagnosis requires a high index of suspicion when confronted with intractable DI, acute mental status change, or focal deficits in the days after TSS. Morbidity and death are significant risks in patients with this complication.

Preoperative radiographic and clinical factors associated with the visualization of intraoperative cerebrospinal fluid during endoscopic transsphenoidal resection of pituitary adenomas

Background:

Intraoperative visualization of cerebrospinal fluid (CSF) during endoscopic endonasal resection of skull base tumors is the most common factor contributing to the development of postoperative CSF leaks. No previous studies have solely evaluated preoperative factors contributing to intraoperative CSF visualization. The purpose of this study was to identify preoperative factors predictive of intraoperative CSF visualization.

Methods:

Retrospective review of patients who underwent transsphenoidal resection of pituitary adenomas was conducted. Clinical and radiographic variables were compared for those who had CSF visualized to those who did not. Nominal logistic regression models were built to determine predictive variables.

Results:

Two hundred and sixty patients were included in the study. All significant demographic and radiographic variables on univariate analysis were included in multivariate analysis. Two multivariate models were built, as tumor height and supraclinoid extension were collinear. The first model, which considered tumor height, found that extension into the third ventricle carried a 4.60-fold greater risk of CSF visualization (P = 0.005). Increasing tumor height showed a stepwise, linear increase in risk; tumors >3 cm carried a 19.02-fold greater risk of CSF visualization (P = 0.003). The second model, which considered supraclinoid tumor extension, demonstrated that extension into the third ventricle carried a 4.38-fold increase in risk for CSF visualization (P = 0.010). Supraclinoid extension showed a stepwise, linear increase in intraoperative CSF risk; tumors with >2 cm of extension carried a 9.26-fold increase in risk (P = 0.017).

Conclusion:

Our findings demonstrate that tumor height, extension into the third ventricle, and extension above the clinoids are predictive of intraoperative CSF visualization.

Evaluation of Complications and Costs During Overlapping Transsphenoidal Surgery in the Treatment of Pituitary Adenoma

BACKGROUND

Pituitary adenomas are among the most common primary brain tumors. Recently, overlapping surgery has been curbed in many institutions because of the suggestion there might be more significant adverse events, despite several studies showing that complication rates are equivalent.

OBJECTIVE

To assess complications and costs associated with overlapping surgery during the transsphenoidal resection of pituitary adenomas.

METHODS

A single-center, retrospective cohort study was performed to evaluate the cases of patients who underwent a transsphenoidal approach for pituitary tumor resection. Patient, surgical, complication, and cost (value-driven outcome) variables were analyzed.

RESULTS

A total of 629 patients (302 nonoverlapping, 327 overlapping cases) were identified. No significant differences in age (P = .6), sex (P = .5), tumor type (P = .5), or prior rates of pituitary adenoma resection (P = .5) were seen. Similar presenting symptoms were observed in the 2 groups, and follow-up length was comparable (P = .3). No differences in tumor sizes (P = .5), operative time (P = .4), fat/fascia use (P = .4), or cerebrospinal fluid diversion (P = .8) were seen between groups. The gross total resection rate was not significantly different (P = .9), and no difference in recurrence rate was seen (P = .4). A comparable complication rate was seen between groups (P = .6). No differences in total or subtotal costs were seen either.

CONCLUSION

The results of this study offer additional evidence that overlapping surgery does not result in worsened complications, lengthened surgery, or increased patient cost for patients undergoing transsphenoidal resection of pituitary adenomas. Thus, studies and policy aiming to improve patient safety and cost should focus on optimizing other aspects of healthcare delivery.

Clinical utility of routine postoperative morning cortisol monitoring in detecting new hypothalamic-pituitary-adrenal axis insufficiency following endoscopic transsphenoidal surgery for sellar lesions

OBJECTIVE

Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is a well-documented complication of transsphenoidal craniotomy (TSC) for sellar lesions. The authors aimed to assess their multidisciplinary approach to the diagnosis and treatment of postoperative hypocortisolemia utilizing conservative screening methods.

METHODS

The authors performed a retrospective review of 257 patients who underwent TSC for pituitary adenoma (PA) or Rathke cleft cyst (RCC) at the University of Southern California between 2012 and 2017. Patients with preoperative adrenal insufficiency, Cushing's disease, or < 3 months of postoperative follow-up were excluded. Patient demographics, pathology, tumor characteristics, and complications were recorded. Postoperative day 1 (POD1) morning serum cortisol was assessed in all patients. Hypocortisolemia on POD1 (serum cortisol < 5 μg/dl) prompted a 7 am cortisol level measurement on POD 2 (POD2). Clinical signs and symptoms of hypocortisolemia were consistently monitored. After two serum cortisol levels < 5 μg/dl, or one serum level < 5 μg/dl plus a high clinical suspicion for HPA dysfunction, high-risk patients received glucocorticoid supplementation.

RESULTS

Data on 165 patients were included in the analysis; there were 101 women (61.2%) and 64 men (38.7%). Preoperative diagnoses included nonfunctional adenoma (n = 97, 58.7%), growth hormone-secreting adenoma (n = 37, 22.4%), RCC (n = 18, 10.9%), prolactinoma (n = 8, 4.8%), and other (n = 5, 3.0%). One hundred thirty-eight patients (63.0%) had either suprasellar extension or cavernous sinus invasion. POD1 hypocortisolemia was diagnosed in 8 patients (4.8%). Of these patients, 2 (1.2%) were clinically asymptomatic and had normalized POD2 cortisol levels. Six patients (3.6%) had clinical symptoms and POD2 cortisol levels confirming HPA axis deficiency. Of these 6 patients treated with early glucocorticoid replacement, 2 patients recovered HPA axis function during follow-up, making the incidence of new, permanent HPA axis deficiency 2.5%.

CONCLUSIONS

In the authors' institutional review, all patients warranting postoperative glucocorticoid replacement had both complicated surgical courses and associated clinical symptoms of hypocortisolemia. The authors' algorithm of withholding steroids until patients demonstrate clear evidence of postoperative hypocortisolemia is safe and clinically efficacious. Their data further suggest that routine postoperative cortisol screening may not be necessary following an uncomplicated operative resection, with gland preservation and the absence of clinical symptoms indicative of HPA dysfunction.

Pituitary gigantism: a rare learning opportunity

INTRODUCTION

Pituitary gigantism is a rare but significant paediatric condition with complexities surrounding diagnosis and management. Transsphenoidal surgery (TSS) is the treatment of choice; however, medical treatment is often considered as adjuvant therapy.

CASE

A 10½ -year-old boy presented with tall stature and a height velocity of 11 cm/year. His height was 178.7 cm (+5.8 SD above mean) and insulin-like growth factor-1 (IGF-1) was elevated. An oral glucose tolerance test demonstrated non-suppression of growth hormone (GH). Initial contrast MRI was inconclusive, but C-11 methionine functional positron emission tomography CT identified a 6 mm pituitary microadenoma. A multidisciplinary team clinic held with the family allowed discussion about medical and surgical treatment options. Due to a number of factors including the patient's young age, prepubertal status, a wish to allow him to settle into his new high school and his desire to reach a final height taller than his father's height, it was decided to try medical therapy first with a somatostatin analogue. Pubertal induction was also commenced and bilateral epiphysiodesis surgery performed. Initial response to octreotide was positive; however, 4 months into therapy his IGF-1 was climbing and a repeat GH profile was not fully suppressed. The patient therefore proceeded to have successful TSS excision of the adenoma.

CONCLUSION

Rare cases such as this require sharing of knowledge and expertise, so the best possible care is offered. It is often necessary to work across sites and disciplines. Each case requires an individual approach tailored to the patient and their family.

Nasal Packing Causing Occlusion of Contralateral Internal Carotid Artery During Control of Pseudoaneurysm Bleed

BACKGROUND

Carotid pseudoaneurysm is a rare complication of pituitary surgery and can present with epistaxis. Nasal packing is considered first-line treatment for the control of carotid bleeding. We describe a case of complete occlusion of the contralateral cavernous carotid artery because of nasal packing placed to control hemorrhage from a cavernous carotid pseudoaneurysm.

CASE DESCRIPTION

A 55-year-old man presented with a history of recurrent epistaxis requiring multiple hospital visits and nasal packing over a 9-month period. Nasal endoscopies failed to show a source of bleeding; therefore, the patient underwent bilateral sphenopalatine artery ligations. Postoperative computed tomography angiogram showed no evidence of aneurysm, but did report indistinctness of the lateral sphenoid walls. Symptoms remained controlled for 4 months, but ultimately, he presented to the emergency department with massive epistaxis. A magnetic resonance angiogram noted a 2- to 3-mm left cavernous carotid pseudoaneurysm, and the patient underwent endovascular embolization of bilateral internal maxillary arteries. Significant epistaxis was noted immediately thereafter and he was taken to the operating room to control bleeding. A 4-cm absorbable nasal packing was placed into each sphenoid cavity after profuse bleeding from the left sphenoid sinus was noted. After control of bleeding, cerebral angiogram showed complete occlusion of bilateral internal carotid arteries (ICAs). The right-sided packing was adjusted, and the ICA profusion improved.

CONCLUSIONS

To our knowledge, this is the only report that describes complete occlusion of the contralateral cavernous carotid artery because of extrinsic compression of the lateral sphenoid wall, in the setting of a symptomatic pseudoaneurysm.

Perioperative nasal and paranasal sinus considerations in transsphenoidal surgery for pituitary disease

Endoscopic endonasal skull base surgery has emerged as the treatment modality of choice for a range of skull base lesions, particularly pituitary adenomas. However, navigation and manipulation of the nasal corridor and paranasal sinuses requires that surgeons are aware of effective techniques to maximize patient outcomes and avoid sinonasal morbidity postoperatively. This paper is a narrative review aimed to provide an updated and consolidated report on the perioperative management of the nasal corridor and paranasal sinuses in the setting of endoscopic skull base surgery for pituitary disease. Anatomic variants and common surgical techniques are discussed. Post-operative complications are evaluated in detail. Understanding the structural implications of the endonasal approach to the sphenoid is crucial to optimization of the surgical outcomes. We propose guidelines for perioperative management of endoscopic endonasal skull base surgery for pituitary diseases. Standardized treatment algorithms can improve patient satisfaction, and increase the comparability and the quality of reported information across research studies.

Rate of rhinosinusitis and sinus surgery following a minimally destructive approach to endoscopic transsphenoidal hypophysectomy

BACKGROUND

There remains considerable variation in the extent of sinonasal preservation during the approach for endoscopic transsphenoidal hypophysectomy (TSH). We advocate for a minimally destructive approach utilizing turbinate lateralization, small posterior septectomy, no ethmoidectomy, and preservation of nasoseptal flap (NSF) pedicles bilaterally. Due to these factors, this approach may affect the rates of postoperative rhinosinusitis. The objective of this study is to define the rates of postoperative rhinosinusitis in patients undergoing this approach.

METHODS

Single institution, retrospective chart review of patients undergoing TSH from 2005 to 2018.

RESULTS

A total of 415 patients were identified and 14% developed an episode of postoperative rhinosinusitis within 3 months. These patients were significantly more likely to have had a history of recurrent acute or chronic rhinosinusitis. Most cases were sphenoethmoidal sinusitis managed with 1 to 2 courses of antibiotics. Of patients with postoperative rhinosinusitis, most did not undergo NSF. Average follow-up was 38 months. Six patients (1.4%) underwent post-TSH functional endoscopic sinus surgery (FESS). Average time from TSH to FESS was 26.3 months. Two of these patients had a history of prior chronic rhinosinusitis without polyposis. Two patients underwent revision TSH for recurrent tumor as the primary indication for surgery at time of FESS. Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores generally increased immediately postoperatively, but frequently decreased below preoperative level by the time of last follow-up, regardless of whether patients developed rhinosinusitis.

CONCLUSION

Sinonasal preservation during TSH is associated with a low rate of postoperative rhinosinusitis requiring FESS and excellent long-term patient reported outcomes. We continue to advocate for sinonasal preservation during pituitary surgery.

Pipeline embolization for an iatrogenic intracranial internal carotid artery pseudoaneurysm after transsphenoidal pituitary tumor surgery: Case report and review of the literature

Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to treat with surgery or endovascular means without parent artery sacrifice. Here, we report on a patient who underwent successful treatment using a flow-diverting stent for an iatrogenic intracranial internal carotid artery pseudoaneurysm following a vessel injury after endoscopic pituitary tumor resection via the transsphenoidal approach. A 62-year-old man with a Rathke's cleft cyst presenting with bitemporal hemianopia and progressive decline of left visual acuity underwent endoscopic transsphenoidal pituitary tumor resection. During dura incision, brisk arterial bleeding was encountered from the right internal carotid artery. Immediate packing was performed, and hemostasis was achieved. Three days after the vessel injury, an angiography revealed a pseudoaneurysm (2.9 × 2.1 mm) at the cavernous segment of the right internal carotid artery, which showed enlargement on follow-up magnetic resonance imaging at six days postoperatively. Pipeline embolization was performed nine days after the vessel injury. Angiography performed one month after Pipeline embolization revealed significant stagnation but not complete occlusion of blood flow inside the pseudoaneurysm cavity. Dual antiplatelet therapy was replaced with single antiplatelet therapy. Follow-up angiograms three months after Pipeline embolization confirmed complete obliteration of the pseudoaneurysm and successful endoluminal reconstruction of the damaged vessel. Despite the possibility of short-term bleeding and the need for dual antiplatelet therapy administration for a certain period, the use of flow-diverting stents is a feasible vessel-sparing option in the management of intracranial internal carotid artery pseudoaneurysms resulting from transsphenoidal surgery injuries if intraoperative hemodynamic stability can be achieved with effective packing.

A Retrospective Observational Study of the Neuroendocrine Stress Response in Patients Undergoing Endoscopic Transsphenoidal Surgery for Removal of Pituitary Adenomas: Total Intravenous Versus Balanced Anesthesia

BACKGROUND

Anesthetic technique affects the neuroendocrine stress response to surgery. In this retrospective study, we compared the neuroendocrine stress response in patients undergoing endoscopic transsphenoidal pituitary adenoma surgery (ETSPAS) with total intravenous anesthesia (TIVA) with propofol-remifentanil or balanced anesthesia (BAL) with sevoflurane-remifentanil.

MATERIALS AND METHODS

Eighty-nine patients undergoing ETSPAS were anesthetized with either propofol-remifentanil (TIVA group, n=62) or sevoflurane-remifentanil (BAL group, n=27). Data were retrospectively collected regarding preoperative and immediate postoperative serum levels of adrenocorticotropic hormone (ACTH) and cortisol (primary outcome measures), as well as other pituitary hormones and their target organ hormones (secondary outcome measures).

RESULTS

There were no significant differences in preoperative pituitary hormone levels between the 2 groups. The immediate postoperative ACTH (89.5 [62.1 to 162.6] vs. 256.0 [92.0 to 570.7] pg/mL; P<0.001) level was lower in the TIVA group than in the BAL group, whereas immediate postoperative cortisol levels were similar between the 2 groups. The immediate postoperative thyroid-stimulating hormone (1.85 [1.21 to 2.98] vs. 1.21 [0.44 to 1.71] μIU/mL; P=0.003), triiodothyronine (91.0 [82.0 to 103.0] vs. 69.1 [64.6 to 76.2] ng/dL; P<0.001), luteinizing hormone (2.2 [1.2 to 4.0] vs. 1.0 [0.5 to 2.3] mIU/mL; P=0.005), and prolactin (22.6±15.8 vs. 12.8±10.2 ng/mL; P=0.005) levels were higher in the TIVA group compared with the BAL group. In both groups, none of the patients who had sufficient preoperative ACTH without hydrocortisone supplementation (n=15) showed hypocortisolism in the immediate postoperative measurement.

CONCLUSIONS

Compared with BAL, TIVA resulted in reduced release of ACTH and increased release of thyroid-stimulating hormone, triiodothyronine, luteinizing hormone, and prolactin in patients undergoing ETSPAS.

Unusual Presentation of Vasospasm Masking Underlying Pseudoaneurysm After Endoscopic Transsphenoidal Surgery in Pituitary Macroadenoma

BACKGROUND

Vascular complications during transsphenoidal surgery can be devastating. Direct vascular injury during surgery can lead to various complications including pseudoaneurysm formation. Postoperative hematoma and direct vascular handling due to arachnoid tear can induce vasospasm. The vasospasm might present with varying clinical symptomatology and at times masks the underlying pathology as well.

CASE DESCRIPTION

We present here a case of pituitary macroadenoma in whom the vasospasm caused vision loss and also concealed a developing pseudoaneurysm.

CONCLUSIONS

Angiograms at regular intervals should be performed in cases where intraoperative vascular injury is suspected to detect such aneurysms and prevent catastrophe.

Economics of Acromegaly Treatment in Brazil: A Budget Impact Analysis of Pituitary Surgery Compared with Long-Term Octreotide LAR

BACKGROUND

Acromegaly is a rare, chronic and debilitating disease whose treatment places a high burden on health systems. In the reality of the Brazilian public health network, many patients are kept on drug treatment because of barriers to access to surgery.

OBJECTIVE

The aim of this study was to estimate the costs and budget impact of routine transsphenoidal endoscopic surgery in relation to those of long-term drug treatment with octreotide long-acting release (LAR) from a cohort of patients followed at the referral medical centre for acromegaly treatment in the Federal District, Brazil.

METHODS

Based on micro-costing data collected using mixed methods from a local perspective of the public health system, we performed a budget impact analysis (BIA) on a 3-year time horizon. Uncertainty was handled with deterministic (tornado and scenario) and probabilistic (Monte Carlo simulations) sensitivity analyses.

RESULTS

Compared with the continued use of octreotide LAR at a dose of 30 mg every 28 days, the incremental budget impact of conducting two surgeries per month, considering a cure rate of 55%, could bring savings of approximately US$879,362.18 (95% CI 860,176.29-898,548.08) over 3 years. Depending on the key variable values, the savings amplitude ranged from US$431,836.39 to US$1,519,132.04.

CONCLUSIONS

Improving access to surgery could result in significant cost reductions in acromegaly treatment. The present study stands out for being the first to estimate the costs of transsphenoidal surgery in the context of the public health system in Brazil.

Secondary pituitary abscess following transsphenoidal surgery with recurrent meningitis: A case report

RATIONALE

The transsphenoidal surgical (TS) approach to sellar masses is the preferred surgical route in most cases. Secondary pituitary abscess (PA) following TS is an extremely rare but serious postoperative complication with potentially high disability and mortality.

PATIENT CONCERNS

We describe an uncommon case of secondary PA in a 42-year-old woman, who underwent uncomplicated transsphenoidal procedures without cerebrospinal fluid leak, to treat primary Rathke cleft cyst. Without obvious cause, the patient suffered recurrent meningitis with complaints of headache, hyperpyrexia, and chills from 1 month after the operation.

DIAGNOSIS

There were no significant imaging findings until a new rim-enhancement lesion was seen in the sellar region on magnetic resonance imaging during the 6th episode of meningitis 11 months after the initial surgery. A diagnosis of secondary PA was considered; INTERVENTIONS:: Therefore, she underwent a 2nd TS with pus evacuation and antibiotic treatment.

OUTCOMES

She improved remarkably and had no recurrence of symptoms during the 9-month follow-up.

LESSONS

Our aim was to present this rare case and discuss the most likely etiologies and preventive measures for this condition. In patients with recurrent meningitis but dormant imaging manifestations after TS, the possibility of secondary PA should considered. Adequate surgical drainage with microbiology-guided antibiotic therapy is the 1st choice for treatment.