Sphenoid sinus anatomy and suprasellar extension of pituitary tumors

Analysis of MRI features and associated factors of the pituitary neuroendocrine tumor streaky sign

OBJECTIVES

Observation of pituitary neuroendocrine tumors with streaky sign on MRI, analysis of their features on imaging and further investigation of the relationship between the direction of the streak sign and the direction of optimal tumor expansion.

METHODS

The MR images of 237 patients with pituitary neuroendocrine tumors were retrospectively analyzed. The streaky-like high signal with a substantial length of more than 10 mm and obvious enhancement on T1WI was defined as the streaky sign. Finally, 66 patients were included in the study, comprising 33 patients with streaky sign pituitary neuroendocrine tumors and 33 randomly selected patients with non-streaky sign pituitary neuroendocrine tumors. The general condition of these 66 patients, the imaging features of the tumor, and the measurement and analysis of the direction of the streaky sign in relation to the direction of optimal tumor extension were observed and analyzed.

RESULTS

On MRI, 85 streaky signs were observed. The average deviation between the direction angle of all the streaky signs and the optimal extension direction angle of the tumor was approximately 11°. The longest streaky sign angle was positively correlated with the optimal extension angle of the tumor, with a correlation coefficient of 0.967.

CONCLUSION

The presence of a streaky sign of pituitary neuroendocrine tumors may indicate a dilated sinus or a small blood vessel. Its direction is highly consistent with the optimal extension direction of the tumor, which has a certain supporting effect on the long-distance growth of the tumor.

Predicting the Consistency of Pituitary Macroadenomas: The Utility of Diffusion-Weighted Imaging and Apparent Diffusion Coefficient Measurements for Surgical Planning

Understanding the consistency of pituitary macroadenomas is crucial for neurosurgeons planning surgery. This retrospective study aimed to evaluate the utility of diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) as non-invasive imaging modalities for predicting the consistency of pituitary macroadenomas. This could contribute to appropriate surgical planning and therefore reduce the likelihood of incomplete resections. The study included 45 patients with pathologically confirmed pituitary macroadenomas. Conventional MRI sequences, DWIs, ADC maps, and pre- and post-contrast MRIs were performed. Two neuroradiologists assessed all of the images. Neurosurgeons assessed the consistency of the tumor macroscopically, and histopathologists examined it microscopically. The MRI findings were compared with postoperative data. According to the operative data, macroadenomas were divided into the two following categories based on their consistency: aspirable (n = 27) and non-aspirable tumors (n = 18). A statistically significant difference in DWI findings was found when comparing macroadenomas of different consistencies (p < 0.001). Most aspirable macroadenomas (66.7%) were hyperintense according to DWI and hypointense on ADC maps, whereas most non-aspirable macroadenomas (83.3%) were hypointense for DWI and hyperintense on ADC maps. At a cut-off value of 0.63 × 10-3 mm2/s, the ADC showed a sensitivity of 85.7% and a specificity of 75% for the detection of non-aspirable macroadenomas (AUC, 0.946). The study concluded that DWI should be routinely performed in conjunction with ADC measurements in the preoperative evaluation of pituitary macroadenomas. This approach may aid in surgical planning, ensure that appropriate techniques are utilized, and reduce the risk of incomplete resection.

Morphological Classification of Pituitary Tumors With Suprasellar Extension

BACKGROUND AND OBJECTIVES

The objective of this study was to study the association among various morphological parameters and surgical outcomes in pituitary macroadenomas with suprasellar extension.

METHODS

MRI studies of 160 patients undergoing endoscopic transsphenoidal resection of pituitary macroadenomas with suprasellar extension were reviewed. In the coronal plane, tumors were classified into Type 1 (dome-shaped, no constriction at the level of diaphragma sellae) and Type 2 (dumbbell-shaped, with constriction at the level of diaphragma sellae). Based on the dome-to-neck ratio (D/Nr), Type 2 tumors were further classified as Type 2A (wide neck; D/Nr >1 and <1.3) and Type 2B (narrow neck; D/Nr ≥1.3). Surgical outcomes and complications were analyzed using a logistic regression model. Overall extent of resection (EOR) and presence of residual sellar-suprasellar tumor was separately assessed in all patients with available postoperative MRI (n = 149).

RESULTS

There were 108 Type 1 tumors and 26 patients each in the Type 2A and Type 2B subgroups. Tumor subtype was significantly associated with tumor size (P < .001), intraoperative cerebrospinal fluid leak (P < .001), EOR (P < .001), postoperative suprasellar residual tumor (P < .001), and postoperative complications, including diabetes insipidus (P = .005) and visual worsening (P = .003). On multivariate analysis, after adjusting for confounders, Type 2B tumors were negatively associated with EOR (odds ratio [OR] 0.22; 95% CI 0.07-0.68; P = .008) and associated with the presence of postoperative suprasellar residual tumor (OR 18.08; 95% CI 5.20-62.89; P < .001), intraoperative cerebrospinal fluid leak (OR 5.33; 95% CI 1.89-14.99; P = .002), and postoperative diabetes insipidus (OR 4.89; 95% CI 1.67-14.35; P < .001).

CONCLUSION

Preoperative tumor classification based on D/Nr is clinically and surgically relevant, and Type 2B macroadenomas are significantly associated with lower rates of gross total resection and higher rates of postoperative complications after endoscopic transsphenoidal resection.

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.

A retrospective cohort study assessing geometrical parameters related to visual deterioration in pituitary macroadenoma

PURPOSE

We aim to identify specific parameters that will allow identification of those patients at greater risk of vision loss, specifically variables such as geometry, volume and size of the pituitary tumour.

METHODOLOGY

Volume measurements were made with both manual (using the formula width × height × length × 0.5) and video size, sub-voxel interpolation using Brainlab software. The shape of the tumour was divided into four categories, ovoid, dumbbell, pyramidal and other. Chiasmal compression was divided into central and lateral compression and the chiasm location was classified based on pre/post and normal fixed chiasm in relation to the tuberculum sella. We used a visual impairment score ranging from (0-100), which was then further subdivided in to four grades: Grade I - 0-25 (mild); Grade II - 26-50 (moderate); Grade III - 51-75 (severe); Grade IV - 76-100 (subtotal or complete).

RESULTS

Univariate analysis of variables related to vision loss found tumour volume, suprasellar growth and lateral chiasmal compression related to pre-operative vision loss. On multivariate regression analysis tumour volume and lateral chiasmal compression remained significant (p < 0.008). In relation to post-operative vision, univariate analysis indicated that variables such as giant macroadenoma, pre-operative visual impairment score and suprasellar growth were significant. Multivariate analysis showed pre-operative visual impairment and suprasellar growth as the only statistically significant variables.

CONCLUSION

Our ROC analysis suggests tumours with suprasellar extension 16 mm (sensitivity 85 %, specificity 67 %) in sagittal plane are more likely to result in moderate to severe grade vision loss (VIS grade ≥ 2).

Multidetector CT of the Nasal Cavity and Paranasal Sinuses Variations in 73 Patients

Detailed knowledge of the anatomy of the nasal cavity and paranasal sinuses is very important in the diagnosis of pathological processes, planning of endoscopic surgery, and radiologic guiding techniques during certain operations. Observational study. Clinic of Neurosurgery, Institute and Department of Anatomy and Pathology, Clinic and Department for Otorhinolaryngology and Maxillofacial Surgery, Faculty of Medicine. Two heads with brains were serially cut in the axial and coronal planes. 73 individuals, who were enrolled among 1848 patients, underwent examination by multidetector computerized tomography. A nasal septal deviation was seen in 65.8%, and septal pneumatization in 11%. Superior concha pneumatization was observed in 1.4% of patients, middle concha bullosa in 30.2%, and its hypoplasia in 1.4%. The lamina papyracea dehiscence was also present in 1.4%. The uncinate process was absent in 1.4%, and it was pneumatized in 4.2%. Agger nasi cells were noticed in 34.3%, and Haller and Onodi cells in 20.7% each. The olfactory fossa was shallow in 9.7%, deep in 31.6%, and very deep in 58.9%. Absence of the frontal sinus was seen in 9.7%. The presellar type of the sphenoidal sinus was present in 11%, the sellar in 35.7%, and the postsellar in 53.5%. Hypoplasia of the maxillary sinus was revealed in 1.4%, and hyperpneumatization in 4.2%. The sinus floor was usually below the level (60.3%), at the same level (20.7%), or above the level of the nasal floor (19.2%). The bony septum within the sinus was seen in 52.1%. The presented data are of a great significance in order to avoid a misdiagnosis of the anatomic variations, to make a proper diagnosis of certain diseases, and for safe endonasal operations.

Anatomical Variations of Sphenoid Sinus in South Indian Population: All That You Need for Trans-Sphenoidal Pituitary Surgery

Pituitary adenomas are one among the most common neurosurgical tumors with an incidence of 10-25% among intracranial neoplasms (Ezzat et al., Cancer 101:613-619, 2004). Surgical management for the same has been practiced since long, and has evolved from trans cranial approach to endoscopic trans sphenoidal method (Hammer and Radberg, Acta Radiol 56:401-422, 1961). Preoperative radiological analysis with CT &MRI is inevitable in planning endonasal trans-sphenoid surgery to avoid complications because of the high variability concerned with sphenoid anatomy. The present study intends to analyze the incidence of various anatomical variations of sphenoid sinus in a cohort of south Indian population as detected by CT& MRI and assess its impact on surgical approach. Retrospective analysis of CT&MRI images of patients who underwent Endonasal Trans-sphenoidal resection of pituitary tumors at JSS Hospital Mysuru from a period of 2009 to 2020 is done. Anatomical variations of sphenoid sinus esp. degree of pneumatization, sellar configuration, septation pattern, inter carotid distance were evaluated. Results were significant and in concordance with other similar studies. Most frequently encountered pnuematization was sellar type and least was conchal type Sphenoid sinus pneumatization is directly linked to safe access to sella. Presence of septae within sinus need to be identified preoperatively to avoid damage and confusion intraoperatively. A meticulous preoperative analysis of sphenoid sinus anatomy will help surgeon in smooth conduct of a complication free surgery.

Dumbbell-shaped pituitary adenomas: prognostic factors for prediction of tumor nondescent of the supradiaphragmal component from a multicenter series

OBJECTIVE

Dumbbell-shaped pituitary adenomas (DSPAs) are a subgroup of macroadenomas with suprasellar extension that are characterized by a smaller diameter at the level of the diaphragma sellae opening compared with the supradiaphragmal tumor component (SDTC). Hence, DSPAs may be particularly prone to a nondescending suprasellar tumor component and risk for residual tumor or postoperative bleeding.

METHODS

A multicenter retrospective cohort analysis of 99 patients with DSPA operated on via direct endoscopic endonasal transsphenoidal approach between 2011 and 2020 was conducted. Patient recruitment was performed at two tertiary care centers (Medical University of Vienna and University of Southern California) with expertise in endoscopic skull base surgery. DSPA was defined as having a smaller diameter at the level of the diaphragma sellae compared with the SDTC.

RESULTS

On preoperative MRI, all DSPAs were macroadenomas (maximum diameter range 17-71 mm, volume range 2-88 cm3). Tumor descent was found in 73 (74%) of 99 patients (group A), and nondescent in 26 (26%) of 99 patients (group B) intraoperatively. DSPAs in group A had a significantly smaller diameter (30 vs 42 mm, p < 0.001) and significantly smaller volume (10 vs 22 cm3, p < 0.001) than those in group B. The ratio of the minimum area at the level of the diaphragmal opening in comparison with the maximum area of the suprasellar tumor component ("neck-to-dome area") was significantly lower in group A than in group B (1.7 vs 2.7, p < 0.001). Receiver operating characteristic curve analysis revealed an area under the curve of 0.75 (95% CI 0.63-0.87). At a cutoff ratio of 1.9, the sensitivity and specificity for a nondescending suprasellar tumor component were 77% and 34%, respectively.

CONCLUSIONS

In the present study, the neck-to-dome area ratio was of prognostic value for prediction of intraoperative tumor nondescent in DSPAs operated on via a direct endonasal endoscopic approach. Pituitary adenoma SDTC nondescent carried the inherent risk of hemorrhagic transformation in all cases.

The Shape grading system: a classification for growth patterns of pituitary adenomas

BACKGROUND

Long-term tumor control of pituitary adenomas may be achieved by gross total resection (GTR). Factors, which influence the extent of resection, are invasiveness, tumor size, and possibly tumor shape. Nevertheless, the latter factor has not been assessed so far and there is no classification for the different shapes. The aim of this study was to evaluate the impact of different tumor shapes on GTR rates and outcome according to our proposed "Shape grading system."

METHODS

In this retrospective single center study, the radiological outcome of nonfunctioning pituitary adenomas was assessed with respect to the following previously defined growth patterns: spherical (Shape I), oval (Shape II), dumbbell (Shape III), mushroom (Shape IV), and polylobulated (Shape V).

RESULTS

A total of 191 patients were included (Shape I, n = 28 (15%); Shape II, n = 91 (48%); Shape III, n = 37 (19%); Shape IV, n = 12 (6%); Shape V, n = 23 (12%)). GTR was achieved in 101 patients (53%) with decreasing likelihood of GTR in higher shape grades (Shape I, n = 23 (82%); Shape II, n = 67 (74%); Shape III, n = 9 (24%); Shape IV, n = 2 (17%); Shape V, n = 0 (0%)). This correlated with larger tumor remnants, a higher risk of tumor recurrence/regrowth and therefore necessity of re-surgery and/or radiotherapy/radiosurgery.

CONCLUSION

The "Shape grading system" may be used as a predictor of the outcome in nonfunctioning pituitary adenomas. The higher the "Shape grade," the higher the likelihood for lower GTR rates, larger tumor remnants, and need for further therapies.

Patterns of extrasellar invasive growth of pituitary adenomas with normal sellar cavity size

BACKGROUND

Pituitary adenomas (PAs) are among the most common brain tumors which characteristically become symptomatic due to the mass effect on surrounding structures and/or hormonal imbalances. This study describes 28 cases of PAs with an extrasellar invasive growth (EIG) at the early stage of tumor growth with normal sellar cavity size.

METHODS

1200 cases of PAs either treated medically or via Endoscopic transsphenoidal surgery were reviewed during a 10-year period. Pre-operative imaging was analyzed to evaluate the tumor expansion pattern, tumor invasion sites and other relevant tumor properties. A comprehensive preoperative endocrinological along with postoperative histopathological studies were conducted to evaluate the subjects' homeostasis and further identify the lesions characteristics.

RESULTS

Of the 28 patients, patients 19, 2, 1 and 6 had a growth hormone (GH)-secreting PA, an adrenocorticotropic hormone (ACTH)-secreting PA, a nonfunctional PA (NFPA) and a mix-hormones secreting PA, respectively. There was a statistically significant difference between patients with and without EIG regarding types of PAs (P = 0.000). Post-hoc tests demonstrated that GH-secreting PAs (P = 0.0003) and mix-hormones secreting PAs (P = 0.0000) are significantly more invasive, while NFPAs (P = 0.0000) are less invasive. There was not a statistically significant difference between the invasion sites and different types of PAs (P = 0.122).

CONCLUSION

Among different histological subtypes of PAs, GH-secreting PAs revealed a remarkable tendency for EIG with normal sellar cavity size. The extra-sellar tumor extension with a normal sella did not correlate with atypical histology. Considering EIG patterns, surgeons should be vigilant to investigate and follow the tumor spreading to its enclosing boundary during surgery, the clival part of sphenoid bone should be more exposed, and both inferomedial and lateral borders of the sphenoid sinus should be carefully explored in order to remove the tumor.

Results of Endoscopic Surgery in Patients with Pituitary Adenomas : Association of Tumor Classification Grades with Resection, Remission, and Complication Rates

Objective

The endoscopic endonasal transsphenoidal approach is a widely-used method for the surgical treatment of pituitary adenomas. We aimed to evaluate the results of endoscopic surgery by comparing preoperative classification methods and investigating their relationship with postoperative resection and remission rates and complications.

Methods

We retrospectively reviewed the medical records of 236 patients (118 males) who underwent surgery for pituitary adenomas. Preoperative Knosp classification, tumor size (TS), suprasellar extension (SSE), postoperative resection and remission rates, and complications were evaluated.

Results

The follow-up period was 3 months to 6 years. The patients’ ages ranged between 16 and 84 years. Endocrinologically, 114 patients (48.3%) had functional adenoma (FA), and 122 patients (51.7%) had non-functional adenoma (NFA). Among the FA group, 92 (80.7%) showed remission. A statistically significant difference was found between patients with and without remission in terms of the Knosp, TS, and SSE classifications (p<0.01). Knosp, TS, and SSE classification grades were found to be correlated with the resection rates (p<0.01). Meningitis was seen in seven patients (3.0%), diabetes insipidus in 16 (6.9%; permanently in two [0.9%]), and rhinorrhea in 19 (8.1%). Thirty-six patients (15.3%) developed pituitary insufficiency and received hormone replacement therapy.

Conclusion

The resection categories and remission rates of FAs were directly proportional to the adenoma sizes and Knosp grades, while the degree of suprasellar growth further complicated resection and remission rates. Adenoma sizes less than 2 cm and SSEs less than 1 cm are associated with favorable remission and resection rates.

Arachnoid prolapse in endoscopic transsphenoidal surgery of pituitary adenoma, technical note

PURPOSE

An arachnoid prolapse after endoscopic transsphenoidal surgery for a pituitary adenoma is an uncommon, but important, phenomenon which should be managed. We have evaluated the efficacy of a new simple technique to correct the prolapsed arachnoid following endoscopic surgery of pituitary adenomas.

METHODS

A total of 1352 patients with pituitary adenomas, 24-76 years old, who underwent full endoscopic transsphenoidal surgeries between February 2014 and February 2019 in Erfan and Loghman Hakim hospitals. 46 patients with arachnoid prolapse participated in this study and41 patients completed the study. Arachnoid prolapse was repaired by bipolar cauterization with either autologous fat grafts (36 patients) or without autologous fat grafts (5patients).

RESULTS

Of 41 patients who completed the study, all except one, had large adenomas with significant suprasellar extension and enlarged diaphragma sellae. All patients had arachnoid prolapse at the end of the tumor removal stage and 13 patients had very minor intraoperative CSF leakage. Prolapsed arachnoid was repaired using a bipolar cautery with or without the autologous fat graft. During the postoperative follow-up period, none of the patient experienced early or delayed postoperative CSF leakage, meningitis, visual deterioration, delayed epistaxis, cranial nerve palsy, recurrence, or death.

CONCLUSION

Bipolar cauterization is a safe, effective technique to repair a suprasellar arachnoid prolapse during reconstruction of the sellar floor following endoscopic transsphenoidal pituitary surgery.

Sphenoid sinuses: pneumatisation and anatomical variants-what the radiologist needs to know and report to avoid intraoperative complications

PURPOSE

Sphenoid sinuses are pneumatised structures, placed in the body of the sphenoid bone, with highly variable morphology. The strict relationships with vascular and nervous structures determine the importance of their anatomical variants in otorhinolaryngology and neurosurgery; a precise understanding of the complex anatomy and anatomic variations of these structures is pivotal for radiological diagnosis of paranasal sinuses pathology and for surgical planning, to avoid potential complications. Our aim is to describe the anatomical variants of sphenoid sinuses, and to help general radiologists and specialists in endoscopic surgery in becoming familiar with these sensitive anatomical structures.

METHODS

A literature search of PubMed and Embase (Elsevier) databases was performed using the keywords "sphenoid sinus" and "anatomy, "sphenoid sinus" and "anatomic variants", "sphenoid sinus", and "anatomic variations".

RESULTS

We described the anatomical variants of the sphenoid sinuses anatomy, according to their size, shape, degree of pneumatisation, protrusion of anatomical structures into their lumen, superimposition of ethmoid cells (Onodi cells), and presence of accessory septations CONCLUSION: The information provided by this study may help in the identification and description of the anatomical variations of the sphenoid sinuses and their relationship to neurovascular structures.

Clinical study of endoscopic treatment of a sellar pituitary adenomas with sellar diaphragm defect

Background

Invasive growth of pituitary macroadenomas to the suprasellar region occurs commonly. Pituitary adenomas show varying growth patterns when the sellar diaphragm is absent, and they are often confused with other common tumors in the sellar region. This article explores the clinical features of suprasellar pituitary adenomas with defects of the sellar diaphragm (SPADSD) and evaluates the efficacy of the endoscopic endonasal approach (EEA) for treatment of such tumors.

Methods

We performed a detailed examination of records from 19 patients collected prior to surgery. After relevant diseases were excluded, the tumor properties were evaluated according to imaging characteristics. Diagnoses were verified using EEA surgery. The concept of SPADSD was put forward. Postoperative recovery was followed to determine whether EEA is suitable for the treatment of such tumors.

Results

In the 19 patients with SPADSD, we found that the tumors were less stressed on the pituitary, and tumors in the suprasellar region often had irregular shapes. During surgery, we took extended supra-saddle approaches and confirmed that unrestricted growth of the tumor was caused by defects in the diaphragm of the sella turcica to the suprasellar region. Recovery was good after surgery, confirming the efficacy of EEA for treatment of these tumors.

Conclusion

SPADSD has different clinical features from those of other pituitary tumors and requires careful screening prior to surgery. Endoscopic surgery is the preferred procedure for this type of tumor.

Anatomic and histologic features of diaphragma sellae that effects the suprasellar extension

This study aimed to determine the anatomical and histological features of diaphragma sellae that affect the suprasellar extension of intrasellar tumours. Twenty-four fresh adult cadavers were dissected for the study. Diaphragma sellae and pituitary capsules with sellar structures were resected. The diaphragma sellae was anatomically reviewed in detail. Immunohistochemical staining was performed for collagen types I, II, III, and IV. We examined the suprasellar growth of 13 sellar tumours extending superiorly through the diaphragma sellae by performing a series of 2704 endoscopic transnasal operations to analyse the anatomic and histologic results of the study. The diameter of the foramen of diaphragma sellae varied between specimens. Of 24 specimens, the diaphragma sellae in five (21%) had a tight-type foramen and those in 19 (79%) were more spacious. An increased expression of collagen types I and IV was observed in the pituitary capsule and the diaphragma sellae. In this clinical series, we observed that all types of sellar tumours could expand through the foramen. We observed radiologically and intraoperatively that the diaphragma sellae was displaced laterally and formed a dome in two cases with an adenoma extending to the suprasellar area. Two types of suprasellar extension through the diaphragma sellae are possible: 1) The collagen structure of diaphragma sellae can be destroyed by invasive tumours; 2) The morphology of the foramen of the diaphragma sellae facilitates suprasellar tumoural extension. All sellar tumours, including non-invasive cystic tumours, may invade the suprasellar area by expanding through the foramen of the diaphragma sellae.

Non-functioning pituitary macroadenoma: surgical outcomes, tumor regrowth, and alterations in pituitary function-3-year experience from the Iranian Pituitary Tumor Registry

PURPOSE

The aim of this study was to assess clinical features and therapeutic outcomes in patients with clinically non-functioning pituitary macroadenomas (NFPMAs).

METHOD

This is a retrospective cohort study of NFPMA patients treated surgically and followed periodically between 2015 and 2017 in a tertiary care center in Iran. Descriptive analysis was performed applying appropriate tests. Binary logistic regression models were used to determine the predictive factors for subtotal tumor resection (STR) and hormonal recovery. Data were analyzed by Stata software.

RESULT

A total of 71 patients with a mean age of 50.6 ± 1.4 years were studied. The mean diameter of the adenoma was 26.8 ± 1.1 mm. The most frequent symptoms were headache (85.75%), visual field defect (VFD) (78.3%), and hypogonadal symptoms (40.3%). Gross total resection (GTR) was achieved in 45.1%. Preoperative hypopituitarism was observed in 50.7% of patients. Recovery of at least one axis occurred in 36.1% of the patients suffering from hypopituitarism preoperatively, while new-onset postoperative hormonal deficiency appeared in 14.3% of patients. Multivariate analyses showing preoperative tumor size (OR = 38.2; P = 0.008) and cavernous sinus extension (OR = 13.4; P = 0.020) were predictors of STR. Moreover, hormonal recovery was observed not to be related to age, gender, tumor size, or the extent of tumor resection.

CONCLUSIONS

Tumor size and cavernous sinus extension are the main predictors for STR. Notably, recovery of the gonadal axis in a large proportion of patients supports the surgical resection of NFPAM in patients suffering from gonadal deficiency, even in the absence of VFD.

Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage

PURPOSE

Although hemorrhage within pituitary adenomas frequently exacerbates the symptoms, there are many grades of severity. Moreover, the contributing factors for symptom severity are still controversial.

METHODS

This retrospective study included 82 patients who underwent transsphenoidal surgery for pituitary adenomas with intratumoral hemorrhage. The grades of preoperative symptoms were classified into group A, asymptomatic or minor symptoms; group B, moderate symptoms sufficient for complain; and group C, severe symptoms disturbing daily life.

RESULTS

The hemorrhage volume within an adenoma was significantly higher in group C (92.6%) than in groups A (48.6%) and B (58.7%). Both headache and diplopia were dominant in group C, occurring in 72.2% and 27.8% of the patients, respectively. In group C, there was no significant difference in frequency between adenoma extensions into the sphenoid sinus (0%) and involvement of the cavernous sinus of Knosp grade 4 (0%), and extensions into the suprasellar region were not common (38.9%). The most distinctive feature was that "no extrasellar extension" was found only in group C (41.2%), and "multidirectional extension" was not detected in this group (0%). Multiple regression analysis revealed that the most powerful determining factors were the high frequencies of intratumoral hemorrhage and lack of extrasellar and multidirectional extensions.

CONCLUSION

Rapid volume expansion of a hematoma and lack of extension or unidirectional extension might lead to significant compression of the sellar and surrounding structures. Of note, the integrity of the sellar dura might contribute to the acute onset of symptom manifestations caused by hemorrhage in pituitary adenomas.

Efficacy of sellar opening in the pituitary adenoma resection of transsphenoidal surgery influences the degree of tumor resection

Background

Endonasal transsphenoidal microsurgery is often adopted in the resection of pituitary adenoma, and has showed satisfactory treatment and minor injuries. It is important to accurately localize sellar floor and properly incise the bone and dura matter.

Methods

Fifty-one patients with pituitary adenoma undergoing endonasal transsphenoidal microsurgery were included in the present study. To identify the scope of sellar floor opening, CT scan of the paranasal sinus and MRI scan of the pituitary gland were performed for each subject. Intraoperatively, internal carotid artery injury, leakage of cerebrospinal fluid, and tumor texture were recorded, and postoperative complications and residual tumors were identified.

Result

The relative size of sellar floor opening significantly differed among the pituitary micro-, macro- and giant adenoma groups, and between the total and partial tumor resection groups. The ratio of sellar floor opening area to maximal tumor area was significantly different between the total and partial resection groups. Logistic regression analysis revealed that the ratio of sellar floor opening area to the largest tumor area, tumor texture, tumor invasion and age were independent prognostic factors. The vertical distance between the top point of sellar floor opening and planum sphenoidale significantly differed between the patients with and without leakage of cerebrospinal fluid.

Conclusion

These results together indicated that relatively insufficient sellar floor opening is a cause of leading to residual tumor, and the higher position of the opening and closer to the planum sphenoidale are likely to induce the occurrence of leakage of cerebrospinal fluid.

Midline dural filum of the sellar floor: Its relationship to the septum attachment to the sellar floor and the ossification in the sphenoid sinus

OBJECTIVES

It is important to identify and maintain a midline orientation during endoscopic transsphenoidal surgery (ETSS) for sellar lesions to prevent critical injury to the internal carotid artery. Therefore, the preoperative neuroradiological assessment of the bony structures in the sphenoid sinus, including the septum attachment to the sellar floor and its surrounding structures, is essential. It has been reported that the midline filum of the sellar dura can function as a useful intraoperative orientation guide during ETSS. However, the relationship between the midline dural filum and the intrasinus bony structures, such as the sellar floor, the intrasinus septation and the ossification, remains unclear and the mechanisms underlying development of the midline dural filum have also not yet been explored.

METHODS

This retrospective study included 160 patients undergoing ETSS to assess both the midline dural filum and the intrasinus bony structures, using video recording reviews. The intrasinus septum and the ossification in the sphenoid sinus were evaluated on the computed tomography images of the bone window.

RESULTS

A midline dural filum was identified in 66 (41.3%) of 160 patients. Attachment of the septum to the sellar midline was found in 61 (39.4%) of 155 patients, after excluding 5 patients with the conchal type of sphenoid sinus, 55 (90.2%) of 61 patients with a septum on the midline and only 6 (6.4%) of the remaining 94 patients without a septum on the midline had a midline dural filum. The relationship between a midline dural filum and a septum on midline was statistically significant (p<0.001), regardless of the number of intrasphenoidal septa. In terms of the types of sphenoid sinus, the midline dural filum was predominantly detected in patients where ossification extended over the midline filum. In patients with the sellar type of sphenoid sinus, 49 (36.0%) of 136 had a midline dural filum, meanwhile, 16 (84.2%) of 19 patients with the pre-sellar type (p=0.039) and all 5 patients (100%) with the choncal type harbored a midline dural filum (p<0.001).

CONCLUSION

This study clearly verified the importance of the midline dural filum in a large series and evaluated the obvious relationship between the midline dural filum and the bony structures on the sellar floor. Our results strongly suggest that, during developing of the midline dural filum, the sellar dura becomes tethered to the bony elements attached to the sellar surface, such as the septum on the midline and the ossification in both the pre-sellar and the conchal type of sphenoid sinus.

Significant improvement of intractable headache after transsphenoidal surgery in patients with pituitary adenomas; preoperative neuroradiological evaluation and intraoperative intrasellar pressure measurement

OBJECT

Headache is the most common symptom of both primary and metastatic brain tumor, and is generally considered the primary symptom in patients with large pituitary adenomas. However, patients with small pituitary adenomas rarely complain of intractable headache, and neurosurgeons are unsure whether such small adenomas actually contribute to headache. If conventional medical treatments for headache prove ineffective, surgical removal of the adenoma can be considered as an alternative management strategy.

METHODS

We conducted a retrospective review of 180 patients who underwent transsphenoidal surgery (TSS) for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. Patients with acute phase intratumoral hemorrhage were excluded. We identified nine patients with intractable headache as the chief complaint associated with small pituitary adenoma (diameters 15.8 ± 2.6 mm, 11-20 mm), non-functioning in eight, and prolactin-secreting in one. The preoperative neuroradiological studies and headache characteristics were assessed retrospectively, and the intrasellar pressure evaluation was performed during TSS in the last seven patients.

RESULTS

All nine patients had complete or substantial resolution of their formerly intractable headache after TSS. Headaches consisted of ocular pain ipsilateral to the adenoma localization within the sella in four cases and bifrontal headache in five. Magnetic resonance imaging of these patients revealed small diaphragmatic foramen, which were so narrow that only the pituitary stalk could pass. Computed tomography scans showed ossification beneath the sellar floor in the sphenoid sinus, presellar type in six cases, and choncal type in three. The adenomas included cysts in seven cases. There was no cavernous sinus invasion. Intrasellar pressure measurements averaged 41.5 ± 8.5 mmHg, range 34-59, significantly higher than in control patients without headache (n = 12), namely 22.2 ± 10.6 mmHg (16-30).

CONCLUSION

In this study, the authors demonstrated the validity of TSS in the treatment of intractable headache associated with pituitary adenoma. The presence of ocular pain, especially ipsilateral to the adenoma, integrity of the diaphragm sella, and ossification in the sphenoid sinus, cyst or hemorrhage and the absence of cavernous sinus invasion were the indications for TSS for patients complaining of intractable headache and having pituitary adenomas.

Sphenovomerine suture: a useful landmark for locating sphenoid sinus ostium

AIM

The aim of this study was to determine whether the sphenovomerine suture (SVS) can be used as a landmark to localize the sphenoidal sinus ostium.

METHODS

Endoscopic imaging was done on 152 skulls to identify ostium of the sphenoidal sinus, the SVS, and the articulation of sphenoidal process of palatine bone between the body of the sphenoid and the sphenopalatine foramen. The variables were as follows: (1) the distance between the medial border of the ostium and SVS (DSO-SVS); (2) the angle between them (ASO-SVS); (3) the distance between the inferior border of the ostium and the horizontal line (DSO-HL); (4) the distance between intersection point of the SVS-sphenoidal process of the palatine bone and the medial border of sphenopalatine foramen (DSPF-SVS); and (5) the number of sphenopalatine foramen.

RESULTS

Of the 152 skulls, 289 sides were included in the study. The mean value for DSO-SVS was 3.15 (1.35) mm, DSO-HL was 5.99 (2.38) mm, DSPF-SVS was 7.07 (1.96) mm, and ASO-SVS was 5.99 (9.73) mm. As DSPF-SVS decreases, DSO-SVS and DSO-HL decrease with statistical significance (Ps = 0.02 and 0.001, respectively). The distribution of the numbers of sphenopalatine foramen was as follows: one 90%, two 9.7%, and four 0.3%.

CONCLUSIONS

The horizontal distance between the SVS and the sphenopalatine foramen plays a significant role in identifying the location of sphenoid sinus ostium. As with the other landmarks, the SVS provides an additional benefit in locating the sphenoid sinus ostium for endoscopic sinus surgeons. The incidence of 4 sphenopalatine foramen is 0.3%.

Somatic IDH1 mutation in a pituitary adenoma of a patient with Maffucci syndrome

Maffucci syndrome is a rare disease characterized by multiple enchondromas and soft-tissue hemangiomas. Additionally, neuroendocrine tumors including pituitary adenomas have been described in these patients. The underlying genetic etiology lies in somatic mosaicism of mutations in isocitrate dehydrogenase 1 (IDH1) or isocitrate dehydrogenase 2 (IDH2). This report describes a patient with Maffucci syndrome who presented with intracranial tumors of the skull base and suprasellar region. The patient underwent resection of both intracranial tumors, revealing histopathological diagnoses of chondrosarcoma and pituitary adenoma. DNA sequencing of the tumors was performed to identify common IDH1/2 mutations. Clinical, radiological, and biochemical assessments were performed. Genotypic studies used standard Sanger sequencing in conjunction with a target-specific peptide nucleic acid to detect IDH1 mutations in tumor tissues. DNA sequencing demonstrated identical IDH1 mutations (c.394C > T) in both tumors. To the authors' knowledge, this report provides the first genetic evidence for the inclusion of pituitary adenomas among tumors characterizing Maffucci syndrome. In patients who are newly diagnosed with Maffucci syndrome, it is appropriate to monitor for development of pituitary pathology and neuroendocrine dysfunction.

Planum-Clival Angle Classification: A Novel Preoperative Evaluation for Sellar/Parasellar Surgery

Objective Endonasal approaches are increasingly used to treat sellar pathologies, leading to increased interest in achieving maximal safe resection. We propose a tool-the planum-clival angle (PCA)-and explore its surgical implications for sellar pathology resections. Design Retrospective analysis. Participants Consecutive patients with pituitary lesions between 2003 and 2013. Outcome Measures The PCA and suprasellar extension ratios; head position and extent of surgical resection. Results We enrolled 89 patients (ages 21-88 years). There were 15 type A patients (17%), 13 with suprasellar extension (89%) and ratios between 0.12 and 0.70. There were 61 type B patients (70%), 49 with suprasellar extension (81%) and ratios from 0.09 to 0.66. Finally, there were 13 type C patients (13%), 10 with suprasellar extension (73%) and ratios from 0.21 to 0.76. Type B was treated with a sphenoidectomy and neutral head positioning, type A with 10 to 20 degrees of flexion and an additional posterior ethmoidectomy with or without posterior planum resection, and type C with 10 to 20 degrees of extension and an additional superior clival resection. Conclusions Sellar anatomy and PCA influence the growth patterns of sellar lesions. Thus PCA should allow for better surgical planning and thereby improve surgical efficacy.

Clinicopathological correlates of extrasellar growth patterns in pituitary adenomas

We reviewed clinical, imaging and histopathology details of 297 patients who underwent surgery for pituitary adenomas, with an equal distribution of functional and non-functioning tumors, to examine clinicopathological correlates of extrasellar growth. Knosp grades of 3 and 4 on MRI defined cavernous sinus invasion, Hardy grades of C and D defined significant suprasellar/subfrontal extension, and intraoperative evidence of tumor eroding through the clivus or sellar floor defined infrasellar invasion. Disease status at follow-up was known in 246 patients overall, including 35 patients who were evaluated for progression of residual disease on serial imaging. On univariate analysis, we found several statistically significant associations (p < 0.05) including adenoma size with age, sex and tumor protein p53 reactivity; cavernous sinus invasion with size, non-functional status, increased mitotic activity, an elevated MIB-1 proliferation index and p53 reactivity; suprasellar/subfrontal extension with p53 reactivity; and infrasellar invasion with age and tumor size. When adjusting for confounders with logistic regression, several significant associations were evident including adenoma size with male sex and p53 reactivity; cavernous sinus invasion with size and elevated MIB-1 proliferation index; suprasellar/subfrontal extension with p53 reactivity; and infrasellar invasion with adenoma size alone. Patients with early progression of postoperative residual tumor were younger with a non-significant trend towards higher MIB-1 proliferation indices. Individual patterns of extrasellar growth in pituitary adenomas are associated with unique clinical and immunohistochemical profiles. Younger patients with elevated MIB-1 values are probably at high risk for early recurrence of non-functioning tumors. Definitions of atypia must be standardized before more robust assumptions about tumor biology can be established.

Ectopic ACTH-secreting pituitary adenomas within the sphenoid sinus

Ectopic pituitary adenomas are defined by the presence of adenomatous pituitary tissue outside the sella and distinctly separate from the pituitary gland. Ectopic ACTH-secreting pituitary adenomas (EAPAs) are a rare cause of Cushing's syndrome. Detecting these radiologically can prove difficult, in part, due to their typically small size and unpredictable anatomical location. In ACTH-dependent Cushing's syndrome, if, despite comprehensive testing, the source of excess ACTH remains occult (including negative work up for ectopic ACTH syndrome) thought should be given to the possibility of the patient harboring an EAPA. In most cases, ectopic ACTH pituitary adenomas within the sphenoid sinus will manifest with symptoms of hormonal excess, have an obvious sphenoid sinus mass on pre-operative imaging and will demonstrate resolution of hypercortisolism after surgical excision if located and removed. Twenty cases of EAPAs have been reported in the literature to date. This paper will review the current literature on all previously reported EAPAs within the sphenoid sinus in addition to the current case.

Complex anatomy of the sphenoid sinus: a radiographic study and literature review

Objectives Nasal endoscopic approaches to the sphenoid sinus are challenging. Variations in septation, shape, and dimensions have a critical impact on surgical planning of the skull base. Previous anatomical studies have small numbers or a limited description of this complex structure. The present study is a radiographic analysis of the septation and dimensions of the sphenoid sinus. Design and Methods High-resolution surgical-guidance computed tomography images of the sinuses from 90 patients at a tertiary care medical center between 2002 and 2007 were studied. Multiple anatomical measurements from axial and sagittal images were obtained and analyzed with imaging and statistical software. Results Of the 90 patients studied, 9% had presellar, 37% sellar, and 54% postsellar pneumatization. In 34%, the posterior extent of the intersinus septum involved the bony covering of the carotid artery. The average presellar width of the sinus was 1.3 cm, the average midline presellar depth was 1.4 cm, and the average infrasellar midline depth was 2.6 cm. Conclusions Approaching the skull base through the sphenoid sinus requires a tailored process based on anatomy. Septal involvement of the carotid artery occurs frequently. Pneumatization patterns are potentially disorienting, and awareness of the sinus's posterior and lateral extensions is critical.