1
|
Findlay MC, Sabahi M, Azab M, Drexler R, Rotermund R, Ricklefs FL, Flitsch J, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Knappe UJ, Uksul N, Schroder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Antunes ACM, Couldwell WT, Budohoski KP, Rennert RC, Karsy M. The role of surgical management for prolactin-secreting tumors in the era of dopaminergic agonists: An international multicenter report. Clin Neurol Neurosurg 2024; 236:108079. [PMID: 38091700 DOI: 10.1016/j.clineuro.2023.108079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE First-line prolactin-secreting tumor (PST) management typically involves treatment with dopamine agonists and the role of surgery remains to be further explored. We examined the international experience of 12 neurosurgical centers to assess the patient characteristics, safety profile, and effectiveness of surgery for PST management. METHODS Patients surgically treated for PST from January 2017 through December 2020 were evaluated for surgical characteristics, outcomes, and safety. RESULTS Among 272 patients identified (65.1% female), the mean age was 38.0 ± 14.3 years. Overall, 54.4% of PST were macroadenomas. Minor complications were seen in 39.3% of patients and major complications were in 4.4%. The most common major complications were epistaxis and worsened vision. Most minor complications involved electrolyte/sodium dysregulation. At 3-6 months, local control on imaging was achieved in 94.8% of cases and residual/recurrent tumor was seen in 19.3%. Reoperations were required for 2.9% of cases. On multivariate analysis, previous surgery was significantly predictive of intraoperative complications (6.14 OR, p < 0.01) and major complications (14.12 OR, p < 0.01). Previous pharmacotherapy (0.27 OR, p = 0.02) and cavernous sinus invasion (0.19 OR, p = 0.03) were significantly protective against early endocrinological cure. Knosp classification was highly predictive of residual tumor or PST recurrence on 6-month follow-up imaging (4.60 OR, p < 0.01). There was noted institutional variation in clinical factors and outcomes. CONCLUSION Our results evaluate a modern, multicenter, global series of PST. These data can serve as a benchmark to compare with DA therapy and other surgical series. Further study and longer term outcomes could provide insight into how patients benefit from surgical treatment.
Collapse
Affiliation(s)
- Matthew C Findlay
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA; School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Mohammadmahdi Sabahi
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA; Boise State University, Boise, ID, USA
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Henry W S Schroder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt, Germany
| | - Apio C M Antunes
- Department of Neurosurgery Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Michael Karsy
- Global Neurosciences Institute, Philadelphia, PA, USA; Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
2
|
Findlay MC, Drexler R, Azab M, Karbe A, Rotermund R, Ricklefs FL, Flitsch J, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Marino AC, Knappe UJ, Uksul N, Rzaev JA, Bervitskiy AV, Schroeder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Antunes ACM, Couldwell WT, Budohoski KP, Rennert RC, Karsy M. Crooke Cell Adenoma Confers Poorer Endocrinological Outcomes Compared with Corticotroph Adenoma: Results of a Multicenter, International Analysis. World Neurosurg 2023; 180:e376-e391. [PMID: 37757948 DOI: 10.1016/j.wneu.2023.09.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Crooke cell adenomas (CCAs) are a rare, aggressive subset of secretory pituitary corticotroph adenomas (sCTAs) found in 5%-10% of patients with Cushing disease. Multiple studies support worse outcomes in CCAs but are limited by small sample size and single-institution databases. We compared outcomes in CCA and sCTA using a multicenter, international retrospective database of high-volume skull base centers. METHODS Patients surgically treated for pituitary adenoma from January 2017 through December 2020 were included. RESULTS Among 2826 patients from 12 international centers, 20 patients with CCA and 480 patients with sCTA were identified. No difference in baseline demographics, tumor characteristics, or postoperative complications was seen. Microsurgical approaches (60% CCA vs. 62.3% sCTA) were most common. Gross total resection was higher in CCA patients (100% vs. 83%, P = 0.05). Among patients with gross total resection according to intraoperative findings, fewer CCA patients had postoperative hormone normalization of pituitary function (50% vs. 77.8%, P < 0.01) and remission of hypersecretion by 3-6 months (75% vs. 84.3%, P < 0.01). This was the case despite CCA having better local control rates (100% vs. 96%, P < 0.01) and fewer patients with remnant on magnetic resonance imaging (0% vs. 7.2%, P < 0.01). A systematic literature review of 35 studies reporting on various treatment strategies reiterated the high rate of residual tumor, persistent hypercortisolism, and tumor-related mortality in CCA patients. CONCLUSIONS This modern, multicenter series of patients with CCA reflects their poor prognosis and reduced postsurgical hormonal normalization. Further work is necessary to better understand the pathophysiology of CCA to devise more targeted treatment approaches.
Collapse
Affiliation(s)
- Matthew C Findlay
- School of Medicine, University of Utah, Salt Lake City, Utah, USA; Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA; Boise State University, Boise, Idaho, USA
| | - Arian Karbe
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Alexandria C Marino
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Jamil A Rzaev
- Federal Center of Neurosurgery, Novosibirsk, Russia; Novosibirsk State Medical University, Novosibirsk, Russia
| | - Anatoliy V Bervitskiy
- Federal Center of Neurosurgery, Novosibirsk, Russia; Novosibirsk State Medical University, Novosibirsk, Russia
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt, Germany
| | - Apio C M Antunes
- Departments of Neurosurgery Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Robert C Rennert
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Michael Karsy
- Global Neurosciences Institute, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
3
|
Findlay MC, Drexler R, Khan M, Cole KL, Karbe A, Rotermund R, Ricklefs FL, Flitsch J, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Marino AC, Knappe UJ, Uksul N, Rzaev JA, Galushko EV, Gormolysova EV, Bervitskiy AV, Schroeder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Antunes ACM, Couldwell WT, Budohoski KP, Rennert RC, Azab M, Karsy M. A Multicenter, Propensity Score-Matched Assessment of Endoscopic Versus Microscopic Approaches in the Management of Pituitary Adenomas. Neurosurgery 2023; 93:794-801. [PMID: 37057921 DOI: 10.1227/neu.0000000000002497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/21/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is considerable controversy as to which of the 2 operating modalities (microsurgical or endoscopic transnasal surgery) currently used to resect pituitary adenomas (PAs) is the safest and most effective intervention. We compared rates of clinical outcomes of patients with PAs who underwent resection by either microsurgical or endoscopic transnasal surgery. METHODS To independently assess the outcomes of each modality type, we sought to isolate endoscopic and microscopic PA surgeries with a 1:1 tight-caliper (0.01) propensity score-matched analysis using a multicenter, neurosurgery-specific database. Surgeries were performed between 2017 and 2020, with data collected retrospectively from 12 international institutions on 4 continents. Matching was based on age, previous neurological deficit, American Society of Anesthesiologists (ASA) score, tumor functionality, tumor size, and Knosp score. Univariate and multivariate analyses were performed. RESULTS Among a pool of 2826 patients, propensity score matching resulted in 600 patients from 9 surgery centers being analyzed. Multivariate analysis showed that microscopic surgery had a 1.91 odds ratio (OR) ( P = .03) of gross total resection (GTR) and shorter operative duration ( P < .01). However, microscopic surgery also had a 7.82 OR ( P < .01) for intensive care unit stay, 2.08 OR ( P < .01) for intraoperative cerebrospinal fluid (CSF) leak, 2.47 OR ( P = .02) for postoperative syndrome of inappropriate antidiuretic hormone secretion (SIADH), and was an independent predictor for longer postoperative stay (β = 2.01, P < .01). Overall, no differences in postoperative complications or 3- to 6-month outcomes were seen by surgical approach. CONCLUSION Our international, multicenter matched analysis suggests microscopic approaches for pituitary tumor resection may offer better GTR rates, albeit with increased intensive care unit stay, CSF leak, SIADH, and hospital utilization. Better prospective studies can further validate these findings as matching patients for outcome analysis remains challenging. These results may provide insight into surgical benchmarks at different centers, offer room for further registry studies, and identify best practices.
Collapse
Affiliation(s)
- Matthew C Findlay
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- School of Medicine, University of Utah, Salt Lake City , Utah , USA
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Majid Khan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Reno School of Medicine, University of Nevada, Reno , Nevada , USA
| | - Kyril L Cole
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- School of Medicine, University of Utah, Salt Lake City , Utah , USA
| | - Arian Karbe
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen , Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen , Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Alexandria C Marino
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden , Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden , Germany
| | - Jamil A Rzaev
- Federal Center of Neurosurgery, Novosibirsk , Russia
- Novosibirsk State Medical University, Novosibirsk , Russia
| | | | | | - Anatoliy V Bervitskiy
- Federal Center of Neurosurgery, Novosibirsk , Russia
- Novosibirsk State Medical University, Novosibirsk , Russia
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald , Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald , Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan , Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan , Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt , Germany
| | - Apio C M Antunes
- Department of Neurosurgery, Hospital de Clínicas de Porto Alegre, Porto Alegre , Rio Grande do Sul , Brazil
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Department of Neurosurgery, University of Southern California, Los Angeles , California , USA
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Boise State University, Boise , Idaho , USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Global Neurosciences Institute, Philadelphia , Pennsylvania , USA
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia , Pennsylvania , USA
| |
Collapse
|
4
|
Drexler R, Rotermund R, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Marino AC, Knappe UJ, Uksul N, Rzaev JA, Galushko EV, Gormolysova EV, Bervitskiy AV, Schroeder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Azab M, Budohoski KP, Rennert RC, Karsy M, Couldwell WT, Antunes ACM, Westphal M, Ricklefs FL, Flitsch J. Defining benchmark outcomes for transsphenoidal surgery of pituitary adenomas: a multicenter analysis. Eur J Endocrinol 2023; 189:379-386. [PMID: 37668325 DOI: 10.1093/ejendo/lvad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/14/2023] [Accepted: 08/01/2023] [Indexed: 09/06/2023]
Abstract
IMPORTANCE Benchmarks aid in improve outcomes for surgical procedures. However, best achievable results that have been validated internationally for transsphenoidal surgery (TS) are not available. OBJECTIVE We aimed to establish standardized outcome benchmarks for TS of pituitary adenomas. DESIGN A total of 2685 transsphenoidal tumor resections from 9 expert centers in 3 continents were analyzed. SETTING Patients were risk stratified, and the median values of each center's outcomes were established. The benchmark was defined as the 75th percentile of all median values for a particular outcome. The postoperative benchmark outcomes included surgical factors, endocrinology-specific values, and neurology-specific values. RESULTS Of 2685 patients, 1149 (42.8%) defined the low-risk benchmark cohort. Within these benchmark cases, 831 (72.3%) patients underwent microscopic TS, and 308 (26.8%) patients underwent endoscopic endonasal resection. Of all tumors, 799 (29.8%) cases invaded the cavernous sinus. The postoperative complication rate was 19.6% with mortality between 0.0% and 0.8%. Benchmark cutoffs were ≤2.9% for reoperation rate, ≤1.9% for cerebrospinal fluid leak requiring intervention, and ≤15.5% for transient diabetes insipidus. At 6 months, benchmark cutoffs were calculated as follows: readmission rate: ≤6.9%, new hypopituitarism ≤6.0%, and tumor remnant ≤19.2%. CONCLUSIONS This analysis defines benchmark values for TS targeting morbidity and mortality and represents the best outcomes in the best patients in expert centers. These cutoffs can be used to assess different centers, patient populations, and novel surgical techniques. It should be noted that the benchmark values may influence each other and must be evaluated in their own context.
Collapse
Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Alexandria C Marino
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Ruhr-University Bochum, Minden, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Ruhr-University Bochum, Minden, Germany
| | - Jamil A Rzaev
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia
| | - Evgeniy V Galushko
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
| | | | - Anatoliy V Bervitskiy
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt, Germany
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Apio C M Antunes
- Department of Neurosurgery, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
5
|
Drexler R, Rotermund R, Smith T, Kilgallon J, Honegger J, Nasi-Kordhishti I, Gardner P, Gersey Z, Abdallah H, Jane J, Marino A, Knappe U, Uksul N, Rzaev J, Galushko E, Gormolysova E, Bervitskiy A, Schroeder H, Eördögh M, Losa M, Mortini P, Gerlach R, Azab M, Budohoski K, Rennert R, Karsy M, Couldwell W, Antunes A, Flitsch J, Ricklefs F. QLTI-09. DEFINING GLOBAL BENCHMARK OUTCOMES FOR TRANSSPHENOIDAL SURGERY OF PITUITARY ADENOMAS: A MULTICENTER ANALYSIS OF 2862 CASES. Neuro Oncol 2022. [PMCID: PMC9661171 DOI: 10.1093/neuonc/noac209.911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Benchmarks are important to measure and aid in improve outcomes for surgical procedures. However, best achievable results that have been validated internationally for transsphenoidal surgery are not available. Therefore, we aimed to establish robust, standardized outcome benchmarks for transsphenoidal surgery of pituitary adenomas. A total of 2862 transsphenoidal tumor resections from 12 high-volume centers in 4 continents were analyzed. Patients were risk stratified and the median values of each center’s outcomes were established. The outcome benchmark was defined as the 75th percentile of all median values for a particular outcome as defined by Staiger et al. Out of 2862 patients, 1201 (41.9%) defined the benchmark cohort. The proportion of benchmark cases contributing to the final cohort ranged across centers between 22.1% to 59.7%. Within the benchmark cases, 928 (73.3%) patients underwent microscopic (MTS) and 263 (21.9%) patients endoscopic endonasal resection (EES). The overall postoperative complication rate was 18.9% with an in-hospital mortality between 0.0-0.8%. Benchmark cutoffs were ≤ 3.3% for reoperation rate, ≤ 4.6% for cerebrospinal fluid leak requiring intervention, and ≤ 15.3% for transient diabetes insipidus. At 6 months follow-up, benchmark cutoffs were calculated as follows: readmission rate: ≤ 7.1%, new hypopituitarism ≤ 15.5%, new neurological deficit ≤ 1.2%, tumor remnant ≤ 25.5%. This analysis defines benchmark values for transsphenoidal resection of pituitary adenomas targeting morbidity, mortality, surgical and tumor-related outcomes. The benchmark cutoffs can be used to assess different centers, patients’ populations, and novel surgical techniques.
Collapse
Affiliation(s)
- Richard Drexler
- University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Roman Rotermund
- University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | | | | | | | | | - Paul Gardner
- University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Zachary Gersey
- University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | | | - John Jane
- University of Virginia Health System , Charlottesville, VA , USA
| | | | | | - Nesrin Uksul
- Johannes Wesling Hospital Minden , Minden , Germany
| | - Jamil Rzaev
- Federal Center of Neurosurgery Novosibirsk , Novosibirsk , Russia
| | - Evgeniy Galushko
- Federal Center of Neurosurgery Novosibirsk , Novosibirsk , Russia
| | | | | | | | | | - Marco Losa
- I.R.C.C.S. San Raffaele Scientific Institute , Milan , Italy
| | - Pietro Mortini
- I.R.C.C.S. San Raffaele Scientific Institute , Milan , Italy
| | | | - Mohammed Azab
- Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Karol Budohoski
- Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Robert Rennert
- Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Michael Karsy
- Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - William Couldwell
- Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Apio Antunes
- Hospital de Clínicas de Porto Alegre , Porto Alegre , Brazil
| | - Jörg Flitsch
- University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Franz Ricklefs
- Universitry Medical Center Hamburg-Eppendorf , Hamburg , Germany
| |
Collapse
|
6
|
Dottermusch M, Uksul N, Knappe UJ, Erdlenbruch B, Wefers AK. An H3F3A K27M-mutation in a sonic hedgehog medulloblastoma. Brain Pathol 2021; 32:e13024. [PMID: 34747078 PMCID: PMC9048514 DOI: 10.1111/bpa.13024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Center for Molecular Neurobiology (ZMNH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhruniversität Bochum, Minden, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhruniversität Bochum, Minden, Germany
| | - Bernhard Erdlenbruch
- Johannes Wesling Klinikum Minden, University Department for Children and Adolescents, Ruhr University Hospital, Bochum, Germany
| | - Annika K Wefers
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
7
|
Dottermusch M, Alomari A, Uksul N, Knappe UJ, Neumann JE. An atypical teratoid/rhabdoid tumor (AT/RT) with molecular features of pleomorphic xanthoastrocytoma (PXA) in a 62-year-old patient. Free Neuropathol 2021; 2:2-31. [PMID: 37284637 PMCID: PMC10209965 DOI: 10.17879/freeneuropathology-2021-3640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/09/2021] [Indexed: 06/08/2023]
Affiliation(s)
- Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, HamburgGermany
- Center for Molecular Neurobiology (ZMNH), University Medical Center Hamburg-Eppendorf, HamburgGermany
| | - Ali Alomari
- Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhruniversität Bochum, MindenGermany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhruniversität Bochum, MindenGermany
| | - Ulrich J. Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhruniversität Bochum, MindenGermany
| | - Julia E. Neumann
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, HamburgGermany
- Center for Molecular Neurobiology (ZMNH), University Medical Center Hamburg-Eppendorf, HamburgGermany
| |
Collapse
|
8
|
Esmaeilzadeh M, Uksul N, Hong B, von Kaisenberg C, Scheinichen D, Lang JM, Hermann EJ, Hillemanns P, Krauss JK. Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment. Clin Neurol Neurosurg 2020; 195:105905. [PMID: 32428795 DOI: 10.1016/j.clineuro.2020.105905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 05/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Despite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment. PATIENTS AND METHODS Data of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008-2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed. RESULTS The mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology. CONCLUSION The individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.
Collapse
Affiliation(s)
| | - Nesrin Uksul
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Bujung Hong
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Dirk Scheinichen
- Department of Anaesthesiology, Hannover Medical School, Hannover, Germany
| | - Josef M Lang
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Peter Hillemanns
- Department of Gynaecology & Obstetrics, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
9
|
Esmaeilzadeh M, Uksul N, Krauss JK. Severe Bilateral Kinetic Tremor Due to Unilateral Midbrain Lesions. Tremor Other Hyperkinet Mov (N Y) 2017; 7:515. [PMID: 29226020 PMCID: PMC5721131 DOI: 10.7916/d88g8z8j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 11/10/2017] [Indexed: 12/01/2022]
Abstract
Background The dentatothalamic tract connects the dentate nucleus of the cerebellum with the contralateral thalamus and plays a major role in the pathogenesis of tremor. Unilateral lesions of the dentatothalamic pathway may affect its ipsilateral predecussational or its contralateral postdecussational course, which results either in ipsilateral or in contralateral tremor. Case Report Here, we present two patients with a unilateral midbrain lesion resulting in bilateral tremor. Both patients presented with severe kinetic tremor. Discussion The corresponding unilateral mesencephalic lesion affected both the ipsilateral predecussational and the ipsilateral postdecussational dentatothalamic tract originating from the contralateral dentate nucleus, which is very unusual and has not been outlined clearly before.
Collapse
Affiliation(s)
| | - Nesrin Uksul
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
10
|
Weigel R, Polemikos M, Uksul N, Krauss JK. Tarlov cysts: long-term follow-up after microsurgical inverted plication and sacroplasty. Eur Spine J 2016; 25:3403-3410. [DOI: 10.1007/s00586-016-4744-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/24/2016] [Accepted: 08/08/2016] [Indexed: 11/27/2022]
|
11
|
Uksul N, Suero EM, Stübig T, Citak M, Hüfner T, Krettek C, Citak M. Mechanical stability analysis of reference clamp fixation in computer-assisted spine surgery. Arch Orthop Trauma Surg 2011; 131:963-8. [PMID: 21191603 DOI: 10.1007/s00402-010-1252-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pedicle screw misplacement is a common complication, while 7% may result in neurological complications. Computer-assisted navigation improves the rate of ideally placed screws. Inappropriate reference marker attachment can cause major problems in the outcome and duration of surgery. OBJECTIVE To improve fixation of reference bases by comparing different designs of spine clamps and measuring their stability against the relevant thoracic and lumbar anatomy. METHODS Force needed to dislocate the clamp from the processus spinosus using defined fixation of 0.79, 0.90 and 1.02 Nm torque was evaluated. Force transmission from clamp to the processus spinosus was also examined. Artificial thoracic and lumbar vertebral bodies were used for attaching spine clamps of three different designs. An instrument transmitted linear force onto the reference clamp and recorded the force when dislocation occurred. Another device determined transmitted force for each clamp utilizing 0.79, 0.90, 1.02, 1.13 and 1.24 Nm torque. RESULTS L-clamp had the most stable fixation in lumbar section for every torque and developed the greatest forces. These transmitted forces were similar to the less stable Y-design. I-design created the smallest forces and had the most stable fixation for thoracic spine. The Y- and the L-design caused a notably high number of fractures. CONCLUSION Great force leads to great stability, but also creates more fractures, favoring the use of smaller forces. Specific anatomy adaptation is important. Different clamp designs create different forces, while still differing in stability depending on their application in the thoracic or the lumbar spine.
Collapse
Affiliation(s)
- Nesrin Uksul
- Trauma Department, Hannover Medical School, Carl Neubergstr. 1, 30625 Hannover, Germany.
| | | | | | | | | | | | | |
Collapse
|
12
|
O'Loughlin PF, Daentzer D, Hüfner T, Uksul N, Citak M, Haentjes J, Krettek C, Citak M. A customized modular reference array clamp for navigated spine surgery. Arch Orthop Trauma Surg 2010; 130:1475-80. [PMID: 20119711 DOI: 10.1007/s00402-010-1060-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The current authors have developed a modular system of reference array fixation which is tailored specifically to the spinal level being operated upon. They believe that this system may further increase the precision and accuracy of pedicle screw placement. MATERIALS AND METHODS Two formalin-fixed whole body cadavers were used for this study. For cervical spine evaluation of the reference clamp, four odontoid screws (two per cadaver) for C1/C2-fusion and four lateral mass screws (two per cadaver) were implanted. Following navigated screw placement with 2D and 3D fluoroscopic verification, insertion of two lateral mass screws was performed. In the same way, lumbar and thoracic pedicle screws were implanted. Two pedicle screws were placed at two levels of the lumbar and two levels of the thoracic areas giving an overall of 16 screws implanted (8 cervical, 4 thoracic, and 4 lumbar). Postoperative evaluation involved comparison of postoperative 3D scans and preoperative planning images. A simple classification system was used for evaluation of any deviation from the planned trajectory. RESULTS All pedicle screw placements were performed as planned without any technical problems. The reference array clamps remained in position at all the spinal levels at which they were employed with no loosening or displacement and no secondary damage to any of the spinous processes. Manual manipulation was performed but no displacement or slippage was observed. Image artefacts caused by the reference clamp were not significant as to obscure the area of interest. Both imaging modalities (Iso-C 3D and Vario 3D) generated sufficiently precise 3D images. There was no substantial difference in quality when those two systems were compared. DISCUSSION Insufficient fixation of the reference clamp can lead to failure and complications. To date, no reference clamp systems have been developed specifically for navigated spine surgery. CONCLUSIONS Stable reference array fixation is a critical step in navigated surgery. To date, the same reference clamps have been applied to the spinal anatomy as have been developed originally for the appendicular skeleton. The current investigators have developed a novel modular clamp and have demonstrated its efficacy in a cadaveric model.
Collapse
Affiliation(s)
- Padhraig F O'Loughlin
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Computer Assisted Surgery Center, 535 East 70th Street, New York, NY 10021, USA
| | | | | | | | | | | | | | | |
Collapse
|