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Webb KL, Hinkle ML, Walsh MT, Bancos I, Shinya Y, Van Gompel JJ. Surgical treatment of cystic pituitary adenomas: literature-based definitions and postoperative outcomes. Pituitary 2024:10.1007/s11102-024-01409-9. [PMID: 38822983 DOI: 10.1007/s11102-024-01409-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND AND OBJECTIVES To survey the applied definitions of 'cystic' among pituitary adenomas and evaluate whether postoperative outcomes differ relative to non-cystic counterparts. METHODS A literature search and meta-analysis was performed using PRISMA guidelines. Studies were eligible if novel data were reported regarding the applied definition of 'cystic' and postoperative outcomes among cases of surgically treated pituitary adenomas. Data were pooled with random effects meta-analysis models into cohorts based on the applied definition of 'cystic'. Categorical meta-regressions were used to investigate differences between cohorts. Among studies comparing cystic and non-cystic pituitary adenomas, meta-analysis models were applied to determine the Odds Ratio [95% Confidence Interval]. Statistical analyses were performed using Comprehensive Meta-Analysis (CMA, 4.0), with a priori significance defined as P < 0.05. RESULTS Ten studies were eligible yielding 283 patients with cystic pituitary adenomas. The definitions of 'cystic' mainly varied between the visual appearance of cystic components on preoperative magnetic resonance imaging and a volumetric definition requiring 50% or greater of tumor volume exhibiting cystic components. Tumor diameter was seldom reported with an associated standard deviation/error, limiting meta-analyses. When the data were pooled in accordance with the definition applied, there were no significant differences in the rates of gross total resection (P = 0.830), endocrinologic remission (P = 0.563), and tumor recurrence (P = 0.320). Meta-analyses on studies comparing cystic versus non-cystic pituitary adenomas indicated no significant difference in the rates of gross total resection (P = 0.729), endocrinologic remission (P = 0.857), and tumor recurrence (P = 0.465). CONCLUSION Despite some individual studies describing a significant influence of pituitary adenoma texture on postoperative outcomes, meta-analyses revealed no such differences between cystic and non-cystic pituitary adenomas. This discrepancy may be explained in part by the inconsistent definition of 'cystic' and between-group differences in tumor size. A notion of a field-standard definition of 'cystic' among pituitary adenomas should be established to facilitate inter-study comparisons.
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Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Mickayla L Hinkle
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota, United States of America
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota, United States of America
- Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, Minnesota, United States of America.
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Matmusaev M, Watanabe T, Iwami K, Akhmediev T. Endoscopic transnasal transsphenoidal management of sellar/suprasellar arachnoid cyst: A case report and literature review. Surg Neurol Int 2023; 14:131. [PMID: 37151455 PMCID: PMC10159303 DOI: 10.25259/sni_1102_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/24/2023] [Indexed: 05/09/2023] Open
Abstract
Background Arachnoid cysts (ACs) are collections of cerebrospinal fluids (CSFs) that develop within the arachnoid layer of the meninges. Sellar ACs are comparatively rare. In general, ACs account for approximately 1% of all intracranial mass lesions, and sellar ACs are 3% of all intracranial ACs. An endoscopic transnasal transsphenoidal approach for the treatment of ACs by fenestrating the cyst's wall and connecting with the subarachnoid space is the most optimal option. Case Description A 74-year-old woman whose sellar AC was diagnosed on magnetic resonance imaging a year ago was admitted to our hospital with complaints of bitemporal hemianopia and diminished visual acuity in the past 2 months. Sellar AC was diagnosed based on the clinical history and presentation, as well as neurologic, endocrinologic, and ophthalmologic examinations, including visual acuity and visual field examination, and additional imaging findings. The patient with a sellar/suprasellar AC was treated by an endoscopic transnasal transsphenoidal approach with cyst drainage and perforation of the lamina terminalis. Postoperatively, the visual disturbances improved markedly. No surgery-related complications occurred. Conclusion The endoscopic transnasal transsphenoidal approach remains a minimally invasive and preferred approach for the treatment of sellar/suprasellar ACs. Hermetically reconstructing the sellar floor is an effective method to prevent CSF leakage.
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Affiliation(s)
- Maruf Matmusaev
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Skull Base Surgery, Republican Specialized Scientific Practical Medical Center of Neurosurgery, Tashkent, Uzbekistan
- Corresponding author: Maruf Matmusaev, Department of Skull Base Surgery, Republican Specialized Scientific Practical Medical Center of Neurosurgery, Tashkent, Uzbekistan.
| | - Tadashi Watanabe
- Department of Neurosurgery, Aichi Medical University, Nagoya, Japan
| | - Kenichiro Iwami
- Department of Neurosurgery, Aichi Medical University, Nagoya, Japan
| | - Tokhir Akhmediev
- Department of Neurosurgery, Tashkent Medical Academy, Tashkent, Uzbekistan
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Gadelha MR, Wildemberg LE, Lamback EB, Barbosa MA, Kasuki L, Ventura N. Approach to the Patient: Differential Diagnosis of Cystic Sellar Lesions. J Clin Endocrinol Metab 2022; 107:1751-1758. [PMID: 35092687 DOI: 10.1210/clinem/dgac033] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 02/13/2023]
Abstract
Cystic lesions arising in the sellar region are not uncommon and encompass cystic pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and arachnoid cysts. Their clinical presentation may be similar, including headache, visual field defects, and anterior pituitary hormone deficits, which makes differential diagnosis challenging. On the other hand, imaging features may indicate certain pathologies. In this approach to the patient, we describe the case of a patient who presented with right temporal hemianopsia and a sellar/suprasellar cystic lesion, which was determined to be Rathke cleft cyst. We discuss the imaging characteristics that may suggest a particular diagnosis between Rathke cleft cyst, cystic pituitary adenoma, craniopharyngioma, and arachnoid cyst and propose a flowchart for aiding in the imaging differential diagnosis.
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Affiliation(s)
- Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Elisa Baranski Lamback
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Monique Alvares Barbosa
- Radiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Radiology Unit, Instituto Nacional de Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brazil
- MRI Unit, Clínica de Diagnóstico por imagem, DASA, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Endocrinology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Nina Ventura
- Radiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroradiology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroradiology Unit, Samaritano Hospital, Grupo Fleury, Rio de Janeiro, Brazil
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Carnevale JA, Babu CS, Goldberg JL, Fong R, Schwartz TH. Visual deterioration after endonasal endoscopic skull base surgery: causes, treatments, and outcomes. J Neurosurg 2022; 136:1103-1113. [PMID: 34598134 DOI: 10.3171/2021.3.jns204378] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood. METHODS The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods. RESULTS Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits. CONCLUSIONS Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.
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Affiliation(s)
| | | | | | | | - Theodore H Schwartz
- Departments of1Neurological Surgery
- 3Neuroscience, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
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Kalyvas A, Milesi M, Leite M, Yang K, Jacques LS, Vescan A, Mete O, Ezzat S, Zadeh G, Gentili F. Endoscopic treatment of sellar arachnoid cysts via a simple cyst-opening technique: Long-term outcomes from a single center. World Neurosurg 2022; 161:e625-e634. [PMID: 35217229 DOI: 10.1016/j.wneu.2022.02.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sellar arachnoid cysts (SACs) are rare lesions that require treatment only if symptomatic. The endoscopic endonasal approach has been widely utilized. Despite their simple cystic appearance and the straight-forward surgical intervention there are important associated risks, with CSF leak being the prevalent one. METHODS A retrospective analysis of patients with pathologically confirmed SAC between January 2006 and December 2019 was conducted. A homogeneous simple cyst-opening technique and skull base reconstruction utilizing nasoseptal flaps was used. RESULTS Ten patients were identified (7 female and 3 male, median age was 54.5 years, range 20-77); 8 had newly diagnosed SACs whereas 2 recurrences from a previously microsurgically fenestrated SAC. Eight patients presented with visual symptoms (VS), 1 with VS and fatigue, and 1 with headaches. Neuro-ophthalmological and endocrinological assessments revealed visual field (VF) deficits in 6, visual acuity (VA) decline in 5 and hypopituitarism in 2 patients. Median calculated volume was 1.71 ml (range 0.27 - 2.54 ml). Postoperatively, no CSF leak and no further surgical complications were noted. VF improved in 4/6 while VA improved in 4/5 patients. Anterior pituitary function improved in 1, worsened in 1 and remained stable in 8 patients. One patient suffered diabetes insipidus. One recurrence was recorded 54 months postoperatively. CONCLUSION SACs can be effectively treated with a simple cyst-opening technique. The routine use of nasoseptal flaps significantly reduces the risk of CSF leak without compromising nasal quality of life in the long-term or mandating additional incisions. A long-term follow-up is important to monitor for late recurrences.
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Affiliation(s)
- Aristotelis Kalyvas
- Division of Neurosurgery, Sprott Department of Surgery and University Health Network/Toronto Western Hospital, University of Toronto, Toronto, ON, Canada.
| | - Matthias Milesi
- Division of Neurosurgery, Sprott Department of Surgery and University Health Network/Toronto Western Hospital, University of Toronto, Toronto, ON, Canada; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Matheus Leite
- Division of Neurosurgery, Sprott Department of Surgery and University Health Network/Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Kaiyun Yang
- Division of Neurosurgery, Sprott Department of Surgery and University Health Network/Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Leslie St Jacques
- Division of Neurosurgery, Sprott Department of Surgery and University Health Network/Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Allan Vescan
- Department of Otolaryngology, Head and Neck Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Ozgur Mete
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shereen Ezzat
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Sprott Department of Surgery and University Health Network/Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Fred Gentili
- Division of Neurosurgery, Sprott Department of Surgery and University Health Network/Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
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Slot EM, Sabaoglu R, Voormolen EH, Hoving EW, van Doormaal TP. Cerebrospinal Fluid Leak after Transsphenoidal Surgery: A Systematic Review and Meta-analysis. J Neurol Surg B Skull Base 2021; 83:e501-e513. [DOI: 10.1055/s-0041-1733918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022] Open
Abstract
Abstract
Background Cerebrospinal fluid (CSF) leak is widely recognized as a challenging and commonly occurring postoperative complication of transsphenoidal surgery (TSS).The primary objective of this study is to benchmark the current prevalence of CSF leak after TSS in the adult population.
Methods The authors followed the PRISMA guidelines. The PubMed, Embase, and Cochrane Library databases were searched for articles reporting CSF leak after TSS in the adult population. Meta-analysis was performed using the Untransformed Proportion metric in OpenMetaAnalyst. For two between-group comparisons a generalized linear mixed model was applied.
Results We identified 2,408 articles through the database search, of which 70, published since 2015, were included in this systematic review. These studies yielded 24,979 patients who underwent a total of 25,034 transsphenoidal surgeries. The overall prevalence of postoperative CSF leak was 3.4% (95% confidence interval or CI 2.8–4.0%). The prevalence of CSF leak found in patients undergoing pituitary adenoma resection was 3.2% (95% CI 2.5–4.2%), whereas patients who underwent TSS for another indication had a CSF leak prevalence rate of 7.1% (95% CI 3.0–15.7%) (odds ratio [OR] 2.3, 95% CI 0.9–5.7). Patients with cavernous sinus invasion (OR 3.0, 95% CI 1.1–8.7) and intraoperative CSF leak (OR 5.9, 95% CI 3.8–9.0) have increased risk of postoperative CSF leak. Previous TSS and microscopic surgery are not significantly associated with postoperative CSF leak.
Conclusion The overall recent prevalence of CSF leak after TSS in adults is 3.4%. Intraoperative CSF leak and cavernous sinus invasion appear to be significant risk factors for postoperative CSF leak.
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Affiliation(s)
- Emma M.H. Slot
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Translational Neuroscience, University Medical Center, Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Rengin Sabaoglu
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eduard H.J. Voormolen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eelco W. Hoving
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Tristan P.C. van Doormaal
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Translational Neuroscience, University Medical Center, Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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