Cushing's disease and sphenoidal aspergilloma: A case report

A rare case of isolated sphenoid sinus aspergillosis in a 51-year-old patient, with the clinical and laboratory diagnosis of Cushing's disease but no radiologically confirmed tumor is presented. The patient made a complete recovery after treatment. The radiologic findings and the management of this potential disease are discussed.

Endoscopic skull base surgery: evaluation of current clinical outcomes

Endoscopic skull base surgery is one of the most recent fields of neurosurgery. Successive innovations were developed throughout history so that the current concepts that rule this surgical field could be reached. The current paper presents the evolution of endoscopic surgery and its current results on the treatment of skull base tumor, based on a review of meta-analysis and clinical series. A PubMed search for articles published between January 1990 and January 2014 about "endoscopic skull base surgery", "endoscopic transsphenoidal approach", "endoscopic treatment of parasellar tumors" and "suprasellar lesions" was performed. According to the current data, endoscopic surgery seems to be superior to open and transsphenoidal microscopic removal of giant pituitary adenomas. Endoscopy is at least as successful as transsphenoidal microsurgery for the removal of pituitary adenomas and craniopharyngiomas. Transcranial open approaches, in the context of anterior midline skull base meningiomas, present higher rates of gross total resection, fewer complications and better clinical results than endoscopy approaches. The rate of postoperative CSF leakage has been significantly reduced with the introduction of new techniques such as the Hadad-Bassagasteguy flap but still represent one of the most important complications of this technique. Currently, selected tumors located at the anterior, middle and posterior fossa can be adequately assessed using the endoscope with low rates of postoperative CSF leaks. Endoscopic surgery has substantially evolved in the last decades through the collaboration of different teams around the world. The endoscope is now an essential tool in the neurosurgery armamentarium with great potential for new applications in the nearby future.

McCune-Albright syndrome and acromegaly: hormonal control with use of cabergoline and long-acting somatostatin--case report

OBJECTIVES

The use of drug therapy based on cabergoline, octreotide and long-acting release (LAR) octreotide has presented varying results in the treatment of GH excessive production in patients with McCune-Albright Syndrome.

METHODS

We report the case of a 29 year-old female patient presenting McCune-Albright Syndrome and complaint of excessive bone growth.

RESULTS

The patient presented a pituitary adenoma involving the right internal carotid artery and excessive secretion of growth hormone (no GH suppression was observed after the oral glucose tolerance test). Due to the presence of diffuse thickness in skull base bones, surgical approach was not considered effective and the patient was submitted to drug therapy with octreotide LAR and cabergoline. At the one year follow-up, GH and IGF-1 levels were normal and no adverse effects were present.

CONCLUSION

The use of drug therapy based on the association of cabergoline and octreotide is safe and able to achieve complete hormonal control in the treatment of acromegaly for McCune-Albright patients.

Hypopituitarism and amenorrhea- galactorrhea syndrome caused by thrombosis of both internal carotid artery and giant intrasellar aneurysm: case report

Giant intra and parasellar aneurysm with a spontaneous thrombosis of internal carotid artery is rare. We report the case of a 34 years old woman presenting a unique giant sellar and parasellar aneurysm associated with hypopituitarism and amenorrhea-galactorrhea syndrome. Computed tomographic scans and magnetic resonance images were suggestive of a sellar tumor with a cystic component. Digital cerebral angiography showed spontaneous thrombosis of a intrasellar and parasellar carotid artery aneurysm and left internal carotid artery in the neck. A transseptal endoscopic biopsy was done and confirmed a thrombosed aneurysm. No other surgical treatment was required in this patient but permanent endocrinological treatment was necessary.

Cushing's disease and sphenoidal aspergilloma

A rare case of isolated sphenoid sinus aspergillosis in a 51-year-old patient, with the clinical and laboratory diagnosis of Cushing's disease but no radiologically confirmed tumor is presented. The patient made a complete recovery after treatment. The radiologic findings and the management of this potential disease are discussed.

[Transnasal endoscopic surgery of the sellar region: study of the first 100 cases]

An endoscopic endonasal transsphenoidal approach to the sella was performed in 100 consecutive patients, with a follow up from 3 to 55 months: 57 females and 43 males, age ranging from 14 and 70 years. 76 cases pituitary adenomas: 22 were acromegaly (7 microadenomas and 15 macroadenomas); 21 null cell adenomas (3 microadenomas and 18 macroadenomas); 19 Cushing disease (11 microadenomas and 8 macroadenomas), 10 prolactinomas (6 microadenomas and 4 macroadenomas), and 4 LH adenomas (4 macroadenomas). In this serie, remission was achieved in 44.8% for macroadenomas, 60% for acromegaly, 27.7% for null cell adenoma, 50% for Cushing disease, 50% for prolactinomas and 50% for LH adenomas, and 81.4% for microadenomas 85% for acromegaly, 100% for null cell adenoma, 81.8% for Cushing disease, 66% for prolactinoma. We had also four craniopharyngiomas, four sphenoidal mucocele, three sphenoidal aspergillus, one Rathke cyst, one hypophysitis, one cavernous aneurysm, one encefalocele, one intrasellar meningioma, one intrasellar tuberculoma and a sphenoid fibrous dysplasia. In this series we also had six fistulas of the anterior base that were completely cured. We had a mortality of 2, one null cell giant adenoma in a 57 years old man and another patient, 38 years old, with a giant craniopharyngioma. The morbidity was: two cured meningitis, three cured fistulas, and two permanent diabetes insipidus. Endoscopic endonasal transsphenoidal surgery in this series resulted with comparable surgical outcomes to conventional microscopic transsphenoidal surgery. The advantages of this technique have been represented by an easier access to the lesion, better visualisation and increased illumination of the surgical sites, microdissection of the tumor with maximum preservation of the pituitary function, and reduction of hospitalization times and coasts. The main limits have been the reduction of field depth, constant need of manual control of the endoscope, and required experience of the endoscope technique.

Minimally invasive pituitary surgery in a hemorrhagic necrosis of adenoma during pregnancy

A 29-year-old woman with a prolactin microadenoma was under good control with bromocriptine (BCP) therapy until she became pregnant, when the treatment was stopped. During the third trimester of pregnancy the patient presented a unilateral visual loss and intermittent headaches. BCP was restarted and one week later she developed a complete ophthalmoplegia on the other side. The patient was submitted to an endoscopic transnasal transeptal resection of a hematoma and tumoral tissue in the pituitary region. One month after surgery, at 39 weeks of gestation, the patient spontaneously delivered a healthy girl weighing 3 kg, with an Apgar score of 9 and 10 at five minutes. This is the first case in the literature of a pregnant woman with second and third cranial nerve lesions, submitted to minimally invasive neuroendoscopic transnasal transsphenoidal approach in the third trimester of pregnancy.

Esthesioneuroblastoma: case report

Esthesioneuroblatoma (ENB) is a rare tumor arising from the olfactory epithelium of the nasal vault which frequently invades the cranial base, cranial vault and orbit. ENB has a bimodal age distribution between 11 and 20 years and between 51 and 60 years. ENB accounts for approximately 1 to 5% of intranasal cancers and no consensus has been reached regarding treatment of this tumor. We report on a 66 year old female patient with a Kadish stage C tumor with frontal lobe invasion submitted a total craniofacial resection with a combined head neck and neurosurgeon team. The purpose of this study is to analyze the natural history, treatment and prognosis of this tumor, based on the literature review.

[Neurosurgical treatment of sphenoidal mucocele by endonasal transseptal endoscopic approach: report of two cases]

Mucoceles are benign, slowly expansive, mucous-filled cystic lesions that arise in the paranasal sinuses. They most commonly occur in the frontal and ethmoid sinuses and are rarely in the sphenoid sinus. The incidence of sphenoid sinus mucoceles is about 1% of paranasal sinus mucoceles. Almost 200 cases of sphenoidal and or intraselar mucoceles have been reported since the first description by Berg in 1889. Sphenoid sinus mucoceles result from accumulation of secretions due to obstruction of the draining sinus osteum. Clinical manifestations are dependent on the direction of the expansion toward adjacent structures, and are therefore variable. The diagnosis is based on CT and MRI. The neurosurgical treatment was marsupialization of the lesion under endoscopic vision by transseptal approach. We report two cases of sphenoidal mucoceles.

[Neuroendoscopic endonasal transseptal approach to the sellar region: study of 30 cases]

An endoscopic endonasal transsphenoidal approach to the sella was performed in 30 patients. The use of endoscope allowed close inspection and differentiation between tumor tissue and glandular remains, resulting in micro dissection of the tumor with maximum preservation of pituitary function. The angled view of the endoscope helps gross total removal of the tumor tissue, from the supra and para sellar extension. The endonasal transseptal endoscopic approach helps from dental problems, and lowers incidence of septal perforation, synechia, and crust formation. However the endoscopic approach has drawbacks. Its decreases the depth of field, needs constant manual control of the endoscope, and requires experience with the endoscope technique.

[Thoracic spinal cord compression at two levels due to ligamentum flavum calcification. Case report]

Calcification and/or ossification of the ligamenta flava is a well reported clinicopathologic entity causing narrowing of the spinal canal cord compression. It has been described almost exclusively in Japanese people. The authors present the case of a non Japanese patient with thoracic myelopathy caused by ossification of the ligamentum flavum.

[Multiple brain abscesses following appendicectomy: case report]

A 39 years old male patient with a 72 hours evolution of acute abdominal syndrome was submitted to appendicectomy. Fourteen days later he developed headache, vomiting, aphasia, torpor, nuchal stiffness and right hemiplegia. A CT-scan showed multiple brain abscesses on both hemispheres. After aspirative puncture of the largest one, antibiotic treatment was established with total recovery of the patient.