Surgical treatment of pituitary neuroendocrine tumors with coexisting intracranial lesions: A case series and review of the literature

Background

Pituitary neuroendocrine tumors (PitNETs) are a diverse group of benign neoplasms that account for a significant proportion of intracranial tumors (13%). The coexistence of PitNET with other intracranial lesions, such as meningiomas and intracranial aneurysms, has been constantly reported in the literature; yet, the pathophysiological mechanisms remain unknown, and the appropriate management is controversial. This study aims to describe the clinical characteristics, surgical treatment, and outcomes of patients with PitNET with coexisting intracranial lesions in a single healthcare center.

Methods

A retrospective analysis was conducted on 12 patients who underwent surgical treatment for PitNET and another intracranial lesion at our single tertiary referral center over 15 years from January 2008 to May 2023.

Results

Among these coexisting lesions, aneurysms were the most commonly found (41.67%), followed by meningiomas (33.33%). Surgical intervention for both lesions was performed in a single-stage procedure for most cases (75%), employing transcranial, endoscopic endonasal, and combined approaches. We found low preoperative Karnofsky Performance Scale scores in three patients, with significant differences in functional outcomes.

Conclusion

These findings contribute to the limited knowledge about PitNET coexisting with other intracranial lesions and emphasize the importance of patient-tailored, multidisciplinary management in these unusual scenarios.

Poorly differentiated sinonasal neuroendocrine carcinoma with skull base invasion: A case report

Background

Sinonasal neuroendocrine carcinoma is a rare head and neck tumor that represents only 5% of sinonasal neoplasms. This lesion has a high risk of invasion to adjacent structures such as the orbit, skull base, and soft tissues, with symptoms usually being nonspecific. Most cases are diagnosed in late stages, decreasing overall survival without treatment. To date, there is no consensus on management given its low prevalence; however, it has been shown that multimodal therapy, with the correct surgical approach as the mainstay, offers a better disease-free prognosis.

Case Description

A 46-year-old woman presented with a 1 year history of nasal symptoms, characterized by obstruction and epistaxis. Imaging studies showed an extra-axial mass causing skull base erosion and displacement of the right fronto-orbital region, without invasion of brain parenchyma or meninges. A biopsy was performed and an unresectable poorly differentiated sinonasal neuroendocrine carcinoma was diagnosed. Treatment with radio and chemotherapy was initiated and, as the tumoral volume decreased, she was referred for neurosurgical intervention; an endonasal endoscopic approach was performed. Gross total resection was achieved and the patient was discharged without postoperative complications and no residual lesion on imaging.

Conclusion

We describe the evolution of a rare advanced-stage neoplasm. It highlights that despite receiving an initial diagnosis of an unresectable mass, multimodal therapy, and an adequate surgical approach deemed the entire lesion to be resected. Despite the favorable clinical evolution, the follow-up of neuroendocrine carcinoma is prioritized as a neoplasm with a high rate of recurrence and metastasis.

A rare case of a right infratentorial meningioma and a left giant posterior communicating thrombosed aneurysm

Background

Giant intracranial aneurysms cause symptoms due to mass effect and can mimic other lesions in imaging studies. The coexistence of tumors and aneurysms is relatively rare, with meningiomas being the predominant tumors found in such cases. The relationship between these two entities is complex and represent a neurosurgical challenge.

Case Description

A 61-year-old woman presented with intermittent headache, vertigo, right peripheral facial palsy, hearing loss, and left hemiparesis. Magnetic resonance imaging revealed two lesions: a supratentorial paraclinoid lesion in the left frontotemporal region and a right infratentorial extra-axial mass, suggestive of a meningioma. The patient underwent a two-staged surgical intervention to address both lesions.

Conclusion

In this particular case, the lesions were located on different sides and in different cranial compartments, making it even rarer.

Photo-Stacking Technique for Neuroanatomical High-Definition Photography and 3D Modeling

BACKGROUND

three-dimensional neuroanatomical knowledge is vital in neurosurgery. Technological advances improved 3D anatomical perception, but they are usually expensive and not widely available. The aim of the present study was to provide a detailed description of the photo-stacking technique for high-resolution neuroanatomical photography and 3D modeling.

METHODS

The photo-stacking technique was described in a step-by-step approach. The time for image acquisition, file conversion, processing, and final production was measured using two processing methods. The toral number and file size of images are presented. Measures of central tendency and dispersion report the measured values.

RESULTS

Ten models were used in both methods achieving 20 models with high-definition images. The mean number of acquired images was 40.6 (14-67), image acquisition time 51.50 ± 18.8s, file conversion time 250 ± 134.6 s, processing time 50.46 ± 21.46 s and 41.97 ± 20.84 s, and 3D reconstruction time was 4.29 ± 0.74 s and 3.89 ± 0.60 s for methods B and C, respectively. The mean file size of RAW files is 1010 ± 452 MB and 101.06 ± 38.09 MB for JPG files after conversion. The mean size of the final image means size is 71.9 ± 0.126 MB, and the mean file size of the 3D model means is 37.4 ± 0.516 MB for both methods. The total equipment used was less expensive than other reported systems.

CONCLUSION

The photo-stacking technique is a simple and inexpensive method to create 3D models and high-definition images that could prove valuable in neuroanatomy training.

De-novo formation of neighboring intracranial aneurysm after spontaneous thrombosis of a ruptured distal anterior cerebral artery aneurysm: A case report and review of the literature

Intracranial aneurysms arise in 1-2% of the population and usually present as hemorrhagic strokes. Spontaneous thrombosis of a ruptured intracranial aneurysm occurs in 1-3% and most commonly in giant aneurysms, with complete thrombosis in just 13-20% of the cases. Thrombosis of smaller aneurysms is rare. Here we present a case of a patient who presented with a ruptured intracranial aneurysm that subsequently thrombosed, discovering a neighboring de-novo aneurysm during follow-up. We hypothesized that after thrombosis, the hemodynamic characteristics that contributed to the formation of the first aneurysm were replicated.

The sellar barrier on preoperative imaging predicts intraoperative cerebrospinal fluid leak: a prospective multicenter cohort study

BACKGROUND

The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery.

METHODS

This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis.

RESULTS

Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001).

CONCLUSIONS

The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.

[Linear accelerator-based stereotactic radiosurgery for the treatment of trigeminal neuralgia. Nine years' experience in a single institution]

INTRODUCTION. Pharmacological treatment is the first therapeutic step towards controlling pain in trigeminal neuralgia, but 25-50% of patients become medication resistant. There are currently several surgical alternatives for treating these patients. AIM. To evaluate the effectiveness and safety of stereotactic radiosurgery for the treatment of patients with trigeminal neuralgia. PATIENTS AND METHODS. A follow-up study was conducted on 30 patients who underwent radiosurgery using a Novalis linear accelerator. Eighty per cent of the dosage was calculated at the isocentre, the entry zone of the root of the trigeminal nerve. The mean follow-up time was 27.5 months (range: 1-65 months). RESULTS. The mean age was 66 years (range: 36-87 years), with a time to progression of 7.1 years (range: 4-27 years). The distribution of the pain was from the right side (63.3%). Of the 30 patients, 27 experienced an improvement (90%) 1.6 months (range: 1 week-4 months) after the treatment; 10 patients (33.3%) scored grade I, and 17 patients (56.6%) obtained a score of grade II. During the follow-up, four patients (14.2%) suffered a relapse; two underwent re-irradiation. Time without recurrence was 62.7 months (range: 54.6-70.8 months). The rate of side effects was 76.7% and only three patients developed facial anaesthesia with loss of the corneal reflex. CONCLUSIONS. The use of the linear accelerator is an effective therapeutic option in the treatment of trigeminal neuralgia, since it provides adequate long-term control of the pain, reduces the use of medication and improves the quality of life.

Plasma taurine as a predictor of poor outcome in patients with mild neurological deficits after aneurysmal subarachnoid hemorrhage

Object

The object of this study was to determine the relationship between plasma taurine and subarachnoid hemorrhage (SAH) outcome.

Methods

Forty patients with SAH and mild neurological deficits were included in this prospective, blinded cohort study. Plasma taurine levels were measured using high-performance liquid chromatography on admission and were correlated with patient outcomes at discharge.

Results

Twenty-five percent of the patients ultimately had a poor outcome. Plasma taurine concentrations at admission were increased (2-fold) in SAH patients with a favorable outcome and were further increased (6-fold) in those who had a poor outcome. Increased taurine levels identified patients who would be discharged with a poor outcome, with sensitivity and specificity values of approximately 80% and 100%, respectively, and positive and negative predictive values of approximately 90%. Delayed cerebral vasospasm showed an OR of 27.9 (95% CI 1.090–714.9) for a poor outcome, whereas an increased taurine concentration had an OR of 105 for a poor outcome (95% CI 8.3–1328.0, p < 0.001).

Conclusions

Increased plasma taurine concentrations on admission predict a poor outcome in SAH.

Knowledge of skull base anatomy and surgical implications of human sacrifice among pre-Columbian Mesoamerican cultures

Human sacrifice became a common cultural trait during the advanced phases of Mesoamerican civilizations. This phenomenon, influenced by complex religious beliefs, included several practices such as decapitation, cranial deformation, and the use of human cranial bones for skull mask manufacturing. Archaeological evidence suggests that all of these practices required specialized knowledge of skull base and upper cervical anatomy. The authors conducted a systematic search for information on skull base anatomical and surgical knowledge among Mesoamerican civilizations. A detailed exposition of these results is presented, along with some interesting information extracted from historical documents and pictorial codices to provide a better understanding of skull base surgical practices among these cultures. Paleoforensic evidence from the Great Temple of Tenochtitlan indicates that Aztec priests used a specialized decapitation technique, based on a deep anatomical knowledge. Trophy skulls were submitted through a stepwise technique for skull mask fabrication, based on skull base anatomical landmarks. Understanding pre-Columbian Mesoamerican religions can only be realized by considering them in their own time and according to their own perspective. Several contributions to medical practice might have arisen from anatomical knowledge emerging from human sacrifice and decapitation techniques.

Anatomic and surgical basis of the sphenoid ridge keyhole approach for cerebral aneurysms

In vascular neurosurgery, the pterional approach has been used primarily for the treatment of a wide variety of diseases (cavernous angiomas, arteriovenous malformations, etc.), and it is used to take advantage of naturally occurring planes and spaces to expose the major structures of the circle of Willis. It provides access to the major part of the anterior circulation aneurysms and those occurring in the upper and most proximal part of the posterior circulation. Conversely, there has been an increasing interest in the so-called minimally invasive procedures or keyhole approaches to treating cerebral aneurysms in specific locations. In this work, we describe a novel keyhole approach that was conceived to achieve the angle of vision and advantages of the classic pterional approach. This surgical approach is based on the anatomic location of the sphenoid ridge and its relationship with the sylvian fissure and basal cisterns. The initial incision is made over the hairline behind the external border of the eye on the side selected. A skin and muscular flap is reflected anteriorly, and a small 3 x 3-cm craniotomy is completed around the external landmarks of the sphenoid ridge. Further extradural drilling is completed down to the anterior clinoid process. The dura is opened in a semilunar manner, and the sylvian fissure is opened completely to reach the sylvian and basal cisterns. Thereafter, the aneurysm is dissected and clipped according to the standard microtechnique of the neurosurgeon. A step-by-step description of the approach is offered in this work to facilitate a clear understanding of it. We recommend this approach for treatment of aneurysms arising at the anterior part of the circle of Willis. It has the advantages of less operative time, fewer days of hospitalization, and similar morbidity and mortality compared with the standard pterional craniotomy (5.7% on our service for nongiant ruptured aneurysms).