Extended Transsphenoidal Approach for Gross Total Resection of Hypothalamic Tumor

Tumors of the optic pathway and/or hypothalamus are uncommon, and the majority occur in patients with neurofibromatosis type 1.1,2 These lesions can be managed with a "watch-and-wait" approach; however, when treatment is indicated, the optimal strategy is wholly case dependent. We present a 22-year-old female patient with neurofibromatosis type 1 who had a partially cystic mass within the right mamillary body (Video 1). The mass was present on prior imaging but had increased in size and was newly enhancing with evidence of mass effect on the right optic tract. Given her history and the lesion's progression, treatment was recommended. The patient elected for surgery over radiation. Preoperatively, there were no visual field deficits or signs of hypopituitarism. We undertook a unilateral, extended transsphenoidal approach. Additional bony removal of the tuberculum sellae and planum sphenoidale enabled greater exposure of the anterior cranial fossa. The circular sinus was cauterized and divided for visualization of the pituitary stalk and clear identification of the hypothalamus. This provided an operative corridor superior to the pituitary gland and just beneath the optic nerves. The procedure proceeded without complication, and gross total resection was achieved. Postoperative imaging demonstrated gross total resection with a normal-appearing pituitary gland. Of note, the patient did experience mildly elevated postoperative sodium and was treated with desmopressin for transient diabetes insipidus. Twelve- and 24-month follow-up imaging showed no recurrence. The extended transsphenoidal approach used here offers a safe and suitable working corridor to achieve total resection of hypothalamic lesions without injury to the pituitary gland.

Hypothalamic hamartoma: a cause of precocious puberty

Hypothalamic hamartomas are uncommon congenital malformations that present as precocious puberty, gelastic seizures and/or psychiatric disorders. Characteristic changes in MRI scans lead to a diagnosis. Treatment may include surgery or gonadotropin-releasing hormone agonists (GnRHa) depending on clinical manifestations.Here, we describe a case of hypothalamic hamartoma diagnosed in a girl in middle childhood, who presented with early development of secondary sexual characteristics. Physical examination, hormonal study, bone age and pelvic ultrasound findings were consistent with those of precocious puberty. The investigation also included a brain MRI scan, which revealed a small nodule with regular limits in the left hypothalamic region/tuber cinereum. GnRHa treatment and neurosurgical follow-ups were initiated promptly. The patient showed a reversal of secondary sexual characteristics and stable hamartoma size. This case illustrates the importance of brain MRI scans as part of the assessment of suspected precocious puberty because clinical features do not identify patients with an underlying pathology.

Case reports of latent HBV hepatitis in patients after neurosurgical treatment for hypothalamic and pituitary tumors

BACKGROUND

Hepatitis B virus (HBV) infection is a major public health problem worldwide. More than 2 billion people have been exposed to HBV, and about 257 million individuals are chronic carriers of HBV. HBV reactivation has been increasingly reported in HBV carriers who have undergone immunosuppression or chemotherapy, resulting in mortality. Treatment of hypothalamic/pituitary tumors in HBV carriers requires extensive care to avoid HBV reactivation as steroid therapy is required after surgery for hypothalamic/pituitary tumors.

CASE PRESENTATION

This retrospective review identified 5 patients, who were HBV carriers positive for hepatitis B surface antigen among 1352 patients with surgically treated hypothalamic/pituitary tumor in Kohnan Hospital between February 2007 and April 2017. Transsphenoidal surgery was performed with particular attention to prevent damage to the pituitary gland, with delicate manipulation to minimize postoperative steroid coverage. All patients received nucleot(s)ide analogue to control HBV-DNA levels before the surgery. As a result, all patients had a good clinical course. Blood examinations found a transient increase of liver enzymes and HBV-DNA levels in all patients, which started to decrease within 2 weeks after surgery. No specific treatment other than nucleot(s)ide analogues was needed to maintain liver function, and all patients returned to their previous activities including reinstatement.

CONCLUSION

Initiation of nucleot(s)ide analogues administration prior to the surgery for hypothalamic/pituitary tumors can be an effective strategy for preventing reactivation in HBV carriers. Appropriate screening of the patient's HBV phase, optimal timing of nucleot(s)ide analogues -administration, and administration period of nucleot(s)ide analogues need to be established.

A Rare High-Grade Glioma with a Histone H3 K27M Mutation in the Hypothalamus of an Adult Patient

BACKGROUND

Diffuse midline glioma H3 K27M mutant is a new tumor entity described in the revised 2016 World Health Organization classification. It is most frequently observed in children and develops in midline structures, including the brainstem, thalamus, and spine. We describe a rare diffuse midline glioma with an H3 K27M mutation arising in the hypothalamus of an adult.

CASE DESCRIPTION

A 27-year-old woman was admitted to our department complaining of amenorrhea, polydipsia, and diuresis for the previous 3 months, and headache and lethargy for approximately 10 days. Computed tomography scan showed an oval isodense solid mass extending from the pituitary toward the suprasellar cistern. A gadolinium-enhanced magnetic resonance imaging (MRI) showed a strongly heterogeneous enhanced solid lesion and nonenhanced cystic lesion. The patient underwent surgery and chemoradiotherapy with temozolomide. Histologic and immunohistochemical analyses revealed H3 K27M-mutant diffuse midline glioma. The patient underwent another resection for a recurrent tumor 5 months after the first surgery. Three months after the second operation, the patient relapsed, with MRI revealing spinal cord and meningeal metastases; she died shortly afterward.

CONCLUSIONS

Diffuse midline glioma with an H3 K27M mutation occurring in the hypothalamus of an adult is rare but should be considered in differential diagnoses. Because histone H3 K27M mutations are associated with aggressive clinical behavior and poor prognosis, molecular analyses should be used to determine the clinical and histopathologic features of such tumors. This will contribute to developing targeted drugs and gene therapy going forward.

Chordoid Glioma with Psychosis: Case Report

OBJECTIVE

A rare, low-grade tumor found in the hypothalamus and anterior third ventricle, a chordoid glioma presents a challenge to neurosurgeons: Its successful resection is complicated by its inconvenient location.

CASE DESCRIPTION

A 42-year-old male patient presented with a 1-year history of major depressive disorder, with psychotic features associated with generalized tonic-clonic seizures. Brain magnetic resonance imaging (MRI) with contrast revealed a suprasellar mass extending into the third ventricle To resect the lesion, an interhemispheric transcallosal transventricular subfornical approach was used. Pathology revealed a chordoid glioma. The patient had a complicated post-operative period that included the development of neurogenic diabetes insipidus, followed by intractable hyponatremia and death (caused by malignant brain edema).

CONCLUSION

A chordoid glioma is a rare neoplasm that, in 2000, was incorporated into the World Health Organization (WHO) classification of central nervous system tumors. Due to its rarity, it is seldom considered in the differential diagnosis of suprasellar masses. Moreover, its unusual presentation and difficult location present a challenge for surgical and medical management.

The role of early intra-operative MRI in partial resection of optic pathway/hypothalamic gliomas in children

INTRODUCTION

Optic pathway/hypothalamic gliomas (OPHGs) are generally benign but situated in an exquisitely sensitive brain region. They follow an unpredictable course and are usually impossible to resect completely. We present a case series of 10 patients who underwent surgery for OPHGs with the aid of intra-operative MRI (ioMRI). The impact of ioMRI on OPHG resection is presented, and a role for ioMRI in partial resection is discussed.

METHODS

Ten patients with OPHGs managed surgically utilising ioMRI at Alder Hey Children's Hospital between 2010 and 2013 were retrospectively identified. Demographic and relevant clinical data were obtained. MRI was used to estimate tumour volume pre-operatively and post-resection. If ioMRI demonstrated that further resection was possible, second-look surgery, at the discretion of the operating surgeon, was performed, followed by post-operative imaging to establish the final status of resection. Tumour volume was estimated for each MR image using the MRIcron software package.

RESULTS

Control of tumour progression was achieved in all patients. Seven patients had, on table, second-look surgery with significant further tumour resection following ioMRI without any surgically related mortality or morbidity. The median additional quantity of tumour removed following second-look surgery, as a percentage of the initial total volume, was 27.79% (range 11.2-59.2%). The final tumour volume remaining with second-look surgery was 23.96 vs. 33.21% without (p = 0.1).

CONCLUSIONS

OPHGs are technically difficult to resect due to their eloquent location, making them suitable for debulking resection only. IoMRI allows surgical goals to be reassessed intra-operatively following primary resection. Second-look surgery can be performed if possible and necessary and allows significant quantities of extra tumour to be resected safely. Although the clinical significance of additional tumour resection is not yet clear, we suggest that ioMRI is a safe and useful additional tool, to be combined with advanced neuronavigation techniques for partial tumour resection.

Nonalcoholic fatty liver disease and fatigue in long-term survivors of childhood-onset craniopharyngioma

OBJECTIVE

Hypothalamic obesity in childhood craniopharyngioma (CP) patients carries a high risk for development of metabolic syndrome. In metabolic syndrome, the development of nonalcoholic fatty liver disease (NAFLD) is known. The aim of this study is to detect the risk for NAFLD in childhood-onset CP.

DESIGN

This cross-sectional study included liver computed tomography (CT); ultrasound analysis of abdomen; measurements of serum parameters, height, weight and body composition; and daily medication of patients with childhood-onset CP.

METHODS

A total of 384 patients recruited in trials HIT Endo and KRANIOPHARYNGEOM 2000 were analyzed. Ninety-four survivors were included by fulfilling the criteria of proven hypothalamic involvement (HI), a minimum time interval of 5 years between diagnosis and study, and a minimum age of 18 years at the time of evaluation. A total of 19 patients agreed to participate. To quantify the degree of steatosis hepatis, analyses of liver density were performed once by non-contrasted CT of liver sections.

RESULTS

NAFLD occurs in about 50% of CP patients with HI and is associated with elevated liver enzymes and homeostasis model assessment index. BMI is not an effective predictive factor but body fat mass measured by near-infrared spectroscopy (NIRS) is. Over half of CP patients (60%) with NAFLD are treated with stimulating agents, with risk of hepatic side effects.

CONCLUSIONS

NAFLD is a major adverse late effect in childhood-onset CP. NIRS rather than BMI should be used to measure body composition and predict NAFLD. Stimulating agents for treatment of fatigue and daytime sleepiness in CP should be prescribed judiciously.

Diffusion tensor imaging--arcuate fasciculus and the importance for the neurosurgeon

OBJECTIVE

Tumors in eloquent areas of the brain like Broca or Wernicke might have disastrous consequences for patients. We intended to visualize the arcuate fasciculus (AF) and to demonstrate his relation with the corticospinal tract and the visual pathway using diffusion tensor imaging (DTI).

METHODS

We depicted between 2012 and 2014 the AF in 71 patients. Men and women of all ages were included. Eleven patients had postoperative controls also. We used a 3DT1-sequence for the navigation. Furthermore T2- and DTI-sequences were performed. The FOV was 200 × 200 mm(2), slice thickness 2mm, and an acquisition matrix of 96 × 96 yielding nearly isotropic voxels of 2 × 2 × 2 mm. 3-Tesla-MRI was carried out strictly axial using 32 gradient directions and one b0-image. We used Echo-Planar-Imaging (EPI) and ASSET parallel imaging with an acceleration factor of 2. b-Value was 800 s/mm(2). Additional scanning time was less than 9 min.

RESULTS

AF was portrayed in 63 patients bilaterally. In one glioblastoma patient it was impossible to visualize the left AF and in seven other patients we could not portray the right one. The lesions affected AF by disrupting or displacing the fibers.

CONCLUSIONS

DTI might be a useful tool to portray AF. It is time-saving and can be used to preserve morbidity in patients with lesions in eloquent brain areas. It might give deeper insights of the white matter and the reorganization of AF-fibers postoperatively.

[Metastasis from breast cancer to the pituitary gland causing hyponatriaemia]

Breast cancer is the most common cancer in Danish women. Pituitary metastases are rare events. We report a 75-year-old woman with metastatic breast cancer who presented with pituitary insufficiency nine years after her initial cancer diagnosis. MRI of the pituitary region showed a parasellar mass and thickening of the infundibulum. Her condition progressed within months and deterioration of visual field and acuity developed. A transsphenoidal resection was performed to rescue her vision and pathology confirmed metastasis from a breast invasive ductal adenocarcinoma.

Pilomyxoid astrocytoma presenting as diencephalic syndrome

We report the case of a child who presented with diencephalic syndrome. During diagnostic work- up, he was found to have a supra-sellar hypothalamic tumour. Histopathological examination of the tumour revealed it to be pilomyxoid astrocytoma, which is a WHO grade-II tumour, previously considered to be part of the spectrum of WHO grade-I pilocytic astrocytomas. However, because of its characteristic histopathology and behaviour, it was later segregated from pilocytic astrocytomas. In this case report, we discuss the cytological and histopathological features of this tumor with the aim of increasing awareness of this tumour amongst general histopathologists, to highlight the importance of its differentiation from pilocytic astrocytomas in view of its different behaviour, treatment and prognosis and that it should be included in the differential diagnosis of diencephalic syndrome.

Memory outcome one year after stereotactic interstitial radiosurgery in patients with epilepsy due to hypothalamic hamartomas

Epileptic seizures caused by hypothalamic hamartomas (HHs) are highly pharmacoresistant. Resective surgical approaches have shown some efficacy in controlling seizures; however, they bear a significant risk of postoperative mnemonic deterioration due to the close anatomical proximity of the HHs to structures essential for memory functions. We report on cognitive outcome in 26 patients with structural epilepsy due to HHs one year after interstitial radiosurgery. Individually, deteriorations occurred more frequently in declarative memory functions (in 20 to 50% of the patients), whereas more than 80% of the patients revealed stable or even improved performance in attentional functions. Preoperative better memory functions were associated with higher risk of postoperative performance decline. After radiosurgery, half of the patients showed more than 50%, and some up to 90%, of seizure reduction. Hypothalamic hamartoma volumes were significantly reduced at follow-up. Transient radiogenic edema found in 10/26 patients was not associated with further cognitive decline after radiosurgery. These results are highly relevant for therapeutic decisions and patient consultation on timing and choice of nonmedical treatment options for HHs.

Severe hypernatremia from a urea-induced diuresis due to body protein wasting in an insulin-resistant type 2 diabetic patient

CONTEXT

Hypernatremia is encountered after pituitary or hypothalamic surgery and typically is secondary to vasopressin deficiency resulting in increased free water clearance with inadequate water replacement.

OBJECTIVE

We report a type 2 diabetic patient with severe hypernatremia (Na⁺ = 161 mEq/L) after hypothalamic surgery. Unexpectedly, this was accompanied by persistent urinary hypertonicity and negative total but positive electrolyte free water clearance.

MAIN OUTCOME MEASURE

Measurement of urinary electrolytes and urea revealed that an osmotic diuresis induced by urea derived principally by breakdown of endogenous protein was causative. Body protein losses over 48 hours were estimated to exceed 2 kg of lean mass. High-dose glucocorticoid, insulin resistance, and a postsurgical catabolic stress likely contributed.

CONCLUSION

In surgically severely stressed individuals, proteolysis of endogenous protein can strongly impact body water metabolism and contribute to severe hypernatremia.

Rare suprasellar glioblastoma: report of two cases and review of the literature

BACKGROUND AND IMPORTANCE

The suprasellar and hypothalamic/chiasmatic regions can harbor a broad range of pathologic conditions, both neoplastic and nonneoplastic; however, malignant gliomas are extremely rare in those regions.

CLINICAL PRESENTATIONS

Patient 1 was a 70 year-old man with weight loss and rapidly progressive visual impairment. A mass centered in the hypothalamus was detected on magnetic resonance (MR) imaging. The second patient, a 45 year-old woman, complained of visual symptoms and headaches. MR imaging revealed a combined intra- and suprasellar mass. In both instances, the preoperative differential diagnosis favored craniopharyngioma. Histological examination confirmed the diagnosis of glioblastoma.

CONCLUSION

We report two rare adult cases of hypothalamic/chiasmatic glioblastoma. The authors review the literature, highlighting the importance of considering this rare entity in the differential diagnosis of suprasellar and hypothalamic lesions.

[Stereotactic radiosurgery in treatment of patients with hypothalamic hamartomas]

Hypothalamic hamartoma (HH) is malformation of the brain manifesting by paroxysmal disorders (gelastic seizures) and endocrine disorders (mostly precocious sexual development). Surgical resection of HH is associated with the risk of severe neurological and neuroendocrine complications. Alternative ways of treatment are being investigasted. Stereotactic radiosurgery is one of the leading techniques in treatment of pharmacoresistant seizures due to high effectiveness and low complication rate. Since 2005 till 2009 7 patients with HH were treated in Burdenko Moscow Neurosurgical Institute. Age of patients varied between 9 months and 20 years 9 mean - 8.5 years). In all cases the disease manifested by gelastic seizures with frequency differing between 2-3 per months and 17 per day. All patients received long-term combined anticonvulsant treatment (using valproates, carbamazepine, lamotrigine, oxcarbazepine, topiramate) with temporary and insufficient effect or without any effect. In 4 patients frequency of seizures increased during anticonvulsant therapy. I patient had been operated (partial resection of HH) with temporary effect which consisted of decrease in frequency of seizures for 8 months; later frequency of paroxysms increased. Main indications to radiosurgical treatment included progressive course of disease, low effectiveness of anticonvulsant therapy and high risk of direct surgical treatment. 6 patients were treated using linear accelerator "Novalis" and 1 using "Cyber-knife". Treatment was performed under pharmacological sedation (midazolam, ketamine). Marginal dose was 11-18 Gy (mean 15.7 Gy). Volume of hamartomas was 0.3-3 cm3. Follow-up period varied between 3 and 50 months. Decreased frequency of seizures was observed in 100% of cases. Stereotactic radiosurgery is an effective and safe method of treatment for HH and may be considered as treatment of choice for pharmacoresistant seizures caused by HH.

[Transcallosal-interforniceal approach treatment of hypothalamic astrocytoma in children]

OBJECTIVE

To explore the clinical features, diagnosis and efficiency of transcallosal-interforniceal approach treatment of hypothalamic astrocytoma in children.

METHODS

A total of 42 pediatric cases of hypothalamic astrocytoma were operated by transcallosal-interforniceal approach. All cases received post-operative radiotherapy and follow-up visits. The clinical and imaging data were analyzed retrospectively.

RESULTS

High ICP and hypothalamic lesions were the main clinical manifestations. All patients suffering from hydrocephalus were operated by transcallosal-interforniceal approach. Seventeen cases received subtotal resection and 25 in great part. None died from operation. All cases received post-operative radiotherapy. Twenty-nine cases were followed up for 1 to 7 years. Among which, 25 led a normal life and 4 stayed in a fair condition.

CONCLUSIONS

Hypothalamic astrocytoma in children have some characteristic in clinical manifestations and neuroradiological examinations. Transcallosal-interforniceal approach is an effective method of treating hypothalamic astrocytoma in children. Total removal is not imperative. And radiotherapy should be performed.

[A successful surgical case of a hypothalamic hamartoma with gelastic seizure: a case report]

Gelastic seizure is a rare form of epilepsy defined as automatic bouts of laughter without mirth commonly associated with a hypothalamic hamartoma. Surgical treatment of hypothalamic hamartomas is associated with a high risk of complications because of the close vicinity of adjacent structures such as the optic tracts and mammillary bodies. This case was an 11-year-old girl who presented with gelastic seizure and complicated partial seizure. She developed gelastic seizure at a frequency of 10 bouts per day. She was found to have an elliptical mass close to the left hypothalamus. The signal intensity on magnetic resonance imaging (MRI) was consistent with hypothalamic hamartoma. The patient underwent surgical resection by a subtemporal approach. Pathological findings confirmed the diagnosis of hypothalamic hamartoma. Postoperative MRI demonstrated that the hypothalamic hamartoma was successfully resected. Twenty four months after surgery, complicated partial seizure in this patient has improved to Engel's class 1a and gelastic seizure has improved to Engel's class IIIa.

Transtemporal-transchoroidal approach and its transamygdala extension to the posterior chiasmatic cistern and diencephalo-mesencephalic lesions

The aim of this report is to illustrate the successful surgical management of five patients with suprasellar retrochiasmatic and diencephalo-mesencephalic tumours, using a trans-amygdala extension of the trans-temporal/trans-choroidal fissure approach. The procedure is described for five surgically treated patients with such lesions that includes three retrochiasmatic craniopharyngiomas, one hypothalamic hamartoma, and one pilocytic astrocytoma in the left crus cerebri. The management procedure included computed tomography scan (CT scan) and magnetic resonance imaging (MRI). The trans-temporal/trans-choroidal fissure approach enabled us to perform total tumour resection in four patients and a subtotal resection in one. Some technical aspects and pitfalls of the procedure are discussed. This method creates optimum conditions for a radical excision of various suprasellar retrochiasmatic and diencephalo-mesencephalic tumours without mortality and only minimum morbidity. However, no single surgical approach can provide access to the entire variety of tumours located in the suprasellar retrochiasmatic and diencephalo-mesencepalic region. Surgical approaches must be tailored to the site, type of lesion, and its extensions. This method is only another surgical option. Its successful use requires a familiarity with the anatomy of these regions and an understanding of its specificity for a radical excision of some selected tumours, as well as its limitations to access others types of lesions. Although, it seems effective, this approach needs to be evaluated by further experience, owing to the small number of patients reported in this series.

Comparison of hypothalamopituitary axis dysfunction of intrasellar and third ventricular craniopharyngiomas in children

In this study, we attempted to determine if different locations of a tumor influence the hypothalamopituitary axis function and outcomes with childhood craniopharyngiomas. The preoperative, postoperative, and long-term follow-up endocrinological disturbances of 66 children with a craniopharyngioma were retrospectively studied. The patients were divided into two subgroups according to the location of the tumor (intrasellar and third ventricle floor). The mean age at onset was 8.02 (range, 1.42-17.58)years. These patients were followed-up for a median duration of 7.2 (range, 2-22)years. Vision problems as the first symptom were more common in Group One (with intrasellar tumors) compared to Group Two (55.6% vs 15.4%; p=0.001; Fisher's exact test). Increased intracranial pressure was the most common initial symptom in patients in Group Two (51.3%) and the second most common symptom in Group One (37%). The majority of patients in both Group One and Group Two required some forms of pituitary hormone supplements (96% vs 84%). At the last follow-up, more patients with intrasellar craniopharyngiomas needed cortisone supplements (79.2% in Group One vs 45.9% in Group Two; p=0.016; Fisher's exact test); however, children with third ventricle floor tumors had more prevalent weight gain (4.2% in Group One vs 27.0% in Group Two; p=0.038; Fisher's exact test). There were different initial presentations and endocrinological outcomes between children with intrasellar and third ventricle floor craniopharyngiomas. The intrasellar tumors had greater pituitary hormone disturbance. However, at the long-term follow-up, children with third ventricle floor tumors had a greater prevalence of being overweight and obese, which was associated with hypothalamic dysfunction.

[Management of chiasmatic-hypothalamic gliomas in children: report of nine pediatric cases]

Radical resection of chiasmatic-hypothalamic glioma (CHG) carries a significant risk of morbidity and the optimum treatment remains undecided. The authors reported 9 children with CHG, who were treated with surgical resection with or without postoperative chemotherapy. Age at the time of diagnosis ranged from 4 months to 7.7 years (mean 3.1 years), and no patient had evidence of neurofibromatosis type 1. Surgical resections of the tumors were performed in all patients because of severe visual impairment or intracranial hypertension caused by large tumors. All of the surgical interventions resulted in partial resections. Pathological examination revealed pilocytic astrocytomas in 7 patients, low grade astrocytoma in 1 and anaplastic astrocytoma in 1. Seven patients with residual tumors received postoperative chemotherapy consisting of cisplatin, cyclophosphamide, etoposide and vincristine. Reduction in tumor size was noticed in 5 patients, although 2 patients had no response and switched to local radiotherapy. Although minor complications of chemotherapy were noticed in 5 patients, severe sequelae such as neuropsychological deficits or endocrinopathies did not occur, and all patients completed chemotherapy programs. Additional treatments are recommended in case of incomplete tumor resections, because our experience demonstrates that the majority of the residual tumors have potential to progress. Our present data suggests that the chemotherapy of the aforementioned regimen is effective in controlling CHGs after partial resections and is relatively well tolerated even in young children who are vulnerable to radiotherapy.

Traumatic pericallosal artery aneurysm: a rare complication of transcallosal surgery. Case report

Traumatic intracranial aneurysms are rare in adults but account for up to 33% of all aneurysms encountered in a pediatric population. The most common location of such lesions in children is the pericallosal or adjacent branch of the anterior cerebral artery, where a head impact exerts sudden decelerating shearing forces on the arteries tethered on the brain surface against an immobile falx cerebri, weakening the arterial wall. This action can lead to dissection of the damaged vascular layers, with resultant expansion of the affected site into a fusiform aneurysm. Pericallosal aneurysms following a penetrating intracranial injury have also been described, and the resultant lesion in some cases can be a pseudoaneurysm. The incidence of iatrogenic pericallosal artery aneurysms, however, is extremely rare. The authors describe the first reported case of a traumatic pericallosal artery aneurysm following transcallosal surgery. This 6-year-old boy underwent resection of a hypothalamic pilocytic astrocytoma, which was approached via the transcallosal corridor. A follow-up magnetic resonance image obtained within 1 year of surgery disclosed a small flow void off the right pericallosal artery, which was initially interpreted as residual tumor. Serial investigations showed the lesion enlarging over time, and subsequent angiography revealed a round 7-mm pericallosal artery aneurysm with an irregularly shaped 2- to 3-mm lumen. The aneurysm was difficult to treat with clip reconstruction or suturing of the affected segment, and an excellent outcome was ultimately achieved with resection of the lesion and autogenous arterial graft interposition. The authors also discuss the likely pathophysiology of the aneurysm and the surgical procedures undertaken to treat it.

Diencephalic syndrome: a frequently delayed diagnosis in failure to thrive

BACKGROUND

Diencephalic syndrome (DS) is a rare cause of failure to thrive in early childhood. It is associated with neoplastic lesions of the hypothalamic-optic chiasmatic region. Treatment options consist of surgical resection, radiation therapy (RT) and chemotherapy. We describe the clinical course of two children suffering from diencephalic syndrome due to unresectable hypothalamic gliomas and emphasize the importance of chemotherapy as a first-line treatment.

PATIENTS AND METHODS

We report about two children, at the age of 21 months and 13 months at diagnosis, who presented with severe dystrophy at 12 months and 6 months respectively. Imaging of the brain showed a suprasellar mass, identified histologically as low grade pilocytic astrocytoma. Both patients were treated with chemotherapy which induced tumor regression and stable disease.

RESULTS

The two children gradually gained weight and improved remaining in stable remission.

CONCLUSIONS

Diencephalic syndrome caused by a hypothalamic/chiasmatic astrocytoma is a rare cause of failure to thrive in children so that diagnosis is frequently delayed. It should be considered as differential diagnosis in any child with dystrophy despite adequate caloric intake. Since most of these tumors in that specific anatomic site are regarded to be unresectable, chemotherapy including carboplatin and vincristine may reveal clinical improvement in these patients.

Giant hypothalamic hamartoma and dacrystic seizures

Ictal crying is a rare type of epileptic seizure associated with hypothalamic hamartoma and with other lesions such as tumours, vascular malformations, hippocampal sclerosis, or cerebral infarction. We describe the case of an infant with gelastic, dacrystic and other types of seizures associated with a giant hypothalamic hamartoma, and present a video sequence of dacrystic seizures. Dacrystic episodes presented in clusters at sleep onset, initially in the form of moaning followed by face-flushing that rapidly evolved to crying, associated with a lateral and upper deviation of both eyeballs, along with clonic aspects of the eyelids. After a few seconds, the crying became less intense, she stared, and oro-alimentary automatisms became prominent along with some slow horizontal movements of the eyes and the head. Following surgery, at the age of nine months, the gelastic seizures stopped, but dacrystic seizures persisted. [Published with video sequences].

Pediatric craniopharyngiomas: classification and treatment according to the degree of hypothalamic involvement

OBJECT

The current treatment of craniopharyngiomas is evolving into one of a multimodal approach in which the aim is disease control and improved preservation of quality of life (QOL). To date, an appropriate classification system with which to individualize treatment is absent. The objectives of this study were to identify preoperative prognostic factors in patients with craniopharyngiomas and to develop a risk-based treatment algorithm.

METHODS

The authors reviewed data obtained in a retrospective cohort of 66 children (mean age 7.4 years, mean follow-up period 7 years) who underwent resection between 1984 and 2001. Postoperative recurrence rates, vision status, and endocrine function were consistent with those reported in the literature. The postoperative morbidity was related to hypothalamic dysfunction. The preoperative magnetic resonance imaging grade, clinically assessed hypothalamic function, and the sugeon's operative experience (p = 0.007, p = 0.047, p = 0.035, respectively) significantly predicted poor outcome. Preoperative hypothalamic grading was used in a prospective cohort of 22 children (mean age 8 years, mean follow-up period 1.2 years) treated between 2002 and 2004 to stratify patients according to whether they underwent gross-total resection (GTR) (20%), complete resection avoiding the hypothalamus (40%), or subtotal resection (STR) (40%). In cases in which residual disease was present, the patient underwent radiotherapy. There have been no new cases of postoperative hyperphagia, morbid obesity, or behavioral dysfunction in this prospective cohort.

CONCLUSIONS

For many children with craniopharyngiomas, the cost of resection is hypothalamic dysfunction and a poor QOL. By using a preoperative classification system to grade hypothalamic involvement and stratify treatment, the authors were able to minimize devastating morbidity. This was achieved by identifying subgroups in which complete resection or STR, performed by an experienced craniopharyngioma surgeon and with postoperative radiotherapy when necessary, yielded better overall results than the traditional GTR.

Optic pathway glioma: outcome and prognostic factors in a surgical series

OBJECTS

The goals of this study were to evaluate the surgical outcomes of optic pathway glioma (OPG) and to analyze the prognostic factors related to the progression-free survival.

MATERIALS AND METHODS

A retrospective review was conducted on 33 patients who underwent surgery for OPG; these included 15 male and 18 female patients with a mean age of 8.3 years. The mean duration of follow-up was 52 months.

RESULTS AND CONCLUSIONS

The preservation rate of ipsilateral vision was 25%, while that of contralateral vision was 83% (P<0.001). There was no remarkable endocrine improvement after surgery. The overall and progression-free survival rates at 5 years were 93.6 and 52.4%, respectively. In our study, the predictors for tumor progression were children younger than 5 years of age (p=0.023) and of female gender (p=0.022). Because of the variable course of OPG, treatment policy should be optimized individually according to patient's status.

Vascularity and angiogenesis as predictors of growth in optic pathway/hypothalamic gliomas

OBJECT

The authors' aim in conducting this study was to investigate retrospectively the prognostic significance of angiogenic features in optic pathway/hypothalamic gliomas (OPHGs) in children.

METHODS

Patients were identified in whom a diagnosis of OPHG was made using pathological analysis at the Toronto Hospital for Sick Children between 1985 and 2002. Tumor specimens were reviewed for diagnostic accuracy and adequacy of the specimen. Sections were immunostained with factor VIII to assess microvessel density (MVD). A ratio of alpha-smooth muscle actin to factor VIII immunostaining was calculated to arrive at a vascular maturity index (VMI). Vascular endothelial growth factor (VEGF) and VEGF receptor (VEGFR) immunostaining were performed to evaluate angiogenic factors. In addition, the MIB-1 labeling index (LI) was used to assess proliferation. These factors were evaluated with respect to progression-free survival (PFS). Forty-one of 60 patients originally identified had adequate samples and follow up for inclusion in the study. Of these, eight patients had coexisting neurofibromatosis Type 1. Twenty-eight patients experienced tumor progression after the initial treatment (surgery with or without adjuvant treatment). Thirty-eight patients are still alive. A high MVD (> 21 vessels/1.2 mm2) was associated with a significantly higher rate of progression compared with a low MVD (< 21 vessels/1.2 mm2; p = 0.017). Microvessel density was also predictive of reduced PFS on multivariate analysis stratified for extent of resection (p = 0.04), and VMI as well as intensity and distribution of VEGF and VEGFR staining and the MIB-1 LI were not significantly associated with PFS.

CONCLUSIONS

These findings suggest that MVD is the best current predictor of PFS in incompletely resected OPHGs. This information highlights the importance of angiogenesis in regard to low-grade gliomas.

Gamma knife radiosurgery for refractory epilepsy caused by hypothalamic hamartomas

BACKGROUND

Hypothalamic hamartomas are associated with precocious puberty and chronic epilepsy characterized by gelastic seizures. The seizure disorder is usually refractory to most antiepileptic drugs. Gamma knife surgery has emerged as an alternative to microsurgical removal or radiofrequency ablation to improve seizure control. We present our experience with radiosurgery in 4 patients afflicted by this disorder.

METHODS

Using gamma knife radiosurgery, 4 patients with intractable gelastic seizures and complex epilepsy were managed. Patient age varied from 5 to 29 years. The duration of symptoms was 4-28 years. A conformal radiosurgery plan was designed with a mean of 4.25 isocenters to cover the hamartoma at the 50% isodose line. A mean margin dose of 17.5 Gy was used. The clinical outcome was evaluated with the Engel scale.

RESULTS

No complication occurred. After a median follow-up of 22 months, 3 patients had shown some improvement, with 2 attaining Engel class II status.

CONCLUSION

Gamma knife surgery is a promising alternative to microsurgical removal for patients with refractory epilepsy caused by hypothalamic hamartomas.

Endoscopic resection of hypothalamic hamartoma using a novel variable aspiration tissue resector

OBJECTIVE

We present a novel variable aspiration tissue resector for use with neuroendoscopy.

METHODS

Two patients, 4 and 14 years old, respectively, presented with intractable gelastic seizures refractory to maximal medical therapies. Magnetic resonance imaging showed mass lesions of the third ventricle consistent with hypothalamic hamartoma.

RESULTS

The patients underwent magnetic resonance imaging wand-guided endoscopic resection of the tumor with the Suros novel variable aspiration tissue resector. There were no device-associated complications or adverse events. The hamartoma was disconnected in one patient, and gross total resection was achieved in the other.

CONCLUSION

Endoscopy for tumor resection is still frustrated by the lack of surgical tools, such as ultrasonic aspirators, comparable with those available for use during open procedures. The variable-aspiration tissue resector reported here can be used to resect tumor tissue safely. These two cases demonstrate that gross total resection of small hypothalamic hamartomas is feasible with minimal morbidity through an endoscopic approach.

intraoperative neuronavigation using diffusion tensor MR tractography for the resection of a deep tumor adjacent to the corticospinal tract

OBJECTIVE AND IMPORTANCE

Delineation of cerebral white matter tracts using MR tractography adds essential information for planning intracranial surgery. Integrating tractography with intraoperative neuronavigation may reduce the likelihood of new neurological deficits after surgery done to remove tumors adjacent to the projection fibers of eloquent cortex. We report the utility of such integration for the resection of deep (paraventricular) tumors.

CLINICAL PRESENTATION

A 67-year-old male with malignant melanoma underwent stereotactic radiosurgery for a single metastasis within the paraventricular white matter of the right frontal lobe near the corticospinal tract. The lesion doubled in size within 12 months of radiotherapy. Surgical extirpation was performed aided by intraoperative neuronavigation.

TECHNIQUE

MR images of the brain including MR tractography and post-contrast T1-weighted sequences were acquired and imported into a neuronavigational workstation. Asymmetric fusion of contrast-enhanced images and tractography was employed to assist in preservation of the integrity of critical white matter tracts during the surgical procedure.

CONCLUSION

Inclusion of tractography in standard imaging protocols for neuronavigational systems may increase the safety of neurosurgical intervention near white matter tracts, including deep areas adjacent to the ventricles.

Les astrocytomes pilocytiques du diencéphale de l’enfant

BACKGROUND AND PURPOSE

Pilocytic astrocytoma (PA) is a WHO grade I tumor of the central nervous system mostly arising in children and young adults. Management of diencephalic PA is a difficult challenge. Surgical treatment has to cope with both the difficulties of deep location and eloquent area tumors.

MATERIALS AND METHODS

We retrospectively reviewed seven pediatric cases (female: 4, male: 3) of diencephalic PA. Opto-chiasmatic tumors were excluded from the series. Mean age at diagnosis was 108 months (9 years) (range: 4 month-18 years), median age was 111 months. Median follow-up for the series was 125 months. Tumor locations were as followed: right thalamus: 2, both thalami: 1, hypothalamus: 3, and right basal ganglia: 1. At the onset, the first symptom was mostly raised intracranial pressure. The delay in diagnosis ranged from 48 hours up to 6 years.

TREATMENT

a shunting procedure was performed in 3 patients, a direct surgical approach in 5 patients (gross total removal: 2; partial removal: 3) and one patient had only a biopsy. Three children were re-operated. Three patients were treated by radiationtherapy (RT) after surgery. Chemotherapy was delivered for 4 children.

RESULTS

The overall survival rate was 71.4 months (almost 6 years) (range: 3-184 months). Median survival rate was 42 months (3.5 years). Three children died, two by tumor progression and one death related to late side-effects of RT. Four patients have a good quality of life with GOS I (n = 3) or II (n = 1). We observed tumor regression in two patients at 1 and 17 years after the beginning of treatment. Correct diagnosis was only made for two cases at the initial pathological examination.

CONCLUSION

The course of diencephalic PA is still unpredictable. The tumor can be controlled by a partial surgical removal, and a residual tumor can sometimes decrease in size after surgery. Gross total removal of these tumors, although difficult, may be performed. With cranial navigation systems, the risk is low. Pathological diagnosis is sometimes difficult to assess.

The craniopharyngioma

The craniopharyngioma is one of the most common destructive lesions of the hypothalamus and pituitary gland. It still remains one of the most difficult tumors to treat effectively since complete resection is often impossible and is associated with frequent recurrence. Current therapy is multimodal and focuses on a combination of surgical decompression, medical treatment, as well as stereotactic radiosurgery. This chapter reviews the embryology, neuroanatomy, current treatment strategies, clinical features and the several surgical approaches to its treatment.

Hypothalamic glioma presenting with seizures. a case report and review of the literature

A rare case of hypothalamic glioma in a 7-year-old boy presenting with seizures and diabetes insipidus is reported. Near total decompression of the hypothalamic glioma was done successfully using subfrontal approach. The patient had a stormy postoperative course due to status epilepticus but went on to make a complete recovery. Postoperative radiotherapy/chemotherapy was not given in view of tumor histology (low grade glioma), patient's age and tumor location. Patient remains symptom and seizure free on antiepileptics at 3-year follow-up. The case is presented in the light of its rarity and the literature is reviewed.

Hyponatremia after transsphenoidal surgery for hypothalamo-pituitary tumors

Transient diabetes insipidus is a well-known complication after transsphenoidal surgery (TSS). On the other hand, transient hyponatremia has been reported as being a delayed complication of TSS. Transient hyponatremia has been attributed to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but the details of hyponatremia have not been clarified. In the present study, we retrospectively reviewed 110 consecutive patients (39 males and 71 females, age 9-80 years) operated on transsphenoidally for pituitary and hypothalamic tumors. We investigated the frequency, time of onset, duration of hyponatremia after TSS, and analyzed possible factors associated with it. A postoperative sodium concentration <135 mEq/l was observed in 29 (26%) patients. Five patients were excluded from this study because their hyponatremia could be due to either overdose of desmopressin or SIADH for meningitis. Therefore, we investigated 24 (22%) patients with hyponatremia in this study. The sodium levels in the patients with hyponatremia ranged from 110 to 134, with a mean of 126.2 +/- 5.3 mEq/l. Hyponatremia was observed on average on postoperative day 9.5 +/- 2.4, the serum sodium levels normalized within 3.8 +/- 1.7 days. Hyponatremia occurred in patients with non-functioning pituitary adenoma (26%, 11/42), Rathke's cleft cyst (29%, 5/17), prolactinoma (31%, 4/13) and acromegaly (15%, 4/27). 18 patients (75%, 6/24) who developed hyponatremia had macrotumor (>10 mm), and 6 patients (25%, 6/24) had microtumor. The plasma arginine vasopressin (AVP) levels in the patients with hyponatremia ranged from 0.21 to 2.1, with a mean of 0.79 +/- 0.46 pg/ml, and the levels were inversely correlated with plasma osmolality (r = -0.80, p = 0.002). The urine to plasma osmolality ratios were >1. All the patients received appropriate hormonal replacement, including hydrocortisone. These data showed that postoperative hyponatremia after TSS was not rare, and the hyponatremia was mainly associated with SIADH. As the hyponatremia could be a life-threatening complication, all patients should be screened for serum electrolytes after TSS.

Surgical strategies for approaching hypothalamic hamartomas causing gelastic seizures in the pediatric population: transventricular compared with skull base approaches

OBJECT

The authors provide evidence that direct resection of hypothalamic hamartomas (HHs) can improve associated gelastic and nongelastic seizures.

METHODS

Ten children younger than 17 years of age underwent resection of HHs (nine sessile and one pedunculated) that were causing refractory epilepsy. Lesions were approached from above transventricularly through a transcallosal anterior interforniceal approach in six cases, endoscopically through the foramen of Monro in one, and from below with a frontotemporal craniotomy including an orbitozygomatic osteotomy in three. Medical charts were reviewed retrospectively, and follow-up data were obtained through office records and phone calls. Follow-up periods ranged between 12 and 84 months (mean 16.8 months). All patients in whom the approach was from above had sessile HHs. Five were free from seizures at follow up and two had a reduction in seizures of at least 95%. The transventricular route allowed excellent exposure and visualization of the local structures during resection. Among the three patients in whom the approach was from below, one became free of seizure after two procedures and one had a 75% reduction in epilepsy; the latter two had sessile HHs. The exposure was inadequate, and critical tissue borders were not readily apparent. Although the HH was adequately exposed and resected, the epilepsy persisted in the third patient, who had a pedunculated lesion. The overall rate of major permanent hypothalamic complications appeared to be slightly lower for the orbitozygomatic osteotomy group.

CONCLUSIONS

Sessile lesions are best approached from above. Approaches from below adequately expose pedunculated hamartomas. The likelihood of curing seizures seems to be higher when lesions are approached from above rather than from below.

Post-shunt ascites in infants with optic chiasmal hypothalamic astrocytoma: role of ventricular gallbladder shunt

INTRODUCTION

We report a series of infants with optic chiasmal hypothalamic astrocytomas (OCHAs) who developed abdominal ascites following ventriculo-peritoneal (VP) shunting. The mechanism of ascites development among these patients with OCHA remains speculative and unclear.

METHODS

We treated four infants with hypothalamic tumors who were shunted for hydrocephalus using standard VP shunts and who subsequently experienced symptomatic ascites.

RESULTS

In three patients the gallbladder proved an effective alternative site for shunting prior to conversion to other sites, and in one patient the gallbladder shunt remains functional and revision-free.

CONCLUSIONS

Several aspects of the gallbladder as a reservoir for CSF make this approach appealing. Ventricular gallbladder shunting provided an effective (at least temporarily) receptacle for CSF in these patients.

Successful resection of a hypothalamic hamartoma and a Rathke cleft cyst

The authors report the case of a 12-year-old girl with Pallister-Hall syndrome, long-standing refractory, symptomatic epilepsy, mental retardation, and panhypopituitarism in whom two rare, deep midline lesions were detected. She underwent successful transsphenoidal resection of the Rathke cleft cyst and transcallosal resection of the hypothalamic hamartoma within a 4-day period without complications. Neuropathological studies confirmed the neuroimaging diagnoses for the two lesions. The patient has been seizure free for 6 months postoperatively.

Juvenile pilocytic astrocytoma `pilomyxoid variant' with spinal metastases

We report a case of juvenile pilocytic astrocytoma of the hypothalamic/chiasmatic region with cerebrospinal fluid dissemination in a 16-month old girl. The tumour in this case had unusual histological features including the abundance of myxoid background, the absence of Rosenthal fibres and the presence of an angiocentric pattern. These features are consistent with the recently described "variant" named pilomyxoid astrocytoma. It remains unclear whether pilomyxoid astrocytoma represents an aggressive variant of classical juvenile pilocytic astrocytoma, or an entirely distinct clinico-pathological entity. Larger series and new molecular techniques may answer this question in the future.

[Surgery for intractable focal epilepsy in children]

Surgery of drug resistant epilepsy in children is a functional surgery which aims at the suppression of the epileptogenic focus. The surgical decision is adopted or rejected as a result of the clinical examination and complementary investigations following a multidisciplinary discussion in which the benefit-risk ratio is being carefully weighed. The objective of the presurgical investigations, dominated by scalp-recorded video-electroencephalography and magnetic resonance imaging, is the localization of the epileptogenic focus. The invasive surgical investigations with intracranial electrode placement are indicated when the limits of a planned resection have to be defined precisely or when the focus is located nearby a functionally eloquent region (sensori-motor and language region). Their identification is possible by means of electrical stimulation. Two methods of exploration are available: The combination of subdural and intracerebral electrode placement through craniotomy and the stereotactic placement of intracerebral depth electrodes (Stereo-EEG). The choice of either of these two methods depends on the child's age and on the topography of the epileptogenic focus. Surgery can be either palliative, with the purpose of reducing the intensity and/or the frequency of a certain seizure type (callosotomy, multiple subpial transsections) or curative, aiming at a suppression of the epileptogenic focus through a resective or a disconnective surgical procedure. We have operated on a population of 148 children and infants between 3 months and 10 years of age during the years 1993 to 2001: In the infant group, dysplastic lesions represented the predominant etiology. In the age group of 3 to 10 years, the underlying pathology was more distributed (dysplastic lesions, epileptogenic tumors, Rasmussen's encephalitis, hypothalamic hamartomas). Extratemporal focal resections required, in the majority of cases, an invasive preoperative exploration and hemispherotomy was frequent in this group (44 p. 100). Sixty-seven percent of the children were seizure-free, with an acceptable morbidity rate, primarily due to shunt placement following hemispherotomy in children with dysplastic lesions. Our preliminary results concerning quality of life and socialization are encouraging and favor surgical treatment at an early stage.

Peripheral Venous Thrombosis in Children and Adolescents with Adipsic Hypernatremia Secondary to Hypothalamic Tumors

OBJECTIVE

To determine the clinical presentation and laboratory follow-up in patients with the syndrome of adipsic hypernatremia complicated with a peripheral thrombosis event.

METHODS

Report of 3 patients (6-19 years old) with chronic hypernatremia with sustained difficulties to normalize their serum osmolality levels.

RESULTS

During post-surgical management the 3 patients developed a peripheral venous thrombotic event as a complication of their chronic hyperosmolality.

CONCLUSIONS

Chronic hypernatremia in patients with prolonged immobilization is associated with an increased risk for development of deep venous thrombosis.

Hypothalamic ganglioglioma treated by temporal lobectomy. Case report and review of the literature

The authors report the case of a hypothalamic ganglioglioma with left-sided temporal lobe extension in an 8-year-old girl who presented with seizures. Other cases of ganglioglioma involving the hypothalamus have been reported in the literature; however, this site of origin is exceedingly rare and worthy of report. Treatment involved medial temporal lobectomy with the hypothalamic component of the tumor remaining untouched. The patient recovered postoperatively with no neurological deficits and was seizure free at 12 months. Neither radio- nor chemotherapy was recommended because of the tumor histology, location, and the patient's age. The authors recommend follow up and surgical treatment for possible tumor recurrence. The prognosis for hypothalamic ganglioglioma is unknown.

[Variants of the course of early noncomplicated postoperative period following excision of hypothalamo-hypophysial region tumors in children]

A study of non-specific and specific reactions in neurosurgical patients as conducted in the early postoperative period revealed three main variations of an early postoperative clinical course, i.e. with a normal stress-reaction, with a normal stress-reaction concomitant with diabetes insi pidus, and with a lower reactivity to surgical intervention. The treatment algorithms were appropriately amended (the preventive component was added) with due respect to the above circumstances.

Multiple deep-seated cavernomas in the third ventricle, hypothalamus and thalamus

BACKGROUND

Cavernomas are rarely located in the third ventricle, hypothalamus, or thalamus. In this report, we present our experience managing a patient with three cavernomas, one each in the floor of the third ventricle, hypothalamus, and left thalamus.

CASE PRESENTATION

This 62-year-old woman had had an unsteady gait and weakness of both legs for six months. Magnetic resonance imaging (MRI) revealed multiple intracranial tumours in the third ventricle, hypothalamus, and left thalamus. The third ventricle tumour was found to be a cavernoma by intra-operative endoscopic examination and then was excised via a transcortical, transventricular approach. Pathology revealed a cavernoma. The other two tumours were assumed to be cavernomas because of their MRI features. Three days after surgery, the patient developed right hemiparesis and disturbance of consciousness. Computed tomography revealed a left thalamic haemorrhage. After conservative treatment, her conscious level gradually recovered and she could walk with support seven months after surgery.

INTERPRETATION

Our experience with this rare case of multiple, deep-seated cavernomas suggests that management of such patients requires specific consideration of the clinical manifestations, location, size, and previous bleeding history.

Endocrine findings in patients with optico-hypothalamic gliomas

OBJECTIVES

Optico-hypothalamic gliomas (OHG) are an important differential diagnosis in suprasellar tumors. Visual impairment and hydrocephalus are the most frequent findings at presentation. However, only limited data are available about endocrine disturbances in these lesions.

PATIENTS AND METHODS

38 consecutive patients (19 children) were studied retrospectively. Clinical assessment and endocrinological evaluation of pituitary and hypothalamic functions (combined pituitary stimulation test, ITT, CRH-GRH test) were performed before and after (1 week and 3 months) the neurosurgical procedure.

RESULTS

Only three patients showed clinical features of endocrine deficiency initially. 16 children and 15 adults out of the 38 patients (31/38, 81.6 %) showed no abnormality in their hormone values when assessed with the combined pituitary stimulation test alone or using more sophisticated investigations such as ITT and CRH-GRH test (72.2 %). Patients with hypothalamic disturbances (8 out of 38, 21 %) had endocrine abnormalities more frequently than those without (57.1 % vs. 9 %, p < 0.05), as assessed by ITT and CRH-GRH-test.

CONCLUSIONS

In contrast to other suprasellar tumors, endocrine deficiencies are surprisingly rare in optico-hypothalamic gliomas despite their large size, especially in the absence of hypothalamic disorders. This may be used as a criterion in the differential diagnosis of these lesions, in addition to the radiological findings.

Occurrence of GH deficiency in adult patients who underwent neurosurgery in the hypothalamus-pituitary area for non-functioning tumour masses

Hypothalamus-pituitary tumours and their treatments (neurosurgery and/or radiotherapy) are major causes of acquired hypopituitarism. Scientific and clinical evidences show the positive effect of GH replacement therapy in severe adult GH deficiency (GHD) pointed toward the need of diagnostic screening of conditions at high risk for GHD. We screened 152 adults (82 males, 70 females; age: 52.3+/-1.2 years, age-range: 20-80 years, BMI: 26.4+/-0.8 kg/m(2)) in order to disclose the presence of GHD after neurosurgery for hypothalamus-pituitary tumours. The whole group (studied at least 3 months after neurosurgery) included: 111 non-functioning pituitary adenomas and 41 peri-pituitary tumours (24 craniopharyngiomas, 7 meningiomas, 5 cysts, 2 chondrosarcomas, 1 colesteatoma, 1 germinoma and 1 hemangiopericitoma). In 14 patients who underwent both neurosurgery and radiotherapy due to a tumour remnant, the somatotroph function was evaluated again 6 months after the end of radiotherapy. GHD was assumed to be shown by GH peak <5 microg/L (severe <3 microg/L) after Insulin Tolerance Test (ITT) or <16.5 microg/L (severe <9 microg/L) after GH-releasing hormone+arginine test (GHRH+ARG) (3rd and 1st centile limits of normality, respectively), two widely accepted provocative tests. Before neurosurgery GHD was present in 97/152 (63.8%) and resulted severe in 66/152 (43.4%) patients. After neurosurgery GHD was present in 122/152 (80.2%) and severe in 106/152 (69.7%). While 26 patients developed severe GHD (GHD) as consequence of neurosurgery, only one patient who had been classified as GHD before neurosurgery showed normal GH response after surgery. After neurosurgery, 91.0% (81/89) of the pan-hypopituitaric patients showed severe GHD. Considering the 14 patients who underwent also radiotherapy after neurosurgery, 7/14 had GHD before neurosurgery while 12/14 became severe GHD after radiotherapy in a context of pan-hypopituitarism. IGF-I levels below the 3rd age-related normal limits were present in 39.0% of patients in whom severe GHD was showed by provocative tests. In conclusion, this study shows that the occurrence of acquired severe GHD is extremely common in adult patients bearing non-functioning tumour masses in the hypothalamus-pituitary area and further increases after neurosurgery. All patients bearing non-functioning hypothalamus-pituitary tumours should undergo evaluation of their somatotroph function before and after neurosurgery that represents a condition at obvious more than high risk for hypopituitarism.

Histologic diagnosis and management of hypothalamic tumors in children by the use of newly developed flexible neuroendoscopes

Hypothalamic tumors are difficult to treat surgically, and chemotherapy and/or radiation are given based on the histology and the neuraxis staging of the tumors. We have developed flexible neuroendoscopes (Yamadori-type 8 and 9) which have excellent image quality and maneuverability as well as capabilities for biopsy and electrocoagulative debulking of the cystic tumors. We report the successful application of the neuroendoscopes to 10 children with hypothalamic tumors diagnosed with computed tomography or magnetic resonance imaging. Histologic diagnosis was obtained from all the patients. Cystic tumors were evacuated, hydrocephalus managed with endoscopic operations, and some benign tumors were removed totally. The relatively non-invasive approach reported here would represent a significant technical advance in the diagnosis and management of hypothalamic and other ventricular tumors.

Severe hypersomnolence after pituitary/hypothalamic surgery in adolescents: clinical characteristics and potential mechanisms

OBJECTIVES

After resection of hypothalamic/pituitary tumors, children are at risk for development of hormonal deficiencies, obesity, and hypersomnolence. However, the prevalence and pathophysiology of these complications are unclear. The purpose of this study was to assess the prevalence and severity of hypersomnolence in children after resection of pituitary tumors and to study the potential factors that contribute to this sleepiness if present. We further hypothesized that decrements in orexin levels may contribute to the sleepiness.

METHODS

Six children who underwent hypothalamic/pituitary surgery were identified. Five of these patients and 5 matched control subjects underwent overnight polysomnography followed by a multiple sleep latency test. Children who had a primary sleep disorder (eg, obstructive sleep apnea) underwent treatment and were restudied subsequently (n = 2). Blood levels of pituitary hormones were measured. Blood and cerebrospinal fluid (CSF) were drawn from 4 patients and 3 control subjects to measure orexin levels.

RESULTS

Endocrine control was appropriate in all children. Although patients had longer sleep duration but similar sleep efficiency than control subjects, relatively severe daytime somnolence was present (mean sleep latency: 10.3 +/- 5.3 minutes vs 26.2 +/- 1.1 minute in control subjects). Sleepiness did not correlate with body mass index or age. Furthermore, serum and CSF orexin levels did not differ between patients and control subjects.

CONCLUSIONS

Severe daytime sleepiness is frequent among children who undergo pituitary/hypothalamic surgery and does not seem to result from inappropriate cortisol or thyroxine replacement, disturbed nocturnal sleep, or low levels of orexin in the serum or CSF. We therefore speculate that other, unidentified neurohormonal mechanisms may mediate the excessive sleepiness of these patients.