Neurosurg Focus
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Comparative Study
Intraoperative magnetic resonance imaging-assisted transsphenoidal pituitary surgery in patients with acromegaly.
Acromegaly is a rare disease, usually caused by a growth hormone (GH)-producing pituitary adenoma. If untreated, severe cardiovascular, metabolic, cosmetic, and orthopedic disturbances will result. Surgery is generally recommended as the first-line treatment. Transsphenoidal surgical techniques were recently extended by the introduction of intraoperative MR (iMR) imaging. In the present study, the contribution of ultra-low-field (0.15-T) iMR imaging to tumor resection, complication avoidance, and endocrinological and neurological outcome was analyzed. ⋯ In this largest study to date of GH-producing pituitary adenomas in which iMR imaging-guided transsphenoidal surgery was analyzed, the results suggest that this method is a highly effective and safe treatment modality, even compared with previously published surgical series in which high-field iMR imaging was used. Limitations of iMR imaging are the detection of small residual tumor in the cavernous sinus and persisting disease that could not be observed, even on diagnostic high-field follow-up MR images. This points to a general limitation regarding remission rates that can be achieved using iMR imaging. Nevertheless, iMR imaging led to an increase of the remission rate in this study.
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Review Comparative Study
Stereotactic radiosurgery for the treatment of symptomatic brainstem cavernous malformations.
The authors performed a retrospective review of prospectively collected data to evaluate the safety and efficacy of stereotactic radiosurgery (SRS) for the treatment of patients harboring symptomatic solitary cavernous malformations (CMs) of the brainstem that bleed repeatedly and are high risk for resection. ⋯ The results of this study support a role for the use of SRS for symptomatic CMs of the brainstem, as it is relatively safe and appears to reduce rebleeding rates in this high-surgical-risk location.
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Symptomatic brainstem cavernous malformations carry a high risk of permanent neurological deficit related to recurrent hemorrhage, which justifies aggressive management. Detailed knowledge of the microscopic and surface anatomy is important for understanding the clinical presentation, predicting possible surgical complications, and formulating an adequate surgical plan. In this article the authors review and illustrate the surgical and microscopic anatomy of the brainstem, provide anatomoclinical correlations, and illustrate a few clinical cases of cavernous malformations in the most common brainstem areas.
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Brainstem cavernous malformations (CMs) are low-flow vascular lesions in eloquent locations. Their presentation is often marked with symptomatic hemorrhages that appear to occur more frequently than hemorrhage from supratentorial cavernomas. Brainstem CMs can be removed using 1 of the 5 standard skull-base approaches: retrosigmoid, suboccipital (with or without telovelar approach), supracerebellar infratentorial, orbitozygomatic, and far lateral. ⋯ Many patients experience new postoperative deficits, most of which are transient and resolve fully. Despite the risks associated with operating in this highly eloquent tissue, most patients have had favorable outcomes in the authors' experience. Surgical treatment of brainstem CMs protects patients from the potentially devastating effects of rehemorrhage, and the authors believe that the benefits of intervention outweigh the risks in patients with the appropriate indications.
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Review Case Reports
Giant posterior fossa cavernous malformations in 2 infants with familial cerebral cavernomatosis: the case for early screening.
The author reports the details in 2 cases of infants with familial cerebral cavernomatosis who presented in dire condition from hemorrhagic posterior fossa cavernous malformations. In Case 1, a 4-month-old boy presented with opisthotonos, gaze palsy, and lethargy. Magnetic resonance imaging revealed a multilobulated cavernous malformation in the fourth ventricle with evidence of bleeding and obstructive hydrocephalus. ⋯ Both patients required immediate surgical intervention, and external ventricular drainage and posterior fossa craniotomies were performed. Both patients made excellent recoveries. These cases suggest that infants in families with suspected or confirmed familial cerebral cavernomatosis should be screened at an early age.