phenylephrine-hydrochloride and Hypopituitarism

The giant pituitary adenoma (GPA)> 4 cm is considered a surgical challenging pathology and associated with higher surgical complications compared to non-giant pituitary adenoma [1]. These tumors are invasive and had extension to nearby neurovascular structures including cranial nerves and internal carotid artery. Endoscopic endonasal approach (EEA) is increasingly used in the last two decades, however tumors with significant height extension in the supraseller region makes surgeons in favor of transcranial approaches or combined approaches [2]. The accompanied symptoms arise from compression of neighboring structures as well as hypopituitarism [3]. In this video we present 65 year old male with PMH significant for HTN who presented with 2-3 months retro-orbital headaches, confusion, gait instability, urinary/fecal incontinence, found to have 5.1 × 2.1 × 2 cm sellaer-suprasellar mass compressing the floor of the third ventricle, mammillary body, and optic apparatus. The mass was associated with hydrocephalus. The endoscopic endonasal skull base approach (trans-sellar, transtubercular) was performed with significant tumor resection without a need for trans cranial approach. A titanium clips was used to reconstruct the diaphragma sella which was very helpful technique to change high flow CSF leak to low flow. The postoperative course of the patient was smooth with improved gait, memory, and vision. He was kept on a hormonal replacement for hypopituitarism.

Topics: Aged; Humans; Hypopituitarism; Male; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Microscopic transnasal transsphenoidal surgery (MTTS) has been a time-confirmed effective treatment for pituitary adenomas; however, the data supporting its use in pediatric patients is limited. In this study, the authors summarize the authors' 5-year experience of pituitary adenomectomy via MTTS in a pediatric population. The authors retrospectively reviewed the medical records of 35 patients aged ≤18 years who underwent microscopic transnasal transsphenoidal approach for pituitary adenomas between January 2011 and December 2015. Age, sex, symptoms, tumor size, extent of tumor resection, surgical outcomes, and complications were reviewed. All patients underwent MTTS 39 times. Total resection was obtained in 31 (88.6%) patients, while subtotal resection was achieved in 4 (11.4%) and no patient had partial resection. For the 21 patients with preoperative visual impairment, 18 (85.7%) resolved and 3 (14.3%) obtained subjective improvement. Of the 33 patients with preoperative hyperhormonal levels, endocrine function reduced to normal reference range in 28 (84.8%), decreased in 3 (9.1%) and 2 (6.1%) patients had no change. Diabetes insipidus occurred in 4 (11.4%) patients, of whom 1 patient (2.9%) developed persistent diabetes insipidus that was treated with Minirin. One patient incurred postoperative cerebrospinal fluid leakage that was resolved by lumbar drainage. Hypopituitarism occurred in 3 patients, of whom 1 patient developed permanent hypopituitarism that required hormone replacement therapy. There were no patients of death, intracranial hematoma, or meningitis. In conclusion, MTTS is a safe and effective surgical option for pediatric pituitary adenomas with minimal morbidity and excellent outcomes.

Topics: Adenoma; Adolescent; Cerebrospinal Fluid Rhinorrhea; Child; Diabetes Insipidus; Female; Humans; Hypopituitarism; Male; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Sinus; Treatment Outcome; Vision Disorders

To analyze the clinical and imaging characteristics of patients with cystic lesions in sella region and to describe the experience of endoscopic transsphenoidal surgery.. Fourty-six cases of cystic lesions in sella region confirmed by surgery and pathology between June 2003 and September 2013 were retrospectively analysed. The clinical features, imaging, surgical technique and postoperative recurrence in 46 cases were presented.. All lesions were resected through transsphenoidal endoscopic endonasal approach. Followed up lasted from 6 months to 6 years. Postoperatively, headache was recovered in 26 cases and wasn't recovered in 8 cases, visual was improved in 12 cases and wasn't improved in 2 cases, hypopituitarism was relieved in 18 cases and wasn't relieved in 15 cases, polyuria was disappeared in 8 cases and wasn't disappeared in 4 cases. Seven cases recurred, including 4 cases of craniopharyngioma, 2 cases of pituitary abscess, 1 case of cystic adenoma. There were no death and serious complication. The small age of onset, visual acuity and visual field symptoms, tumor in suprasellar, third ventricle compression was easy to occur in craniopharyngioma; cystic tumor, cavernous sinus invasion, the solid part homogeneous enhancement could be seen in cystic adenoma; Rathke cyst showed simple cystic, lighter clinical symptoms and a short course. Prone to diabetes insipidus, low multiple hormone level and the lesions of annular enhancement was more common in pituitary abscess.. The clinical features and imaging of cystic lesions in sella region feature overlap each other, but there are certain specificity. Transsphenoidal endoscopic endonasal approach for the surgery of cystic lesions in sella is effective and safe.

Topics: Abscess; Adenoma; Craniopharyngioma; Cysts; Endoscopy; Headache; Humans; Hypopituitarism; Neoplasm Recurrence, Local; Nose; Pituitary Diseases; Pituitary Neoplasms; Retrospective Studies; Sella Turcica

To evaluate the safety and efficacy of the endoscopic endonasal transsphenoidal approach (EETA) for nonfunctioning pituitary adenoma (NFPA) in the elderly population.. We performed a retrospective review of operative cases over a 7-year period, in which 158 elderly patients (age 65 years and older) who underwent a pure EETA to remove a pituitary adenoma were identified and compared with a series of 155 younger patients (age 40-55 years) who underwent the same procedure during the same period. The medical charts of the patients were reviewed to collect demographic information, such as age, sex, clinical symptoms, tumor size, the extent of tumor resection, clinical outcome, and complications.. In the elderly group, total resection was achieved in 120 patients (75.9%), and 124 patients (78.5%) achieved significant postsurgical visual remission. In the younger group, total resection was achieved in 119 patients (76.8%), with 126 patients (81.2%) achieving significant postsurgical visual remission. Regarding surgical complications in the elderly group, transient diabetes insipidus occurred postoperatively in 28 (17.8%) patients, and permanent diabetes insipidus occurred in 7 (4.4%) patients. Six (6.4%) patients experienced postoperative cerebrospinal fluid leakage, and new developments of anterior hypopituitarism occurred in 15 (9.5%) cases. In the younger group, 21 (13.6%) patients developed transient diabetes insipidus postoperatively, and 5 (3.2%) patients experienced permanent diabetes insipidus. Six (3.9%) patients reported postoperative cerebrospinal fluid leaks, and 13 (8.4%) patients developed a new anterior hypopituitarism. There were no cases of either carotid artery injury or death in either group. During the follow-up (mean, 32 months), 11 (6.9%) patients experienced tumor recurrence in the elderly group compared with 24 (15.5%) patients in the younger group. Of the 15 elderly patients who developed new hypopituitarism, 13 (86.7%) recovered without hormone replacement; accordingly, the rate of hypopituitarism remission was 84.6% in the younger patients.. NFPAs in the elderly can be resected via a pure endoscopic technique with low morbidity and mortality.

Topics: Adenoma; Adult; Aged; Aging; Cerebrospinal Fluid Leak; Diabetes Insipidus; Female; Hormone Replacement Therapy; Humans; Hypopituitarism; Incidence; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Sinus; Treatment Outcome

Endoscopic endonasal (transnasal) transsphenoidal approach (EETA) for management of sellar lesions has gained popularity as a reliable and atraumatic method. Most reported studies of EETA have focused on surgical outcome in adult patients; and there are few reports to describe outcome in pediatric patients. The authors report our early experience of 11 patients aged 14 to 18 years managed with EETA to evaluate the safety and effectiveness of EETA in the pediatric.. Retrospective review of hospital records of 11 pediatric patients who underwent endonasal endoscopic transsphenoidal approach for resection of sellar region lesion over 2 years. Age, sex, symptoms, tumor size, extent of tumor resection, clinical outcome, and surgical complications were reviewed.. Total resection was achieved in 9 (81.8%) patients, subtotal resection in 2 (18.2%), and no patient had partial or insufficient resection. All (100%) patients achieved visual remission, 7 (87.5%) of 8 patients with hyperhormone preoperative had endocrinological remission. Two (18.2%) patients incurred temporary diabetes insipidus (DI) postoperatively. One (9.1%) patient incurred postoperative cerebrospinal fluid (CSF) leakage which resolved following lumbar drainage. Three (27.3%) patients developed hypopituitarism needed hormone replacement therapy. There were no cases of meningitis, intracranial hematoma, or death.. Endoscopic endonasal (transnasal) transsphenoidal approach (EETA) provides a safe and effective surgical option with low morbidity and mortality in pediatric patients.

Topics: Adolescent; Cerebrospinal Fluid Leak; Cohort Studies; Diabetes Insipidus; Female; Follow-Up Studies; Humans; Hypopituitarism; Male; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Remission Induction; Retrospective Studies; Safety; Spinal Puncture; Treatment Outcome

The aim of this study was to evaluate the effectiveness of the extended endoscopic endonasal transsphenoidal approach (TSA) for recurrent or residual craniopharyngiomas, focusing on the extent of tumor resection and complications resulting from surgery at a single institution.. Twelve adult patients (six men and six women) underwent extended endoscopic endonasal TSA for a recurrent or residual craniopharyngioma after a previous surgical intervention at a single institution by a single surgeon. The mean number of surgeries patients had undergone before TSA was 1.3 (range, 1-3). The mean period between patients' most recent surgery and extended TSA was 55.9 months (range, 1-184). The mean preoperative (that is, pre-extended TSA) tumor volume was 2.87 cm³. The mean follow-up period was 15.8 months (range, 4-32). We reviewed clinical and radiological features in each case, focusing on the degree of tumor resection as well as endocrinological and ophthalmological outcomes.. Gross total resection was achieved in ten patients (83.3 %), and the mean resection rate was 87 % in the other two cases. There were no significant differences between pre- and postoperative endocrine function, except in one patient who suffered postoperative panhypopituitarism resulting in pituitary stalk resection, which was necessary because of obvious tumor involvement. Three patients suffered transient diabetic insipidus (DI). With respect to ophthalmological outcomes, three patients showed improvement, two others showed decline, and the remainder showed no significant changes.. The extended endoscopic endonasal transsphenoidal approach is an effective and safe surgical approach for treating recurrent or residual craniopharyngioma.

Topics: Adult; Craniopharyngioma; Female; Humans; Hypopituitarism; Male; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Postoperative Period; Recurrence; Treatment Outcome; Tumor Burden

Endoscopy as a visual aid (endoscope assisted) or as the sole visual method (fully endoscopic) is increasingly used in pituitary adenoma surgery. Authors of this study assessed the value of endoscopic visualization for finding and removing residual adenoma after initial microscopic removal.. Consecutive patients who underwent endoscope-assisted microsurgical removal of pituitary adenoma were included in this study. The utility of the endoscope in finding and removing residual adenoma not visualized by the microscope was noted intraoperatively. After maximal tumor removal under microscopic visualization, surgeries were categorized as to whether additional tumor was removed via endoscopy. Tumor removal and remission rates were also noted. Patients undergoing fully endoscopic tumor removal during this same period were excluded from the study.. Over 3 years, 140 patients (41% women, mean age 50 years) underwent endoscope-assisted adenoma removal of 30 endocrine-active microadenomas and 110 macroadenomas (39 endocrine-active, 71 endocrine-inactive); 16% (23/140) of patients had prior surgery. After initial microscopic removal, endoscopy revealed residual tumor in 40% (56/140) of cases and the additional tumor was removed in 36% (50 cases) of these cases. Endoscopy facilitated additional tumor removal in 54% (36/67) of the adenomas measuring ≥ 2 cm in diameter and in 19% (14/73) of the adenomas smaller than 2 cm in diameter (p < 0.0001); additional tumor removal was achieved in 20% (6/30) of the microadenomas. Residual tumor was typically removed from the suprasellar extension and folds of the collapsed diaphragma sellae or along or within the medial cavernous sinus. Overall, 91% of endocrine-inactive tumors were gross-totally or near-totally removed, and 70% of endocrine-active adenomas had early remission.. After microscope-based tumor removal, endoscopic visualization led to additional adenoma removal in over one-third of patients. The panoramic visualization of the endoscope appears to facilitate more complete tumor removal than is possible with the microscope alone. These findings further emphasize the utility of endoscopic visualization in pituitary adenoma surgery. Longer follow-ups and additional case series are needed to determine if endoscopic adenomectomy translates into higher long-term remission rates.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Diabetes Insipidus; Female; Follow-Up Studies; Humans; Hypopituitarism; Incidence; Magnetic Resonance Imaging; Male; Middle Aged; Neoplasm Recurrence, Local; Neoplasm, Residual; Neuroendoscopy; Nose; Pituitary Neoplasms; Radiotherapy, Adjuvant; Retrospective Studies; Risk Factors; Sphenoid Sinus; Stroke; Treatment Outcome; Vision Disorders

Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique.. The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome.. Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1-114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up.. Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Diabetes Insipidus; Female; Follow-Up Studies; Humans; Hypopituitarism; Incidence; Magnetic Resonance Imaging; Male; Middle Aged; Neoplasm Recurrence, Local; Neoplasm, Residual; Neuroendoscopy; Nose; Pituitary Neoplasms; Radiotherapy, Adjuvant; Retrospective Studies; Risk Factors; Sphenoid Sinus; Stroke; Treatment Outcome; Vision Disorders

Topics: Abnormalities, Multiple; Child, Preschool; Deafness; Humans; Hypopituitarism; Intellectual Disability; Male; Nose; Syndrome

Since the early days of pituitary surgery, a variety of transnasal approaches have been used to gain access to the sella turcica. Each of these approaches requires crossing the sphenoid sinus, hence the transsphenoidalnoidal designation of these methods. Since the growth and refinement of microsurgery as a distinct surgical discipline, there has been a coincidental maturation of transsphenoidal microsurgical techniques for the management of a variety of pituitary disorders. The present paper reviews the historical events leading to the current methods of transphenoidal pituitary surgery. Detailed descriptions of each method are given, with the advantages and disadvantages of each. The author's method is described and illustrated in a step-by-step manner, and the criteria which determine operability by transsphenoidal versus transfrontal craniotomy are discussed. The advantages which transsphenoidal techniques offer over transfrontal methods are emphasized. The paper deals with pituitary disorders on a clinical and pathological basis. The work-up of pituitary lesions is discussed, with a detailed presentation of the endocrine evaluation. Further emphasis is given to the value of tomography of the sphenosellar complex in planning operative approaches for removal of pituitary lesions, particularly when the lesion is a so-called "microadenoma," producing no obvious expansion nor erosion of the cellar floor. The author's experience in the management of 125 lesions of the pituitary or associated sella turcica is presented and complications are discussed. Because of the relatively brief period of follow-up, no conclusive evidence can be offered regarding cures in the author's series. However, on the basis of reported experience by others working in the same area, one may expect acceptable long-term improvement or cures in selected pituitary lesions operated on by transshpenoidal methods. The team management of pituitary disorders is stressed. In particular, emphasis is given to the contributions which the current day otorhinolaryngologist can make, because of his knowledge and experience in rhinological and microsurgical techniques. There is no other surgical specialty so uniquely qualified to provide operative treatment of pituitary lesions using transsphenoidal surgical pathways.

Topics: Adenoma; Cortisone; Ethmoid Bone; Fascia; History, 19th Century; History, 20th Century; Humans; Hypophysectomy; Hypopituitarism; Maxillary Sinus; Methods; Nasal Septum; Nose; Otolaryngology; Palate; Pituitary Function Tests; Pituitary Gland, Anterior; Pituitary Hormones, Anterior; Pituitary Neoplasms; Sella Turcica; Sphenoid Bone; Transplantation, Autologous