Clinical Outcome of Cranial Neuropathy in Patients with Pituitary Apoplexy

Objective

Pituitary apoplexy (PA) is described as a clinical syndrome characterized by sudden headache, vomiting, visual impairment, and meningismus caused by rapid enlargement of a pituitary adenoma. We retrospectively analyzed the clinical presentation and surgical outcome in PA presenting with cranial neuropathy.

Methods

Twelve cases (3.3%) of PA were retrospectively reviewed among 359 patients diagnosed with pituitary adenoma. The study included 6 males and 6 females. Mean age of patients was 49.0 years, with a range of 16 to 74 years. Follow-up duration ranged from 3 to 20 months, with an average of 12 months. All patients were submitted to surgery, using the transsphenoidal approach (TSA).

Results

Symptoms included abrupt headache (11/12), decreased visual acuity (12/12), visual field defect (11/12), and cranial nerve palsy of the third (5/12) and sixth (2/12). Mean height of the mass was 29.0 mm (range 15-46). Duration between the ictus and operation ranged from 1 to 15 days (mean 7.0). The symptom duration before operation and the recovery period of cranial neuropathy correlated significantly (p = 0.0286). TSA resulted in improvement of decreased visual acuity in 91.6%, visual field defect in 54.5%, and cranial neuropathy in 100% at 3 months after surgery.

Conclusion

PA is a rare event, complicating 3.3% in our series. Even in blindness following pituitary apoplexy cases, improvement of cranial neuropathy is possible if adequate management is initiated in time. Surgical decompression must be considered as soon as possible in cases with severe visual impairment or cranial neuropathy.     

The Influence of Pituitary Adenoma Size on Vision and Visual Outcomes after Trans-Sphenoidal Adenectomy: A Report of 78 Cases

Objective

The aims of this study were to investigate the quantitative relationship between pituitary macroadenoma size and degree of visual impairment, and assess visual improvement after surgical resection of the tumor.

Methods

The medical records of patients with pituitary adenoma, who had undergone trans-sphenoidal adenectomy between January 2009 and January 2011, were reviewed. Patients underwent an ocular examination and brain MRI before and after surgery. The visual impairment score (VIS) was derived by combining the scores of best-corrected visual acuity and visual field. The relationship between VIS and tumor size/tumor type/position of the optic chiasm was assessed.

Results

Seventy-eight patients were included (41 male, 37 female). Thirty-two (41%) patients experienced blurred vision or visual field defect as an initial symptom. Receiver operating characteristic curve analysis showed that tumors <2.2 cm tended to cause minimal or no visual impairment. Statistical analysis showed that 1) poor preoperative vision is related to tumor size, displacement of the optic chiasm in the sagittal view on MRI and optic atrophy, and 2) poorer visual prognosis is associated with greater preoperative VIS. In multivariate analysis the only factor significantly related to VIS improvement was increasing pituitary adenoma size, which predicted decreased improvement.

Conclusion

Results from this study show that pituitary adenomas larger than 2 cm cause defects in vision while adenomas 2 cm or smaller do not cause significant visual impairment. Patients with a large macroadenoma or giant adenoma should undergo surgical resection as soon as possible to prevent permanent visual loss.     

Outcome of Endoscopic Transsphenoidal Surgery in Combination with Somatostatin Analogues in Patients with Growth Hormone Producing Pituitary Adenoma

Objective

To determine the efficacy of endoscopic surgery in combination with long-acting somatostatin analogues (SSAs) in treating patients with growth hormone (GH)-secreting pituitary tumor.

Methods

We performed retrospective analysis of 133 patients with GH producing pituitary adenoma who underwent pure endoscopic transsphenoidal surgery in our center from January 2007 to July 2012. Patients were followed up for a range of 3-48 months. The radiological remission, biochemical remission and complication were evaluated.

Results

A total of 110 (82.7%) patients achieved radiological complete resection, 11 (8.2%) subtotal resection, and 12 (9.0%) partial resection. Eighty-eight (66.2%) patients showed nadir GH level less than 1 ng/mL after oral glucose administration. No mortality or severe disability was observed during follow up. Preoperative long-acting SSA successfully improved left ventricle ejection fraction (LVEF) and blood glucose in three patients who subsequently underwent success operation. Long-acting SSA (20 mg every 30 days) achieved biochemical remission in 19 out 23 (82.6%) patients who showed persistent high GH level after surgery.

Conclusion

Endoscopic transsphenoidal surgery can biochemically cure the majority of GH producing pituitary adenoma. Post-operative use of SSA can improve biochemical remission.     

Radiological Apoplexy and Its Correlation with Acute Clinical Presentation, Angiogenesis and Tumor Microvascular Density in Pituitary Adenomas

Objective

Pituitary apoplexy is life-threatening clinical syndrome caused by the rapid enlargement of a pituitary tumor due to hemorrhage and/or infarction. The pathogenesis of pituitary apoplexy is not completely understood. We analyzed the magnetic resonance imaging (MRI) of pituitary tumors and subsequently correlated the radiological findings with the clinical presentation. Additionally, immunohistochemistry was also performed to determine whether certain biomarkers are related to radiological apoplexy.

Methods

Thirty-four cases of pituitary adenoma were enrolled for retrospective analysis. In this study, the radiological apoplexy was defined as cases where hemorrhage, infarction or cysts were identified on MRI. Acute clinical presentation was defined as the presence of any of the following symptoms: severe sudden onset headache, decreased visual acuity and/or visual field deficit, and acute mental status changes. Angiogenesis was quantified by immunohistochemical expression of fetal liver kinase 1 (Flk-1), neuropilin (NRP) and vascular endothelial growth factor (VEGF) expression, while microvascular density (MVD) was assessed using Endoglin and CD31.

Results

Clinically, fourteen patients presented with acute symptoms and 20 for mild or none clinical symptoms. Radiologically, fifteen patients met the criteria for radiological apoplexy. Of the fifteen patients with radiologic apoplexy, 9 patients presented acute symptoms whereas of the 19 patient without radiologic apoplexy, 5 patients presented acute symptoms. Of the five biomarkers tracked, only VEGF was found to be positively correlated with both radiological and nonradiological apoplexy.

Conclusion

While pituitary apoplexy is currently defined in cases where clinical symptoms can be histologically confirmed, we contend that cases of radiologically identified pituitary hemorrhages that present with mild or no symptoms should be designated subacute or subclinical apoplexy. VEGF is believed to have a positive correlation with pituitary hemorrhage. Considering the high rate of symptomatic or asymptomatic pituitary tumor hemorrhage, additional studies are needed to detect predictors of the pituitary hemorrhage.     

Feasibility of Endoscopic Endonasal Approach for Recurrent Pituitary Adenomas after Microscopic Trans-Sphenoidal Approach

Objective

The surgical approach for recurrent pituitary adenoma after trans-sphenoidal approach (TSA) is challenging. We report the outcomes of the endoscopic TSA for recurrent pituitary adenoma after microscopic TSA.

Methods

From February 2010 to February 2013, endoscopic TSA was performed for removal of 30 recurrent pituitary adenomas after microscopic TSA. Twenty-seven (90%) patients had a clinically non-functioning pituitary adenoma. Twenty-four (80%) patients suffered from a visual disturbance related to tumor growth. The clinical features and surgical outcomes were retrospectively analyzed for the ophthalmological, endocrinological, and oncological aspects.

Results

The mean tumor volume was 11.7 cm³, and gross total resection was achieved in 50% of patients. The volumetric analysis based on the postoperative MR showed that the mean extent of resection rates were 90%. Vision was improved in 19 (79%) of 24 patients with visual symptoms, and endocrinological cure was achieved in all of three functioning pituitary adenomas; however, the post-operative follow-up endocrinological examination revealed a new endocrinological deficit in one patient. Two patients required antibiotics management for post-operative meningitis.

Conclusion

The endoscopic TSA can be an effective treatment option for recurrent pituitary adenoma after microscopic TSA with acceptable outcome.     

Clinical efficacy of radiation-sterilized allografts for sellar reconstruction after transsphenoidal surgery

Objective

The aim of this study was to assess the safety and efficacy of radiation-sterilized allografts of iliac bone and fascia lata from cadaver specimens to repair skull base defects after transsphenoidal surgery.

Methods

Between May 2009 and January 2010, 31 consecutive patients underwent endonasal transsphenoidal surgery and all patients received sellar reconstruction using allografts following tumor removal. The allografts were obtained from the local tissue bank and harvested from cadaver donors. The specimens used in our approach were tensor fascia lata and the flat area of iliac bone. For preparation, allografts were treated with gamma irradiation after routine screening by culture, and then stored at -70℃.

Results

The mean follow-up period after surgery was 12.6 months (range, 7.4-16 months). Overall, postoperative cerebrospinal fluid (CSF) leaks occurred in three patients (9.7%) and postoperative meningitis in one patient (3.2%). There was no definitive evidence of wound infection at the routine postoperative follow-up examination or during re-do surgery in three patients. Postoperative meningitis in one patient was improved with the use of antibiotics and prolonged CSF diversion.

Conclusion

We suggest that allograft materials can be a feasible alternative to autologous tissue grafts for sellar reconstruction following transsphenoidal surgery under selected circumstances such as no or little intraoperative CSF leaks.     

Morphometric Study of the Korean Adult Pituitary Glands and the Diaphragma Sellae

Objective

To investigate the morphometric characteristics of the pituitary gland and diaphragma sellae in Korean adults.

Methods

Using the 33 formaline fixed adult cadavers (23 male, 10 female), the measurements were taken at the diaphragma sellae and pituitary gland. The authors investigated the relationship between dura and structures surrounding pituitary gland, morphometric aspects of pituitary gland and stalk, and morphometric aspect of central opening of diaphragma sellae.

Results

The boundary between the lateral surface of pituitary gland and the medial wall of cavernous sinus was formed by the thin dural layer and pituitary capsule. The pituitary capsule adherent tightly to the pituitary gland was observed to continue from the diaphragma sellae. Mean width, length, and height of the pituitary gland were 14.3 ± 2.1, 7.9 ± 1.3, and 6.0 ± 0.9 mm in anterior lobes, and 8.7 ± 1.7, 2.9 ± 1.1, and 5.8 ± 1.0 mm in posterior lobes, respectively. Although all dimensions of anterior lobe in female were slightly larger than those in male, statistical significance was noted in only longitudinal dimension. The ratio of posterior lobe to the whole length of pituitary gland was about 27%. The mean thickness of pituitary stalk was 2 mm. The diaphragmal opening was 5 mm or more in 26 (78.8%) of 33 specimen. The opening was round in 60.6% of the specimen, and elliptical oriented in an anterior-posterior or transverse direction in 39.4%.

Conclusion

These results provide the safe anatomical knowledge during the transsphenoidal surgery and may be helpful to access the possibility of the development of empty sella syndrome.     

Verbal and Visual Memory Impairments in Bipolar I and II Disorder

Objective

To compare verbal and visual memory performances between patients with bipolar I disorder (BD I) and patients with bipolar II disorder (BD II) and to determine whether memory deficits were mediated by impaired organizational strategies.

Methods

Performances on the Korean-California Verbal Learning Test (K-CVLT) and the Rey-Osterrieth Complex Figure Test (ROCF) in 37 patients with BD I, 46 patients with BD II and 42 healthy subjects were compared. Mediating effects of impaired organization strategies on poor delayed recall was tested by comparing direct and mediated models using multiple regression analysis.

Results

Both patients groups recalled fewer words and figure components and showed lower Semantic Clustering compared to controls. Verbal memory impairment was partly mediated by difficulties in Semantic Clustering in both subtypes, whereas the mediating effect of Organization deficit on the visual memory impairment was present only in BD I. In all mediated models, group differences in delayed recall remained significant.

Conclusion

Our findings suggest that memory impairment may be one of the fundamental cognitive deficits in bipolar disorders and that executive dysfunctions can exert an additional influence on memory impairments.     

Modified trans-middle temporal gyrus approach for trigonal tumor to preserve visual field

Objective

We evaluated a modified trans-middle temporal gyrus (MTG) approach with good postoperative visual preservation for patients with trigonal tumors.

Methods

Three patients with a trigonal tumor were treated via the modified trans-MTG approach guided by a neuro-navigator. Modified trans-MTG approach involve the incision at the MTG within 5 mm to the superior temporal sulcus. This approach makes a proper trajectory to the trigone but also reduces the retraction injury of MTG as little as possible to prevent postoperative visual field defect. Preoperative and postoperative visual field examination using perimetry was performed to evaluate the visual field.

Results

Three patients underwent surgery for lymphoma in the right trigone, meningioma in the left trigone, and focal enhancing nodule in the right paratrigonal area, respectively. In case of lymphoma, preoperative examination showed a left homonymous hemianopsia : one week later after surgery, a visual field examination was performed and revealed improvement of the visual field defect. In case of the meningioma, the preoperative examination showed no visual field defect : one month later, the visual field had no defect. In case of the enhancing nodule, preoperative visual field testing revealed a partial left homonymous hemianopsia. Visual examination within one month after surgery showed no visual field defect. All three patients treated with the modified trans-MTG approach showed no visual deterioration after surgery.

Conclusion

The modified trans-MTG approach provides a safe and useful technique for trigonal tumors without postoperative visual field deterioration and affords adequate exposure of the trigonal tumor with a short trajectory.     

A Comparison of the Effect of Epidural Patient-Controlled Analgesia with Intravenous Patient-Controlled Analgesia on Pain Control after Posterior Lumbar Instrumented Fusion

Objective

Retrospective analysis to compare the effect and complication of epidural patient-controlled analgesia (epidural PCA) with intravenous patient-controlled analgesia (IV PCA) for the treatment of the post-operative pain after posterior lumbar instrumented fusion.

Methods

Sixty patients who underwent posterior lumbar instrumented fusion for degenerative lumbar disease at our institution from September 2007 to January 2008 were enrolled in this study. Out of sixty patients, thirty patients received IV PCA group and thirty patients received epidural PCA group. The pain scale was measured by the visual analogue scale (VAS) score.

Results

There were no significant difference between IV PCA group and epidural PCA group on the PCA related complications (p=0.7168). Ten patients in IV PCA group and six patients in epidural PCA group showed PCA related complications. Also, there were no significant differences in reduction of VAS score between two groups on postoperative 2 hours (p=0.9618) and 6 hours (p=0.0744). However, postoperative 12 hours, 24 hours and 48 hours showed the significant differences as mean of reduction of VAS score (p=0.0069, 0.0165, 0.0058 respectively).

Conclusion

The epidural PCA is more effective method to control the post-operative pain than IV PCA after 12 hours of spinal fusion operation. However, during the first twelve hours after operation, there were no differences between IV PCA and epidural PCA.     

Ablative thyroid treatment for thyrotoxicosis due to thyrotropin-producing pituitary tumours

Background

Thyrotropin (TSH)‐secreting pituitary adenomas (TSHomas) are rare tumours that can be invasive. It has been suggested that thyroid surgery or radioiodine treatment should not be considered in patients with such tumours as these treatments may facilitate rapid and aggressive tumour expansion.

Aim

To study the effects of thyroid ablative treatment on tumour size and thyroid status in two patients with TSHomas in whom the size of the adenoma was clearly documented before treatment was started.

Methods

Patients studied were: (1) a female patient with a TSHoma who declined to undergo pituitary surgery and underwent a total thyroidectomy instead and (2) a male patient who opted for radioiodine treatment for his recurrent TSHoma. Changes in tumour size on serial magnetic resonance imaging scans, and restoration of euthyroidism were studied.

Results

No marked changes in tumour size or features of aggressiveness occurred in these patients over periods of 8 and 12 years. Euthyroidism was restored and maintained in both patients.

Conclusions

Ablative thyroid treatment can be a safe and successful option to treat TSHomas, but long‐term and close follow‐up of these patients is mandatory to ensure that the size and behaviour of the tumours do not change markedly.Thyrotropin (TSH)‐producing pituitary tumours are rare tumours that can be invasive. It has been suggested that thyroid surgery, thyroid drugs or radioiodine treatment should not be considered in patients with these tumours as these treatments may facilitate rapid and aggressive tumour expansion.¹We report on the first two patients with TSH‐secreting pituitary tumours, who were successfully and safely treated with thyroid ablative treatment and followed up for 8 and 12 years.     

Pituitary Hemorrhage : Classification and Related Factors

Objective

Clinical features of pituitary hemorrhage vary from asymptomatic to catastrophic. The purpose of this study was to evaluate the factors related to severity of hemorrhage of pituitary adenoma.

Methods

Pituitary hemorrhage was noted in 32 of 88 patients who underwent operations between January 2000 and December 2007. Clinical status was classified into group I (no hemorrhage symptoms), II (mild to moderate symptoms without neurological deficit), and III (with neurological deficit), and was compared to radiological, pathological, and operative findings. All patients were operated by transsphenoidal approach, and hemorrhage-related symptoms were relieved.

Results

Groups I, II, and III comprised 15, 10 and 7 patients, respectively. In group I, hemorrhage volume was under 1 mL in 11 (73.3%), but, it was above 1 mL in 7 (70%) of group II and in all cases of group III. Hemorrhage stage based on MRI findings was chronic or subacute in 11 (73.3%) of group I, acute in 6 (60%) of group II, and acute or hyperacute in 6 (85.7%) of group III. Pathological examination revealed chronic-stage hematomas in 5 (50%) group II patients. Functioning adenomas were found in 5 (33.3%) group I patients but none in group II or III patients. Silent adenomas were found in 4 (26.7%), 8 (80%), and 3 (42.9%) in groups I, II, and III, respectively.

Conclusion

Clinical features of pituitary hemorrhage may differ with the radiological and immunohistopathlogical findings. Persistent symptoms are related to the chronic stage of hematoma requiring surgery for symptom relief. Neurological deficits are caused by large amount of acute hemorrhage requiring emergency operation. Silent adenoma is related to the severity of pituitary hemorrhage.     

Microvascular Decompression for Primary Trigeminal Neuralgia : Short-Term Follow-Up Results and Prognostic Factors

Objective

The aim of this prospective study was to demonstrate the influence of some factors on the prognosis of microvascular decompression in 37 patients with trigeminal neuralgia.

Methods

The results of microvascular decompression (MVD) in 37 patients with trigeminal neuralgia were evaluated at 6 months after surgery and were compared with clinical and operative findings.

Results

The sex of the patient, the patient''s age at surgery, the side of the pain, and the duration of symptoms before surgery did not play any significant roles in prognosis. Also, the visual analogue scale (VAS) of the patient, the duration of each pain attack, and the frequency of pain over 24 hours did not play any significant roles in prognosis. In addition, intraoperative detection of the type of conflicting vessel, the degree of severity of conflict, and the location of the conflict around the circumference of the root did not play any roles in prognosis. The only factors affecting the prognosis in MVD surgery were intraoperative detection of the site of the conflict along the root and neuroradiological compression signs on preoperative magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA).

Conclusion

These findings demonstrated that if neurovascular compression is seen on preoperative MRI/MRA and/or compression is found intraoperative at the root entry zone, then the patient will most likely benefit from MVD surgery.     

Technical Considerations to Prevent Postoperative Endocrine Dysfunction after the Fenestration of Suprasellar Arachnoid Cyst

Objective

The endocrine dysfunction after the operation for suprasellar arachnoid cysts is not rare. The careful operation to prevent structures can prevent this complication, but it is not enough and effective to prevent it. Authors present technical surgical considerations to prevent this complication with a review of our suprasellar arachnoid cyst patients who had postoperative endocrine dysfunction.

Methods

From January 2002 to December 2009, eight patients who had suprasellar arachnoid cysts with visual impairment underwent surgery. The mean age was 57.1 years (range, 33-77). Preoperatively, their endocrine function was clinically normal, and laboratory hormonal levels were within normal ranges. Cyst fenestration was performed by craniotomy (n=6) or by a neuro-endoscopic procedure (n=2), and, simultaneously, along with a cyst wall biopsy.

Results

The surgery was uneventful in all eight patients, and there were no neurological morbidities. However, in four patients, endocrine dysfunction occurred postoperatively. We compared these four patients (group A) to the other 4 patients without endocrine dysfunction (group B) with intraoperative findings and with the histopathological findings of the cyst wall biopsy. The group A patients had more abundant vasculature on the cystic wall than the group B patients according to both the intraoperative findings and the histopathological findings.

Conclusion

When performing a surgical cyst wall fenestration, surgeons should try to minimize the destruction of the cystic wall vasculature and not to make the fenestration at a site that contains many vascular striae.     

The Associations between Visual Attention and Facial Expression Identification in Patients with Schizophrenia

Objective

Visual search is an important attention process that precedes the information processing. Visual search also mediates the relationship between cognition function (attention) and social cognition (such as facial expression identification). However, the association between visual attention and social cognition in patients with schizophrenia remains unknown. The purposes of this study were to examine the differences in visual search performance and facial expression identification between patients with schizophrenia and normal controls, and to explore the relationship between visual search performance and facial expression identification in patients with schizophrenia.

Methods

Fourteen patients with schizophrenia (mean age=46.36±6.74) and 15 normal controls (mean age=40.87±9.33) participated this study. The visual search task, including feature search and conjunction search, and Japanese and Caucasian Facial Expression of Emotion were administered.

Results

Patients with schizophrenia had worse visual search performance both in feature search and conjunction search than normal controls, as well as had worse facial expression identification, especially in surprised and sadness. In addition, there were negative associations between visual search performance and facial expression identification in patients with schizophrenia, especially in surprised and sadness. However, this phenomenon was not showed in normal controls.

Conclusion

Patients with schizophrenia who had visual search deficits had the impairment on facial expression identification. Increasing ability of visual search and facial expression identification may improve their social function and interpersonal relationship.     

Surgical Results of Growth Hormone-Secreting Pituitary Adenoma

Objective

We retrospectively analyzed the surgical outcomes of 42 patients with growth hormone (GH)-secreting pituitary adenoma to evaluate the clinical manifestations and to determine which preoperative factors that significantly influence the remission.

Methods

Forty-two patients with GH-secreting pituitary adenoma underwent transsphenoidal surgery (TSS) between 1995 and 2007. The patient group included 23 women and 19 men, with a mean age of 40.2 (range 13-61) years, and a mean follow-up duration of 49.4 (range 3-178) months after the operation. For comparable radiological criteria, we classified parasellar growth into five grades according to the Knosp classification. We analyzed the surgical results of the patients according to the most recent stringent criteria for cure.

Results

The overall rate of endocrinological remission in the group of 42 patients after primary TSS was 64% (26 of 42). The remission rate was 67% (8 of 12) for microadenoma and 60% (18 of 30) for macroadenoma. The remission rate was 30% (3 of 10) for the group with cavernous sinus invasion and 72% (23 of 32) for the group with intact cavernous sinus. Cavernous sinus invasion in Knosp grade III and IV was significantly correlated with the remission rate. There was a significant relationship between preoperative mean GH concentration and early postoperative outcome, with most patients in remission having a lower preoperative GH concentration.

Conclusion

TSS is thought to be an effective primary treatment for GH-secreting pituitary adenomas according to the most recent criteria of cure. Because the remission rate in cases with cavernous sinus invasion is very low, early detection of the tumor before it extends into the cavernous sinus and a long-term endocrinological and radiological follow-up are necessary in order to improve the remission rate of acromegaly.     

Indications and Surgical Results of Twist-Drill Craniostomy at the Pre-Coronal Point for Symptomatic Chronic Subdural Hematoma Patients

Objective

Twist-drill craniostomy (TDC) with closed-system drainage and burr-hole drainage (BHD) with a closed system are effective treatment options for chronic subdural hematoma (CSDH). The aim of this study was to analyze clinical data and surgical results from symptomatic CSDH patients who underwent TDC with closed-system drainage at the pre-coronal point (PCP).

Methods

We analyzed data for 134 symptomatic CSDH patients who underwent TDC at the PCP with closed-system drainage. We defined the PCP for TDC to be 1 cm anterior to the coronal suture at the level of superior temporal line. TDC at the PCP with closed-system drainage was selected in patients with CSDH that extended beyond the coronal suture, confirmed by preoperative CT scans. Medical records, radiological findings, and clinical performance were reviewed retrospectively.

Results

Of the 134 CSDH patients, 114 (85.1%) showed improved clinical performance and imaging findings after surgery. Catheter failures were seen in two cases (1.4%); the catheters were inserted in the epidural space. Recurrent cases were seen in eight patients (5.6%), and they were improved with a second BHD with a closed-system operation.

Conclusion

TDC at the PCP with closed-system drainage is safe and effective for patients with symptomatic CSDH whose hematomas extend beyond the coronal suture.     

Early assessment of delirium in elderly patients after hip surgery

Objective

This study is intended to identify predictive factors of delirium, including risk factors and prodromal symptoms.

Methods

This study included sixty-five patients aged 65 years or older who had undergone hip surgery. Baseline assessments included age; gender; admission type (acute/elective); reason for surgery (fracture/replacement); C-reactive protein (CRP); Acute Physiology, Age, Chronic Health Evaluation (APACHE III); and the Mini-Mental State Examination (MMSE). The Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98) was used to assess prodromal symptoms daily before the onset of delirium.

Results

Almost 28% (n=18) of the 65 patients developed delirium after surgery. Delirium in elderly patients after hip surgery was observed more often in older patients and those with acute admission, hip fracture, higher APACHE III score, lower MMSE score, and higher CRP levels within early days after the operation. Sleep-wake cycle disturbances, thought process abnormalities, orientation, and long-term memory in symptom items of K-DRS-98 were showed significant difference on 4 days before delirium, lability of affect on 3 days before, perceptual disturbances and hallucination, and visuo-spatial ability on 2 days before, and delusion, motor agitation, and short-term memory on the day before the occurrence of delirium. CRP levels within 24 hours and 72 hours after hospitalization were significantly higher in the delirium group.

Conclusion

Medical professionals must pay attention to behavioral, cognitive changes and risk factors in elderly patients undergoing hip surgery and to the prodromal phase of delirium. K-DRS-98 may help in identifying the prodromal symptoms of delirium in elderly patients after hip surgery.     

Transsphenoidal surgery assisted by a new guidance device: results of a series of 747 cases

Objective

The objective of this study is to report the efficacy and safety of microsurgical transsphenoidal surgery using a frame for sella guidance in a series of patients with untreated pituitary adenoma.

Methods

In this study, seven hundred and forty-seven patients undergoing transsphenoidal resection of a pituitary adenoma involving use of the frame were included. Follow-up of twelve to one hundred months was performed in all patients.

Results

During the procedures using the frame, pituitary adenomas were fully exposed, and no cavernous sinus haemorrhage due to anteroposterior displacement or internal carotid artery lesion due to right-and-left deviation occurred. The duration of the surgical procedure ranged from 28 min to 87 min with a mean of 44 min. The most frequent tumour type was prolactin-secreting adenoma (32.4%), followed by clinically non-functioning adenoma (NFPA) (28.5%), growth hormone-secreting adenoma (25.0%), and adrenocorticotropin-secreting adenoma (13.7%). Normalisation of visual defects occurred in 226 (42.2%) of the 535 patients with visual disturbances. Normalisation of hormone occurred in 458 of 551 patients with endocrine-active tumour in the follow-up period. Two patients died as a consequence of surgery.

Conclusion

The endonasal transsphenoidal technique is a safe, quick, and effective approach to pituitary adenomas. Our guidance frame allows the surgeon to open and close the wound rapidly, which avoids trajectory deviation and shortens the duration of the surgical procedure.     

Is the Complete Resection of Craniopharyngiomas in Adults Feasible Considering Both the Oncologic and Functional Outcomes?

Objective

To assess the impact of the complete resection of craniopharyngioma (CP) in adults on oncologic and functional outcomes.

Methods

We retrospectively analyzed 82 patients with CP who were surgically treated by the same neurosurgeon at our institution between January 1994 and December 2012.

Results

Gross total resection (GTR) was achieved in 71 patients (86.6%), near total resection (NTR) in 7 patients (8.5%), and subtotal resection (STR) in 3 patients (3.7%). The disease-specific overall survival rate was 100% with the exclusion of 2 surgery-related mortalities. The overall recurrence rate was 12.2% (10 of 82 patients), however the recurrence rate according to extent of resection (EOR) was 9.9% (7 of 71 patients) after GTR, 14.3% (1 of 7 patients) after NTR, and 66.7% (2 of 3 patients) after STR. The overall recurrence-free survival (RFS) rates at 5 and 10 years were 87.0% and 76.8%, respectively. Postoperatively, most patients (86.3%) needed hormone replacement for at least 1 hypothalamic-pituitary axis. Vision improved in 56.4% of the patients with preoperative abnormal vision, but deteriorated in 27.4% of patients. Hypothalamic dysfunction developed in 32.9% of patients. There were no significant differences in the risks of pituitary dysfunction, visual deterioration, or hypothalamic dysfunction between the groups with complete vs. incomplete removal. The overall rate of postoperative complications was 22.0%, which did not differ between groups (p=0.053).

Conclusion

The complete removal of a CP at first surgery can provide a chance for a cure with acceptable morbidity and mortality risks.