Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks?

Objective

Large suprasellar craniopharyngiomas are surgically challenging. The aim of our study was to explore the therapeutic efficacy of the frontobasal interhemispheric approach for these lesions.

Methods

Twenty-nine consecutive adult patients with large suprasellar craniopharyngiomas (diameter?>4 cm) who underwent the frontobasal interhemispheric approach were retrospectively evaluated. Surgical and clinical outcomes were analyzed.

Results

Gross total removal was achieved in 23 cases (79.3 %) and subtotal removal in 6 cases (20.7 %). The mean follow-up period was 76.5?±?33.2 months (range, 12-132 months). Twenty-four patients (82.7 %) had improvement of the visual impairment score (VIS) after surgery. VIS was unchanged in five patients (17.3 %), and no patients experienced visual deterioration. Among 23 patients who had preoperative hypopituitarism, 8 (34.8 %) had an improvement. Postoperative new or aggravated hypopituitarism was observed in four patients (13.8 %). Permanent diabetes insipidus was observed in ten patients (34.4 %). Postoperative anosmia occurred in two earlier cases (6.9 %). There was no intracranial infection or cerebrospinal fluid fistula. At last follow-up, >9 % BMI gain was observed in 34.5 % of patients, and 65.5 % of patients returned to work. Four patients (13.8 %) suffered recurrence.

Conclusion

Although the frontobasal interhemispheric approach has some disadvantages, it provides ideal access to the suprasellar region and the third ventricle with limited brain retraction. The surgically visible angle is adequate; thus, vital structures can be better protected. For large suprasellar craniopharyngiomas, the benefits of this approach can outweigh its potential risks.     

Surgical specialty and outcomes for carotid endarterectomy: evidence from the National Surgical Quality Improvement Program

Background

Carotid endarterectomy (CEA) has been performed since the 1950s and remains one of the most common surgical procedures in the United States. The procedure is performed by cardiothoracic, general, neurologic, and vascular surgeons. This study uses data from the National Surgical Quality Improvement Program (NSQIP) to examine the outcomes after CEA when performed by general or vascular surgeons.

Materials and methods

Data included 34,493 CEAs from years 2005 to 2010 recorded in the NSQIP database. Primary outcomes measured were length of stay, 30-d mortality, surgical site infection, cerebrovascular accident, myocardial infarction, and blood transfusion requirement. Secondary outcomes measured were the remaining intraoperative outcomes from the NSQIP database.

Results

After controlling for patient and surgical characteristics, patients treated by general surgeons did not have a significantly different LOS or 30-d mortality than those treated by vascular surgeons. Patients of general surgeons had nearly twice the risk of acquiring a surgical site infection (odds ratio [OR] = 1.94; P = 0.012), >1.5 times the risk of cerebrovascular accident (OR = 1.56; P = 0.008), and >1.8 times the risk of blood transfusion (OR = 1.85; P = 0.017) than those of vascular surgeons. Patients of general surgeons had less than half the risk of having a myocardial infarction (OR = 0.34; P = 0.031) than those of vascular surgeons.

Conclusions

Surgical specialty is associated with a wide range of postoperative outcomes after CEA. Additional research is needed to explore practice and cultural differences across surgical specialty that may lead to outcome differences.     

Selective verbal memory impairment due to left fornical crus injury in a patient with intraventricular hemorrhage

<正>The fornix,a part of the Papez circuit,transfers information of episodic memory between the medial temporal lobe and the medial diencephalon(Aggleton and Brown,1999).The right medial temporal lobe is known to be specialized for visual memory and the left medial temporal lobe for verbal memory(Tucker et al.,1988;Aggleton and Brown,1999).Many studies have reported on fornix injury,however,most of them focused on bilateral injury(Tucker et al.,1988;Aggleton et al.,2000;Nakayama et al.,2006;Sugiyama et al.,2007;