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.     

Stereotactic Hematoma Removal of Spontaneous Intracerebral Hemorrhage through Parietal Approach

ObjectiveTo determine the advantages of parietal approach compared to Kocher''s point approach for spontaneous, oval-shaped intracerebral hemorrhage (ICH) with expansion to the parietal region.MethodsWe divided patients into two groups : group A had burr holes in the parietal bone and group B had burr holes at Kocher''s point. The hematoma volume, Glasgow coma scale (GCS) score, and modified Barthel Index (mBI) score were calculated. At discharge, we evaluated the patients'' Glasgow outcome scale (GOS) score, modified Rankin Scale (mRS) score, motor grade, and hospitalization duration. We evaluated the patients'' mBI scores and motor grades at 6 months after surgery.ResultsThe hematoma volume in group A was significantly less than that in group B on postoperative days 1, 3, 5, 7, 14, and 21. Group A had significantly higher GCS scores than did group B on postoperative days 1 and 3. Group A had higher mBI scores postoperatively than did group B, but the scores were not significantly different. No differences were observed for the GOS score, mRS score, motor grade at discharge, or duration of hospitalization. The mBI score of group A at 6 months after surgery was significantly higher, and more patients in group A showed muscle strength improvement.ConclusionIn oval-shaped ICH with expansion to the parietal region, the parietal approach is considered to improve the clinical symptoms at the acute phase by removing the hematoma more effectively in the early stages. The parietal approach might help promote the long-term recovery of motor power.     

Quantification of Pediatric Cervical Spine Growth at the Cranio-Vertebral Junction

Objective

The purpose of this study was to investigate morphological change at the craniovertebral junction (CVJ) region using computed tomography.

Methods

A total of 238 patients were included in this study, and mean age was 47.8±21.3 months. Spinal canal diameter, Power''s ratio, McRae line, antero-posterior C1 ring height, atlantoaxial joint space, C2 growth, epidural space from the dens (M-PB-C2) and longitudinal distance (basion to C2 lower margin, B-C2) were measured. The mean value of each parameter was assessed for individual age groups. The cohorts were then divided into three larger age groups : infancy (I) (≤2 years), very early (VE) childhood (2-5 years) and early (E) childhood (5≥ years).

Results

Spinal canal diameter increased with age; however, this value did not increase with statistical significance after VE age. A significant age-related difference was found for all C2 body and odontoid parameters (p<0.05). Mean McRae line was 8.5, 8, and 7.5 mm in the I, VE, and E groups, respectively. The M-PB-C2 line showed up-and-down dynamic change during early pediatric periods.

Conclusion

Expansion of the spinal canal was restricted to the very early childhood period (less than 5 years) in the CVJ region; however, the C2 body and odontoid process increased continuously with age. The above results induced a dynamic change in the M-PB-C2 line. Although C2 longitudinal growth continued with age, the McRae line showed relatively little change.     

Association of Carotid Intraplaque Hemorrhage and Territorial Acute Infarction in Patients with Acute Neurological Symptoms Using Carotid Magnetization-Prepared Rapid Acquisition with Gradient-Echo

Objective

The purpose of our study was to assess prevalence of carotid intraplaque hemorrhage (IPH) and associations between territorial acute infarction and IPH on magnetization-prepared rapid acquisition with gradient-echo (MPRAGE) in patients with acute neurologic symptoms.

Methods

83 patients with suspected acute neurologic symptoms were evaluated with both brain diffusion weighted imaging (DWI) and carotid MPRAGE sequences. Carotid plaque with high signal intensity on MPRAGE of >200% that of adjacent muscle was categorized as IPH. We analyzed the prevalence of IPH and its correlation with territorial acute infarction.

Results

Of 166 arteries, 39 had a carotid artery plaque. Of these arteries, 26 had carotid artery stenosis less than 50%. In all carotid arteries, MR-depicted IPH was found in 7.2% (12/166). High-signal intensity on DWI was found in 17.5% (29/166). Combined lesion with ipsilateral high-signal intensity on DWI and IPH on carotid MPRAGE sequence was found in 6 lesions (6/166, 3.6%). Of patients with carotid artery plaque, MR-predicted IPH was found in 30.8% (12/39) and match lesions with high-signal intensity on DWI and MPRAGE was found in 15.4% (6/39). MR-predicted IPH was significantly higher prevalence in high-grade stenosis group (p=0.010). Relative risk between carotid MPRAGE-positive signal and ipsilateral high-signal intensity on DWI in arteries with carotid artery plaques was 6.8 (p=0.010).

Conclusion

Carotid MPRAGE-positive signal in patients was associated with an increased risk of territorial acute infarction as detected objectively by brain DWI. The relative risk of stroke was increased in high-grade stenosis categories.     

Simian immunodeficiency virus infection of CD4+CD8+ T cells in a macaque with an unusually high peripheral CD4+CD8+ T lymphocyte count

We assessed the possible role in vivo CD4(+) CD8(+) T cells as a viral reservoir for simian immunodeficiency virus (SIV), in a macaque with 50% CD4(+) CD8(+) T cells in peripheral blood. During primary infection (day 14) of this rhesus macaque with the pathogenic SIVmac251 strain, proviruses were detected at similar frequencies in CD4(+) CD8(+) T cells (1/10) and CD4(+) T cells (1/10) and at a lower frequency in CD8(+) T cells (1/800). On day 235, no viral DNA was detected in CD8(+) cells, despite the persistent high viral load, indicating that CD8(+) cells do not constitute a reservoir during the chronic phase of SIV infection. Infection induced early lymphopenia of CD4(+), CD4(+) CD8(+), and CD8(+) cells; only the CD8(+) cell population returned to initial levels and expanded further. We found that CD4(+) CD8(+) T cells expressed the costimulatory CD28 molecule less and were more prone to die in vitro after phytohemagglutinin/interleukin 2 stimulation than were CD4(+) T cells. Taken together, massive death of CD4(+) CD8(+) T cells during acute stages of SIV infection may explain why CD8(+) T cells did not represent a major reservoir for SIV at the onset of infection.