Objective Pointing out our surgical strategy and experience in selection of surgical approaches in giant pituitary adenomas patients and its relation to surgical and clinical outcome. Methods 31 patients with giant pituitary adenomas (maximum diameter ≥ 4 cm). We analyzed the preoperative clinical presentation, radiological criteria of the tumor, endocrinological profile, approach selected, extent of resection, clinical outcomes and complications. Results 16 males (51.6%) and 15 females (48.4%). All the patients had a visual complaint (13 had mild impairment (41.9%), 18 had significant visual loss (58.1%). 20 were nonfunctioning (64.6%), 5 prolactin secreting (16%) and 6 growth hormone secreting (19.4%). Surgical approaches included: standard endoscopic endonasal approach in 7, extended approach in 4, transcranial (extended pterional approach) in 3. Staged endoscopic surgery in 5. Extended pterional approach followed endoscopic approach in 12. Gross total resection in 18 (58%) subtotal resection in 8 patients (25.8%) and partial resection in 5 patients (16.2%). The most common complications was tumor recurrence in 8, CSF leakage in 3, Permanent diabetes insipidus in 2, postoperative hydrocephalus in 1, transient 6th CN palsy in 3, and unfortunately only one patient died. 8 had complete Visual recovery, 9 were improved partially, and 11 remain unchanged. Only 3 showed further deterioration of vision. Conclusions Giant invasive pituitary adenoma is still one of the challenging issues in decision making for selection of the appropriate management strategy. Advancement of the endoscopic surgical techniques made the transsphenoidal approach is the primary choice for management of giant pituitary adenoma. However, the door is still opened for transcranial approach as staged the procedure after endoscopic approach or sole approach for some selected cases.
Background: Vestibular schwannomas exerting brainstem compression with or without hydrocephalus are challenging for neurosurgeons regarding the plan of surgery, operative risk and postoperative sequale. Purpose: To report our experience with the surgical challenges and outcomes for Hannover type T4a & T4b vestibular schwannomas. Methods: Retrospective case study conducted at neurosurgery department, Mansoura University between October 2016 and May 2019 of 16 patients with vestibular schwannoma compressing the brainstem. We reviewed their clinical, radiological, surgical data, incidence of complications and outcome. Results: We had 16 patients: 10 of Hanover grade T4b and 6 of grade T4a. Gross total resection was achieved in 2 cases while subtotal resection was achieved in 5 cases and in the remaining 9 cases; only partial resection was feasible. We had 4 cases of mortality. Among new onset morbidity after surgery, 3 cases had post-operative bulbar manifestation and 4 cases had brainstem dysfunction. Conclusion: Vestibular schwannomas compressing the brain stem are challenging in their clinical presentation, surgery and post-operative outcome. The outcome of patients treated with hydrocephalus prior to vestibular schwannoma surgery is better than those who did initial VS surgery. Patients presented with significant brainstem, bulbar manifestation had worse outcome and needed longer ICU stay and longer time for recovery.
Background: Post-craniotomy CSF collection is a problem that may cause severe complications as meningitis, wound disruption, prolonged hospitalization, and additional surgeries. Objective: To evaluate our cases with resistant post-operative subgaleal CSF collection, trying to identify causes and optimal management. Methods: Retrospective review of elective skull base cases during the period of January 2104 to January 2019 identification of cases with post-operative CSF subgaleal collection, which either managed conservatively or needed a second surgery. Results: 219 patients, 30 of them suffered subgaleal CSF collection, 22 patients improved with non-operative measures, eight patients needed second surgery with pericranial graft augmentation, and obliteration of subgaleal space resulted in resolution of CSF leak with no morbidities. Conclusion: Meticulous tensionless dural closure, obliteration of subgaleal space, tethering of dural grafts to bone edges are useful techniques in preventing post-operative CSF leak.
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