A 51-year-old woman with COVID-19 infection developed coma and an impaired oculocephalic response to one side. MRI of the brain demonstrated acute multifocal demyelinating lesions, and CSF testing did not identify a direct cerebral infection. High-dose steroids followed by a course of IVIG was administered, and the patient regained consciousness over the course of several weeks. As more patients reach the weeks after initial infection with COVID-19, acute disseminated encephalomyelitis should be considered a potentially treatable cause of profound encephalopathy or multifocal neurological deficits.

Contusion progression is a common phenomenon that is seen more commonly in larger contusions. Patients with large contusions and low initial GCS scores are at risk for delayed deterioration. A proposed management algorithm for patients with contusions initially treated conservatively may help practitioners identify the best course of treatment.

These results suggest that silent corticotroph adenomas have some unique features compared to non-functioning adenomas. Within the limits of our follow-up duration and sample size and our review of the literature, we would recommend that the traditional view to manage all silent corticotroph adenomas with adjuvant radiation should be reconsidered. We suggest adopting an initially more conservative follow-up surveillance and delay of upfront radiation until there is clear evidence of tumor recurrence.

334Cushing's Disease (CD) is the commonest cause of endogenous hypercortisolemia 1 and is associated with significant morbidity and mortality. [2][3][4] Transsphenoidal pituitary surgery remains the first line treatment for this condition with reported remission rates of 52% to 89%. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Many attempts have been made to identify factors that would predict sustained remission after surgical intervention. Suggested factors include smaller adenomas and the confirmation of adenoma intraoperatively. 18,20 The question of whether the newer endoscopic surgical technique (endo TSS) 21 has improved results compared to the older microscopic technique (micro TSS) remains to be answered. The aim of this report is to study the outcomes of ABSTRACT: Background: Cushing disease (CD) constitutes a challenging condition for the pituitary surgeon. Given the variety of factors affecting outcomes in CD, it is uncertain whether the newer endoscopic technique improves the results of surgery. Methods: A review was conducted of CD cases at our institution between 2000 and 2010. Analysis was done to: determine if surgical technique had an effect on outcome, identify the predictors of outcome and provide details of failed cases. Remission was defined as normal postoperative 24-hour urinary free cortisol (24-h UFC), suppression of morning serum cortisol to <50 nmol/L after 1mg of dexamethasone or being dependent on steroid replacement. Results: Forty-two patients met our inclusion criteria. Average follow-up period was 33 months. There were 15 macroadenomas and 27 microadenomas. Seventeen patients had an endoscopic transsphenoidal surgery and twenty-five patients had a microscopic transsphenoidal procedure. Long-term overall remission was achieved in 26 (62%) patients. There was no significant difference in remission rates between the two techniques (p value 0.757). Patient's subjective symptomatic improvement and drop of morning serum cortisol in the postoperative period to less than 100 nmol/L correlated with longterm remission (p value 0.0031and 0.0101, respectively) while repeat surgery was the only predictor of the lack of postoperative remission (p value 0.0008). Conclusions: Revision surgery predicted poor remission rate for CD. Within the power of our study size, there was no difference in outcome between the endoscopic and microscopic approaches. Surgical outcomes should be reviewed in association with remission criteria used in a study. RÉSUMÉ: Évaluation de l'impact de la technique utilisée, au moyen de critères de rémission rigoureux, sur le résultat de la chirurgie dans le traitement de la maladie de Cushing. Contexte : La maladie de Cushing (MC) présente des défis pour le chirurgien qui la traite. Compte tenu de la variété des facteurs qui influencent le résultat du traitement dans la MC, nous ne savons pas si la nouvelle technique endoscopique améliore le résultat de la chirurgie. Méthode : Nous avons revu les dossiers des patients atteints de la MC traités dans notre instit...

Silent corticotroph adenomas (SCAs) represent a distinct subset of clinically non-functioning pituitary adenomas. There are two variants of SCA; type I are densely granulated basophilic tumors and type II are sparsely granulated and chromophobic tumors. SCAs are known to be aggressive than the more common non-functioning gonadotroph adenomas (NFGAs). Cell-matrix interactions play an important role in the pathogenesis of pituitary adenomas. In this study, we compared 19 SCAs and 50 NFGAs with known fibroblast growth factor receptor-4 (FGFR4) status using semi-quantitative immunohistochemistry to localize β1-integrin, osteopontin, and matrix metalloproteinase-1 (MMP-1) as cytoplasmic, membranous, or mixed cytoplasmic-membranous staining to achieve scores of 1-4. Staining for β1-integrin was significantly higher in SCAs (100 %, score 3.3) than in NFGAs (96 %; score 2.6) (p = 0.0482); there was no statistical difference within subgroups of SCA (type II score 3.4; type I score 2.8) (p = 0.2663). Osteopontin immunoreactivity was also higher in SCAs (100 %, score 3.7) than in NFGAs (42 %, score 0.8) (p = 0.0001); there was no statistical difference within subgroups of SCA (type II score 3.6; type I score 3.9) (p = 0.2787). In contrast, MMP-1 immunoreactivity was lower in SCAs (89 %; score 2.5) than in NFGAs (98 %; score 3.6) (p = 0.0005); there was no statistical difference within subgroups of SCA (type II score 2.7; type I score 2.0) (p = 0.30704). The MMP-1 results correlated with FGFR4 expression (NFGA 96 %, type II SCA 71 %, type I SCA 40 %). Our data indicate that the biological aggressivity of SCAs compared with NFGA may be due to high osteopontin expression; in contrast, high MMP-1 is characteristic of NFGAs that also express more FGFR4. Further investigations are warranted to clarify the underlying regulatory mechanisms of these markers. The high osteopontin or FGFR4/MMP-1 expression levels in SCAs and NFGAs, respectively, indicate the potential for therapeutic strategies targeting osteopontin or FGFR4/MMP-1 for inoperable tumors of these types.

Study design: Retrospective case series. Objectives: The objective of this study is to identify imaging and intraoperative characteristics that may predict surgical resection for myxopapillary ependymoma (MPE). The diffuse involvement in the conus-filum region makes complete resection challenging. The preoperative characteristics that may estimate the extent of resection has not been reported. Setting: Toronto, Canada. Methods: All MPE cases between 1972 and 2005 at a single institution were identified and reexamined by a neuropathologist. Neurological outcomes (Frankel scale), clinical features, operative findings, pre and postoperative imaging results were reviewed. Results: A total of 18 operations were performed on 15 MPE patients (8 females/7 males; age range: 18-71 years). Median postoperative follow-up was 56 months. Three patients (17%) developed tumor regrowth requiring reoperations. Preoperative magnetic resonance imaging (MRI; in 14/18 procedures) determined that tumors involved the conus in 70% of cases, which was significantly associated with intraoperative findings (P ¼ 0.02). Complete microsurgical resection was accomplished in 4 out of 7 cases where conus was not involved, but in only 1 out of 10 cases with conus involvement (P ¼ 0.056). The degree of conus involvement in one case was unclear. None of patients with total surgical resection developed recurrence. All patients survived at long-term follow-up. Conclusion: Our series is the first to correlate MPE involvement to conus medullaris on preoperative MRI with intraoperative findings, and examine its significance on surgical resectability. This information could guide clinicians in preoperative planning and advising patients on treatment options and potential risks/benefits. MRI is very sensitive (100%) and moderately specific (67%) in detecting direct anatomical contact between conus and MPE tumors.

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