DOCSLIB.ORG

Endoscopic Endonasal Approach for Craniopharyngiomas

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Endoscopic Endonasal Approach for Craniopharyngiomas Endoscopic Endonasal Approach for Craniopharyngiomas Jörg Baldauf, MDa, Werner Hosemann, MDb, Henry W.S. Schroeder, MDa,* KEYWORDS Endoscopic endonasal approach Craniopharyngiomas Retrochiasmatic tumor KEY POINTS The endoscopic endonasal approach for the management of craniopharyngiomas has increasingly been used as an alternative to microsurgical transsphenoidal or transcranial approaches. This approach is a major step forward in the treatment of these difficult lesions because of improved resection rates and better visual outcome. Especially in retrochiasmatic tumors, the endonasal approach provides better access to the lesion and reduces the degree of manipulations of the optic apparatus. The panoramic view offered by endoscopy and the use of angulated optics allows the removal of lesions extending far into the third ventricle avoiding microsurgical brain splitting. A video of the endoscopic endonasal resection of an intraventricular craniopharyngeoma accompanies this article at http://www.neurosurgery.theclinics.com/ INTRODUCTION amplitude in childhood. However, the prognosis of these tumors in particular is a matter of growth Craniopharyngiomas (CPs) represent one of the pattern. The extent of the tumor in relation to the most challenging tumor entities in neurosurgery. optic chiasm, pituitary gland and stalk, hypothala- Because of its critical vicinity to important neuro- mus, carotid artery, and anterior cerebral artery vascular structures, the surgery is demanding complex as well as the location of the tumor with and requires a thorough understanding of the respect to the sella and diaphragm, is important anatomy of the suprasellar region. for surgical planning. In addition to the tumor CPs are benign epithelial tumors of the sellar size and the multilobulated characteristics with region originating from remnants of Rathke’s cleft. solid and cystic components, it is of significant in- They are classified by the World Health Organiza- 1 terest whether the lesion does extend into the third tion as grade I neoplasms. The papillary form is ventricle or not and its relation to it. To solve the almost exclusively found in the adult population problem of choosing the right surgical strategy and the adamantinomatous subtype mainly oc- 2,3 for individual cases, a variety of topographic curs in children. There is a bimodal age dis- and clinical classifications of CPs have been trans- tribution of the incidence of CPs with a higher ferred into surgical practice parallel to Disclosure: H.W.S. Schroeder is consultant to Karl Storz GmbH & Co KG (Tuttlingen, Germany). a Department of Neurosurgery, Ernst Moritz Arndt University, Sauerbruchstrasse, Greifswald 17475, Germany; b Department of Otorhinolaryngology, Ernst Moritz Arndt University, Walter-Rathenau-Strasse 43-45, Greifs- wald 17475, Germany * Corresponding author. E-mail address: [email protected] Neurosurg Clin N Am - (2015) -–- http://dx.doi.org/10.1016/j.nec.2015.03.013 1042-3680/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved. neurosurgery.theclinics.com 2 Baldauf et al technological progress of instrumentation and endoscope to transsphenoidal surgery more than equipment.2,4–7 a decade earlier.18 Two decades later, Carrau Albert E. Halsted has been credited with the first and Jho reported their first series of purely endo- successful transsphenoidal resection of a CP per- scopic endonasal removal of pituitary ade- formed in 1909.8 The transsphenoidal approach nomas.19,20 The continuous advancement of the for tumors of the sellar region is strongly related endoscope, in addition to the development of spe- to Harvey Cushing and Oskar Hirsch.9 In 1909, cific instruments and sophisticated endoscopic Cushing described his first surgery through the studies of the parasellar and anterior skull base transsphenoidal route for partial removal of the pi- anatomy allowed the extension of the spectrum tuitary gland in a patient with acromegaly.10 A of indications for the technique. This initial work detailed historical review concerning the endo- was spearheaded by “The original Pittsburgh nasal approach for CPs written by Gardner and group” with Carrau, Kassam and co-workers as colleagues11 mentioned that Cushing abandoned well as the Naples group with Cappabianca and the approach for CPs for safety reasons given by De Divitiis, and also the Bologna group with Frank technological and visualization limitations. In and Pasquini, who promoted the endoscopic contrast, Hirsch developed and kept to the endo- extended endonasal approach in the early years nasal transsphenoidal approach and reported his of the 21st century.21–24 Nowadays, the endo- first small series of 12 patients treated for tumors scopic approach is widely accepted and is used of the pituitary gland in 1911 at the third interna- regularly. However, there is a long learning curve tional laryngo-rhinological congress in Berlin.12 and cadaver studies are recommended. Addition- Ten of the patients improved in clinical outcome ally, close cooperation between an ENT-head and 2 died. The latter were subjected to autopsy. and neck surgeon and neurosurgeon is necessary. In one, a large tumor of the pituitary gland was Based on their extraordinary experience, Kassam found that mainly extended into the intracranial and colleagues24 specified a V-level scale of space and third ventricle. Hirsch made 2 important complexity of endoscopic endonasal skull base statements about his experience regarding the procedures that provides a useful guide. Accord- transsphenoidal approach. First, an improvement ing to their scale, the endoscopic endonasal of clinical symptoms can be expected if the tumor approach to CPs is a level IV category referring to is located exclusively inside the sella and reveals the fact that intradural surgery is usually required. cystic components. Second, if a tumor is mainly Several studies have demonstrated already excel- growing intracranially, the endonasal approach lent results for CP patients.25–30 Compared with the and all other extracranial methods will not suc- transcranial microscopic approach, the endo- ceed. Fortunately, the introduction of the oper- scopic approach promises a higher rate of gross ating microscope opened a new door to total resection (GTR) and improved visual outcome neurosurgery in general, as well as to the trans- because there is less manipulation of the optic sphenoidal endonasal route particularly. Hardy apparatus, especially in retrochiasmatic lesions.31 stressed the importance of the microsurgical approach for pituitary adenomas and CPs in INDICATIONS AND LIMITATIONS FOR 1971 and mentioned that “the intrasellar subdiag- ENDOSCOPIC EXTENDED ENDONASAL phragmatic type of CP can be totally removed APPROACH transphenoidally.”13 Laws improved the microsur- gical technique for CPs and expressly underlined Patients with CPs can present with a great variety that if “the sella turcica is enlarged, transsphenoi- of symptoms including headache, visual symp- dal microsurgery can be the procedure of choice, toms, hormonal disorders such diabetes insipidus even when significant intracranial extension is and hypopituitarism, mental and memory dis- present.”14,15 turbances, gait difficulties, and hypothalamic The stepwise technological progress extended disturbances such as the Fro¨ hlich’s syndrome the transsphenoidal access, initially described by (adiposogenital dystrophy). The typical symptoms Weiss,16 to reach the suprasellar/supradiaphrag- of increased intracranial pressure are commonly matic space. However, transcranial approaches related to an associated hydrocephalus owing to to CPs with intraventricular growth have also tumor extension into the third ventricle. been used via pterional, transcortical, interhemi- All symptomatic CPs are an indication for sur- spheric, transcallosal, and transforaminal routes.2 gery. Asymptomatic lesions can be followed with The microsurgical–endonasal resection of sellar MRI. However, growing lesions should be treated tumors was successfully complemented by the before they become symptomatic.32 If the patient use of an endoscope by Apuzzo and colleagues17 presents with acute hydrocephalus owing to in 1977 after Guiot had already introduced the obstruction of the foramina of Monro by a cystic Endonasal Approach for Craniopharyngiomas 3 component of the tumor, an initial transcranial Box 1 transventricular endoscopic cyst fenestration can Limitations and unfavorable factors of the be performed before the endonasal tumor resec- endoscopic extended endonasal approach tion to release the increased intracranial pressure. The goal of surgery for CPs is GTR or near total 1. Hypoplastic sphenoid sinus resection, if feasible. However, tumor removal has 2. Narrow sellar floor/reduced intercarotid ar- to be restricted to subtotal resection or even par- tery distance tial resection when the risk of neurovascular dam- 3. Combined prechiasmatic and retrochias- age is expected to be high to avoid unacceptable matic tumor extension postoperative morbidity. The surgical approach 4. Significant lateral tumor extension depends on the individual growth pattern of the tu- mor. Important essentials for the endoscopic 5. Predominantly solid component in large extended endonasal approach are listed in Table 1 tumors and limitations are presented in Box 1 with respect 6. Type IV lesions according to Kassam6 to the recent literature.6,25,27,30 Categories A through G try to display an increase of the neces- sary surgical expertise according
Load more

Recommended publications
  • CT of the Abnormal Pituitary Stalk
    49 CT of the Abnormal Pituitary Stalk Robert G. Peyster1 Seven cases are presented in which enlargement of the pituitary stalk was demon­ Eric D. Hoover1 strated by computed tomography (eT). Histiocytosis X, sarcoidosis, and metastatic cancer were the proven or presumed causes. The discovery of pituitary stalk enlarge­ ment prompted radiation treatment in three patients and led to the diagnosis of previ­ ously unsuspected diabetes insipidus in one. High-resolution computed tomography (CT) permits visualization of the pituitary stalk, especially when thin sections (5 mm or small er) are used [1,2]. This structure normally is no more than 4 mm in diameter [1-3]. Although many pathologic conditions are known to involve the pituitary stalk, either from clinical manifestations or autopsy studies, there are few reports of CT visualization of such lesions [4, 5]. We present cases illustrating several causes of enlargement of the pituitary stalk, as demonstrated by CT, and emphasize that this finding , either in isolation or associated with other abnormalities on the CT scan, may significantly affect patient management. Materials and Methods The cases were selected from more than 9000 cranial CT scans obtained at our institution since the installation of the GEj8800 scanner in April 1980. All scans were obtained after rapid drip infusion of 150 ml of Conray 60 (Mallinckrodt). Axial sections were 5 or 10 mm thick and parallel to the orbitomeatal line. Coronal sections were 5 or 1.5 mm thick and as close to perpendicular to the orbitomeatal line as pOSSible, given limitations imposed by patient mobility and metallic dental work.
    [Show full text]
  • Brain, Ovis Aries (Sheep)
    Comparative Vertebrate Anatomy, BIOL 021, Fall 2012 LABORATORY #10: Brain, Ovis aries (sheep) 1. We begin by looking at the brain of the sheep. The tough connective tissue surrounding the brain is the dura mater, one of the three meninges of the brain (the arachnoid and pia mater are the others). Using the scissors carefully remove the dura mater noting that it projects ventrally between the cerebrum and cerebellum (the tentorium) and into the longitudinal cerebral fissure (the falx cerebri). Be careful not to remove the hypophysis (figure 9-16; 9-18 in the Eighth Edition) during this process. The arachnoid and pia mater are imposssible to distinguish in dissection. FOREBRAIN: TELENCEPHALON 2. Notice that the surface of the cerebral hemispheres is formed of folds and the creases among them. The folds are gyri and the creases are sulci. Use your fingers to carefully spread the cerebral hemispheres apart. You should be able to see ventrally to the corpus callosum. This is a commissure, comprised of tracts that allow for communication between the left and right hemispheres. 3. Use figure 9-12 (figure 9-13 in the Eighth Edition) to identify the olfactory bulbs, the olfactory tract, the piriform lobe of the lateral pallium (processing center for olfactory information) and the rhinal sulcus. FOREBRAIN: DIENCEPHALON 4. The epithalamus is the dorsal part of the diencephalon. To see it, use your fingers to spread the cerebral hemispheres apart. This time, use your scalpel to cut through the corpus callosum. Move slowly so as to prevent cutting through the diencephalon. The epithalamus includes the pineal gland (regulation of biological rhythms) and the region just rostral to it.
    [Show full text]
  • Does Pituitary Stalk Compression Cause Hyperprolactinemia?
    Editorial " ~ ~ Does Pituitary Stalk Compression Cause Hyperprolactinemia ? Accepted thinking has been that all adenohy- releasing factors that could be responsible, at pophyseal hormones are under stimulatory least in part, for the hyperprolactinemia control of hypothalamic-releasing factors ex- found in this group of patients. Thyrotropin- cept for prolactin, which is believed to be releasing hormone (TRH) causes prolactin controlled by an inhibitory factor, dopamine. release, but its physiological role is unclear: If the hypothalamic factors are denied access Prolactin release is not impaired in hyperthy- through interruption of the portal circulation, roidism in which TRH is probably suppressed, which occurs when the stalk is damaged, but the hyperprolactinemia found in associa- prolactin secretion increases and that of the tion with primary hypothyroidism is most other pituitary hormones falls (7,14). The probably related to TRH excess, although hyperprotactinemia found in association with hypothalamic dopamine depletion may also pituitary tumors that do not secrete prolactin play a roleo Vasoactive intestinal polypeptide or with other space-occupying lesions such as (VIP) is a 28-amino acid peptide that is craniopharyngiomas, metastases, and the like synthesized in the paraventricular region of is believed to be due to pressure on the the hypothalamus and that has a marked pituitary stalk, which then deprives the prolactin-releasing effect. It is secreted as a normal prolactin-secreting cells of adequate prohormone, which also contains a 27-amino inhibition (3,6,9,11). How tenable is this acid peptide, called peptide histidine methio- supposition? nine (PHM 27) (13). PHM, like VIP, is a First of all, do tumors pressing on the member of the secretin-glucagon group of stalk interrupt the portal circulation? As the peptides and has a wide distribution in adenohypophysis relies for its blood supply various tissues including the hypothalamus on the portal circulation (8), experimental and pituitary stalk, paralleling that of VIP.
    [Show full text]
  • Distribution and Characterization of Different Molecular Products of Pro
    The Journal of Neuroscience. March 1992, 12(3): 946-961 Distribution and Characterization of Different Molecular Products of Pro-somatostatin in the Hypothalamus and Posterior Pituitary Lobe of the Mongolian Gerbil (Meriones unguiculatus) Philip J. Larsen,’ Maurizio Bersani,2 Jens J. Hoist,* Marten Msller,l and Jens D. Mikkelsenl ‘Institute of Medical Anatomy B and *Institute of Medical Physiology C, University of Copenhagen, DK-2200 Copenhagen N, Denmark Antisera raised against various synthetic peptide fragments intracellular processing of pro-somatostatin. Somatostati- of the pro-somatostatin molecule were used to visualize im- nergic nerve fibers and terminals in hypothalamic areas and munohistochemically the distributions of different pro-so- the posterior pituitary lobe were immunoreactive to all of the matostatin fragments in the hypothalamus and posterior pi- employed antisera. tuitary of the Mongolian gerbil. To define the nature of the From the present results, obvious differences between immunoreactive somatostatin-related molecular forms, gel intrahypothalamic and hypothalamo-pituitary somatostatin- chromatography combined with radioimmunoassays of hy- ergic neurons emerge. Within hypothalamic neurons not pro- pothalamic and posterior pituitary extracts was performed. jecting to the median eminence and the posterior pituitary Within the hypothalamus, only trace amounts of somato- lobe, pro-somatostatin is posttranslationally processed in statin- and somatostatin-28( l-l 2) were present, whereas the cell body predominantly
    [Show full text]
  • Motor Systems Review Angie Nietz
    Motor Systems Review Angie Nietz Organization of the motor cortex • Go to the white board. Draw the circuitry from primary motor cortex to the right biceps muscle in the arm. Your drawing should include a simple cross-section of each level of the brainstem and spinal cord with the relevant axons labeled. 4 Corticospinal Tracts • Neuron in layer V of motor cortex (precentral gyrus) (pyramidal tract) • Internal capsule through the forebrain • Cerebral peduncle in the midbrain • Pyramidal tract in the pons • Pyramids in the medulla • Decussation of the pyramids in the lower medulla • Lateral corticospinal tract in the spinal cord • Synapse in ventral horn in the cervical spinal cord • Motor neuron • Ventral root • Spinal nerve • Neuromuscular junction 5 Ventral Corticospinal Tract • descends in the spinal cord uncrossed. • projects bilaterally mainly to lower motor neurons for trunk musculature. 6 Lateral Corticospinal Tract • Decussation of the pyramids (lower medulla) • to lateral corticospinal tract (spinal cord) • to synapse with lower motor neuron in ventral horn of spinal cord 7 Muscle Unit • A motor neuron can synapse with one or more muscle fibers. • One motor neuron and all the fibers with which it synapses is a motor unit. • Muscles with fine control have small motor units (e.g. finger muscles). • Muscles with only course control have large motor units (e.g. gluteus maximus muscle in your butt). 8 Types of muscle fibers • Muscle fibers are of three types: type size speed force fatigability I thin slow, long low slowly IIa thick intermediate intermediate intermediate IIb thick fast, short high rapidly . 9 Muscle Physiology • Acetylcholine activates acetylcholine receptors on the myofiber.
    [Show full text]
  • Transection of the Pituitary Stalk in Man: Anatomical Changes in the Pituitary Glands of 21 Patients
    J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.29.6.545 on 1 December 1966. Downloaded from J. Neurol. Neurosurg. Psychiat., 1966, 29, 545 Transection of the pituitary stalk in man: anatomical changes in the pituitary glands of 21 patients J. HUME ADAMS, PETER M. DANIEL, AND MARJORIE M. L. PRICHARD From the Department ofPathology, The University and Western Infirmary, Glasgow, the Department of Neuropathology, Institute ofPsychiatry, Maudsley Hospital, London, and the Nuffield Institute for Medical Research, University of Oxford In recent years hypophysectomy (Luft and Olive- MATERIAL AND METHODS crona, 1953) and adrenalectomy (which is nearly The pituitary glands from 21 patients were available for always combined with ovariectomy) have been used study. In 20 cases the operation was undertaken for the as methods of treating cases of advanced cancer of relief of carcinoma of the breast or prostate but in one the breast (Atkins, Falconer, Hayward, MacLean, (case 4 in Table I) the indication was a rapidly advancing and Schurr, 1966) and the results of comparative diabetic retinopathy. Fourteen of the patients were trials suggest that hypophysectomy is slightly the females and seven were males. The age range was from guest. Protected by copyright. two (Atkins, Fal- 36 to 67 years. The pituitary stalk was approached by more effective of these operations way of a frontal craniotomy, and in some cases the coner, Hayward, MacLean, Schurr, and Armitage, pituitary stalk was clipped before it was transected at as 1960). As an alternative to hypophysectomy neuro- low a level as was technically possible. In the majority surgeons have sometimes used the operation of pitui- of cases an inert and impermeable barrier or 'plate' tary stalk section for relieving such cases and also for (composed usually of dental acrylic resin or tantalum) treating patients with cancer of the prostate (see was placed between the cut ends of the stalk to prevent Schurr, 1966).
    [Show full text]
  • Correlation Between the Position of the Pituitary Stalk As Determined By
    Clinical Article J Korean Neurosurg Soc 63 (4) : 504-512, 2020 https://doi.org/10.3340/jkns.2019.0205 pISSN 2005-3711 eISSN 1598-7876 Correlation between the Position of the Pituitary Stalk as Determined by Diffusion Tensor Imaging and Its Location as Determined at the Time of Surgical Resection of Pitu- itary Adenomas Fu-yu Wang,* Peng Wang,* Chen-xuan Yang, Tao Zhou, Jin-li Jiang, Xiang-hui Meng Department of Neurosurgery, The First Medical Center, PLA General Hospital, Beijing, China Objective : An important factor during pituitary adenoma surgery is to preserve pituitary stalk (PS) as this plays a role in reduction of the risk of postoperative diabetes insipidus. The hypothalamic-hypophyseal tract (HHT) projects through the PS to the posterior pituitary gland. To reconstruct white matter fiber pathways, methods like diffusion tensor imaging (DTI) tractography have been widely used. In this report we attempted to predict the position of PS using DTI tractography and to assess its intraoperative correlation during surgery of pituitary adenomas. Methods : DTI tractography was used to tract the HHT in nine patients before craniotomy for pituitary adenomas. The DTI location of the HHT was compared with the PS position identified at the time of surgery. DTI fiber tracking was carried out in nine patients prior to the planned craniotomy for pituitary adenomas. In one patient, the PS could not be identified during the surgery. In the other eight patients, a comparison was made between the location of the HHT identified by DTI and the position of the PS visualized at the time of surgery.
    [Show full text]
  • Diversity of Pathological Conditions Affecting Pituitary Stalk
    Journal of Clinical Medicine Article Diversity of Pathological Conditions Affecting Pituitary Stalk Łukasz Kluczy ´nski 1,† , Aleksandra Gilis-Januszewska 1,*,†, Magdalena Godlewska 1, Małgorzata Wójcik 2, Agata Zygmunt-Górska 2, Jerzy Starzyk 2 and Alicja Hubalewska-Dydejczyk 1 1 Department of Endocrinology, Faculty of Medicine, Medical College, Jagiellonian University, 31-008 Krakow, Poland; [email protected] (Ł.K.); [email protected] (M.G.); [email protected] (A.H.-D.) 2 Department of Paediatric and Adolescent Endocrinology, Faculty of Medicine, Medical College, Jagiellonian University, 31-008 Krakow, Poland; [email protected] (M.W.); [email protected] (A.Z.-G.); [email protected] (J.S.) * Correspondence: [email protected]; Tel.: +48-12-400-23-30; Fax: +48-12-400-23-17 † These authors contributed equally to this work. Abstract: Pituitary stalk lesions (PSL) are a very rare pathology. The majority of conditions affecting the infundibulum do not present with clinically apparent symptoms, what makes the diagnosis difficult. The recognition might be also complicated by the non-specific and transient characteristics of hormonal insufficiencies. In our study, we retrospectively analysed demographic, biochemical, and clinical long-term data of 60 consecutive, unselected adult patients (34 women and 26 men) with PSL diagnosed in the Department of Endocrinology, Jagiellonian University in Krakow. The diagnosis of PSL were categorized as confirmed, probable, or undetermined in 26, 26 and 8 patients, accordingly. Given the possible aetiology congenital, inflammatory, and neoplastic stalk lesions were diagnosed in 17, 15 and 20 patients, accordingly. In eight cases the underlying pathology remained Citation: Kluczy´nski,Ł.; undetermined.
    [Show full text]
  • Pituitary Stalk Lesions Demetra Rupp and Mark Molitch
    Pituitary stalk lesions Demetra Rupp and Mark Molitch Division of Endocrinology, Metabolism and Molecular Purpose of review Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA To describe the diverse causes of pituitary stalk lesions, their diagnosis, and treatment. Recent findings Correspondence to Mark Molitch, MD, Professor of Medicine, Division of Endocrinology, Metabolism and Pathology of the pituitary stalk is often distinct from disease processes that affect the Molecular Medicine, Northwestern University Feinberg hypothalamus and/or pituitary. Pituitary stalk lesions fall into one of three categories: School of Medicine, Chicago, Illinois, USA Tel: +1 312 503 4130; congenital, inflammatory/infectious, and neoplastic lesions. e-mail: [email protected] Summary Stalk thickening may be found incidentally or when evaluating pituitary functional Current Opinion in Endocrinology, Diabetes & Obesity 2008, 15:339–345 abnormalities. The precise cause must be looked for to enable the proper form of therapy of the underlying process. Hormone replacement is often also necessary. Keywords diabetes insipidus, hyperprolactinemia, hypopituitarism, infundibulum, pituitary stalk Curr Opin Endocrinol Diabetes Obes 15:339–345. ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 1752-296X thereby causing hypopituitarism. As the hypothalamic Introduction influence on prolactin is predominantly inhibitory via Disease processes that affect the pituitary stalk can be dopamine, however, pituitary stalk disease commonly distinct from processes that affect the hypothalamus or causes hyperprolactinemia along with deficiencies of pituitary. Pituitary stalk lesions fall into one of three the other hormones. As a consequence of this critical categories: congenital and developmental, inflammatory position of the pituitary stalk, patients who develop and infectious, and neoplastic [1 ].
    [Show full text]
  • MR Imaging Presentation of Intracranial Disease Associated with Langerhans Cell Histiocytosis
    AJNR Am J Neuroradiol 25:880–891, May 2004 MR Imaging Presentation of Intracranial Disease Associated with Langerhans Cell Histiocytosis Daniela Prayer, Nicole Grois, Helmut Prosch, Helmut Gadner, and Anthony J. Barkovich BACKGROUND AND PURPOSE: Intracranial manifestations of Langerhans cell histiocytosis (LCH) are underestimated in frequency and diversity. We categorized the spectrum of MR imaging changes in LCH. METHODS: We retrospectively reviewed 474 MR images in 163 patients with LCH and 55 control subjects. Lesions were characterized by anatomic region and signal intensity. Brain atrophy was assessed. RESULTS: We noted osseous lesions in the craniofacial or skull bones in 56% of patients, meningeal lesions in 29%, and choroid-plexus involvement in 6%. In the hypothalamic-pituitary region, infundibular thickening occurred in 50%; pronounced hypothalamic mass lesions in 10%; and infundibular atrophy in 29%. The pineal gland had a cystic appearance in 28%, and pineal-gland enlargement (>10 mm) was noted in 14%. Nonspecific paranasal-sinus or mastoid opacifications were seen in 55% of patients versus 20% of controls, and accentuated Virchow- Robin spaces occurred in 70% of patients versus 27% of controls (P < .001). Intra-axial, white-matter parenchymal changes resulted in a leukoencephalopathy-like pattern in 36%. Enhancing lesions in a vascular distribution were noted in 5%. Gray-matter changes suggestive of neurodegeneration were identified in the cerebellar dentate nucleus in 40% and in the supratentorial basal ganglia in 26%. All patients with neurodegenerative lesions had lesions in the extra-axial spaces. Cerebral atrophy was found in 8%. CONCLUSION: In LCH, cranial and intracranial changes at MR imaging include 1) lesions of the craniofacial bone and skull base with or without soft-tissue extension; 2) intracranial, extra-axial changes (hypothalamic-pituitary region, meninges, circumventricular organs); 3) intracranial, intra-axial changes (white matter and gray matter); and 4) cerebral atrophy.
    [Show full text]
  • Pituitary Stalk Thickening Evaluated at a Although the Patients Were Submitted to Different Large Referral Centre Over the Last Decade
    175:4 E Sbardella and others Imaging in pituitary stalk 175:4 255–263 Clinical Study thickening Pituitary stalk thickening: the role of an innovative MRI imaging analysis which may assist in determining clinical management Emilia Sbardella1,3, Robin N Joseph2, Bahram Jafar-Mohammadi1, Andrea M Isidori3, Simon Cudlip4 and Ashley B Grossman1 1Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Correspondence Hospital, University of Oxford, Oxford, UK, 2Department of Neuroradiology, John Radcliffe Hospital, should be addressed University of Oxford, Oxford, UK, 3Department of Experimental Medicine, Sapienza University of Rome, to A B Grossman Rome, Italy, and 4Department of Neurological Surgery, John Radcliffe Hospital, University of Oxford, Email Oxford, UK [email protected]. ac.uk Abstract Context: Disease processes that affect the pituitary stalk are broad; the diagnosis and management of these lesions remains unclear. Objective: The aim was to assess the clinical, biochemical and histopathological characteristics of pituitary stalk lesions and their association with specific MRI features in order to provide diagnostic and prognostic guidance. Design and methods: Retrospective observational study of 36 patients (mean age 37 years, range: 4–83) with pituitary stalk thickening evaluated at a university hospital in Oxford, UK, 2007–2015. We reviewed morphology, signal intensity, enhancement and texture appearance at MRI (evaluated with the ImageJ programme), along with clinical, biochemical, histopathological and long-term follow-up data. Results: Diagnosis was considered certain for 22 patients: 46% neoplastic, 32% inflammatory and 22% congenital lesions. In the remaining 14 patients, a diagnosis of a non-neoplastic disorder was assumed on the basis of long-term European Journal European of Endocrinology follow-up (mean 41.3 months, range: 12–84).
    [Show full text]
  • Pupilllary Light Reflex Pathways
    Neuro-Ophthalmology Michael Davidson, D.V.M. Professor, Ophthalmology Diplomate, American College of Veterinary Ophthalmologists College of Veterinary Medicine Raleigh, North Carolina, USA <[email protected]> The Pupil Determination of the integrity of the pupillary light reflex (PLR) is a critical step in neurophthalmic evaluation. This reflex is initiated with photic stimulation of the photoreceptors (rods and cones) in the outer retina, which synapse in the bipolar cells of the middle retina, and again in the ganglion cells in the inner retina. Ganglion cell axons comprise the optic nerve, and pass through the fibrous lamina cribosa, posteriorly into the orbit, through the optic foramen to join the opposite optic nerve at the optic chiasm in the cranial fossa. Here, a species-dependent number of axons decussate or cross-over to the contralateral optic tract (primate=50%, feline=65%, canine=75%, equine, bovine, porcine=80-90%, submammalian species=100%), Fibers then course to the ipsilateral or contralateral optic tract, and then project in a topographical fashion to the ipsilateral dorsal lateral geniculate body (dLGB). From here, the majority of fibers (80%) project to the optic radiation and visual cortex. Twenty percent of fibers in the optic tract bypass the LGB project and many of these project to the pretectal nuclei near to rostral colliculi to control pupilomotor function. Note that other fibers bypassing the dLGB synapse in the hypothalamus to regulated circadian rhythm, and the rostral colliculi to elicit the optic dazzle reflex, reflexive redirection of gaze, and stimulation of the reticular activating system. From the pretectal region, the pupillomotor fibers then undergo a second deccusation near the caudal commisure, and project to the contralateral parasympathetic nuclei of CN III.
    [Show full text]