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The patient died about 3 months later, and the autopsy revealed a tangerine-sized pituitary tumor pulse pressure glaucoma generic nifedipine 20 mg on line. The histologic diagnosis was "round cell sarcoma," the prevailing nosology for pituitary adenomas at the time. Horsely2 subsequently used temporal and subfrontal approaches to treat 10 patients with pituitary tumors and reported this series in 1906. The next major technical and conceptual advance came from Vienna, where a number of surgeons devised and successfully applied extracranial approaches to the sella. Schloffer3 was the first in 1907, employing an extensive lateral rhinotomy type of 1476 incision, with resection of the septum and turbinates en route to the sella. A variation of this approach was advocated by von Eisenberg4 and subsequently modified by Hochenegg,5 who accessed the sella through the frontal sinus. As cranial neurosurgery continued to evolve, so did transcranial approaches to pituitary tumors. The second decade of the 20th century brought an escalating enthusiasm for transcranial approaches, and transsphenoidal approaches were all but abandoned, particularly in North America. Owing to technical contributions by Heuer, Frazier, Krause, Elsberg, Cushing, and others, transcranial approaches to the pituitary became routine. A former pupil of Cushing, Dott continued to practice, refine, and teach transsphenoidal techniques. One of his students, Guiot,11 popularized the procedure in France and became one of its major advocates. Guiot passed on transsphenoidal methods to Hardy12 of Montreal, who reintroduced this approach to the neurosurgical mainstream in North America. In doing so, Hardy merged the procedure with the operating microscope, illuminating the microsurgical aspects of the technique, promulgating the concept of microadenoma, and showing the feasibility of selective tumor removal while preserving normal pituitary tissue and function. Together, Guiot and Hardy popularized their work in the 1960s and established the technical and conceptual elements of the procedure that form the basis of transsphenoidal microsurgery as it is practiced today. Further evolution of the transsphenoidal approach occurred with the introduction of the endoscope. Although used intermittently as an adjunct to microscopic transsphenoidal surgery,19,20 the concept of a pure endoscopic transsphenoidal technique (without the use of the operating microscope) was introduced in the 1990s and has recently become popular. Data from academic medical centers suggest that pituitary tumors represent as many as 20% of surgically resected primary brain tumors. Unselected autopsy studies have repeatedly shown that 20% to 25% of the general population harbor small pituitary microadenomas. These lesions are clinically silent; occur in patients without apparent endocrine symptoms; have the morphology of null cell, gonadotroph, or lactotroph adenomas; and are identified only after careful microscopic postmortem examination of a serially sectioned pituitary gland. Although pituitary adenomas occur in all age groups, the highest incidence is between the third and sixth decades of life.
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Care is taken to identify and preserve the pericallosal arteries on the corpus callosum blood pressure 88 over 60 nifedipine 30 mg purchase amex. Tumor may be resected through an enlarged foramen of Monro, or the choroidal fissure can be opened to allow greater access to the third ventricle. Alternatively, an interforniceal approach with direct access to the third ventricle can be used. Internal decompression with piecemeal extirpation of tumor is favored in this location. This approach puts at risk the medial hemisphere from retraction, in addition to the pericallosal arteries and fornix, as well as the veins and floor of the third ventricle. A frontotemporal incision is made, and the temporalis muscle can be raised with the skin as a myocutaneous flap or reflected posteriorly after interfascial dissection. A frontotemporal bone flap is elevated, and the lateral aspect of the lesser wing of the sphenoid is drilled away. Frontal extension of the craniotomy is advocated by some authors to improve access. The sylvian fissure is split, and frontal and temporal retractors may be used judiciously to provide access to the tumor. Extension of craniopharyngioma into the third ventricle may be removed by opening the lamina terminalis. In the case of large retrochiasmatic or retrosellar lesions, the pterional approach offers a narrow window that may be obstructed by perforating vessels. A frontotemporal incision is made, followed by interfascial dissection to reflect the temporalis inferoposteriorly. The frontotemporal craniotomy is extended to involve the lateral orbital bar and zygoma. The dural opening and intradural procedure is then similar to the pterional approach but is extended to allow access to lesions with more vertical height. A candidate for this approach, generally in combination with a basal approach, would be a patient with hydrocephalus and craniopharyngioma extending into the third ventricle, particularly through the foramen of Monro. A linear or U-shaped flap incision is made to expose the frontal bone just anterior to the coronal suture. A neuronavigation system can be useful for planning the bone flap and to direct access to the ventricle. The dura is reflected medially and the corticectomy performed through the middle frontal gyrus. The tumor is identified and may be resected from the ventricle and followed through the foramen of Monro into the third ventricle. The size of the ventricle is important, and hence in the absence of significant hydrocephalus, this approach is unfavorable. Ipsilateral dissection of the wall of the third ventricle is also difficult with this approach.
A plane of cleavage along the carotid artery can be developed in half these cases arrhythmia classification cheap nifedipine 30 mg visa. Venous bleeding, typically not a problem when the tumor fills the sinus, may occur as the venous plexus is decompressed by tumor removal. In that event, homeostasis can be obtained by packing the cavernous sinus space with oxidized cellulose or a similar hemostatic agent. In our series, gross resection of cavernous sinus meningioma was possible in 76% of patients. Preoperative cranial nerve deficits improved in 14%, remained unchanged in 80%, and permanently worsened in 6%. Because of the oculomotor function outcome after operating in the cavernous sinus, some authors shy away from the surgical removal of cavernous sinus meningiomas and resort to radiosurgery. Secondary tumors are those involving the anterior clinoid, sphenoid wing, tuberculum sellae, or cavernous sinus or other surrounding lesions that enter the optic foramen or superior orbital tissue. The two main symptoms of orbital meningioma are progressive, usually painless vision loss and proptosis. Other signs associated with orbital meningioma include optic disc swelling, optic atrophy, and visual field defects. The natural history of optic nerve and orbital meningiomas is not well understood. Historically, several investigators indicated that these tumors tend not to progress or do so very slowly. Kennerdell and associates192 observed 18 patients without treatment, and of the 9 patients with visual acuity greater than 20/40, none retained it for more than 5 years. PosteriorFossaMeningiomas Ten percent of all intracranial meningiomas arise in the posterior fossa. Hearing loss, facial pain or numbness, and facial weakness or spasm are common, as are headaches and cerebellar hemispheric signs. After the tumor is removed, the dural attachment should be removed or coagulated (with the bipolar coagulation or laser), and any hyperostotic bone is drilled away, keeping in mind the location of the nearby inner ear structures. Differentiation among clival, petroclival, and sphenopetroclival meningiomas is based on the surgical anatomy of the lesion. Petroclival meningiomas also involve the superior two thirds of the clivus and are located medial to cranial nerve V. In the latter group, the brainstem and basilar artery are typically displaced to the contralateral side. Sphenopetroclival meningiomas have characteristics similar to those of petroclival meningiomas, but the sphenoid forms also invade the lateral wall of the cavernous sinus along the medial sphenoid wing. Headache and ataxia from cerebellar compression are the most frequently identified clinical findings. Long-track signs, spastic paresis, and cranial neuropathies are also common findings.
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Trano, 21 years: Neurological complications result from one of the following causes: (1) direct injury to normal brain structures, (2) brain edema, (3) vascular injury, or (4) hematoma.
Grok, 35 years: The endoscope overcomes all these limitations and thereby allows effective endoscopically controlled surgery.
Cruz, 34 years: The fundamentals of lesion localization have not changed very much over the years, although the tools for doing so have made the task easier.
Goran, 57 years: There are some exceptions to the general rule that sensory information enters the spinal cord via the dorsal roots.