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Postoperative cerebrospinal fluid (CSF) leakage is the leading adverse event in transsphenoidal surgery. Intraoperative CSF (ioCSF) leakage is one of the most important predictive factors for postoperative CSF leakage. This systematic review and meta-analysis aimed to evaluate the effectiveness of artificial intelligence (AI) models in predicting ioCSF. Literature records were retrieved on June 13, 2024, using the relevant key terms without filters in PubMed, Embase, Scopus, and Web of Science. Records were screened according to the eligibility criteria, and the data from the included studies were extracted. The quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies–2 tool. The meta-analysis, sensitivity analysis, and meta-regression were conducted using R software. Our results demonstrate that the AI models achieved a pooled sensitivity of 93.4% (95% confidence interval [CI]: 74.8%–98.6%) and specificity of 91.7% (95% CI: 75%–97.6%). The subgroup analysis revealed that the pooled sensitivities in machine learning and deep learning were 86.2% (95% CI: 83%–88.8%) and 99% (95% CI: 93%–99%), respectively (P < 0.01). The subgroup analysis demonstrated a pooled specificity of 92.1% (95% CI: 63.1%–98.7%) for machine learning and 90.6% (95% CI: 78.2%–96.3%) for deep learning models (P = 0.87). The diagnostic odds ratio meta-analysis revealed an odds ratio 114.6 (95% CI: 17.6–750.9). The summary receiver operating characteristic curve demonstrated that the overall area under the curve of the studies was 0.955, which is a considerable performance. AI models have demonstrated promising performance for predicting the ioCSF leakage in pituitary surgery and can optimize the treatment strategy. [ABSTRACT FROM AUTHOR]

To objectively correlate distortions of optic apparatus morphology in patients with pituitary adenomas undergoing trans-sphenoidal surgery. In this retrospective analysis, visual acuity (VA), visual field (VF), and total visual (TV) function were objectively scored in patients selected from an institutional cohort of pituitary adenomas. The following imaging measures of optico-chiasmatic morphology were recorded preoperatively, and at 3 months after surgery: chiasm area, mid-chiasm height (CH), optic nerve-canal bending angle (BA), and optic nerve kinking angle (ONKA). Receiver operator characteristic analysis was performed to establish optimal thresholds for achieving a "normal" TV score of 200 at 1-year follow-up. Seventy-one eyes were individually studied. VA, VF, and TV scores significantly improved after surgery, both at the 3-month and at the 1-year follow-up visits (P < 0.001). Cranio-caudal tumor dimension was significantly associated with VA, VF, and TV scores, both preoperatively and postoperatively. There were significant changes in CH (P < 0.001), BA (P < 0.001), and ONKA (P < 0.001) at 3 months after surgery, but not in chiasm area (P = 0.061). Baseline VA, VF, and TV scores were positively correlated with preoperative CH and ONKA, while VF and TV scores also demonstrated significant negative correlations with preoperative BA. VF scores at 1-year follow-up were significantly correlated with preoperative and change in BA values, as well as with preoperative and change in ONKA values. Receiver operator characteristic analysis revealed that only the preoperative ONKA was found to have acceptable discrimination (area under the curve >0.7) for predicting "normal" TV score. Chiasm sag was noted in 45.8% of patients at 1-year follow-up, but was not associated with delayed visual deterioration in any case. Anatomic realignment of the optic apparatus 3 months following trans-sphenoidal surgery predicts VF scores, but not VA or TV scores at 1-year follow-up. Patients with preoperative ONKA values of more than 139.3° have a 76% chance of achieving normal TV scores 1 year after surgery. Postoperative chiasm sag appears to be clinically irrelevant at short-term follow-up. [ABSTRACT FROM AUTHOR]

Almost all postoperative assessments for pituitary patients are performed in clinical settings under the supervision of medical providers. With the emergence of telemedicine, however, there are opportunities to monitor these patients remotely. The potential for use of such technologies is inconsistently described in the brain tumor literature, especially for patients with pituitary adenomas. In this comprehensive narrative review, we present the literature for the use of mobile applications (apps) for monitoring of postoperative symptomatology that is specific to patients undergoing pituitary surgery. Our primary research question was: "Which smartphone apps exist in the literature to monitor parameters associated with common complications of pituitary surgery?" Specifically, we search for apps in the literature that facilitate the measurement of parameters associated with adrenal insufficiency, disorders of water imbalance, and visual changes—3 common complications of pituitary surgery. Twenty-six apps were identified. Fourteen apps pertained to monitoring of visual changes, followed by 9 apps for monitoring water and electrolyte imbalances and 3 apps for monitoring adrenal dysfunction. Novel technologies that were integrated into these apps included digital image-based colorimetry, sonouroflowmetry, visual contrast sensitivity, and lateral flow immunoassays, among others. Due to advancing capabilities of smartphone apps, the potential of telemedicine may extend beyond patient appointments. We show that by integrating novel advances in medical technologies from a variety of specialties, it is possible to develop smartphone-based protocols for remote monitoring of patients after pituitary surgery. [ABSTRACT FROM AUTHOR]

Superior surgical skill improves surgical outcomes in endoscopic pituitary adenoma surgery. Video-based coaching programs, pioneered in professional sports, have shown promise in surgical training. In this study, we developed and assessed a video-based coaching program using artificial intelligence (AI) assistance. An AI-assisted video-based surgical coaching was implemented over 6 months with the pituitary surgery team. The program consisted of 1) monthly random video analysis and review; and 2) quarterly 2-hour educational meetings discussing these videos and learning points. Each video was annotated for surgical phases and steps using AI, which improved video interactivity and allowed the calculation of quantitative metrics. Primary outcomes were program feasibility, acceptability, and appropriateness. Surgical performance (via modified Objective Structured Assessment of Technical Skills) and early surgical outcomes were recorded for every case during the 6-month coaching period, and a preceding 6-month control period. Beta and logistic regression were used to assess the change in modified Objective Structured Assessment of Technical Skills scores and surgical outcomes after the coaching program implementation. All participants highly rated the program's feasibility, acceptability, and appropriateness. During the coaching program, 63 endoscopic pituitary adenoma cases were included, with 41 in the control group. Surgical performance across all operative phases improved during the coaching period (P < 0.001), with a reduction in new postoperative anterior pituitary hormone deficit (P = 0.01). We have developed a novel AI-assisted video surgical coaching program for endoscopic pituitary adenoma surgery - demonstrating its viability and impact on surgical performance. Early results also suggest improvement in patient outcomes. Future studies should be multicenter and longer term. [ABSTRACT FROM AUTHOR]

Advances in endoscopic endonasal transsphenoidal surgery have led to improved postoperative outcomes after pituitary adenoma resection, including reduced length of stay, complications and readmission rates, without compromising safety and satisfaction. Our team implemented a perioperative protocol in January 2021 for patients undergoing endoscopic, transsphenoidal pituitary surgery. This study compares preoperative characteristics and postoperative outcomes in 279 patients between 2016 and 2022 (128 preprotocol and 151 postprotocol). Our protocol includes interdisciplinary preoperative evaluations, unified communication, cortisol thresholds for postoperative glucocorticoid replacement, and fluid restriction to prevent delayed hyponatremia. Median age was 54 ± 17 years with 50.8% female patients. There were 229 (82.1%) macroadenomas (>1 cm) and 50 (17.9%) microadenomas/cysts (<1 cm). Mean diameter was 18 (transverse), 18 (craniocaudal), 16 (anteroposterior) mm. Tumor types included 125 (44.8%) gonadotroph, 46 (16.4%) adrenocorticotroph, 40 (14.3%) lactotroph, 26 (9.3%) Rathke cysts, 19 (6.8%) somatotroph, 13 (4.6%) nondiagnostic, 3 (1%) somatotroph-lactotroph, 3 (1%) mammosomatotroph, 2 (0.71%) null cell, and 2 (0.7%) thyrotroph adenomas. Postprotocol, 74.2% of patients were discharged on postoperative day 1 compared with 46.1% preprotocol (P < 0.0001). Transient arginine vasopressin deficiency decreased from 10.4% (preprotocol) to 4.6% postprotocol (P = 0.101). Hyponatremia occurred in 13.3% pre-protocol and 4.6% postprotocol. Emergency department visits dropped from 9.4% to 3.9%, and readmissions decreased from 7.8% to 2.6%. Persistent arginine vasopressin deficiency affected 2.3% preprotocol and 1.3% postprotocol patients. Cerebrospinal fluid leaks occurred in 8.5% preprotocol and 7.3% postprotocol. Implementing an interdisciplinary, perioperative protocol for transsphenoidal endoscopic pituitary surgery improves length of stay while minimizing readmissions and surgery-related complications. [ABSTRACT FROM AUTHOR]

Hyponatremia is a common complication following endoscopic endonasal resection (EER) of pituitary adenomas. We report a single-center, multisurgeon study detailing baseline clinical data, outcomes, and factors associated with postoperative hyponatremia. This was a retrospective cohort study of patients undergoing EER for pituitary adenoma at Tufts Medical Center. Most procedures were performed by the senior author (C.B.H.). Cases were included if at least 1 postoperative sodium value was available and pathology confirmed pituitary adenoma. Hyponatremia was defined as a postoperative sodium level <135 mEq/L. A total of 272 patients underwent 310 EER procedures that met the study inclusion criteria. The mean patient age was 53.3 years, and mean tumor size was 18.8 mm. Postoperative hyponatremia occurred in 12.6% of cases, with 3.6% developing hyponatremia prior to discharge. Lower preoperative sodium level was associated with an increased risk of developing any postoperative hyponatremia. Older age, prolactinoma pathology, and use of selective serotonin reuptake inhibitors were associated with moderate to severe hyponatremia (≤129 mEq/L), and lower preoperative sodium was associated with mild hyponatremia (130–134 mEq/L). Hyponatremia-related readmissions within 30 days occurred in 3.9% of patients. Both African-American race and postoperative hyponatremia were associated with an increased risk of 30-day readmission. The mean nadir sodium for hyponatremic patients was 129.9 mEq/L. Growth hormone–secreting pathology was associated with lower postoperative nadir sodium, whereas higher preoperative sodium was associated with higher postoperative nadir sodium. Hyponatremia is a common postoperative complication of EER for pituitary lesions that can cause significant morbidity, increased readmissions, and increased healthcare costs. [ABSTRACT FROM AUTHOR]

Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS. [ABSTRACT FROM AUTHOR]

Routine evaluation and surveillance imaging after pituitary adenoma (PA) endoscopic endonasal transsphenoidal resection (EETS) is a neurosurgical practice to identify tumor recurrence. This study aims to identify social and clinical factors that may contribute to patients missing their initial 1-year follow-up appointment and provide guidance for targeted education to improve patient adherence with postoperative treatment plans, ultimately reducing unknown adenoma recurrence. The authors performed a single-center retrospective review of patients who underwent EETS for PAs from 2007 to 2023. Patients were analyzed for sociodemographic factors, presenting symptoms, time to surgery, surgical outcomes, and adherence to postoperative follow-up visits at 1 year after surgery. A total of 256 patients with PAs treated by EETS met inclusion criteria; 218 (85%) of these patients attended 1-year follow-up, and 38 (15%) missed this visit. Twenty-nine (76%) individuals who missed their 1-year follow up were men (P = 0.006). Divorced/widowed/separated patients were 2 times more likely to miss their follow-up compared with their married counterparts (P = 0.008). Additional significant risk factors included older age, as the mean age for patients who missed their 1-year appointment was 60.1 years compared with 54.7 years (P = 0.028). Patients with visual field deficits at initial presentation were also less likely to follow-up at 1 year (P = 0.03). Risk factors of missed 1-year follow-up appointments after PA resection include male sex, divorced/widowed/separated marital status, older age, and the presence of visual deficits at initial presentation. Increased education efforts can be selectively aimed at these at-risk patient cohorts to improve patient compliance and reduce consequences of undetected tumor recurrence. [ABSTRACT FROM AUTHOR]

Cerebrospinal fluid (CSF) leak during endoscopic endonasal transsphenoidal surgery can lead to postoperative complications. The clinical and anatomic risk factors of intraoperative CSF leak are not well defined. We applied a two-dimensional (2D) convolutional neural network (CNN) machine learning model to identify risk factors from preoperative magnetic resonance imaging. All adults who underwent endoscopic endonasal transsphenoidal surgery at our institution from January 2007 to March 2023 who had accessible preoperative stereotactic magnetic resonance imaging were included. A retrospective classic statistical analysis was performed to identify demographic, clinical, and anatomic risk factors of intraoperative CSF leak. Stereotactic T2-weighted brain magnetic resonance imaging scans were used to train and test a 2D CNN model. Of 220 included patients, 81 (36.8%) experienced intraoperative CSF leak. Among all preoperative variables, visual disturbance was the only statistically significant identified risk factor (P = 0.008). The trained 2D CNN model predicted CSF leak with 92% accuracy and area under receiver operating characteristic curve of 0.90 (sensitivity of 86% and specificity of 93%). Class activation mapping of this model revealed that anatomic regions of CSF flow were most important in predicting CSF leak. Further review of the class activation mapping gradients revealed regions of the diaphragma sellae, clinoid processes, temporal horns, and optic nerves to have anatomic correlation to intraoperative CSF leak risk. Additionally, visual disturbances from anatomic compression of the optic chiasm were the only identified clinical risk factor. Our 2D CNN model can help a treating team to better anticipate and prepare for intraoperative CSF leak. [ABSTRACT FROM AUTHOR]

To identify high-risk patients for delayed postoperative hyponatremia (DPH) early, we constructed a simple and effective scoring system. We retrospectively analyzed 141 consecutive patients who underwent endoscopic transsphenoidal surgery from January 2019 to December 2022. Patients were divided into DPH group and nondelayed postoperative hyponatremia group based on whether hyponatremia occurred after the third postoperative day. Multivariable logistic regression analysis was conducted to determine the predictive factors of DPH, and a simple scoring system was constructed based on these predictors. Among 141 patients, 36 (25.5%) developed DPH. Multivariable logistic regression analysis showed that age ≥48 years (odds ratio [OR], 3.74; 95% confidence interval [CI], 1.14–12.21; P = 0.029), Knosp grade ≥3 (OR, 5.17; 95% CI, 1.20–22.27; P = 0.027), postoperative hypokalemia within three days (OR, 3.13; 95% CI, 1.05–9.33; P = 0.040), a difference in blood sodium levels between the first and second day after surgery ≥1 mEq/L (OR, 3.65; 95% CI, 1.05–12.77; P = 0.043), and postoperative diabetes insipidus (OR, 3.57; 95% CI, 1.16–10.96; P = 0.026) were independent predictors of DPH. This scoring system for predicting DPH has an area under the receiver operating characteristic curve of 0.856 (95% CI, 0.787–0.925), indicating moderate to good predictive value for DPH in our cohort, but further prospective external validation is needed. [ABSTRACT FROM AUTHOR]

This study aims to assess the utility of magnetic resonance imaging (MRI) 3D SPACE T2-weighted imaging (T2WI) sequences in evaluating cavernous sinus invasion by pituitary adenomas. Data were collected from patients who underwent continuous pituitary MRIexaminations at the Medical Imaging Center of our hospital from October 2019 to February 2021. Eligible cases were evaluated for sagittal and axial T1WI sequences, coronal 3D SPACE T2WI sequences, and sagittal and coronal enhanced T1-weighted imaging (T1WI) sequences using the INFINITT PACS workstation. The Wilcoxon signed-rank test for paired samples and the Mann–Whitney U test for 2 independent samples were used to statistically analyze differences in image quality scores among various groups. In addition, the sensitivity, specificity, positive predictive value, and negative predictive value of each observation index were compared with intraoperative results. 3D SPACE T2WI showed superior cavernous sinus imaging quality compared with contrast enhanced T1WI and T2WI plain scans (P < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 90.0%, 55.60%, and 100.0%, respectively. The accuracy for pituitary adenoma invasiveness diagnosis based on cavernous sinus medial wall integrity was 94.40%. The imaging quality of the medial wall of the cavernous sinus on the 3D SPACE T2WI plain scan sequence surpassed that of contrast enhanced T1WI TSE-enhanced scans and T2WI TSE plain scans. The continuous observation of the medial wall of the cavernous sinus using this sequence holds great diagnostic value for assessing cavernous sinus invasion by pituitary adenomas. This strategy is more reliable than traditional MRI observation indicators. [ABSTRACT FROM AUTHOR]

As surgical techniques become less invasive, the use of endoscopy in brain surgery supports this trend. Numerous endoscopic surgical approaches have been defined, especially for skull base diseases. The current study summarizes our experience of using the rarely reported endoscopic transnasal transdiaphragmatic approach through the existing hole in the diaphragma sella to access lesions extending into the suprasellar region. Our surgical team performed 4876 endoscopic endonasal surgeries between August 1997 and December 2022 at the Department of Neurosurgery, Pituitary Research Center, Faculty of Medicine, Kocaeli University. The study retrospectively analyzed data from 11 patients who had undergone endoscopic transnasal transdiaphragmatic surgery since January 2020. Preoperative and postoperative magnetic resonance imaging, pituitary function examination, and clinical observation were carried out. The mean age of the patients was 31.1 ± 10.7 years and the female/male ratio was 6:5. Pathologic subtypes observed included breast cancer metastasis (n = 1), adrenocorticotropic hormone–secreting adenoma (n = 4), growth hormone–secreting adenoma (n = 3), craniopharyngioma (n = 2), and Rathke cleft cyst (n = 1). The mean postoperative hospital stay was 4.7 ± 1.1 days and none of the patients showed cerebrospinal fluid leakage during this period. The endoscopic transnasal transdiaphragmatic approach may be considered an alternative to the conventional extended endoscopic transnasal approach in patients with lesions extending into the suprasellar region. The main strength of this method is that it facilitates suprasellar region access through a small dural incision and bone defect in the base of the skull. As a result, it also reduces the risk of postoperative cerebrospinal fluid leakage and associated complications. [ABSTRACT FROM AUTHOR]

The heterogeneity of the somatotroph adenomas, especially for sparsely granulated (SG) and densely granulated (DG) subtypes, has attracted great attention in identifying their imaging biomarker. The purpose of the current study was to compare the diagnostic performance of diffusion-weighted and T2-weighted magnetic resonance imaging (MRI) sequences for preoperatively distinguishing the granulation patterns of somatotroph adenomas. Thirty-two patients with a clinical diagnosis of somatotroph adenomas from October 2018 to March 2023 were included in this study. Coronal diffusion-weighted imaging (DWI) and T2-weighted MRI sequence data were collected from 3.0T MRI and compared between SG and DG groups. The immunohistochemistry was used to confirm the electron microscopy pathologic subtypes and Ki67 expression levels of somatotroph adenomas postoperatively. Patients in the SG group had significantly higher signal intensity (SI) ratio of DWI (rDWI) (P < 0.001), lower SI ratio of apparent diffusion coefficient (rADC) (P < 0.001), and higher SI ratio of T2-weighted imaging (P = 0.011). The combined diagnosis index of rDWI and rADC had the highest diagnostic efficiency in predicting SG adenomas (sensitivity, 93.3%; specificity, 88.2%; P < 0.001). The rDWI and rADC values had positive and negative correlations with the Ki67 index and tumor maximum diameter, respectively. Lower rADC×103 was an independent predictor for SG adenomas. Our results indicated that compared with previously used T2-weighted imaging, the DWI sequence, especially the combined diagnosis index of rDWI and rADC, could more efficiently distinguish the granulation patterns of somatotroph adenomas preoperatively. [ABSTRACT FROM AUTHOR]

According to the 2017 World Health Organization classification of neuro-endocrine tumors, pituitary adenomas (PAs) are classified according to immunoexpression of the pituitary-specific transcription factors (TFs). A small subset of PAs exhibit multiple TF staining on immunohistochemistry and we present a series of 27 pathologically-confirmed cases of dual TF staining PAs (dsTF-PAs), and report clinically relevant implications. A retrospective chart review of a multi-institutional database of patients with PAs surgically resected between 2008–2021 was performed. PAs expressing immunopositivity 2+ TFs. Patient demographics, neuro-imaging characteristics, histopathologic findings, and clinical data were collected. Twenty-seven patients had pathologically verified dsTF-PAs, of whom 17 were female (63%), with ages ranging from 20–84 years. Twenty-three (85.2%) patients harbored functional PAs, with acromegaly being the most common functional subtype (86.4%). The most common combination of TFs within a single tumor was PIT-1/SF-1 (85.2%). Six PAs exhibited Knosp cavernous sinus invasion grades of 3 or 4 and the Ki-67 labeling index was ≥3% in 6 patients (24.0%) and all stained for PIT-1/SF-1. Hormonal remission was achieved in 78% of functional dsTF-PAs. No PAs showed evidence of recurrence or progression over the mean follow-up period of 28.5 months. PAs exhibiting dsTF-PAs represent a small but clinically relevant diagnostic subset of PAs according to the 2021 World Health Organization criteria, as a majority are GH-producing. Precise classification using TF staining plays a key role in understanding the biology of these tumors. Favorable outcomes can be achieved in this subset of PAs with evolving TF classification. [ABSTRACT FROM AUTHOR]

Giant pituitary adenomas (>4 cm, GPAs) have presented great challenges to surgeons because the residual tumor in the subarachnoid space can cause hemorrhage or vessel injury following apoplexy. This study aimed to investigate the factors limiting surgical success in endoscopic skull base surgery (ESS) for GPAs. ESS was performed on 67 consecutive patients with GPAs from 2010 to 2020. We retrospectively analyzed the clinical and radiologic features and surgical outcomes. Correlations between the tumor characteristics and extent of resection were statistically presented with odds ratios (ORs). Preoperative visual and hormonal impairments were present in 59 (88.1%) and 55 patients (82.1%), respectively. Gross total resection (GTR) was achieved in 58.2% of patients, and the tumor remained on the lateral side of the subarachnoid space or the cavernous sinus when complete resection failed. The tumor volume, maximal diameter, multilobulated shape, cavernous sinus invasion, posterior fossa extension, and extent of suprasellar lateral extension of tumors were significantly correlated with incomplete resection. In tumors with subarachnoid lateral extension, greater distances from the medial wall of the proximal cavernous internal carotid artery to the most lateral tumor significantly increased the risk of incomplete resection for the suprasellar lateral portion of the tumor, with an OR of 1.21. Considerable surgical planning in ESS for GPAs is crucial for complete resection and patient safety. We elucidated that lateral extension of tumors in the subarachnoid space hindered the surgical success of the suprasellar portion of the tumor. [ABSTRACT FROM AUTHOR]

Fractionated stereotactic radiotherapy (FSRT) is a common modality used to treat pituitary adenomas with good control rates. It is not known whether FSRT should be performed early or delayed until progression occurs. We compared FSRT in treating nonfunctional pituitary adenomas (NFPA) as an adjuvant (ADJ) or on-progression (PRG) therapy. A retrospective review of patients who underwent FSRT for an NFPA between January 2004 and December 2022 at a single institution was performed. We compared endocrinologic, ophthalmologic, and radiographic outcomes in FSRT delivered as ADJ and PRG treatment. Seventy-five patients were analyzed, with a median follow-up of 53 months. FSRT was administered to 35 and 40 patients as ADJ and PRG, with a median time to treatment of 5.5 and 40 months, respectively. The tumor control rate was 94.3% for ADJ and 95.0% for PRG. Treatment resulted in 4 (11.4%) versus 7 (17.5%) new endocrinopathies and 2 (5.7%) versus 1 (2.5%) new visual deficits for ADJ versus PRG. A survival analysis of time to new endocrinopathy showed no difference between the 2 cohorts. The median time from surgery to new endocrinopathy was significantly different between ADJ and PRG, at 15.5 and 102.0 months, respectively. FSRT is effective in treating NFPA for residual and progressive tumors, with excellent tumor control rates and a low risk of developing new endocrinopathies and visual deficits. Delaying treatment delayed the development of new endocrinopathies, suggesting that observation with FSRT on tumor progression may delay the onset of hypopituitarism and maintain similar effectiveness in tumor control. [ABSTRACT FROM AUTHOR]

Patients with pituitary adenomas (PAs) are at an increased risk preoperatively and postoperatively for hypopituitarism. Postoperative hypocortisolism is associated with increased mortality and morbidity as well as poor quality of life. However, research about the risk factors for postoperative hypocortisolism is limited, and a predictive nomogram for postoperative hypocortisolism has not yet been developed. We aimed to investigate the predictive factors for postoperative hypocortisolism and construct a dynamic online nomogram. Our database included 438 consecutive PA patients who were hospitalized and treated with transsphenoidal surgery by experienced neurosurgeons from the different medical teams in the Neurosurgery Department, Jinling Hospital, between January 2018 and October 2020. The final study group included 238 eligible patients. Data on possible predictors, including age, sex, treatment history of PAs, preoperative signs and symptoms, primary recurrence subtype, and clinical subtypes, were collected. Univariable and multivariable logistic regression analyses were applied to identify independent predictors, which were included in constructing the nomogram model. The calibration curve and receiver operating characteristic curve were computed to evaluate the predictive performance of the nomogram model. The incidence of postoperative hypocortisolism was 12.08%. Three preoperative predictors were identified to construct the nomogram: surgical type (microscopic or endoscopic, with endoscopic surgery proven to be the protective factor) (odds ratio, 0.24; 95% confidence interval [CI], 0.093–0.610; P = 0.003), prothrombin time (odds ratio, 2.40; 95% CI, 1.332–4.326; P = 0.004), and basophil cell count (odds ratio, 5.25; 95% CI, 1.270–21.816; P = 0.022,). The area under the curve of receiver operating characteristic curve for the constructed nomogram was 0.749 (95% CI, 0.640–0.763); a well-fixed calibration curve was generated for the nomogram model. An interactive web-based dynamic nomogram application was also constructed. In this study, surgical type, prothrombin time, and basophil cell count were the most relevant predictive factors for postoperative hypocortisolism. A predictive nomogram that can preoperatively assess the risk of hypocortisolism after surgical treatment of PAs was developed. This nomogram could be helpful in identifying high-risk patients who require close monitoring of serum cortisol levels and initiating clinical procedures for patients requiring cortisol administration therapy as a lifesaving strategy. [ABSTRACT FROM AUTHOR]

The primary objective of this systematic review is to evaluate the effectiveness of intraoperative ultrasound (IOUS) in improving outcomes in patients undergoing pituitary surgery. A systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic bibliographic databases from conception to 2022. The included studies yielded a total of 660 patients, with 488 patients undergoing IOUS. Outcome were available for 341 patients treated with IOUS and 157 patients who were treated without the IOUS application, and the remission rates following surgery were 76% and 59%, respectively. Only 2 studies reported remission rates for both groups, and meta-analysis for these studies showed significant superiority of intraoperative ultrasonography (Random effect, odds ratio 4.99, P < 0.01). Regarding extent of resection, IOUS resulted in 71% gross total resection, while absence of IOUS yielded a gross total resection rate of 44%. Among studies with available follow-up on IOUS, the recurrence rate was 3%. Pituitary dysfunction (34%), cerebrospinal fluid leak (31%), and central nervous system infection (8%) were the most common complications in the IOUS group. The mean follow-up was 19.97 months in studies reporting follow-up time. The application of the IOUS is both safe and effective and could improve the outcome of pituitary surgeries. IOUS can assist surgeons in the identification of pituitary tumors and their surrounding anatomy and can help minimize the risk of complications associated with this complex surgical procedure. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the association between intraoperative intrasellar pressure (ISP) and pre- and postoperative endocrine disturbances with focus on hyperprolactinemia and hypopituitarism in patients with pituitary tumors. The study is a consecutive, retrospective study with ISP collected prospectively. One hundred patients operated with transsphenoidal surgery due to a pituitary tumor, who had their ISP measured intraoperatively, were included. Data on patient endocrine status preoperatively and from 3-month postoperative follow-up were collected from medical records. The risk of preoperative hyperprolactinemia in patients with nonprolactinoma pituitary tumors increased with ISP (unit odds ratio 1.067, n = 70) (P = 0.041). Preoperative hyperprolactinemia was normalized at 3 months after surgery. Mean ISP was higher in patients with preoperative thyroid-stimulating hormone (TSH) deficiency (25.3 ± 9.2 mmHg, n = 37) than in patients with intact thyroid axis (21.6 ± 7.2 mmHg, n = 50) (P = 0.041). No significant difference in ISP was found between patients with and without adrenocorticotropic hormone(ACTH) deficiency. No association was found between ISP and postoperative hypopituitarism at 3 months after surgery. In patients with pituitary tumors, preoperative hypothyroidism and hyperprolactinemia may be associated with higher ISP. This is in line with the theory of pituitary stalk compression, suggested to be mediated by an elevated ISP. ISP does not predict the risk of postoperative hypopituitarism 3 months after surgical treatment. [ABSTRACT FROM AUTHOR]

Diabetes insipidus (DI) is a common complication after endoscopic transsphenoidal surgery (TSS) for pituitary adenoma (PA), which affects the quality of life in patients. Therefore, there is a need to develop prediction models of postoperative DI specifically for patients who undergo endoscopic TSS. This study establishes and validates prediction models of DI after endoscopic TSS for patients with PA using machine learning algorithms. We retrospectively collected information about patients with PA who underwent endoscopic TSS in otorhinolaryngology and neurosurgery departments between January 2018 and December 2020. The patients were randomly split into a training set (70%) and a test set (30%). The 4 machine learning algorithms (logistic regression, random forest, support vector machine, and decision tree) were used to establish the prediction models. Area under the receiver operating characteristic curves were calculated to compare the performance of the models. A total of 232 patients were included, and 78 patients (33.6%) developed transient DI after surgery. Data were randomly divided into a training set (n = 162) and a test set (n = 70) for development and validation of the model, respectively. The area under the receiver operating characteristic curve was highest in the random forest model (0.815) and lowest in the logistic regression model (0.601). Invasion of pituitary stalk was the most important feature for model performance, closely followed by macroadenomas, size classification of PA, tumor texture, and Hardy-Wilson suprasellar grade. Machine learning algorithms identify preoperative features of importance and reliably predict DI after endoscopic TSS for patients with PA. Such a prediction model may enable clinicians to develop individualized treatment strategy and follow-up management. [ABSTRACT FROM AUTHOR]

The literature includes many studies examining the genetic abnormalities that influence pituitary adenomas (PAs). We aimed to state the collective knowledge on the genetic underpinnings of PAs by organizing, summarizing, and consolidating the literature to serve as a comprehensive review for scientists and clinicians of the most up-to-date information underlying the genetic landscape of PAs. The PubMed and Google Scholar databases were searched using multiple key words and combined Medical Subject Headings terms; only articles published in English between January 2000 and January 2022 were included. Articles in which the focus did not relate to genetics, that included mainly anecdotal evidence, or that were single case studies were eliminated. PAs are one of the most common intracranial neoplasms. However, the genetic underpinnings for these tumors are not yet fully elucidated. There are several categories of PAs: clinically significant versus not clinically significant, functional versus nonfunctional, and germline-derived versus sporadic origin. Each of these disease subcategories is characterized by unique genetic aberrations. Recently, more genes and other types of genetic aberrations have been identified as possible causes of PAs, such as copy number variations and altered levels of microRNAs. This review serves to consolidate and summarize the literature discussing the genetic motifs of PAs to help physicians and scientists deliver patient-centered therapies. [ABSTRACT FROM AUTHOR]

Clinical paradigms and consensus recommend dopamine agonists (DAs) as the primary treatment for prolactinomas. However, medically treated patients also encounter challenges such as DA resistance, intolerable side effects, and recurrence of hyperprolactinemia after DA withdrawal. Technical advances in transsphenoidal resection, with an endoscopic endonasal approach, have led to improved visualization of tumor, decreased postoperative morbidity, and shortened length of stay. We examined the indications and outcomes in patients with prolactinomas who underwent surgical resection at our center. A retrospective analysis was performed of 60 consecutive patients with prolactinomas who underwent endoscopic endonasal transsphenoidal resection between August 2010 and July 2019 and were followed by the same multidisciplinary team. Women comprised 73% of surgical cases, and 60% of the tumors were macroadenomas. The most common primary surgical indication was patient preference (26.6%) followed by DA intolerance (25%) and DA failure (18.3% inadequate shrinkage, 15% persistent hyperprolactinemia, 11.7% both). Gross total resection was noted in 83% and length of stay was 1 day in 92% of patients. Early remission (postoperative day 1 normalization of prolactin off DA therapy) was seen in 71% of all patients, 91% of microadenomas, 56% of macroadenomas, 65% of Knosp grade 0–2 macroadenomas, and 75% of macroadenomas operated on with expectation of a cure. Only 3 patients had recurrence, at 4.3, 3.3, and 1.6 years of follow-up, respectively. Endoscopic endonasal resection is a viable option for management of patients with prolactinomas in the setting of a high-volume pituitary center, with minimal postoperative complications. [ABSTRACT FROM AUTHOR]

The aim of this study was to understand the global trends in the proliferation of various minimal invasive approaches including the endonasal endoscopic approach (EEA) and the extended EEA. Questions about the use of the supraorbital and transorbital approach were also included. We conducted an online anonymized and validated survey using a structured questionnaire on the use of EEA and EEEA, as well as periorbital approaches, in the management of sellar, suprasellar, and parasellar lesions in different parts of the world. A total of 261 responses were received. Of respondents, 195 (74.71%) received training in EEA, but less than half during residency. Of respondents, 108 mentioned that parasellar lesions comprised 5%–25% of the total cases encountered in the past 5 years in their practice. Only half of the respondents relied on ENT (ear, nose, and throat) colleagues for the approach. Whereas Europe and South America relied on EEA about half the time, North America and Asia used EEA only a third of the time; in Africa, EEA was hardly used at all. The proportion of respondents using EEA for >50% of giant pituitary adenoma, olfactory groove meningiomas, craniopharyngiomas, chordoma, tuberculum sella meningiomas, and malignant skull base tumors was 34.5%, 3.4%, 13%, 16%, 7%, and 10%, respectively. EEEA, the supraorbital approach, and the transorbital approach were used by 50.6%, 54.4%, and 34.5%, respectively. EEEA was used predominantly by those having an experience of 11–20 years or >30 years after residency (P = 0.018) and those from North America (64.1%). Our survey highlights the various geographic and demographic trends in the use of the EEA for sellar, suprasellar, and parasellar diseases. Although EEA training was present in almost all countries, the approach was not used as frequently as would have been expected for giant adenomas, craniopharyngiomas, and chordomas. After 20 years of education about the technique and indications of the endoscopic endonasal approach, through countless courses and publications, the use of EEA is still lagging, particularly in developing countries. [ABSTRACT FROM AUTHOR]

Endoscopic endonasal surgery is the main transsphenoidal approach for pituitary surgery in many centers; however, few studies compare the endoscopic and microscopic surgical approaches with regard to long-term follow-up. This single-center study aimed to compare the 2 techniques over 15 years. Medical records and magnetic resonance images from 40 patients with primary transsphenoidal surgery for Cushing's disease at Sahlgrenska University Hospital between 2003 and 2018 were reviewed. 14 patients who underwent microscopic surgery and 26 patients who underwent endoscopic surgery were included in this study. In the microscopic group, 12 of 14 patients achieved endocrine remission, compared to 19 of 26 patients in the endoscopic group (n. s.). Three patients in each group developed a late recurrence. Complications were seen in 5 patients in the microscopic group and in 8 patients in the endoscopic group (n. s.). No serious complications, such as carotid artery damage, cerebrovascular fluid leakage, epistaxis, or meningitis, occurred in any group. The postoperative hospital stay was shorter in the endoscopic than in the microscopic group. Endoscopic endonasal surgery for Cushing's disease showed no difference in remission, recurrence, and complication rates compared to the microscopic approach. The endoscopic group had a shorter postoperative hospital stay than the microscopic group, which in part may be due to the minimal invasiveness of the endoscopic approach. [ABSTRACT FROM AUTHOR]

Increasing patient age has been associated with worse outcomes after pituitary adenoma resection in previous studies, but the prognostic value of frailty compared with advancing age on pituitary adenoma resection outcomes has not been clearly evaluated. The National Surgical Quality Improvement Program from 2015 to 2019 was queried for data for patients aged >18 years who underwent pituitary adenoma resection (n = 1454 identified patients). Univariate and multivariate analyses of age and frailty (5-factor modified frailty index [mFI-5]) were performed on 30-day mortality, major complications, extended length of stay (eLOS), discharge destination, and readmission and reoperation. The receiver operating characteristic curve analysis was performed to compare effect of age and mFI-5. On univariate analysis, increasing frailty was significantly associated with greater risk of unplanned readmission (frail: odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2–3.2; severely frail: OR, 6.9; 95% CI, 2.4–19.8) and a major complication (frail: OR, 3.6; 95% CI, 2.1–6.1). Severe frailty was also associated with nonhome discharge (OR, 10.6; 95% CI, 3.2–35.8) and eLOS (OR, 4.5; 95% CI, 1.5–13.4). Increasing age was not associated with any of these outcome measures. Multivariate analysis also demonstrated similar trends. In receiver operating characteristic curve analysis, the mFI-5 score showed higher discrimination for major complications compared with age (area under the curve: 0.624 vs. 0.503; P < 0.001). Increasing frailty, and not advancing age, was an independent predictor for major complications, unplanned readmissions, eLOS, and nonhome discharge after pituitary adenoma resection, suggesting frailty to be superior to age in preoperative risk stratification in this patient population. [ABSTRACT FROM AUTHOR]

Adjuvant radiotherapy (RT) can help achieve local control (LC) and reduce hormonal overexpression for pituitary adenomas (PAs). Prior reports involved Gamma Knife or older linear accelerator (LINAC) techniques. The aim of this study was to report long-term outcomes for modern LINAC RT. Institutional retrospective review of LINAC RT for PAs with minimum 3 years of magnetic resonance imaging follow-up was performed. Hormonal control was defined as biochemical remission in absence of medications targeting hormone excess. LC defined using Response Evaluation Criteria in Solid Tumors on surveillance magnetic resonance imaging. Progression-free survival defined as time alive with LC without return of or worsening hormonal excess from secretory PA. Kaplan-Meier and Cox proportional hazard models used. From 2003 to 2017, 140 patients with PAs (94 nonsecretory, 46 secretory) were treated with LINAC RT (105 fractionated RT, 35 radiosurgery) with median follow-up of 5.35 years. Techniques included fixed gantry intensity-modulated radiotherapy (51.4%), dynamic conformal arcs (9.3%), and volumetric modulated arc therapy (39.3%). Progression-free survival at 5 years was 95.3% for secretory tumors and 94.8% for nonsecretory tumors. Worse progression-free survival was associated with larger planning target volume on multivariable analysis (hazard ratio 2.87, 95% confidence interval 1.01–8.21, P = 0.049). Hormonal control at 5 years was 50.0% and associated with higher dose to tumor (hazard ratio 1.05, 95% confidence interval 1.02–1.09, P = 0.005) and number of surgeries (hazard ratio 1.74, 95% confidence interval 1.05–2.89, P = 0.032). Patients requiring any pituitary hormone replacement increased from 57.9% to 70.0% after RT. Modern LINAC RT for patients with PAs was safe and effective for hormonal control and LC. No difference in LC was noted for functional versus nonfunctional tumors, possibly owing to higher total dose and daily image guidance. [ABSTRACT FROM AUTHOR]

Increasing use of imaging is associated with increasing diagnoses of pituitary incidentalomas (PIs), which often do not require surgical or medical treatment. In this study, we evaluate U.S. incidence, epidemiology, and trends of pituitary adenomas (PAs) and PIs from 2004 to 2018. A total of 50,220 PAs were selected from the SEER (Surveillance Epidemiology and End Results) 2020 submission. PIs that do not initially require surgical or medical treatment were filtered from PAs if they were best diagnostically confirmed by radiography, not indicated as prolactinomas in physician reports, not recommended surgery initially, and reported a correct tumor size. Age-adjusted incidence rates, patient demographics, tumor characteristics, trends over time, and differences between PAs and PIs were explored. Between 2004 and 2018, the incidence rates of PAs and PIs were 4.28 ± 0.04 and 1.53 ± 0.02 per 100,000 population, respectively. When observing changes from 2004 to 2018, a nearly 3-fold increase from 0.73 ± 0.05 to 2.00 ± 0.09 per 100,000 was observed for PIs. The proportion of PIs significantly increased from 24.91% of all PA diagnoses in 2004 to 42.07% in 2018 (P < 0.001). When comparing non-PI PAs with PIs, PIs were more commonly diagnosed in females (64.72% vs. 54.27%; P < 0.001) with microadenomas (61.68% vs. 13.37%; P < 0.001). Reports of increasing PAs in the United States are likely caused by an increase in diagnosing PIs. This result parallels findings from other countries. This national PI estimate may serve as a point of comparison for future studies investigating imaging and PI rates at individual institutions. [ABSTRACT FROM AUTHOR]

Crooke cell adenomas (CCAs) are rare, potentially aggressive pituitary adenomas. Data regarding prevalence and clinical course are sparse. We performed a retrospective review of 59 consecutive functioning corticotroph adenomas operated on between October 2017 and November 2020 and a literature review of CCA publications since 1991. The prevalence of CCAs among functioning corticotroph adenomas at our institution was 8.5% (5/59). In the 4 other surgical case series, prevalence of CCAs was 0%–6.8%. Our patients (4 women and 1 man, mean age 46 ± 11 years) presented with hypercortisolism (3/5), with vision loss (1/5), and incidentally (1/5). All patients had elevated adrenocorticotropic hormone (151 ± 54 pg/mL) and urinary free cortisol (830 ± 796.5 μg/day). Radiologically, 3 tumors were macroadenomas and 2 had cavernous sinus invasion. All patients achieved biochemical remission at 3 months postoperatively. One patient with a giant pituitary adenoma underwent fractionated radiation for residual tumor. During follow-up (range, 3.1–31.0 months), no patients had evidence of radiological or biochemical recurrence. The literature review identified 22 functioning corticotroph adenomas with outcome data. Additional treatments included reoperation (50%), radiation (59%), bilateral adrenalectomy (23%), and temozolomide (36%). We found a higher CCA prevalence among functioning adrenocorticotropic hormone adenomas after implementation of the 2017 World Health Organization classification. In our series and the literature, most CCAs were macroadenomas with high adrenocorticotropic hormone levels. Postoperative outcomes were excellent in our series, while some cases from the literature were refractory to standard treatments. Larger clinical and molecular studies are needed to identify patients at risk. [ABSTRACT FROM AUTHOR]

Background: Endoscopic pituitary adenoma surgery has a steep learning curve, with varying surgical techniques and outcomes across centers. In other surgeries, superior performance is linked with superior surgical outcomes. This study aimed to explore the prediction of patient-specific outcomes using surgical video analysis in pituitary surgery., Methods: Endoscopic pituitary adenoma surgery videos from a single center were annotated by experts for operative workflow (3 surgical phases and 15 surgical steps) and operative skill (using modified Objective Structured Assessment of Technical Skills [mOSATS]). Quantitative workflow metrics were calculated, including phase duration and step transitions. Poisson or logistic regression was used to assess the association of workflow metrics and mOSATS with common inpatient surgical outcomes., Results: 100 videos from 100 patients were included. Nasal phase mean duration was 24 minutes and mean mOSATS was 21.2/30. Mean duration was 34 minutes and mean mOSATS was 20.9/30 for the sellar phase, and 11 minutes and 21.7/30, respectively, for the closure phase. The most common adverse outcomes were new anterior pituitary hormone deficiency (n = 26), dysnatremia (n = 24), and cerebrospinal fluid leak (n = 5). Higher mOSATS for all 3 phases and shorter operation duration were associated with decreased length of stay (P = 0.003 &P < 0.001). Superior closure phase mOSATS were associated with reduced postoperative cerebrospinal fluid leak (P < 0.001), and superior sellar phase mOSATS were associated with reduced postoperative visual deterioration (P = 0.041)., Conclusions: Superior surgical skill and shorter surgical time were associated with superior surgical outcomes, at a generic and phase-specific level. Such video-based analysis has promise for integration into data-driven training and service improvement initiatives., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Improving the gross total resection (GTR) rate of suprasellar pituitary macroadenomas (SPMAs) using the pure endoscopic endonasal transsphenoidal approach (EETA) has been a long-standing focus of neurosurgeons. This study was aimed at evaluating the influences of the removal of the tuberculum sellae bone (TSB) without opening the dura of the tuberculum sellae on the GTR rate of SPMAs via the EETA. We retrospectively analyzed medical reports of patients with SPMAs who underwent EETA between February 2015 and November 2020. Data on clinical manifestations, endocrinologic types, imaging features (Hardy classification, morphology, and texture), clinical outcomes, and TSB removal status were collected. All patients were followed up for 6 months postoperatively. Seventy-eight patients were enrolled in our study. The GTR rates of the TSB removal group (45/78, 57.7%) and nonremoval group (33/78, 42.3%) were 80.0% (36/45) and 57.6% (19/33), respectively. Univariate logistic regression analysis found that the removal of TSB, rounded morphology, and low Hardy classification were correlated with higher GTR rates. Multiple logistic regression analysis indicated that even after adjusting for tumor types and imaging features, the removal of TSB had an independent effect on the GTR rate (odds ratio, 7.6; 95% confidence interval, 1.8–31.6; P = 0.005). The incidence rates of postoperative cerebrospinal fluid leakage and diabetes insipidus were not significantly different between the TSB removal group and TSB nonremoval group. TSB removal using EETA without opening the tuberculum sellae dura improves the GTR rate of SPMAs without increasing the incidence of postoperative complications. [ABSTRACT FROM AUTHOR]

Surgical resection remains the standard treatment for most giant pituitary adenomas (GPAs). The selected surgical approach for these complex lesions depends mainly on their extension. Single approaches may be limited in some cases presenting with invasion into multiple compartments, thereby limiting extent of resection. We report a series of patients with GPA operated on through a combined approach involving an endoscopic endonasal transsphenoidal approach and a tubular retractor-assisted transventricular approach, describing the technique, its indications, limitations, and outcomes. Baseline and postoperative clinical, functional, and morphologic variables were documented up until each patient's last follow-up visit. Five patients harboring tumors extending into the third and lateral ventricles were included. Mean extent of resection was 94.6%. Mean follow-up was 39.4 months. One patient presented with a growth hormone-secreting GPA, who achieved remission after repeat resection during follow-up. There were no intraoperative complications, and 1 patient required reoperation for cerebrospinal fluid leak repair. One patient received adjuvant radiotherapy, and 3 patients remained stable requiring no additional treatment. All patients maintained an adequate postoperative functional status. The combined approach herein described may be a safe and effective option for some patients with GPAs extending into the third and lateral ventricles. An adequate patient selection is mandatory to exploit the benefits of each individual approach. [ABSTRACT FROM AUTHOR]

Our aim was to assess the factors influencing the development of delayed hyponatremia after transsphenoidal surgery (TSS) for pituitary adenomas and analyze the effect of the difference between preoperative and postoperative pituitary stalk deviation angles on delayed hyponatremia. A retrospective study was performed on the clinical data of patients with pituitary adenomas who were treated with TSS at a single institution. On the basis of the observation of indicators such as pituitary stalk deviation angle and length of "measurable pituitary stalk" on magnetic resonance imaging, we determined the predictors of postoperative delayed hyponatremia through univariate and multivariate analyses. Microscopic TSS was performed in 422 patients with pituitary adenoma, of whom 66 experienced postoperative delayed hyponatremia. Logistic regression analysis showed that the risk of delayed hyponatremia was greater for patients with a large difference between preoperative and postoperative pituitary stalk deviation angle (odds ratio = 1.040, 95% confidence interval: 1.018–1.051; P < 0.001) and a large difference in the "measurable pituitary stalk" (odds ratio = 1.128, 95% confidence interval: 1.011–1.258; P = 0.032), and patients with high blood sodium on the second day after surgery have a lower probability of developing delayed hyponatremia. This study is the first to suggest the important role of the difference between preoperative and postoperative pituitary stalk deviation angles in predicting the development of delayed hyponatremia after TSS for pituitary adenomas. [ABSTRACT FROM AUTHOR]

Primary resection of adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma has become a front-line standard-of-care treatment for Cushing disease. However, surgical intervention can be challenging because of elevated blood pressure, as well as direct cortisol impacts on endothelial cells, vascular permeability, and tissue friability—potentially resulting in increased intraoperative bleeding. Tranexamic acid (TXA) is a well-studied, widely used intravenous hemostatic; however, the potential benefit during resection of ACTH-secreting pituitary adenoma is unstudied. The purpose of this study was to define an institutional protocol for perioperative administration of TXA in patients undergoing endoscopic endonasal approach for resection of ACTH-secreting pituitary adenoma, and to study the implementation of our novel protocol in a prospective fashion. Criteria for preoperative TXA were defined by age, medical history, and risk factors. Descriptive statistics were reported for all patients receiving perioperative TXA. Thirty patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus in 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg/hour for the duration of the procedure. No incidence of myocardial infarction or postoperative thromboembolic events were noted. Subjective assessments indicated satisfaction with the patient selection protocol, and meaningful reduction in the extent of intraoperative bleeding. Perioperative TXA represents a potentially efficacious approach for control of intraoperative bleeding during endonasal resection of ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously. [ABSTRACT FROM AUTHOR]

Pituitary apoplexy (PA) is a rare, but life-threatening, condition characterized by pituitary infarction and hemorrhage, most often in the setting of a preexisting adenoma. The risk factors and mechanisms associated with PA are poorly understood. Although neurovascular manifestations of coronavirus disease 2019 (COVID-19) infection have been documented, its association with PA has not yet been determined. From a prospectively collected database of patients treated at a tertiary care center for pituitary adenoma, we conducted a retrospective medical record review of PA cases during the COVID-19 pandemic from March 2020 to December 2020. We also conducted a literature review to identify other reported cases. We identified 3 consecutive cases of PA and concomitant COVID-19 infection. The most common symptoms at presentation were headache and vision changes. The included patients were successfully treated with surgical decompression and medical management of the associated endocrinopathy, ultimately experiencing improvement in their visual symptoms at the latest follow-up examination. COVID-19 infection in the perioperative period was corroborated by polymerase chain reaction test results in all the patients. With the addition of our series to the literature, 10 cases of PA in the setting of COVID-19 infection have been confirmed. The present series was limited in its ability to draw conclusions about the relationship between these 2 entities. However, COVID-19 infection might represent a risk factor for the development of PA. Further studies are required. [ABSTRACT FROM AUTHOR]

No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost. In 2018–2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated. Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of –8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016. These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients. [ABSTRACT FROM AUTHOR]

This study aims to evaluate the impact of surgical intervention on anxiety levels in patients with various types of pituitary adenoma (PA). A systematic review was conducted following PRISMA guidelines until October 2022, searching Embase, PubMed, Web of Sciences, and Scopus. A total of 32 studies were included, encompassing 2,681 patients with the mean age of 53.33 ± 6.48 years (43.4% male). Among all subtypes, 664 diagnosed with Cushing's disease (25.8%), 612 with acromegaly (23.8%), 282 with prolactinoma (10.9%), and 969 with nonfunctional pituitary adenomas (37.6%). Pituitary insufficiency was the most common complication. Considering therapeutic modalities, 515 patients (29.8%) underwent endoscopic trans-sphenoidal surgery, while 222 (12.9%) underwent microscopic trans-sphenoidal surgery. The type of trans-sphenoidal surgery was not specified in 977 (56.6%) patients. A total of 17 studies including 1510 patients which mostly assessed anxiety using the Hospital Anxiety and Depression Scale (HADS) and Zung Self-Rating Anxiety Scale (SAS) were included in the meta-analysis. Preoperative evaluation using Hospital Anxiety and Depression Scale (HADS) questionnaire showed a pooled score of 8.27 (95%CI 4.54–12.01), while postoperative evaluation yielded a pooled score of 6.49 (95%CI 5.35–7.63), indicating no significant difference. Preoperative SAS assessment resulted in a pooled score of 50.43 (95%CI 37.40–63.45), with postoperative pooled score of 55.91 (95%CI 49.40–62.41), showing no significant difference. Our analysis revealed no significant difference in anxiety scores pre- and postoperatively. While our findings suggest stability in anxiety levels following surgical intervention, it is imperative to recognize the limitations of the current evidence base. The observed lack of consensus may be influenced by factors such as the heterogeneous nature of the patient population, variations in the characteristics of pituitary adenomas, diverse therapeutic approaches, and potential confounding variables such as pre-existing mental health conditions and coping mechanisms. Further research is warranted to elucidate the nuanced relationship between surgical intervention for PA and anxiety outcomes, considering these complex interactions and employing rigorous methodologies to address potential sources of bias. [ABSTRACT FROM AUTHOR]

The 2017 World Health Organization classification of pituitary adenomas identified the plurihormonal PIT-1–positive (PP1) adenoma as a distinct subtype. The reported data suggest that PP1 adenomas encompass the former class of silent subtype 3 (SS3) adenomas and might have an aggressive phenotype. In the present study, we summarized the current clinical data on PP1 and SS3 adenomas and compared the reported data with the data from a single institutional cohort. Medline and Google Scholar were searched from 1990 to 2020 for clinical series of PP1 and SS3 adenomas in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. Studies were included if they had reported pituitary pathology as PP1 or SS3 adenomas and had reported the clinical outcomes after surgical intervention. To better define the PP1 phenotype compared with non-PP1 adenomas, we also reviewed the adenomas treated surgically at our institution from 2012 to 2019. Of all the tumors reported in the studies as PP1 or SS3, 99% were macroadenomas and 18% were giant adenomas (>4 cm). Of the reported patients, 31.8% had received radiotherapy, and 22.9% had undergone multiple surgeries for their pituitary tumor. In our single-center experience, 20 patients had an adenoma that met the criteria for a PP1 adenoma. Compared with the 1146 non-PP1 tumors, the PP1 tumors did not show statistically significant differences in the extent of resection, size, number of previous surgeries, future reoperations, rate of radiotherapy, p53 staining, or MIB-1 labeling index. The findings from the present large, single-center study comparing PP1 and non–PP1 adenomas do not suggest that PP1 tumors are more aggressive. Further work is warranted to identify the pathologic subtypes of pituitary adenomas that are consistently more clinically aggressive. [ABSTRACT FROM AUTHOR]

The purpose of the present study was to investigate the relationship between the intrasellar pressure (ISP) and the microvascular structure of pituitary adenomas. We retrospectively analyzed the ISP in 66 patients with pituitary adenomas. The corresponding microvascular structure was obtained using immunohistochemistry and analyzed for its correlation with the ISP. The average ISP was 25.89 ± 8.27 mm Hg, and the ISP was not related to the size of the adenoma (Pearson correlation coefficient, 0.103; P = 0.415). The ISPs of adenomas with different Knosp grades were significantly different (P < 0.05). From grade 0 to grade 4, at first, the ISP increased with the Knosp grade and reached the first peak at grade 2. It then decreased at grade 3 and increased again at grade 4, showing a "double-peak" pattern. The minimal diameter and perimeter of the microvessels and the vessel-covered area percentage were positively related to the ISP. When these parameters were compared among the adenomas of different Knosp grades, they also exhibited a "double-peak" pattern. In the present study, we found that with the increase in pituitary adenoma size and invasion of the surrounding tissues, the ISP of pituitary adenomas showed a "double-peak" pattern. The ISP and certain parameters of the microvascular structure are related, because the microvasculature adaptively changes its structure in response to the changing ISP to ensure a sufficient blood supply to the adenoma. The specific mechanism of this phenomenon requires further study. [ABSTRACT FROM AUTHOR]

Gonadotroph pituitary adenoma (Gn-PA) may rarely cause ovarian hyperstimulation syndrome, leading to infertility in women, although this remains poorly described. We present a quantitative systematic review including 2 patients from our institutional and 48 from the literature with Gn-PA causing ovarian hyperstimulation syndrome to thoroughly describe the clinical features and therapeutic outcomes from multidisciplinary aspects. The patients had a mean age of 31.5 years and a mean follicle-stimulating hormone level of 14.4 IU/L. Estradiol level was high in 82% of patients, at >350 pg/mL. The mean maximal adenoma diameter was 22 mm, with a Knosp grade ≥3 in 10 patients. Abdominal surgery preceded adenoma resection in 24 patients (48%). Among 25 patients for whom extent of resection was recorded, total adenoma resection was achieved in 12. Through a mean follow-up of 25 months, adenoma recurrence was observed in 5 patients, who were treated with re-resection (n = 2), radiation (n = 2), and medical therapy followed by bilateral oophorectomy (n = 1). Medical therapies were partially effective or ineffective, and adenoma shrinkage did not follow; gonadotropin-releasing hormone agonists/antagonists were partially effective in 20% of patients (2/10), dopamine agonists in 44% (8/18), and somatostatin analogues in 50% (1/2). Four experienced swelling of tumor/ovaries after gonadotropin-releasing hormone agonists/antagonists administration. Overall, chemical remission was obtained in 26 of 28 patients, normalization of ovaries in 25 of 27, and successful pregnancy in 12 of 14. Adenoma resection is the main treatment, leading to reduction in ovarian size and biochemical remission, with a high likelihood of subsequent spontaneous pregnancy. Increased awareness of this rare condition may help avoid unnecessary abdominal procedures. [ABSTRACT FROM AUTHOR]

The collision of pituitary adenoma and craniopharyngioma is extremely rare and thus there remains a paucity of data. We described a patient from our institution. We also performed a systematic review and subsequent quantitative synthesis of the literature (n = 21) and our institutional case to yield an integrated cohort, and a descriptive analysis was carried out. Twenty-two patients (15 males and 7 females) were included in the integrated cohort. The median age was 47.0 years (range, 8–75 years). The tumor subtypes were 5 somatotropic, 5 lactotropic, 4 nonfunctioning, 3 gonadotropic, 2 corticotropic, 1 plurihormonal, and 1 silent subtype 3 for pituitary adenomas, and 19 adamantinomatous, 2 papillary, and 1 unknown subtype for craniopharyngiomas. Three different radiographic patterns were observed: solid mass with cystic component (n = 5), coexistence of two distinct solid components (n = 3), and a mixed-intensity solid mass (n = 5). The first 2 were consistent with histologically separate collision, whereas the third was consistent with histologically admixed collision. Among 19 patients in whom the postoperative course was recorded, a secondary intervention was required in 14 (73.7%) because of tumor progression or residual. The recurrence rate after gross total resection was 33.3%. Postoperative hormone replacement was required in 33.3%. The 10-year cumulative overall survival was 73.1%. Most craniopharyngiomas were adamantinomatous. There are 2 types of collisions: separated and admixed. Tumor control, overall survival, and endocrinologic remission are more challenging to achieve than for solitary tumors, but gross total resection of both tumors is important for satisfactory tumor control. [ABSTRACT FROM AUTHOR]

Fluorescence-guided surgery may improve completeness of resection in transsphenoidal surgery for Cushing disease (CD) by enabling visualization of residual tumor tissue at the margins. In this review we discuss somatostatin receptors (SSTRs) as targets for fluorescence-guided surgery and overview existing SSTR-specific imaging agents. We also compare SSTR expression in normal pituitary and corticotrophinoma tissues from human and canine CD patients to assess canines as a translational model for CD. A PubMed literature search was conducted for publications containing the terms canine, somatostatin receptor, Cushing's disease, and corticotroph adenoma. SSTR expression data from each study was documented as the presence or absence of expression or, when possible, the number of tumors expressing a given SSTR subtype within a group of tumors being studied. Studies that used reverse transcription polymerase chain reaction to quantify SSTR expression were selected for additional comparative analysis. SSTR5 is strongly expressed in human corticotroph adenomas and weakly expressed in surrounding pituitary parenchyma, a pattern not conclusively observed in canine patients. SSTR2 mRNA expression is similar in human normal pituitary and corticotrophinoma cells but may be significantly higher in canine normal pituitary tissue than in corticotroph tumoral tissue. Limited data were available on SSTR subtypes 1, 3, and 4. Further studies must fill the knowledge gaps related to species-specific SSTR expression, so using canine CD as a translational model may be premature. We do conclude that the expression profile of SSTR5 (i.e., high local expression in pituitary adenomas relative to normal surrounding tissues) makes SSTR5 a promising molecular target for FGS. [ABSTRACT FROM AUTHOR]

Although endoscopic endonasal approach (EEA) has been popularized worldwide for pituitary adenoma surgery, in sub-Saharan Africa, neurosurgeons are still only starting their experience with it. This study was designed to assess the early results of EEA for pituitary adenoma from an under-equipped environment, namely, the Department of Neurosurgery of the Teaching Hospital of Yopougon Abidjan and Bouaké in Ivory Coast. The data of 56 cases of EEA for pituitary adenoma surgery performed between 2016 and March 2019 at the Teaching Hospital of Yopougon-Abidjan and Bouaké were retrospectively assessed. Pre- and postoperative neuro-ophthalmologic and hormonal status were analyzed. Moreover, the quality of tumor removal, and pre- and postoperative complications were also evaluated. In this study, there were nonfunctional adenomas (20), prolactinoma (18), Cushing disease (9), and acromegaly (3). A reduced visual acuity and/or visual field defect was observed in 49 cases. The mean operation time was 225 ± 94.7 minutes. The tumor removals were complete in 57.14%, subtotal in 35.71%, and partial in 7.14%. These led to a visual improvement in 69.64%. Postoperative complications were cerebrospinal fluid leaks (19.64%), diabetes insipidus (12.50%), visual worsening (7.14%), meningitis (3.57%), and carotid injury (3.57%) that led to death. This study represents the early surgical experience using EEA for treating pituitary adenoma in an under-equipped environment. Although the postoperative complication rate was relatively high, refinements of local surgeons' technique would lead to a better patient outcome. [ABSTRACT FROM AUTHOR]

Internal carotid artery (ICA) stenosis rarely occurs in pituitary apoplexy. Little is known of the causes of this condition. The present study investigated the factors related to ICA stenosis associated with pituitary apoplexy. Forty-five patients with pituitary apoplexy were retrospectively examined and divided into the stenotic and normal ICA groups. The baseline characteristics of patient background, tumor properties, clinical findings, and treatment overview were compared between the groups. Eight patients were assigned to the stenotic ICA group and 37 to the normal ICA group. Patient age in the stenotic ICA group was significantly lower than that in the normal ICA group (P = 0.001). Maximum tumor diameter (P = 0.001), tumor volume (P = 0.044), and Knosp grade (P < 0.001) were significantly greater in the stenotic ICA group than in the normal ICA group. The stenotic ICA group had a significantly greater incidence of sphenoid sinus mucosal thickening than the normal-ICA group (P = 0.039). Multivariate logistic regression analysis demonstrated that age (odds ratio 0.915, 95% confidence interval 0.846–0.991, P = 0.029) was a significant and independent predictor of ICA stenosis associated with pituitary apoplexy. Receiver operating characteristic curve analysis showed that the optimal cut-off point for age was 35.0 years (specificity 0.946, sensitivity 0.750). Our study revealed that age, tumor size, and sphenoid sinus mucosal thickening were strongly related to the occurrence of ICA stenosis in pituitary apoplexy. Among these factors, age had the potential of being an independent predictor of the condition. [ABSTRACT FROM AUTHOR]

The direct endoscopic endonasal approach (EEA) has become the primary technique used for resection of sellar pathology, meriting investigation into the risk factors for complications and predictors of postoperative outcomes after direct EEA. We retrospectively analyzed the patient and tumor characteristics from 404 patients who had undergone direct EEA for sellar pathology at the USC Pituitary Center from September 2011 to December 2019. Of the 404 pathologic entities included, 349 (86%) were pituitary adenomas (PAs), 29 (7%) were Rathke cleft cysts, and 26 (6%) were other sellar lesions. The mean lesion diameter was 2.3 cm, with 34 microadenomas (10%) and 315 macroadenomas (90%). Cavernous sinus invasion was present in 39% of the PAs. No patient died. The surgical complications included internal carotid artery injury without neurological sequelae (0.2%), vision loss (0.7%), meningitis (0.7%), cerebrospinal fluid leak (4%), epistaxis (4%), sinusitis (1%), transient cranial nerve paresis (0.5%), and postoperative abscess (0.25%). New hypopituitarism developed in 3%. Gross total resection was achieved in 208 PA cases (58%). Clinical improvement of headaches and visual deficits were reported for 67% and 76% of cases, respectively. Hormonal remission was achieved in 82% of patients with functional PAs. The median hospital stay was 2 days, with 34 patients (8%) readmitted within 30 days and 10 (3%) undergoing early reoperation. Disease recurrence or progression developed in 10% and was less likely in the case of gross total resection and apoplexy. In the present, large, consecutive, mostly single-surgeon series, the patients experienced clinical improvement in most preoperative symptoms and had low rates of perioperative morbidity. We have demonstrated that direct EEA can be efficiently, safely, and successfully performed by a neurosurgical team. [ABSTRACT FROM AUTHOR]

Pure intrasellar meningioma is an extremely rare tumor that is difficult to diagnose as it resembles a pituitary adenoma in its clinical, endocrinologic, and radiologic presentation; it can only be distinguished through histopathologic examination. All previously reported cases of this lesion were considered those of pituitary adenoma at the initial diagnosis. This poses major challenges in clinical diagnosis. We report a case of a pure intrasellar meningioma in a 27-year-old man. A boundary between the tumor and pituitary gland may be evident on magnetic resonance imaging, thus enhancing the diagnosis of pure intrasellar meningioma. [ABSTRACT FROM AUTHOR]

Cyclooxygenase 2 (COX-2) is a key enzyme in the synthesis of prostaglandins. Recent studies have shown that overexpression of COX-2 can reduce the antitumor effect of the immune system by inhibiting the proliferation of B and T lymphocytes. Programmed cell death ligand 1 (PD-L1) was the first functionally characterized ligand of programmed cell death protein 1. It plays an important role in maintaining peripheral and central immune tolerance by combining with programmed cell death protein 1. Arginase 1 (ARG1) can process L -arginine in the local microenvironment and affect the function of T cells, resulting in immune escape. In this study, COX-2, PD-L1, and ARG1 expression in human pituitary adenoma (PA) and their relationship were investigated, which provided an initial theoretic basis for further study of the immune escape mechanism in PA in cellular and animal experiments. The protein expression of COX-2, PD-L1, and ARG1 in 55 PA samples was detected by immunohistochemistry, with 10 normal brain tissues as the control group. The location of COX-2, PD-L1, and ARG1 in PA cells was studied by double immunofluorescence colocalization. The results of immunohistochemistry were further verified by Western blot. The expression of COX-2, PD-L1, and ARG1 in PA was significantly higher than that in normal brain tissue. In functional PA (FPA) and nonfunctional PA (NFPA), there was no significant difference in the expression of COX-2 and PD-L1, whereas ARG1 was higher in NFPA. Moreover, the protein expression level of COX-2 was positively correlated with that of PD-L1 and ARG1, and the expression of PD-L1 was positively correlated with that of ARG1. Immunofluorescence confocal imaging showed that COX-2, PD-L1, and ARG1 were all expressed in the cytoplasm of PA cells, and the physical positions of COX-2, PD-L1, and ARG1 were partially coincident. These findings indicate that overexpression of COX-2, PD-L1, and ARG1 may be involved in the pathogenesis of PA. ARG1 plays a more important role in the development of NFPA. By upregulating the expression of PD-L1, COX-2 may promote the expression of ARG1, forming the COX-2/PD-L1/ARG1 signal pathway in promoting the occurrence and development of PA. Perhaps further study of the pathogenesis of PA can start with the mechanism of immune escape. [ABSTRACT FROM AUTHOR]

In patients with residual or recurrent nonfunctioning pituitary adenomas (NFPAs) after transsphenoidal resection, both GammaKnife (GKRS) and CyberKnife (CKRS) stereotactic radiosurgery (SRS) are viable treatment options. We report a retrospective single center series comparing assessing the effectiveness and complications from of these 2 commonly used SRS techniques. A total of 53 patients with prior surgical resection and residual or recurrent NFPAs who underwent GKRS or CKRS and minimum 3-month follow-up between January 2002 and February 2017 at a single center were identified. A total of 34 patients underwent GKRS and 19 received CKRS. CKRS patients had a larger maximal tumor diameter (P = 0.005) and tumor volume treated (P = 0.001). Differences between GKRS and CKRS treatment parameters included target volume, target volume treated, prescribed dose, maximum dose, prescription isodose line, and conformity index (P < 0.05). The mean follow-up time was 53.74 months for GKRS and 41.48 months for CKRS patients. Tumor progression developed in 6% of cases after GKRS versus 5% after CKRS. The mean progression-free survival was 48.44 months after GKRS and 38.57 months after CKRS (P = 0.61). Five-year actuarial tumor control rates were 91% after GKRS versus 89% after CKRS (P > 0.99). There were no differences in worsened vision or rates of hypopituitarism. In patients undergoing single fraction GKRS versus fractionated CKRS for NFPAs, both modalities had similar rates of tumor control, new hypopituitarism, and visual morbidity despite varying indications. This study validates the versatile use of these 2 SRS modalities for patients meeting their relative criteria, especially based on proximity to the optic apparatus and normal pituitary gland. [ABSTRACT FROM AUTHOR]

Rathke cleft cyst (RCC) can cause acute symptoms mimicking pituitary adenoma (PA) apoplexy. We evaluated the clinicoradiologic features for distinguishing RCC from PA apoplexy. We retrospectively evaluated 22 patients with RCC and 24 patients with PA with apoplexy-like symptoms who underwent surgery via a transsphenoidal approach between November 1999 and December 2016. We compared the clinical data and magnetic resonance (MR) images between the 2 groups. The RCC group was younger and had smaller tumors compared with the PA group (P = 0.02 and 0.001, respectively). The incidences of visual deficits and cranial nerve palsy were lower in the RCCs than in the PAs (P ≤ 0.02 for all). MR images showed more frequent intracystic nodules in the RCCs (P < 0.001), whereas nodular enhancement and lateral deviation of the pituitary stalk were more commonly seen in the PAs (P ≤ 0.003 for both). However, the presence of endocrine dysfunction or decreased consciousness, and the recurrence ratio, were not significantly different between the groups (P ≥ 0.48 for all). In the multivariable logistic regression analysis, patients without nodular enhancement had a 15.84-fold greater risk of RCC than did those with nodular enhancement (P = 0.031). The probability of RCC decreased 0.59-fold with each 1-cm3 increase in tumor volume. RCC with apoplexy-like symptoms has different clinicoradiologic features compared with PA apoplexy. Patients with RCC present with milder ocular symptoms and smaller tumor volumes compared with those with PA apoplexy. The absence of nodular enhancement on MR images could suggest RCC. [ABSTRACT FROM AUTHOR]

Factors associated with visual outcomes after transcranial surgery for large-to-giant pituitary adenomas have not been fully elucidated. We recruited 37 patients with large-to-giant pituitary adenomas between January 2014 and December 2016 and assessed their tumor characteristics and surgical outcomes. Visual acuity and visual field were evaluated by visual impairment score before and 3–6 months after transcranial surgery. Multivariable logistic regression analysis was applied to show the factors associated with visual outcomes after surgery. The severity levels of visual impairment before surgery were mild, moderate, severe, and complete in 24.3% (9/37), 24.3% (9/37), 35.1% (13/37), and 16.2% (6/37), respectively. After surgery, the visual function was improved, stabilized, and worsened in 43.2% (16/37), 43.2% (16/37), and 13.5% (5/37) of patients, respectively. Multivariable logistic regression analysis showed that subarachnoid space invasion was the only independent prognostic factor adversely influencing the postoperative visual outcomes. Patients with subarachnoid space invasion had a higher possibility of visual deterioration (36.4% vs. 3.8%; P = 0.021) after transcranial surgery, compared with those without subarachnoid space invasion. Visual compromise is still an unignorable complication during transcranial surgery for large-to-giant pituitary adenomas. Subarachnoid space invasion indicated by preoperative magnetic resonance imaging was an independent negative predictor for visual outcomes after surgery. [ABSTRACT FROM AUTHOR]

A novel viral strain known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created a worldwide pandemic known as coronavirus 2019 (COVID-19). Early reports from China have highlighted the risks associated with performing endoscopic endonasal skull base surgery in patients with SARS-CoV-2. We present a rare complication of nasoseptal flap (NSF) necrosis associated with COVID-19, further emphasizing the challenges of performing these procedures in this era. A 78-year-old man underwent an extended endoscopic endonasal transplanum resection of a pituitary macroadenoma for decompression of the optic chiasm. The resulting skull base defect was repaired using a pedicled NSF. The patient developed meningitis and cerebrospinal fluid (CSF) leak on postoperative day 13, requiring revision repair of the defect. Twelve days later, he developed persistent fever and rhinorrhea. The patient was reexplored endoscopically, and the NSF was noted to be necrotic and devitalized with evident CSF leakage. At that time, the patient tested positive for SARS-CoV-2. Postoperatively, he developed acute respiratory distress syndrome complicated by hypoxic respiratory failure and death. To our knowledge, this is the first reported case of NSF necrosis in a patient with COVID-19. We postulate that the thrombotic complications of COVID-19 may have contributed to vascular pedicle thrombosis and NSF necrosis. Although the pathophysiology of SARS-CoV-2 and its effect on the nasal tissues is still being elucidated, this case highlights some challenges of performing endoscopic skull base surgery in the era of COVID-19. [ABSTRACT FROM AUTHOR]