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Background 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. Methods 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. Results 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. Conclusions 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.

Gerstmann syndrome is a neurobehavioral syndrome characterized by four cardinal symptoms: acalculia, agraphia, finger-toe agnosia, and dysgraphia. The syndrome is caused primarily by lesions at the confluence of parietal, temporal, and occipital lobes, but also can involve the middle frontal lobe of the dominant hemisphere. Documented inciting lesions include stroke, tumor, hemorrhage, arteriovenous malformations, and seizures. A meningeal solitary fibrous tumor (SFT)/hemangiopericytoma (HPC) is a diagnostic challenge due to its resemblance to more common brain tumors like meningioma, with histopathology being the definitive diagnostic test. A 37-year-old male presented to our tertiary center with blurred vision, “not being himself,” and “acting funny” for three weeks. On exam, he was found to have a right inferior quadrantanopia, grade II papilledema and demonstrated all four symptoms of Gerstmann syndrome - inability to perform simple calculations (acalculia), or identify his fingers (finger agnosia), could not distinguish his left side from the right (left-right disorientation), nor write out his name (agraphia). Brain imaging showed an extra-axial, highly vascularized 7.6-cm mass compressing the left parietal lobe. He underwent a complete resection of the mass. Postoperatively, he had gradual improvement with complete resolution of agraphia, acalculia, finger agnosia, and left-right disorientation within a week status post-resection. Tumor pathology indicated hemangiopericytoma/solitary fibrous tumor. This case enunciates the enigmatic tetrad of Gerstmann syndrome. Though classically described as a sequela of stroke, the mass effect of the tumor on the parietal lobe may produce the symptoms, which can resolve following resection.

Background 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. Methods 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. Results 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. Conclusions 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.

Background. Pituitary apoplexy (PA) is a rare and potentially life-threatening condition characterized by pituitary hemorrhage, often in the setting of a preexisting pituitary adenoma. Risk factors and mechanisms associated to PA are poorly understood. Although involvement of the nervous system in SARS-CoV-2 infection causing intracranial hemorrhagic complications has been documented, the association between COVID-19 infection and PA has yet to be determined. Methods . From a prospectively collected database of patients with pituitary adenomas, we retrospectively reviewed the electronical medical records and scans of patients with pituitary apoplexy during the COVID-19 outbreak, since March 2020 to December 2020, that were treated at a tertiary care center. Results. Herein, we report three consecutive cases of patients with PA and concomitant COVID-19 infection. Most common symptom at presentation was headache and visual worsening. Included patients were successfully treated with surgical decompression and medical management of the hormonal deficits, experiencing moderate to significant improvement of their visual symptoms at last follow up. COVID-19 infection in the perioperative period was corroborated throughout polymerase chain reaction testing in all patients. Conclusions. COVID-19 positive patients may be at an increased risk of developing PA. Angiotensin-converting enzyme 2 receptors expressed in cerebrovascular endothelium may potentially play a role in the molecular mechanisms that induce changes of the vascular autoregulation and cerebral blood flow and predispose to pituitary hemorrhage in patients harboring a pituitary adenoma.

The maxillary artery (MA) has gained attention in neurosurgery particularly in cerebral revascularization techniques, intracranial endonasal approaches and endovascular procedures. To describe and illustrate the anatomy of the MA and its neurosurgical importance in a detailed manner. Six cadaveric heads (12 MAs) were injected with latex. The arteries and surrounding structures were dissected and studied using microsurgical techniques. The dimensions, course and branching patterns of the MA were recollected. In addition, 20 three-dimensional reconstruction CT head and neck angiograms (3D CTAs) of actual patients were correlated with the cadaveric findings. The MA can be divided in three segments: mandibular, pterygoid and pterygopalatine. Medial and lateral trunk variants regarding its course around the lateral pterygoid muscle can be found. The different branching patterns of the MA have a direct correlation with the course of its main trunk at the base of the skull. Branching and trunk variants on one side do not predict the findings on the contralateral side. In this study the highly variable course, branching patterns and relations of the MA are illustrated and described in human cadaveric heads and 3D CTAs. MA 3D CTA with bone reconstruction can be useful preoperatively for the identification of the medial or lateral course variants of this artery, particularly its pterygoid segment, which should be taken into account when considering the MA as a donor vessel for an EC-IC bypass.

The Fogarty catheter represents a major advancement for the effective removal of distal thrombi during vascular surgery, including carotid endarterectomy (CEA). One complication related to its use is injury to the cavernous carotid artery with development of a carotid cavernous fistula (CCF). Including a recent case at our institution, 21 patients with a Fogarty-related CCF have been reported since 1967. We performed a detailed review of all Fogarty-related CCFs during the treatment of carotid occlusive disease. We suggest a management algorithm for post-CEA acute carotid occlusion.

Malignant prolactinoma is an exceedingly rare endocrine tumor and cannot be diagnosed on histological grounds alone. Similarly to other neuroendocrine tumors such as pheochromocytoma, the mitoses index, Ki-67, p53, and others are utilized in helping understand whether a tumor is benign or malignant or to better predict tumor behavior. We here present the unusual case of an unfortunate young man with an aggressive prolactinoma, the complications of which led to his premature death.A 25-year-old white man developed severe headaches, low energy, and decreased libido. A brain magnetic resonance imaging (MRI) showed a 4 x 3 x 2 cm pituitary tumor invading the left cavernous sinus. Laboratory findings revealed elevated prolactin (470 ng/mL) and adrenocorticotropic hormone (ACTH, 82 pg/ml) and decreased total testosterone (176 ng/dl). Visual fields showed superior quadrantanopia in the left eye. Transsphenoidal pituitary resection was undertaken. Pathology revealed a prolactinoma with atypical cells, diffuse p53 nuclear labeling, and a Ki-67 index of 23% (high). Postoperatively, prolactin remained elevated (725-891 ng/ml) and cabergoline was increased to 1 mg three times weekly, with serum prolactin further increasing to 3507 ng/ml five months postoperatively. Repeat MRI revealed extension of the tumor with optic chiasm compression and left orbit invasion. Because of acute left vision loss with ophthalmoplegia, an urgent left frontotemporal craniotomy and tumor resection were conducted. The Ki-67 index of the tumor was 24.8%, the mitotic figure immunostain phosphohistone-H3 positive. Sixty percent (60%) of tumor cells were positive for p53. Cabergoline was increased to 1 mg daily but prolactin remained elevated (770 ng/ml). The patient then underwent proton beam radiation to the area of concern involving the sella. Prolactin thereafter improved to 44 ng/ml. He then developed acute vision loss of the right eye with an MRI showing tumor in the right cavernous sinus. A 15 mm dural-based right temporal mass believed to be a metastasis was also noted. Following this scan, he was considered too high risk for debulking surgery and instead underwent gamma knife irradiation to the sella area. This shrank the right cavernous sinus tumor mass, while the right temporal mass increased in size. The patient developed blindness and left-sided weakness and required enteral feeding and tracheostomy after prolonged intubation. A trial of chemotherapy with temozolomide (350 mg daily for 5 days) near the end of his life was unsuccessful. He died on home hospice 31 months after his first surgery.Headaches, vision changes, and symptoms of androgen deficiency syndrome can be manifestations of an aggressive prolactinoma that might require surgery and additional medical therapy including cabergoline and temozolomide with an unpredictable time of survival.

Perfusion-computed tomography (CTP) is a relatively new technique that allows rapid semiquantitative noninvasive evaluation of cerebral perfusion aiding in the diagnosis of cerebral ischemia and infarction. There is a paucity of data on its application within the posterior circulation, especially, the brainstem. We describe a case of basilar artery thrombosis with cerebellar and brainstem CTP mismatch and discuss possible future applications of CTP for acute posterior fossa circulation and infarction. Case report. Successful use of CTP to aid in decision to proceed with neurointervention in acute basilar artery occlusion and confirm its resolution after mechanical clot retrieval. Perfusion-computed tomography can successfully be used to define cerebral ischemia and infarction within the posterior fossa and aid in decisions to proceed with neurointervention.

Background: Not all vascular lesions of the brain that are amenable to endovascular treatment are safely accessible via the transfemoral route. We describe our technique of carotid cut down for endovascular access and present a couple of illustrative cases. The increasing number of neurosurgeons performing endovascular procedures, or collaborating with interventional neuroradiologists, suggests that this technique should be revived. Methods: Through a small transverse neck incision at the level of the thyroid cartilage, the CCA, ICA, and external carotid artery are exposed. After obtaining vascular control with vessel loupes, a purse-string suture is placed in the CCA. Puncture of the artery in the center of the purse string is followed by navigation of a wire, and then a sheath, into the ICA. The neurointervention is then carried out. At the conclusion of the procedure, the sheath is removed from the CCA and the purse string tied to secure the artery. Results: This technique has allowed us to successfully access the intracranial circulation in 6 patients with challenging anatomy. We present here 2 of the original cases leading to our increasing use of this technique. Conclusion: Carotid cut down for direct puncture of the CCA is a viable option to gain access to the intracranial circulation when the transfemoral route seems difficult or dangerous.

BACKGROUND Anaplastic ependymomas are considered to be uncommon cerebral tumors by most authors. We have had the opportunity to study 34 cases of such lesions in 13 years. METHODS 34 cases of anaplastic ependymoma operated in different hospitals of Maracaibo, Venezuela, during the period of 1983-1995 were analyzed. Cases of ependymoblastoma were excluded. RESULTS Adult patients made up most of the present series. All patients harbored supratentorial growths in locations distant from the ventricular system. The microscopic pattern was of limited value to establish prognosis, for there was no constant correlation between the histologic features and tumor relapse; only in sporadic cases in which high cell density and conspicuous mitotic activity were maximally expressed, did tumor relapse occur shortly after removal of the lesion. CONCLUSION This type of paradoxical behavior being the rule makes all attempts at predicting prognosis in these entities a disappointing task.

Summary Preliminary experience using a balloon assisted technique (BAT) for embolization of arteriovenous malformations (AVM) is reported. Two patients with large pericallosal AVMs were successfully embolized with Onyx under Scepter C balloon catheter flow arrest. Clinical presentation One patient presented with a large intraventricular hemorrhage and hydrocephalus. The second patient presented with a long history of seizures and a small intracerebral hemorrhage. Both patients demonstrated extensive interhemispheric AVMs with multiple arterial feeders, predominantly from the pericallosal arteries. Intervention A Marathon microcatheter was navigated into the target arterial feeders and a Scepter C occlusion balloon catheter was inflated immediately proximal. Under flow arrest, Onyx was injected via the microcatheter with excellent nidal penetration. In both cases, there was complete angiographic obliteration of the treated component of the AVM. Conclusions Onyx embolization under balloon catheter flow arrest allows for greater nidal penetration of embolic material and improved reflux control. The technique is limited by the current deliverability of balloon catheters and the potential risk for earlier embolization of dangerous anastomosis.

Neurosurgery case review : , Neurosurgery case review : , کتابخانه دیجیتال جندی شاپور اهواز

Introduction Surgical carotid revascularization has been described with various degrees of technical and clinical success. Currently, carotid revascularization is not recommended, based on the high potential for embolic stroke during the procedure. The data is however limited to only surgical cases. One series of endovascular revascularization for occluded carotids of unknown length of time has already been communicated. The authors present a similar series using a flow reversal device. Method During the period of February 2009 to November 2011 a total of 13 patients underwent endovascular revascularization of either single or both occluded carotid arteries. The procedure was done in all cases using a flow reversal system (the Gore flow reversal) In three cases the procedure had to be aborted due to the fact that the occluded segment included part of the supraclinoid carotid. In the rest of cases the procedure was technically feasible succesfully. After revascularization all patients underwent stenting of their extracranial carotids. Two patients had either bilateral occlusions or presented with a non-disabling stroke due to a severe stenosis on one side and a chronic occlusion on the other. In these cases the revascularizations have been performed in stages with a 2–3 month interval in between interventions. Results There were no neurologic complications related to the procedure either in the successful or in the aborted cases. Two patients developed large inguinal hematomas and had to be transfused. Conclusion The endovascular revascularization of carotid artery occlusion of unknown duration is feasible using a flow reversal device. Addditional information regarding clinical and imaging indications for the procedure is necessary in order to proper select patients that might benefit. Long term follow-up will also be necessary in order to assess the viability of re-opened carotids as well as risks for stroke in patients after this procedure. Competing interests None.