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Purpose This study evaluates the temporal evolution of the spatial relationship between the pituitary adenoma transsphenoidal surgical cavity and the adjacent optic chiasm and discusses implications on timing and choice of radiotherapy modality. Methods This retrospective observational review analyzed factors that might influence the postoperative relationship between the surgical cavity and the optic chiasm, including tumor type, craniocaudal tumor and resection cavity dimensions, the preoperative distance between tumor and the optic chiasm, the presence of cavernous sinus invasion, and the choice of intraoperative packing material. Changes observed on magnetic resonance imaging in the preoperative, immediate (within 72 h), and delayed (≥3 months) postoperative periods were compared. Results Sixty-five patient histories were analyzed. Preoperatively, the pituitary adenoma was apposed to the optic chiasm in 43 patients (66%). Postoperatively, 34 patients (52%) in the immediate postoperative period and 54 patients (83%) in the delayed postoperative period had a distance ≥2 mm between the resection cavity and the optic chiasm. This distance provides a greater margin of safety with adjuvant radiosurgery. Preoperative tumor size showed a strong association with postoperative descent of the optic chiasm. Conclusions Preoperative tumor size and degree of mass effect on the optic chiasm predict postoperative changes. In this study, the distance between the resection cavity and the optic chiasm was greater at ≥3 months postoperatively than in the immediate postoperative period, regardless of preoperative mass effect, indicating radiotherapy planning should be deferred to ≥3 months postoperatively when not precluded by aggressive histological characteristics that necessitate more immediate treatment. Precis To investigate the temporal relationship between the postoperative sellar surgical cavity and the adjacent optic apparatus after transsphenoidal resection of pituitary adenomas and the implications for radiotherapy.

Background Pneumomediastinum following blunt trauma is often observed on CT imaging, and concern for associated aerodigestive injury often prompts endoscopy and/or fluoroscopy. In recent years, adoption of multi-detector CT technology has resulted in high resolution images that may clearly identify aerodigestive injuries. The purpose of this study was to evaluate the utility of multi-detector CT in the identification of blunt aerodigestive injuries. Methods Over five years, patients with pneumomediastinum following blunt trauma were identified from the registry of a level 1 trauma center. All CT imaging of trauma patients during this time period was accomplished with 64-slice scanners. Results 127 patients with blunt traumatic pneumomediastinum were identified. Five airway injuries were identified, and all injuries were evident on CT imaging. No patient was found to have airway injury by endoscopy that was not evident on CT. No patient had an esophageal injury. Conclusion Multi-detector CT imaging identifies aerodigestive injuries associated with pneumomediastinum following blunt trauma. The absence of a recognizable aerodigestive injury by CT effectively rules out the presence of such injury.

Surgical resection is the standard initial therapy for patients with symptomatic non-prolactin secreting adenomas and other pituitary tumors (1). After surgical resection select patients will require adjuvant radiation therapy. There are a number of radiation modalities available for treatment. One factor that influences the choice of radiation modality is proximity of tumor to local critical anatomy, namely the optic chiasm (2). MRI is the modality of choice for evaluating pituitary tumors, postoperative resection cavities and the relationship between tumor and the optic chiasm (3). To study the expected evolution of postoperative pituitary resection cavities and the relationship between residual sellar tissue and the optic chiasm we retrospectively reviewed MRI’s of patients with surgically resected pituitary tumors obtained during the preoperative (PreO), immediate postoperative (IPO) (3 mo) phases. 91 patients (45 F, 46 M, mean age 50.9 yrs) with functional adenomas (26.4%), non-functional adenomas (46.2%), Rathke cleft cysts (9.9%), craniopharyngioma’s (3.3%) and other lesions (14.2%) were studied. PreO estimated tumor volume was 4.3 cc (0-28.7), craniocaudal (CC) dimension 17.2 mm (2-49), and distance between tumor and optic chiasm 2.0 mm (0-10). 9.9 % of patients had cavernous sinus invasion by imaging criteria. On IPO imaging 83.5 % of patients had gross total resection. Average IPO and DPO resection cavity estimated volumes were 3.3 cc (0.1-16.3) and 1.6 cc (0.0-8.7), respectively. Average % decrease in cavity volume from IPO to DPO scans was 51.5%. Average distance between residual sellar tissue and chiasm was 2.5 mm on IPO and 4.7 mm on DPO scans. The distance between tissue and chiasm on IPO and DPO scans was greater for tumors 10mm (p=0.019). Percent change in CC dimension of resection cavities from IPO to DPO scans was higher for cavities without fat packing (63.2%) vs cavities with fat packing (52.1%) (p=0.025). Tumor histology, cavernous sinus invasion, degree of PreO chiasm mass effect, and presence of fluid or blood within the IPO cavity did not correlate with distance between tissue and chiasm on DPO scans. Conclusion: There is a significant reduction in cavity volume and increased distance between the chiasm and residual sellar tissue on DPO vs IPO scans. Evaluation for radiosurgery as a treatment option, which has less total and chiasm dose, may be an option after reviewing DPO scans. References: (1) Rim et al., Radiat Oncol J. 2011;29(3):156-63. (2) Minniti et al., Radiat Oncol. 2016;(11)135. (3) Patel et al., World Neurosurg. 2014;82(5):770-80.

Injuries to the inferior vena cava (IVC) secondary to blunt trauma are rare and occur in only 1–10% of all blunt trauma patients. Management of these injuries has not been subjected to major studies, but several case reports and small retrospective studies have demonstrated that management can be tailored to the hemodynamic status of the patient; this is similar to the management of blunt liver injuries. Stable patients whose injuries have achieved local venous tamponade have been successfully treated without surgical intervention, while unstable patients require operative management. Regardless of patient status, however, IVC injuries are highly fatal with mortality rates between 70 and 90%. This report describes the case of a patient with a blunt traumatic injury to the supradiaphragmatic IVC with development of a pseudoaneurysm who was successfully managed conservatively.