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Marc R. Mayberg

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Jun Muto, Daniel M. Prevedello, and Ricardo L. Carrau

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André Beer-Furlan, Ali O. Jamshidi, Ricardo L. Carrau, and Daniel M. Prevedello

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André Beer-Furlan, Bradley A. Otto, Ricardo L. Carrau, and Daniel M. Prevedello

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André Beer-Furlan, Diego A. Servián, Ricardo L. Carrau, and Daniel M. Prevedello

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Ricky Madhok, Daniel M. Prevedello, Paul Gardner, Ricardo L. Carrau, Carl H. Snyderman, and Amin B. Kassam

Object

Rathke cleft cysts (RCCs) are benign lesions that can be diagnosed as an incidental finding associated with headaches, pituitary dysfunction, or vision deterioration. Typically, they occur in a sellar or suprasellar location. The aim of this study was to review the clinical presentation and outcomes associated with endoscopic endonasal resection of these lesions.

Methods

The authors retrospectively reviewed a series of 35 patients with a diagnosis of RCC after endoscopic endonasal resection at the University of Pittsburgh between January 1998 and July 2008.

Results

All 35 patients underwent a purely endoscopic endonasal approach (EEA). The average patient age was 34 years (range 12–67 years), and the average follow-up was 19 months (range 1–60 months). Clinical follow-up data were available for 32 patients, and radiographic follow-up data were accessible for 33 patients. All of the patients underwent complete removal of the cyst contents, and according to radiography studies 2 patients had a recurrence, neither of which required reoperation. The mean cyst volume was 1052.7 mm3 (range 114–6044 mm3). Headache was a presenting symptom in 26 (81.2%) of 32 patients, with 25 (96.1%) of 26 having postoperative improvement in their headaches. Fifteen (57.7%) of the 26 patients had complete pain resolution, and 10 (38.5%) had a > 50% reduction in their pain scores. Six (18.8%) of 32 patients initially presented with pituitary dysfunction, although 2 (33.3%) had postoperative improvement. Three (9.4%) of 32 patients had temporary pituitary dysfunction postoperatively, although there was no permanent pituitary dysfunction. Neither were there any intraoperative complications, postoperative CSF leaks, or new neurological deficits. The average hospital stay was 1.8 days (range 1–5 days).

Conclusions

The EEA is a safe and effective approach in the treatment of RCCs. None of the patients in this study experienced any worsening of their preoperative symptoms or pituitary function, and 96% of the patients who had presented with headache experienced complete or significant pain relief following treatment.

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Paul A. Gardner, Daniel M. Prevedello, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau, and Arlan H. Mintz

✓Craniopharyngiomas have always been an extremely challenging type of tumor to treat. The transsphenoidal route has been used for resection of these lesions since its introduction. The authors present a historical review of the literature from the introduction of the endonasal route for resection of craniopharyngiomas until the present. Abandoned early due to technological limitations, this approach has been expanded both in its application and in its anatomical boundaries with subsequent progressive improvements in outcomes. This expansion has coincided with advances in visualization devices, imaging guidance techniques, and anatomical understanding. The progression from the use of headlights, to microscopy, to endoscopy and fluoroscopy, and finally to modern intraoperative magnetic resonance–guided techniques, combined with collaboration between otolaryngologists and neurosurgeons, has provided the framework for the development of current techniques for the resection of sellar and suprasellar craniopharyngiomas.

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Edward E. Kerr, Daniel M. Prevedello, Ali Jamshidi, Leo F. Ditzel Filho, Bradley A. Otto, and Ricardo L. Carrau

Endoscopic expanded endonasal approaches (EEAs) to the skull base are increasingly being used to address a variety of skull base pathologies. Postoperative CSF leakage from the large skull base defects has been well described as one of the most common complications of EEAs. There are reports of associated formation of delayed subdural hematoma and tension pneumocephalus from approximately 1 week to 3 months postoperatively. However, there have been no reports of immediate complications of high-volume CSF leakage from EEA skull base surgery. The authors describe two cases of EEAs in which complications related to rapid, large-volume CSF egress through the skull base surgical defect were detected in the immediate postoperative period. Preventive measures to reduce the likelihood of these immediate complications are presented.

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Danielle de Lara, Leo F. S. Ditzel Filho, Jun Muto, Bradley A. Otto, Ricardo L. Carrau, Daniel M. Prevedello, and M.D.

Craniopharyngiomas are notorious for their ability to invade the hypothalamus and third ventricle. Although several transcranial approaches have been proposed for their treatment, the endonasal route provides direct access to the tumor with no need for cerebral retraction or manipulation of the optic apparatus. After the lesion is debulked, the unique angle of approach achieved with this technique enables the surgeon to perform an extra-capsular dissection and visualize the walls of the third ventricle, the foramina of Monro, and the anterior comissure. Moreover, the enhanced magnification and lighting afforded by the endoscope facilitate safe tumor removal, particularly in areas where there is loss of clear lesion delimitation and greater infiltration of the surrounding structures.

Herein we present the case of a 68-year-old female patient with a 3-month history of visual deterioration accompanied by worsening headaches. Investigation with magnetic resonance imaging revealed a heterogeneous mass in the suprasellar region, extending into the third ventricle and displacing the pituitary gland and stalk inferiorly. Hormonal profile was within expected range for her age. An endonasal, fully endoscopic, transplanum transtuberculum approach was performed. Gross-total removal was achieved and pathology confirmed the diagnosis of craniopharyngioma. Postoperative recovery was marked by transient diabetes insipidus. Closure was achieved with a pedicled nasoseptal flap; despite exploration of the third ventricle, there was no cerebrospinal fluid leakage. Pituitary function was preserved. Visual function has fully recovered and the patient has been uneventfully followed since surgery.

The video can be found here: http://youtu.be/it5mpofZl0Q.

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Daniel C. Kreatsoulas, Varun S. Shah, Bradley A. Otto, Ricardo L. Carrau, Daniel M. Prevedello, and Douglas A. Hardesty

OBJECTIVE

Spontaneous CSF leaks are rare, their diagnosis is often delayed, and they can precipitate meningitis. Craniotomy is the historical “gold standard” repair for these leaks. An endonasal endoscopic approach (EEA) offers potentially less invasiveness and lower surgical morbidity than a traditional craniotomy but must yield the same surgical success. A paucity of data exists studying EEA as the primary management for spontaneous CSF leaks.

METHODS

The authors retrospectively reviewed patients undergoing spontaneous CSF rhinorrhea repair at their institution from July 2010 to August 2018. Standardized management includes EEA as first-line treatment, and lumbar puncture (LP) performed 24–48 hours postoperatively. If opening pressure on LP is elevated, CSF diversion or acetazolamide therapy is used as needed. Perioperative lumbar drains are not used.

RESULTS

Of 46 patients identified, the most common CSF rhinorrhea etiology was encephalocele (28/46, 60.9%), and the most common location was cribriform/ethmoid (26/46, 56.5%). Forty-three patients underwent EEA alone, and 3 underwent a simultaneous EEA/craniotomy. The most common repair strategy was nasoseptal or other pedicled flaps (18/46, 39.1%). Postoperatively, 15 patients (32.6%) received CSF diversion due to elevated ICP, with BMI > 40 kg/m2 being a significant risk factor (odds ratio 4.35, p = 0.033) for postrepair shunt placement. Twelve patients received acetazolamide therapy for treatment of mildly elevated pressures. The average opening pressure of the shunted group was 36 cm H2O and the average for the acetazolamide-only group was 26 cm H2O. Two patients underwent CSF leak repair revision, one because of progressive fungal sinusitis and the other because of recurrent CSF leak. The mean follow-up duration was 15 months.

CONCLUSIONS

The paradigm of EEA repair of spontaneous CSF rhinorrhea with postoperative LP to identify undiagnosed idiopathic intracranial hypertension appears to be safe and effective. In the authors’ cohort, morbid obesity was statistically associated with the need for postoperative CSF diversion. This has implications for future surgical treatment as obesity levels continue to rise worldwide.