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Brian T. Andrews and Charles B. Wilson

✓ The authors reviewed 38 cases of suprasellar meningioma to determine the correlation between tumor site and postoperative visual outcome. Progressive visual loss, the most frequent initial complaint (94.7%), occurred over a mean of 24½ months, was most often unilateral (18 patients) or bilateral but asymmetrical (14 patients), and was severe (20/200 vision or worse) in 23 patients; 24 patients had visual field abnormalities. Computerized tomography or magnetic resonance studies clearly delineated the lesions but did not appear to permit earlier diagnosis. Eleven patients had tumors limited to the tuberculum sellae; the tumor extended from the tuberculum sellae onto the planum sphenoidale in nine patients, into one optic canal in eight, onto the diaphragma sellae in seven, and onto the medial sphenoid wing in three. Patients with tumors affecting the optic canal had severe unilateral visual loss more often than those with tumors at other sites. Tumors limited to the tuberculum sellae were most often completely resected; postoperative recovery of vision was also most frequent in patients with tumors at this site. Tumors involving the diaphragma sellae or the medial sphenoid wing were least often completely removed and most likely to be associated with postoperative visual deterioration. Overall, 42% of patients had improved vision postoperatively, 30% remained unchanged, and 28% were worse. After a mean follow-up period of 38 months, 24 patients are doing well, four have significant visual disability, and three are blind or doing poorly. Two patients died of causes unrelated to their tumor. Three patients have had tumor recurrence.

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Jennifer L. Quon, Lily H. Kim, Peter H. Hwang, Zara M. Patel, Gerald A. Grant, Samuel H. Cheshier and Michael S. B. Edwards

OBJECTIVE

Transnasal endoscopic transsphenoidal approaches constitute an essential technique for the resection of skull base tumors in adults. However, in the pediatric population, sellar and suprasellar lesions have historically been treated by craniotomy. Transnasal endoscopic approaches are less invasive and thus may be preferable to craniotomy, especially in children. In this case series, the authors present their institutional experience with transnasal endoscopic transsphenoidal approaches for pediatric skull base tumors.

METHODS

The authors retrospectively reviewed pediatric patients (age ≤ 18 years) who had undergone transnasal endoscopic transsphenoidal approaches for either biopsy or resection of sellar or suprasellar lesions between 2007 and 2016. All operations were performed jointly by a team of pediatric neurosurgeons and skull base otolaryngologists, except for 8 cases performed by one neurosurgeon.

RESULTS

The series included 42 patients between 4 and 18 years old (average 12.5 years) who underwent 51 operations. Headache (45%), visual symptoms (69%), and symptoms related to hormonal abnormalities (71%) were the predominant presenting symptoms. Improvement in preoperative symptoms was seen in 92% of cases. Most patients had craniopharyngiomas (n = 16), followed by pituitary adenomas (n = 12), Rathke cleft cysts (n = 4), germinomas (n = 4), chordomas (n = 2), and other lesion subtypes (n = 4). Lesions ranged from 0.3 to 6.2 cm (median 2.5 cm) in their greatest dimension. Gross-total resection was primarily performed (63% of cases), with 5 subsequent recurrences. Nasoseptal flaps were used in 47% of cases, fat grafts in 37%, and lumbar drains in 47%. CSF space was entered intraoperatively in 15 cases, and postoperative CSF was observed only in lesions with suprasellar extension. There were 8 cases of new hormonal deficits and 3 cases of new cranial nerve deficits. Length of hospital stay ranged from 1 to 61 days (median 5 days). Patients were clinically followed up for a median of 46 months (range 1–120 months), accompanied by a median radiological follow-up period of 45 months (range 3.8–120 months). Most patients (76%) were offered adjuvant therapy.

CONCLUSIONS

In this single-institution report of the transnasal endoscopic transsphenoidal approach, the authors demonstrated that this technique is generally safe and effective for different types of pediatric skull base lesions. Favorable effects of surgery were sustained during a follow-up period of 4 years. Further refinement in technology will allow for more widespread use in the pediatric population.

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Ahmed El-Banhawy and Fouad El-Nadi

craniopharyngioma. The tumor was occupying the intrasellar and suprasellar regions with a forward protrusion into the floor of the anterior cranial fossa and a more extensive backward extension into the 3rd ventricle. The growth was removed partially and the patient was improved markedly. However, recurrence appeared within 4 months and the boy's parents refused to submit him for a second operation. ANGIOGRAPHIC DATA For a better understanding of the various changes in the vascular landmarks produced by sellar and suprasellar neoplasms, we found it advisable to fashion a

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T. Vasudev Rao, Randhir Puri and G. N. Narayana Reddy

microscopic and histochemical evidence concerning its Schwann cell derivation and nature (granular cell schwannoma). Cancer 15 : 936 – 954 , 1962 Fisher ER, Wechsler H: Granular cell myoblastoma — a misnomer. Electron microscopic and histochemical evidence concerning its Schwann cell derivation and nature (granular cell schwannoma). Cancer 15: 936–954, 1962 8. Friede RL , Yaşargil MG : Suprasellar neoplasm with a granular cell component. J Neuropathol Exp Neurol 36 : 769 – 782 , 1977 Friede RL, Yaşargil MG

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John R. Mawk, James I. Ausman, Donald L. Erickson and Robert E. Maxwell

. Left: Preoperative angiogram showing superior displacement of the anterior cerebral artery. Center: First postoperative angiogram demonstrates spasm in the proximal middle cerebral artery (arrow). Right: Second postoperative angiogram shows extremely severe spasm and displacement of the anterior cerebral artery (arrow) . Operation A right frontal craniotomy was carried out. There was minimal retraction of the brain. A large, pink suprasellar neoplasm was encountered beneath the chiasm and both optic nerves. The tumor was quite soft and was removed

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Gustavo A. Carvalho, Anette Lindeke, Marcos Tatagiba, Helmut Ostertag and Madjid Samii

—a misnomer. Electron microscopic and histochemical evidence concerning its Schwann cell derivation and nature (granular cell schwannoma). Cancer 15: 936–954, 1962 14. Friede RL , Yaşargil MG : Suprasellar neoplasm with a granular cell component. J Neuropathol Exp Neurol 36 : 769 – 782 , 1977 Friede RL, Yaşargil MG: Suprasellar neoplasm with a granular cell component. J Neuropathol Exp Neurol 36: 769–782, 1977 15. Gamboa LG : Malignant granular-cell myoblastoma. Arch Pathol 60 : 663 – 668

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Michael D. Cusimano, Kalman Kovacs, Juan M. Bilbao, William S. Tucker and William Singer

. Nelson DH , Meakin JW , Thorn GW : ACTH-producing pituitary tumors following adrenalectomy for Cushing's syndrome. Ann Intern Med 52 : 560 – 569 , 1960 Nelson DH, Meakin JW, Thorn GW: ACTH-producing pituitary tumors following adrenalectomy for Cushing's syndrome. Ann Intern Med 52: 560–569, 1960 27. Newman CB , Levine LS , New MI : Endocrine function in children with intrasellar and suprasellar neoplasms. Before and after therapy. Am J Dis Child 135 : 259 – 262 , 1981 Newman CB, Levine

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Garrett K. Zoeller, Carole D. Brathwaite and David I. Sandberg

completely with excellent long-term outcomes, OPGs are typically not completely resectable and can be associated with considerable morbidity. 1 , 16 Optic pathway gliomas confined to 1 or both optic nerves that are not enlarging are typically observed using serial imaging studies. Larger tumors involving the optic chiasm and hypothalamus often require surgery, both to distinguish them pathologically from other suprasellar neoplasms and to relieve mass effect. 16 Gross-total resection is typically not performed due to potentially severe endocrine and visual morbidity

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Carotid-ophthalmic aneurysms

A study of 19 patients

Ponneri Kothandaram, Benjamin H. Dawson and Rudolph C. Kruyt

untreated carotid-ophthalmic aneurysms do not have a strong tendency to bleed. Four patients had symptoms of intermittent optic nerve or chiasmal compression; three had blurring of vision or blindness; one complained of flickering flashes of light in front of one eye. Scotomata, quadrantic, or hemianopic field defects were observed in two patients who were referred directly to the Neurosurgical Department from the Ophthalmic Service because their visual field defects were thought to be arising from suprasellar neoplasms. The importance of oblique angiographic

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Pituitary adenomas in childhood and adolescence

Results of transsphenoidal surgery

Michael D. Partington, Dudley H. Davis, Edward R. Laws Jr. and Bernd W. Scheithauer

. Nakane T , Kuwayama A , Watanabe M , et al : Long term results of transsphenoidal adenomectomy in patients with Cushing's disease. Neurosurgery 21 : 218 – 222 , 1987 Nakane T, Kuwayama A, Watanabe M, et al: Long term results of transsphenoidal adenomectomy in patients with Cushing's disease. Neurosurgery 21: 218–222, 1987 33. Newman CB , Levine LS , New MI : Endocrine function in children with intrasellar and suprasellar neoplasms. Before and after therapy. Am J Dis Child 135 : 259 – 262