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1. Makarenko S, Alzahrani I, Karsy M, Deopujari C, Couldwell WT. Outcomes and surgical nuances in management of giant pituitary adenomas: a review of 108 cases in the endoscopic era. J Neurosurg. 2022;137(September):1-12. doi:10.3171/2021.10.jns21659

Pituitary adenomas are histologically benign lesions that are the third most common intracranial neoplasm. They account for 10%–25% of intracranial neoplasms, with a prevalence of 17%. A subgroup of these lesions that are ≥ 4 cm in maximum diameter are classified as giant pituitary adenomas. Estimated at 5%–10% of all pituitary lesions, these giant pituitary adenomas are particularly challenging to manage because surgery can be problematic in large lesions that grow beyond the sella turcica due to limited space and the proximity of key anatomical structures such as the optic nerves, chiasm, carotid arteries, and cranial nerves, as well as the normal pituitary gland. The lesions may present with symptoms of mass effect such as headaches, visual loss, and diplopia, but also symptoms resulting from inappropriate hormonal secretion.

The authors present a 108-patient, single-surgeon series of management of giant pituitary adenomas. They characterize the lesions and discuss surgical outcomes. They also outline how the surgical management paradigm has evolved with experience and illustrate surgical nuances utilized to treat these lesions with case examples.

Patients in this study underwent resection of a pituitary adenoma with stereotactic image guidance and use of microvascular Doppler probes when necessary to identify the carotid arteries and to guide the extent of bony resection. The approach was selected on a case-by-case basis: either transnasal microscopic transsphenoidal resection with or without assistance of an endoscope for visualization or a transcranial approach. In select cases, a combination of transsphenoidal and transcranial approaches was used to achieve GTR, which was defined as no visible tumor on follow-up imaging. Autologous fat or fascia lata graft was used in cases in which there was a high risk of postoperative CSF leak. Surgicel (Ethicon) was used to buttress the fat graft packing in a “sling technique” within the sphenoid sinus.

The mean preoperative tumor diameter in this cohort was 4.6, with a mean volume of 25.9 cm3. Ninety-seven patients underwent transsphenoidal approaches only, 3 underwent transcranial resection, and 8 patients underwent a combined approach. Gross-total resection was achieved in 42 patients. Tumor stability without a need for additional therapy was achieved in 77 patients, with 26 patients undergoing subsequent adjuvant radiotherapy. Among 100 patients with sufficient follow-up, 14 underwent adjuvant therapy—repeat operation and/or adjuvant radiation therapy—because of recurrence or tumor progression. Six patients with recurrence were observed without additional treatment. Overall, the morbidity associated with removal of these lesions was 11.1%; the most common morbidities were cerebrospinal fluid leak (5 patients, 4.6%) and hydrocephalus (4 patients, 3.7%).

They conclude that giant pituitary tumors still represent a surgical challenge, with significant morbidity. Gross-total resection occurs in a minority of patients. Surgical goals for removal of giant pituitary tumors should include attempts at removal of most tumor tissue to minimize the risk of residual tumor apoplexy by tailoring the approach along the major axis of the tumor.

7 figures with MR

2. Peng D, Yan M, Liu T, et al. Prognostic Factors and Treatments Efficacy in Spontaneous Spinal Epidural Hematoma. Neurology. 2022;99(8):e843-e850. doi:10.1212/WNL.0000000000200844

Spontaneous spinal epidural hematoma (SSEH) is a relatively uncommon but potentially devastating disorder. Patients generally present with sudden onset acute back or neck pain, followed by progressive motor, sensory symptoms, or sphincter dysfunction, which ultimately leads to complete/incomplete motor deficit caused by spinal cord/nerve root compression or cauda equina. Once the diagnosis is suspected, early surgical intervention should be considered. Although there is no consensus on the ideal timing for surgery, most authors consider that surgery performed within 12 hours after the onset of symptoms is associated with better outcomes. Owing to the relative rarity of SSEH, many of these reports were gleaned from single-center data with limited sample sizes. The clinical implication of these studies is therefore might be limited. A recent individual patient data meta-analysis from the published literature enrolled 617 patients and identified that severity of preoperative neurologic deficit and use of anticoagulants determine the postoperative outcomes, but not the time interval between symptom onset and surgery.

A total of 105 patients with SSEH were retrieved from medical records, with a mean age of 51.3 years. Eighty-three patients (79%) complained of acute onset of severe neck or back pain. Eighty-two patients (78%) suffered from moderate to severe neurologic deficits. Anticoagulation usage was found in 20% of cases. Lower thoracic spine, use of anticoagulants, sphincter function disfunction, severe neurologic deficits at admission, and rapid deterioration (<1 hour) were found to be associated with poor outcomes. Surgical decompression was performed in 74 (70%) cases.

They conclude that preoperative neurologic deficit and extended paraplegia time were strongly correlated with the prognosis in the subset of patients who underwent surgical decompression. Timely surgical decompression is recommended for patients with moderate/severe neurologic deficits or progressive neurologic deterioration.

3 tables, 1 figure, no imaging

3. Neth BJ, Carabenciov ID, Ruff MW, Johnson DR. Temporal Trends in Glioblastoma Survival. The Neurologist. 2022;27(3):119-124. doi:10.1097/NRL.0000000000000393

Glioblastoma is the most common primary CNS malignancy with a current median overall survival (OS) of ~15 months, ranking near the worst prognoses of all cancer. Historical management has focused on surgical resection and radiation therapy (RT) alone, with little additional progress until 2005 with the FDA approval of temozolomide (TMZ) as a first-line chemotherapy in combination with RT and maximal surgical resection, leading to a population-level survival benefit.

Multiple analyses have also documented a subsequent improvement in survival several years after TMZ was fully integrated into the standard of care. The reasons for this later improvement well after the FDA approval of TMZ are less clear, with hypotheses including use of bevacizumab (BEV), incremental improvements in RT and surgical techniques, and better quality of supportive care. In recent years, there have been further advances in GBM management such as the FDA approval of tumor-treating fields (TTF) (TT Fields represent a non-invasive anticancer modality consisting of low-intensity, intermediate-frequency, alternating electric fields delivered via cutaneous transducer arrays configured to provide optimal tumor-site coverage), continued advancements to RT, and surgical techniques with the tumor visualizing agent 5-ALA.

The authors evaluated population-based data (2000-2017) from the Survival, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI) to identify recent trends in GBM survival.

A total of 38,352 patients diagnosed with GBM between 2000 and 2017 met inclusion criteria. Median survival and percent survival to 12 and 24 months all progressively increased between 2000 and 2011. There were no significant differences in survival comparing 2009-2011 with 2012-2014 or 2015-2017. During the 2015-2017 period, median survival was 11 months.

After a period of progressive improvement in GBM survival between 2000 and 2011, survival plateaued. Subsequent advances since 2011 have not yet been translated to improved survival on the population-level as of 2017. As the most common primary CNS malignancy, GBM continues to have dismal survival despite persistent efforts in management and therapeutic development. After modest gains in short-term survival after the introduction of TMZ and BEV, there has been negligible survival improvement since 2011.

2 figures, 3 tables, no imaging

4. Winegar BA. Imaging of Painful Ophthalmologic Disorders. Neurol Clin. 2022;40(3):641-660. doi:10.1016/j.ncl.2022.03.002

Nice pictorial review with 21 figures. Always disconcerting to see a diagnosis that you have never made in 35+ years of neuroradiology…meaning that I don’t k