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Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.tv

 

 

10-DECEMBER-2006  FATIMAH AL-SAGHEER WANIS  42 YEARS  PITUITARY STALK CRANIOPHARYNGIOMA WITH SUBCHIASMATIC  AND LEFT PARA-RETRO-SUPRASELLAR EXTENSION.

The patient came to the clinic 30-November-2006  complaining of headache for 1 year with progressing course. weight gain, dyspnea, thirst, polyurea for 6 months and visual disturbances for the last 3 months. Amenorrhea for 4 months. MRI performed 15-November-2006 in Libya, showing suprasellar mass.

On examination; The patient had signs of panhypopituitarism with hypothyroidism. Visual fields were full of scatomas and decreased vision both eyes more in the left.  She had slight weak right upper and lower limbs with Hoffmann positive in the right side and Babinski positive both sides. She had pretibial edema both lower limbs.

The patient was started in minirin nasal spray and L-thyroxin 50 microgram a day, predinoisolone 5 mg 2 tab three times a day. Cardio consultation was negative.

The patient was sent for more detailed investigations and MRI of the sella showed the above diagnosed craniopharyngioma.

Combined bifrontal with left pterional approach was created and the left olfactory tract was tiny at the retrobulbar part and it was impossible to mobilize it. The right one was preserved. Most of the tumor was resected lateral to the left optic nerve and tract. The cavity was cleaned properly and the solid part was removed from the basilar artery, left ICA, chiasm and tract. It was possible to see the pushed behind the left oculomotor nerve. The chiasm remained pushed by the underlying mass, for what, starting from under the right optic nerve the solid partially soft, partially calcified tumor mass was remove. Working under the chiasm. every attempt was directed to preserve the pituitary stalk, which was pushed to the left and posteriorly under the left optic nerve. Inspection for remnants behind the chiasm confirmed absence of remnants. All the neural structures were hanging free after the tumor removal completion and meticulous heamostasis was achieved. Ommaya reservoir was inserted lateral to the left optic tract and directed laterally parallel to the sylvian cistern  and after closure the reservoir was put under the skin.

Uneventful postoperative recovery and the patient kept in minirin and decadron.

Comments:

1.  Craniopharyngiomas are different in origin and in this case it was from the pituitary stalk. In contrast, the previously operated case was originating from the tuber cenirium.

2. Almost radical removal of the tumor is the best choice. For more details click here! Radiotherapy is preferred to prevent tumor recurrence and insertion of Ommaya reservoir during the first surgery, can help to avoid future surgeries in case of recurrence with cystic formation.

3. During the 27 years of performing more than 800 operations with subfrontal approach, an hypoplastic olfactory tract was noted and it was impossible to mobilize it, but the contralateral right one was anatomically preserved.

4. There is a relationship between the prominence of the frontal sinuses and the thickness and deepness of the crista Gallii. When the frontal sinus is hypoplastic, the crista Gallii also do so. This important, because during performance of subfrontal approach, surgeon must know how to create the bone flap with minimal burr holes. In this case, it was necessary to perform midline burr hole using high-speed drill above the nasion and violate the frontal sinuses to achieve an approach flush with anterior fossa to minimize traction injury.  For more details about this topic, click here!

 

 


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved