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
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14-FEBRUARY-2009 AYDA ABDEL-RAOOF BAKEER 47 YEARS
GIANT CRANIOPHARYNGIOMA MIMICKING PITUITARY ADENOMA WITH MASSIVE SUPRA AND PARASELLAR EXTENSION.
The patient was transferred
from Amman Surgical Center with clinical picture
of giant pituitary adenoma.
The patient started to
complain of loss of vision in the right eye fro
18 months. The last 10 days got deterioration of
vision of the left eye with lagophthalm and
complete paralysis of the left eye. She had
attacks of vomiting due to
On examination: the patient
is practically blind in the right eye with light
perception of the left eye. Complete paralysis
of the left oculomotor nerve.
MRI of the brain done
11-February-2009 showing giant pituitary adenoma
with massive suprasellar and bilateral
Bilateral subfrontal approach
was performed, with reflection of the bony flap
to the left.
The dura was opened parallel
to the inferior bony defect and the SSS was
coagulated at the most proximal part, preserving
during that all the draining veins. Mobilization
of the olfactory tracts was performed from under
the mideo-basal parts of the frontal lobe down
to the trigones. The tumor was pushing both
optic nerves laterally and they were of long
type. The tumor was attacked at the middle of
the tuberculum sella and gradual debulking was
achieved. The left side of the tumor was
attacked first and the left optic nerve became
lax. The right optic nerve was severely
compressed by the tumor and resection of the
tumor was achieved after further debulking. The
suprasellar part was then removed after sharp
dissection of the mass from the chiasm and
mediobasal frontal lobe. All the suprasellar
part was brought down and subsequently removed.
After removal of the right parasellar extension,
the right optic nerve became free and it was
possible to see the right oculomotor nerve and
the basilar artery.
Inspection of the pituitary
stalk, showed that it was tumorous and there was
no connection to viable pituitary gland. It was
decided to resect the pituitary stalk at the
tumor involvement. All the vascular structures
were preserved and no vascular injury took place
at any stage of the operation.
The frontal lobes were
looking normal ruling out any surgical trauma.
The patient was weaned and
sent to the ICU.
The patient final
histological result was craniopharyngioma. It is
retrospectively arising from the middle of
pituitary stalk destroying all the pituitary
The patient still in the ICU
19-February-2009 with clinical picture of severe
apathic syndrome with left hemiparesis. The
vital signs are all the time stable and she was
in Nimotop to decrease the arterial vasospasm
and hormonal replacement therapy. She did not
showed signs of diabetes insipidus and several
control CT-scan were acceptable.
The patient in
23-February-2009 at 1.15 P.M. during ambulation
progressed massive pulmonary embolism with
cardiac arrest and several attempts to
recover the cardiac function failed and brain
death confirmed at 2.30 P.M.
It is the usual practice to
preserve the pituitary stalk and the pituitary
gland during such operation, but when the tumor
is invading the pituitary stalk as in this case,
total tumor resection mandate the resection of
the tumorous stalk with the rest of the tumor.
After such procedure hormonal
replacement therapy must be considered after
Despite the anatomical
preservation of the olfactory apparatus, only in
85% of cases recover their olfaction. For more
details about craniopharyngiomas
The patient is obese and she
was covered with anticoagulants to avoid such
event as pulmonary embolism. Despite this fact,
she progressed this catastrophic event and we
lost the patient.
In major surgeries, the cause
of death is pulmonary embolism and figuring
first. Most of the patients rarely die in the
operating table. They die when they start to
ambulate. It was impossible to ambulate the
patient early, because she was practically blind
and obese and apathic. When she start to show
improvement, the thrombotic phenomena started
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Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .