International Journal of Neurology and Neurosurgery

Parkinson’s disease is the second most common aged associated neurodegenerative disorder after Alzhiemer affecting approximately 1% of the population above the age 50. James Parkinson for the first time medically described Parkinson disease as a neurological disorder in his famous work “An Essay of the shaking palsy”. The pathological hallmark of PD is selective and progressive degeneration of dopaminergic neurons in the substantia nigra pars compacta of human brain and the accumulation of Lewy bodies in the surviving neurons. Cardinal symptoms of Parkinson’s disease include resting tremor, rigidity, postural instability. Besides motor symptoms, several nonmotor symptoms are manifested many years before the onset of motor symptoms. Parkinson’s disease is classified into sporadic and familial PD. Therapeutic strategies prior to Levodopa and Deep Brain stimulation include bloodletting from the neck, vesicatories, shaking chair, hydrotherapy, spa treatments, light exercise and treating with hyoscyamine, arsenic, morphia, conium, Indian hemp” (cannabis). Though levodopa is the leading treatment for PD, it has many limitations. Stem cell therapy appears to be a promising therapy to replenish degenerated dopaminergic neurons.

Keywords: Parkinson’s Disease; Motor Symptoms; NonMotor Symptoms; Deep Brain Stimulation; Levodopa; Stem Cell Therapy; Biomarkers. 

Primary leptomeningeal gliomatosis is a rare, neoplastic syndrome which is highly fatal. Here is a 15 year female presenting with weakness of both lower limbs for 3 months of duration. Started on ATT presuming as tuberculous meningitis. MRI studies showed subacute infarcts in the medulla, B/l cerebellar hemisphere and superior vermis, abnormal basal enhancement, and meningeal enhancement in prepontine and premedullary region, edematous cord with T2, STIR hyperintensities from D3 to D10 and with D6 to D12 diffuse nodular intramedullary and dural enhancement. CSF analysis showed increase in protein ,with low glucose with no malignant cells. Weakness progressed rapidly for last 10 days and the patient succumbed to death after receiving 2 cycles of radiotherapy. Histopathology showed leptomeningeal gliomatosis (IHC: GFAPstrongly positive in tumour cells, with Ki6720%) in the spinal subdural lesion. Suspected morphology should be differentiated with conditions like cord astrocytoma, lymphoma, sarcoid, tuberculosis and leptomeningeal gliomatosis should be ruled out in case of rapidly progressing disease course.

 Traumatic acute subdural hematoma is one of the most common neurosurgical emergencies accounting for 1020% of all trauma cases. It is usually associated with mortality rate ranging 5090% but increases to 90100% in patients receiving anticoagulants. Majority of these patients are managed surgically by evacuation of hematoma depending upon clinical and radiological findings. Acute subdural hematoma with thickness more than 10mm or midline shift more than 5mm should be evacuated regardless of GCS. Patients with acute subdural hematoma thickness less than 10mm or midline shift less than 5mm should undergo evacuation if GCS drops more than 2 points from admission to injury, pupils asymmetrical, fixed or dilated or ICP more than 20mmhg. Whereas conservative treatment is warranted for patients with acute subdural hematoma thickness less than 3mm. There are case reports regarding spontaneous resolution of acute subdural hematomas even with thickness more than 10mm and midline shift more than 5mm but clear incidences are not available. Here in our article we represent a case of young adult with post traumatic acute subdural hematoma which resolved spontaneously within three days after head injury.

Keywords: Traumatic Acute Subdural Hematoma; Spontaneous Resolution; Conservative Management.

Intraosseous angiolipomas are very rare tumors occurring most commonly in the ribs and mandible. So far, only five cases of intraosseous angiolipomas of skull have been reported in the literature. We report the rare case of a 52 years old lady admitted with a swelling over the right frontotemporoparietal region of 12 years duration, which turned out to be an angiolipoma. We discuss its radiological features, histological features and management. We also present a review of the literature on intraosseus calvarial angiolipomas.

Keywords: Angiolipoma; Intraosseous; Skull. 

In almost all neurodegenerative diseases, progressive neuronal loss is a common phenomenon. Hence neurodegenerative diseases are customarily defined by the progressive loss of neurons. Traditionally the novel treatment strategies focused on replacing the lost neurons by neural precursor cells (NPCs)/neural stem cells (NSCs). Huge amount of research reports demonstrate the proofof concept that transplantation of NSCs has therapeutic potential and have been used for Alzheimer’s disease (AD), Parkinson’s disease (PD), Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis (MS) and other neurodegenerative diseases. The basic concept stand out in this point and question arises what happens to the selfrenewing and multipotent properties of NSCs that subsist in the adult brain. How adult NPCs/NSCs loss their capacity to overcome the effect of amyloid plaque pathology that cause AD, Lewis body that cause PD etc. It is not yet clear, whether prominent alteration of adult neurogenesis happens simultaneously during the initiation stage of plaque deposit (preplaque) stage. Parallel observations of generation of adult new neuron might affect by early hippocampus dysfunction which in turn follow the plaque deposit. This review article will try to define novel therapeutic strategies for neurodegenerative disorders and novel tools for high scale generation of adult NPCs/NSCs in vivo as well as in vitro. More importantly it will focus to explain the regulatory switches of adult neurogenesis and the factors that regulate adult neurogenesis.

Keywords: Adult Neurogenesis; SubVentricular Zone; SubGranular Zone; Neural Stem Cell; Neural Precursor Cell. 

The presentation of cauda equina syndrome as a result of herniated lumber disc is a very rare phenomenon during pregnancy. Only a handful of such cases have been reported in the literature. Cauda equina syndrome is a surgical emergency which requires urgent surgical decompression regardless of the stage of pregnancy. Therefore high suspicion should be kept by primary care physician for its diagnosis in symptomatic patient presenting low back pain with lower limbs weakness, saddle anesthesia or sphincter disturbance. Early diagnosis of cauda equina syndrome, through thorough physical examination and imaging studies, is of paramount importance to prevent irreversible sphincter damage. A case of 32 year old female at POG 25 weeks with cauda equina syndrome is presented here which was operated late and resulting in poor recovery.

Keywords: Cauda equina Syndrome; Herniated Lumber Disc; Low Backache; Sphincter Disturbance; Pregnancy. 

We report the case of a 34 year old male patient with acute onset and rapidly progressive paraplegia caused by leptomeningeal metastases of an intracranial Glioblastoma Multiforme (GBM), as an illustrative example to enumerate the clinical features and explain the mechanism of spread on the basis of the immunohistochemistry (IHC) of both the primary and secondary tumours. The biopsies of the primary intracranial and the secondary spinal leptomeningeal lesions were subjected to IHC analysis for Glial Fibrillary Acidic Protein (GFAP). Also, 98 additional cases of intracranial GBM with symptomatic leptomeningeal and intramedullary spinal metastases, obtained by review of the literature, are presented here. Mean interval between the identification of spinal metastases and death was 4.5 months. Location of the symptomatic spinal metastases was more frequently leptomeningeal than intramedullary. The case presented in this case report showed high and prominent GFAP expression in both the primary intracranial and secondary leptomeningeal lesions. This runs contrary to the hypothesis proposed by Onda et al and supported by Arita et al. This finding is important as further prospective studies are needed before the pathomechanisms of spinal seeding can be explained on the basis of the tumour’s IHC characteristics alone.

Keywords: Glioblastoma Multiforme; Spinal Metastases; Leptomeningeal Spread; GFAP Expression. 

Aim: To determine the prognostic value of AQP4 (aqua protein 4) antibody in the cohort of Chinese patients, and evaluate the diagnosis of AQP4 antibody detection inneuromyelitisoptica (NMO) and HRNMO (highrisk NMO), and explore the treatment. Methods: China national Knowledge Infrastructure, Wanfang Data, China Biology Medicine disc, Chinesescience and technology journal database, PubMed, Embase and the Cochrane Library weresearched up to November 2014 for randomized control trails of related key words. The quality ofstudies was assessed according to the inclusion and exclusion criteria as recommended by the Cochrane Handbook for Systematic Reviews. Metaanalysis was conducted using STATA V.12. Results: Total 13 trials of 11 studies having 472 and 362 cases in NMO and HRNMO groups were included and the numbers of AQP4 antibody positive were 350 and 168 casesrespectively. The metaanalysis showed: The total AQP4 antibody positive ratein NMO group was higher than HRNMO group (RR=0.66y95%Cl (0.53, 0.83); after stratification, inthe cell based assay group (RR = 0.636, 95%CI (0.461, 0.878), the AQP4IgG positive rate in NMOgroup was higher than HRNMO. In indirect immunofluorescence assay method group (RR =0.681, 95%CI (0.460, 1.009), there were no significant differences in AQP4 antibody positive rate between two groups. The Egger linear regression and sensitivity analysis of these studies suggested no evidence of publication bias. Conclusion: The AQP4 antibody positive rate in NMO group was higher than in HRNMO group of Chinese population; with a significant difference between the two groups.

Keywords: Demyelinating Disease; Neuromyelitisoptica; HighRisk NMO; Aquaporin4 Antibody; MetaAnalysis. 

Context: Study of outcome and analyzing various factors is important in various settings to identify factors that can lead to serious sequel but at the same time if identified early, are preventable, thereby leading to better management and good outcome in children. Aims: To study the outcome and analyze factors that affect outcome in children with severe head injury. Settings and Design: A hospital based prospective study was carried out at Osmania Medical College and General Hospital, Hyderabad. Methods and Material: A hospital based prospective study was carried out among 764 eligible children less than 14 years of age with head injury. Statistical Analysis: The data was entered in Microsoft Excel Worksheet and analyzed using proportions. Appropriate statistical test was applied wherever necessary. Results: Maximum cases were seen in children less than three years of age. But the proportion of severe head injuries was more among older children of 914 years. Most common mode of head injury was fall from height. Mild head injury was most common. Linear type of skull fracture was most common finding. Extradural hematoma was the most common intracranial hematoma. Vomiting was the most common presentation. Conservative management was carried out in maximum number of cases. Poor GCS score of 35, presence of pupillary abnormality, and presence of diffuse cerebral edema were found to be significant predictors of poor outcome among children (p < 0.05). Conclusion: Endotracheal intubation, elective ventilation for patient with poor GCS and early tracheostomy when necessary have shown good outcome in children with diffuse brain injury. Poor GCS at presentation, presence of shock, presence of diffuse cerebral edema on CT scan were the factors associated with poor prognosis.

Keywords: Outcome; Factors; Head Injury; Children; Prognosis. 

Context: The ideal surgical treatment of chronic subdural haematoma has not been clearly defined. The choice of intervention in most centres is largely based on the personal preference of the neurosurgeon. Aims: 1. To study the neurological outcome of twist drill craniostomy in patients with chronic subdural hematoma. 2. To study the efficacy of twist drill craniostomy in chronic subdural haematoma. Settings and Design: The prospective study was conducted in a single centre, in the department of neurosurgery of a teaching hospital in South India. Methods and Material: Seventy consecutive chronic subdural haematoma patients admitted from 15January2015 to 14July2016, needing operative intervention, were subjected to twist drill craniostomy. The diagnosis was confirmed by radiological means, with significant hemispheric haematoma on imaging. Statistical analysis used: Frequencies and percentages were calculated and Friedman test was applied. Results: There was significant clinical improvement in both Markwalder grading system and Glasgow coma scale after twist drill craniostomy within 24 hours of the intervention and in the regular follow up period. There were nine deaths [12.86%] in the study group. The recurrence rate was 18.57% among the operated subjects, and could be managed mostly by aspiration through the same drill hole. Conclusions: This therapeutic approach is suitable both for elderly and for medically frail patients who pose a high anaesthetic and operative risk. The major advantage of twist drill craniostomy was that it can be performed at the patient’s bedside under local anaesthesia. The complication rate is as low as other modern surgical techniques.

Keywords: Chronic Subdural Haematoma; Twist Drill Craniostomy; Markwalder Grading System; Glasgow Coma Scale; Neurological Outcome. 

Aims: To study Aetiology of lower Motor Neuron facial paralysis in rural area. Settings and Design: Prospective cross sectional study. Methods and Material: Total 78 patients presenting with LMN type of facial paralysis to ENT OPD from Nov 2013 to Nov 2015 were included. Detailed evaluation to find aetiopathogenesis, age and sex distribution, severity at presentation in different aetiologies was carried out. Results: Bells paralysis was commonest aetiology in present study, followed by otitis Media. Trauma was only third aetiological factor. Vehicular trauma leading to facial palsy was found in males only. Common age of presentation was 2140 years however patients with Heres zoster presented in 4060 age group. Traumatic facial palsy was more common in 3140 age group. Patients with Bells paralysis presented with lower HB grades while those with otitis Media, Herpes zoster and trauma presented with higher grades of palsy at presentation. Conclusion: Aetiological Profile of patients with facial palsy is markedly different in rural area Otitis Media is still an important cause of facial palsy with patientspresenting late in course if disease. Tuberculosis is still rarely seen as cause of facial palsy and trauma is more common cause of facial palsy in males.

Keyword: Facial Nerve Paralysis; Bells Paralysis; Aetiology. 

Background: Carotid artery stenosis has been associated with ischemic events of the brain. However, itýÿs frequency and thus, impact has not been clearly established in an Indian setting. Aim: This study was done to find the frequency of carotid artery stenosis in hospitalized ischemic stroke patients of above 45 years of age, as well as the risk factors associated with its presence. Materials and methods: A retrospective study was done on 128 patients hospitalized with acute ischemic stroke during the years 2011 and 2012 in a hospital in Southern India aged 45 years or older, excluding those with vasculitis. The data was collected using a clinical proforma and included details obtained on clinical examination, biochemical parameters, radiological investigations including CV Doppler and MR Angiography. CV Doppler findings were used as the basis of evaluation of carotid artery stenosis and degree of the same. Statistical analysis between the various parameters and presence of carotid artery stenosis was done using SPSS v 17. Results: Out of 128 patients, 34 (26.6%) were females and 94 (73.5%) males. The frequency of carotid artery stenosis was found to be 26.6%. Dyslipidemia was found to be a risk factor statistically significant with carotid artery stenosis. Conclusion: Carotid artery stenosis was found to be quite prevalent among ischemic stroke patients. This signifies the need for early detection as well as examination of plaque morphology for identification of those at risk of developing cerebral ischemia.

Keywords: Carotid Artery Stenosis; Dyslipidemia; Stroke and Risk Factors. 

The aim of the study was to perform Carotid Doppler in children aged 215 years with Sickle cell anemia. We also studied transcranial velocities in Internal carotid arteries & mean velocities in Common carotid, External carotid and Vertebral arteries. Correlation of increased velocity of blood flow with number of blood transfusions in past, HbF levels and Hydroxyurea therapy was also studied. Materials and Method: It was a hospital based crosssectional study conducted in a Tertiary care hospital in Nagpur from 1st March 2016 to 28 February 2017. Results: Total 64 patients were enrolled. 51.6% ofpatients were in age group of 510 years. Transcranialvelocity in Internal carotid artery between 170200cm/ s was present in 37.5% of patients and 6.25% of patients had TCV of >200cm/s. There was no correlation of TCV with number of blood transfusions in past andHbF levels. Patients who were on Hydroxyurea therapy had reduced transcranial velocities as compared to those who were not on therapy.

Keywords: Transcranialvelocity; Sickle Cell Anemia; Hydroxyurea. 

Introduction: Ocular myasthenia gravis (OMG) is a most common focal presentation of myasthenia gravis (MG). Most of the recent studies on myasthenia gravis including both generalized and ocular myasthenia used Edrophonium in the diagnosis. As per our knowledge after reviewing available literatures, no study mentioned about the Neostigmine test in a systematic manner. Neostigmine has some advantages over Edrophonium. Present study focused on Neostigmine test in a systematic manner in the diagnosis of OMG Methods: Twenty seven patients of suspected ocular myasthenia underwent clinical examination, electrophysiological (RNS and SFEMG) tests, ice pack test and neostigmine test in a systematic manner. After recording baseline data, 0.6mg of atropine was given intramuscularly and 15min later 0.03mg/kg of neostigmine was given intramuscularly. Subjective and objective improvement in clinical parameters was assessed at 15 minute intervals after Neostigmine injection for up to 1.5 hours. Results: Of 27 patients, 20 were diagnosed to have ocular myasthenia gravis based on clinical criteria and electrophysiological tests. Out 20 OMG patients, 11 (55%) had shown unequivocally positive results and equivocal result seen in 6 (30%) of patients. 2 patients with restricted extraocular movements without baseline diplopia developed diplopia at 3044 minutes of the test. All seven non myasthenia patients had shown negative results. It has 85% sensitivity, 100% specificity with 100% positive predictive value and 70% negative predictive value. Conclusion: The lower dose (0.03mg/kg) of neostigmine appears to be associated with fewer side effects compared to earlier literature mentioned dose (0.04mg/kg) with equal sensitivity. Improvement in ptosis was more frequent than diplopia. The time interval for maximal improvement in different clinical features varies in a given patient. Therefore, it is necessary to observe the patient for up to 60 minutes during Neostigmine test.

Keywords: Diplopia; Ptosis; Ocular; Neostigmine. 

Background: Meningiomas account for approximately 15 percent of primary cranial tumor and the most common tumors of the sphenoid wing region in the anterior cranial fossa base [1]. A thorough knowledge of the anatomy of the region and adherence to basic microneurosurgical principles can help achieve outstanding surgical results. We present our experience in surgical management of these cases for a total of 23 cases and a mean follow up of 18 months at a single centre. Methods: This prospective observational study was conducted from August 2013 to December 2016 in the department of Neurosurgery in our centre which is a tertiary care hospital in western India. All patients were operated using standard microneurosurgical techniques. Results: The average age of the patients was 43.13±11 years. Middlelateral location was the most common presentation (43.47%) followed by lateral location (30.43%). Optic canal invasion, cavernous sinus involvement was more in medial tumours as compared to lateral tumours. Gross total resection of the tumour was achieved in 19 of 23 (82.60%) cases. Orbitozygomatic craniotomy was done in 8 (34.78%) cases. Majority (69.56%) of the tumours were found to be gradeII on HPE. No new neurodeficit developed in most cases. Persistent neurodeficits were observed in 5 patients (Diplopia3, seizures1, headaches1). Conclusion: Our results are consistent with the current acceptable standards in treatment lateral sphenoid wing meningioms. However, there is scope for much improvement in dealing with medial sphenoid meningiomas, treatment of which should be planned on case to case basis.

Keywords: Sphenoid Wing Meningioma; Microneuro Surgery. 

Background: A seizure is a paroxysmal involuntary disturbance of brain functions. Seizures are broadly divided into generalized and partial seizures. Generalized tonicclonic seizures are the most common type of seizures in childhood. Aim: To study the clinical profile and probable etiology of children presenting with seizures. Material And Methods: A Prospective observational study in tertiary care during February 2013 to 2016. A total of 527 cases presenting with seizures between 1 month and 12 years of age were included. A detailed history with demographic details and clinical examination were noted in a preformed structured proforma. Results: Generalized Tonic Clonic 214 (62.02%) was the most common type of seizure type followed by generalized tonic 111 (32.17%) and myoclonic 08 (2.31%). Simple partial seizure was the most common type observed in 110 (60.4%) patients followed by complex partial seizure 58 (31.8%) and complex partial seizures with secondary generalization in 14 (7.69%) patients. Most common symptom apart from seizure was fever in 381 (72.2%) patients and etiology for seizure was febrile seizures in 204 (38.7%) followed by acute symptomatic seizures 178 (33.77%). The most common etiology was acute bacterial meningitis in 71 (39.88%) ,viral encephalitis 53 (29.77%), tubercular meningitis 28 (15.73%). Conclusion: Febrile seizures and CNS infections are common causes of seizures in febrile children. Neuroimaging should be advised in all patients with partial and afebrile seizures.

Keyword: Seizure; Febrile; CNS Infections. 

Background: Parkinson’s disease (PD) is associated with many nonmotor features including various types of sleep dysfunction. So, the present study was conducted to compare pattern and prevalence of sleep disturbances in sporadic and familial PD. Materials & Methods: The patients in present study were recruited from movement disorders clinic of tertiary teaching hospital after approval from the institution ethics committee and written informed consent from all patients. Patients with comorbid illness likely to cause sleep dysfunction were excluded from the study. Familial and sporadic PD patients who participated in the study were interviewed using standardised questionnaires using Parkinson’s Disease Sleep Scale (PDSS) and Epworth Sleepiness Scale (ESS). All patients underwent Polysomnography (PSG) using Biological Sleep Scan machine and results were evaluated with the help of a Qualified Sleep Specialist. Results: There was no significant difference with respect to PDSS total score and ESS total score between the two groups of PD. The overall prevalence of any sleep disturbance on PSG in Familial PD patients was 80% and it was 90% in Sporadic PD patients. There was no significant difference in the prevalence of Sleep disordered breathing, sleep fragmentation and periodic limb movements between the two groups. Conclusion: Sleep disturbances were common in both Familial and Sporadic PD patients in present study. No difference was found in overall nocturnal and daytime sleep symptomatology except less severe nocturnal akinesia and morning dystonia in Familial group.

Keywords: Familial; Sporadic; Parkinson’s Disease; Sleep Disorders; Polysomnography. 

Context: Gliomas account for nearly 50 to 60% of primary brain tumors. Preoperative diagnosis and grading of cerebral gliomas aids in prognostication and forecasting treatment. MRI alone has been suboptimal for preoperative evaluation of gliomas and advance sequences like Proton Magnetic Resonance Spectroscopy (MRS) and Diffusion Weighted Imaging (DWI) have abetted to improve characterization of gliomas. Aim: To assess the efficacy of MRS and DWI in diagnosing cerebral gliomas. Material and Methods: A Diagnostic Efficacy study was carried out among 31 patients presenting with neurological symptoms and suspected to have gliomas through MRI. In addition, MRS and DWI were also performed along with histopathological grading among these patients. At MRS, nCho, Cho/Cr, Cho/NAA along with lipid and lactate peaks were assessed. In DWI, minimum apparent diffusion coefficient was calculated for the tumour (ADCT), peritumoural oedema (ADCP) as well a ratio of ADCT to the minimum ADC in the contralateral normal tissue (ADCN). Tumours were graded as high grade or low grade based on MRS and DWI findings. Results: Twenty nine out of the 31 patients (21 male and 10 female) in the age range of 8 to 71 years were confirmed to have glioma at histopathology. Of these, glioblastoma multiforme (GBM) were most common (n=13). At histology, 4 tumours were low grade (grade I:2, grade II:2); while 25 were high grade (grade III:12, grade IV:13). Conventional MRI showed a diagnostic accuracy of 80.60% in correctly classifying the various lesions and 82.76% for grading them. At MRS, there was a significant positive correlation of nCho (p=0.006) and Cho/Cr ratio (p=0.029) for grading of gliomas. Moreover there was a significant difference between these two parameters between high (I and II) and low grades (III and IV). Lipid and lactate peaks were also significantly associated with high grade gliomas (p value was 0.042 for lipids and 0.01 for lactate). On DWI, ADCT and ADC ratio had statistically significant negative correlation with increasing tumour grades (p value was 0.015 for ADCT and 0.006 for ADC ratio). These two parameters were significant in differentiating high grade from low grade gliomas (p<0.05). Combining the findings in MRS and DWI resulted in a sensitivity, specificity and accuracy of 100%, 50% and 93.10% respectively. Conclusion: MR Spectroscopy, using nCho and Cho/Cr and DWI using ADCT and ADC ratio were found to be useful in evaluating the grades of cerebral glioma. Conventional MRI, however, was indispensable because of its ability to characterize and classify gliomas into subtypes. Combination of conventional contrast enhanced MRI, MRS and DWI is most appropriate to evaluate gliomas preoperatively.

Keywords: Brain; Gliomas; Grading; Magnetic Resonance Imaging; Magnetic Resonance Spectroscopy; Diffusion Weighted Imaging; Apparent Diffusion Coefficient. 

We retrospectively analyzed 65 patients of pituitary macroadenomas operated in superspeciality hospital of Bangalore medical college and research institute from June 2010 to June 2016. Management of pituitary adenomas represents a significant challenge for neurosurgeons, which is further amplified by the degree of local tumor infiltration into adjacent structures such as the cavernous sinus. The goal of the treatment of pituitary tumors are improvement of the visual, endocrinological and neurological symptoms with least morbidity and acceptable cosmetic results. The aim of our study was focused on surgical outcome of four approaches that we used, that is primary transcranial (PTC), sublabial transphenoidal (SLTS), endoscopic transphenoidal (ETS) and endoscope assisted transphenoidal (EATS). Results: forty patients were men and 25 were women. The youngest was 10 years of age and eldest was 66 year, with mean and median age of 38 and 41years respectively. Fiftyfive patients had nonfunctioning pituitary adenomas (NFAs) and 10 had hormonally active pituitary adenomas (PAs). The presenting symptoms were, visual obscuration (90.7%), headache (89%) and 7 patients had acromegaly due to growth harmone producing pituitary adenoma. Thirteen patients were operated by PTC, 30 patients by SLTS, 7 patients by ETS and 15 EATS. Gross total resection (GTR) was achieved in 70%, 42.8%, 73.8% and 46.6% patients in PTC, ETS, EATS and SLTS groups respectively. Visual improvement was seen in 70%, 42.8%, 73.8% and 46.6% of the patients in PTC, ETS, EATS and SLTS group respectively. Conclusions: since the goal of the treatment of pituitary adenomas are improvement of the visual, endocrinological and neurological symptoms with the lowest morbidity and acceptable cosmetic results. We suggest endoscope assisted transnasal transphenoidal approach as it combines the advantages of the stereoscopic view obtainable with a microscope and the endoscopic magnified panoramic view with best cosmetic results.

Keywords: Pituitary Adenomas; Giant Pituitary Adenomas; Transphenoidal; Endoscopic.