Hyperprolactinemia, intrasellar pituitary tissue pressure, and the pituitary stalk compression syndrome

1987 ◽  
Vol 67 (2) ◽  
pp. 192-196 ◽  
Author(s):  
Peter D. Lees ◽  
John D. Pickard
Keyword(s):  
Pituitary Adenoma ◽  
Transsphenoidal Surgery ◽  
Pituitary Stalk ◽  
Consecutive Series ◽  
Tissue Pressure ◽  
Content Type ◽  
Compression Syndrome ◽  
The Mean ◽  
Intrasellar Pressure ◽  
Fine Print

✓ The intrasellar pressure has been studied in a consecutive series of 24 patients undergoing transsphenoidal surgery for pituitary adenoma. The mean intrasellar pressure for the group was 23 ± 2.5 mm Hg (± standard error of the mean), with a mean pulse pressure of 3.5 ± 1 mm Hg. The waveform partly resembled the arterial configuration. The results are correlated with the radiological and endocrinological features of the tumors. A hypothesis is proposed to explain the mechanism of hyperprolactinemia associated with the pituitary stalk compression syndrome.

The long-term significance of microscopic dural invasion in 354 patients with pituitary adenomas treated with transsphenoidal surgery

2002 ◽  
Vol 96 (2) ◽  
pp. 195-208 ◽  
Author(s):  
Björn P. Meij ◽  
Maria-Beatriz S. Lopes ◽  
Dilantha B. Ellegala ◽  
Tord D. Alden ◽  
Edward R. Laws
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Tumor Tissue ◽  
Pituitary Surgery ◽  
Mr Images ◽  
Content Type ◽  
Pituitary Disease ◽  
The Mean ◽  
Fine Print

Object. Pituitary adenomas are considered benign tumors; however, they may infiltrate surrounding tissues including the dura mater. In this paper the authors analyze the clinical significance of microscopically confirmed dural invasion by comparing a range of variables (age and sex of patients, adenoma type, adenoma size on magnetic resonance [MR] images, remission, residual pituitary disease, recurrence, survival, and disease-free interval after surgery) between patients with noninvasive adenomas and those with invasive ones. Methods. Between 1992 and 1997 dural specimens were obtained in 354 patients with pituitary adenomas who underwent transsphenoidal surgery performed by the senior author (E.R.L.). Dural specimens were examined using routine histological methods and assessed for invasion by pituitary adenoma tissue. The dura was invaded by the pituitary adenoma in 161 patients (45.5%), and in 192 patients (54.5%) no evidence of dural invasion was found. Dural invasion was present significantly more frequently in the repeated surgery group (69%, 55 patients) than in the primary transsphenoidal surgery group (41%, 291 patients). The mean age of patients undergoing primary transsphenoidal surgery was significantly older in cases of invasive adenomas (50 years) compared with cases of noninvasive adenomas (43 years), and these age differences also correlated with adenoma size. Women tend to develop clinically evident, smaller adenomas at a younger age than men. Of the patients with pituitary adenomas that were 20 mm or smaller, 117 (76%) of 154 were women, whereas of the patients with adenomas that were larger than 20 mm, 74 (54%) of 137 were men. The frequency of dural invasion increased with increasing size of the pituitary adenoma as measured on MR images. In 291 patients who underwent primary pituitary surgery, the frequency of dural invasion according to adenoma size was 24% (≤ 10 mm), 35% (> 10 to ≤ 20 mm), 55% (> 20 to ≤ 40 mm), and 70% (> 40 mm). In patients who underwent primary transsphenoidal surgery, dural invasion was present in more than 50% of those with nonfunctioning adenomas and in 30 to 35% of patients with endocrinologically active adenomas. The mean diameter of the gonadotrophic adenomas and null-cell adenomas was significantly larger than that of each of the endocrinologically active adenomas. In 58 (20%) of 291 patients who underwent primary pituitary surgery there was residual pituitary disease postsurgery, and 20% of this subset of patients showed clinical improvement to such an extent that no further management was recommended. After pituitary surgery, residual tumor tissue was demonstrable significantly more frequently in patients with invasive adenomas than in those with noninvasive adenomas. Recurrences after initial remission (cure) of pituitary disease occurred in 18 (8.8%) of 205 patients between 2 and 79 months after primary pituitary surgery (median 25 months). The recurrence rate was not related to dural invasion in a consistent or significant fashion. Seven patients died between 14 and 79 months after pituitary surgery and all had invasive adenomas identified on gross observation at surgery and on microscopy. The survival rate was slightly but significantly decreased for patients with invasive adenomas (91%) compared with patients with noninvasive adenomas (100%) at 6 years postsurgery. Conclusions. The principal significance of dural invasion by pituitary adenoma is the persistence of tumor tissue after transsphenoidal surgery (incomplete adenomectomy; 20% in primary pituitary tumor resections). The increase in adenoma size with time and the concurrent development of dural invasion are the major factors that determine an incomplete adenomectomy. When the adenoma remains restricted to the sellar compartment or shows only moderate suprasellar extension, dural invasion may not yet have developed and conditions for complete selective adenomectomy are improved.

Delayed hyponatremia after transsphenoidal surgery for pituitary adenoma

1995 ◽  
Vol 83 (2) ◽  
pp. 363-367 ◽  
Author(s):  
Daniel F. Kelly ◽  
Edward R. Laws ◽  
Damirez Fossett
Keyword(s):  
Pituitary Adenoma ◽  
Antidiuretic Hormone ◽  
Intravenous Administration ◽  
Serum Sodium ◽  
Transsphenoidal Surgery ◽  
Fluid Restriction ◽  
Content Type ◽  
Inappropriate Secretion ◽  
Average Serum ◽  
Fine Print

✓ Hyponatremia, usually attributed to the syndrome of inappropriate secretion of antidiuretic hormone, typically occurs in a delayed fashion following transsphenoidal removal of a pituitary adenoma. In a series of 99 consecutive patients who underwent transsphenoidal surgery for pituitary adenoma, nine patients developed delayed hyponatremia, seven of whom were symptomatic. Of these seven patients, four had been discharged from the hospital and required readmission on postoperative Day 7 to 9. In the nine patients who developed hyponatremia, on the average, serum sodium levels began to fall on Day 4 and reached a nadir on Day 7 (mean serum sodium nadir 123 mmol/L). The development of delayed hyponatremia was associated with the presence of a macroadenoma in eight of the nine patients. Seven of the nine patients had serum sodium levels less than 130 mmol/L and required treatment. One patient was treated with fluid restriction alone and six were treated with both fluid restriction and intravenous urea therapy. Twenty-four and 48 hours after urea administration, serum sodium levels rose by an average of 6 and 10 mmol/L, respectively, and at discharge, levels averaged 136 mmol/L. Intravenous administration of urea provides a rapid yet safe means of correcting symptomatic hyponatremia when fluid restriction alone is inadequate. In this article, the authors discuss the pathogenesis of delayed hyponatremia.

Pituitary apoplexy: its incidence and clinical significance

1981 ◽  
Vol 55 (2) ◽  
pp. 187-193 ◽  
Author(s):  
Susumu Wakai ◽  
Takanori Fukushima ◽  
Akira Teramoto ◽  
Keiji Sano
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Pituitary Apoplexy ◽  
Clinical Symptoms ◽  
Consecutive Series ◽  
Content Type ◽  
Histological Types ◽  
Hormonal Function ◽  
A Minor ◽  
Fine Print

✓ The occurrence of hemorrhage from pituitary adenoma (so-called “pituitary apoplexy”) was investigated in a consecutive series of 560 cases operated on during the past 30 years. There were 93 cases (16.6%) in which hemorrhage from pituitary adenomas was confirmed either clinically or surgically. These patients were analyzed in terms of age, sex, symptoms and signs, size of tumor, hormonal function, and histological types of adenomas, and computerized tomography findings. In 90 cases (16.1%), hematoma or old bloody fluid was verified within the tumor tissue at surgery. Three other patients presented with subarachnoid hemorrhage, but there was no detectable intratumor hematoma in any of them. Among these 93 patients, 42 (7.5%) showed no evidence of clinical symptoms related to hemorrhage (asymptomatic hemorrhage). Fifty-one patients (9.1%) had definite histories of an acute episode that suggested sudden bleeding (symptomatic hemorrhage: pituitary apoplexy). Thirty-eight patients (6.8%) had a major attack manifested by disturbances of consciousness, hemiparesis, loss of vision, or ocular palsy. In two acromegalic patients, pituitary apoplexy developed during bromocriptine treatment. There was one case of sudden death due to massive hemorrhage from the tumor 14 months after the completion of postoperative radiation therapy. The other 13 symptomatic patients (2.3%) developed a minor attack which included headache, nausea, vomiting, and vertigo. Bleeding from pituitary adenomas was not statistically correlated with any of the following factors: sex, hormonal function of adenomas, and histological types, but it was correlated with age. The number of asymptomatic cases in the third decade was significantly greater than that of the whole group of pituitary adenoma patients in the same decade. The present investigation revealed that the incidence of pituitary apoplexy was unexpectedly high: a major attack in 6.8% of pituitary adenoma patients, a minor attack in 2.3%, and asymptomatic hemorrhage in 7.5% of the cases. This risk of pituitary apoplexy should be kept in mind in treating pituitary adenomas.

Transsphenoidal decompression of the optic nerve and chiasm

1977 ◽  
Vol 46 (6) ◽  
pp. 717-722 ◽  
Author(s):  
Edward R. Laws ◽  
James C. Trautmann ◽  
Robert W. Hollenhorst
Keyword(s):  
Pituitary Adenoma ◽  
Optic Nerve ◽  
Transsphenoidal Surgery ◽  
Visual Loss ◽  
Sella Turcica ◽  
Recent Experience ◽  
Content Type ◽  
Visual Status ◽  
Fine Print

✓ A review of recent experience with transsphenoidal surgery for lesions in and about the sella turcica establishes the value of this approach for the management of patients with visual loss. The lesions encountered consisted of pituitary adenoma in 45 cases, craniopharyngioma in 10 cases, and miscellaneous tumors involving the sella in the remaining seven cases. Sixty of the 62 patients in this series had quantitative determination of preoperative and postoperative visual status; after surgery, vision was improved in 81%, unchanged in 11%, and worse in 5%. Two patients (3%) died during the immediate postoperative period before their visual status could be evaluated.

Surgery for primary brain tumors at United States academic training centers: results from the Residency Review Committee for Neurological Surgery

2005 ◽  
Vol 103 (5) ◽  
pp. 789-793 ◽  
Author(s):  
John A. Jane ◽  
Larry D. Sulton ◽  
Edward R. Laws
Keyword(s):  
Brain Tumors ◽  
Transsphenoidal Surgery ◽  
Training Programs ◽  
Primary Brain Tumor ◽  
Annual Number ◽  
Academic Training ◽  
Content Type ◽  
Primary Brain Tumors ◽  
The Mean ◽  
Fine Print

Object. Surgery for primary brain tumors has been an important index of the quality of neurosurgical training programs in the US. The scope of such cases and the proportion of surgeries performed transsphenoidally are an interesting means of tracking the effectiveness of residency education. Methods. Program Information Forms from the 94 American Council for Graduate Medical Education—approved US neurosurgical residency programs were reviewed for the period between 2000 and 2003. Particular attention was focused on an analysis of the cases requiring craniotomy for primary brain tumor and transsphenoidal surgery. The mean annual number of primary brain tumor cases per program was 195, with a range from 36 to 724 cases. The proportion of primary brain tumors accessed transsphenoidally was 20%. The mean annual number of transsphenoidal operations performed at academic training centers was 39. A wide range in the frequency of transsphenoidal cases from one program to another was also noted. Almost one third of training centers performed fewer than 20 transsphenoidal operations annually and 80% performed fewer than 50. Conclusions. Most neurosurgical training programs provide residents with excellent experience in craniotomy for primary brain tumors. Practice with transsphenoidal surgery, however, is less well represented and tends to be clustered at several active centers. The implications for neurosurgical education are significant.

Gamma knife radiosurgery for pituitary adenomas

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 19-22 ◽  
Author(s):  
Masahiro Izawa ◽  
Motohiro Hayashi ◽  
Kohtarou Nakaya ◽  
Hiroyuki Satoh ◽  
Taku Ochiai ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Tumor Growth ◽  
Gamma Knife ◽  
Pituitary Adenomas ◽  
Gamma Knife Radiosurgery ◽  
Single Institution ◽  
Hormone Production ◽  
Content Type ◽  
The Mean ◽  
Fine Print

Object. The purpose of this study was the analysis of a large series of patients treated with gamma knife radiosurgery for pituitary adenoma in a single institution. Methods. One hundred eight patients with pituitary adenomas were treated over the last 7 years. Seventy-four patients have been followed for more than 6 months and form the basis of this report. Conclusions. Twenty-three patients harbored nonfunctioning adenomas, and 56 harbored functioning adenomas. The mean margin dose was 22.5 Gy (nonfunctioning adenomas, 19.5 Gy; functioning adenomas, 23.8 Gy). Control of tumor growth was achieved in 91%. A significant decrease of excessive hormone production was seen in 80% of patients, and the endocrinological normalization rate was 30.3%. Postradiosurgical complications were seen in 2.5%.

Quantification of in vivo Photofrin uptake by human pituitary adenoma tissue

2004 ◽  
Vol 101 (2) ◽  
pp. 272-277 ◽  
Author(s):  
Usiakimi Igbaseimokumo
Keyword(s):  
Photodynamic Therapy ◽  
Pituitary Adenoma ◽  
The Body ◽  
Human Pituitary ◽  
Human Pituitary Adenoma ◽  
Content Type ◽  
The Mean ◽  
Adenoma Tissue ◽  
Fine Print

Object. Photofrin is widely distributed in the body after intravenous injection. This study was designed to quantify the preferential uptake of Photofrin by pituitary adenoma tissue for intraoperative photodynamic therapy. Methods. Eight patients (seven men) with recurrent pituitary adenomas who had undergone previous surgery and radiation therapy were recruited for a Phase I/II feasibility study of the application of photodynamic therapy to pituitary tumors. Photofrin was administered intravenously at a dose of 2 mg/kg body weight 48 hours before repeated transsphenoidal hypophysectomy was performed. At the time of the operation, pituitary adenoma tissue, muscle, fat, skin, and plasma were obtained for measurement of Photofrin content by fluorometric assay. The mean Photofrin level in pituitary adenoma tissue was 6.87 ng/mg (95% confidence interval [CI] 3.99–9.75), which was significantly higher than the uptake by skeletal muscle (2.24 ng/mg, 95% CI 1.28–3.2; p = 0.008), or fat (2.54 ng/mg, 95% CI 0.66–4.42; p = 0.007). Nevertheless, the mean drug concentration in pituitary adenoma tissue was not significantly different from the level in plasma (7.65 µg/ml, 95% CI 5.38–9.90; p = 0.558). Skin specimens were available in four patients, and these showed a mean uptake of 2.19 ng/mg. Conclusions. Photofrin is preferentially retained by pituitary adenoma tissue to levels both adequate for intraoperative photodynamic therapy and approximately 50% higher than those reported for gliomas.

Collection of blood from the pituitary stalk and portal veins in monkeys, and from the pituitary sinusoidal system of monkey and man

1979 ◽  
Vol 50 (1) ◽  
pp. 75-80 ◽  
Author(s):  
Peter W. Carmel ◽  
J. Lobo Antunes ◽  
Michel Ferin
Keyword(s):  
Transsphenoidal Surgery ◽  
Blood Sampling ◽  
Pituitary Stalk ◽  
Portal System ◽  
Content Type ◽  
Risk Of Mortality ◽  
Microsurgical Approach ◽  
Portal Veins ◽  
Fine Print

✓ A transorbital, transsphenoidal microsurgical approach to the pituitary stalk and gland was used to collect blood from the hypothalamo-hypophyseal portal system in monkeys. Specimens may be obtained from the entire pituitary stalk, individual long portal veins, or the pituitary sinusoidal bed, with little risk of mortality. Continuous stalk blood sampling was carried out for periods of up to 10 hours. Pituitary sinusoidal-system blood was also collected during transsphenoidal surgery in man. The uses of data concerning hypothalamic-hypophyseal regulation obtained by these methods are illustrated.

Repeated transsphenoidal surgery to treat recurrent or residual pituitary adenoma

2005 ◽  
Vol 102 (6) ◽  
pp. 1004-1012 ◽  
Author(s):  
Ronald J. Benveniste ◽  
Wesley A. King ◽  
Jane Walsh ◽  
Jacob S. Lee ◽  
Bradley N. Delman ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Transsphenoidal Surgery ◽  
Initial Symptom ◽  
Pituitary Mass ◽  
Cushing Disease ◽  
Content Type ◽  
Tumor Mass ◽  
Major Complications ◽  
Symptom Remission ◽  
Fine Print

Object. In this paper the authors describe the indications for and the results and complications of repeated transsphenoidal surgery (RTSS) to treat recurrent or residual pituitary adenoma. Methods. A retrospective review was conducted of 96 consecutive patients who underwent RTSS to treat recurrent or residual pituitary adenoma. Ninety-six patients underwent RTSS: 42 to treat a recurrent or residual pituitary mass and 54 to treat a recurrent or persistent hormone hypersecretion. There was no case of perioperative death and there was a 1% incidence of major complications. Postoperative endocrinological deficiencies were uncommon unless planned total hypophysectomy was performed to treat Cushing disease. Clinical remission occurred in 93% of patients undergoing RTSS to treat a tumor mass, and 15% of patients initially experienced remission only to face a relapse after a mean of 32 months. Endocrinological remission occurred in 57% of patients undergoing RTSS to treat hormone hypersecretion; most of these patients had Cushing disease. Thirty-five percent of patients with an initial endocrinological remission experienced a relapse of their symptoms after a mean of 31 months (thus, 37% of patients achieved sustained endocrinological remission). We failed to identify factors that accurately predicted initial symptom remission or delayed relapse following RTSS. Ten patients in our series eventually underwent a third transsphenoidal surgery without major complications. Conclusions. Repeated transsphenoidal surgery is a more effective treatment for recurrent or residual mass than it is for hormone hypersecretion and has acceptable rates of morbidity and mortality. If hypophysectomy is not performed, endocrinological deficiencies are unlikely following RTSS.

Transsphenoidal surgery and adjuvant gamma knife treatment for growth hormone—secreting pituitary adenoma

2001 ◽  
Vol 95 (2) ◽  
pp. 285-291 ◽  
Author(s):  
Hidetoshi Ikeda ◽  
Hidefumi Jokura ◽  
Takashi Yoshimoto
Keyword(s):  
Growth Hormone ◽  
Pituitary Adenoma ◽  
Mr Imaging ◽  
Transsphenoidal Surgery ◽  
Residual Tumor ◽  
Cure Rate ◽  
Content Type ◽  
Transsphenoidal Microsurgery ◽  
Biochemical Cure ◽  
Fine Print

Object. The results of combined transsphenoidal surgery and adjuvant gamma knife surgery (GKS) for growth hormone (GH)—secreting adenoma were investigated using biochemical cure criteria for surgery and biological cure criteria for adjuvant GKS. Methods. Ninety patients (42 male and 48 female patients), ranging from 11 to 75 years of age, underwent transsphenoidal surgery for GH-secreting pituitary adenoma. Preoperative and postoperative GH and insulin-like growth factor-I levels were measured, as was the postoperative GH level after the oral glucose tolerance test. Tumor size, cavernous sinus (CS) invasion, and residual tumor were evaluated using magnetic resonance (MR) imaging. Transsphenoidal microsurgery was performed, followed by adjuvant GKS when there was persistent biochemical evidence of GH hypersecretion with residual tumor detectable in the CS on MR imaging. Patients in whom GKS was contraindicated were treated with conventional radiotherapy or by medical means. Conclusions. The overall surgical cure rate was 57% based on recently accepted biochemical cure criteria. Patients with no CS invasion achieved a 100% cure rate, whereas patients with CS invasion achieved an 82% cure rate (14 of 17 patients) after adjuvant GKS. The combination of transsphenoidal microsurgery and adjuvant GKS is the optimal therapy for patients with GH-secreting adenoma.

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