Internal Carotid Injury during Transsphenoidal Resection of Pituitary Macroadenoma Managed with Neurointervention Technique

Iatrogenic internal carotid artery (ICA) injuries during transsphenoidal pituitary tumor surgery are extremely rare but are associated with potentially disabling or life-threatening complications. Management options of ICA injuries are sacrifice, embolization, and endoluminal reconstruction. We report a case of ICA injury during transsphenoidal pituitary macroadenoma surgery, which was managed with endovascular covered stent placement for left carotid-ophthalmic pseudoaneurysm.

Postoperative GH and Degree of Reduction in IGF-1 Predicts Postoperative Hormonal Remission in Acromegaly

PurposeDetermine predictive factors for long-term remission of acromegaly after transsphenoidal resection of growth hormone (GH)-secreting pituitary adenomas.MethodsWe identified 94 patients who had undergone transsphenoidal resection of GH-secreting pituitary adenomas for treatment of acromegaly at the USC Pituitary Center from 1999-2019 to determine the predictive value of postoperative endocrine lab values.ResultsPatients underwent direct endoscopic endonasal (60%), microscopic transsphenoidal (38%), and extended endoscopic approaches (2%). The cohort was 63% female and 37% male, with average age of 48.9 years. Patients presented with acral enlargement (72, 77%), macroglossia (40, 43%), excessive sweating (39, 42%), prognathism (38, 40%) and frontal bossing (35, 37%). Seventy-five (80%) were macroadenomas and 19 (20%) were microadenomas. Cavernous sinus invasion was present in 45%. Available immunohistochemical data demonstrated GH staining in 88 (94%) and prolactin in 44 (47%). Available postoperative MRI demonstrated gross total resection in 63% of patients and subtotal resection in 37%. Most patients (66%) exhibited hormonal remission at 12 weeks postoperatively. Receiver operating characteristic (ROC) curves demonstrated postoperative day 1 (POD1) GH levels ≥1.55ng/mL predicted failure to remit from surgical resection alone (59% specificity, 75% sensitivity). A second ROC curve showed decrease in corrected insulin-like growth factor-1 (IGF-1) levels of at least 37% prognosticated biochemical control (90% sensitivity, 80% specificity).ConclusionPOD1 GH and short-term postoperative IGF-1 levels can be used to successfully predict immediate and long-term hormonal remission respectively. A POD1 GH cutoff can identify patients likely to require adjuvant therapy to emphasize clinical follow-up.

1351 Primary Pituitary Abscess Presenting as An Isolated Bitemporal Hemianopia

Pituitary abscesses are rare yet life-threatening entities. Most common presenting features are headache, hypopituitarism, and visual changes. Majority of patients are found to have a predisposing risk factor, such as a pre-existing pituitary lesion, recent pituitary surgery or irradiation, or a primary source of infection. We present the case of a 53-year-old male with a spontaneous pituitary abscess, who presented with an isolated bitemporal hemianopia, but was otherwise asymptomatic with no known risk factors. Magnetic resonance imaging showed a sellar and suprasellar mass, thought to be a pituitary macroadenoma. He underwent endoscopic transsphenoidal adenectomy and cystic fluid was seen intraoperatively. Microbiology analysis showed Staphylococcus Aureus, and a course of intravenous ceftriaxone was commenced. Histopathology reported no evidence of adenoma and impression was of a pituitary abscess. Following transsphenoidal resection and commencement of antibiotic therapy, the bitemporal hemianopia resolved. We therefore report a rare case of primary pituitary abscess and emphasise the importance of including this condition as a differential diagnosis in any patient with a visual deficit or new pituitary lesion.

Sinusitis Independently Predicts the Presence of Headache Following Endoscopic Transsphenoidal Resection for Pituitary Adenomas

Purpose Headache is common among patients with pituitary adenomas undergone endoscopic endonasal surgery (EES), but was seldomly concerned before. The present study aims to investigate the incidence and profile of risk factors of headache after EES.Methods A meta-analysis was performed to evaluate the occurrence proportions of postoperative headache in patients with pituitary adenomas. Then, a cohort of 101 patients undergone EES were enrolled for analyzing risk factors of headache. The Headache Impact Test (HIT-6) was used to score the headache preoperatively, 1 month and 3 months postoperatively. Results A total of 18 studies and 4442 participants were included for meta-analysis. The pooled occurrence proportion of postoperative headache was 29% (95% confidential interval: 20-38%). For the 101 patients enrolled in the present study, 26 (25.74%) of them had a HIT-6 scores of > 55 preoperatively, but decreased to 22 (21.78%) at 1 month, and 6 (5.94%) at 3 months, postoperatively. Multivariate analysis showed that pituitary apoplexy (OR=3.591, 95%CI 1.219-10.575, p=0.020) and Hardy's grade C-D (OR=21.06, 95%CI 2.25-197.02, p=0.008) were independently risk factors for preoperative headache. In contrast, postoperative sinusitis (OR=3.88, 95%CI 1.16-13.03, P=0.028) and Hardy's grade C-D (OR=10.53, 95%CI 1.02-109.19, P=0.049) independently predicted the presence of postoperative headache at 1 month. At 3 months postoperatively, the proportion of sinusitis tended to be higher in the headache group than the one in non-headache group (100% vs. 30.0%, p=0.070). Conclusion Headache is very common following EES for pituitary adenomas. Prophylactic management of postoperative sinusitis may help to alleviate postoperative headache.

Radiographic pituitary stalk disruption: A rare sequela of secondary empty sella syndrome

Background: This two-patient case series describes a rare sequela of postoperative empty sella syndrome (ESS) following transsphenoidal resection of pituitary macroadenomas. This is characterized by progressive hormone dysfunction, diabetes insipidus (DI), and associated MRI evidence of pituitary stalk disruption. Case Description: This phenomenon was retrospectively evaluated in a review of 2000 pituitary tumor resections performed by a single neurosurgeon (KOL). Chart review was retrospectively conducted to gather data on demographics, pituitary hormone status, tumor characteristics, and management. We identified 2 (0.1%) cases of progressive pituitary endocrine dysfunction occurring in the postoperative period associated with MRI evidence of pituitary stalk disruption within 6 weeks of discharge from the hospital. This was felt to be caused by the rapid descent of the residual normal pituitary gland down to the floor of the postoperative empty sella, causing relatively swift stalk stretching. Both patients developed DI, and one patient demonstrated increased pituitary hormone dysfunction. Conclusion: This phenomenon is a rare manifestation of postoperative ESS, secondary to surgical resection of a pituitary macroadenoma. We discuss the associated potential risk factors and strategies for avoidance in these two cases. Routine instillation of intrasellar fat in patients at risk is felt to be protective.

Routine postoperative fluid restriction to prevent syndrome of inappropriate antidiuretic hormone secretion after transsphenoidal resection of pituitary adenoma

OBJECTIVE Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common problem during the postoperative course after pituitary surgery. Although treatment of this condition is well characterized, prevention strategies are less studied and reported. The authors sought to characterize outcomes and predictive factors of SIADH after implementation of routine postoperative fluid restriction for patients undergoing endoscopic transsphenoidal surgery for pituitary adenoma. METHODS In March 2018, routine postoperative fluid restriction to 1000 ml/day for 7 days was instituted for all patients who underwent surgery for pituitary adenoma. These patients were compared with patients who underwent surgery for pituitary adenoma between March 2016 and March 2018, prior to implementation of routine fluid restriction. Patients with preoperative history of diabetes insipidus (DI) or concern for postsurgical DI were excluded. Patients were followed by neuroendocrinologists and neurosurgeons, and sodium levels were checked between 7 and 10 days postoperatively. SIADH was defined by a serum sodium level less than 136 mmol/L, with or without symptoms within 10 days after surgery. Thirty-day readmission was recorded and reviewed to determine underlying reasons. RESULTS In total, 82 patients in the fluid-unrestricted cohort and 135 patients in the fluid-restricted cohort were analyzed. The patients in the fluid-restricted cohort had a significantly lower rate of postoperative SIADH than patients in the fluid-unrestricted cohort (5% vs 15%, adjusted OR [95% CI] 0.1 [0.0–0.6], p = 0.01). Higher BMI was associated with lower rate of postoperative SIADH (adjusted OR [95%] 0.9 [0.9–1.0], p = 0.03), whereas female sex was associated with higher rate of SIADH (adjusted OR [95% CI] 3.1 [1.1–9.8], p = 0.03). There was no difference in the 30-day readmission rates between patients in the fluid-unrestricted and fluid-restricted cohorts (4% vs 7%, adjusted OR [95% CI] 0.5 [0–5.1], p = 0.56). Thirty-day readmission was more likely for patients with history of hypertension (adjusted OR [95% CI] 5.7 [1.3–26.3], p = 0.02) and less likely for White patients (adjusted OR [95% CI] 0.3 [0.1–0.9], p = 0.04). CONCLUSIONS Routine fluid restriction reduced the rate of SIADH in patients who underwent surgery for pituitary adenoma but was not associated with reduction in 30-day readmission rate.

Coronavirus disease 2019 infection and pituitary apoplexy: A causal relation or just a coincidence? A case report and review of the literature

Background: Pituitary tumor apoplexy (PA) is an emergency condition caused by hemorrhage or infarction of the preexisting adenoma. Many factors are currently well-known to predispose to PA. However, during the period of coronavirus disease 2019 (COVID-19) pandemic, case reports of PA associated with COVID-19 infection have been sequentially published. To the best of our knowledge, four cases have been reported so far in the English literature. We herein report the fifth case of this association and review the pertinent literature. Case Description: A 55-year-old male patient with confirmed COVID-19 infection presented by progressive decrease in visual acuity and oculomotor nerve palsy. His medical history is notable for diabetes mellitus, hypertension, and pituitary macroadenoma resection 11 years ago. He was on hormonal replacement therapy for panhypopituitarism that complicated the surgery. Previous magnetic resonance (MR) imaging studies were consistent with enlarging residual pituitary adenoma. During the current hospitalization, computed tomography revealed hyperdensity of the sellar and suprasellar areas. MR imaging revealed PA in a recurrent large adenoma. Endoscopic endonasal transsphenoidal resection was uneventfully undertaken with near total excision of the adenoma and partial improvement of visual loss and oculomotor palsy. Histopathological examination demonstrated classic features of PA. However, his chest condition progressed and he had to be transferred to COVID-19 intensive care unit in the referring hospital where he was intubated and put on mechanical ventilation. One week later, the patient unfortunately passed away due to complications of severe COVID-19 pneumonia. Conclusion: We report the fifth case of PA associated with COVID-19 infection. Based on our patient’s clinical findings, review of the other reported cases, as well as the available literature, we put forth a multitude of pathophysiological mechanisms induced by COVID-19 that can possibly lead to the development of PA. In our opinion, the association between both conditions is not just a mere coincidence. Although the histopathological features of PA associated with COVID-19 are similar to PA induced by other etiologies, future research may disclose unique pathological fingerprints of COVID-19 virus that explains its capability of inducing PA.