术前诊断垂体腺瘤经蝶手术的几点教训(附7例报告)

目的吸取经蝶窦手术切除垂体腺瘤并发症的经验教训。方法报告7例术前诊断垂体腺瘤经蝶手术的严重并发症。结果3例术后并发严重蛛网膜下腔出血,第三脑室、侧脑室出血;3例并发术后癫痫持续状态;1例并发化脓性脑膜炎。死亡4例。结论颅内出血是极高的并发症。应从解剖定位、手术操作等诸多问题引起重视、吸取教训。     

Delayed lymphocytic infundibuloneurohypophysitis following successful transsphenoidal treatment of Cushing's disease.

Lymphocytic infundibuloneurohypophysitis is a rare disorder in which neurohypophyseal function is impaired by an autoimmune process. Although several etiologies for this rare entity have been suggested, its occurrence following transsphenoidal adenomectomy has not been reported. A 20-year-old man presented with diabetes insipidus - seven years after successful transsphenoidal microadenomectomy for Cushing's disease, first diagnosed at the age of 13. Seven years later, he developed fairly rapid onset of polydipsia and polyuria. Magnetic resonance imaging demonstrated swelling of the posterior pituitary gland with thickening of the pituitary stalk. Endocrinological evaluation revealed neurohypophyseal dysfunction without the adenohypophysis being affected. On the basis of these findings, a diagnosis of lymphocytic infundibuloneurohypophysitis was made. The mass lesion of the posterior pituitary resolved after the administration of corticosteroids for two months and no operation was required. Lymphocytic infundibuloneurohypophysitis should be considered in the differential diagnosis of pituitary mass lesions following transsphenoidal surgery, especially when the mass is confined to the posterior pituitary gland with neurohypophyseal function being compromised.     

Management of Cushing's disease after failed surgery--a review

Selective transsphenoidal adenomectomy is generally recommended for initial treatment of Cushing's disease (CD) because it achieves a high (70-85%) rate of remission. However, if initial surgery is not successful, the approach to persistent or recurrent CD is more complex. Because residual or recurrent adenoma is typically found at the site of the original adenoma, repeat transsphenoidal surgery is recommended including selective adenomectomy, hemihypophysectomy or total hypophysectomy. If repeat pituitary surgery does not achieve remission, then possible adjuvant therapies include radiosurgery or stereotactic radiotherapy, bilateral adrenalectomy, and/or medical therapy. In all cases of persistent or recurrent CD, successful treatment requires close collaboration of endocrinologists, radiation oncologists and neurosurgeons.     

Delayed postoperative hyponatremia followed by acute renal failure in a patient with an ACTH-secreting microadenoma of the pituitary

The selective transsphenoidal adenomectomy of an ACTH-secreting microadenoma was followed by clinically symptomatic delayed hyponatremia in an otherwise healthy patient. During mild fluid restriction for the treatment of the hyponatremia, acute renal failure occurred. The renal failure was resolved by treatment with furosemide. Fluid restriction is considered a standard therapeutic approach for the treatment of this probably SIADH-induced hyponatremia. Until now, acute renal failure has not been reported under these circumstances. This unique case demonstrates the need of close monitoring of patients with delayed hyponatremia following pituitary surgery.     

Acute monocular disturbances mimicking optic neuritis in pituitary apoplexy

Three patients with acute monocular central scotoma and headache had the initial diagnosis of optic neuritis. Computed tomography showed large pituitary adenomas with necrosis and cyst formation consistent with the clinical symptoms of a previous pituitary apoplexy. After transsphenoidal adenomectomy the visual disturbances disappeared.     

Endoscopic endonasal pituitary surgery: surgical and outcome analysis of 50 cases.

OBJECTIVE: Microsurgical transsphenoidal surgery for pituitary tumors has been standard therapy for decades and was established by Harvey Cushing in the early twentieth century. Today, endoscopy is increasingly accepted in the therapy of pituitary lesions. In this retrospective study, we analysed the surgical technique and outcome of 50 patients with pituitary lesions treated with an endoscopic endonasal trans-sphenoidal approach. METHODS: Between January 2004 and July 2005, 50 patients (30 female and 20 male) with pituitary tumors were operated upon using an endoscopic endonasal trans-sphenoidal procedure without nasal speculum or postoperative nasal packing. The follow-up period ranged from 3 to 18 months. RESULTS: All patients had normal airways through both nostrils immediately after extubation. Postoperative discomfort was minimal and hospitalization was 4-5 days. Three patients developed postoperative transient diabetes insipidus, persisting in one for a further 2 months. Among the 50 patients, total tumor removal was achieved in 47 patients (94%), subtotal in two patients (4%). One patient died intraoperatively due to subarachnoid haemorrhage. CONCLUSION: The endoscopic endonasal transsphenoidal approach for removing pituitary lesions is a form of minimally invasive surgery offering excellent postoperative results.     

Pituitary abscess in a pregnant woman.

Pituitary abscess is a rare and potentially lethal condition. Pituitary abscess in a pregnant woman has not been previously described. A 38-year-old pregnant woman (34 weeks gestation) with a pituitary mass complained of a progressive headache and sudden visual impairment. She was afebrile and had no inflammatory symptoms on admission. On MRI, the preoperative diagnosis was pituitary adenoma with sphenoid sinusitis. She underwent an uncomplicated transsphenoidal procedure for removal of the pituitary mass. The next day, labor commenced and a healthy preterm baby was delivered. Pathologic examination of the intrasellar mass showed polymorphonuclear cells, debris and no tumor cells. The sellar contents were cultured and Streptococcus viridans was grown. To our knowledge this is the first case of pituitary abscess reported during pregnancy. Although the patient was pregnant, the transsphenoidal approach was safe for the mother and the fetus. Surgical drainage and antibiotic therapy are required for the definitive treatment of this condition.     

Bypass to the intracranial internal carotid artery.

Extracranial to intracranial internal carotid artery bypass surgery with vein is well described for a number of diverse conditions. They provide high blood flow with good initial patency. However, long term patencies for specific graft types remains unknown. This is an analysis of consecutive interposition saphenous vein bypass cases between the common carotid artery (CCA) and the intracranial internal carotid artery (ICA) where the distal anastomosis was placed end-to-end immediately proximal to the posterior communicating artery in 55 patients undergoing 57 bypass procedures (bilateral in 2 cases). Twenty-five patients underwent grafting for planned vessel obliteration where the pathology required vessel sacrifice. Twenty-eight patients had bypass grafting for stroke risk reduction in the setting of threatening stroke and 4 patients had bypass grafts for emergency revascularisation in the setting of stroke in evolution. Patients were assessed preoperatively and at follow-up with modified Rankin scores. Procedural related complications included a 7% mortality and 7% functional decline. Early graft occlusion occurred in 5% of grafts leading to death in each case. A further patient died of rupture at the distal anastomosis site. In surviving patients, patency was present in 100% at last follow-up (mean 5 years and maximum 11 years) with no patient sustaining new hemispheric ischemic events. One patient developed a delayed asymptomatic stenosis within the vein graft requiring stenting. Because of the high initial management risks this technique of common carotid to intracranial internal carotid artery saphenous vein bypass surgery should be reserved for patients at considerable risk by alternate management. However, once the acute postoperative period is past the bypass appears to be robust and capable of supplying the entire distribution of a normal internal carotid artery.     

经蝶窦显微外科手术治疗541例库欣病

目的 探讨经蝶窦入路显微外科手术治疗库欣病的疗效。方法 总结北京协和医院神经外科1981年至2007年收治的541例库欣病的临床资料。结果CT和（或）MRI显示微腺瘤、大腺瘤、巨大腺瘤和未见异常的比例分别为66.2％( 358/541)、14.0％( 76/541)、0.6％( 3/541)和19.2％(104/541)。病理为垂体ACTH腺瘤、增生和既未见肿瘤又未见增生的比例分别为75.4％(408/541)、8.3％ (45/541)和16.3％ (88/541)。病理明确腺瘤、增生以及病理阴性者术后近期（半年内）治愈率分别是85.0％( 347/408)、24.4％ (11/45)和45.5％(40/88)。随访0.5 -25.0年（平均3.1年）,复发率13.3％(53/398),复发时间0.5 -16.5年（平均3.4年）。结论 经蝶窦选择性垂体腺瘤切除加瘤周垂体组织大部分切除是治疗库欣病安全有效的首选方法。对首次手术无效或复发性库欣病,可以再次经蝶窦手术或垂体放疗。     

老年无功能性垂体腺瘤的外科治疗

目的：评价老年无功能性垂 体腺瘤行经蝶窦显微手术的安全性和有效性。方法：回顾性分析42例老年无功能性垂体腺瘤，经蝶窦显微外科治疗的临床资料，所有患者均在显微镜放大8－10倍下切除肿瘤。结果：本组大腺瘤30例，巨腺瘤12例,全切除27例，次全切除10例，大部分切除5例，术后无死亡。随访6 月－5年，肿瘤消失20例，残瘤静止7例，复发再手术3例。结论：经过正确的围手术期处理，经蝶窦 显微外科治疗老年无功能性垂体腺瘤是一种安全、有效的方法。     

A case of primary abscess of the pituitary gland]

This report details the management of a patient with a primary pituitary abscess with secondary amenorrhea, mimicking pituitary adenoma. The preoperative diagnosis of intra- and suprasellar pituitary abscess was established by X-ray examination of the skull, CT-scans and anamnesis. After transsphenoidal removal of the abscess with accompanying antibiotic therapy the patient had a progressive and nearly complete recovery with normalization of menstruation.     

神经内窥镜在垂体腺瘤切除术中的应用

目的探讨神经内窥镜技术在垂体腺瘤切除术中的应用方式及特点。方法在32例垂体腺瘤切除术中使用了神经内窥镜。其中15例采用内镜辅助下眶上“锁孔”入路垂体腺瘤显微切除术,17例采用神经内镜控制下经单鼻孔-蝶窦入路垂体腺瘤切除术。结果本组32例术后无1例死亡,无1例出现颅内出血、视神经损伤、颈内动脉损伤及脑脊液鼻漏等现象。用内镜控制的经单鼻孔-蝶窦入路垂体腺瘤切除术的17例病例中,15例肿瘤全切,1例肿瘤近全切除,1例肿瘤大部分切除。用内镜辅助的经眉切口眶上“锁孔”入路垂体腺瘤显微切除术的15例病例中,14例肿瘤全切,1例肿瘤近全切除。2例病人术后出现一过性多尿。本组32例患者术后随访3～15个月,原有症状均有所改善,异常增高的激素水平均降至正常,MRI检查显示无1例肿瘤复发。结论内镜辅助下经眉切口眶上“锁孔”入路垂体腺瘤显微切除术和内镜控制下经单鼻孔-蝶窦入路垂体腺瘤切除术符合微创原则,术后并发症少,疗效满意。提倡在垂体腺瘤切除术中使用神经内窥镜技术。     

神经导航辅助经蝶入路手术切除垂体腺瘤

目的探讨神经导航在经蝶入路垂体腺瘤切除术中应用的意义。方法在18例经蝶入路垂体腺瘤切除术中应用神经导航技术。术前行MRI三维影像重建，术中运用导航引导手术入路并监测鞍底开窗的范围、进入鞍内的深度及与颈内动脉、视神经的关系，其中8例最后用神经内镜辅助，随时了解肿瘤切除情况。结果18例经导航下均能精确定位，术中导航误差在1．4mm以内。肿瘤全切除者12例，次全切除者6例，术后无严重并发症。结论神经导航在经蝶窦入路垂体腺瘤切除术中起有效的辅助作用，能增加手术的安全性，但肿瘤切除的范围和程度仍然有赖于医生的技术与经验，必要时须用神经内镜辅助。     

Pituitary abscess

Pituitary abscess is a rare disease, but one with potentially high mortality and morbidity. We present a 46-year-old man with progressive visual disturbance and general malaise for 1 year. Endocrine studies revealed hypopituitarism, and magnetic resonance imaging revealed a pituitary lesion with suprasellar extension. We attempted to excise the lesion using a transsphenoidal approach, but pus in the pituitary fossa was found at operation, and no tumour was identified. The culture yielded coagulase-negative Staphylococcus. Antibiotics were administered for 3 weeks, and the patient made a good postoperative recovery. He required life-long hormone replacement therapy. After one and a half years of follow-up, he was well and had no evidence of focal or systemic infection. We review the literature regarding pituitary abscess and discuss the appropriate treatment and possible pathological mechanism.     

海绵窦内侧壁的显微解剖与扩大经蝶窦入路治疗侵袭海绵窦的垂体腺瘤（附103例分析）

目的研究海绵窦内侧壁结构的解剖特点，并探讨采用扩大经蝶窦入路治疗侵袭海绵窦垂体腺瘤的方法。方法在10具成人新鲜尸头上模拟扩大经蝶窦手术入路，观察海绵窦内侧壁结构的解剖特点。根据解剖学研究结果，指导临床采用扩大经蝶窦手术入路治疗侵袭海绵窦的垂体腺瘤103例。结果垂体侧方的海绵窦内侧壁薄弱，仅有一层疏松的纤维组织结构。颈内动脉是扩大经蝶窦入路海绵窦内所见的主要结构，可分为5段，有3个主要分支。颈内动脉海绵窦段主要的分支有脑膜垂体干、海绵窦下动脉和被囊动脉。向内侧走行的脑膜垂体干和被囊动脉是经蝶窦入路中较易损伤的血管。手术显微镜下全切除肿瘤62例（60．2％），次全切除38例（36．9％），大部切除3例（2．9％）；无手术死亡；手术并发症包括短暂性脑脊液鼻漏5例，暂时性脑神经功能损伤4例，垂体功能低下3例，颈内动脉损伤2例，永久性尿崩症1例。术后行放射治疗17例，γ刀治疗15例，药物治疗13例。随访3个月～8年，2例出现肿瘤复发而予以γ刀治疗。无再手术病例。结论扩大经蝶窦入路是切除侵袭海绵窦垂体腺瘤理想的入路；了解颈内动脉海绵窦段及其分支在解剖形态上的变化，对于减少术中出血，确保术中安全，具有重要意义。     

Metastatic melanoma to the pituitary gland

BACKGROUND: Metastasis to the pituitary gland is unusual, and occurs most often in patients with carcinomas of the breast or lung. Despite its propensity for spread to the brain, metastatic melanoma has rarely been described within the sella. METHODS: We report two cases of malignant melanoma pathologically confirmed within the pituitary, both metastatic from a primary site on the chest wall. In each patient, transsphenoidal resection of the tumor was incomplete and each received local radiotherapy after surgery. RESULTS: One patient recurred quickly and developed brain metastasis as well. He died four months after resection of the pituitary metastasis, but the second patient survived six months without recurrence. As intrasellar metastasis portends widespread systemic disease and may be synchronous with parenchymal brain metastasis, survival in such patients is limited regardless of adjunctive therapy. CONCLUSIONS: Such cases are likely to arise more commonly in future due to the increasing incidence of melanoma. Identifying them by imaging alone is difficult due to inconsistent signal characteristics on MRI (as shown by these cases) and the confusion introduced by any associated intratumoral hemorrhage.     

垂体细胞增生所致库欣病术后复发的诊断和处理

目的讨论垂体细胞增生所致库欣病经蝶术后复发的诊断和处理。方法根据临床症状,内分泌学检查和蝶鞍区MRI检查,5例病人被诊断为垂体ACTH腺瘤而行经蝶手术,术后病理为垂体细胞增生。术后1例症状无改善,4例症状改善3～11个月后复发皮质醇增高为降低皮质醇例行垂体放疗和肾上腺切除术,。2,3例行肾上腺切除术。在肾上腺切除的例中例症状32再次复发复查,MRI发现垂体腺瘤并再次经蝶手术,术后病理为垂体腺瘤。结果随诊1～5年,行二次经蝶手术的2例病人皮质醇降至正常行垂体放疗和肾上腺切除术者因垂体功能低下用强的松替代治疗结论当垂体细胞增生病人术后症状复发影像学。检查发现垂体肿瘤时应再次经蝶手术没有发现垂体腺瘤时可行肾上腺切除和垂体放疗。     

垂体腺瘤显微手术入路的选择应用

目的：本文总结各种垂体腺瘤显微手术的入路、方法及手术后的效果,分析其术后并发症发生的原因,探讨可采取的预防措施,以便于临床更科学、更合理地选用垂体瘤切除术式。方法：回顾性分析了2003年1月至2006年6月经CT、MRI及内分泌检查确诊的垂体腺瘤197例;其中经翼点入路切除肿瘤21例;经额入路切除肿瘤9例;经蝶入路（包括单鼻孔入路）切除肿瘤167例。结果：经翼点入路全切除肿瘤14例、次全切除肿瘤2例、大部分切除肿瘤5例;经额入路全切除肿瘤6例、大部分切除肿瘤1例、次全切除肿瘤2例。经蝶入路全切除肿瘤148例;次全切除肿瘤14例;部分切除肿瘤5例。复发率：经翼点入路病例中2例复发;经额入路病例中1例复发;经鼻蝶入路病例中6例复发。结论：在严格掌握各种手术入路适应证的情况下,取各自的优点,目前经单鼻孔蝶窦入路手术具有颅内干扰轻,视神经减压充分,视力改善理想,并发症少,恢复快,不影响外观,术中显露满意,内分泌紊乱纠正较完全等优点,已基本取代其他入路。对于巨大型垂体腺瘤,肿瘤向鞍上和颈内动脉两侧膨胀生长,手术可选二种入路或分二期进行,以期望提高全切率、降低死亡率和复发率、减少并发症。     

Cognitive dysfunction in cholesterol embolic disease

A patient who developed neurological and renal complications following coronary angiogram and coronary artery bypass grafting is reported. Neurological involvement was in the form of fluctuating sensorium and a subcortical pattern of dementia. Renal failure was seen in the form of raised urea and creatinine levels. Renal biopsy revealed the cause of the renal failure to be due to cholesterol embolic disease. While the sensorium often improved following renal replacement therapy (dialysis), the dementia was poorly responsive to therapy. The patient succumbed due to progressive renal failure. Awareness of the protean manifestations and a high index of suspicion are essential for appropriate diagnosis in order to enable the clinician to accurately prognosticate in this often fatal disease.     

Myopathy in acromegaly. Report of two cases

Acromegaly is often associated with neuromuscular disorders. Most of them are caused by compression of nerves with hypertrophic bone and soft tissues or complications of diabetes mellitus. Myopathy has rarely been reported in the Japanese literature. We report two cases with myopathy out of 14 cases of acromegaly. Case 1 is a 62-year-old woman who developed muscle weakness and atrophy in the shoulder girdle, pelvic girdle and femoral regions after a 10-year history of acromegaly. She showed positive Gowers' sign and normal DTRs. Basal growth hormone (GH) level in plasma was 1076 ng/ml. Electromyograms (EMG) obtained from the deltoid and rectus femoris muscles revealed typical myopathic abnormalities; an excess of small-amplitude, short-duration, polyphasic motor unit potentials. Histological examinations of the rectus femoris muscle showed diffuse atrophy of both type I and type II fibers. She also had bilateral carpal tunnel syndrome and bilateral tarsal tunnel syndrome, which were confirmed by nerve conduction studies of median nerves and posterior tibial nerves. A cranial computed tomography (CT) scan demonstrated sellar mass with suprasellar extension. She underwent transsphenoidal adenomectomy and radiation therapy. GH level lowered to 29 ng/ml, however, myopathy remained unchanged for 3 years after the surgery. Case 2 is a 38-year-old woman who had undergone partial removal of a pituitary adenoma 9 years after the onset of acromegaly. Basal GH level in plasma before the surgery had been 1694 ng/ml and was still high after the surgery (100-505 ng/ml). The patient developed proximal muscle weakness and atrophy 4 years after the surgery.(ABSTRACT TRUNCATED AT 250 WORDS)