Unusual scotomas after transsphenoidal surgery of a pituitary macroadenoma

The case of a woman presenting unusual bilateral campimetric defects following transphenoidal surgery is presented. The defects, consisting of a necklace of small round scotomas, disappeared after a corticosteroid treatment. A postoperative inflammatory mechanism may explain these unusual visual field abnormalities.     

Suprasellar tension pneumocyst after transsphenoidal surgery. Case report

Tension pneumocephalus is an uncommon occurrence after transsphenoidal surgery. The author presents an unusual case of postoperative visual deterioration related to expanding air within a suprasellar tumor cavity.     

CT guided transsphenoidal surgery: report of nine cases

A total of 83 adult patients between 25 and 60 years of age who acquired pulmonary infectious disease within 48 hours after being admitted to the medical, surgical and/or intensive care units at the university hospital of the "Universidad de Los Andes" (Mérida, Venezuela) were studied during a period of 18 months. The most frequent clinical entity observed was pneumonia (49.4%). In all types of pulmonary samples obtained by secretion or puncture, more than half gave positive results to the microbiological analysis. Gram-negative bacilli prevailed as the etiological agents, with a preponderance of the species from Klebsiella (21.7%) and Pseudomonas (15.1%) genus. Staphylococcus aureus was also isolated in 13.3% of all cases. Satisfactory sensitivity to third generation cephalosporins and aminoglucosides was observed on these strains. Quinolones showed the highest antimicrobial activity. The application of an adequate antimicrobial therapy, according to the antibiotics sensitivity test results, allowed a successful clinical efficacy in 67.4% of all cases.     

Manifestation of primary hyperthyroidism after pituitary adenomectomy: a case report

We report a 47-year-old Japanese man who presented with visual disturbance due to a pituitary tumor with suprasellar extension. The patient had mild secondary hypothyroidism preoperatively, and was started on administration of levothyroxine sodium immediately before transsphenoidal surgery. After the operation, levothyroxine sodium was continued for several months. Pathological examination of the surgical specimen, together with endocrinological investigation revealed that the suprasellar tumor was a FSH-producing pituitary adenoma. Since 3 months after the operation, he has developed muscle weakness and finger tremor. He was found to be thyrotoxicosis, and levothyroxine sodium was discontinued. Seven weeks after levothyroxine sodium was discontinued, thyrotoxicosis continued, with a positive thyrotropin binding inhibitory immunoglobulin (TBII) and a high diffuse 123I-uptake by the thyroid. He was started on thiamazole 30 mg/day. Although his thyroid dysfunction improved within 2 months, hyperthyroidism worsened repeatedly on attempts to discontinue thiamazole, and he required continuous treatment at 2.5 mg/day. Patients with occult autoimmune thyroiditis rarely progress to thyrotoxicosis after operations on other endocrine organs such as the adrenal or parathyroid gland. In patients with pituitary adenoma, thyroid function and thyroid-associated autoantibodies should be investigated pre- and post-operatively.     

Assessment of pituitary function after transsphenoidal hypophysectomy in beagle dogs

Pituitary function was assessed in healthy adult beagle dogs before and after hypophysectomy. Anterior pituitary function was tested by use of the combined anterior pituitary (CAP) function test, which consisted of sequential 30-sec intravenous injections of four hypothalamic releasing hormones, in the following order and doses: 1 microgram of corticotropin-releasing hormone (CRH)/kg, 1 microgram of growth hormone-releasing hormone (GHRH)/kg, 10 micrograms of gonadotropin-releasing hormone (GnRH)/kg, and 10 micrograms of thyrotropin-releasing hormone (TRH)/kg. Plasma samples were assayed for adrenocorticotropin (ACTH), cortisol, GH, luteinizing hormone (LH), and prolactin (PRL) at multiple times for 120 min after injection. Pars intermedia function was assessed by the alpha-melanotropin (alpha-MSH) response to the intravenous injection of the dopamine antagonist haloperidol in a dosage of 0.2 mg/kg. Posterior pituitary function was assessed by the plasma vasopressin (AVP) response to the intravenous infusion of 20% saline. Basal plasma ACTH, cortisol, thyroxine, LH. PRL, and AVP concentrations were significantly lower at 10 wk after hypophysectomy than before hypophysectomy. In the CAP test and the haloperidol test, the peaks for the plasma concentrations of ACTH, cortisol, GH, LH, PRL, and alpha-MSH occurred within 45 min after injection. At 2 and 10 wk after hypophysectomy, there were no responses of plasma GH, LH, PRL, and alpha-MSH to stimulation. In four of eight hypophysectomized dogs, there were also no plasma ACTH and cortisol responses, whereas in the other four dogs, plasma ACTH and cortisol responses were significantly attenuated. The basal plasma ACTH and cortisol concentrations were significantly lower in the corticotropic nonresponders than in the responders. Plasma AVP responses were completely abolished by hypophysectomy, although water intake by the dogs was normal. Histopathological examinations at 10 wk after hypophysectomy revealed that adrenocortical atrophy was much more pronounced in the corticotropic nonresponders than in the responders. No residual pituitary tissue was found along the ventral hypothalamic diencephalon. However, in all hypophysectomized dogs that were investigated, islets of pituitary cells were found embedded in fibrous tissue in the sella turcica. A significant positive correlation was found between the number of ACTH-immunopositive cells and the ACTH increment in the CAP test at 10 wk after hypophysectomy. It is concluded that 1) stimulation of the anterior pituitary with multiple hypophysiotropic hormones, stimulation of the pars intermedia with a dopamine antagonist, and stimulation of the neurohypophysis with hypertonic saline do not cause side effects that would prohibit routine use, 2) in the routine stimulation of the anterior pituitary and the pars intermedia, blood sampling can be confined to the first 45 min, 3) the ACTH and cortisol responses to hypophysiotropic stimulation are the most sensitive indicators for residual pituitary function after hypophysectomy, 4) small islets of pituitary cells in the sella turcica, containing corticotropic cells, are the most likely source of the attenuated corticotropic response that may occur after hypophysectomy, and 5) residual AVP release from the hypothalamus after hypophysectomy is sufficient to prevent diabetes insipidus, despite the fact that the AVP response to hypertonic saline infusion is completely abolished.     

Surgical indications for and limitations of staged transsphenoidal surgery for large pituitary tumors

Surgical indications and limitations of transsphenoidal surgery and intentionally staged transsphenoidal surgery for large pituitary tumors were investigated by retrospective analysis of the surgical and neuroradiological findings of 22 patients with large tumor and suprasellar extension. Twelve patients underwent intentionally staged transsphenoidal surgery, and 10 underwent combined transsphenoidal and transcranial surgeries. Successful removal by intentionally staged surgery required descent of the suprasellar part following the first transsphenoidal surgery. Analysis showed that a smooth suprasellar extension and/or soft tumor are indications for intentionally staged transsphenoidal surgery even in patients with small sella. However, lobulated suprasellar extension, fibrous and firm tumor without descent, and small sella with normal pituitary gland located at the bottom of the sella are contraindications for staged transsphenoidal surgery. The first transsphenoidal surgery is always indicated to achieve histological confirmation and decompression of optic nerves. Transcranial surgery should be attempted instead of repeated transsphenoidal surgeries when the residual tumor does not descend following the first transsphenoidal surgery.     

Medical management after pituitary surgery

Although the majority of patients with pituitary tumor, undergoing transsphenoidal microsurgery, have a low incidence of hormonal deficiency after surgery, the endocrinological evaluations should be carefully done before and after surgery. Glucocorticoid replacement is necessary in patients with Cushing's disease during and after surgery as well as those with adrenal insufficiency. Repeated CRF test is useful to assess the secondary adrenal insufficiency of Cushing's disease after surgery. Patients with impaired secretion of both ACTH and TSH should receive glucocorticoid replacement before thyroid hormone replacement in order to avoid adrenal crisis. A combination of CRF, GRF, TRH and GnRH is a safer and more reliable test to evaluate pituitary function than the conventional triple test consisting of insulin, TRH and GnRH, especially in patients predicted to have pituitary-adrenal insufficiency. Diabetes insipidus(DI), immediately after pituitary surgery, should be treated with subcutaneous injection of Pitressin. Even if patients seem to have recovered from DI several days after surgery, they must be monitored closely because of the incidence of triphasic DI. Less attention has been given to replacement for GH deficiency in adults. Recent reports revealed that GH replacement in adults with GH deficiency decreases visceral fat tissue and increases plasma calcium, phosphorus, osteocalcin and procollagen III levels. GH replacement will become more popular even in adults. Many options and technological advantages in the diagnosis and treatment of pituitary tumors have developed in a decade. In the near future, post-operative patients with pituitary tumors must be cared for in view of the "quality of life".     

Pregnancy after heart transplant: update and case report

Based on their ability to induce leukocyte chemotaxis and adhesion to endothelial cells (ECs), chemokines have been implicated in driving inflammatory leukocyte emigration. Recently, it was suggested that chemokines can accomplish their pro-emigratory role more effectively while being bound to the luminal surface of the ECs. Previously, such binding was demonstrated in situ in human skin for the prototype alpha-chemokine interleukin (IL)-8. Here we used an in situ binding assay to investigate the binding characteristics of several beta-chemokines in intact human skin. RANTES, MCP-1, and MCP-3 bound, similar to IL-8, in a specific saturable manner to the ECs of venules and small veins but not arteries or capillaries. RANTES inhibited MCP-1 and MCP-3 binding and vice versa, indicating that the EC binding sites are shared among these beta-chemokines; moreover, IL-8 and RANTES cross-competed for each other's binding, suggesting that the same chemokine binding sites are used by members of alpha- and beta-chemokine subfamilies. Conversely, MIP-1alpha did not bind to the ECs and did not compete for binding of RANTES. Analogous to IL-8, all of the tested beta-chemokines bound to the resident dermal cells. As a novel aspect of chemokine interaction with cells in normal skin, we observed specific, saturable binding of RANTES, MCP-1, and MCP-3 but not MIP-1alpha or IL-8 to the ECs of dermal afferent lymphatic vessels. RANTES, MCP-1, and MCP-3 also cross-competed for each other's binding to lymphatics, suggesting a common binding site with a novel chemokine binding profile. We suggest that the chemokine binding to the ECs of lymphatics may be involved in the process of leukocyte entry into the afferent lymphatic vessels.     

Individual change after epilepsy surgery: Practice effects and base-rate information.

To evaluate the role of practice and to establish statistically meaningful methods for assessing cognitive outcome after epilepsy surgery, test–retest scores for 47 left (LTL) and 49 right (RTL) temporal lobectomy patients on the Wechsler Adult Intelligence Scale—Revised (WAIS—R) and Wechsler Memory Scale—Revised (WMS—R) were compared with the scores of 40 epilepsy patients who had not received lobectomies (SZCs). Reliable change indexes were calculated to control for measurement error, and base-rate tables for individual change were constructed for each variable before and after adjustment for observed practice effects. More frequent positive Full Scale IQ changes were noted among LTL than among RTL patients following surgery, whereas negative changes on the WMS-R General Memory and Verbal Memory Indexes were more common among the LTL patients than among either the RTL or SZC groups. When practice effects were controlled, the RTL patients also exceeded base-rate expectations for negative outcomes on the Verbal Memory Index. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A composite silent corticotroph pituitary adenoma with interspersed adrenocortical cells: case report

Recently, perfusion imaging has been of increasing interest in MRI. We applied this method for semiquantitative evaluation of hepatic parenchymal portal blood flow in patients with diffuse liver damage. Twenty patients with diffuse hepatic damage were divided according to the Child's Classification and studied. Gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) was administered into the superior mesenteric artery (SMA), and a dynamic series of T2*-weighted fast low angle shot (FLASH) images was obtained. We evaluated relative regional portal blood volume (rrPBV), mean transit time (MTT), and relative regional portal blood flow (rrPBF). The relationship between the rrPBV, rrPBF, and plasma indocyanine green retention rate test at 15 minutes (ICGR15 was also evaluated in 12 patients. Both rrPBF and rrPBV are significantly decreased in Child B & C patients compared with Child A patients. On the other hand, the MTT is significantly prolonged in Child B & C patients compared with Child A patients. Significant correlations were also noted between rrPBV and ICGR15 and between rrPBF and ICGR15. By means of selective catheterization into the SMA, we were able to estimate rrPBV, rrPBF, and MTT. This method may play a clinical role for assessment of regional portal perfusion in various diseases with diffuse liver damage.     

Application of nasal endoscopy and cryosurgery in transsphenoidal removal of pituitary tumors

In order to sum up the experience of transsphenoidal resection of pituitary tumors, 60 cases operated between 1984 and 1995 were reviewed. The operation was performed via a columella nasi "V" incision and transseptal-sphenoidal approach. 0 degree and 30 degrees endoscopes were used in 16 cases and the cryotherapy was used to destroy the remnant tumor cells in 51 cases. The duration of freezing was only one minute each time and it was repeated once again after thawing. The advantages of this method were as follows: (1) wider operative field and better illumination; (2) magnified operative pictures and TV monitoring; (3) wide and changeable visual angle; (4) lack of complications such as hemorrhage, optic nerve injury, permanent diabetes insipidus. The proper applications of endoscopy and cryosurgery were recommended for transsphenoidal removal of pituitary tumors.     

Applied behavioral analysis of societal problems: Population change, a case in point.

Suggests that current approaches to societal problems, such as population change, have resulted in inadequate solutions and that various methodological and conceptual biases exist which limit problem solution alternatives. Applied behavior analysis approaches employ strategies which have been successful in effecting behavior change in educational, clinical, and institutional contexts and should be carefully considered in approaching population change problems. Interdisciplinary contributions are suggested that facilitate identification of relevant behaviors and selection of appropriate behavioral intervention strategies. Training programs for family planning trainers and workers are currently feasible and are felt to provide a potentially effective response to the individual family's needs. (54 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bilateral spermatocele developed after vasectomy: a case report

A rare case of bilateral spermatocele developed 17 years after vasectomy was presented. A forty-seven year old man visited to our hospital with a chief complaint of swelling of bilateral intrascrotal contents. Sonographic findings demonstrated multilocular lesions of the bilateral intrascrotal contents. Operative procedure revealed bilateral cysts originating from the caput of the epididymis. Bilateral epididymectomy were performed. It was diagnosed as spermatocele because of demonstration of spermatozoa in the cystic fluid. We concluded that bilateral spermatocele has been induced by prolonged increased pressure of the intraepididymal duct following vasectomy 17 years ago.     

Prolonged weakness after cisatracurium infusion: a case report

OBJECTIVE: To present the first documented case report of myopathy persisting for >48 hrs in a patient treated with cisatracurium and concomitant high-dose corticosteroids. DESIGN: Anecdotal observations in one patient. SETTING: Medical-respiratory intensive care unit (ICU) at a tertiary care, university teaching hospital. PATIENT: A 45-yr-old female admitted status for post-bilateral total knee replacement complicated by aspiration pneumonitis and acute respiratory distress syndrome (ARDS). INTERVENTIONS: The patient required pressure control ventilation and sedation with midazolam and fentanyl infusions. On ICU day 2, the patient was placed on inverse ratio ventilation and paralyzed with cisatracurium. On ICU day 6, methylprednisolone 125 mg i.v. every 6 hrs was initiated for fibroproliferative ARDS. On ICU day 11, methylprednisolone was reduced to 60 mg i.v. every 6 hrs and tapered over several weeks. Cisatracurium infusion rates ranged from 6.3 to 10.5 microg/kg/min, with an average of 8.0 microg/kg/min. MEASUREMENTS AND MAIN RESULTS: Train-of-Four was assessed before initiation of therapy and every 4 hrs, thereafter. Train-of-Four values were maintained from 1 to 4 throughout therapy and a value of 4 was recorded when therapy was discontinued. On day 13, neuromuscular blocking agent therapy was discontinued, but severe proximal and distal muscle weakness was observed bilaterally. Creatinine kinase concentrations on 3 and 13 days after discontinuation of the paralytic agent were 181 and 96 units/L, respectively. On day 24, the patient moved her fingertips. On ICU day 30, the patient was weaned from the mechanical ventilator. The patient was transferred to the ward on day 33. Extensive rehabilitation with physical and occupational therapy was required for several months. CONCLUSION: Clinicians should remember that irrespective of chemical structural, neuromuscular blocking agents might produce prolonged paralysis in predisposed patients.