Apoplejía hipofisaria / Pituitary apoplexy

La apoplejía hipofisaria es una complicación poco frecuente de los adenomas de hipófisis, producida por un infarto hemorrágico o isquémico en el adenoma y con una clínica característica: cefalea intensa de comienzo agudo, alteraciones visuales y somnolencia o coma. En los últimos 10 años hemos tratado a 8 pacientes con apoplejía hipofisaria. El diagnóstico fue clínico: 7 presentaron cefalea intensa y vómitos, 8 alteraciones visuales y 1 disminución del nivel de conciencia asociado a síndrome meníngeo. En 6 casos, la apoplejía fue la primera manifestación del adenoma de hipófisis. La resonancia magnética y la tomografía computada demostraron el ictus hipofisario en 7 pacientes. La cirugía descompresiva transesfenoidal se efectuó en 7 casos, sólo en uno de urgencia. Todos presentaron una significativa recuperación de las alteraciones visuales, sin embargo, en ninguno se observó mejoría de las alteraciones endocrinológicas preoperatorias. Consideramos que el diagnóstico precoz, el rápido inicio del tratamiento hormonal sustitutivo y la cirugía transesfenoidal urgente o diferida en función de la clínica, deben ser la base del tratamiento adecuado de la apoplejía hipofisaria (AU)

[Pituitary apoplexy]. / Apoplejía hipofisaria.

Pituitary apoplexy is an infrequent complication of pituitary adenomas, caused by hemorrhagic or ischemic infarction in the tumor, with typical clinical presentation: severe headache of sudden onset, visual disturbances, sleep tendency or comma. Along the last ten years we have treated eight patients with pituitary apoplexy. The diagnostic was clinically established in all of them. Seven cases complained of severe headache and vomiting. Eight patients reported visual disturbances. In one case low level of consciousness and meningeal irritation were the only findings. In six cases the apoplexy was the first pituitary adenoma manifestation. MRI and CT studies demonstrated the pituitary stroke in seven patients. Surgical trans-sphenoidal decompression was performed in seven patients, requiring urgent management in only one case. All patients experienced a marked visual improvement, but there was no amelioration of endocrine preoperative disturbances in any case. We conclude that quick diagnosis, early onset of hormonal therapy and urgent or delayed trans-sphenoidal surgery, depending on clinical manifestations, constitute the principies of the appropriate treatment of pituitary apoplexy.

Primary brain abscess with Nocardia otitidiscaviarum in an intravenous drug abuser.

A primary brain abscess with Nocardia otitidiscaviarum in an intravenous drug abuser is reported. Nocardia brain abscess has been reported infrequently and normally only in immunocompromised patients. The lungs are the most common primary focus, but brain abscess may also occur following direct cutaneous inoculation. In this case the clinical presentation was first diagnosed as an astrocytoma. However, N. otitidiscaviarum was isolated from the lesion after emergency craniotomy. In contrast to five cases described previously the patient survived after surgical removal and antibiotic treatment with imipenem and trimethoprim-sulphamethoxazole.

Dolor radicular / No disponible

Las hernias discales y la enfermedad degenerativa artrósica de la columna son responsables de la gran mayoría de los dolores radiculares. El mecanismo fisiopatológico de la p roducción del dolor radicular no ha sido completamente establecido, probablemente factores mecánicos, isquémicos e inflamatorios (radiculitis química) actuarían conjuntamente. Existe una gran número de procesos que pueden dar origen a un dolor radicular: hernias de disco, tumores, infecciones, traumatismos, etc. Una correcta historia clínica y exploración orientan el diagnóstico, que confirmará la Resonancia Magnética. El tratamiento debe ser etiológico. En patología discal y degenerativa el tratamiento conservador consigue una mejoría en el 80-90% de los pacientes. Cuando a pesar del tratamiento etiológico adecuado (médico y/o quirúrgico) persiste el dolor radicular es preciso efectuar un tratamiento neuroquirúrgico del dolor, mediante intervenciones sobre las raíces (rizotomías), sobre la médula espinal (DREZ, cordotomías) y mediante intervenciones de neuroestimulación (periférica, medular o cerebral). El tratamiento ideal debe ser el más eficaz, el menos invasivo, el de menor morbilidad, el más confortable para el paciente y el de menor coste económico (AU)

Disk disease and arthrosic degenerative disease of the column are responsible of most radicular pains. The physiopathologic mechanism of radicular pain has not been fully established, but probably several mechanical, ischemic and inflammatory (chemical radiculitis) factors act simultaneously. There are many processes that may cause radicular pain: disk hernias, tumors, infections, traumas, etc. A correct clinical history and examination guides the diagnosis, which is confirmed by Magnetic Resonance. The treatment must have an etiologic focus. In disk and degenerative pathology, the conservative therapy allows an improvement in 80-90 per cent of the patients. When despite an appropriate etiologic therapy (medical and/or surgical), the radicular pain persists, a neurosurgical management of pain is required, with procedures involving the roots (rhizotomies), the spinal cord (DREZ, cordotomies ) and through neuroestimulation (peripheral, medullar or cerebral). The ideal therapy would be the most effective, the less invasive, the less morbid, the most comfortable for the patient and the one with the less economic cost (AU)

[Analysis of prognostic factors in adults with chronic subdural hematoma]. / Análisis de los factores pronósticos en pacientes adultos con hematoma subdural crónico.

The objective of the study is the analysis of prognostic factors observed in the evolution of 65 patients who presented chronic subdural hematoma surgically evacuated. Morbimortality ratio corresponding to our surgical technique is also presented. A retrospective statistical analysis of epidemiologic, clinic and radiologic factors was performed. Personal background of alcoholism or coagulopathy, decrease of the level of consciousness, a lower score at the Glasgow Coma Score, a maximum thickness of the hematoma superior to 2 cm, and the respiratory and neurologic complications were found to be related to a worst prognosis. Our surgical technique showed 4.6% of mortality and 1.5% of recurrence. Detection of prognostic factors may have important implications in the selection of patients for surgery. Our small craniectomy has similar clinical outcome than other surgical methods.

Effects of the serotonin-uptake inhibitor, fluoxetine, on immunoreactive serotonin innervation in the rat pituitary gland.

Serotonin (5-HT)-immunoreactive innervation can be demonstrated in both the pars intermedia and pars nervosa of the rat pituitary gland. Fluoxetine hydrochloride, a 5-HT uptake inhibitor, was administered in single or multiple doses to adult male Sprague-Dawley rats to examine the possibility that 5-HT present in pituitary fibers may be due to uptake of the indoleamine. Paraffin-embedded sections of pituitaries from fluoxetine-treated rats revealed diminution or loss of 5-HT fiber staining in the intermediate, but not in the neural lobe, in all animals examined. Multiple doses of fluoxetine produced the most consistent effects on immunostaining. These observations along with results of our previous studies suggest that the intermediate lobe innervation immunoreactive for 5-HT may be due to uptake of indoleamine from extrinsic sources, while the pars nervosa terminals containing 5-HT most likely originate from 5-HT neuronal perikarya in the lower brainstem or hypothalamus.

Naltrexone induces melanocyte-stimulating hormone release and degenerative changes in pituitary innervation in amphibians.

Adult Rana pipiens (common frog) were treated with the long-acting opiate antagonist drug naltrexone hydrochloride to study potential effects of an opiate-receptor block on release of pro-opiomelanocortin (POMC) peptides from the pituitary intermediate lobe. The melanophore response of the animals was used to assess relative release of melanocyte-stimulating hormone (MSH). Animals were adapted to a light background, then injected with 20 or 50 mg/kg naltrexone for up to 3.5 days. All drug-treated animals showed increased release of MSH while on the light background while controls remained light-adapted. Ultrastructure of the pars intermedia of naltrexone-treated frogs revealed nerve fibers containing myelin figures, swelling of neurovesicles, and abnormal membrane components indicative of degenerative changes. The observations suggest that naltrexone has a damaging effect on pituitary innervation, and that MSH release may be the result of loss of neuroregulation from the normally inhibitory innervation. The findings are in agreement with our earlier studies in rats, which also demonstrated degenerative changes induced by naltrexone in intermediate lobe innervation. The long-acting antagonist may therefore have a "neurotoxic" effect after multiple injections or chronic use.

Serotonin-immunoreactive nerve fibers of the rat pituitary: effects of anticatecholamine and antiserotonin drugs on staining patterns.

Serotonin-immunoreactive (5-HT-IR) nerve fibers observed in the pars intermedia and pars nervosa of the rat pituitary gland were examined after treatment of animals with antiserotonergic or anti-catecholaminergic drugs. p-Chlorophenylalanine, (PCPA), an inhibitor of 5-HT synthesis, eliminated staining in both areas of pituitary gland. p-Chloroamphetamine (PCA), a serotonin neurotoxin, did not produce a significant change in 5-HT-IR from control tissue. Unexpectedly, 6-hydroxydopamine (6-OHDA), a catecholamine neurotoxin, eliminated 5-HT staining in the pars intermedia, but not in the pars nervosa. These observations suggest that 5-HT present in fibers innervating the intermediate and neural lobes is synthesized in axons locally, or is taken up into fibers from extrinsic sources. In addition, catecholamines and 5-HT may co-exist in nerve terminals of both lobes of the pituitary gland.

6-Hydroxydopamine induces degenerative changes in innervation of the rat pituitary gland.

Administration of 6-hydroxydopamine to adult male rats by peripheral injections induces degenerative changes in nerve terminals innervating cells of the pituitary intermediate lobe. Additional animals were treated with 5-hydroxydopamine, which produced images of nerve profiles containing vesicles with electron-dense centers, indicative of uptake of the false catecholamine (CA) neurotransmitter. Endocrine cells showed cytologic evidence of activation of synthetic and secretory compartments. The ultrastructural observations suggest that innervation to opiomelanocortin cells is sensitive to a CA-specific neurotoxin and strengthens the hypothesis that CA-containing fibers play a role in intermediate lobe neuroregulation.