TSH-secreting pituitary adenoma: benefits of pre-operative octreotide.

UNLABELLED: TSH-secreting pituitary adenomas are rare and the optimal investigation and management is uncertain. We describe a case of a 43 year-old woman with a TSH-secreting pituitary adenoma, highlighting diagnostic testing and our use, pre-operatively of somatostatin analogue therapy, which induced biochemical euthyroidism and a reduction in tumour size. LEARNING POINTS: The differential diagnosis of the syndrome of inappropriate TSH secretion is non-thyroidal illness, medications, assay interference due to heterophilic antibodies, thyroid hormone resistance and TSH-secreting pituitary adenoma.TRH stimulation test and triiodothyronine suppression test assist in differentiating thyroid hormone resistance and TSH-secreting pituitary adenoma.Somatostatin analogue therapy can induce biochemical euthyroidism and reduce tumour size.

Abdominal wall endometrioma in a patient with lumbo-peritoneal shunt: case report.

Lumbo-peritoneal shunt as one of the modalities for management of benign intracranial hypertension is prone to complications. We are reporting a rare complication of lumbo-peritoneal shunt insertion in which our patient had developed a painful swelling on the scar site. Surgical exploration confirmed diagnosis of abdominal wall endometriosis. Abdominal wall swelling with variation in size and tenderness during menstrual cycle in female patients with shunt, especially lumbo-peritoneal shunt, should raise the suspicion of endometriosis.

Life threatening complication of biocompatible osteoconductive polymer graft after anterior cervical discectomy.

Graft extrusion following anterior cervical discectomy is a recognized complication. We report a case of acute laryngeal obstruction secondary to synthetic graft extrusion to highlight potential dangers of interbody spacing devices and to stress the importance of investigation of patients who have symptoms attributable to early graft extrusion.

Medical rapid prototyping and 3D CT in the manufacture of custom made cranial titanium plates.

This report describes a new method of custom making cranial titanium plates for the repair of skull defects. We have combined 3D CT imaging and surface modelling with rapid prototyping (RP) technology to produce physical models of our patients' skulls from which custom titanium plates were made. We have expanded the use of image processing tools applied to the CT image data to fabricate a representation of the skull defect. Medical RP models are relatively expensive and particular attention has been paid to developing image processing methods to reduce costs. Our technique used the patient as their own model and generated data from the contralateral side of the head where appropriate. We present the results of 10 patients who have had a custom made cranial titanium plate fitted and discuss the models for these cases. The benefits of our custom made titanium plates are reduced patient attendances to hospital and a more accurate titanium plate which has improved fitting and cosmesis.

The epidemiology of major trauma in Northern Ireland.

In a one year population based study of major trauma (Injury Severity Score greater than 15) reaching hospitals in Northern Ireland in 1990/91 the incidence was 23.2 per 100,000 of the population or 20.5 per 100,000 excluding terrorist activities. The expected number of patients with major trauma for the province, (population 1.54 million) is 359 patients per annum. Road accidents and falls accounted for 71% of all trauma. Ninetynine patients per annum are expected to require immediate surgery, a laparotomy in 59 instances and neurosurgical procedures in 26. These data facilitate resource allocation and help predict the effects of future changes in the trauma system.

Use of the Injury Severity Score in head injury.

As part of a study of the early management of severe head injury, the use of the Glasgow Coma Score (GCS), Injury Severity Score (ISS) and TRISS was investigated. These injury scores were compared in correlating with outcome at one year as assessed by the Glasgow Outcome Score (GOS) and mortality. One hundred and thirty-one patients had a severe head injury, as defined by an ISS of 16 or higher, in whom the Abbreviated Injury Score (AIS) for craniocerebral injury was 3 or higher. Seventy-eight of these also fulfilled the accepted GCS definition of severe head injury (GCS less than 8 with no eye-opening). Thirty-eight had evacuation of an acute intracranial haematoma; 26 of these patients would not have been classified as severe head injury by GCS. The overall mortality rate was 38 per cent, and 24 per cent for those transferred to the neurosurgical unit. TRISS was slightly better than GCS for predicting outcome based on both GOS and mortality, however this difference was not significant. TRISS identified patients who died that are not considered as severe head injury by GCS. Use of TRISS allows the effects of systemic factors and other injuries to be taken into account when assessing severity of head injury.

Early management of severe head injury in Northern Ireland.

As part of a study into the management of major trauma, the early management of severe head injury in Northern Ireland was evaluated over a 12-month period. The injury severity score was used to define those patients considered to have severe head injury. There were 131 patients with severe head injury; 27 per cent were hypoxic and 18 per cent were hypotensive on admission to the primary hospital. Almost half had severe multiple injuries. Early endotracheal intubation was performed in 92 per cent of comatose patients, and adequate resuscitation (including laparotomy in some) was performed in 87 per cent of shocked patients transferred to the neurosurgical unit (NSU). Eighty patients were transferred to the NSU; 60 per cent were comatose, 68 per cent were intubated and ventilated, and 74 per cent were transferred by an anaesthetist. Two patients were in hypovolaemic shock after transfer and required laparotomy. Thirty-eight had evacuation of an acute intracranial haematoma; 26 of these would not have been classified as severe head injury by the Glasgow coma scale. The overall mortality rate was 38 per cent, and 24 per cent for those transferred to the NSU. We conclude that the early management of head injury in Northern Ireland is good, but there are problems, including pre-hospital oxygenation and delays in transfer.

Osteochondroma of the cervical spine: case report and review of the literature.

Osteochondroma of the spine is a rare condition; we report a patient who presented with a spastic tetraparesis due to such a lesion of the second cervical vertebra. Surgical removal resulted in improvement of the original symptoms, but a transient hemiparesis developed postoperatively. Postoperative magnetic resonance imaging was performed and demonstrated a region of myelomalacia at the level of surgery. Survey of the literature confirms the rarity of this lesion and the use of radiology in diagnosis is discussed.

Experience with the direct transnasal transsphenoidal approach to the pituitary fossa.

The direct transnasal transsphenoidal approach to the pituitary fossa has been used in our unit since 1987. We describe the procedure and report its use in 48 patients with pituitary lesions. Successful access to the pituitary fossa was made in 46 out of 50 operations (92%). In two cases, repeat transnasal exploration was successfully performed for recurrent tumour 3 and 5 years following an initial trans-nasal exploration. This approach is straightforward, quick and does not require dissection of nasal mucosa or removal of septal cartilage. There was a 5.8% rate of major post-operative complications, and this compares favourably with other routes of access to the pituitary fossa. No long-term nasal, septal or dental complications have occurred, such as may happen with the other routes to the sphenoid sinus and pituitary fossa.