The causes of hypopituitarism in the absence of abnormal pituitary imaging.

BACKGROUND: Hypopituitarism in the absence of a history of pituitary pathology or abnormal pituitary imaging is rare. AIM: To identify the cause of hypopituitarism in individuals in whom pituitary imaging was normal. DESIGN: Retrospective analysis of electronic patient record. METHOD: A review of the pituitary function in the 506 patients on the Morriston Hospital pituitary database revealed 230 had some degree of hypopituitarism and of these, 21 (9%) had normal pituitary imaging. RESULTS: Of this group, six patients had a past medical history of subarachnoid haemorrhage, head injury or meningitis, and mainly suffered from a deficiency of antidiuretic hormone. One patient had a stroke resulting in multiple anterior hormone deficiencies and six individuals had idiopathic cranial diabetes insipidus (DI). Subsequent investigations of the remaining eight patients with normal pituitary imaging revealed that two had neurosarcoidosis both of whom had panhypopituitarism. Four patients had haemochromatosis which resulted in gonadotropin deficiency in two, DI in one and panhypopituitarism in the other. There were two individuals with confirmed hypopituitarism and multiple hormone deficiencies in which no cause could be identified. CONCLUSION: These results show that hypopituitarism in the absence of pituitary pathology or an identifiable cause is rare. In patients with multiple anterior pituitary hormone deficiencies haemochromatosis and sarcoidosis should be considered.

Carotid-cavernous fistula after blunt trauma to the neck.

Carotid-cavernous fistulas (CCF) are uncommon conditions, but cause significant morbidity if untreated. The majority of CCFs in young men are attributed to direct skull trauma. We present a case of CCF following a blunt injury to the neck.

Assessment of fusion after anterior cervical discectomy.

There is no established method to assess fusion in patients following anterior cervical discectomy. In this study we have made a series of measurements to detect movement between vertebrae adjacent to an operated space. The absence of movement implies structural union between adjacent vertebrae. Measurements have been made in two distinct surgical groups. Group A patients had anterior cervical discectomy with insertion of a BOP graft into the disc space. Group B patients underwent simple anterior cervical discectomy with no spacer or graft material inserted, the disc space being left empty. Details of the measurements and interpretation of results are described. In the absence of a 'gold standard' to assess bony union we propose that these measurement methods provide an objective and scientific method to assess fusion at the operated level after anterior cervical discectomy. Objective measurement of fusion will allow comparison between different surgical techniques that claim fusion as an end point. It will also become possible to study the influence of fusion on clinical outcome in different surgical populations.

Deafness--a complication of nasopharyngeal airways.

We report a patient who developed temporary deafness secondary to oedema of the uvula and soft palate following prolonged continuous positive airway pressure via a nasopharyngeal airway.

Localized pneumocephalus caused by Clostridium perfringens meningitis.

Clostridium meningitis is a rare complication of elective surgery, but the presence of pneumocephalus on CT in the absence of penetrating injuries, should raise the possibility of anaerobic infections. We report a case of fatal Clostridium perfringens meningitis which occurred 4 months after a craniotomy for glioblastoma multiforme. The diagnosis was suspected based on the CT findings. The literature of this rare condition is reviewed.

Extradural application of bismuth iodoform paraffin paste causing relapsing bismuth encephalopathy: a case report with CT and MRI studies.

Bismuth iodoform paraffin paste (BIPP) is used in dressings in ear, nose, and throat, dental, and neurosurgical practice. Neurotoxicity due to absorption of bismuth from the BIPP pack is rare. It is preventable and reversible but likely to be fatal if unrecognised. A case of relapsing but reversible toxic encephalopathy due to a large extradural BIPP pack is reported in a 57 year old Caucasian woman, operated on for a huge basal cell carcinoma of the vertex invading the skull and extradural space. Clinical, neuroradiological (CT and MRI), and biochemical studies are presented and discussed in the light of the available literature.

Idiopathic spinal extradural lipomatosis in a non-obese otherwise healthy man.

Spinal extradural lipomatosis is rare and is usually associated with long-term steroid administration or obesity. It is most commonly thoracic in situation. We present a unique case of spinal extradural lipomatosis in a 20-year-old non-obese, clinically normal man. The role of MRI in investigation and the management options are discussed.

The activity of an analogue of MPF (beta-endorphin 28-31) in a rat model of Parkinson's disease.

A single intrastriatal injection of a slow release formulation of a metabolically-stable MPF analogue was given to rats with lesioned right nigrostriatal pathways. After 6 weeks the turning behaviour of the rats in response to D-amphetamine began to decline, and after 12 weeks the reduction was marked and consistent. The implication of our results in the use of intracerebral grafts in parkinsonian patients is discussed.

Stimulation of dopamine output from adrenal medullary cells by beta-endorphin and its C-terminal tetrapeptide (MPF).

The output of dopamine from cultures of rat adrenal medullary strips was increased by 71-120% when Lys-Lys-Gly-Glu (MPF), the C-terminal tetrapeptide sequence of human beta-endorphin, was added to the culture medium at 100 micrograms/ml concentration. Human beta-endorphin caused a 44% increase, but an N-terminal fragment of its molecule and somatotrophin caused no increase. Results with analogs of MPF show that small structural change of the C-terminal Glu residue causes complete loss of activity.

Stabilisation of the infected spine.

A metal stabilising rod was inserted at the time of surgical drainage of the abscess in six patients with spinal instability secondary to vertebral osteomyelitis. The procedure enabled early postoperative mobilisation to be undertaken in five patients. All cases obtained immediate relief of pain. One case of delayed wound healing occurred but not late recurrent infections were encountered after discontinuing antibiotic therapy. The technique was employed in cases of pyogenic as well as tuberculous spinal osteomyelitis.

The natural history of subarachnoid haemorrhage with negative angiography: a prospective study and 3-year follow-up.

One hundred and forty-eight patients with negative cerebral angiography after subarachnoid haemorrhage are reported. Good grade, normotension and normal CT are associated with a favourable outcome. In 89 patients with negative four-vessel angiography the overall annual risks of rebleeding and fatal rebleeding were 1.5% and 0.4% respectively. In 52 patients undergoing appropriate limited angiography corresponding risks were 2.5% and 1.9%. No fatal rebleeds occurred after 6 months. Initial CT scanning in 104 patients was abnormal in 34. Of these, 14 had SAH alone, in whom no episodes of rebleeding occurred, although SAH on CT was associated with an increased chance of a poor outcome. Twenty had other abnormalities, three of whom rebled, two (both with ICH on CT) being fatal. The annual risks of rebleeding and fatal rebleeding in patients with these CT abnormalities were 5.0% and 3.33% respectively. Fifty-two patients were hypertensive, of whom six rebled, four fatally. Two of the 89 normotensive patients rebled, neither fatally.

The place of thalamotomy in the treatment of parkinsonism.

L-Dopa therapy, like thalamotomy, is capable of suppressing some of the symptoms of Parkinsonism but is not a cure. The side effects of L-Dopa therapy can prove as incapacitating as the original symptoms of Parkinsonism. There remains a place for thalamotomy in the treatment of selected cases where symptoms are mainly localised, particularly to the non-dominant limbs, and it has also shown itself to be effective in suppressing dyskinetic movements due to L-Dopa.

A method for identification of vertebral level.

A method of spinal level marking applicable particularly for use in thoracolumbar posterior spinal operations is described. The use of patent blue V dye in this procedure is discussed in a consecutive series of over 100 cases. No serious adverse effects were observed. The technique ensures accurate identification of spinal marking and helps to minimize anaesthetic time.

Long-term survival with optic nerve glioma.

A patient with long-term survival following partial removal of a left optic nerve glioma is described. Various aspects of the pathology and treatment of the tumour are discussed in conjunction with a brief review of the recent literature. Particular attention is drawn to those features of the tumour which favour its classification as a neoplastic lesion rather than a hamartoma.