Shaping the curve from the microscopic transsphenoidal to the endoscopic endonasal approach for the sellar region.

OBJECTIVE: This study aimed to investigate the limitations, barriers, and complications in the early transition from the microscopic transsphenoidal approach (MTA) to the endonasal endoscopic approach (EEA) to the skull base in our institution. METHODS: Technical challenges, as well as clinical features and complications, were compared between MTA, EEA, and mixed cases during the early surgical curve. RESULTS: The period from the early learning curve was 1 year until the EEA protocol was used routinely. A total of 34 patients registered a resection using a transsphenoidal approach. Eighteen patients underwent EEA, 11 underwent MTA, and five underwent a mixed endonasal and microscopic approach. Non-significant differences were found in endocrine outcomes between the three groups. Patients with unchanged or improved visual function were higher in the EEA group (p = 0.147). Non-significant differences were found in terms of the extent of resection (EOR) between groups (p = 0.369). Only 1 (2.9%) patient in the whole series developed a post-operative CSF leaking that resolved with medical management, belonging to the EEA group (5.5%). CONCLUSIONS: The early phase of the learning curve did not affect our series significantly in terms of the EOR, endocrine status, and visual outcomes.

OBJETIVO: Investigar las limitaciones, las barreras y las complicaciones en la transición del abordaje transesfenoidal microscópico (ATM) al abordaje endonasal endoscópico (AEE) para la base del cráneo en nuestra institución. MÉTODO: Se compararon las características clínicas y las complicaciones entre ATM, AEE y casos mixtos durante la curva quirúrgica temprana. RESULTADOS: El periodo desde la curva de aprendizaje inicial fue de 1 año hasta que se utilizó el protocolo AEE de forma sistemática. Un total de 34 pacientes tuvieron una resección por vía transesfenoidal. A 18 pacientes se les realizó AEE, a 11 ATM y a 5 abordaje mixto endonasal y microscópico. Se encontraron diferencias no significativas en los resultados endocrinos entre los tres grupos. Los pacientes con función visual sin cambios o mejorada fueron más en el grupo AEE (p = 0.147). No se encontraron diferencias significativas respecto a la extensión de la resección (p = 0.369). Solo 1 (2.9%) paciente desarrolló una fístula de líquido cefalorraquídeo que se resolvió con manejo médico, perteneciente al grupo AEE (5.5%). CONCLUSIONES: La fase inicial de la curva de aprendizaje no afectó significativamente a nuestra serie en términos de extensión de la resección, estado endocrino y resultados visuales.

Diagnosis and Treatment of Pituitary Apoplexy, A True Endocrine Emergency.

Pituitary apoplexy (PA) is a clinical syndrome resulting from a hemorrhagic infarction of the pituitary gland. It is characterized by the sudden onset of visual disturbances, nausea, vomiting, headache and occasionally, signs of meningeal irritation and an altered mental status. The exact pathogenesis of PA remains to be elucidated, although tumor overgrowth of its blood supply remains the most popular theory. Main risk factors for the development of PA include systemic, iatrogenic, and external factors as well as the presence of an underlying pituitary tumor. The diagnostic approach of PA includes both neuroimaging and evaluation of pituitary secretory function. PA is a potentially life-threatening condition which should be managed with hemodynamic stabilization, correction of electrolyte abnormalities and replacement of hormonal deficiencies. PA treatment should be individualized based on the severity of the clinical picture which may vary widely. Treatment options include conservative management with periodic follow-up or neurosurgical intervention, which should be decided by a multidisciplinary team. We conducted a systematic review of the literature to unveil the frequency of PA predisposing factors, clinical and biochemical presentations, management strategies and outcomes.

Progress, challenges and perspectives in the management of hypopituitarism.

Hypopituitarism is a rare endocrine disorder characterized by insufficient hormone secretion from the pituitary gland. This condition leads to deficient production of one or more pituitary hormones, including growth hormone (GH), thyroid-stimulating hormone (TSH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), adrenocorticotropic hormone (ACTH), and antidiuretic hormone (ADH), also called arginine vasopressin (AVP). Symptoms vary widely and are often not, late recognized.Diagnosis typically involves a thorough clinical evaluation, hormone level assessments, and neuroimaging studies to identify underlying causes. Treatment aims to replace deficient hormones and address the underlying cause and related complications when possible. In this special issue we address diagnosis, comorbidities, and management of hypopituitarism. We hope that it will help healthcare professionals to manage their patients.

Lymphocytic hypophysitis in dogs infected with Leishmania spp.

Background: Morphological involvement of endocrine glands, such as the pituitary gland, remain uninvestigated in dogs with canine visceral leishmaniasis. Therefore, this study investigated the presence of amastigotes of Leishmania spp. and characterized inflammatory changes, highlighting the involvement of TCD3+ lymphocytes in different regions of the pituitary gland of dogs. Methods: Samples were collected from 21 naturally infected dogs and 5 control, uninfected dogs. The different pituitary regions were analyzed in histological sections stained with hematoxylin and eosin (HE) under light microscopy. Inflammation was classified by intensity in a score from 0 to 3, absent (0), mild (1), moderate (2), and marked (3). The immunohistochemical (IHC) evaluation was performed in five high-power fields (hot spot) in a 40x objective of each region with manual counting (Image J1.52ª) of the TCD3+ lymphocytes and for amastigotes analyzed in 40x and 100x objectives. The Shapiro-Wilk test was used to assess the normality of the data. Differences between groups were determined by the Mann Whitney test. The correlation between variables was assessed by Sperman's correlation test. p < 0.05 were considered statistically significant. Results: Amastigotes from the pituitary glands of two infected dogs were identified using IHC. The histopathological evaluation stained with hematoxylin and eosin showed greater intensity of inflammation in the pars distalis and pars intermedia regions of infected dogs. IHC for TCD3+ lymphocytes showed a higher median number of immunolabeled cells in pars nervosa in the infected group than in the control group (p < 0.05); and expecting a variation in the distribution and number of these cells in naturally infected dogs, the median of the control group was considered a cut-off point, an increase in T lymphocytes (p < 0.05) was also observed in the pars intermedia and pars distalis of an infected subgroup (n = 10). A moderate significant correlation between the intensity of inflammation and the number of immunolabeled TCD3+ lymphocytes was established in the analyzed pituitary regions, characterizing the occurrence of hypophysitis. Conclusion: These findings presuppose that inflammation and/or the parasite in the pituitary region can result in gland dysfunction, worsening the clinical condition of the patient and compromising the efficiency of treatment and prognosis.

Endoscopic Orientation of Juxta-pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications

Abstract Introduction In sphenoid sinuses with ill-defined carotid bony landmarks, accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications, which is particularly reported in the endoscopic endonasal transsphenoidal approaches (EETAs). Objectives To describe an anatomical model for the endoscopic orientation of the juxta-pituitary segment of the ICA in relation to the lateral opticocarotid recess (OCR) as a nearby bony landmark. Methods Dissection was performed progressively, simulating the EETA, in twenty fresh adult cadavers. After reducing the posterior and lateral walls of the sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" on the juxta-pituitary segment of the ICA and lateral margins of the pituitary gland. Results The current results have enabled us to divide the region between the lateral OCRs into 3 compartments: 2 lateral parasellar compartments contain juxta-pituitary segments of the ICA with a mean width of 8 mm and a narrow range from 7 mm to 10 mm; and a central intercarotid sellar compartment represents the safe region for bone drilling, showing widely variable widths ranging from 9 mm to 20 mm. In all specimens, the variation in the width of the intercarotid compartment correlated with the distance between both lateral OCRs. Conclusion The present study improves surgeon awareness of the variations in the course of the ICA through the EETA along sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements taken in the present study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with a higher risk of injury.

Endoscopic Orientation of Juxta-pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications.

Introduction In sphenoid sinuses with ill-defined carotid bony landmarks, accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications, which is particularly reported in the endoscopic endonasal transsphenoidal approaches (EETAs). Objectives To describe an anatomical model for the endoscopic orientation of the juxta-pituitary segment of the ICA in relation to the lateral opticocarotid recess (OCR) as a nearby bony landmark. Methods Dissection was performed progressively, simulating the EETA, in twenty fresh adult cadavers. After reducing the posterior and lateral walls of the sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" on the juxta-pituitary segment of the ICA and lateral margins of the pituitary gland. Results The current results have enabled us to divide the region between the lateral OCRs into 3 compartments: 2 lateral parasellar compartments contain juxta-pituitary segments of the ICA with a mean width of 8 mm and a narrow range from 7 mm to 10 mm; and a central intercarotid sellar compartment represents the safe region for bone drilling, showing widely variable widths ranging from 9 mm to 20mm. In all specimens, the variation in the width of the intercarotid compartment correlated with the distance between both lateral OCRs. Conclusion The present study improves surgeon awareness of the variations in the course of the ICA through the EETA along sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements taken in the present study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with a higher risk of injury.

Endoscopic Transsphenoidal Surgery of Pituitary Adenomas: Preliminary Results of the Neurosurgery Service of Hospital Cristo Redentor / Cirurgia endoscópica transesfenoidal de adenomas pituitários: resultados preliminares do Serviço de Neurocirurgia do Hospital Cristo Redentor

Objective The transsphenoidal surgery is a safe and effective technique to manage different skull base pathologies, such as pituitary adenomas. The purpose of the present study is to describe the initial experience with endoscopic transsphenoidal surgery in the treatment of pituitary adenoma patients at a tertiary hospital that is a reference in neurosurgery in Southern Brazil. Materials and Methods We retrospectively analyzed data from 60 patients with pituitary adenoma who underwent endoscopic transsphenoidal surgery between 2012 and 2019. Demographic characteristics, type of tumor, baseline hormonal changes, and clinical presentation were reported, as well as postoperative outcomes, tumor resection rate, and complications. Results The male/female ratio was of 0.53:1, and the mean age of the sample was of 54 (range: 26 to 79) years. In total, 34 patients (57%) presented the non-functioning adenoma subtype, and 26 (43%), the functioning adenoma subtype. In the non-functioning and functioning subtype groups, the average tumor diameter was of 32 mm and 18 mm, and the mean follow-up was of 27 months and 32 months respectively. Regarding visual symptoms, 79% of the patients showed improvement after surgery. Hormonal remission was achieved in 71% of the patients with prolactinoma, 85% of those with cushing, and 57% of patients with acromegaly. Overall, gross total resection (GTR) was achieved in 50% of patients but with a significantly lower rate among patients with tumors with parasellar growth (high grade on the Knosp classification). The most prevalent surgical complications observed were postoperative cerebrospinal fluid (CSF) leak and meningitis in 11% and 6% of the cases respectively. Conclusion We have shown that transsphenoidal endoscopic surgery can produce good results in the management of pituitary adenomas, with acceptable peri- and postoperative morbidity and mortality. Regardless of the technique used, the presence of large and giant pituitary adenomas with a high Knosp grade represents an enormous challenge for contemporary neurosurgery.

Objetivo A cirurgia transesfenoidal é uma técnica segura e eficaz para o tratamento de patologias da base do crânio, como os adenomas hipofisários. O objetivo deste estudo é demonstrar a experiência inicial com a cirurgia endoscópica transesfenoidal no tratamento de pacientes com adenoma hipofisário em hospital terciário, referência em neurocirurgia no Sul do Brasil. Materiais e Métodos Analisamos retrospectivamente os dados de 60 pacientes com adenoma hipofisário submetidos à cirurgia endoscópica transesfenoidal entre 2012 e 2019. Características demográficas, tipo de tumor, alterações hormonais basais e apresentação clínica foram relatadas, bem como evolução pós-operatória, grau de ressecção tumoral e complicações. Resultados A proporção homem/mulher foi de 0.53:1, e a idade média da amostra foi de 54 (variação: 26 a 79) anos. Ao todo, 34 pacientes (57%) tinham o subtipo funcional de adenoma, e 26 (43%), o subtipo não funcional de adenoma. Nos grupos não funcional e funcional, o diâmetro médio do tumor foi de 32 mm e 18 mm, e o tempo médio de acompanhamento foi de 27 meses e 32 meses, respectivamente. Em relação aos sintomas visuais, 79% dos pacientes apresentaram melhora após a cirurgia. A remissão hormonal foi alcançada em 71% dos pacientes com adenomas secretores de prolactina, em 85% daqueles com adenomas secretores de hormônio adrenocorticotrófico e em 57% dos pacientes com adenomas secretores de hormônio do crescimento. A ressecção total foi obtida em 50% dos pacientes, mas com taxa significativamente menor em pacientes com tumores com crescimento parasselar (grau elevado na classificação de Knosp). As complicações cirúrgicas mais prevalentes observadas foram fístula liquórica pós-operatória e meningite, em 11% e 6% dos casos, respectivamente. Conclusão Demostramos que a cirurgia endoscópica transesfenoidal pode produzir bons resultados no manejo de adenomas hipofisários, com aceitável morbimortalidade peri e pós-operatória. Independentemente da técnica utilizada, a presença de adenomas hipofisários grandes e gigantes com grau de Knosp elevado representa um enorme desafio para a neurocirurgia contemporânea.

Pituitary Hormonal Disturbances in Aneurysmal Subarachnoid Hemorrhage / Distúrbios hormonais pituitários na hemorragia subaracnóidea aneurismática

Objective The objective of the present study was to assess the hormonal alterations that occurred in patients with subarachnoid hemorrhage. Methods This is a case series with 21 patients diagnosed with subarachnoid hemorrhage of aneurysmal etiology up to 30 days after the ictus. The following hormonal measurements were performed in these patients: cortisol, GH, testosterone, prolactin, estradiol, FSH, LH, FSH, T3, T4 and free T4. The hormonal results of the cases were compared with the results of twelve volunteers from the control group and correlated with findings in brain tomography, cerebral angiography, Hunt-Hess scale, and vasospasm. Results The main altered hormones were cortisol (52.6%), GH (42.9%) and TSH (28.6%). There was a trend towards more severe cases in the following groups of patients: Hunt-Hess scale > 2, Fisher scale > 1, aneurysmal topography in the anterior communicating artery and those who had vasospasm. Conclusion The present study observed the tendency of pituitary hormonal changes in patients with subarachnoid hemorrhage of aneurysmal etiology, corroborating the need for dosage of hormones from the hypothalamic-pituitary axis in the management of these cases.

Objetivo O objetivo do presente estudo foi avaliar as alterações hormonais em pacientes com hemorragia subaracnóidea e correlacionar tais alterações com a gravidade da hemorragia. Métodos Trata-se de uma série de casos com 21 pacientes com diagnóstico de hemorragia subaracnóidea de etiologia aneurismática até 30 dias do ictus. Foram realizadas as seguintes dosagens hormonais nesses pacientes: cortisol, GH, testosterona, prolactina, estradiol, FSH, LH, FSH, T3, T4 e T4 livre. Os resultados hormonais dos casos foram comparados com os resultados de 12 voluntários do grupo controle e correlacionados com achados em tomografia de crânio, estudo angiográfico cerebral, escala de Hunt-Hess e vasoespasmo. Resultados Os principais hormônios alterados foram o cortisol (52,6%), GH (42,9%) e o TSH (28,6%). Houve uma tendência de casos mais graves nos seguintes grupos de pacientes: escala de Hunt-Hess > 2, escala de Fisher > 1, topografia aneurismática na artéria comunicante anterior e aqueles que cursaram com o vasoespasmo. Conclusão O presente estudo observou a tendência de alterações hormonais hipofisárias em pacientes com hemorragia subaracnóidea de etiologia aneurismática, corroborando a necessidade de dosagem dos hormônios do eixo hipotálamo-hipofisário no manejo desses casos.

Extra-pituitary midline structural abnormalities associated with ectopic posterior pituitary detected on a new rapid MRI protocol (FAST1.2)

ABSTRACT Objective: Test if the MRI FAST1.2 protocol can detect extra-pituitary midline structural brain abnormalities in patients with ectopic posterior pituitary (EPP), and highlighting their radiological-laboratory correlations. Subjects and methods: Cross-sectional study of patients with EPP and control group. All individuals were submitted to FAST1.2, which combines the FAST1 protocol developed by our group with 3D T2DRIVE imaging. Results: We evaluated 36 individuals with EPP and 78 as control group. Pituitary stalk (PS) was identified in 7/36 patients in EPP group by FAST1, and in 24/36 patients in FAST1.2 (p < 0.001). FAST1 failed to detect PS in one individual in the control group, while the FAST1.2 defined the PS in all individuals. In EPP group, eleven had interhypothalamic adhesion (IHA), three septo-optic dysplasia, and one cerebellar malformation. We didn't observe higher frequency of panhypopituitarism or developmental delay in patients with IHA. In control group, three had pars intermedia cysts, one hydrocephalus, and one hypothalamic hamartoma. Conclusions: FAST1.2 allows confident recognition of midline structural abnormalities, including the pituitary stalk and IHA, thereby making MRI acquisition faster and with no need for contrast administration. IHA could be associated with defects in neuronal migration, as occur in patients with EPP, with no clinical significance.

Extra-pituitary midline structural abnormalities associated with ectopic posterior pituitary detected on a new rapid MRI protocol (FAST1.2).

Objective: Test if the MRI FAST1.2 protocol can detect extra-pituitary midline structural brain abnormalities in patients with ectopic posterior pituitary (EPP), and highlighting their radiological-laboratory correlations. Subjects and methods: Cross-sectional study of patients with EPP and control group. All individuals were submitted to FAST1.2, which combines the FAST1 protocol developed by our group with 3D T2DRIVE imaging. Results: We evaluated 36 individuals with EPP and 78 as control group. Pituitary stalk (PS) was identified in 7/36 patients in EPP group by FAST1, and in 24/36 patients in FAST1.2 (p < 0.001). FAST1 failed to detect PS in one individual in the control group, while the FAST1.2 defined the PS in all individuals. In EPP group, eleven had interhypothalamic adhesion (IHA), three septo-optic dysplasia, and one cerebellar malformation. We didn't observe higher frequency of panhypopituitarism or developmental delay in patients with IHA. In control group, three had pars intermedia cysts, one hydrocephalus, and one hypothalamic hamartoma. Conclusion: FAST1.2 allows confident recognition of midline structural abnormalities, including the pituitary stalk and IHA, thereby making MRI acquisition faster and with no need for contrast administration. IHA could be associated with defects in neuronal migration, as occur in patients with EPP, with no clinical significance.

Architects of Pituitary Tumour Growth.

The pituitary is a master gland responsible for the modulation of critical endocrine functions. Pituitary neuroendocrine tumours (PitNETs) display a considerable prevalence of 1/1106, frequently observed as benign solid tumours. PitNETs still represent a cause of important morbidity, due to hormonal systemic deregulation, with surgical, radiological or chronic treatment required for illness management. The apparent scarceness, uncommon behaviour and molecular features of PitNETs have resulted in a relatively slow progress in depicting their pathogenesis. An appropriate interpretation of different phenotypes or cellular outcomes during tumour growth is desirable, since histopathological characterization still remains the main option for prognosis elucidation. Improved knowledge obtained in recent decades about pituitary tumorigenesis has revealed that this process involves several cellular routes in addition to proliferation and death, with its modulation depending on many signalling pathways rather than being the result of abnormalities of a unique proliferation pathway, as sometimes presented. PitNETs can display intrinsic heterogeneity and cell subpopulations with diverse biological, genetic and epigenetic particularities, including tumorigenic potential. Hence, to obtain a better understanding of PitNET growth new approaches are required and the systematization of the available data, with the role of cell death programs, autophagy, stem cells, cellular senescence, mitochondrial function, metabolic reprogramming still being emerging fields in pituitary research. We envisage that through the combination of molecular, genetic and epigenetic data, together with the improved morphological, biochemical, physiological and metabolically knowledge on pituitary neoplastic potential accumulated in recent decades, tumour classification schemes will become more accurate regarding tumour origin, behaviour and plausible clinical results.

[Pituitary apoplexy in pediatric patients: systematic review]. / Apoplejía hipofisaria en pacientes pediátricos: revisión sistemática.

Introduction: Necrosis or hemorrhage associated with pituitary tumors is an infrequent complication. The term pituitary apoplexy is related to the development of an inflammatory process that leads to irritation of the meningeal and periselar areas. Regardless of the mechanism (hemorrhage or infarction), the extent of the hemorrhage and necrosis will produce an increase in intraselar pressure which, in turn, will lead to a more or less pronounced compression of neighboring structures, thus explaining the broad spectrum clinical. Methods: We carried out a systematic review of cases published internationally. The analysis of 8 cases published in the literature was carried out, 5 cases in the male pediatric population (62.5%), and 3 cases of the female gender (37.5%). Results: The mean age was 12.8 years (SD ± 2.5). The clinical manifestations included: headache, impaired vision, nausea and vomiting, fever, cranial nerve involvement, and, to a lesser extent, compromise of consciousness. Seventy-five percent (n = 6) of the patients had a headache, 16.6% had a frontal location, 16.6% accompanied by retroorbital pain, and 66.6% did not specify the location. On the other hand, only 37.5% of the patients had nausea and/or vomiting. While 25% were admitted with fever and 12.5% (n = 1) had changes in the state of consciousness. Conclusion: Pituitary apoplexy is a pathology that requires a multidisciplinary approach at the pediatric level. Management directed by pediatric neurosurgery and endocrinology will allow us to offer our patients the best, evidence-based treatment available.

Introducción: Introducción: La necrosis o hemorragia asociada a tumores hipofisiarios es una complicación infrecuente. El termino apoplejía pituitaria está relacionado con el desarrollo de un proceso inflamatorio que conduce a irritación meníngea y de las zonas periselares. A nivel pediátrico, la apoplejía pituitaria es una patología muy rara y poco analizada en la literatura. Métodos: Realizamos una revisión sistemática de casos publicados a nivel internacional. Se realizo el análisis de 8 casos publicados en la literatura, 5 casos en población pediátrica masculina (62.5%), y 3 casos del género femenino (37.5%). Resultados: La media de edad fue de 12,8 años (DE ±2.5). Las manifestaciones clínicas abarcaron: cefalea, alteración en la visión, náuseas y vómitos, fiebre, compromiso de pares craneales y en menor medida compromiso del estado de conciencia. El 75% (n=6) de los pacientes cursó con cefalea, el 16.6% de localización frontal, 16.6% acompañado de dolor retroorbitario, y un 66.6% no especificaron la localización. Por otro lado, solo el 37.5% de los pacientes presentaron nauseas y/o vómitos. Mientras que un 25% ingresaron con fiebre y un 12.5% (n=1) tuvieron cambios en el estado de conciencia. Conclusión: La apoplejía pituitaria es una patología que requiere un abordaje multidisciplinario a nivel pediátrico, el manejo dirigido por neurocirugía y endocrinología pediátrica permitirá ofrecer a nuestros pacientes el mejor, tratamiento disponible basado en la evidencia.

Apoplejía hipofisaria durante el embarazo: reporte de un caso / Pituitary apoplexy during pregnancy: A case report

Resumen ANTECEDENTES: La apoplejía hipofisaria es un infarto o hemorragia súbita en un tumor o tejido sano de la glándula pituitaria. El 80% de los casos es en pacientes con un adenoma hipofisario. El cuadro clínico se caracteriza por: cefalea, alteraciones visuales, náuseas y vómito; además, insuficiencia hipofisaria, que puede ser potencialmente mortal para la madre y el feto. El tratamiento conservador incluye analgésicos, corticosteroides y agonistas dopaminérgicos en caso de prolactinoma. El tratamiento quirúrgico de elección es la resección transesfenoidal. CASO CLÍNICO: Paciente de 35 años, con antecedentes de tres embarazos, un aborto y prolactinoma diagnosticado a los 22 años, en tratamiento con cabergolina. Acudió a consulta debido a cefalea a las 17 semanas de embarazo que se exacerbó a las 28.4 semanas. En la resonancia magnética se observó que la hipófisis medía 17 x 12 x 7 mm, con datos de hemorragia subaguda; con base en ello se diagnosticó: apoplejía hipofisaria. Se indicó tratamiento conservador con antiinflamatorios no esteroideos, opioides y corticosteroides; sin embargo, ante el deterioro del cuadro clínico se decidió la resección transeptal-transesfenoidal endoscópica del adenoma hipofisiario, a las 30.5 semanas de embarazo. La paciente evidenció una mejoría significativa y permaneció asintomática hasta la finalización del embarazo a las 37.5 semanas. CONCLUSIONES: Si bien la apoplejía hipofisaria es de baja incidencia en el embarazo se torna en un factor de riesgo de muerte; por ello, el ginecoobstetra debe tener conocimiento de las posibles implicaciones en el embarazo, ofrecer atención multidisciplinaria y considerar que el tratamiento quirúrgico es una opción segura en el embarazo.

Abstract BACKGROUND: Pituitary apoplexy is a sudden infarction or hemorrhage in a tumor or healthy tissue of the pituitary gland. Eighty percent of cases are in patients with a pituitary adenoma. The clinical picture is characterized by headache, visual disturbances, nausea and vomiting, and pituitary insufficiency, which can be life-threatening for the mother and fetus. Conservative treatment includes analgesics, corticosteroids and dopaminergic agonists in case of prolactinoma. The surgical treatment of choice is transsphenoidal resection. CLINICAL CASE: 35-year-old female patient with a history of three pregnancies, one miscarriage and prolactinoma diagnosed at 22 years of age, under treatment with cabergoline. She came for consultation due to headache at 17 weeks of pregnancy that was exacerbated at 28.4 weeks. Magnetic resonance imaging showed that the pituitary gland measured 17 x 12 x 7 mm, with evidence of subacute hemorrhage; based on this, a diagnosis of pituitary apoplexy was made. Conservative treatment with non-steroidal anti-inflammatory drugs, opioids and corticosteroids was indicated; however, due to the deterioration of the clinical picture, endoscopic transseptal-transsphenoidal resection of the pituitary adenoma was decided at 30.5 weeks of pregnancy. The patient showed significant improvement and remained asymptomatic until the end of pregnancy at 37.5 weeks. CONCLUSIONS: Although pituitary apoplexy is of low incidence in pregnancy, it becomes a risk factor for death; therefore, the obstetrician/gynecologist should be aware of the possible implications in pregnancy, offer multidisciplinary care and consider that surgical treatment is a safe option in pregnancy.

Tumor de hipófise em paciente com hidrocefalia: um desafio diagnóstico / Pituitary tumor in a patient with hydrocephalus: a diagnostic challenge

RESUMO A hidrocefalia é definida como a dilatação ventricular pelo aumento da pressão intraventricular e intracraniana quando não tratada ou por insucesso do tratamento. Muitas vezes, leva ao dano das vias ópticas, podendo causar atrofia óptica, devido à proximidade dessas vias com o ventrículo lateral quando ocorre a dilatação. Assim como a hidrocefalia pode levar à atrofia óptica, outras patologias também podem. Tumores hipofisários compartilham desse mesmo sinal, além de causar hemianospsia bitemporal quando o tumor comprime quiasma óptico. Ademais, a hemianopsia bitemporal é o distúrbio visual mais comum encontrado em pacientes com tumor de hipófise. Os tumores de hipófise, por exemplo, geram manifestações clínicas que podem estar relacionadas à disfunção da glândula ou aos efeitos mecânicos da expansão tumoral. Sinais e sintomas visuais estão mais ligados ao efeito mecânico do tumor. Assim, muitas vezes, o paciente procura o oftalmologista antes do endocrinologista. Neste caso, analisaremos uma paciente portadora de hidrocefalia que apresentava, concomitantemente, um tumor hipofisário, e a investigação oftalmológica fez toda a diferença no tratamento da paciente.

ABSTRACT Hydrocephalus is defined as ventricular dilation caused by increased intraventricular and intracranial pressure when untreated or due to treatment failure. Optical pathways can often cause optic atrophy due to the proximity to the lateral hazard when dilation occurs. Hydrocephalus can lead to optic atrophy, as well as other pathologies. Pituitary tumors share this same sign, in addition to causing bitemporal hemianopia when it compresses the optic chiasm. In addition, bitemporal hemianopia is the visual disturbance most commonly found in patients with pituitary tumors. Pituitary tumors, for example, have clinical manifestations that may be related to gland dysfunction, or to mechanisms of tumor expansion. Visual signs and symptoms are more linked to the mechanical effect of the tumor. Therefore, the patient usually seeks the ophthalmologist before the endocrinologist. In this case, we analyzed a patient with hydrocephalus who presented, at the same time, a pituitary tumor, and the ophthalmological investigation made all the difference in the treatment of the patient.

Hiperplasia de hipófise secundária a hipotireoidismo primário - relato de caso / Pituitary hyperplasia secondary to primary hypothyroidism - case report

A hiperplasia hipofisária é definida como um aumento não neoplásico no número de um dos tipos de células presentes na hipófise. Ela pode ocorrer por um processo fisiológico ou patológico. O hipotireoidismo primário prolongado é uma das causas patológicas desta condição, e ocorre devido a perda do feedback negativo. O objetivo desse relato foi demonstrar a presença de hiperplasia hipofisária em um paciente masculino com características corporais sugestivas de acromegalia. A investigação laboratorial confirmou a presença de hipotireoidismo primário e descartou a acromegalia. Foi instituído tratamento com levotiroxina, levando a regressão da hiperplasia hipofisária. Esse caso ilustra a importância de uma investigação apropriada em pacientes com hiperplasia hipofisária, bem como discute a fisiopatologia e o tratamento dessa doença.

Pituitary hyperplasia is defined as a non-neoplastic increase in the number of one of the cell types present in the pituitary gland. It can occur by a physiological or pathological process. Prolonged primary hypothyroidism is one of the pathological causes of this condition and occurs due to the lack of negative feedback. The objective of this report was to demonstrate the presence of pituitary hyperplasia in a male patient with body characteristics suggestive of acromegaly. Laboratory investigation confirmed the presence of primary hypothyroidism and ruled out acromegaly. Treatment with levothyroxine was instituted, leading to regression of pituitary hyperplasia. This case illustrates the importance of an appropriate investigation in patients with pituitary hyperplasia, as well as discussing the pathophysiology and treatment of this disease.

Primary pituitary tuberculosis.

Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

Comparative study of complications after primary and revision transsphenoidal endoscopic surgeries.

A preferred treatment for residual/recurrent pituitary adenomas has not been established. The existence of higher complication rates for revision surgeries remains under debate. This study aimed to compare complication rates of primary and revision transsphenoidal endoscopic surgeries and to identify risk factors for complications. Data from 144 primary and 39 revision surgeries were analysed. The surgical complications evaluated were intraoperative and postoperative cerebrospinal fluid (CSF) leaks; meningitis; permanent diabetes insipidus (DI) and hypopituitarism; worsening visual acuity; ophthalmoplegias; visual field defects; otorhinolaryngological, systemic and vascular complications; and death. The variables that were potentially associated with surgical complications were gender, age, comorbidities, lumbar drain use, duration of lumbar drain use, invasion of the sphenoid and cavernous sinuses, presence and degree of suprasellar expansion, preoperative identification of the pituitary, CSF leaks and intraoperative pituitary identification. Intraoperative CSF leaks, visual field losses and worsening visual acuity were more common for revision surgeries. There were no between-group differences in the occurrence of postoperative CSF leaks; systemic, vascular and otorhinolaryngological complications; meningitis; DI and hypopituitarism; ophthalmoplegias; or death. Intraoperative identification of the pituitary was associated with lower rates of permanent DI and hypopituitarism, systemic complications, intraoperative CSF leaks and worsening visual acuity. Suprasellar expansion increased the risk of intraoperative CSF leaks but not endocrinological deficits or visual impairment. Intraoperative CSF leaks were associated with postoperative CSF leaks, meningitis, anterior hypopituitarism, DI and worsening visual acuity. Intraoperative CSF leaks, worsening visual acuity and visual field losses were more common in reoperated patients.

Primary pituitary tuberculosis

Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

As consequências irreversíveis do diagnóstico tardio de macroadenoma de hipófise em paciente jovem / The irreversible consequences of late diagnosis of pituitary macroadenoma in a young patient

Resumo Os tumores de hipófise representam aproximadamente 15% de todos os tumores cerebrais e dependendo do tamanho, pressionam o quiasma óptico, resultando em comprometimento da função visual que se manifesta como defeitos no campo visual, diminuição da acuidade visual e da visão das cores. O objetivo do presente estudo foi relatar um caso de macroadenoma de hipófise com compressão do quiasma óptico e defeito no campo visual, tratado inicialmente como glaucoma, levando a um diagnóstico e tratamento tardio.

Abstract Pituitary tumors represent approximately 15% of all brain tumors and depending on size, pressure optic chiasma, resulting in impaired visual func-tion that manifests itself as defective in the visual field, decreased acuity visual and color vision. The ob-jetive of the present study was to report a case of pitui-tary macroadenoma with compression of optical chiasma and visual field de-fect, initially treated as glaucoma, leading to a late diagnosis and treatment.

"Seat of the soul"? The structure and function of the pineal gland in women with alleged spirit possession-Results of two experimental studies.

BACKGROUND: Cultural traditions attribute to pineal gland an important role for spiritual experiences. Mediumship and spirit possession are cultural phenomena found worldwide which have been described as having dissociative and psychotic-like characteristics, but with nonpathological aspects. A sympathetic activation pattern in response to spirit possession has been reported in some studies, but empirical data on pineal gland is scarce in this context. METHODS: We aimed to investigate pineal gland and pituitary volumes, as well as urinary 6-sulfatoxymelatonin levels in 16 alleged mediums (Medium Group-MG) compared with 16 healthy nonmedium controls (Control Group) (Experiment 1). Furthermore, we aimed to evaluate urinary 6-sulfatoxymelatonin and stress reactivity in GM (n = 10) under different physiological conditions (Experiment 2). RESULTS: In Experiment 1, MG presented higher scores of anomalous experiences, but there were no between-group differences regarding mental health or subjective sleep quality. Similar pineal gland and pituitary volumes were observed between groups. There were no between-group differences in urinary 6-sulfatoxymelatonin collected under equivalent baseline conditions. In Experiment 2, the rise of anxiety and heart rate in response to mediumistic experience was intermediate between a nonstressful control task (reading) and a stressful control task (Trier Social Stress Test-TSST). No significant differences were observed in 6-sulfatoxymelatonin urinary levels between the three conditions. The pattern of stress reactivity during the TSST was normal, but with an attenuated salivary cortisol response. CONCLUSION: The normal neuroimaging and stress reactivity findings in MG contrast with the abnormal results usually observed in subjects with psychotic and dissociative disorders.