Recovery of pituitary function following treatment of an unruptured giant cavernous carotid aneurysm using Surpass flow-diverting stents.

Giant aneurysms arising from the cavernous internal carotid artery (ICA) can mimic pituitary adenomas and may cause pituitary dysfunction due to their mass effect on the pituitary gland. We report a case of a 56-year-old man presenting with impotence, fatigue and panhypopituitarism who was found to have a giant unruptured aneurysm arising from the right cavernous ICA with severe mass effect on the pituitary gland. The patient underwent endovascular treatment of the giant aneurysm using two telescoping Surpass flow-diverting stents. At 6-month follow-up, repeat cerebral angiography showed Raymond grade II occlusion of the aneurysm with a small neck remnant. At the 10-month follow-up the patient showed full recovery of his pituitary function and clinical resolution of impotence and fatigue. This is the first report of occlusion of a giant cavernous carotid aneurysm using next generation Surpass flow-diverting stents leading to complete recovery of pituitary function.

Recovery of pituitary function following treatment of an unruptured giant cavernous carotid aneurysm using Surpass flow-diverting stents.

Giant aneurysms arising from the cavernous internal carotid artery (ICA) can mimic pituitary adenomas and may cause pituitary dysfunction due to their mass effect on the pituitary gland. We report a case of a 56-year-old man presenting with impotence, fatigue and panhypopituitarism who was found to have a giant unruptured aneurysm arising from the right cavernous ICA with severe mass effect on the pituitary gland. The patient underwent endovascular treatment of the giant aneurysm using two telescoping Surpass flow-diverting stents. At 6-month follow-up, repeat cerebral angiography showed Raymond grade II occlusion of the aneurysm with a small neck remnant. At the 10-month follow-up the patient showed full recovery of his pituitary function and clinical resolution of impotence and fatigue. This is the first report of occlusion of a giant cavernous carotid aneurysm using next generation Surpass flow-diverting stents leading to complete recovery of pituitary function.

Hashimoto's thyroiditis pathology and risk for thyroid cancer.

BACKGROUND: Hashimoto's thyroiditis (HT) has been found to coexist with differentiated thyroid cancer (DTC) in surgical specimens, but an association between the two conditions has been discounted by the medical literature. Therefore, we performed this study to determine any potential relationship between HT and the risk of developing DTC. METHODS: We collected data for thyrotropin (TSH), thyroxine (T4), thyroid peroxidase antibody (TPO-Ab) titers, surgical pathology, and weight-based levothyroxine (LT4) replacement dose for patients who were referred for thyroid surgery. Patients with HT at final pathology were studied further. To estimate thyroid function, patients with preoperative hypothyroid HT (Hypo-HT) were divided into three equal groups based on their LT4 replacement: LT4-Low (<0.90 µg/kg), LT4-Mid (0.90-1.43 µg/kg), and LT4-High (>1.43 µg/kg). A group of preoperatively euthyroid (Euth-HT) patients but with HT by pathology was also studied. All subjects were also grouped based on their TPO-Ab titer in TPO-high (titer >1:1000) or TPO-low/negative (titer <1:1000 or undetectable) groups. The relationship of HT and DTC was studied extensively. RESULTS: Of 2811 subjects, 582 had HT on surgical pathology, 365 of whom were Euth-HT preoperatively. DTC was present in 47.9% of the Euth-HT, in 59.7% of LT4-Low, 29.8% of LT4-Mid, and 27.9% of LT4-High groups. The relative risk (RR) for DTC was significantly elevated for the Euth-HT and LT4-Low groups (p<0.001), but not for the LT4-Mid or LT4-High replacement dose groups. TPO-low/negative status conferred an increased RR in the Euth-HT and LT4-Low replacement dose groups (p<0.001 both), while TPO-high status decreased it in Euth-HT group (p<0.05) and made it nonsignificant in the LT4-Low group. CONCLUSIONS: HT pathology increases the risk for DTC only in euthyroid subjects and those with partially functional thyroid glands (LT4-Low) but not in fully hypothyroid HT (LT4-Mid and LT4-High). High TPO-Ab titers appear to protect against DTC in patients with HT.

Screening for parathyroid hormone resistance in patients with nonphenotypically evident pseudohypoparathyroidism.

OBJECTIVE: Hypocalcemia and hyperphosphatemia in the setting of elevated parathyroid hormone (PTH) and normal vitamin D metabolites, raises the possibility of PTH resistance. The idiopathic and inherited forms of PTH resistance are referred to as pseudohypoparathyroidism. Nonphenotypically evident pseudohypoparathyroidism can go undiagnosed for decades. We have designed a new test to diagnose PTH resistance and confirmed its clinical utility in the diagnosis of pseudohypoparathyroidism. METHODS: Our test consists of a subcutaneous injection of commercially available recombinant PTH and concomitant measurement of cyclic adenosine monophosphate in urine. We implemented the test in 2 patients with recalcitrant hypocalcemia and a healthy control subject. RESULTS: Our test unequivocally demonstrated PTH resistance in both patients. One of the patients had phenotypically evident pseudohypoparathyroidism type-1a hence, PTH resistance was suspected. The other patient with nonphenotypically evident disease, also showed PTH resistance and was later demonstrated to have pseudohypoparathyroidism type-1b at the genomic level and confirmed to be of familial type. CONCLUSION: Our results show for the first time the implementation of a simple new diagnostic tool designed to check for PTH resistance. This new test has already proven to be useful in few occasions at our institution. Larger populations, however, should be tested before implementation of such a test is considered a standard of care.

Hashimoto thyroiditis is more frequent than expected when diagnosed by cytology which uncovers a pre-clinical state.

BACKGROUND: Our Thyroid-Multidisciplinary Clinic is a large referral site for thyroid diseases. Thyroid biopsies are mainly performed for thyroid cancer screening. Yet, Hashimoto thyroiditis (HT) is being too frequently diagnosed. The prevalence of HT is reported as 0.3-1.2% or twice the prevalence of type 1 diabetes. However, the prevalence of HT confirmed by cytology is still uncertain. To evaluate different aspects of thyroid physiopathology including prevalence of Hashimoto's, a database of clinical features, ultrasound images and cytology results of patients referred for FNA of thyroid nodules was prospectively developed. METHODS: We retrospectively studied 811 consecutive patients for whom ultrasound guided thyroid FNA biopsies were performed at our clinic over 2.5 year period (Mar/2006-Sep/2008). RESULTS: The analysis of our database revealed that from 761 patients, 102 (13.4%) had HT, from whom 56 (7.4%) were euthyroid or had sub-clinical (non-hypothyroid) disease, and 46 (6%) were clinically hypothyroid. CONCLUSIONS: This is the first study to show such a high prevalence of HT diagnosed by ultrasound-guided FNA. More strikingly, the prevalence of euthyroid HT, appears to be >5% similar to that of type 2 diabetes. Based on our results, there might be a need to follow up on cytological Hashimoto's to monitor for thyroid failure, especially in high risk states, like pregnancy. The potential risk for thyroid cancer in patients with biopsy-proven inflammation of thyroid epithelium remains to be established prospectively. However, it may explain the increased risk for thyroid cancer observed in patients with elevated but within normal TSH.