Prevalence of hypopituitarism after intracranial operations not directly associated with the pituitary gland.

BACKGROUND: Over the last few years, awareness and detection rates of hypopituitarism following traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) has steadily increased. Moreover, recent studies have found that a clinically relevant number of patients develop pituitary insufficiency after intracranial operations and radiation treatment for non-pituitary tumors. But, in a substantial portion of more than 40%, the hypopituitarism already exists before surgery. We sought to determine the frequency, pattern, and severity of endocrine disturbances using basal and advanced dynamic pituitary testing following non-pituitary intracranial procedures. METHODS: 51 patients (29 women, 22 men) with a mean age of 55 years (range of 20 to 75 years) underwent prospective evaluation of basal parameters and pituitary function testing (combined growth hormone releasing hormone (GHRH)/arginine test, insulin tolerance test (ITT), low dose adrenocorticotropic hormone (ACTH) test), performed 5 to 168 months (median 47.2 months) after intracranial operation (4 patients had additional radiation and 2 patients received additional radiation combined with chemotherapy). RESULTS: We discovered an overall rate of hypopituitarism with distinct magnitude in 64.7% (solitary in 45.1%, multiple in 19.6%, complete in 0%). Adrenocorticotropic hormone insufficiency was found in 51.0% (partial in 41.2%, complete in 9.8%) and growth hormone deficiency (GHD) occurred in 31.4% (partial in 25.5%, severe in 5.9%). Thyrotropic hormone deficiency was not identified. The frequency of hypogonadism was 9.1% in men. Pituitary deficits were associated with operations both in close proximity to the sella turcica and more distant regions (p = 0.91). Age (p = 0.76) and gender (p = 0.24) did not significantly differ across patients with versus those without hormonal deficiencies. Groups did not significantly differ across pathology and operation type (p = 0.07). CONCLUSION: Hypopituitarism occurs more frequently than expected in patients who have undergone neurosurgical intracranial procedures for conditions other then pituitary tumors or may already exists in a neurosurgical population before surgery. Pituitary function testing and adequate substitution may be warranted for neurosurgical patients with intracranial pathologies at least if unexplained symptoms like fatigue, weakness, altered mental activity, and decreased exercise tolerance are present.

Blunt craniocervical artery injury in cervical spine lesions: the value of CT angiography.

OBJECTIVE: The awareness of traumatic craniocervical artery injuries has increased over the last years, and the detection rate varies in published trauma series. These injuries are often associated with cervical spinal and cranial trauma. The purpose of this prospective study was to determine the frequency and injury characteristics of blunt traumatic cervical artery injuries in patients suffering from cervical spine injuries by using a standardized CT angiography (CTA) protocol of the craniocervical vessels. METHODS: Over a period of 32 months (February 2006 to September 2008), we prospectively evaluated 53 patients with osseous cervical spine injuries. Of these, 41 patients were screened for blunt craniocervical vessel injuries using CT angiography in 718 consecutive patients requiring a whole-body trauma CT due to the mechanism of their injury and injury patterns. All examinations were performed using a 16-row multi-slice computed tomography (Sensation 16, Siemens, Erlangen, Germany). Initially, a scan of the neurocranium angulated in orbito-meatal orientation was acquired. Then, a CT angiography of the craniocervical vessels with 40 ml of iodinated contrast agent (flow 4 ml/s; 40 ml saline flush, flow 4 ml/s) was performed starting at the level of Th2 up to the roof of the lateral ventricles. The scan was started using bolus tracking. Finally, a contrast-enhanced spiral thoraco-abdominal scan was performed with a delay of 20 s after administering a second contrast bolus of 60 ml. Besides, 11 patients with already detected isolated cervical spine injury, who were not initially involved in the whole-body trauma imaging protocol, underwent a secondary CT angiography with 60 ml of contrast agent (flow 4 ml/s; 40 ml saline flush, flow 4 ml/s), starting at the level of Th2 up to the roof of the lateral ventricles. The craniocervical vessels were analyzed in the source images, with the use of maximum-intensity projections and curved multi-planar reconstructions. Alternatively, a duplex ultrasound (DUS) was performed in one patient with respect to pregnancy. RESULTS: CTA was considered adequate for diagnosis in all but one case due to reduced CTA imaging quality. In one patient, DUS instead of CTA was performed with respect to pregnancy. We detected isolated osseous cervical spine injury in 53 consecutive patients. Of these patients, 18.9% suffered from vertebral artery injuries (VAI) (14 VAI in 10 patients). Carotid artery injuries were not detected in these patients. In five (50%) patients, we observed cerebral infarction due to VAI. CONCLUSION: Craniocervical vessel injury is a life-threatening and underdiagnosed event in cases of cervical spine injury. CTA of the craniocervical vessels offers a fast, safe, and feasible method for detecting vascular injuries of the craniocervical region and allows prompt further treatment if necessary to reduce the risk of cerebral infarction. CTA of the craniocervical vessels is strongly indicated in cases of cervical spine trauma and in trauma mechanisms involving the cervical spine. Our data underscore the need for screening of blunt carotid and vertebral injury especially in injured cervical spine.

Arachnoid cyst confined to the internal auditory canal-endoscope-assisted resection: case report and review of the literature.

BACKGROUND AND IMPORTANCE: An arachnoid cyst confined to the internal auditory canal is a rare condition. Different pathogeneses are discussed, and a progressive enlargement of the cysts has been reported. This case illustrates the beneficial aspect of endoscopic assistance in microsurgical resection of this lesion. CLINICAL PRESENTATION: A slowly progressive hearing loss developed in a 35-year-old woman over 2 years; she reported experiencing tinnitus for 7 years. Magnetic resonance imaging revealed a cystic lesion in the internal auditory canal appearing hypointense on T1-weighted images and hyperintense on T2-weighted images, suggesting an arachnoid cyst. INTERVENTION: The cyst wall was fenestrated and partially resected in an endoscope-assisted microsurgical technique. Adherent vestibular nerve fibers in the cyst wall prevented total removal of the cyst. The histological examination confirmed the diagnosis of an arachnoid cyst. CONCLUSION: The endoscope-assisted microsurgical technique enables a safe cyst resection with good visualization of important neurovascular structures within the internal auditory canal. Small remnants of the capsule that are firmly attached to important neurovascular structures should be left in place rather than risk neurological deficits.