Hyponatremia after trans-sphenoidal surgery.

Fluid and electrolyte imbalances are the most frequent complications following pituitary surgery. Among the several patterns of occurrence, hyponatremia can occur in an isolated fashion or as part of a bi- or triphasic pattern. The frequency of hyponatremia after trans-sphenoidal surgery is between 2% and 25%, according to the literature. However, these numbers are probably underestimating the real prevalence, since mild hyponatremia does not lead to symptoms and measurement of sodium level. No association has been described between entity of the pituitary tumor or tumor size and hyponatremia. Therefore no predictors exist to determine patients with a higher risk for electrolyte imbalances after surgery. However, since delayed hyponatremia occurs mainly around the 8-10th day after surgery, routine measurement of sodium should be recommended on the day of hospital dismission. In case of a symptomatic hyponatremia, insufficiency of the corticotrophe pituitary function as the leading differential diagnosis needs to be ruled out. If the patient is euvoleme, pretest probability of syndrome of inadequate antidiuretic hormone production (SIADH) is very high and therapy may be started according to this. In case of SIADH, therapeutic options include fluid restriction or vaptane therapy. Only in severe cases infusion of hypertonic saline is appropriate. Usually SIADH following pituitary surgery is a self-limiting condition and will cease within 2-5 days.

Microparticles generated by decompression stress cause central nervous system injury manifested as neurohypophysial terminal action potential broadening.

The study goal was to use membrane voltage changes during neurohypophysial action potential (AP) propagation as an index of nerve function to evaluate the role that circulating microparticles (MPs) play in causing central nervous system injury in response to decompression stress in a murine model. Mice studied 1 h following decompression from 790 kPa air pressure for 2 h exhibit a 45% broadening of the neurohypophysial AP. Broadening did not occur if mice were injected with the MP lytic agent polyethylene glycol telomere B immediately after decompression, were rendered thrombocytopenic, or were treated with an inhibitor of nitric oxide synthase-2 (iNOS) prior to decompression, or in knockout (KO) mice lacking myeloperoxidase or iNOS. If MPs were harvested from control (no decompression) mice and injected into naive mice, no AP broadening occurred, but AP broadening was observed with injections of equal numbers of MPs from either wild-type or iNOS KO mice subjected to decompression stress. Although not required for AP broadening, MPs from decompressed mice, but not control mice, exhibit NADPH oxidase activation. We conclude that inherent differences in MPs from decompressed mice, rather than elevated MPs numbers, mediate neurological injury and that a component of the perivascular response to MPs involves iNOS. Additional study is needed to determine the mechanism of AP broadening and also mechanisms for MP generation associated with exposure to elevated gas pressure.

Inhibition of the Jak-STAT pathway prevents CNTF-mediated survival of axotomized oxytocinergic magnocellular neurons in organotypic cultures of the rat supraoptic nucleus.

Previous studies have demonstrated that ciliary neurotrophic factor (CNTF) enhances survival and process outgrowth from magnocellular neurons in the paraventricular (PVN) and the supraoptic (SON) nuclei. However, the mechanisms by which CNTF facilitates these processes remain to be determined. Therefore, the aim of this study was to identify the immediate signal transduction events that occur within the rat SON following administration of exogenous rat recombinant CNTF (rrCNTF) and to determine the contribution of those intracellular signaling pathway(s) to neuronal survival and process outgrowth, respectively. Immunohistochemical and Western blot analyses demonstrated that axonal injury and acute unilateral pressure injection of 100 ng/µl of rrCNTF directly over the rat SON resulted in a rapid and transient increase in phosphorylated-STAT3 (pSTAT3) in astrocytes but not neurons in the SON in vivo. Utilizing rat hypothalamic organotypic explant cultures, we then demonstrated that administration of 25 ng/ml rrCNTF for 14days significantly increased the survival and process outgrowth of OT magnocellular neurons. In addition, pharmacological inhibition of the Jak-STAT pathway via AG490 and cucurbitacin I significantly reduced the survival of OT magnocellular neurons in the SON and PVN; however, the contribution of the Jak-STAT pathway to CNTF-mediated process outgrowth remains to be determined. Together, these data indicate that CNTF-induced survival of OT magnocellular neurons is mediated indirectly through astrocytes via the Jak-STAT signaling pathway.

MR imaging of central diabetes insipidus: a pictorial essay.

Central diabetes insipidus (DI) can be the outcome of a number of diseases that affect the hypothalamic-neurohypophyseal axis. The causes of the condition can be classified as traumatic, inflammatory, or neoplastic. Traumatic causes include postoperative sella or transection of the pituitary stalk, while infectious or inflammatory causes include meningitis, lymphocytic hypophysitis, and granulomatous inflammations such as sarcoidosis and Wegener's granulomatosis. Various neoplastic conditions such as germinoma, Langerhans cell histiocytosis, metastasis, leukemic infiltration, lymphoma, teratoma, pituitary adenoma, craniopharyngioma, Rathke cleft cyst, hypothalamic glioma, and meningioma are also causes of central DI. In affected patients, careful analysis of these MR imaging features and correlation with the clinical manifestations can allow a more specific diagnosis, which is essential for treatment.

Pathophysiology of hyponatremia after transsphenoidal pituitary surgery.

Hyponatremia after pituitary surgery is presumed to be due to antidiuresis; however, detailed prospective investigations of water balance that would define its pathophysiology and true incidence have not been established. In this prospective study, the authors documented water balance in patients for 10 days after surgery, monitored any sodium dysregulation, further characterized the pathophysiology of hyponatremia, and correlated the degree of intraoperative stalk and posterior pituitary damage with water balance dysfunction. Ninety-two patients who underwent transsphenoidal pituitary surgery were studied. To evaluate posterior pituitary damage, a questionnaire was completed immediately after surgery in 61 patients. To examine the osmotic regulation of vasopressin secretion in normonatremic patients, water loads were administered 7 days after surgery. Patients were categorized on the basis of postoperative plasma sodium patterns. After pituitary surgery, 25% of the patients developed spontaneous isolated hyponatremia (Day 7 +/- 0.4). Twenty percent of the patients developed diabetes insipidus and 46% remained normonatremic. Plasma arginine vasopressin (AVP) was not suppressed in hyponatremic patients during hypoosmolality or in two-thirds of the normonatremic patients after water-load testing. Only one-third of the normonatremic patients excreted the water load and suppressed AVP normally. Hyponatremic patients were more natriuretic, had lower dietary sodium intake, and had similar fluid intake and cortisol and atrial natriuretic peptide (ANP) levels compared with normonatremic patients. Normnonatremia, hyponatremia, and diabetes insipidus were associated with increasing degrees of surgical manipulation of the posterior lobe and pituitary stalk during surgery. The pathophysiology of hyponatremia after transsphenoidal surgery is complex. It is initiated by pituitary damage that produces AVP secretion and dysfunctional osmoregulation in most surgically treated patients. Additional events that act together to promote the clinical expression of hyponatremia include nonatrial natriuretic peptide-related excess natriuresis, inappropriately normal fluid intake and thirst, as well as low dietary sodium intake. Patients should be monitored closely for plasma sodium, plentiful dietary sodium replacement, mild fluid restriction, and attention to symptoms of hyponatremia during the first 2 weeks after transsphenoidal surgery.

Marked changes of arginine vasopressin, oxytocin, and corticotropin-releasing hormone in hypophysial portal plasma after pituitary stalk damage in the rat.

Mechanical compression of the pituitary stalk with the help of a blunt stereotaxic knife results in posterior pituitary denervation (PPD) and sprouting proximal to the injury, leading to formation of an ectopic neurohypophysis in the stalk. This provides an experimental model for those cases in which traumatic damage severs the nerve fibers to the neural lobe but does not obliterate the hypophysial-portal circulation. The effect of PPD on the hypophysial-portal concentration profile of putative ACTH secretagogues as well as basal and stimulated ACTH secretion in vitro were investigated at varying times after PPD. The contents of arginine vasopressin (AVP) and oxytocin (OT) in extracts of the stalk median eminence 1 week after PPD were markedly elevated, whereas corticotropin-releasing hormone (CRH) content was unaffected. Levels of these three neuropeptides in hypophysial-portal blood collected under anesthesia from the proximal stump of the transected stalk (or the ectopic neural lobe) were measured at weekly intervals in groups of rats after sham or PPD surgery. Hypophysial-portal AVP levels showed a monotonic increase with time after PPD from a 1.8-fold elevation at 1 week post-PPD to a maximum concentration 6-fold greater than that in sham groups at 4 weeks post-PPD. Portal plasma OT levels also exhibited extreme elevation. In contrast, portal plasma CRH levels showed an initial 72% decline 1 week post-PPD. We suggest that mechanical damage to the pituitary stalk and the subsequent sprouting redirected secretion of AVP and OT from the neural lobe to the pituitary stalk. This caused sustained elevations of portal plasma concentrations of AVP and OT. The resulting tonic exposure to AVP and/or OT may down-regulate anterior pituitary receptors to these neurohypophyseal peptides and indirectly decrease CRH release into the portal circulation.

Exploring the functional domain and the target of the tetanus toxin light chain in neurohypophysial terminals.

The tetanus toxin light chain blocks calcium induced vasopressin release from neurohypophysial nerve terminals. Here we show that histidine residue 233 within the putative zinc binding motif of the tetanus toxin light chain is essential for the inhibition of exocytosis, in the rat. The zinc chelating agent dipicolinic acid as well as captopril, an inhibitor of zinc-dependent peptidases, counteract the effect of the neurotoxin. Synthetic peptides, the sequences of which correspond to motifs present in the cytoplasmic domain of the synaptic vesicle membrane protein synaptobrevin 1 and 2, prevent the effect of the tetanus toxin light chain. Our results indicate that zinc bound to the zinc binding motif constitutes the active site of the tetanus toxin light chain. Moreover they suggest that cleavage of synaptobrevin by the neurotoxin causes the inhibition of exocytotic release of vasopressin from secretory granules.

Neurohypophyseal function of an ectopic posterior lobe in patients with growth hormone deficiency.

We studied the neurohypophyseal function of 20 patients with complete GH deficiency owing to pituitary stalk transection by means of the water deprivation and the hypertonic saline infusion test. In T1-weighted magnetic resonance images, high-signal intensity of the posterior lobe of the hypophysis was missing in all the patients. An ectopic posterior lobe was observed at the proximal stump of the transected stalk in 17 patients, whereas the 3 patients without ectopic posterior lobe had overt diabetes insipidus or intractable nocturnal enuresis. After water deprivation, 3 patients with large ectopic posterior lobes (length along the pituitary stalk axis exceeding 5 mm) showed urinary osmolality and plasma AVP levels as high as those of 13 patients with partial GH deficiency in whom magnetic resonance images revealed no abnormalities. On the other hand, 14 patients with small ectopic posterior lobes (length less than 5 mm) showed significantly lower urinary osmolality and plasma AVP levels than the patients with large ectopic posterior lobes (p less than 0.01 and p less than 0.01, respectively) and the patients with partial GH deficiency (p less than 0.01 and p less than 0.01, respectively). Urinary osmolality in the patients with small ectopic posterior lobes, however, was higher than that in 3 patients without ectopic posterior lobes (p less than 0.01). During the hypertonic saline infusion test, peak plasma AVP levels in the patients with small ectopic posterior lobes were significantly lower than those in the patients with partial GH deficiency (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Evidences against a primary role for the pituitary neural lobe in the development and maintenance of DOC-salt hypertension.

The role of the antidiuretic hormone (ADH) in the development and maintenance of the hypertensive state produced by deoxycorticosterone (DOC) and salt in rats is a matter of controversy. The effects of neural lobe lesions that would prevent the release of the hormone to the systemic circulation without affecting the hypothetical release from the hypothalamic nuclei to other areas of the central nervous system was tested. A diabetes insipidus-like syndrome was obtained. But, neither the delay in the onset nor the development of DOC-salt hypertension was modified. This lesion made in rats at 3-4 weeks post DOC-salt did not alter the hypertension during the following 3 more weeks of treatment. These results suggest that the neural lobe would not be essential for the development and maintenance of DOC-salt hypertension in rats.

Evidences against a primary role for the pituitary neural lobe in the development and maintenance of Doc-salt hipertension

El papel de la hormona antidiurètica(ADH) en el desarrollo y mantenimiento de la hipertensión producida por la desoxicorticosterona y la sal en las ratas está sujeto a discusión. Por ello se estudió el efecto de la lesión del lóbulo neural, la cual prevendria la descarga de la hormona a la circulación, sin modificar la hipotètica descarga desde los nucleos hipotalamicos a otras àreas del sistema nervioso central, sobre la presión arterial de las ratas tratadas con DOC-sal. Se obtuvo un sindrome similar al producido por la diabetes insipida (ausencia de ADH circulante). No obstante, la lesión no modifica ni el intervalo hasta la manifestación de la hipertensión ni su desarrollo. La lesión hecha en animales previamente tratados durante 3-4 semanas con DOC-sal no modificó la hipertensión mantenida al continuar el tratamiento 3 semanas mas. Estos resultados sugieren que en la rata el lóbulo neural no seria esencial para el desarrollo y mantenimiento de la hipertensión por DOC-sal