[Prediction of pharmacological effect of octreotide in acromegaly by means of 111In-pentetreotide scintigraphy and calculation of a pituitary uptake index]. / Prädiktion der pharmakologischen Wirkung von Octreotid bei Akromegalie mittels 111In-Pentetreotid-Szintigraphie und Berechnung eines hypophysären Uptake-Index.

AIM: The aim of our prospective study was to optimize the determination of the pituitary somatostatin receptor status by means of 111-In-pentetreotide scintigraphy and to compare it intraindividually with the pharmacological effect of octreotide in active acromegaly. METHODS: In n = 22 patients with growth hormone (GH) secreting pituitary adenoma, 111-In-pentetreotide scintigraphy was performed, and the specific radionuclide accumulation in the pituitary area (evaluation visually as well as semiquantitatively by means of ROI technique and calculation of various uptake indices) was correlated with the acute drop of GH after administration of 100 micrograms octreotide s. c. (octreotide acute test). RESULTS: The uptake index we propose (cts/pixel-ratio circular pituitary ROI: irregular cerebrum ROI after background correction in the sagittal SPECT slice with maximum pituitary uptake 24 h p.i.) correlates best with the pharmacological effect (acute decrease of GH levels) of octreotide; its upper normal limit amounts of 3.5. CONCLUSION: As often the normal pituitary gland can be visualized scintigraphically, the purely visual differentiation between a normal and a pathological receptor status sometimes is equivocal. A pituitary uptake index, calculated by means of a standardized ROI technique, facilitates this discrimination and so contributes to select possible responders for a treatment with octreotide.

[Hyperthyroidism in TSH-producing hypophyseal adenoma]. / Hyperthyreose bei TSH-produzierendem Hypophysenadenom.

HISTORY AND CLINICAL FINDINGS: For 5 years a 59-year-old man had been treated with thyrostatic drugs for hyperthyroidism of unknown aetiology. As he had been losing weight, computed tomography had been performed in the search for a malignancy. It revealed a hypophyseal space-occupying lesion. INVESTIGATIONS: Peripheral thyroid hormone activities were raised, while thyroid-stimulating hormone (TSH) was also raised to 12.4 mU/l and there was evidence of partial hypophyseal insufficiency. Octreotide scintigraphy demonstrated increased activity in the area of the hypophysis. TREATMENT AND COURSE: The transsphenoidal surgery and immunohistochemical tests confirmed the diagnosis of TSH-producing hypophyseal adenoma. The patient became euthyroid after the operation. CONCLUSION: TSH-producing hypophyseal adenoma should be considered as a rare cause of hyperthyroidism when it is combined with non-suppressed TSH.

Treatment results of acromegaly as analyzed by different criteria.

Results of treatment of acromegaly are often incomparable due to the different criteria which have been used for defining cure or control of disease. At the present time it is widely accepted, that the main criteria of cure must be normalization of IGF-1 and a GH in the OGTT < 2 ng/ml. In this retrospective study we investigated the endocrinological results of 56 patients, who were surgically treated because of a GH-producing pituitary adenoma, by different criteria. Twelve of our patients had had additional medical treatment after surgery, two received radiotherapy. At a mean follow-up of 34 months after surgery 66% of patients had a basal GH < 5 ng/ml, 64% had a GH in the OGTT < 2 ng/ml and 73% had normalization of IGF-1. The combined criteria of OGTT < 2 ng/ml and IGF-1 normalization have been fulfilled in 59% of patients. None of these latter patients developed a clinical recurrence during the follow-up period. An optimal result (endocrinological cure, no permanent surgical complications and intact pituitary function) was achieved in 43% of patients. Although surgery was responsible for 19 new pituitary axis deficiencies (7 corticotropic axis, 8 thyrotropic axis and gonadotropic axis), 22 partial deficiencies improved to normalization after surgery (respectively 6, 3, and 13). Pre-operatively 55% of patients had no pituitary deficiency, after surgery this was 61%, leaving a net positive result of 6% less pituitary deficiencies. The authors conclude that normalization of IGF-1 combined with an OGTT < 2 ng/ml are adequate criteria for the definition of cure of acromegaly. However, the authors propose to include post-treatment hypopituitarism as an additional criterion by which treatment of acromegaly should be evaluated.

Amyloidomas of the gasserian ganglion.

An amyloidoma is a local deposition of amyloid that becomes a space-occupying lesion. Amyloidomas of the central nervous system are very uncommon lesions and only four amyloidomas of the gasserian ganglion have been reported so far. We present the neuroradiologic and surgical characteristics of three more amyloidomas of the gasserian ganglion seen at one neurosurgical department in 11 years.

Amyloidoma of the gasserian ganglion as a cause of symptomatic neuralgia of the trigeminal nerve: report of three cases.

Three cases of symptomatic neuralgia of the trigeminal nerve due to an amyloidoma in the gasserian ganglion are described. The correct diagnosis was not made prior to histological examination of the surgical biopsy specimens. Medical history and clinical observation led to the diagnosis of a malignant process of the nasal cavities in the first patient; of an inflammatory dental focus in the second patient; and of multiple sclerosis in the third patient. CT findings were normal in cases 1 and 2; in case 3, a schwannoma was suspected from the CT appearances. In case 1, MRI had not been performed; in cases 2 and 3, MRI revealed a tumour mass which was also considered to be a schwannoma. Histologically, the tumours consisted of masses of amyloid deposits which had largely replaced the pre-existing ganglionic cells and satellite cells. Electron microscopy confirmed the fibrillar structure of the deposits. Immunohistochemistry and immunocytochemistry revealed the amyloid to belong to the AL-lambda subtype.

Intrasellar cysticercosis mimicking a pituitary adenoma.

A case of a 50-year-old female with an intrasellar and suprasellar cysticercus cyst, which was pre-operatively misinterpreted as a macroadenoma of the adenohypophysis is described. Cranial computed tomography revealed a homogeneous hyperdense intrasellar and suprasellar lesion. In T1-weighted magnetic resonance images, a spotty hyperintense tumor of the sellar region was shown.

Cerebral aneurysms: assessment of 377 cases (1956-1982).

A review of 177 patients with cerebral aneurysms is made, out of whom 106 with ruptured aneurysms were examined, whose operational timing and prognostic chances were well documented (group B, 1979-1982) and in part updated to 1984. Furthermore, relevant data of a previous series of 200 cases of cerebral aneurysm, treated between 1956-1978 were used (group A). The patients were graded according to Hunt and Hess, assessing the risks involved. The percentages of recurrent bleeding were in group A 36.5% and 28% in group B. The incidence of vasospasm (as seen in angiography) was in group B 39.6% (42/106 patients). The highest rate of vasospasm in the spasm group division B was found to occur in the second and third week after subarachnoid haemorrhage and amounted to 64.7% and 62.5%. A pre-operatively present vasospasm had no negative effects on the mortality rate, but influenced the outcome for the survivors effectively. The total mortality in group A was 22.5% and in group B 11.7%. Timing of the operation among patients in Hunt and Hess-grades I and II needs to discussion. The surgical position of patients in grade V is also certain. What remains to be discussed and needs attention is grade III and patients in grade IVa. Here the time of operative intervention must be planned individually depending on the course of the neurological status.

Management of giant aneurysms.

Technical aspects and anatomical difficulties involved in the management of this entity and the risks associated give giant aneurysms a special place in the treatment of aneurysms as a whole. The direct attack needs careful planning and the right choice of instruments, especially clips. In spite of the progress in recent years, the rate of mortality is still very high. The indirect approach requires in many cases the occlusion of a major cerebral vessel, which in some cases could result in cerebral ischemia. However, by means of extra-intracranial by-pass operation this risk could be reduced. The method of balloon embolisation has progressed recently. This procedure brings the least discomfort to the patient. Results of this method of treatment must be observed critically for future assessment.

Cerebral aneurysms: assessment of 377 cases (1956-1982)

Os autores aprresentam revisäo de 177 pacientes com aneurisma observados durante o período de 1979 a 1982 (Grupo B) e dos quais 106 sofreram ruptura aneurismática. E feita comparaçäo com série prévia tratada de 1956 a 1978 (Grupo A), com 200 pacientes. Observou-se a classificaçäo de Hunt e Hess. No Grupo A, 36,5% sofreram ressangramento no Grupo B, 28%. Vasoespasmo foi observado (angiograficamente) em 42 de 106 pacientes do Grupo B (39,6%). Observou-se ainda que o vasoespasmo ocorreu preponderantemente na segunda e na terceira semanas após o sangramento inicial (64,7% - 62,5%). A presença de vasoespasmo pré-operatório näo mostrou efeito negativo quando relacionada ao índice de mortalidade, embora tenha influenciado no prognóstico e na recuperaçäo do paciente. A mortalidade do grupo A foi 22,5% e no grupo B, 11,7%. O cirúrgico para os pacientes classificados em grau I e grau II (Hunt e Hess) merece ainda discussäo. Pacientes em grau III e grau IV merecem atençäo especial: a indicaçäo cirúrgica deve ser planejada individualmente, dependendo da evoluçäo do quadro clínico-neurológico

Management of giant aneurysms

Os aneurismas gigantes merecem atençäo especial no que se refere a seus aspectos anatômicos, riscos e, principalmente, dificuldades técnicas ao seu manueio. A abordagem de tais aneurismas necessita de planejamento adequado e, sobremaneira, de material apropriado para sua clipagem. A mortalidade ainda permanece alta, apesar dos recentes progressos observados nos últimos anos. Por outro lado, a abordagem indireta requer, muitas vezes, oclusäo de um vaso cerebral importante, o que pode acarretar isquemia cerebral. Entretanto, por anastomose extra-intracraniana tais riscos podem ser diminuídos. O método de embolizaçäo por balöes tem-se mostrado eficaz. Este processo oferece menor incômodo ao paciente. Os resultados deste método devem ser observados criteriosamente para melhor avaliaçäo no futuro

[FSH-producing hypophyseal tumor in a 13-year-old girl]. / FSH-produzierender Hypophysentumor bei einem 13jährigen Mädchen.

We report on a 13 year old girl with a FSH, secreting pituitary tumour, who was presented with recurrent bleeding disorders. Gynaecological examination revealed large cystic ovarian tumours on both sides. The endocrinological work-up showed high serum levels of oestradiol and FSH, and low serum levels of testosterone and LH. Computed tomography demonstrated a pituitary tumour of 3 cm diameter.

[MR tomography of benign brain tumors]. / MR-Tomographie benigner Hirntumoren.

69 Patients with benign brain tumours were examined via MRI (30 meningiomas, 17 pituitary adenomas, 14 acoustic neuromas, and 8 craniopharyngiomas). Typical morphological characteristics and values of the MR tissue parameters (T1, T2, Rho) are presented. The combined analysis of tissue parameters and morphological details allows a satisfying differentiation between different pathohistological entities. Tumour capsule and displacement of neighbouring structures without signs of infiltrating growth are typical criteria of benign neoplasms.

[Selective blood sampling from the inferior petrosal sinus using digital subtraction angiography]. / Selektive Blutentnahme aus dem Sinus petrosus inferior mit digitaler Subtraktionsangiographie.

Simultaneous bilateral venous sampling of blood from the inferior petrosal sinuses helps in the differentiation between peripheral and central ACTH hypersecretion. One can also locate the site of a hormonally active hypophyseal micro-adenoma that cannot be demonstrated by other methods. The authors have experience with fifteen patients and discuss the indications, technique and problems as well as the advantages of using digital subtraction angiography.

[Pregnancy and hyperprolactinemia]. / Schwangerschaftsverlauf bei Hyperprolaktinämie.

After endocrinological and radiological evaluation of a hyperprolactinemia 13 patients became pregnant under bromocriptine therapy. In two of these patients a selective adenomectomy was performed by the transphenoidal route because of a prolactin (PRL) secreting adenoma. In 12 patients the pregnancy was not complicated. The serum PRL levels were different but mostly in a normal range. The control of x-ray and visual field in patients with a rapid increase of the PRL levels did not result in a tumor recurrence. After a normal course of the serum PRL concentrations one patient with a microadenoma developed suddenly a chiasma syndrome in the 31th week of gestation. The further evaluation resulted in a pituitary tumor with suprasellar extension. The discrepancy between the radiological result and the normal serum PRL levels was explained by a hemorrhage into the adenoma. After the operation the chiasma syndrome was reversible within a short period. Altogether, the course of the pregnancies was not complicated. We did not see fetal malformations. Post partum the sella x-ray of all patients did not reveal any significant changes so far.

[Imaging adrenergic tumours with 131J-meta-benzylguanidine]. / Szintigraphie adrenerger Tumoren mit 131J-meta-Benzylguanidin.

Pheochromocytoma scanning using 131J-meta-benzylguanidine was done in one patient with metastasizing paraganglioma, one patient with multiple endocrine neoplasia type IIb. No activity of tumour tissue could be demonstrated in the patient with metastasizing paraganglioma, whereas the pheochromocytoma could be clearly defined in the patient with multiple endocrine neoplasia type IIa. The female with multiple endocrine neoplasia type IIb showed a suspect space-occupying lesion of the left adrenal using computed tomography. Pheochromocytoma could be excluded by 131J-benzylguanidine scanning, selective estimation of catecholamines in adrenal venous blood as well as the glucagon stimulation and clonidine suppression.