Central diabetes insipidus epidemiology

Central diabetes insipidus epidemiology

Central diabetes insipidus (CDI) is a rare disease with a reported prevalence of 1/25,000.


Central diabetes insipidus is a significant cause of morbidity in craniopharyngioma surgery.


The incidence of CDI in children presenting with polydipsia and polyuria is low. Factors associated with higher likelihood of pathology include older age, propensity for cold beverage intake, and higher baseline serum Na and osmolality on a WDT 1).


Central DI is observed in 16-34% of patients recovering from sellar region operations and is generally transient; however, this condition may increase the length of hospitalization, as well as cause morbidity after pituitary surgery. In addition, DI can lead to severe hypernatremia if the fluid is not instantly replenished. Hence, monitoring for DI is essential during the first post-operative days; correspondingly, accurate diagnosis followed by correct treatment is crucial 2).

Angelousi et al. systematically reviewed the existing data for defining the prevalence of DI before any treatment in adult patients with sellar lesion/parasellar lesions, excluding pituitary adenomas and pituitary metastases. In total, 646 patients with sellar lesion/parasellar lesions presenting with DI at diagnosis were identified. The most common pathologies of sellar/parasellar lesions presenting with DI at diagnosis were lymphocytic hypophysitis (26.5%), craniopharyngiomas (23.4%), Langerhans cell histiocytosis (18.9%) and Rathke’s cleft cyst (12.7%), accounting for the vast majority (more than 80%) of these lesions. Overall, DI at diagnosis was found in 23.4% of all patients with sellar/parasellar lesions, albeit with a wide range from 10.6% to 76.7%, depending on the nature of the pathology. The highest prevalence of DI was found in less commonly encountered lesions namely germ cell tumors (76.7%), abscesses (55.4%), and neurosarcoidosis (54.5%), each accounting for less than 3% of all sellar/parasellar lesions. Most DI cases (68.8%) were associated with anterior pituitary hormonal deficiencies, in contrast to pituitary adenomas that rarely present with DI. The enlargement and enhancement of the pituitary stalk were the most common findings on magnetic resonance imaging besides the loss of the high signal of the posterior pituitary on T1-weighted images. Resolution of DI spontaneously or following systemic and surgical management occurred in 22.4% of cases. Post-operative DI, not evident before surgery, was found in 27.8% of non-adenomatous sellar/parasellar lesions and was transient in 11.6% of them. Besides distinctive imaging features and symptoms, early recognition of DI in such lesions is important because it directs the diagnosis towards a non-adenomatous sellar/parasellar tumor and the early initiation of appropriate treatment 3).


1)

Haddad NG, Nabhan ZM, Eugster EA. INCIDENCE OF CENTRAL DIABETES INSIPIDUS IN CHILDREN PRESENTING WITH POLYDIPSIA AND POLYURIA. Endocr Pract. 2016 Dec;22(12):1383-1386. doi: 10.4158/EP161333.OR. Epub 2016 Aug 19. PMID: 27540876.
2)

Lampropoulos KI, Samonis G, Nomikos P. Factors influencing the outcome of microsurgical transsphenoidal surgery for pituitary adenomas: a study on 184 patients. Hormones (Athens). 2013 Apr-Jun;12(2):254-64. PubMed PMID: 23933694.
3)

Angelousi A, Mytareli C, Xekouki P, Kassi E, Barkas K, Grossman A, Kaltsas G. Diabetes insipidus secondary to sellar/parasellar lesions. J Neuroendocrinol. 2021 Mar;33(3):e12954. doi: 10.1111/jne.12954. PMID: 33769630.

Acute ischemic stroke in COVID-19 pandemic

Acute ischemic stroke in COVID-19 pandemic

Patients infected with SARS-CoV-2 develop arterial thrombosis including strokemyocardial infarction and peripheral arterial thrombosis, all of which result in poor outcomes despite maximal medical, endovascular, and microsurgical treatment compared with non-COVID-19-infected patients 1).


Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19 2).



Large Vessel Occlusion was predominant in patients with acute ischemic stroke and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA 3).

The goal of a study of Shahjouei et al. was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients.

This multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines.

Shahjouei et al. received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke-123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1-3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4-4.7, p = 0.006) were predictive of stroke.

Interpretation: The results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients 4).

Based on a literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee.

These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home).

The recommendations presented may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals 5).

A series of 10 ischemic stroke patients with concomitant COVID-19 disease. Out of 10, 8 had large infarcts (3 massive middle cerebral artery, 2 basilar artery, 2 posterior cerebral artery, and 1 internal carotid artery infarct territory). Two had cardiogenic embolic stroke due to atrial fibrillation. Almost half of our patients did not have a vascular risk factor. Nine did not have fever and were diagnosed with COVID-19 upon admission for stroke. Stroke occurred in the first week of respiratory symptoms with moderate pulmonary involvement. Most Patients did not have hypoxia and did not establish respiratory failure or acute respiratory distress syndrome. The blood pressures were low and hemorrhagic transformation did not occur even after antiplatelet or anticoagulant therapy. Patients had markedly increased levels of lactate dehydrogenase, C-reactive protein, and D-dimer. Three patients died. It seems that ischemic strokes in COVID-19 patients tend to occur as large infarct and can be seen in patients with mild to moderate pulmonary involvement 6).


1)

Zakeri A, Jadhav AP, Sullenger BA, Nimjee SM. Ischemic stroke in COVID-19-positive patients: an overview of SARS-CoV-2 and thrombotic mechanisms for the neurointerventionalist. J Neurointerv Surg. 2021 Mar;13(3):202-206. doi: 10.1136/neurintsurg-2020-016794. Epub 2020 Dec 9. PMID: 33298508.
2)

Qureshi AI, Baskett WI, Huang W, Shyu D, Myers D, Raju M, Lobanova I, Suri MFK, Naqvi SH, French BR, Siddiq F, Gomez CR, Shyu CR. Acute Ischemic Stroke and COVID-19: An Analysis of 27 676 Patients. Stroke. 2021 Mar;52(3):905-912. doi: 10.1161/STROKEAHA.120.031786. Epub 2021 Feb 4. PMID: 33535779; PMCID: PMC7903982.
3)

Khandelwal P, Al-Mufti F, Tiwari A, Singla A, Dmytriw AA, Piano M, Quilici L, Pero G, Renieri L, Limbucci N, Martínez-Galdámez M, Schüller-Arteaga M, Galván J, Arenillas-Lara JF, Hashim Z, Nayak S, Desousa K, Sun H, Agarwalla PK, Nanda A, Roychowdhury JS, Nourollahzadeh E, Prakash T, Gandhi CD, Xavier AR, Lozano JD, Gupta G, Yavagal DR. Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study. Neurosurgery. 2021 Mar 18:nyab111. doi: 10.1093/neuros/nyab111. Epub ahead of print. PMID: 33734404.
4)

Shahjouei S, Naderi S, Li J, et al. Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study [published online ahead of print, 2020 Aug 17]. EBioMedicine. 2020;59:102939. doi:10.1016/j.ebiom.2020.102939
5)

Rodríguez-Pardo J, Fuentes B, Alonso de Leciñana M, Campollo J, Calleja Castaño P, Carneado Ruiz J, Egido Herrero J, García Leal R, Gil Núñez A, Gómez Cerezo JF, Martín Martínez A, Masjuán Vallejo J, Palomino Aguado B, Riera López N, Simón de Las Heras R, Vivancos Mora J, Díez Tejedor E; en nombre del Grupo Multidisciplinar del Plan Ictus Madrid. Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. Neurologia. 2020 May;35(4):258-263. English, Spanish. doi: 10.1016/j.nrl.2020.04.008. Epub 2020 Apr 24. PMID: 32364127; PMCID: PMC7180371.
6)

Ahmadi Karvigh S, Vahabizad F, Banihashemi G, Sahraian MA, Gheini MR, Eslami M, Marhamati H, Mirhadi MS. Ischemic Stroke in Patients with COVID-19 Disease: A Report of 10 Cases from Iran. Cerebrovasc Dis. 2020 Dec 15:1-6. doi: 10.1159/000513279. Epub ahead of print. PMID: 33321492; PMCID: PMC7801957.

Thoracolumbar spondylodiscitis surgery

Thoracolumbar spondylodiscitis surgery

see Spondylodiscitis surgery indications.

The aim of a study was to investigate the suitability of percutaneous posterior pedicle screw fixation for surgical treatment in patients with thoracolumbar spondylodiscitis.

Janssen et al. conducted a retrospective review of a consecutive cohort of patients undergoing surgical treatment for thoracolumbar spondylodiscitis between January 2017 and December 2019. They assessed intraoperative and clinical data, comparing the classic open and the percutaneous approach. In total, they analyzed 125 cases (39 female, 86 male). The mean age was 69.49 years ± 12.63 years.

Forty-seven (37.6%) patients were operated on by a percutaneous approach for pedicle screw fixation, and 78 (62.4%) received open surgery. There was no significant difference in the mean age of patients between both groups (p= 0.57). The time of surgery for percutaneous fixation was statistically significantly shorter (p= 0.03). Furthermore, the estimated intraoperative blood loss was significantly lower in the minimally invasive group (p < 0.001). No significant difference could be observed regarding the recurrence rate of spondylodiscitis and the occurrence of surgical site infections (p= 0.2 and 0.5, respectively).

Percutaneous posterior pedicle screw fixation appears to be a feasible option for the surgical treatment of a selected patient group with spondylodiscitis of the thoracic spine and lumbar spine 1).

Although minimally invasive spine stabilization (MISt) with percutaneous pedicle screws is less invasive, percutaneous sacropelvic fixation techniques are not common practice.

Surgical intervention is indicated if neurological deficit, progressive deformity, failure to respond to conservative treatment, or the need to obtain specimens to identify causative pathogens is present. However, traditional anterior debridement and reconstruction with or without posterior instrumentation are associated with high rates of morbidity and mortality, especially in elderly immunocompromised patients and patients with multiple comorbidities. Percutaneous endoscopic discectomy, debridement, and drainage provide a minimally invasive surgical choice for the treatment of infectious spondylodiscitis 2) 3) 4).

High rates of fusion and infection clearance have been reported with anterior lumbar interbody fusion (ALIF), but this approach requires a morbid exposure, associated with non-trivial rates of vascular and peritoneal complications. XLIF is an increasingly popular interbody fusion technique that utilizes a fast and minimally invasive approach, sparing the anterior longitudinal ligament, and allowing sufficient visualization of the intervertebral discs and bodies to debride and place a large, lordotic cage. The outcome measures for this study included lumbar lordosis, sagittal balance, subsidence, fusion, pain, neurological deficit, and microbiology/laboratory evidence of infection. The mean follow-up time was 9.3months. All patients had improvements in pain and neurological symptoms. The mean lordosis change was 11.0°, from 23.1° preoperatively to 34.0° postoperatively. Fusion was confirmed with CT scans in five of six patients. At the last follow-up, all patients had normalization of inflammatory markers, no symptoms of infection, and none required repeat surgical treatment for spondylodiscitis. XLIF with percutaneous posterior instrumentation is a minimally invasive technique with reduced morbidity for lumbar spine fusion which affords adequate exposure to the vertebral bodies and discs to aggressively debride necrotic and infected tissue.

XLIF may be a safe and effective alternative to ALIF for the treatment of spondylodiscitis 5).


High rates of fusion and infection clearance have been reported with anterior lumbar interbody fusion (ALIF), but this approach requires a morbid exposure, associated with non-trivial rates of vascular and peritoneal complications. XLIF is an increasingly popular interbody fusion technique which utilizes a fast and minimally invasive approach, sparing the anterior longitudinal ligament, and allowing sufficient visualization of the intervertebral discs and bodies to debride and place a large, lordotic cage. The outcome measures for this study included lumbar lordosis, sagittal balance, subsidence, fusion, pain, neurological deficit, and microbiology/laboratory evidence of infection. The mean follow-up time was 9.3months. All patients had improvements in pain and neurological symptoms. The mean lordosis change was 11.0°, from 23.1° preoperatively to 34.0° postoperatively. Fusion was confirmed with CT scans in five of six patients. At the last follow-up, all patients had normalization of inflammatory markers, no symptoms of infection, and none required repeat surgical treatment for spondylodiscitis. XLIF with percutaneous posterior instrumentation is a minimally invasive technique with reduced morbidity for lumbar spine fusion which affords adequate exposure to the vertebral bodies and discs to aggressively debride necrotic and infected tissue.

XLIF may be a safe and effective alternative to ALIF for the treatment of spondylodiscitis 6).


Mini-open anterior debridement and lumbar interbody fusion in combination with posterior percutaneous fixation via a modified ALIF approach results in little surgical trauma and intraoperative blood loss, acceptable postoperative complications, and is effective and safe for the treatment of single-level lumbar pyogenic spondylodiscitis. This approach could be an alternative to the conventional open surgery 7).


Funao et al., describe two cases in which spondylodiscitis in the lumbosacral spine was treated with a percutaneous stabilization using S2 alar-iliac (S2AI) screw technique.

Case 1: a 77-year-old male presented with low back pain and high fever. He was diagnosed with spondylodiscitis at L4-5. He had a history of lung cancer, which was complicated by the recurrence. Because non-surgical treatment failed, MISt with percutaneous S2AI screws was performed. The patient’s low back pain subsided markedly one week after surgery, and there was no screw/rod breakage or recurrence of infection during follow-up period.

Case 2: a 71-year-old male presented with hemiparesis due to a stroke. He also developed high fever and was diagnosed with spondylodiscitis at L5-S. Because non-surgical treatment failed, the patient was treated by MISt with percutaneous S2AI screws while being maintained on anticoagulants for stroke. Although his clinical symptoms had markedly improved, a postoperative lumbar computed tomography demonstrated a bone defect at L5-S. An anterior spinal fusion with an iliac bone graft at L5-S was performed when a temporary cessation of anticoagulants was permitted. Both patients tolerated the procedures well, and had no major perioperative complications.

MISt with percutaneous S2AI screws was less invasive and efficacious for lumbosacral spondylodiscitis in providing rigid percutaneous sacropelvic fixation 8).


1)

Janssen IK, Jörger AK, Barz M, Sarkar C, Wostrack M, Meyer B. Minimally invasive posterior pedicle screw fixation versus open instrumentation in patients with thoracolumbar spondylodiscitis. Acta Neurochir (Wien). 2021 Mar 3. doi: 10.1007/s00701-021-04744-z. Epub ahead of print. PMID: 33655377.
2)

Fu T.-S., Chen L.-H., Chen W.-J. Minimally invasive percutaneous endoscopic discectomy and drainage for infectious spondylodiscitis. Biomedical Journal. 2013;36(4):168–174. doi: 10.4103/2319-4170.112742.
3)

Ito M., Abumi K., Kotani Y., Kadoya K., Minami A. Clinical outcome of posterolateral endoscopic surgery for pyogenic spondylodiscitis: results of 15 patients with serious comorbid conditions. Spine. 2007;32(2):200–206. doi: 10.1097/01.brs.0000251645.58076.96.
4)

Yang S.-C., Fu T.-S., Chen H.-S., Kao Y.-H., Yu S.-W., Tu Y.-K. Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center. BMC Musculoskeletal Disorders. 2014;15(1, article 105) doi: 10.1186/1471-2474-15-105.
5) , 6)

Blizzard DJ, Hills CP, Isaacs RE, Brown CR. Extreme lateral interbody fusion with posterior instrumentation for spondylodiscitis. J Clin Neurosci. 2015 Jun 29. pii: S0967-5868(15)00282-9. doi: 10.1016/j.jocn.2015.05.021. [Epub ahead of print] PubMed PMID: 26138052.
7)

Lin Y, Li F, Chen W, Zeng H, Chen A, Xiong W. Single-level lumbar pyogenic spondylodiscitis treated with mini-open anterior debridement and fusion in combination with posterior percutaneous fixation via a modified anterior lumbar interbody fusion approach. J Neurosurg Spine. 2015 Sep 4:1-7. [Epub ahead of print] PubMed PMID: 26340382.
8)

Funao H, Kebaish KM, Isogai N, Koyanagi T, Matsumoto M, Ishii K. Utilization of a technique of percutaneous S2-alar-iliac fixation in immunocompromised patients with spondylodiscitis: Two case reports. World Neurosurg. 2016 Oct 15. pii: S1878-8750(16)31006-3. doi: 10.1016/j.wneu.2016.10.018. PubMed PMID: 27756675.
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