Pituitary apoplexy treatment

Pituitary apoplexy treatment

Optimal pituitary apoplexy management remains controversial.

The pituitary function is consistently compromised, necessitating rapid administration of corticosteroids and endocrine evaluation.


Patients with pituitary apoplexy may have a spontaneous remission of hormonal hypersecretion. If it is not an emergency, we should delay a decision to undertake surgery following apoplexy and re-evaluate hormone secretion. Hyponatremia is an acute sign of hypocortisolism in pituitary apoplexy. However, SIADH although uncommon, could appear later as a consequence of direct hypothalamic insult and requires active and individualized treatment. For this reason, closely monitoring sodium at the beginning of the episode and throughout the first week is advisable to guard against SIADH. Despite being less frequent, if pituitary apoplexy is limited to the tumor, the patient can recover pituitary function previously damaged by the undiagnosed macroadenoma 1).


In the absence of visual deficits, prolactinomas may be treated with bromocriptine.

Rapid decompression is required for: sudden constriction of visual fields, severe and/or rapid deterioration of acuity, or neurologic deterioration due to hydrocephalus. Surgery in ≤7 days of pituitary apoplexy resulted in better improvement in ophthalmoplegia (100%), visual acuity (88%) and field cuts (95%) than surgery after 7 days, based on a retrospective study of 37 patients. 2).

Decompression is usually via a transsphenoidal route (transcranial approach may be advantageous in some cases).

A systematic literature search was performed of MedLineEmbase, the Cochrane Library, and the Web of Science for articles published between January 1992 and September 2014. Studies of the outcomes in consecutive patients that compared surgical intervention with non-surgical treatment for pituitary apoplexy were included.

Six studies met the inclusion criteria. As compared to the non-surgically treated patients, surgically treated patients had a significantly higher rate of recovery of ocular palsy and visual field (both P<0.05). However, there was no significant difference in the recovery of visual acuity and pituitary function (P>0.05) between the two groups.

The findings of this study suggest that surgical intervention should be advocated for pituitary apoplexy patients with visual field defects and ocular palsy 3).

Goals of surgery

1. To decompress the following structures if under pressure: optic apparatus, pituitary glandcavernous sinusthird ventricle (relieving hydrocephalus)

2. Obtain tissue for pathology

3. Complete removal of the tumor is usually not necessary

4. For hydrocephalus: ventricular drainage is generally required.

References

1)

Sanz-Sapera E, Sarria-Estrada S, Arikan F, Biagetti B. Acromegaly remission, SIADH and pituitary function recovery after macroadenoma apoplexy. Endocrinol Diabetes Metab Case Rep. 2019 Jul 15;2019(1). doi: 10.1530/EDM-19-0057. PubMed PMID: 31310082.
2)

Bills DC, Meyer FB, Laws ER,Jr, Davis DH, Ebersold MJ, Scheithauer BW, Ilstrup DM, Abboud CF. A retrospective analysis of pituitary apoplexy. Neurosurgery. 1993; 33:602–8; discussion 608-9
3)

Tu M, Lu Q, Zhu P, Zheng W. Surgical versus non-surgical treatment for pituitary apoplexy: A systematic review and meta-analysis. J Neurol Sci. 2016 Nov 15;370:258-262. doi: 10.1016/j.jns.2016.09.047. Review. PubMed PMID: 27772771.

Thalamic glioma treatment

Thalamic glioma treatment

Deep-seated astrocytomas within the basal ganglia and the thalamus are considered unfavourable for microsurgical removal since the circumferential neighbourhood of critical structures limits radical resection. On closer assessment, the thalamus has a unique configuration within the basal ganglia.

Its tetrahedric shape has 3 free surfaces and only the ventrolateral border is in contact with vital and critical functional structures, e.g. the subthalamic nuclei and the internal capsule.

see Transcallosal approach.


Tumors here are usually treated with biopsy and adjuvant therapy with relatively poor results. Rarely do patients undergo extensive surgical intervention. It seems reasonable to suggest that successful cytoreduction may help these patients. However, this hypothesis has not been studied due to the general view that it is not possible to remove deep-seated brain tumors with acceptable outcomes.

Through retrospective data collection, Briggs et al., described a small case series undergoing awake contralateral, transcallosal approach surgery for deep-seated brain tumors affecting the basal ganglia. They described the patient cohort, report on patient outcomes, and described the surgical technique.

Four patients underwent awake contralateral, transcallosal surgery for glioblastoma invading the basal ganglia. All four patients demonstrated hemibody weakness contralateral to the side of their tumor, with three patients confined to wheelchairs at presentation. Ages ranged from 25-64 years. Tumor volumes ranged from 14-93 cm3. Greater than 50% resection of each tumor was achieved during surgery. In two cases, approximately 90% resection was achieved. Motor strength improved in one patient who presented with hemiplegia. Two patients required ventriculoperitoneal shunting for complications related to hydrocephalus. When writing this manuscript, two of our patients were still alive, functional, and free of tumor progression.

They presented results attempting to resect large gliomas infiltrating the basal ganglia in four patients. This technique combined a contralateral, transcallosal approach with awake neuromonitoring. The results suggest it is possible to remove these tumors with reasonable outcomes 1).


From May 2011 to Aug 2015, 49 patients with thalamic gliomas underwent microsurgical resection, and received chemotherapy and radiotherapy postoperatively. The postoperative symptoms and complications were documented, and the overall survival (OS) and the progression-free survival (PFS) data were collected. The prognostic factors were evaluated by univariate and multivariate analyses. Finally, there was no perioperative death. Twenty cases, 24 cases and 5 cases were achieved subtotal resection (>90%), partial resection (70-90%) and less than partial resection (<70%) respectively. All patients’ pathological diagnosis was confirmed. The symptoms were improved in 32 cases, unchanged in 11 cases, and worsen in 6 cases. Postoperative complications were absent in 9 cases. The 6-month, 12-month, and 24-month OS were 71.4%, 38.9%, and 12.1% respectively; corresponding PFS were 66.6%, 27.1%, and 10.2% respectively. The median OS time and PFS time were 9.0 months (95% CI 6.9-11.1) and 9.0 months (95% CI 6.6-11.4) respectively. Multivariate analysis revealed extent of resection were independent prognostic factors for OS (p < .05), patients with postoperative adjuvant chemotherapy and radiotherapy had a significant prolonged OS (p < .001) and PFS (p < .001). The study shows that the short-term efficacy of microsurgery for high-grade thalamic gliomas is satisfactory. Microsurgery can effectively alleviate patients’ symptoms and improve life quality. Postoperative adjuvant chemotherapy and radiotherapy are helpful for prolonging the survival time 2).


Series demonstrated the feasibility of the microsurgical concept. Comparison with other treatment modalities, such as brachytherapy, requires future consideration 3).

References

1)

Briggs RG, Nix CE, Conner AK, Palejwala AH, Smitherman AD, Teo C, Sughrue ME. An Awake, Contralateral, Transcallosal Approach for Deep-Seated Gliomas of the Basal Ganglia. World Neurosurg. 2019 Jul 10. pii: S1878-8750(19)31937-0. doi: 10.1016/j.wneu.2019.07.031. [Epub ahead of print] PubMed PMID: 31301441.
2)

Wu B, Tang C, Wang Y, Li Z, Hu S, Hua W, Li W, Huang S, Ma J, Zhang Y. High-grade thalamic gliomas: Microsurgical treatment and prognosis analysis. J Clin Neurosci. 2018 Mar;49:56-61. doi: 10.1016/j.jocn.2017.12.008. Epub 2017 Dec 14. PubMed PMID: 29248381.
3)

Steiger HJ, Götz C, Schmid-Elsaesser R, Stummer W. Thalamic astrocytomas: surgical anatomy and results of a pilot series using maximum microsurgical removal. Acta Neurochir (Wien). 2000;142(12):1327-36; discussion 1336-7. PubMed PMID: 11214625.

Cerebral venous sinus thrombosis treatment

Cerebral venous sinus thrombosis treatment

Hydration with IV fluids and IV anticoagulation are part of the initial treatment for cranial sinus thrombosis (CST). Prior to initiation of treatment, blood for hypercoagulopathy tests is drawn.

Severity of cerebral venous thrombosis (CVT) may require the transfer to intensive care unit (ICU).

Treatment is with anticoagulants and rarely thrombolysis (enzymatic destruction of the blood clot).


Batroxobin may promote venous sinus recanalization and attenuate CVT-induced stenosis. Further randomized study of this promising drug may be warranted to better delineate the amount of benefit 1).

Timing

Current guidelines recommend anticoagulation after cerebral venous sinus thrombosis (CVT) even in the setting of intracranial hemorrhage, but the timing of initiation is unclear.

A literature review demonstrated a wide variation of timing for anticoagulation initiation in patients with CVT and intracranial hemorrhage. Most started anticoagulation within 24 hours of admission with similar functional neurological recovery. Current guidelines on the treatment of CVT, even with intracranial hemorrhage, recommend anticoagulation. Most reports in the literature state initiation of anticoagulation within 24 hours. However, the literature does not definitively state when to initiate anticoagulation in a patient with CVT, intracranial hemorrhage, thrombectomy, and decompressive hemicraniectomy 2).

Given that there is usually an underlying cause for the disease, tests may be performed to look for these. The disease may be complicated by raised intracranial pressure, which may warrant surgical intervention such as the placement of a shunt.

There are several other terms for the condition, such as cerebral venous and sinus thrombosis, (superior) sagittal sinus thrombosis, dural sinus thrombosis and intracranial venous thrombosis as well as the older term cerebral thrombophlebitis.

Indications for endovascular intervention

● Persistent ischemic symptoms despite anticoagulation therapy.

● Contraindication to anticoagulation and/or anti-platelet therapy including hemorrhagic infarct 3).

● Impending risk of stroke.

Endovascular treatment

Chemical Thrombolysis: A catheter may be advanced to the involved sinus or close to it, through the femoral vein. The advantage of local administration is that, a larger amount of tPA actually reaches the clot vs systemic administration through a peripheral vein. Usually, 2–5mg are administered through the thrombus and then an infusion started at a rate of 1 mg/hr, usually for 12 hours. If clot burden is still there on angiography, the infusion may be continued for longer, until the clot resolves.

For CST, the infusion may be prepared in a concentration of 1 mg/10 ml (0.1 mg/ml), for a rate of 10 ml/hr.

Mechanical Thrombolysis: Similar to arterial embolic stroke, devices such as Stentriever or Penumbra may be used for clot extraction. Additionally, devices intended for other sites e.g., clot extraction from dialysis fistula, have also been used in cranial sinuses 4).

The challenge during endovascular intervention is negotiating the sigmoid-transverse sinus junction especially when using bulkier catheters e.g., AngioJet.

References

1)

Ding JY, Pan LQ, Hu YY, Rajah GB, Zhou D, Bai CB, Ya JY, Wang ZA, Jin KX, Guan JW, Ding YC, Ji XM, Meng R. Batroxobin in combination with anticoagulation may promote venous sinus recanalization in cerebral venous thrombosis: A real-world experience. CNS Neurosci Ther. 2019 May;25(5):638-646. doi: 10.1111/cns.13093. Epub 2019 Jan 23. PubMed PMID: 30675757; PubMed Central PMCID: PMC6488911.
2)

Pizzi MA, Alejos DA, Siegel JL, Kim BY, Miller DA, Freeman WD. Cerebral Venous Thrombosis Associated with Intracranial Hemorrhage and Timing of Anticoagulation after Hemicraniectomy. J Stroke Cerebrovasc Dis. 2016 Jun 16. pii: S1052-3057(16)30098-2. doi: 10.1016/j.jstrokecerebrovasdis.2016.05.025. [Epub ahead of print] PubMed PMID: 27321968.
3) , 4)

Khan SH, Adeoye O, Abruzzo TA, Shutter LA, Ringer AJ. Intracranial dural sinus thrombosis: novel use of a mechanical thrombectomy catheter and review of management strategies. Clin Med Res. 2009; 7:157– 165
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