Incidence Of Diabetes Insipidus Research Articles

MANAGEMENT OF DIABETES INSIPIDUS AFTER SUBLABIAL TRANSSPHENOIDAL HYPOPHYSECTOMY SURGERY

MANAGEMENT OF DIABETES INSIPIDUS AFTER SUBLABIAL TRANSSPHENOIDAL HYPOPHYSECTOMY SURGERY

Serum sodium and water imbalance after sellar, suprasellar, and parasellar surgeries: A prospective and observational study

Background: Sodium and water imbalance is common after sellar, suprasellar, and parasellar surgeries. A wide variation in the diagnostic criteria of diabetes insipidus (DI) has been noted in literature. A highly variable incidence of DI and hyponatraemia has been reported. There is paucity of Indian studies. Aims and Objectives: The study was designed to evaluate serum sodium level and water imbalance after sellar, suprasellar, and parasellar surgeries. This was evaluated in terms of occurrence of hyponatraemia and central DI on day 1 and day 7 in the post-operative period. Materials and Methods: Patients of either sex, aged from 18 to 65 years, ASA physical status I-II, GCS score ≥13, with baseline normal electrolyte level, posted for elective neurosurgical procedures for sellar, suprasellar, and parasellar tumours, were included for this study after satisfying the inclusion and exclusion criteria. A convenient sampling of 50 patients was considered for this study. The primary outcome measures were to determine the incidence of hyponatraemia and central DI. Other adverse event and any requirement of desmopressin in the post-operative period were also noted. Results: In the present study, the majority (74%) of patients were 31–50 years. Female preponderance was noted with male: female ratio as 1:1.4. Out of 50 cases 41 (82%) had transcranial surgery and 9 (18%) had transphenoidal surgery. The incidence of sodium and water disturbances (SWD) was observed in 22% (11/50) patients. Out of these 11 patients, nine developed DI and two had hyponatremia on day 1 in the post-operative period. Both the abnormalities were found to recover on day 7. Only 1 patient (2%) required desmopressin. Conclusion: The incidence of SWD after sellar, suprasellar, and parasellar surgeries was found to be common (22%). The hyponatraemia and DI responded to the therapy and were transient in nature.

Craniofacial involvement in Langerhans cell histiocytosis: A review of 44 cases at a single medical center

BackgroundCraniofacial bones are the most commonly involved site of Langerhans cell histiocytosis (LCH). The main purpose of this study was to clarify the relation between subsites of craniofacial bone and clinical presentation, treatment modalities, outcomes, and permanent consequences (PCs) in patients with LCH. MethodsForty-four patients diagnosed with LCH involving the craniofacial region presenting at a single medical center during 2001–2019 were collected and divided into four groups: single system with unifocal bone lesion (SS-LCH, UFB); single system with multifocal bone lesions (SS-LCH, MFB); multisystem without risk organ involvement (MS-LCH, RO-); and multisystem with risk organ involvement (MS-LCH, RO+). Data including demographics, clinical presentation, treatments, outcomes, and the development of PC were retrospectively reviewed. ResultsTemporal bone (66.7% versus 7.7%, p = 0.001), occipital bone (44.4% versus 7.7%, p = 0.022), and sphenoid bone (33.3% versus 3.8%, p = 0.041) involvement were more common in SS-LCH, MFB than they were in SS-LCH, UFB. No difference of reactivation rate was noted among the four groups. The most common PC is diabetes insipidus (DI), reported in 9 of the 16 (56.25%) patients with PC. The single system group was reported with the lowest incidence of DI (7.7%, p = 0.035). The reactivation rate was also higher in patients with PC (33.3% versus 4.0%, p = 0.021) or DI (62.5% versus 3.1%, p < 0.001). ConclusionAn increased risk of multifocal or multisystem lesions was associated with temporal bone, occipital bone, sphenoid bone, maxillary bone, eye, ear, and oral involvement, which may indicate poor outcomes. Longer follow-up may be indicated if there is the presence of PC or DI due to the high risk of reactivation. Therefore, multidisciplinary evaluation and treatment according to risk stratification are vital for patients diagnosed with LCH involving the craniofacial region.

Incidence of Diabetes Insipidus and SiADH in Postoperative of Transsphenoidal Resection of Pituitary Adenoma

Diabetes Insipidus (DI) and Syndrome of inappropriate ADH secretion (SiADH) are well-known complications of transsphenoidal resection of pituitary adenoma. The incidence of these complications had not been evaluated in Canada. Furthermore, there is no expert recommendations regarding the follow-up of natremia after transsphenoidal surgery. The objective of this study was to determine the incidence of transitory DI, permanent DI and SiADH.

Limited Surgery and Conformal Photon Radiation Therapy for Pediatric Craniopharyngioma: Long-Term Results From the RT1 Protocol

To estimate long-term disease control and selected complications for children and adolescents with craniopharyngioma after treatment with limited surgery and conformal photon radiation therapy (CRT) at a single institution. To benchmark outcomes to guide new treatment approaches, interventions, and surveillance.A total of 101 pediatric patients with craniopharyngioma were prospectively enrolled on a phase II single institutional protocol beginning 1998. Surgery was individualized to treat presenting symptoms, reduce the irradiated volume, and avoid diabetes insipidus (DI). CRT (54Gy) was administered using a 1.0cm or 0.5cm clinical target volume margin and MRI was used during treatment to monitor the targeted volume. Patients were followed in the radiation oncology clinic for 10 years. Follow-up included serial MRI/MRA and a battery of tests to measure CNS effects.Tumor progression was experienced by 20 patients. The median time to progression was 5.1 years. Death occurred in 12 patients who experienced tumor progression (n = 6), complications related to tumor or treatment (n = 5) or both (n = 1). With a median follow-up of 14.94 years for survivors, the 10-year estimates (± SE) of progression-free, event-free, and overall-survival were 78.84% ± 4.10%, 77.12% ± 4.19%, and 96.02% ± 1.95%, respectively. The 10-year cumulative incidence (± SE) of secondary tumor (1.99% ± 1.40%), secondary malignant tumor (1.0% ± 1.0%), necrosis (1.98% ± 1.39%), vasculopathy (8.47% ± 2.90%), and other permanent neurologic deficits (8.28% ± 3.37%) were estimated with tumor progression, secondary malignancy and death as competing risks. Three patients required revascularization surgery. Surgery was characterized by tumor-directed procedures: none (n = 5), single (n = 50), and multiple (n = 46). Excluding those who presented with DI (n = 7), there was no difference in prevalence of DI by number of procedures; however, the single procedure group had a higher incidence of DI after craniotomy compared to bur hole procedures (P < 0.001). Salvage therapy was successful in 13 patients using combinations of surgery and radiosurgery. Including frontline and salvage therapy, the incidence of diabetes insipidus (62%), growth hormone (82%), thyroid hormone (92%), adrenal hormone (89%), and sex hormone (81%) replacement therapies were individually assessed. Seizures that required treatment were observed in 19% and aspirin therapy was prescribed in 23%.Limited surgery and CRT using photons results in excellent tumor control. Pediatric patients with craniopharyngioma experience a wide range of complications. The incidence and severity of complications may be further reduced by improving the type and extent of surgery procedures, newer methods of irradiation, and improving patient compliance with follow-up.

Management Options for Suprasellar Cystic Craniopharyngioma: Endoscopic Transventricular Approach and Microsurgical Approach

Objective The treatment of cystic craniopharyngioma in children is varied. The treatment ranges from radical excision to direct radiotherapy. As the morbidity of excision is high, more conservative approaches are used. Transventricular endoscopy is a minimally invasive treatment for cystic craniopharyngiomas. The objective of this study is to compare the outcome of microscopic versus endoscopic transventricular approach for cystic craniopharyngioma. Methods This is a retrospective study of series of children managed with microscopic excision and endoscopic transventricular approach for suprasellar cystic craniopharyngiomas. Operative details, visual outcome, endocrinological outcome, tumor-related cyst recurrence rate, and complication were compared between microscopic and endoscopic groups. Results A total of 28 children underwent microscopic excision and 14 children underwent endoscopic procedure. The anesthesia time was significantly lower with endoscopic as compared to microscopic group ( p = 0.0001) as well as blood loss during surgery ( p = 0.0001). Hospital stay after surgery was shorter in endoscopic group. Incidence of diabetes insipidus was more in microscopic group (25%) compared to endoscopic group (7.14%). Visual outcome was almost same with approaches. Requirement of hormone replacement was more in microscopic group than in endoscopic group ( p = 0.006). Incidence of cyst recurrence was more in microscopic (39.3%) compared to endoscopic group (7.7%). Conclusion Endoscopic transventricular approach is a safe alternative for initial treatment of suprasellar cystic craniopharyngioma in children.

Comparison of outcomes between endoscopic and microscopic transsphenoidal surgery for the treatment of pituitary adenoma: a meta-analysis.

Pituitary tumors are among the most common intracranial tumors. Surgical resection is the most effective treatment for patients with pituitary tumors. Microscopic transsphenoidal surgery has become the first-choice surgical approach to treating this malignancy, although it has certain limitations. Neuroendoscopy has also been widely used for pituitary tumor surgery in recent years. This study aimed to compare the efficacy and safety of these two surgical options for the treatment of pituitary tumors. We conducted a literature search of the PubMed, Embase, Cochrane Controlled Center Register of Controlled Trials (CENTRAL), Web of Science database, Google Scholar, and Baidu Scholar. Relevant articles published up to September 25, 2020 were retrieved and then meta-analyzed using RevMan software 5.1. A total of 29 case-control studies involving 7,774 patients were included in the meta-analysis. There was no significant difference in gross tumor removal (GTR) (RR =1.11, 95% CI: 0.97-1.26, P=0.12) or hormone excess secretion (HES) remission (RR =1.08, 95% CI: 0.97-1.21, P=0.16) between the two groups. Endoscopic transsphenoidal surgery was associated with a lower incidence of diabetes insipidus (DI) than was microscopic transsphenoidal surgery (RR =0.76, 95% CI: 0.60-0.97, P=0.03). Endoscopic transsphenoidal surgery does not significantly improve GTR or HES remission, but it can reduce the incidence of DI without increasing the rates of other complications.

Non-functioning pituitary adenomas: epidemiology, clinical and postoperative outcome

Non-functioning pituitary adenomas are the most frequent tumor group in the sellar region. They are usually benign neoplasms diagnosed after visual or hormonal symptoms, although it is not uncommon to detect them as a casual finding. To analyze the clinical aspects found in this disease and its response after surgical treatment. In a series of 100 cases, epidemiological, clinical, endocrinological, visual and radiological data were analyzed before and after surgical treatment, as well as the complications related to surgery and long-term follow-up. The most frequent symptom at the time of diagnosis was visual field involvement (62%), and only the 7% of adenomas were a casual finding. The most common hormonal deficit was hypogonadotropic hypogonadism (48%). After surgery, complete recovery of the visual field defect was observed in 54.8% of the patients, only 1% worsening after surgery, and the incidence of diabetes insipidus was 4%. The resection was superior to 95% in 63% of cases, although the percentage of adenomas with invasion of the cavernous sinus in Knosp grades 3 and 4 it was high (45%). Although the most frequent symptom of non-functioning pituitary adenomas is campimetric involvement, it has an excellent response to surgery if it is performed within the appropriate time. The grade of invasion of the cavernous sinus is the most limiting factor for a complete surgical resection.

Difference in the incidence of cerebrospinal fluid leakage and residual tumors between functional and nonfunctional pituitary adenomas treated by endoscopic transsphenoidal pituitary adenomectomy.

ObjectiveThis study compared the incidence of cerebrospinal fluid (CSF) leakage and residual tumors between functional and nonfunctional pituitary adenomas treated with the endoscopic endonasal transsphenoidal approach (EETA).MethodsAll patients underwent endocrine examinations and brain magnetic resonance imaging before and after surgery. The length of admission, incidence of central diabetes insipidus, incidence of CSF leakage, symptom relief, and presence of residual tumors were compared between patients with functional and nonfunctional pituitary adenomas.ResultsThirty-eight patients were enrolled, among whom 12 and 26 had functional and nonfunctional pituitary adenomas, respectively. The incidence of CSF leakage was significantly higher in patients with nonfunctional adenomas; a hard or elastic tumor character accounted for the difference. A large tumor size and cavernous sinus invasion were risk factors for residual tumors. No significant differences were found in sex, length of admission, operative times, incidence of diabetes insipidus, or number of residual tumors between the two groups. The hormone levels were lower postoperatively than preoperatively in patients with nonfunctional adenomas.ConclusionNonfunctional pituitary macroadenomas resulted in more CSF leakage. Use of the rescue nasoseptal flap reduced unnecessary nasal destruction. Cooperation between a neurosurgeon and otolaryngologist was safer and more effective when using the EETA.

Clinical analysis of pediatric Langerhans cell histiocytosis with craniofacial bone involvement

Objective To investigate the clinical characteristics and outcomes of pediatric Langerhans cell histiocytosis (LCH) with craniofacial bone involvement. Methods A retrospective analysis was performed on 145 pediatric LCH patients with craniofacial bone involvement registered at Beijing Children′s Hospital Affiliated to Capital Medical University from January 2007 to July 2013.The patients were divided into 2 groups: central nervous system risk craniofacial bone involvement group(CNS-RISK) and non-central nervous system risk craniofacial bone involvement group(non-CNS-RISK). All patients were assessed at 5 weeks, 11 weeks, 25 weeks and 52 weeks respectively after chemotherapy started, and 3 months, 6 months, 1 year and 3 years after chemotherapy withdrawal.Statistics and related risk analysis was performed respectively. Results A total of 145 craniofacial bone involved LCH cases were included, which was composed of 62.5% of 232 LCH cases hospitalized during the same period.The median age of these patients was 29 months, and median follow-up time period was 31 months.The most commonly involved craniofacial bone was parietal bone(78 cases, 53.8%), followed by temporal bone(59 cases, 40.7%) and frontal bone(57 cases, 39.3%). The onset age was significantly different (26 months vs.54 months, Z=-2.777, P<0.05) between CNS-RISK group (103 cases) and non-CNS-RISK group (42 cases). Moreover, compared with non-CNS-RISK group, CNS-RISK group showed higher ratio of patients classified as multisystem involvement of risk organs (72/103 cases, 69.9%)vs.(15/42 cases, 35.7%)(χ2=16.908, P<0.05), and a higher rate of overall relapse rate (45/103 cases, 43.7%) vs. (7/42 cases, 16.7%) (χ2=9.427, P<0.05), a lower survival rate of 3-year relapse-free survival rate [(66.9±5.7)% vs.(88.2±7.8)%, Z=2.205, P<0.05]. The incidence of diabetes insipidus was 13.7% in 232 LCH patients.Compared with patients without craniofacial bone involvement, patients with craniofacial bone involvement demonstrated a higher rate of diabetes insipidus [(27/145 cases, 18.6%) vs.(5/87 cases, 5.7%), χ2=7.579, P=0.006]. But the incidence of diabetes insipidus showed no statistical difference between CNS-RISK group and non-CNS-RISK group (21.3% and 11.9%, χ2=1.760, P=0.185). Diabetes insipidus was not found in single system LCH with Single-Bone CNS-RISK lesions.Till the end of follow-up, 1 out of 145 patients died.Among 145 patients, 5 cases had a single-bone CNS-RISK lesion.They received systemic chemotherapy.One showed reactivation, and none of them died.Multivariate analysis of variance showed that all the independent factors indicating diabetes insipidus included parietal bone, frontal bone, maxilla and mandible involvement(HR=2.697, 3.487, 5.425, all P<0.05), while independent factors indicating relapse included temporal bone, maxilla and mandible involvement(HR=3.712, 3.380, all P<0.05). Conclusions Among involved craniofacial bones, the parietal bone is most commonly involved.LCH occurs averagely at an earlier age in CNS-RISK group, along with lower 3-year relapse-free survival rate, high relapse rate, and more patients classified as multisystem LCH involvement of risk organs.The incidence of diabetes insipidus in children with craniofacial bone involvement with single system CNS-RISK is low.Patients with the parietal bone, frontal bone, maxilla and mandible involvement at diagnosis are at a increasing risk a significantly to develop DI during the course of disease. Key words: Langerhans cell histiocytosis; Child; Craniofacial bone; Clinical characteristics.

SAT-233 Management of Pregestational Diabetes Insipidus in Pregnancy

Introduction: The incidence of diabetes insipidus (DI) in pregnancy is rare, affecting 2 to 4 cases per 100,000 gestations. Management of pregestational DI poses a challenge for patients who are already on 1-deamino-8-D-arginine vasopressin (desmopressin acetate) (DDAVP) as limited data is available on DDAVP adjustments during pregnancy. This case series describes three patients with pregestational central DI, all of whom required increased DDAVP doses during pregnancy. Case Presentation; Case 1: A 28 year old female with central DI from Langerhans cell histiocytosis was maintained on DDAVP nasal spray 10 mcg twice daily. At 16 weeks gestation, she reported symptoms of polyuria and polydipsia and DDAVP was increased to 20 mcg twice daily. Urine osmolality trended down by 67% (146 mOsm/kg) at 24 weeks gestation but serum sodium (136-143 mmol/L) remained in normal range. Case 2: A 30 year old female with central DI from a concussion was maintained on DDAVP tablet 50 mcg twice daily. Increased polydipsia was reported within the first trimester, however self-reported polyuria occurred at 23 weeks. At this time DDAVP was increased to150 mcg. Urine osmolality trended down by 52% at 27 weeks gestation (237 mOsm/kg) while serum sodium (134-137mmol/L) remained stable. Case 3: A 34 year old female with congenital central DI was maintained on DDAVP tablet 300 mcg total daily dose. During her first pregnancy DDAVP was increased to 500 mcg at 10 weeks gestation due to polyuria and polydipsia. During her second pregnancy DDAVP was increased to 600 mcg at 18 weeks gestation. Serum sodium levels (135-138 mmol/L) in second pregnancy remained stable in normal range. Post-partum, all three patients resumed pre-pregnancy DDAVP dose. Discussion: Although the development and management of gestational DI is reviewed in several papers, there is limited information on the management of pregestational central DI in pregnancy. Physiologic changes in water homeostasis predispose pregnant women to developing symptoms of polyuria and polydipsia. It may therefore be difficult to determine if worsening symptoms are related to inadequate DDAVP dosing. Patients with pregestational central DI can perceive worsening symptoms as early as the first trimester. DDAVP doses increased by 25-100% between the second and third trimester correlating with a decline in urine osmolality by 53-67% in two of our patients. Serum sodium levels remained in normal range. Our goal is to share our clinical experience with managing pregestational DI in pregnancy. It is important to be aware of the physiological changes and how they correlate with fluctuations in DDAVP requirements. Additional standardization regarding the management of pregestational DI would be beneficial for future pregnancy cases, however this may be difficult to achieve due to the rarity of the condition.

Predictors of Postoperative Diabetes Insipidus Following Endoscopic Resection of Pituitary Adenomas.

ContextThe development of diabetes insipidus (DI) following transsphenoidal resection of pituitary adenomas has been associated with higher postsurgical morbidity and longer hospitalizations. Identifying these patients promptly and efficiently can lead to improved health care outcomes.ObjectiveWe evaluated our institution’s incidence of DI following pituitary adenoma resection and assessed for preoperative risk factors that were associated with postoperative DI.DesignA retrospective review of 271 patients who underwent endoscopic endonasal resection of a pituitary adenoma between July 2010 and December 2016 by a single neurosurgical provider was completed.SettingAll cases were from a single-center, academic institution.PatientsPatients with a pituitary adenoma diagnosis confirmed on histology were included in the study. Those with previous surgery by a different provider were excluded.ResultsThe incidence of DI at our institution was 16.6% (45 of 271 patients), with only 4% (11 patients) having permanent DI. The presence of visual abnormalities (CI 1.29 to 4.75), suprasellar extension (CI 1.36 to 6.88), and maximal tumor diameter (1.02 to 1.08) was significantly associated with an increased incidence of postoperative DI (P < 0.05). Hyperprolactinemia, tumor functionality, and cerebrospinal fluid exposure were not associated with higher rates of postoperative DI (P > 0.05).ConclusionPituitary adenoma patients presenting with visual abnormalities, suprasellar extension, or large tumors are at higher risk of developing DI postoperatively. These patients warrant closer postoperative monitoring as well as adequate preoperative counseling to decrease their postsurgical morbidity.

Therapeutic outcomes of transsphenoidal surgery in pediatric patients with craniopharyngiomas: a single-center study.

OBJECTIVE The aim of this study was to analyze the outcomes of transsphenoidal surgery (TSS) in a single-center clinical series of pediatric craniopharyngioma patients treated with gross-total resection (GTR). METHODS The authors retrospectively reviewed the surgical outcomes for 65 consecutive patients with childhood craniopharyngiomas (28 girls and 37 boys, mean age 9.6 years) treated with TSS (45 primary and 20 repeat surgeries) between 1990 and 2015. Tumors were classified as subdiaphragmatic or supradiaphragmatic. Demographic and clinical characteristics, including extent of resection, complications, incidence of recurrence, pre- and postoperative visual disturbance, pituitary function, and incidence of diabetes insipidus (DI), as well as new-onset obesity, were analyzed and compared between the primary surgery and repeat surgery groups. RESULTS Of the 45 patients in the primary surgery group, 26 (58%) had subdiaphragmatic tumors and 19 had supradiaphragmatic tumors. Of the 20 patients in the repeat surgery group, 9 (45%) had subdiaphragmatic tumors and 11 had supradiaphragmatic tumors. The only statistically significant difference between the 2 surgical groups was in tumor size; tumors were larger (mean maximum diameter 30 mm) in the primary surgery group than in the repeat surgery group (25 mm) (p = 0.008). GTR was accomplished in 59 (91%) of the 65 cases; the GTR rate was higher in the primary surgery group than in the repeat surgery group (98% vs 75%, p = 0.009). Among the patients who underwent GTR, 12% experienced tumor recurrence, with a median follow-up of 7.8 years, and recurrence tended to occur less frequently in primary than in repeat surgery patients (7% vs 27%, p = 0.06). Of the 45 primary surgery patients, 80% had deteriorated pituitary function and 83% developed DI, whereas 100% of the repeat surgery patients developed these conditions. Among patients with preoperative visual disturbance, vision improved in 62% but worsened in 11%. Visual improvement was more frequent in primary than in repeat surgery patients (71% vs 47%, p < 0.001), whereas visual deterioration was less frequent following primary surgery than repeat surgery (4% vs 24%, p = 0.04). Among the 57 patients without preoperative obesity, new-onset postoperative obesity was found in 9% of primary surgery patients and 21% of repeat surgery patients (p = 0.34) despite aggressive resection, suggesting that hypothalamic dysfunction was rarely associated with GTR by TSS in this series. However, obesity was found in 25% of the repeat surgery patients preoperatively due to prior transcranial surgery. Although there were no perioperative deaths, there were complications in 12 cases (18%) (6 cases of CSF leaks, 3 cases of meningitis, 2 cases of transient memory disturbance, and 1 case of hydrocephalus). Postoperative CSF leakage appeared to be more common in repeat than in primary surgery patients (20% vs 4.4%, p = 0.2). CONCLUSIONS The results of TSS for pediatric craniopharyngioma in this case series suggest that GTR should be the goal for the first surgical attempt. GTR should be achievable without serious complications, although most patients require postoperative hormonal replacement. When GTR is not possible or tumor recurrence occurs after GTR, radiosurgery is recommended to prevent tumor regrowth or progression.

Postoperative Diabetes Insipidus and Hyponatremia in Children after Transsphenoidal Surgery for Adrenocorticotropin Hormone and Growth Hormone Secreting Adenomas

To define the incidence and risk factors of postoperative sodium alterations in pediatric patients undergoing transsphenoidal surgery (TSS) for adrenocorticotropic hormone and growth hormone secreting pituitary adenomas. We retrospectively reviewed 160 patients ≤18 years of age who had TSS for pituitary adenomas at our institution from 1999 to 2017. Variables included daily serum sodium through postoperative day 10, urine specific gravity, and medications administered. We examined associations between sex, repeat surgery, manipulation of the posterior pituitary (PP), tumor invasion into the PP, tumor type and size, cerebrospinal fluid (CSF) leak, lumbar drain insertion, body mass index, puberty, and development of diabetes insipidus (DI) or syndrome of inappropriate antidiuretic hormone secretion (SIADH). Mean age was 12.9 ± 3.4 years (female = 81). Patients had adrenocorticotropic hormone (150/160) and growth hormone (10/160) producing adenomas. Forty-two (26%) patients developed DI. Among the 37 of 160 who required desmopressin acutely, 13 of 37 required it long term. Risk of long-term need for desmopressin was significantly higher in patients who had CSF leak 9 of 48 (P = .003), lumbar drain 6 of 30 (P = .019), manipulation 11 of 50 (P < .001), or invasion 4 of 15 (P = .022) of the PP. Sixty patients developed hyponatremia, 19 because of SIADH, 39 to hypotonic fluids and 2 to cerebral salt wasting syndrome. Patients with SIADH were placed on fluid restriction; 1 received salt tablets. Among 160 children who underwent TSS for pituitary adenomas, the incidence of DI and SIADH after TSS was 26% and 14%, respectively. Combined risk factors for DI and/or SIADH include female sex, manipulation of and/or tumor invasion into the PP, and CSF leak or lumbar drain. ClinicalTrials.gov: NCT00001595 and NCT00060541.

Influence of preventive use of vasopressin tannate on diabetes insipidus and serum sodium at the early postoperation of craniopharyngioma

To explore the influence of preventive use of vasopressin tannate on diabetes insipidus and serum sodium at the early postoperation of craniopharyngioma. Methods: The data of 83 patients, who underwent unilateral sub-frontal approach resection of craniopharyngioma between 2010 and 2014 by the same senior neurosurgeon, were retrospectively analyzed. The patients were divided into a vasopressin tannate group (used group) and a control group. The diabetes insipidus and serum sodium changes were compared between the two groups. Results: Compared with the control group, the incidence of diabetes insipidus decreased at the early postoperation in the vasopressin tannate group (P<0.05). There was high incidence of diabetes insipidus in patients with pituitary stalk excision and tumor close adhesion to the third ventricle floor at the early postoperation (P<0.05). Under such conditions, the incidence of diabetes insipidus in the vasopressin tannate group was decreased compared with the control group (P<0.05). Postoperative hypernatremia occurred in 37 patients (44.6%), and hyponatremia occurred in 60 patients (72.3%), the average time of the occurrence of hpernatremia and hyponatremia was 1.4 and 3.7 days after surgery. Postoperative high serum sodium and low serum sodium appeared alternately in 19 patients (22.9%). There was significant difference in the serum sodium distribution in the first day after surgery in both groups (P<0.05), and the percent of hpernatremia in the vasopressin tannate group was significantly less than that in the control group (P<0.05). Conclusion: Preventive use of vasopressin tannate can effectively reduce diabetes insipidus and hypernatremia incidence at the early postoperative stage after microsurgery for craniopharyngioma.

Pediatric anterior visual pathway gliomas: trends in fluid and electrolyte dynamics and their management nuances

Trends in pre- and postoperative fluid, electrolyte and osmolarity changes, and incidence of diabetes insipidus (DI) were assessed in pediatric patients with anterior visual pathway gliomas (AVPGs). Thirty-three patients with AVPGs (age < 16years) were divided into two groups: (1) no hypothalamic involvement [NHI; n = 17 (51.5%) including optic (5, 15.2%); chiasmal (5, 15.2%); and optico-chiasmal (7, 21.2%)] and (2) hypothalamic involvement [HI; n = 16 (48.5%) including chiasmal-hypothalamic (12, 36.4%) and optico-chiasmal-hypothalamic (4, 12.1%)]. Frontotemporal transylvian decompression/biopsy was undertaken in 32 patients, while one patient (with severe diencephalic syndrome) was treated conservatively. Their endocrinal and fluid/electrolyte balance, serum osmolarity, and DI status were noted. Chi-square test compared clinical/endocrinological parameters, and unpaired T test evaluated mean daily water/electrolyte changes (p value < 0.05: significant). Significant visual deterioration (perception of light (PL) positive (left: n = 4; right: n = 4) and PL negative (left: n = 5; right: n = 5) was encountered due to optic atrophy. Larger lesions (>3cm), hydrocephalus [(NHI: n = 7, 41.18%; HI: n = 12, 75%), endocrinopathies (p = 0.047), Na(+)/K(+) derangements, and preoperative DI (n = 8, p = 0.004)] were present in the group HI. Increased postoperative urine output (almost double in those with hypothalamic involvement) and hypernatremia/hyperkalemia were seen in group HI until the sixth postoperative day (p < 0.05). Two patients with progressive hypernatremia without increased urine output showed dehydration on central venous pressure monitoring and improved with vasopressin administration. Five patients [NHI: n = 4 (23.5%); HI: n = 1 (6.3%)] had neurofibromatosis types I and 3 (NHI: n = 1, 5.9%; HI: n = 2, 12.5%) had a diencephalic syndrome. Hypothalamic infiltration significantly increases the incidence of DI and fluid and electrolyte disturbances. Strict vigilance over postoperative fluid balance is mandatory during the first postoperative week. Rapidly rising serial serum sodium values without increased urine output mandates immediate central venous pressure measurement to detect DI associated with dehydration.

The clinical features and surgical treatment strategy of hypothalamic gliomas

Objective To investigate the clinical manifestation and radiological features of hypothalamic glioma (HG),and to evaluate the surgical efficacy and prognosis.Methods 36 cases of HG presenting in the department of neurosurgery of Nanfang hospital were respectively analyzed.The long term follow-up was performed through recheck in outpatient department,telephone and letter.Results Solid and cystic mixed tumor was more common in pilocytic astrocytoma (PAS).However,fiber astrocytoma was predominantly solid.The calcification of tumor was more common in astrocytoma or oligodendroglioma.The postoperative endocrinological deterioration in varying degrees was found in all patients.Between GTR group and STR + PTR group,there was no significant difference of the incidence of multi-axial hormone deficiency (P =0.474) and diabetes insipidus after surgery (P =0.366).During the follow-up period,among 7 recurrence cases,three occurred in GTR group (18.7％),was slightly lower than STR + PTR group (P =0.022).Moreover,there was no difference about the quality of life of two groups (P =0.216).Conclusions It was useful to make the clinical diagnosis better with well understanding the clinical characteristics of HG.Surgical treatment remained the first choice of treatment.GTR won't deteriorate the incidence of diabetes insipidus and endocrine levels more than STR + PTR.For unclear interface and close adherence to hypothalamus,STR based on sufficient decompression reduced the perioperative incidence of death,and meanwhile obtained the satisfying clinical effects. Key words: Glioma; Hypothalamus ; Endocrinology ; Quality of life ; Neurosurgery

Hyponatremia following endoscopic third ventriculostomy: a report of 5 cases and analysis of risk factors

Electrolyte and endocrinological complications of endoscopic third ventriculostomy (ETV) are infrequent but serious events, likely due to transient hypothalamic-pituitary dysfunction. While the incidence of diabetes insipidus is relatively well known, hyponatremia is not often reported. The authors report on a series of 5 patients with post-ETV hyponatremia. The records of patients undergoing ETV between 2008 and 2010 were reviewed. All ETVs were performed with a rigid neuroendoscope via a frontal bur hole, standard third ventricle floor blunt perforation, Fogarty catheter dilation, and intermittent normal saline irrigation. Postoperative MR images were evaluated for endoscope tract injury as well as the trajectory from the bur hole center to the fenestration site. Thirty-two patients (20 male and 12 female) underwent ETV. Their median age was 6 years (range 3 weeks-28 years). Hydrocephalus was most commonly due to nontumoral aqueductal stenosis (43%), nontectal tumor (25%), or tectal glioma (13%). Five patients (16%) had multicystic/loculated hydrocephalus. Five patients (16%) developed hyponatremia between 1 and 8 days following ETV, including 2 patients with seizures (1 of whom was still hospitalized at the time of the seizure and 1 of whom was readmitted as a result of the seizure) and 3 patients who were readmitted because of decline in their condition following routine discharge. No hypothalamic injuries were noted on imaging. Univariate risk factors consisted of age of 2 years or less (p = 0.02), presence of cystic lesions (p = 0.02), and ETV trajectory angle 10° or more from perpendicular (p = 0.001). Endoscopic third ventriculostomy is a well-tolerated procedure but can result in serious complications. Hyponatremia is rare and may be more likely in younger patients or those with cystic loculations. Patients with altered craniometry may be at particular risk with a rigid endoscopic approach requiring greater manipulation of subforniceal or hypothalamic structures.

Single Brain Death Examination Is Equivalent to Dual Brain Death Examinations

Although the new Practice Parameters for brain death support a single examination, there is paucity of data comparing its impact to dual brain death (DBD) examinations. We reviewed all brain deaths in our hospital over a 39-month period and compared the optional single brain death (SBD) exam requiring an apnea and a mandatory confirmatory blood flow test to the DBD for organ function at the time of death, rate of donation, and cost. Thirty-six patients had a SBD and 59 DBD exams, without any of them regaining neurological functioning. There was no difference in serum electrolytes (except for higher Na(+) and Cl(-) in the SBD group), blood urea nitrogen, creatinine, blood gases, incidence of diabetes insipidus, apnea completion, consent for donation, and organs recovered and transplanted. During the second BD exam, 35% of patients with DBD were on higher dose of vasopressors, but had lower systolic blood pressure (P=0.046). For DBD patients, the mean interval between the two exams was 14.4h, which contributed to a higher cost of $43,707.67 compared to SBD. There was a trend for increased consent rates (adjusted for age, race, and type of exam) when patients were declared by the neurointensivist service following a strict family approach protocol (P=0.06). SBD exam is easier, faster to perform, with no brain function recovery and leads to similar donation rates, equivalent or better organ function status at the time of BD and lower cost than conventional DBD exams.

PREDICTORS AND INCIDENCE OF CENTRAL DIABETES INSIPIDUS AFTER ENDOSCOPIC PITUITARY SURGERY

With the advent of minimally invasive endoscopic pituitary surgery, there has been concern that the technique may be associated with higher rates of complications such as diabetes insipidus (DI) than traditional approaches, particularly early in a center's experience. We report the incidence and predictors of diabetes insipidus in patients after endoscopic transnasal resection (minimally invasive pituitary surgery) of pituitary lesions. Data were collected from hospital and clinic records on the first 119 consecutive patients undergoing endoscopic pituitary surgery at our center. The rate of postoperative diabetes insipidus is low in patients undergoing minimally invasive pituitary surgery (permanent, 2.7%; transient, 13.6%). Factors associated with development of DI after minimally invasive pituitary surgery include Rathke's cleft cyst histology, intraoperative cerebrospinal fluid leak, and previous nonendoscopic lesion resection. Elevated serum sodium (>145 mmol/L) within the first 5 days postoperatively has a high sensitivity (87.5%), specificity (83.5%), and negative predictive value (99.5%) for permanent postoperative DI development. Transitioning from microscopic to endoscopic pituitary surgery can be achieved with a low incidence of DI. An elevated serum sodium level in the first 5 postoperative days using standard monitoring can predict the chance of developing permanent DI. Patients having no elevated serum sodium measurements, defined as >145 mmol/L, in the first 5 days postoperatively will rarely, if ever, develop permanent DI, thereby validating short postoperative inpatient stays with minimal risk of readmission for DI management. Those with a single serum sodium measurement greater than 145 mmol/L have a 15% risk of developing permanent DI.