Permanent Central Diabetes Insipidus Research Articles

Central diabetes insipidus after transnasal adenomectomy:trends in development and recovery, clinical and laboratory characteristics

Background: Currently, there is an increase in the incidence of chiasmosellar neoplasms and respective neurosurgical interventions. The postoperative period may be complicated by vasopressin synthesis and secretion disorders. Both the development and abortion of the fluid and electrolyte disorders can be delayed. Due to a tendency for an earlier discharge of the patients, a proportion of the disorders remain unaddressed. There is no data on the evolution and time to regress of transient abnormalities in the published studies with a long-term postoperative follow-up.
 Aim: To assess the incidence, evolution and regression trends, clinical and laboratory characteristic of postoperative central diabetes insipidus (CDI).
 Materials and methods: The single center retrospective comparative study included 150 patients who had undergone transnasal adenomectomy for Cushings disease, acromegaly, prolactinomas, and hormonally inactive pituitary adenomas. Clinical and laboratory assessments were performed pre- and postoperatively. In the event of CDI, treatment with desmopressin was administered. Ninety six (96) patients aged 20 to 65 years (median age 43 [35; 54] years) were followed for at least 60 months after the procedure.
 Results: Median time to the onset of permanent CDI (pCDI) was Day 5 [1; 9.5] after surgery, that of transient CDI (tCDI) Day 1 [1; 4.5] with its remission by Day 30 [1.5; 199]. The maximally delayed onset was on Day 86 for the pCDI and Day 61 for tCDI; that to the remission of tCDI, 738 days. At discharge from the hospital, postoperative CDI was present in 34/150 patients (23%; 95% CI 1730), and in 25/150 of the patients (16%; 95% CI 1224) the disorder resolved. At 5 to 7 years after surgery, the prevalence of pCDI was 16% (95% CI 1024), that of tCDI 35% (95% CI 2745), 49% (95% CI 3959) of the patients had no abnormalities (respective absolute patient numbers being 15, 34, and 47 of 96 followed for at least 60 months). At Days 1 to 7 after surgery, the patients with pCDI and tCDI had more frequent complaints of dry mouth and thirst than those without the disorder. These complaints were verified by higher 24-hour fluid intake and diuresis at the day of surgery and Days 5 to 7 thereafter, compared to those in the patients without the disorders. At Days 57 after surgery, urine sodium and urine specific gravity were significantly lower, as was urine osmolality at all postoperative stages, compared to those in the patients without the disorders.
 Conclusion: Within 2 years after transnasal adenomectomy, the incidence of postoperative CDI is gradually decreasing (from 23% to 16%). Due to potentially delayed manifestation of water and electrolyte imbalance, it is recommended that these parameters should be monitored at least for 2,5 months after the discharge from hospital. Due to potentially delayed remission (12 months and more), follow-up and monitoring for 1.5 years is reasonable, with periodic assessment of sodium levels, fluid intake and excretion, and attempts to withdraw desmopressin.

Clinical and therapeutic outcomes of pediatric pituitary adenomas: a single pituitary center experience.

Pediatric pituitary adenomas (PPA) are rare. Although PPAs are mostly benign, they can be challenging to manage. Most studies evaluating PPA are based on surgical series. We aimed to present the clinical features, hormonal status and treatment outcomes of children with PPA managed in a joint neuroendocrine setting. In this single-center study, demographic, clinical and endocrinological data of patients under 19 years old who were followed up with the diagnosis of PPA between 2002-2022 were retrospectively reviewed. A total of 21 studies published in the past 20 years were also systematically reviewed. There were 79 patients (52 girls, 27 boys) with a median age of 15.8 years. Median follow-up time was 30 months. The most common adenoma subtype was non-functioning adenoma (NFA) (35.5%), followed by prolactinoma (29.1%), corticotropinoma (21.5%), and somatotropinoma (13.9%), respectively. The frequency of micro and macroadenomas was almost equal while 38% of all adenomas were invasive. Headache, visual impairment and menstrual irregularity were the most common complaints, while the most common hormonal deficiency at diagnosis was central hypothyroidism (31.6%), followed by hypogonadotropic hypogonadism (22.7%), growth hormone deficiency (15.2%) and central adrenal insufficiency (11.4%), respectively. Fifty patients (63.2%) underwent endoscopic endonasal transsphenoidal surgery (EETS). Following the surgery, impaired endocrine functions recovered at a rate of 62% while permanent central diabetes insipidus was observed in 6%, and new onset hypopituitarism developed in 4%. NFA was more common in this cohort than in previous reports, which is one of the largest PPA series in the literature. Hormonal disorders, which were common at the time of diagnosis, were largely resolved with appropriate endocrinological and surgical approaches, while the rate of pituitary hormonal deficiencies after EETS was relatively low. Therefore, we recommend that children with PPA be managed in the setting of a high-volume pituitary center to provide long-term low morbidity.

Permanent central diabetes insipidus after traumatic brain injury

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Risk factors of central diabetes insipidus after transnasal adenomectomy

Background: At present, surgical intervention is a major treatment strategy for pituitary adenomas. It is commonly complicated with water and electrolyte imbalance. The prevalence of post-surgical central diabetes insipidus (CDI) may amount to 30%; however, its risk factors have not been established.Aim: To assess the rates and nosological distribution of CDI after transnasal adenomectomy and to identify its risk factors.Materials and methods: This retrospective study included 96 patients aged 20 to 65 years (median [Q1; Q3] 43 [34.5; 53.5]), who had transnasal adenomectomy in 2010-2011 due to Cushing's disease, acromegaly, prolactinoma, non-functioning pituitary adenoma. All patients underwent clinical examination and laboratory work-up before and after surgery. Their post-surgical course was assessed for 5 to 7 years. Depending on identified manifestations, the patients were categorized into the permanent CDI (n = 15) and transient CDI (n = 34); 47 patients had no CDI.Results: Cushing's disease (odds ratio (OR) 6.1, 95% confidence interval (CI) 2.3-16.1), secondary adrenal insufficiency (OR 6.8, 95% CI 2.618.3) and adrenocorticotropic hormone levels of < 15.8 pg/mL (OR 5.0, 95% CI 1.9-13.5), microadenoma (OR 4.5, 95% CI 1.7-11.5) promote transient postoperative CDI, whereas macroadenoma decrease this risk (OR 0.2, 95% CI 0.1-0.5). The transient CDI was also more common in patients with secondary hypothyroidism, cortisol level of<200 nmol/L, adenoma's volume at magnetic resonance imaging of < 0.83 cm3 at trend level and more rare in patients with acromegaly and loss of tropic hormones before surgery at trend level as well. No significant risk factors were identified for permanent CDI, but it could be more often associated with secondary hypothyroidism, absence of any adenoma at magnetic resonance imaging and pituitary injury during the surgery and less frequent in patients with macroadenomas at trend level.Conclusion: The proportion of permanent postoperative CDI was 16% (95% CI 9-24), and that of the transient form 35% (95% CI 25-45). Cushing's disease, microadenoma, development of secondary adrenal insufficiency and adrenocorticotropic hormone levels of < 15.8 pg/mL after surgery increase the probability of transient CDI, whereas macroadenoma does decrease this risk. No significant risk factors were identified for permanent CDI.

Changes in copeptin levels before and 3\xa0months after transsphenoidal surgery according to the presence of postoperative central diabetes insipidus

Copeptin levels reflect arginine vasopressin (AVP) release from the hypothalamus. Pituitary surgery often impairs AVP release and results in central diabetes insipidus (CDI). Here, we aimed to investigate how serum copeptin level changes 3 months after pituitary surgery and whether it has a diagnostic value for postoperative permanent CDI. Consecutive patients who underwent endoscopic transsphenoidal surgery at a single tertiary hospital were recruited. Serum copeptin levels were measured preoperatively and 3 months postoperatively. Among 88 patients, transient and permanent CDI occurred in 17 (19.3%) and 23 (26.1%), respectively. Three-month postoperative copeptin levels significantly declined from preoperative levels in permanent CDI group (P < 0.001, percentage difference = − 42.2%) and also in the transient CDI group (P = 0.002, − 27.2%). Three months postoperative copeptin level < 1.9 pmol/L under normal serum sodium levels was the optimal cutoff value for diagnosing permanent CDI with an accuracy of 81.8%, while 3-month postoperative copeptin level ≥ 3.5 pmol/L excluded the CDI with a negative predictive value of 100%. Conclusively, 3 months postoperative copeptin levels significantly decreased from preoperative levels in the transient CDI group as well as the permanent CDI group. Three-month postoperative copeptin levels ≥ 3.5 pmol/L under normal serum sodium levels may be diagnostic for excluding postoperative CDI.

&lt;p&gt;Transsphenoidal Surgery in Canines: Safety, Efficacy and Patient Selection&lt;/p&gt;

Pituitary-dependent hyperadrenocorticism (PDH) is the cause of approximately 80-85% of naturally occurring cases of hyperadrenocorticism(HAC) in canines and is triggered by an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma or hyperplasia of the corticotroph in the pituitary anterior lobe or intermediate lobe. Transsphenoidal surgery(TSS) is an effective treatment that can directly remove pituitary tumors that cause PDH in canines under a single course of general anesthesia. However, careful evaluations of the definitive diagnosis, adenoma size and growth rate, relationship with surrounding tissue, general condition, and neurosurgical procedural skill involved in each case are important to determine TSS suitability. The basic principle is to confirm that the present HAC case is PDH, that is, an ACTH-producing adenoma or the hyperplasia of the corticotroph originating from either the pituitary anterior or intermediate lobe. Evaluations based on endocrinology, particularly plasma ACTH concentration, and imaging diagnosis, particularly MRI is essential for definitive diagnosis. Enlarged pituitary tumors can shorten the post-TSS survival time, increase the recurrence rate of clinical symptoms, and increase the risk for developing permanent central diabetes insipidus. Therefore, complete removal of adenomas of up to Grade IIIA according to the MRI-based classification system is relatively easy to achieve with TSS, and long-term remission and survival can be expected.

Early Copeptin Determination Allows Prompt Diagnosis of Post-Neurosurgical Central Diabetes Insipidus

Introduction: Central diabetes insipidus (CDI) is a frequent complication of pituitary surgery, but its diagnosis lacks standardized criteria. Copeptin, a surrogate marker of arginine vasopressin release, is triggered by psycho-physical stresses such as pituitary surgery. Low postoperative copeptin could predict CDI onset. The aims of this study were the validation of copeptin as a predictor of post-neurosurgical CDI and the identification of the optimal timing for its determination. Methods: Sixty-six consecutive patients operated for a hypothalamic-pituitary lesion were evaluated. Copeptin was determined preoperatively and at 1, 6, 12, 24 and 48 h post-extubation. Fifty-eight patients were reassessed after 3–6 months post-surgery to confirm transient (3 cases) or permanent CDI (5 cases) diagnosis. Results: A marked copeptin peak was identified at 1 h after extubation, when a value below or equal to 12.8 pmol/L had a good accuracy in identifying CDI cases (AUC 0.866, 95% CI 0.751–0.941). Moreover, a copeptin peak above 4.2 pmol/L excluded permanent forms (AUC 1, 95% CI 0.629–1). Regression analysis identified copeptin as the only significant predictor of CDI (OR 0.86, 95% CI 0.75–0.98, p = 0.02). A copeptin T1/T0 ratio below or equal to 1.47 identified patients at risk of isolated biochemical alterations even in the absence of an overt CDI. Conclusions: A prompt increase of copeptin is expected at 1 h after extubation. The absence of this peak is a reliable predictor of post-neurosurgical CDI.

SUN-404 Diabetes Insipidus and Hypopituitarism in a Patient with Transient Isolated Pituitary Stalk Enlargement

Background. The differential diagnosis of pituitary stalk lesions is broad and includes neoplastic, inflammatory, infectious, and congenital disorders. Lymphocytic infundibuloneurohypophysitis (LIN) has been identified as an etiology of transient pituitary stalk enlargement leading to permanent central diabetes insipidus (DI). We present a case of transient isolated pituitary stalk enlargement complicated by both central DI and hypopituitarism. Case. A 65-year-old male presented to hospital with polyuria, polydipsia, nausea and vomiting, and a 20 lb. unintentional weight loss over three weeks. Hypernatremia (149 mM, 133-142) and inappropriately dilute urine (180 mOsm/kg) were noted on admission. Treatment with desmopressin resulted in prompt resolution of polyuria and hypertonicity. MRI was notable for nodular thickening of the pituitary stalk and loss of the posterior pituitary bright spot on T-1 weighted images, and lumbar puncture yielded clear fluid with mild lymphocytic pleocytosis, no malignant cells, and unremarkable angiotensin converting enzyme level. Evaluation of anterior pituitary function revealed secondary adrenal insufficiency, secondary hypothyroidism, secondary hypogonadism, impaired somatotroph function, and mild hyperprolactinemia (16.2 ng/mL, 3.6-13.2). The patient recovered to baseline weight and well-being on treatment with hydrocortisone, thyroxine, and intramuscular testosterone. He declined biopsy in favor of serial imaging of the pituitary stalk. Over the course of 18 months, radiographic changes in the pituitary stalk resolved, though DI and anterior pituitary deficits persist. Conclusion. Radiographic lesions confined to the pituitary stalk present a significant diagnostic challenge because biopsies are difficult and potentially injurious to patients. Diagnosis is based mostly on clinical evaluation and imaging. Epidemiological data are sparse; out of 150,045 head MRI studies at Mayo Clinic from 1987-2006, 2,700 were reviewed due to mention of “pituitary stalk” or “infundibulum” and 152 were found to have a pituitary stalk abnormality. LIN has been demonstrated on biopsy in patients with central DI and reversible pituitary stalk enlargement. In a series of 17 adult patients with LIN, central DI was persistent despite improvement in pituitary stalk abnormalities, but anterior pituitary function was preserved. A more recent series of nine children with central DI and apparent LIN followed for a mean of five years found six patients with resolution of pituitary stalk abnormalities; central DI persisted in all patients, and only one experienced loss of anterior pituitary function. Though unusual, this case illustrates that LIN may be complicated by permanent hypopituitarism in addition to central DI, possibly by injury from undetectable extension of pituitary stalk inflammation to the pituitary gland or hypothalamus.

Management and consequences of postoperative fluctuations in plasma sodium concentration after pediatric brain tumor surgery in the sellar region: a national cohort analysis

PurposeSevere fluctuations in plasma sodium concentration and plasma osmolarity, including central diabetes insipidus (CDI), may have significant influence on postoperative morbidity and mortality after pediatric brain tumor surgery.The aim of this study was to describe the frequency, severity and neurological consequences of these fluctuations in pediatric brain tumor survivors.MethodsA retrospective, multi-institutional chart review was conducted among all children who underwent brain tumor surgery in the sellar or suprasellar region in seven university hospitals in the Netherlands between January 2004 and December 2013.ResultsPostoperative CDI was observed in 67.5% of 120 included children. Fluctuations of plasma sodium concentration ≥ 10 mmol/L/24 h during the first ten postoperative days were seen in 75.3% of patients with CDI, with a maximum delta of 46 mmol/L/24 h. When compared to patients without CDI, altered mental status occurred more frequently in patients with postoperative CDI (5.1 vs. 23.5% respectively, p = 0.009). Low plasma sodium concentration was related to altered mental status and the occurrence of seizures. Frequency and severity of fluctuations in plasma sodium concentration during the first ten postoperative days were significantly higher in patients with permanent CDI at last follow-up than in patients with transient CDI or without CDI (p = 0.007).ConclusionPostoperative CDI is a common complication after pediatric brain tumor surgery in the sellar or suprasellar region. Extreme plasma sodium concentrations and large intra-day fluctuations still occur and seem to influence the postoperative neurological course. These results illustrate the need for intensive monitoring in a highly experienced center.

The efficacy of desmopressin in the treatment of central diabetes insipidus after resection of chiasmo-sellar region tumors

to study the efficacy and safety of desmopressin in CDI patients after resection of chiasmatic-sellar region (CSR) tumors. Examination and treatment of patients were performed at a hospital for 7-14 days after surgery and then were continued after discharge. During treatment, the following tests were performed: a daily fluid intake and excretion volume, serum levels of sodium, potassium, and glucose twice a day, morning urine specific gravity, and Zimnitsky's test. Twenty-three patients with CSR tumors (11 craniopharyngiomas, 10 pituitary adenomas, 1 skull base chordoma, and 1 CSR meningioma) and CDI after neurosurgical treatment received desmopressin. On treatment, a thirst decrease, a reduced rate of diuresis, a reduced amount of excreted urine, and normalization of the sodium level were observed in all patients. In 12 patients (with pituitary adenoma, skull base chordoma, and meningioma) with transient CDI, desmopressin therapy was discontinued upon regression of symptoms 7-30 days after surgery. Eleven patients with permanent CDI continued to receive the drug at a dose of 1 to 4 doses per day. All patients well tolerated the drug without significant adverse effects. Therapy with desmopressin in the form of a nasal spray (vazomirin) in patients with transient and permanent CDI after resection CSR tumors of various histological nature (craniopharyngiomas, pituitary adenomas, meningiomas, and chordomas) was effective and safe in the early postoperative and long-term postoperative periods.

Central Diabetes Insipidus in Infancy With or Without Hypothalamic Adipsic Hypernatremia Syndrome: Early Identification and Outcome.

Neonatal central diabetes insipidus (CDI) with or without adipsia is a very rare complication of various complex hypothalamic disorders. It is associated with greater morbidity and a high risk of developing both hypernatremia and hyponatremia, due to the condition itself or secondary to treatment with vasopressin analogs or fluid administration. Its outcomes have yet to be evaluated. To investigate the clinical outcomes of patients with neonatal-onset CDI or adipsic CDI with hypernatremia. All patients diagnosed with neonatal CDI in a university hospital-based observational study and followed between 2005 and 2015 were included and analyzed retrospectively. The various causes of CDI were grouped. Clinical outcome and comorbidities were analyzed. Ten of the 12 patients had an underlying condition with brain malformations: optic nerve hypoplasia (n = 3), septo-optic dysplasia (n = 2), semilobar holoprosencephaly (n = 1), ectopic neurohypophysis (n = 3), and unilateral absence of the internal carotid artery (n = 1). The other two were idiopathic cases. During the median follow-up period of 7.8 (4.9-16.8) years, all but one patient displayed anterior pituitary deficiency. Transient CDI was found in three (25%) patients for whom a posterior pituitary hyperintense signal was observed with (n = 2) and without (n = 1) structural hypothalamic pituitary abnormalities, and with no other underlying cerebral malformations. Patients with permanent CDI with persistent adipsia (n = 4) and without adipsia (n = 5) required adequate fluid intake and various doses of desamino-D-arginine-8-vasopressin. Those with adipsia were more likely to develop hypernatremia (45 vs 33%), hyponatremia (16 vs 4%) (P < .0001), and severe neurodevelopmental delay (P < .05) than those without adipsia. Comorbidities were common. The underlying cause remains unknown at the age of 23 years for one patient with CDI and normal thirst. Neonatal CDI may be transient or permanent. These vulnerable patients have high rates of comorbidity and require careful monitoring.

Permanent central diabetes insipidus as a complication of sphenoid sinus mucocele

Although mucocele is a benign lesion, its unavoidable expansions may result in irreversible damages in adjacent organs. In spheno-ethmoid mucoceles which are extremely rare, this condition may cause more severe problems. Central diabetes insipidus, developed secondary to sphenoid sinus mucocele, was detected in a 54-year-old male patient, who underwent endoscopic sinus surgery 2 times due to nasal polyposis. Endoscopic sphenoid mucocele marsupialization was performed to the patient, but despite partial regression in the 1-year follow up, complete recovery was not observed.

Central Diabetes Insipidus after Transsphenoidal Surgery in Dogs with Cushing's Disease

Transsphenoidal surgery (TSS) is an effective treatment for canine Cushing's disease, as well as human Cushing's disease. In humans, only the pituitary adenoma tissue is resected by TSS. However, in dogs, the whole pituitary including normal tissue is resected. Hence, central diabetes insipidus (CDI) may complicate the postoperative course in almost all dogs with Cushing's disease treated by TSS. However, it is difficult to assess the duration of the postoperative CDI, and whether it may be transient or permanent. In this study, postoperative CDI in 21 dogs with Cushing's disease and its predicted prognosis by preoperative parameters was investigated. In this study, CDI after TSS was classified as either transient or permanent based on the requirement for desmopressin. Preoperative circulating serum cortisol concentrations and pre- and post-operative plasma AVP concentrations were not significantly different between the transient CDI dogs and permanent CDI dogs. The duration of postoperative CDI was not correlated to the signal intensity ratio (posterior lobe of the pituitary/cerebral cortex), which is obtained from preoperative magnetic resonance imaging (MRI). However, the pituitary height/brain area (P/B) ratio of the permanent CDI dogs was significantly greater than that of the transient CDI dogs. In addition, there was a significant difference between the enlarged-pituitary (P/B ratio > 0.31) transient CDI dogs and the permanent CDI dogs. These results suggest that the incidence of postoperative permanent CDI is strongly influenced by the pituitary size.

Intraoperative magnetic resonance imaging-guided transsphenoidal surgery for giant pituitary adenomas

Giant pituitary adenomas (GPAs), defined as >/=40 mm in one extension, present a challenging subgroup of pituitary adenomas in terms of radical tumor removal and complication rates. The potential impact of intraoperative magnetic resonance imaging (iMRI) is investigated in a consecutive series and the results compared to the literature. From November 2004 until February 2005, six (five male) patients were operated for GPAs via an iMRI-guided transsphenoidal approach in the PoleStar N20. Clinical, endocrinological, and neuroradiological outcomes (at 3 months and yearly postoperative over 4 years) were assessed. Mean age was 46 years (range, 34-60). All patients presented with preoperative visual field defects, five with pituitary failure. Five adenomas were clinically nonfunctioning, one was producing GH and TSH. Preoperative imaging showed invasion of the cavernous sinus in all and extension to the interventricular foramen in two patients (one with occlusive hydrocephalus). Resection was total in four and subtotal (small cavernous sinus remnants) in two patients, leading to transsphenoidal reoperation in one patient. Visual acuity and fields improved in all six patients. The patient with occlusive hydrocephalus developed a postoperative cerebrospinal fluid leak (subsequently revised), two patients developed temporary, one permanent central diabetes insipidus, and one of them transient hyponatremia. Compared to the preoperative situation, endocrine status in the long-term follow-up (mean, 25 months) remained unchanged in four and worsened in two. Two patients were considered not to require hormone replacement therapy. IMRI supports transsphenoidal resections of GPAs because residual adenoma and related risk structures are easily detected and localized intraoperatively, extending the restricted visual access of the microscope beyond mere surface anatomy to a three-dimensional view. More radical removal of adenomas in a single surgical session combined with low complication rates are accomplished. This may add to a favorable clinical and endocrinological outcome in GPAs.

Permanent Central Diabetes Insipidus with Complete Regression of Pituitary Stalk Enlargement After 4 Years of Follow-up

A 14 year−old patient was admitted because of a history of polyuria and polydipsia. A diagnosis of central diabetes insipidus (CDI) accompanied by growth hormone (GH) and gonadotropin deficiency was made. Hypophyseal magnetic resonance imaging (MRI) of the patient demonstrated isolated pituitary stalk enlargement. Although GH deficiency and gonadotropin deficiency were transient, CDI was persistent despite the regression of the pituitary stalk enlargement over the 4 years of follow−up.Conflict of interest:None declared.

Central diabetes insipidus: A complication of ventriculoperitoneal shunt malfunction during pregnancy

During pregnancy ventriculoperitoneal shunts have reported complication rates of 30% to 60%. In this case a functionally occluded shunt resulted in prolonged increased intracranial pressure, pituitary stalk damage, and permanent central diabetes insipidus. This complication of ventriculoperitoneal shunt occlusion during pregnancy has not been previously reported. (A M J O BSTET G YNECOL 1996;174:1655-7.)