Stalk Lesions Research Articles

Long term observation of patients with pituitary stalk lesions - single center experience

Long term observation of patients with pituitary stalk lesions - single center experience

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.

SAT-445 Pituitary Stalk Lesions: Difficult to Identify with Varied Clinical, Biochemical, and Radiological Presentations

Background: Pituitary stalk connects the hypothalamus and pituitary. It measures 1.9-3.5mm with a mean value of around 1.5 mm. Detection of such lesions upon MR imaging therefore requires an experienced neuro-radiologist. Etiologies can include autoimmune causes like lymphocytic hypophysitis or granulomatous disorders such as sarcoidosis, neoplastic lesions like germinomas and others. These conditions are relatively rare with poorly understood clinical presentations and can be very challenging diagnostically. Objectives: To study the clinical presentation, imaging and endocrine abnormalities in patients presenting with apparent pituitary stalk lesions to a tertiary endocrine clinic in the UK. Materials and methods: We conducted a retrospective case notes review of patients referred with pituitary stalk lesions who attended the Joint Pituitary clinic between 2010 and 2018.Results: 73 cases with Pituitary stalk lesion were identified by initial MRI generalist radiologist reporting. 60 patients were diagnosed as Rathke’s cleft cyst by the pituitary MDT. The other 13 cases (7 males) had median age of 50 (range 32-85) years at diagnosis. Median size of Pituitary stalk lesions on MRI scans was 7 mm (range 2mm to 30mm). Five patients (38%) had associated pituitary gland abnormalities (3 bulky pituitary, 2 adenomas). Five cases (38%) presented with polyuria and polydypsia, 2 patients (15%) with fatigue and 1 patient with galactorrhea as the main symptoms while 4 cases (31%) were identified during MR scans done to evaluate headaches. 11 (85%) cases had an endocrine abnormality. Eight patients (62%) were identified to have cranial diabetes insipidus (CDI) on its own or in combination with other endocrine anomalies which included three cases (23%) with panhypopituitarism and three other cases with partial anterior pituitary hypofunction. Of the ten patients who had an IST/GST performed, nine (90%) had Growth hormone deficiency and four (30%) had cortisol deficiency. Three patients (23%) had only partial anterior pituitary hypofunction without CDI. Four cases (30%) had hyperprolactinemia in combination with cranial diabetes insipidus or partial anterior pituitary hypofunction. Two patients(15%) had biopsies of the lesions (one germinoma and one granular cell lesion). On radiological grounds, one patient was thought to have a meningioma, two lymphocytic hypophysitis and one felt to have an epidermoid cyst. Conclusions: Most Pituitary stalk lesions referred to the pituitary MDT are actually misreported Rathkes cleft cysts. Pituitary stalk lesions can present with multiple endocrine abnormalities, the commonest being Growth hormone deficiency and cranial diabetes insipidus. A high index of suspicion is needed during radiological evaluation of such presentations. An IST/GST should be performed in all cases of pituitary stalk lesions.

Abstract #498 Long-Term Follow-Up in a Series of Pituitary Stalk Lesions

Abstract #498 Long-Term Follow-Up in a Series of Pituitary Stalk Lesions

Single center study of 53 consecutive patients with pituitary stalk lesions.

The etiological spectrum of pituitary stalk lesions (PSL) is wide and yet specific compared to the other diseases of the sellar and suprasellar region. Because of the pituitary stalk's (PS) critical location and role, biopsies of these lesions are rarely performed, and their underlying pathology is often a conundrum for clinicians. A pituitary MRI in association with a clinical context can facilitate their diagnosis. To present the various causes of PSL-their clinical, hormonal, histopathological, and MRI characteristics in order to gain better insight into this pathology. A retrospective observational study consisting of 53 consecutive patients with PSL of the mean age 32 ± 4.2years (range 6-67), conducted at the Department for Neuroendocrinology, Clinical Center of Serbia 2010-2018. Congenital malformations were the most common cause of PSL in 25 of 53 patients (47.1%), followed by inflammatory (9/53; 16.9%) and neoplastic lesions (9/53; 16.9%). The exact cause of PSL was established in 31 (58.4%) patients, of whom 23 were with congenital PS abnormalities and 8 with histopathology of PSL (7 neoplastic and 1 Langerhans Cell Hystiocytosis). A probable diagnosis of PSL was stated in 12 patients (22.6%): 6 with lymphocytic panhypophysitis, while Rathke cleft cyst, tuberculosis, dissemination of malignancy in PS were each diagnosed in 2 patients. In 10 patients (18.8%), the etiology of PSL remained unknown. Due to the inability of establishing an exact diagnosis, the management and prognosis of PSL are difficult in many patients. By presenting a wide array of causes implicated in this condition, we believe that our study can aid clinicians in the challenging cases of this pathology.

Functional ectopic neural lobe increases GAP-43 expression via PI3K/AKT pathways to alleviate central diabetes insipidus after pituitary stalk lesion in rats

Central diabetes insipidus can occur after hypothalamic-hypophyseal tract injury. This injury is linked with a deficit in circulating vasopressin and oxytocin, which are produced in the supraoptic nuclei and the hypothalamic paraventricular nuclei. Previous studies indicate that an ectopic neural lobe forms after pituitary stalk lesion in rats, and while the relationship between an ectopic neural lobe and CDI outcomes is unclear, the underlying mechanisms are also unknown. Here, we report that two different CDI characteristics are shown in rats that underwent pituitary stalk electric lesion and are defined by two different groups classified as the recovery group and the no-recovery group. Rats showed an enlarged functional ectopic neural lobe at the lesion site with a low CDI index. Moreover, growth associated protein-43, p-PI3K and p-AKT were up-regulated in the unmyelinated fibers of the ectopic neural lobe. Our findings suggest that the enlarged structure formed a functional ectopic neural lobe after the pituitary stalk lesion, and its regeneration might influence the CDI outcome. This regeneration might be due to an increase in GAP-43 expression through the PI3K/AKT pathway.

Joint approach based on clinical and imaging features to distinguish non-neoplastic from neoplastic pituitary stalk lesions.

PurposeDistinguishing non-neoplastic pituitary stalk lesions (non-NPSLs) from neoplastic pituitary stalk lesions (NPSLs) is a major concern in guiding treatment for a thickened pituitary stalk. Our study aimed to aid provide preoperative diagnostic assistance by combining clinical and magnetic resonance imaging (MRI) findings to distinguish non-NPSLs from NPSLs.Materials and methodsWe recruited 158 patients with thickened pituitary stalk lesions visible on MRI. Laboratory findings included hypopituitarism, diabetes insipidus (DI), and hyperprolactinemia. MR images were assessed for anterior–posterior thickness (mm), diffuse pituitary stalk thickening, cystic changes, a high T1 signal, and glandular or extrasellar involvement. A diagnostic model was developed using a recursive partitioning logistic regression analysis. The model was validated in an independent dataset comprising 63 patients, and its diagnostic performance was compared with that of the original radiological reports.ResultsA univariate analysis found significant associations of DI (P = 0.006), absence of extrasellar involvement (P = 0.002), and lower stalk thickness (P = 0.031) with non-NPSLs. A diagnostic model was created using the following parameters (in order of priority): 1) lack of extrasellar involvement, 2) stalk thickness < 5.3 mm, and 3) presence of DI. The diagnostic performance (area under the curve; AUC) of this model in the independent set was 0.813, representing a significant improvement over the original radiological reports (AUC: 0.713, P = 0.029).ConclusionThe joint diagnostic approach based on clinical and imaging-based factors robustly distinguished non-NPSLs from NPSLs. This approach could guide treatment strategies and prevent unnecessary surgery in patients with non-NPSL.

Hypothalamic and pituitary stalk lesions in adolescents

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

Pituitary stalk lesions - experience of single center

Pituitary stalk lesions - experience of single center

Modification of surgical procedure for "probable" limited dorsal myeloschisis.

OBJECTIVE Since the entity limited dorsal myeloschisis (LDM) was proposed, numerous confusing clinical cases have been renamed according to the embryopathogenesis. However, clinical application of this label appears to require some clarification with regard to pathology. There have been cases in which all criteria for the diagnosis of LDM were met except for the presence of a neural component in the stalk, an entity the authors call "probable" LDM. The present study was performed to meticulously review these cases and suggest that a modified surgical strategy using limited laminectomy is sufficient to achieve the surgical goal of untethering. METHODS The authors retrospectively reviewed the imaging findings, operative notes, and pathology reports of spinal dysraphism patients with subcutaneous stalk lesions who had presented to their institution between 2010 and 2014. RESULTS Among 33 patients with LDM, 13 had the typical nonsaccular lesions with simple subcutaneous stalks connecting the skin opening to the spinal cord. Four cases had "true" LDM meeting all criteria for diagnosis, including pathological confirmation of CNS tissue by immunohistochemical staining with glial fibrillary acidic protein. There were also 9 cases in which all clinical, imaging, and surgical findings were compatible with LDM, but the "neural" component in the resected stalk was not confirmed. For all the cases, limited exposure of the stalk was done and satisfactory untethering was achieved. CONCLUSIONS One can speculate based on the initial error of embryogenesis that if the entire stalk were traced to the point of insertion on the cord, the neural component would be proven. However, this would require an extended level of laminectomy/laminotomy, which may be unnecessary, at least with regard to the completeness of untethering. Therefore, the authors propose that for some selected cases of LDM, a minimal extent of laminectomy may suffice for untethering, although it may be insufficient for diagnosing a true LDM.

Pituitary Stalk Thickening

Abstract: MRI revealed enlargement of the pituitary stalk in two patients with different clinical presentations. A 60 y/o female had autoimmune hypothyroidism associated with blunted cortisol response to ACTH, while the other, a 30 y/o female had amenorrhea and polyuria with high plasma and low urinary osmolality. Keywords: Pituitary stalk thickening; Hypothyroidism; Adrenal insufficiency; Amenorrhea; Polyuria Case Report: As a result of the advances in imaging technologies, the finding of pituitary stalk lesions presents a diagnostic challenge to clinicians and endocrinologists. They are usually discovered incidentally on magnetic resonance imaging (MRI), or during the investigation of symptoms related to hypothalamic-pituitary dysfunction such as central diabetes insipidus or hypopituitarism. The etiology of these lesions may be congenital/developmental, inflammatory, infectious or neoplastic. Due to its particular location and function, the pituitary stalk is not often biopsied and diagnosis is based generally on clinical evaluation and images Report of two cases Enlargement of the pituitary stalk was found during the endocrine evaluation of two patients with the following clinical presentations. Patient 1: A 64 year old woman was admitted to the emergency room for vomiting and high blood pressure. Otherwise normal, she had been suffering from proximal muscle weakness, fatigue, reduced appetite, cognitive impairment and pre-tibial myxedema during the last two months. The patient denied glucocorticoid intake. Mild hyponatremia (132 mEq/l) and anemia (hct: 30%) were detected. TSH was high (13.74 µU/ml) with low FT4: 0.57ng/dl. Anti-peroxidase antibodies were positive. Serum potassium was normal (4.2 mEq/l). Serum morning cortisol was less than 1.0 µg/dl and ACTH was 6.7 pg/ml and 5.0 pg/ ml in two different occasions. An ACTH stimulating test (Synacthen 250.0 µg, i.m) showed a blunted cortisol response at 30 and 60 min after stimulus, confirming adrenal insufficiency. The remaining pituitary function was normal. MRI showed a thickened pituitary stalk (Figure 1). The patient improved on hydrocortisone and LT4. Patient 2: A 30 year old woman complained of amenorrhea and polyuria (9 L/day). She had high plasma and low urinary osmolality (311 mOsm/kg and 136 mOsm/kg, respectively). Low serum estradiol and gonadotropins were found. Thyroid and adrenal functions were normal. MRI showed a thickened pituitary stalk (Figure 2). She started on desmopressin (0.1 mg/day) which reduced daily diuresis by 60% and lowered plasma osmolality (290 mOsm/day). Additionally she began on estrogen and progestin replacement. Discussion: Pituitary stalk lesions may be found by chance or during the evaluation of endocrine disorders. In a series of 152 patients, the etiologies were attributed to neoplasia in 32%, inflammatory lesions 20%, and congenital anomalies in 9% and in 39% remained unknown [2]. Primary hypophysitis is rare, between 0.2 and 6.5% among pituitary pathologies. Three histopathological types are described in this category: lymphocytic, granulomatous and xanthomatous hypophysitis [3].These conditions are usually confined to the pituitary. In secondary hypophysitis, a systemic disease is the cause of the pituitary lesion: Sarcoidosis, Wegener granulomatosis, Langerhans cell histyocitosis and IgG4 related plasmatic histiocytosis may affect the pituitary. Monoclonal antibodies against the cytotoxic T-lymphocyte antigen-4 (CTLA-4) for treating metastatic cancer, may induce hypophysitis [4,5]. In the setting of immunosuppression, fungal infection, tuberculosis and toxoplasmosis may involve the pituitary gland [4]. Interestingly, these two patients showed different clinical presentations. After excluding secondary etiologies, primary hypophysitis was suspected in both [4]. Although histological confirmation is needed, biopsy of a pituitary stalk lesion is technically demanding, and must be performed by an experienced neurosurgeon. In order to avoid invasive procedures, the approach was based on clinical, biochemical and radiological features. A close follow-up is mandatory to detect new symptoms and to determine if the lesions progress over time.

An unusual pituitary stalk lesion: What is the place of surgery?

BackgroundSellar and suprasellar primary melanocytic tumors are exceptional occurrences. Besides the difficulty of differential diagnosis between a primary and secondary lesion, treatment of these pathologies is still unclear and controversial. Case reportWe describe the case of a 36-year-old woman with no relevant previous medical history who presented with 1 month history of diabetes insipidus, blurred vision and generalized weakness; a brain MRI disclosed an atypical pituitary stalk lesion; initially the tumor was biopsied through an endonasal endoscopic approach that revealed a melanocytic tumor; the patient was afterwards managed by a second stage extended endonasal endoscopic approach achieving a subtotal tumor removal. The overall survival was of 14 months due to the multidisciplinary management including surgery, radio and chemotherapy. ConclusionIf a biopsy is essential to deal with these invasive lesions, treatment including surgical resection should be part of a multidisciplinary approach.

Pituitary stalk thickening: the role of an innovative MRI imaging analysis which may assist in determining clinical management.

Disease processes that affect the pituitary stalk are broad; the diagnosis and management of these lesions remains unclear. The aim was to assess the clinical, biochemical and histopathological characteristics of pituitary stalk lesions and their association with specific MRI features in order to provide diagnostic and prognostic guidance. Retrospective observational study of 36 patients (mean age 37years, range: 4-83) with pituitary stalk thickening evaluated at a university hospital in Oxford, UK, 2007-2015. We reviewed morphology, signal intensity, enhancement and texture appearance at MRI (evaluated with the ImageJ programme), along with clinical, biochemical, histopathological and long-term follow-up data. Diagnosis was considered certain for 22 patients: 46% neoplastic, 32% inflammatory and 22% congenital lesions. In the remaining 14 patients, a diagnosis of a non-neoplastic disorder was assumed on the basis of long-term follow-up (mean 41.3months, range: 12-84). Diabetes insipidus and headache were common features in 47 and 42% at presentation, with secondary hypogonadism the most frequent anterior pituitary defect. Neoplasia was suggested on size criteria or progression with 30% sensitivity. However, textural analysis of MRI scans revealed a significant correlation between the tumour pathology and pituitary stalk heterogeneity in pre- and post-gadolinium T1-weighted images (sensitivity: 88.9%, specificity: 91.7%). New techniques of MRI imaging analysis may identify clinically significant neoplastic lesions, thus directing future therapy. We propose possible textural heterogeneity criteria of the pituitary stalk on pre- and post-gadolinium T1 images with the aim of differentiating between neoplastic and non-neoplastic lesions with a high degree of accuracy.

Stalk Rot Diseases Impact Sweet Sorghum Biofuel Traits

Owing to its sugar-rich stalks and high biomass, sweet sorghum [Sorghum bicolor (L.) Moench] has potential as a source of biofuel feedstock for juice and lignocellulosic-based bioethanol production. However, stalk rot-mediated lodging is an important concern. The potential impacts of disease on sweet sorghum biofuel traits are currently unknown. The objectives of this study were to test the effects of Fusarium stalk rot and charcoal rot on sweet sorghum biofuel traits and to assess the combining ability of the parental genotypes for resistance to the two diseases. Nineteen genotypes including 7 parents and 12 hybrids were tested in the field in 2014 (Ashland, Kansas) and 2015 (Manhattan, Kansas) against Fusarium thapsinum (FT) and Macrophomina phaseolina (MP). Fourteen days after flowering, plants were inoculated with FT and MP. Plants were harvested at 35 days after inoculation and measured for disease severity using stalk lesion length. Grain weight, juice weight, Brix (°Bx), and dried bagasse weight were also determined. Total soluble sugars per plant (TSSP) were determined using juice weight and °Bx. On average, FT and MP resulted in reduced grain weight and dried bagasse weight by 17.4 and 17.6 %, respectively, across genotypes. Depending on the genotype, pathogens reduced juice weight, °Bx, and TSSP in the ranges of 11.3 to 25.9, 0.2 to 16.7, and 21.2 to 33.3 %, respectively. Parental line general and specific combining abilities were found to be statistically insignificant. This study revealed the adverse effects of stalk rot diseases on harvestable biofuel traits and the need to breed sweet sorghum for stalk rot resistance.

Pituitary stalk lesions: systematic review and clinical guidance

The spectrum of pituitary stalk (PS) pathology is vast, presenting a diagnostic challenge. Published large series of PS lesions demonstrate neoplastic conditions are most frequent, followed by inflammatory, infectious and congenital diseases. Inflammatory pathologies however, account for the majority of PS lesions in published small case series and case reports. Physicians must be familiar with the major differential diagnoses and necessary investigations. A comprehensive history and thorough clinical examination is critical. Although magnetic resonance imaging of the PS in disease is nonspecific, associated intracranial features may narrow the differential diagnosis. Initial investigations include basic pathology and computer tomography imaging of the neck, chest, abdomen and pelvis. Further investigations should be guided by the clinical context. PS biopsy should be considered when a diagnosis is regarded essential in centres where an experienced neurosurgeon is available. Treatment is dependent on the underlying disease process and may necessitate pituitary hormone replacement.

Diagnosis and management of tumor-like hypophysitis: A retrospective case series.

Tumor-like hypophysitis is an uncommon sellar condition that presents as inflammatory lesions on the structures of the pituitary gland. The diagnosis and management of hypophysitis poses a significant challenge, as its clinical manifestation and appearance in imaging studies are difficult to distinguish from that of pituitary tumors. The present retrospective study summarizes two rare cases of primary granulomatous hypophysitis, two cases of lymphocytic hypophysitis, and three cases in which a pathological diagnosis was not determined due to the use of hormone replacement therapy only. The mean age of the patients studied was 45.71±22.16 years, and the patients comprised two males and five females. The clinical signs of hypophysitis included headache, fever, gradual decrease in visual acuity, nausea and vomiting. Enhanced magnetic resonance imaging revealed sellar and pituitary stalk lesions, with iso- or hypodense signals on T1-weighted images. Transsphenoidal surgery was performed in three cases. It was challenging to diagnose hypophysitis due to the lack of any significant specific clinical signs. A transsphenoidal biopsy with fast-frozen pathology is able to diagnose hypophysitis. Glucocorticoid therapy may be a potential treatment for hypophysitis, as complete removal of pituitary masses may disable pituitary function.

Pituitary stalk thickening on MRI: when is the best time to re-scan and how long should we continue re-scanning for?

Magnetic resonance imaging (MRI) has proved to be an essential tool in the assessment of pituitary stalk lesions including lymphocytic infundibulo-hypophysitis, Langerhans cell histiocytosis (LCH), germ cell tumours, nongerminomatous germ cell tumours, pituicytomas and other tumours, metastases from lymphoma or breast cancer, Wegener's hypophysitis, neurosarcoidosis and inflammatory infiltrations by infectious diseases. The diagnosis of lesions determining pituitary stalk thickness is challenging, and the identification of the underlying condition may require a long-term follow-up. Thus, clinicians should readily recognize that, when the diagnosis of central diabetes insipidus has been established, specific MRI sequences should be used in the assessment of the hypothalamic-pituitary region, and whole-brain evaluation is recommended. For clinical practice, a timely diagnosis is advisable to avoid central nervous system damage, pituitary defects and the risk of dissemination of germ cell tumours or organ involvement by LCH. Proper aetiological diagnosis can be achieved via a series of steps that start with careful observation of several neuroimaging predictors and endocrine dysfunction and then progress to more sophisticated and advanced imaging techniques.

Surgical biopsies in patients with central diabetes insipidus and thickened pituitary stalks

Thickened pituitary stalks (TPSs) on magnetic resonance imaging (MRI) result from diverse pathologies; therefore, it is essential to make specific diagnoses for clinical decision-making. The diagnoses and indications for surgical biopsies in patients with central diabetes insipidus (CDI) and TPSs are thoroughly discussed in this paper. Thirty-seven patients with CDI and TPSs were retrospectively reviewed. The mean age at the diagnosis of CDI was 29.0 ± 15.9 years (range 8.0-63.3), and the median duration of follow-up was 5.5 ± 2.8 years (range 0.7-13.0). Anterior pituitary hormone deficiencies were documented in 26 (70.3 %) patients. All patients had a TPS on MRI at the diagnosis of CDI, and 21 (56.8 %) patients exhibited radiological changes during the follow-up. Of these 21 patients, 11 exhibited increases in the thickness of the stalk, and two patients exhibited reversals of the TPSs. Involvements of the hypothalamus, pituitary gland, basal ganglia or supersellar, and pineal gland were found in four, three, one, and 1 patient, respectively. Ultimately, clear diagnoses were established in 17 patients who underwent biopsies, nine of whom had germinomas, six of whom had Langerhans cell histiocytosis, one of whom had a granular cell tumor, and one of whom had Erdheim-Chester disease. Patients with CDI and TPSs should submit to periodic clinic follow-ups with serial MRI assessments to establish anterior pituitary deficiencies and to detect radiological progressions that are appropriate for surgical biopsies. Endoscopic-assisted microsurgery via the supraorbital keyhole approach is a good choice for the biopsy of pituitary stalk lesions.

Clinical and radiological features of pituitary stalk lesions in children and adolescents.

PurposeThe diagnosis of pituitary stalk lesion has been based on clinical feature, radiologic assessment for its critical location and role. This study aimed to investigate clinical symptoms, endocrine disturbance, magnetic resonance imaging (MRI) findings of pituitary stalk lesions in children and adolescents and to evaluate differences between neoplastic lesions with the others.MethodsWe performed a retrospective review of patients under 18 years old with pituitary stalk lesions diagnosed at the Seoul National University Children's Hospital between 2000 and 2013, by a text search for head MRI reports by using 'pituitary stalk', 'infundibulum', and 'infundibular stalk', as keywords.ResultsFor the 76 patients, sixteen patients (21.1%) had congenital lesions, and 52 (68.4%) had neoplasms. No inflammatory lesions were found. Diabetes insipidus (DI) was the most common endocrine defect, diagnosed in 38 patients (50%). There was male predominance especially in neoplastic group. Thickened pituitary stalk was, but enhancement of lesion was not, associated with neoplasm. DI was more prevalent in neoplastic stalk lesions. Anterior pituitary dysfunction such as growth hormone and adrenocorticotropic hormone deficiencies were less prevalent in neoplastic lesions of pituitary stalk.ConclusionIn conclusion, the etiology of pituitary stalk lesions in children and adolescents is diverse and different from that in adults. Neoplastic pituitary stalk lesions can be differentiated from nonneoplastic lesions by systemic evaluation of clinical, hormonal, radiological findings.

Pituitary Stalk Lesions: The Mayo Clinic Experience

Pituitary stalk lesions have various etiologies, often not clinically apparent. Pathological samples from these lesions are rarely obtained, because of the critical location and function of the hypophyseal stalk. The purpose of this study was to characterize the etiological spectrum of pituitary stalk lesions seen at Mayo Clinic Rochester over 20 years and to determine whether specific magnetic resonance imaging (MRI) characteristics could provide clinician guidance with regard to the etiology of infundibular lesions. A retrospective review of patients with pituitary stalk lesions seen at Mayo Clinic Rochester between 1987 and 2006 was conducted. Demographic, clinical presentation, imaging, laboratory, operative, and pathology data were reviewed and are reported using descriptive statistics. Of the 152 pituitary stalk lesions included, 49 (32%) were neoplastic, 30 (20%) were inflammatory, 13 (9%) were congenital anomalies, and 60 (39%) were of unclear etiology. Diabetes insipidus was diagnosed in 43 (28%) of the 152 patients, and 49 (32%) patients had at least one anterior pituitary hormone deficit. Secondary hypogonadism was the most common endocrine deficiency. Eleven of 13 congenital lesions were round in appearance and 5 of 7 patients with neurosarcoidosis confirmed by pathology had a uniformly thickened pituitary stalk on MRI. There were no statistically significant correlations between hypopituitarism and the pattern of enhancement or size of the lesion. Findings on MRI remain key in guiding the diagnosis of pituitary stalk lesions, particularly when used in conjunction with other clinical clues. There are no good imaging predictors for hypopituitarism, making clinical evaluation of all patients with pituitary stalk lesions crucial.