Transient Diabetes Insipidus Research Articles

Extended Endoscopic Transsphenoidal Surgery with Total Cyst Wall Decollement for Suprasellar Cystic Craniopharyngioma: Case Report and Literature Review.

For most cystic craniopharyngiomas, intracapsular debulking is a good strategy to get a large operation space and protect vital structures. However, this surgical strategy may lead to the residual and recurrence of the tumor capsule wall. Therefore, there is an urgent need for a new surgical strategy without residual capsule walls for the removal of cystic craniopharyngiomas. We reviewed a 45-year-old male with vision loss and visual field defects, whose head MRI revealed a suprasellar cystic lesion. The patient underwent extended endoscopic transsphenoidal surgery. The surgical strategy of total cystic wall decollement was adopted, which was that the lesion surrounded by the capsule was completely separated from the surrounding tissue without destroying the capsule and maintaining the tension of the capsule. The lesion was totally resected and pathological findings confirmed the diagnosis of craniopharyngioma. After the operation, both the visual acuity and pituitary function were significantly improved. In addition, he suffered from transient diabetes insipidus, which was subsequently relieved. During the 33-month follow-up, there was no tumor recurrence. Compared with the traditional surgical strategy of intracapsular debulking, the surgical strategy of total cystic wall decollement has the advantages of less residual tumor capsules, low tumor recurrence rates, etc. Therefore, for specific cystic craniopharyngiomas, the surgical strategy of total cystic wall decollement may be an effective surgical strategy to reduce tumor recurrence.

Prevalence and Clinical Course of Water and Electrolyte Disturbances Following Transsphenoidal Pituitary Adenoma Surgery in Immediate and Early Postoperative Period: A Prospective Observational Study.

Transsphenoidal pituitary adenoma surgery (TSS) was commonly associated with water and electrolyte disturbances (WEDs) in the postoperative period, which could lead to prolonged hospital stay, readmission and is rarely life threatening. The present study aimed to investigate the prevalence and predictive factors of WEDs following TSS. Fifty-eight patients with pituitary adenoma were prospectively studied for the occurrence of WEDs. Patients were checked at 6 weeks postoperatively for persistence of diabetes insipidus and new-onset hormone deficiencies or recovery. Multivariate regression was applied to determine predictive factors for the occurrence of WEDs. A total of 58 patients underwent TSS (median age: 43 years, 66% male). In the immediate postoperative period, 16 (27.6%) had transient diabetes insipidus (DI), two (3%) had transient DI followed by syndrome of inappropriate antidiuretic hormone (SIADH), five (8.6%) had isolated SIADH, five (8.6%) had persistent DI and only one patient had a triple-phase response. At 6 weeks, five (11%) patients continued to have persistent DI. In multivariate analysis, apoplexy and duration of surgery were predictive of DI occurrence. Recovery rate at 6 weeks was 11.1%, 13% and 9.3% for cortisol, thyroid and gonad axis, respectively. New-onset hormone deficiencies at 6 weeks were 5.6%, 5.6% and 7.4% for cortisol, thyroid and gonad axis, respectively. WEDs remain an important concern post-TSS. Timely follow-up should always be integral part of postoperative care for early diagnosis of new hormone deficiencies and avoiding unnecessary treatment in those with recovered axis.

The Application of Pneumatic Arm in Neuroendoscopic Transsphenoidal Pituitary Adenoma Resection.

To summarize the application experience of the pneumatic arm in transnasal sphenoidal pituitary adenoma resection under neuroendoscope. A retrospective analysis was conducted on the clinical data of 52 patients with pituitary adenoma who underwent endoscopic transsphenoidal surgery with pneumatic arm fixation in the Neurosurgery Department of the First Affiliated Hospital of Anhui Medical University from July 2021 to March 2024. Among them, there were 5 cases of pituitary microadenoma, 35 cases of macroadenoma, and 12 cases of giant adenoma. Head CT and a full set of hormones were re-examined within 24 hours after surgery to evaluate the surgical effect. Follow-up was conducted by the outpatient department after surgery to assess the clinical symptoms, hormone level, and imaging of all patients. Among 52 patients, gross total resection was achieved in 48 cases (92.3%), subtotal resection in 3 cases (5.8%), and partial resection in 1 case (1.9%). Preoperatively, 43 patients had diminished vision, with 40 showing improvement postoperatively, 1 worsening, and 2 having no significant improvement. Thirty-eight patients had headaches preoperatively, and all showed varying degrees of improvement postoperatively. Routine hormone examination within 24 hours after surgery showed that all 20 prolactinoma patients had restored normal hormone levels, 10 of 12 growth hormone-secreting adenoma patients normalized, and 4 of 6 cases of adrenocorticotropic hormone-secreting adenoma immediately relieved after surgery. Postoperative complications included intracranial hematoma in 1 case, cerebrospinal fluid leakage in 2 cases, transient diabetes insipidus in 6 cases, intracranial infection in 1 case, and no death cases. The median follow-up time of 52 patients was 18.6 months (range: 1-32 mo). During the follow-up period, the initial clinical symptoms of all patients improved to varying degrees, and they were able to work and live normally. At the last follow-up, 1 patient had recurrent tumor and 1 patient had progression. Transnasal sphenoidal resection of pituitary adenoma using a pneumatic arm-fixed neuroendoscope allows the operator to perform the surgery with both hands, resulting in satisfactory overall tumor resection and fewer surgical complications. This technique has good clinical value for promotion.

Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent cushing’s disease: safety, feasibility, and success

PurposeThe success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing’s disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients.MethodsA retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission.ResultsAmong the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission.ConclusionRepeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.

In Reply to the Letter to the Editor Regarding “Risk Factors Related to Transient Diabetes Insipidus Development Following Transsphenoidal Pituitary Adenoma Resection: A Multicentric Study”

In Reply to the Letter to the Editor Regarding “Risk Factors Related to Transient Diabetes Insipidus Development Following Transsphenoidal Pituitary Adenoma Resection: A Multicentric Study”

Clinical and radiographic characteristics of patients with non-functioning pituitary adenomas categorized according to their serum prolactin concentration: novel predictors of postoperative transient diabetes insipidus following surgery.

Non-functioning pituitary adenomas (NFPAs) are often associated with hyperprolactinemia, which is known as the "stalk effect". However, the relationships between hyperprolactinemia and the radiographic characteristics of the tumor that affects the pituitary stalk have not been well characterized. We aimed to identify the differences in the clinical and radiographic characteristics of patients with NFPA, with and without hyperprolactinemia. We enrolled 107 patients with NFPA and allocated them to hyperprolactinemia and non-hyperprolactinemia groups using two different cut-off values: (1) the upper limit of the normal reference range, adjusted for sex and menopausal status, and (2) the upper quartile across the cohort, and compared their clinical and radiographic characteristics. These analyses were conducted to clarify the relationship between the "stalk effect" and the postoperative change in antidiuretic hormone secretion. The specific radiographic characteristics of the patients included the presence of a cystic or hemorrhagic tumor and the presence of pituitary stalk deviation, which were more frequent in the patients with hyperprolactinemia. Interestingly, the incidence of postoperative transient diabetes insipidus was statistically significantly higher in the hyperprolactinemia group (≥40 ng/mL) and in the group with radiologic evidence of stalk deviation, which were shown to be independent risk factors on multivariate analysis. The presence of a "stalk effect" was associated with a higher risk of postoperative transient diabetes insipidus, reflecting perioperative pituitary stalk dysfunction following NFPA surgery, especially in patients with serum prolactin concentrations ≥40 ng/mL and radiologic evidence of stalk deviation.

Complications and visual outcomes following surgical resection of pediatric optic pathway/hypothalamic gliomas: a systematic review and meta-analysis.

Pediatric optic pathway/hypothalamic gliomas (OPHG) pose challenges in treatment due to their location and proximity to vital structures. Surgical resection plays a key role in the management of OPHG especially when the tumor exhibits mass effect and causes symptoms. However, data regarding outcomes and complications of surgical resection for OPHG remains heterogenous. The authors performed a systematic review on pediatric OPHG in four databases: PubMed, EMBASE, Cochrane Library, and Google Scholar. We included studies that reported on the visual outcomes and complications of OPHG resection. A meta-analysis was performed and reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 26 retrospective studies were included. Seven hundred ninety-seven pediatric patients with OPHG undergoing surgical resection were examined. A diagnosis of NF1 was confirmed in 9.7%. Gross total resection was achieved in 36.7%. Intraorbital optic pathway gliomas showed a significantly higher gross total resection rate compared to those located in the chiasmatic/hypothalamic region (75.8% vs. 9.6%). Postoperatively, visual acuity improved in 24.6%, remained unchanged in 68.2%, and worsened in 18.2%. Complications included hydrocephalus (35.4%), anterior pituitary dysfunction (19.6%), and transient diabetes insipidus (29%). Tumor progression post-resection occurred in 12.8%, through a mean follow-up of 53.5months. Surgical resection remains an essential strategy for treating symptomatic and large pediatric OPHG and can result in favorable vision outcomes in most patients. Careful patient selection is critical. Patients should be monitored for hydrocephalus development postoperatively and followed up to assess for tumor progression and adjuvant treatment necessity.

MANAGEMENT OF DIABETES INSIPIDUS AFTER SUBLABIAL TRANSSPHENOIDAL HYPOPHYSECTOMY SURGERY

MANAGEMENT OF DIABETES INSIPIDUS AFTER SUBLABIAL TRANSSPHENOIDAL HYPOPHYSECTOMY SURGERY

Role of Copeptin in Predicting Postoperative Hyponatremia and Hypernatremia in Patients Undergoing Endoscopic Pituitary Adenoma Surgery.

Arginine vasopressin (AVP) is an important hormone responsible for maintaining sodium homeostasis after pituitary surgery. The measurement of AVP levels is difficult because of its short half-life (t 1/2 ). Copeptin is a preprohormone of AVP, and it is a more stable peptide, which can be used as surrogate marker for AVP. This study aims to assess the role of copeptin as a predictor of postoperative hyponatremia and hypernatremia in patients undergoing endoscopic pituitary adenoma surgery. This prospective study included 50 patients who underwent endoscopic pituitary adenoma surgery. Serum copeptin levels of these patients were assessed (1) preoperatively (C1), (2) at extubation (C2), and (3) postoperative day 4 (C3). Perioperative data regarding fluid and sodium balance were collected from patients. Statistical analysis was done using the above data. The copeptin values were assessed against the sodium disturbances. 100% of patients who developed transient diabetes insipidus had a relative decrease in C2 from C1 ( P - .0002). 88% of patients who developed early hyponatremia had a relative increase in C2 as compared with C1 ( P < .01). 75% of patients who developed delayed hyponatremia had a relative increase in C3 as compared with C1 ( P = .003). A relative increase or decrease in early change in copeptin (C2-C1) can predict development of early hyponatremia or transient central diabetes insipidus, respectively. A relative increase in delayed change in copeptin (C3-C1) can predict development of delayed hyponatremia.

Protocol-Based Standardized Endocrinological Evaluation of Children With Traumatic Brain Injury: A Quality Improvement Initiative.

Traumatic brain injury (TBI) can disrupt the hypothalamo-pituitary axis, causing neuroendocrine dysfunction. As a third of children can develop post-traumatic hypothalamo-pituitary axis dysfunction (HPAD), a longitudinal follow-up is required in children with TBI. The study comprised a pre-quality improvement (QI) phase (baseline phase) and a QI phase (post-intervention phase). Retrospective data were collected on children with TBI at our hospital during the pre-QI phase of the study to estimate the baseline data on HPAD prevalence and pediatric endocrine referral rate. Guidance protocol for standardizing the pediatric endocrine referral, evaluation, and follow-up of children with TBI was implemented. Prospective data were collected to estimate outcome measures (prevalence of HPAD, rate of initial endocrine consultation and outpatient follow-up) and process measures (protocol adherence rate). Twenty-seven children, aged ≤19 years, were admitted with TBI in the pre-QI phase. The median age was 9 years. Motor vehicle accidents predominated. Thirty percent had limited endocrine evaluation, and 4% had transient cranial diabetes insipidus (DI). The QI phase included 8 children. Demographic data were similar to those in the pre-QI phase. Both outcome and process measures increased to 75% from the pre-QI phase following the protocol implementation. A lower prevalence rate of HPAD in the current cohort may be owing to underevaluation and a smaller sample size. The QI initiative incorporating a guidance protocol-based endocrinological approach to children with TBI improved the pediatric endocrinology referral and follow-up rates.

Pediatric sellar teratoma – Case report and review of the literature

BackgroundIntracranial teratoma represents a rare neoplasm, occurring predominantly during childhood. Characteristic symptoms depend on the location but are mainly hydrocephalus, visual disturbances, hypopituitarism, and diabetes insipidus. Initial diagnosis can be challenging due to similar radiological features in both teratomas and other lesions such as craniopharyngiomas. Gross total resection is recommended if feasible and associated with a good prognosis.Case descriptionA 10-year-old girl presented with newly diagnosed growth retardation, fatigue, cephalgia and bilateral hemianopia. Further laboratory analysis confirmed central hypothyroidism and hypercortisolism. Cranial magnetic resonance imaging showed a cystic space-occupying lesion in the sellar and suprasellar compartment with compression of the optic chiasm without hydrocephalus present, suspicious of craniopharyngioma. Subsequently, an endonasal endoscopic transsphenoidal near-total tumor resection with decompression of the optic chiasm was performed. During postoperative recovery the patient developed transient diabetes insipidus, the bilateral hemianopia remained unchanged. The patient could be discharged in a stable condition, while hormone replacement for multiple pituitary hormone deficiency was required. Surprisingly, histopathology revealed conspicuous areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma.ConclusionsWe present an extremely rare case of pediatric sellar teratoma originating from the pituitary gland and a review of literature focusing on the variation in presentation and treatment. Sellar teratomas are often mistaken for craniopharyngioma due to their similar radiographic appearances. However, the primary goal of treatment for both pathologies is to decompress eloquent surrounding structures such as the optic tract, and if applicable, resolution of hydrocephalus while avoiding damage to the pituitary stalk and especially the hypothalamic structures. If feasible, the aim of surgery should be gross total resection.

P-62 Silent Corticotroph Adenoma or Cyclic Cushing's Syndrome?

Abstract Introduction Silent corticotroph adenomas (pituitary neuroendocrine tumours (PitNET)) are a rare subset of nonfunctioning adenomas. The higher aggressiveness in terms of invasion and recurrence make these tumors dangerous and close follow-up in experienced centers is recommended. Clinical Case A 21-year-old obeseo (Body Mass Index:31.71) male patient unable to lose weight and complaining of headaches was referred to the Department of Neurosurgery for a pituitary macroadenoma. He had previously used liraglutide treatment Many purple striae were also seen on the body of the patient, who stated that his wounds did not heal easily. Visual acuity and visual field were normal. There was no neurodeficiency. Endocrinological evaluation revealed that the tumor was nonfunctioning (Table 1). Magnetic resonance imaging of the pituitary gland showed a mass lesion in the right side of the pituitary gland extending to the suprasellar and parasellar area (Knosp grade II) (Fig.1). The tumor with soft consistency was totally removed by endoscopic binostril transsphenoidal approach. The postoperative cortisol was 11.53 µg/dl (6.02-18.4) and free T4 was 1.32 ng/dL (0.93-1.7). The patient had a transient diabetes insipidus in the postoperative course, and he was discharged on the 4th day after surgery. Pathological examination revealed a pituitary adenoma immunostaining diffusely with ACTH, other hormones were unexpressed. Ki-67 was %2. Histological invasion of the dura was noted. Although the patient was clinically overweight and had purple striae suggestive of Cushing's syndrome (CS), his cortisol and ACTH levels were normal and suppressible with 1 mg dexamethasone suppression test. However, his tumour tissue showed diffuse ACTH expression, which led to the diagnosis of a silent ACTH adenoma. Since the clinical findings were not completely silent, could we assume that he suffered from cyclic CS? Cyclic (intermittent or periodic) CS is a condition characterised by alternating periods of transiently elevated cortisol levels followed by normal to reduced levels. The diagnosis of cyclic CS requires the presence of at least three confirmed episodes of elevated cortisol levels interspersed with two periods of normal cortisol levels. As we know, the cortisol secretion cycle is unpredictable and laboratory tests during the normal cortisol secretion period of the cyclic CS often show negative results as in our patient. Conclusion Postoperative follow-up of a silent corticotroph PitNET and cyclic CS patient, both of whom require close and life-long monitoring.Figure 1.Magnetic resonance imaging of the pituitary gland; coronal sections T1- weighted (a), T2-weighted (b), sagittal (c), and coronal (d) sections with T1 contrast enhancement. The mass lesion on the right side of the pituitary gland extending superiorly to the right internal carotid artery contains a hemorrhagic fluid component with heterogeneous contrast enhancement, is 16*12*9 mm in size, and corresponds to a hemorrhagic pituitary macroadenoma. Table 1.Hormonal values at presentationACTH, adrenocorticotropic hormone; DST, dexamethasone suppression test; fT4, free thyroxine; IGF-1, insulin-like growth factor 1; PRL, prolactin; TSH, thyroid-stimulating hormone.

Retrospective analysis of the outcomes of endoscopic transsphenoidal surgery for Cushing's disease.

The first-line surgical management of an adrenocorticotropic hormone (ACTH)--secreting pituitary adenoma causing Cushing's disease (CD) is endoscopic transsphenoidal resection of the tumor. This study was performed to assess postoperative (postop) complications and remission in endoscopic surgically resected cases of CD. Data of patients who underwent endoscopic transsphenoidal surgery (ETSS) for CD were collected from the neurosurgery department at a tertiary care center in a retrospective manner from January 2015 to February 2022 and analyzed. Postoperative remission was categorized as - early morning serum cortisol <138 nmol/L within 7 days of the surgery, as per the Endocrine Society Guidelines, with significant clinical improvement in features of hypercortisolism in the operated patient and strict cutoff rate of <50 nmol/L at postop day 3 was also utilized, to look for the early identification of remission. A total of 41 patients were identified who underwent 44 ETSS during the same timeframe. Preoperative magnetic resonance imaging localized an adenoma in all 41 patients, out of which 32 were microadenoma, and nine were macroadenoma (2 with cavernous sinus invasion). Intrapetrosal sinus sampling was performed in 35 (85%) patients. The rate of remission for the initial surgery was 85.4% using the standard criteria and 68.3% using strict criteria. Three patients underwent early repeat surgery for the persistent disease as the day 3 cortisol was high (306-555 nmol/L). Once the outcome of this surgery was also included, the overall rate of remission was 90.2% (37/41). None of the patients had meningitis, cerebrospinal fluid leakage, visual deterioration, or vascular injury. Permanent and transient diabetes insipidus (DI) occurred in 9.75% and 26.8% following the first ETSS, respectively. We also noted a single case of CD recurrence in 9 months during the total follow-up period of 84 months. ETSS has satisfactory rates of remission for the primary treatment of CD, with rates being higher for microadenomas. A long follow-up period is needed to assess the rates of recurrence. Patients must be counseled regarding the risk of postop DI, whether transient or permanent, as a possible complication.

Diabetes Insipidus: Types, Diagnosis and Management

Diabetes insipidus (DI) is an acquired or hereditary water imbalance disorder characterized by polydipsia and polyuria. It is a condition that involves the excretion of dilute urine in large volumes. The illness can strike at any age, with males and females have identical rates of occurrence of the disease. The two main mechanisms responsible for diabetes insipidus are either insufficient release or production of ADH (antidiuretic hormone) from the hypothalamus (central diabetes insipidus) or ADH resistance in which the kidneys are unable to respond to ADH (nephrogenic diabetes insipidus). Another form of DI is transient diabetes insipidus commonly known as gestational diabetes insipidus that occurs in the second/third trimester of pregnancy due to increased levels of placental vasopressinase that occurs progressively during pregnancy and increases metabolic clearance of vasopressin. The fourth type of DI is primary polydipsia, characterized by elevated levels of water intake that physiologically lower vasopressin and may be psychogenic, iatrogenic or dipsogenic. Signs and symptoms of DI often include water electrolyte-imbalance, excessive or severe thirst, frequent and excessive urination, fatigue, dehydration, and weight loss. Diabetes insipidus (DI) should be distinguished from primary polydipsia, and whether it is caused by a central, nephrogenic, or gestational cause. This distinction is critical since incorrect treatment can result in serious repercussions. Diagnosis of DI includes measurement of plasma sodium and osmolality, baseline copeptin, hypertonic saline stimulation and arginine stimulation test. The treatment for DI includes the use of drugs such as desmopressin, thiazide diuretics, indomethacin and amiloride.

Management of pituitary adenoma: Preliminary experience with endoscopic endonasal transphenoidal surgery in a developing country. Example of Senegal about 180 cases

IntroductionEndoscopic endonasal transsphenoidal surgery is currently the gold-standard therapeutic approach for pituitary adenomas. Although being spread worldwide, the endoscopic endonasal approach for pituitary adenomas is recently implemented in Senegal.This study aimed to report our results and the complications observed in the context of an under-equipped facility. Materials and methodsWe conducted a retrospective study including all patients with a pituitary adenoma treated who underwent endonasal transsphenoidal resection under a single endoscopic approach from January 2014 to May 2022, in the Neurosurgery Department of Fann National Hospital Centre, Dakar. All patients were assessed according to clinical, radiological, and endocrinological criteria. They all were operated by the same team with an average follow-up of 24 months. ResultsIn this series of 180 patients, including 57.7 % women and 42.3% men with a mean age of 44.8 years (extremes of 18 and 76 years), the visual deficit was the most frequent onset symptom (69.4 %), followed by clinical forms of hormone hypersecretion (30.5 %). Twelve cases of pituitary apoplexy and 1 case of incidentaloma were reported. The most frequent tumors were non-functional tumors (61.6 %). Among the functional adenomas, the most frequent was prolactinoma (15.5 %). Regarding tumor size, 75 % were macroadenomas, 15.5 % were microadenomas, and 9.5 % were giants. Cavernous sinus invasion (Knosp grade ≥ 3) and suprasellar extension were noted in 14.4 % and 53.3 %, respectively. The resection was total in 80 % of cases, subtotal in 18.8 %, and partial in 1.2 %. Partial improvement of sight was observed in 91.1% and endocrine hypersecretion remission in 76.6 %. As for complications, the most frequent was transient diabetes insipidus (32.7 %). ConclusionDespite the scanty resources, our results are similar to the best-reported series and strengthen scientific evidence on the efficacy and safety of performing this technique in an under-equipped setting context.

Effectiveness of endoscopic endonasal surgery for pituitary apoplexy: A comprehensive evaluation of presentation and clinical outcomes from a tertiary care center

BackgroundThe management of pituitary apoplexy (PA) is under debate. Therefore, we studied the clinical manifestations and neuroendocrine outcomes of PA after surgical management, as well as the efficacy and safety of the endoscopic endonasal transsphenoidal approach (EETA). MethodsThis retrospective study was conducted between January 2013 and May 2021, and included 62 cases of pituitary adenoma apoplexy that were managed with EETA. ResultsData from 62 patients were analyzed with a mean age of 50.7 ± 10.9 years, 90.3 % of whom were female. On admission, most patients presented with abrupt onset severe headache and vomiting, associated with endocrine dysfunction in 43.5 % and deteriorated visual acuity in 92 %. Third nerve palsy was the most noted ocular nerve palsy. After using EETA, the adenoma was resected totally, subtotally, and partially in 59.7 %, 29 %, and 11.3 % of the cases, respectively. Postoperative improvement in visual acuity was achieved in 90.3 % of patients, unchanged in 6.5 % with vision defects, and deteriorated in 3.2 %. Endocrine dysfunction improved to 19.3 % after being 43.5 %. Six patients (9.6 %) experienced transient diabetes insipidus (DI) that responded completely to desmopressin therapy for a time, and three cases were complicated with CSF leakage after the operation, but it resolved completely. No intracranial infection, carotid artery injury, or death occurred. ConclusionDespite the availability of alternative treatment options, the surgical intervention by EETA remains the most effective and reliable method for managing patients with PA who present with sudden visual or endocrine symptoms. EETA has been shown to result in significant improvements in both visual and endocrine function, with an acceptable complication rate that can be managed effectively in many cases. As such, EETA continues to represent the cornerstone in the management of PA and should be considered the first-line treatment option for amenable patients.

Healthcare disparities in pituitary surgery: a systematic review.

Pituitary surgery is a frequent neurosurgical procedure for the management of pituitary adenomas, but little research has been done on the impact of healthcare disparities on surgical results. Healthcare inequity/disparity in terms of race and socioeconomic status (SES), in addition to age and gender, was evaluated in this study to see if they affect the results of pituitary surgery. A systematic literature search was carried out utilizing the MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic databases from conception to 2023. The Newcastle-Ottawa Scale was used for quality assessment of the included studies. Twenty-one studies yielded a total of 381,643 patients, and removal of the studies with temporal overlap resulted in 134,832 patients with a mean ± SD age of 51.52 ± 0.41 years. Based on the available data, 46.63% of patients were male. Black patients were more likely to be recommended against surgery, while Asian or Pacific Islander patients were more likely to be recommended for surgery. Postoperative course and outcome showed mixed results, with some studies reporting higher rates of transient diabetes insipidus and stroke in racial minority populations. Private hospitals admitted more White patients, and certain racial groups had reduced access to high-volume centers. SES disparities were assessed in terms of insurance and income. Patients with government insurance or without insurance were more likely to be recommended active surveillance instead of definitive treatment. Furthermore, high SES was associated with a higher likelihood of receiving surgical treatment, better treatment outcomes, and better access to high-volume centers. In terms of age and gender disparity, older patients and females were less likely to be recommended for surgical treatment. Age and gender did not consistently impact postoperative course and treatment outcomes, with varying results across studies. No significant age and gender disparities were observed in hospital admissions and charges. This study revealed the presence of disparities in pituitary adenoma surgery based on race, SES, age, and gender. These disparities highlight the need for further research and interventions to ensure equitable access to appropriate surgical treatment and improved outcomes for all patients with pituitary adenomas.

OTHER-15 ENDOSCOPIC SURGERY FOR PATHOLOGIES OF SKULL BASE: ABOUT A SERIES OF CASES

Abstract INTRODUCTION Transsphenoidal endoscopic surgery (TS) is currently the reference method for the treatment of pathologies affecting the sellar region. It is a relatively safe technique, with low per and postoperative morbidity. We report through this retrospective study the experience of the neurosurgery department of the HSR in this field. PATIENTS AND METHODS We have collected the records of 176 patients operated endoscopically (TS), since the advent of the technique in the service in January 2016 until March 2022. Epidemiological, radiological and endocrine clinical data were analyzed by jamovi software version 1.6. RESULTS Over 6 years, 176 interventions were performed endoscopically transsphenoidal, these were 66 men and 110 women sex ratio = 1.66. The average age at surgery was estimated at 42 years. Several pathologies were treated by TS route, namely: pituitary adenoma (80%), and the other pathologies were divided between meningiomas; craniopharyngiomas; chordomas; pituitary abscess and OMB. Symptoms were dominated by: intracranial hypertension syndrome, optochiasmatic syndrome, endocrine syndrome. The diagnosis was based on imaging all our patients benefited from an injected brain MRI, as well as the anatomo-pathological examination the endocrine balance was disrupted in 9 patients (5.3%) Postoperative follow-up was favorable in 128 patients (75%),15 patients required revision surgery, 8 patients developed transient or prolonged diabetes Insipidus (4%), 5 cases of rhinorrhea (2%), 11 patients had meningitis (6%), new pituitary deficiency constituted 3.20%, hemorrhages and Epistaxis found in 6% of patients, no cases of ophthalmic complication were reported, deploring the death of 2 patients postoperatively. CONCLUSION The usage of Endoscopic Surgery (TS) in our department is the result of several efforts developed by different generations of neurosurgeons. Currently we operate about thirty patients per year by adopting this technique, with a significant reduction in hospitalization days as well as complications.

FRI349 Atypical Timing: Transient Diabetes Insipidus After Pituitary Apoplexy

Abstract Disclosure: I.A. Rivera Nazario: None. A.M. Santiago Carrion: None. M.T. Torres: None. A. Figueroa Cruz: None. Y. Ortiz: None. A. Aponte Velez: None. A. Vazquez: None. E.J. Sola Sanchez: None. M.M. Mangual Garcia: None. Pituitary apoplexy results from acute hemorrhage or infarction of the pituitary gland. Also, an adenoma that can develop transient or permanent pituitary hormone deficiency. Posterior pituitary function is nearly always preserved due to alternate blood supply. Most cases presenting among the fifth or sixth decade. Few cases of transient Diabetes Insipidus (DI) have been described in literature, approximately 4% of patients, making this an uncommon complication of this condition. Hereby, we describe a young male with sudden onset headache due to pituitary apoplexy with transient DI. A 33-year-old man without past medical history, presented to the emergency room with the chief complain of sudden severe headache. Physical examination without altered consciousness, visual impairment or meningeal irritation. Initial head CT was negative, except for findings of muscle spasms. Patient was discharged home with muscle relaxant and NSAIDs. Ten days later, patient continued with worsening headache, not responding to medical therapy. On reevaluation, brain MRI identified a pituitary macroadenoma, measuring 2.2 cm, with mass effect, suprasellar extension impinging the pituitary stalk, prechiasmatic optic nerves and cavernous sinus extension. Blood tests showed Na 139 mEq/L, K 4.1 mmol/L and adequate renal function. Pituitary function test consistent for hypopituitarism with free T4 0.39 ng/dL, TSH 0.084 mIU/mL, cortisol 0.19 mcg/dL, ACTH 9.39 ng/mL, GH &amp;lt;0.1 ng/mL, IGF-1 22.8 ng/mL and prolactin 1.52 ng/mL; except normal FSH, LH and testosterone levels. After four months of apoplectic episode, he developed polyuria and polydipsia. Brain MRI with residual sellar mass of 1.2 cm with resolution of mass effect. Visual field charting was normal. Blood tests showed Na 139 mEq/L, K 4.1 mmol/L and adequate renal function. Started on hydrocortisone and levothyroxine replacement. Diagnosis of DI was suspected, but he refused water deprivation test or DDAVP therapy. During follow-up, patient was found with serum osmolality 288 mOsm/kg, urine osmolality 202 mOsm/kg and 4.6 L 24-hour urine collection. Three months later serum osmolality was 294 mOsm/kg, urine osmolality of 383 mOsm/kg with resolution of polyuria and polydipsia. This case presents a delayed onset of transient DI treated in a conservative way. In documented cases average onset was a period of 2 weeks with resolution in 2 months. Etiology most likely due to compression or destruction of the pituitary gland or stalk impeding transit of ADH from hypothalamus to the neurohypophysis. Transient impairment of the ADH secretion is rare in pituitary apoplexy deserving evaluation in this clinical scenario. When seen, it has been related to glucocorticoid use. This is an example of an atypical pituitary disorder requiring prompt recognition to prevent further complications. Presentation: Friday, June 16, 2023

FRI350 Prolonged Transient Central Diabetes Insipidus Induced By Traumatic Brain Injury

Abstract Disclosure: R. Marques: None. S. Sharma: None. B.S. Flores Chang: None. A. Sajan: None. Introduction: Central diabetes insipidus (CDI) is a rare complication of traumatic brain injury (TBI). Most cases of CDI due to TBI are transient and resolve within 2-5 days. We report a patient with prolonged transient CDI which lasted for 35 days after sustaining a gunshot wound to the head. Case Description: A 17-year-old male with no past medical history presented after gunshot wound in the head. He had comminuted fractures of the right temporal bone, right zygomatic arch, greater and lesser rings of sphenoid bone, right maxillary sinus, right medial orbital wall, right orbital floor and bilateral frontal sinuses. A computerized tomography of head showed subarachnoid haemorrhage of the frontal lobes as well as subdural haemorrhage of right parietal lobe, right falx cerebri and left cerebral hemisphere. On hospital day 2, he had an intracranial pressure monitor placed which was unremarkable. He underwent right hemicraniectomy with debridement and washout on hospital day 3. Shortly afterwards, his urine output increased to &amp;gt;500 cc/hr with serum sodium of 172 mEq/L [135-145], serum osmolality 307 mOsmol/kg [270-295], and urine osmolality of 117 mOsm/kg [300-900]; consistent with CDI. He was acutely treated with intravenous desmopressin with resolution of hypernatremia. During the next five weeks of his 3-month hospitalization, he continued to have polyuria with specific gravity as low as 1.003 [1.005-1.030], and occasional hypernatremia, with a peak serum sodium of 150 mEq/L. Intranasal desmopressin as well as free water supplementation were given daily to alleviate his polyuria and hypernatremia. Evaluation of anterior pituitary function was normal except for decreased gonadotrophins. His polyuria resolved after five weeks, and labs showed urine osmolality of 530 mOsm/kg with serum sodium 138 mEq/L and urine specific gravity 1.010, consistent with resolution of CDI. Intranasal desmopressin was discontinued. His serum sodium remained stable without desmopressin for the next 7 weeks with serum sodium at discharge of 141 mEq/L. Discussion: The damage of the hypothalamic vasopressin-producing neurons, their axons or the posterior pituitary results in permanent post-TBI CDI. In cases of transient CDI, the pathogenesis is likely related to small vessel damage or inflammatory edema rather than direct neuronal damage. In our case, the patient initially developed hypernatremia and polyuria from acute CDI due to hemicraniectomy with debridement and washout. He continued to have prolonged transient CDI due to the extensive intracranial hemorrhage and edema. The CDI resolved with desmopressin (both intravenous and intranasal) and fluid replacement. Transient CDI is a rare complication intracranial haemorrhage. Our case highlights that the severity of TBI may correlate with the duration of transient CDI. Presentation: Friday, June 16, 2023