Panhypopituitarism caused by a suprasellar germinoma: A case report

BACKGROUND Suprasellar germinomas are rare intracranial tumors frequently associated with permanent endocrine disorders.We present the clinical picture,treatment,and complications of suprasellar germinoma at pediatric age which,besides being lifethreatening,has lifelong endocrinological consequences.CASE SUMMARY A 12-year-old female patient was presented having had intensive headaches for three weeks and visual disturbances for six months.An ophthalmological examination revealed bilateral papilledema and a marked loss of vision.Emergency brain magnetic resonance imaging(MRI)showed a suprasellar tumor,involving the infundibulum and the optic chiasm,extending to the third ventricle.Laboratory tests confirmed decreased levels of thyroxine,cortisol,gonadotropins,and insulin-like growth factor 1.Maximal tumor reduction was performed,and immunohistopathology established the diagnosis of suprasellar germinoma.MRI of the spine and cerebrospinal fluid cytology confirmed the localized disease.Adjuvant chemotherapy and radiotherapy were performed according to the SIOP CNS GCT II protocol.A post-treatment MRI showed no residual tumor,but pituitary function had not recovered.Three and a half years after the end of the treatment,the patient is in a complete remission,requiring hormonal replacement therapy,continuous education,and psychological support.CONCLUSION This complex case highlights the importance of timely diagnosis,a multidisciplinary approach,and close follow-up in children with suprasellar germinomas.

Emergency irradiation with 3.4 Gy/2f in sellar/suprasellar germinoma patients with rapid visual acuity decline

Background: Rapid visual acuity (VA) decline was a common complaint in patients with sellar/suprasellar germinoma. In our hospital, 3.4 Gy/2f of emergency irradiation was applied to save patient VA and enable subsequent chemoradiotherapy. This study aimed to investigate the efficacy of emergency irradiation with 3.4 Gy/2f in patients with sellar/suprasellar germinoma who had rapid VA decline. Methods: From January 2014 to December 2017, 33 patients with sellar/suprasellar germinoma who complained of VA decline within 3 months received 3.4 Gy/2f of emergency irradiation in Beijing Tiantan Hospital. The best-corrected VA (BCVA) and mean deviation (MD) were measured. Correlations between visual function change and clinical factors, including age at diagnosis, duration of VA decline, extent of tumor regression, serum level of tumor markers, were analyzed. Results: Among 33 patients with sellar/suprasellar germinoma, the median diameter and volume of sellar/suprasellar lesions were 32 mm (range: 5–55 mm) and 12.9 cm3 (range 0.6–58.5 cm3), respectively. Data on pre- and post-emergency-irradiation BCVA were obtained in 32 patients. For the right eyes, BCVA was improved in 23 patients (71.9%), unchanged in 7 (21.9%), and worsened in 2 (6.2%);and for the left eyes, these numbers were 27 (84.4%), 4 (12.5%), and 1 (3.1%), respectively. In terms of the logarithm of the minimum angle of resolution (logarithm of the minimum angle of resolution = Log (1/BCVA) score, the improvement was significant in both eyes (P < 0.001). In terms of MD, six patients had paired data and the improvement was marginal in the right eyes (P = 0.068) and significant in the left eyes (P = 0.043). However, no clinical factor was found to have correlation with visual function improvement. Conclusion: In sellar/suprasellar germinoma patients with VA decline, 3.4 Gy/2f of emergency irradiation was effective in improving visual function.

Suprasellar cistern tuberculoma presenting as unilateral ocular motility disorder and ptosis:A case report

BACKGROUND Intracranial tuberculoma is a rare and serious type of tuberculosis,which mostly occurs in the frontoparietal and cerebellar hemispheres,with predominance in the gray-white matter junction area,while tuberculomas only in the cistern are extremely rare with only a few reported cases in the literature.We describe a unique case of isolated tuberculoma in the suprasellar cistern,with only right ocular motility disorder and upper eyelid ptosis.CASE SUMMARY A 5-year-old boy without any medical history presented with right ocular motility disorder and upper eyelid ptosis one month ago.He had no history of fever,headache,vomiting,convulsions,or limb weakness.Neurological examination showed right third cranial nerve palsy with restrictions of eye movements and ptosis,pupil dilation and negative light reflex.Imaging suggested a spaceoccupying lesion in the suprasellar cistern with calcification and ring-enhancement.Moreover,no Mycobacterium tuberculosis was found in cerebrospinal fluid by polymerase chain reaction(PCR).The lesion was initially diagnosed as a tumor,while postoperative pathology combined with PCR indicated tuberculoma.The patient continued postoperative anti-tuberculosis treatment.At present,the patient's condition is stable and the symptoms are partially relieved compared with those before surgery.CONCLUSION This case confirmed that isolated intracranial tuberculoma can occur in the suprasellar cistern.Therefore,for space-occupying lesions in the suprasellar cistern,tuberculoma should be included in the differential diagnosis even if there is no history or indication of tuberculosis infection.

Transsphenoidal microsurgical operation for pituitary adenomas with suprasellar extensions

Objective: To evaluate the feasibility and therapeutic effectiveness of the transsphenoidal microsurgical removal of pituitary adenomas with suprasellar extensions. MethodS: We reviewed the diagnosticmodes, surgical technique, and outcomes of 152 patients suffering from pituitary adenomas with suprasellarextensions who were treated by transsphenoidal microsurgery in our department. Diagnosis was confirmed byCT or MRI scanning. All tumours with diameter >10 mm were characterized by suprasellar extensions. Op.erations were performed via either sublabio-septo-sphenoidal approach or naso-vestibulo-sphenoidal approachunder microscope. A subarachnoid catheter was preoperatively inserted in the lumbar cistern, through whichsaline was slowly injected during operation to increase the intracranial pressure (ICP) so as to deliver thesuprasellar tumour into the operative field to aid the removal. Result: Of the 152 cases, the gross total removal of adenoma in 106 cases (69. 7% ) and subtotal removal in 37 cases (24. 4% ) were achieved, and partial removal was carried out in the remaining 9 cases (5. 9 % ) of fibrous or dumbbell-shaped adenomas. Therewere no deaths after operation in this group. Follow-up review (median 3. 5 years) in 137 patients revealedgood recovery in 97 patients (70. 8% ), and late recurrence in 40 patients (29. 2% ) who need reoperativemanagement, drug therapy, radiotherapy, or radiosurgery used either alone or combined. Conclusion: Microsurgical technique via transsphenoidal approach is a safe and effective way to remove the pitoitary adenomas with suprasellar extensions but not for fibrous or dumbbell-shaped ones.

高龄多发性骨髓瘤鞍区占位1例

目的通过总结1例高龄多发性骨髓瘤鞍区占位患者的临床特点,增加对此类疾病的认识。方法回顾性分析1例高龄多发性骨髓瘤鞍区占位患者的临床表现、生化检验、影像学资料。结果患者为85岁男性,主要临床表现为乏力、纳差、多尿。辅助检查提示血钠明显降低、轻度高总蛋白及垂体占位、多项垂体前叶激素水平下降、泌乳素水平升高。完善病因筛查时发现血免疫球蛋白G(IgG)水平显著升高,血M蛋白阳性,骨髓涂片示骨髓瘤细胞,同时伴有全身骨骼多发溶骨性病变,考虑多发性骨髓瘤诊断明确,垂体占位为髓外受累可能性大。结论鞍区占位病因多样,多发性骨髓瘤鞍区受累发生率低,起病隐匿,临床特征、影像学表现缺乏特异性,易造成误诊及漏诊。

Characterization of grain growth behaviors by BP-ANN and Sellars models for nickle-base superalloy and their comparisons

In order to deeply understand the grain growth behaviors of Ni80A superalloy,a series of grain growth experiments were conducted at holding temperatures ranging from 1223 to 1423 K and holding time ranging from 0 to 3600 s.A back-propagation artificial neural network(BP-ANN)model and a Sellars model were solved based on the experimental data.The prediction and generalization capabilities of these two models were evaluated and compared on the basis of four statistical indicators.The results show that the solved BP-ANN model has better performance as it has higher correlation coefficient(r),lower average absolute relative error(AARE),lower absolute values of mean value(μ)and standard deviation(ω).Eventually,a response surface of average grain size to holding temperature and holding time is constructed based on the data expanded by the solved BP-ANN model,and the grain growth behaviors are described.

RECONSTRUCTION OF THE SELLAR FLOOR FOLLOWING TRANSSPHENOIDAL SURGERY USING GELATIN FOAM AND FIBRIN GLUE

Objective To introduce a new principle of sellar reconstruction and to evaluate the effectiveness of absorbable gelatin foam and fibrin glue for sellar reconstruction. Methods A total of 176 consecutive patients who underwent surgery for pituitary adenomas, cysts, chordomas, or subdiaphragmatic craniopharyngiomas in the sella turcica between January 2001 and April 2003 at Peking Union Medical College Hospital were enrolled. Different techniques of sellar closure and indications for each specific condition were retrospectively reviewed. Results Seventy-seven (43.7%) patients developed a visible cerebrospinal fluid (CSF) leakage during surgery. Intra- operative CSF leakage were repaired simply with gelatin foam and fibrin glue in 62 (35.2%) patients, and with autologous fat graft and sellar floor reconstruction in 15 (8.5%) patients. Postoperative CSF rhinorrhea occurred only in 1 case. There were no visual deterioration, allergic rhinitis, meningitis, pneumocranium, granulomas, or other complications asso- ciated with the reconstruction procedure. Conclusion The procedure of using gelatin foam and fibrin glue and principle of cranial base reconstruction is safe and effective in preventing postoperative complications following transsphenoidal surgery.

Sellar Chordoma Presenting as Pseudo-macroprolactinoma with Unilateral Third Cranial Nerve Palsy

We described a 61-year-old female with a sellar chordoma, which presented as pseudo-macroprolactinoma with unilateral third cranial nerve palsy. Physical examination revealed that her right upper lid could not be raised by itself, right eyeball movement limited to the abduction direction, right pupil dilated to 4.5 mm with negative reaction to light, and hemianopsia in bitemporal sides. CT scanning showed a hyperdense lesion at sellar region without bone destruction. Magnetic resonance imaging （MRI） revealed the tumor was 2.3 cmx2.8 cmx2.6 cm, with iso-intensity on TlWl, hyper-intensity on T2WI and heterogeneous enhancement on contrast imaging. Endocrine examination showed her serum prolactin level increased to 2,032.49 mlU/ml. The tumor was sub-totally resected via pterional craniotomy under microscope and was histologically proven to be a chordoma. Postoperatively, she recovered uneventfully but ptosis and hemianopsia remained at the 6th month.

Sellar Arachnoidocele: An Unusual Evolution in a Case Report

The sellar archnoidocele is a herniation of the subarachnoid space within the sella turcica which is often associated with a variable degree of flattening of the pituitary. Its clinical presentations range from an asymptomatic radiological finding to endocrine and neuro-ophthalmological manifestations. Its management depends on the initial symptomatology and requires long-term follow-up. We report here the case of a young child followed for a statural delay on a GH deficiency secondary to a sellar arachnoidocele, and who presents a rather unusual evolution.

Evaluation of Empty Nose Syndrome Scores in Patients Undergoing Extended Endoscopic Transnasal Sellar Surgery

Background: Several large series have established endoscopic transnasal sellar surgery as the procedure of choice for removal of tumors in the sellar area. Although this procedure provides a less invasive approach to the sella, it entails complications such as nasal bleeding, impaired olfactory function, atrophic rhinitis, synechiae, etc. No studies have yet reported potential morbidities such as empty nose syndrome (ENS), although patients have a relatively empty nasal cavity after surgery. Therefore, we sought to verify the percentage of patients who truly met the diagnostic criteria for ENS after endoscopic transnasal sellar surgery, determine the variation between pre- and postoperative scores in each Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) item, and further evaluate the symptoms that may affect the patients the most after surgery. Methods: Between March 2015 and January 2019, eventually 11 patients who underwent extended endoscopic transnasal sellar surgery in Shin Kong Wu Ho-Su Memorial Hospital, a tertiary referral medical center in Taipei, Taiwan, were enrolled. The patients completed the recently validated ENS6Q after surgery. Results: One patient met the objective diagnostic criteria for ENS (score ≥ 11 in ENS6Q). Significant differences were observed in the pre- and postoperative total ENS6Q scores. The pre- and postoperative scores of “nose feeling too open” and nasal crusting showed statistically significant differences. Further, compared with the other items, the postoperative score of nasal crusting increased most obviously, and it may be the most apparent operation-related symptom. Conclusion: This study is the first to report the possibility of developing ENS after endoscopic transnasal sellar surgery. Although the transnasal endoscopic approach is a safe and minimally invasive procedure for the treatment of sellar lesions, possible complications such as ENS should be considered.

Individualized Sellar Floor Reconstruction Method and Nursing Strategy for the Intraoperative Cerebrospinal Fluid Leakage Caused by Neuroendoscopic Transsphenoidal Pituitary Adenoma Resection

Objective: To explore the clinical effect of and the method and nursing strategy for sellar reconstruction for intraoperative cerebrospinal fluid (CSF) leakage in pituitary adenoma resection under neuroendoscopy. Methods: The data from 20 cases of intraoperative CSF leak caused by transsphenoidal pituitary adenoma resection were retrospectively analyzed. Six patients were treated with mucosal flap and artificial dural reconstruction of sellar (simple sellar floor reconstruction). In 45 patients, autologous fat, fascia lata, and artificial dura were used to repair and reconstruct the sellar floor (multilayer sellar floor reconstruction). After the operation, all patients underwent follow-up for 6 - 24 months. Results: Fifty patients were followed up without CSF leakage. One patient was cured after leakage of CSF through the lumbar cistern 1 month after discharge. Conclusion: For patients with CSF leakage during neuroendoscopic transsphenoidal pituitary adenoma resection, individualized sellar floor reconstruction should be adopted according to the degree of CSF leakage and the size of the sellar floor defect. Strict nursing measures can effectively prevent CSF leakage and reduce postoperative complications.

Intra-Sellary Arachniodocele: About a Case at the Medical Clinic “The Stars” of Bamako

Intrasellar arachnoidocele is a herniation of the optochiasmatic cistern through a dehiscence of the sellar diaphragm producing an empty sella turcica, hence its name empty sella turcica syndrome. It is an extremely rare benign malformative pathology. We report a case of intra-sellar arachnoidocele in a 34-year-old woman revealed during an annual control of a sellar mass under dossinex by cerebral magnetic resonance imaging (MRI) which found the cystic formation of liquid signal identical to that of the LCS in hypo signal T1 and hyper signal T2 without enhancement after injection of Gadolinium. The epidemiological, clinical and radiological aspects of arachnoidocele were analyzed. The purpose of this work is to bring the interest of MRI in the management of this pathology.

The Missing Argument in Sellars＇s Case against Classical Sense Datum Theory in ＂Empiricism and the Philosophy of Mind＂

Our objectives in this paper are, first, to identify several puzzling aspects of the ＂Trilemma Argument＂ of Section 6 against the Sense Datum Theory; second, to resolve these puzzles by reconstructing the Trilemma Argument; third to point to a distinction Sellars makes between two versions of the Sense Datum Theory, the ＂nominalist＂ version and the ＂realist＂ version; fourth, to reconstruct Sellars＇s arguments against both; and, finally, to fmd in an earlier paper, ＂Is There a Synthetic A Priort？＂ that his argument against the second version, assumed but not actually given in EPM, is against property realism and depends on taking language expressing propositional perception as fundamental and language expressing non-propositional perception as incomplete and derivative from the former.

研究鞍区肿瘤术后脑性耗盐综合征的预见性护理干预应用价值

目的探究鞍区肿瘤术后脑性耗盐综合征应用预见性护理干预的临床有效性。方法简单随机选取2022年12月—2023年12月广西医科大学附属肿瘤医院收治的60例鞍区肿瘤术后脑性耗盐综合征患者为研究对象,依据随机数字表法分为对照组(传统护理干预)和观察组(预见性护理干预),每组30例。比较两组患者术后尿崩症和电解质紊乱发生率、护理满意度及生活质量评分。结果观察组术后尿崩症、电解质紊乱发生率均低于对照组,差异有统计学意义(P均<0.05)。观察组护理满意度为93.33%,高于对照组的70.00%,差异有统计学意义(χ^(2)=5.455,P<0.05)。护理后,观察组生活质量评分高于对照组,差异有统计学意义(P<0.05)。结论预见性护理干预运用在鞍区肿瘤术后脑性耗盐综合征患者中的效果显著,不仅可以降低患者的并发症发生率,还可以提高患者的满意度。

鞍区病变相关下丘脑性肥胖诊疗中国专家共识

肥胖是鞍区疾病及相关治疗的常见并发症,对临床医师综合管理能力要求较高。为提升鞍区病变相关下丘脑性肥胖的诊疗质量,该共识整合了国内外临床研究证据及中国多学科专家的临床诊疗经验,总结了下丘脑性肥胖的临床特征和诊断标准,采用GRADE方法就鞍区病变相关下丘脑性肥胖的识别、筛查、评估、药物治疗、减重手术及预防等关键问题分别进行了推荐。推荐鞍区病变或其治疗累及下丘脑并出现肥胖的患者,以及肥胖伴下丘脑/垂体功能障碍的患者进行体重指数、下丘脑垂体内分泌及非内分泌功能评估,判断是否为下丘脑性肥胖,建议同时评估代谢并发症及原发病。推荐下丘脑性肥胖患者强化生活方式干预,必要时考虑减重药物或代谢手术治疗,同时注意内分泌激素的合理替代治疗。

神经内镜下经鼻蝶入路治疗Rathke’s囊肿

目的研究神经内镜技术治疗Rathke’s囊肿(Rathke’scleft cysts,RCC)的有效性。方法回顾性分析34例RCC病例资料,均采用神经内镜技术治疗,对比手术前后病人头疼、视力障碍、内分泌障碍等症状的改善,以及术后脑脊液漏的发生与囊肿复发情况等。结果33例采用内镜下囊肿开窗或囊壁部分切除术,1例囊壁全切除。术前有头疼症状21例(61.8%),术后1周~12个月头疼症状改善9例。术前视力下降9例(26.5%),术后改善2例。术前垂体功能异常21例(61.8%),术后恢复正常7例。1例囊壁全切除病人,术后持续性脑脊液漏,保守治疗1个月后行二次手术修补。复发2例(5.9%),1例随访未手术,1例2年后囊肿萎缩消失。无手术相关死亡。结论神经内镜技术可用于治疗出现头疼、视力下降、激素水平改变的RCC病人。

自体组织鞍底缝合技术在垂体腺瘤经鼻蝶入路神经内镜切除术后脑脊液漏修补中的应用

目的探讨自体组织鞍底缝合技术在垂体腺瘤经鼻蝶入路神经内镜切除术后脑脊液漏修补中的安全性及有效性。方法回顾性分析2021年1月至2023年12月经鼻蝶窦入路神经内镜手术切除的21例垂体腺瘤的临床资料。结果21例术中开放鞍隔后均出现脑脊液漏,均采用自体组织鞍底硬膜缝合技术重建鞍底,术后均未出现脑脊液鼻漏。2例术后继发颅内感染,感染率为9.5%;1例术后1个月内发生鼻出血。术后随访3~21个月,平均(9.3±6.6)个月,未见脑脊液鼻漏。结论垂体腺瘤经鼻蝶窦入路神经内镜切除术中因开放鞍隔导致的脑脊液漏,术中采用自体组织修补加缝合术进行鞍底重建,可有效预防术后脑脊液鼻漏,且手术安全性良好。

脂肪填塞对神经内镜经蝶垂体腺瘤切除术中脑脊液漏的疗效分析

目的探讨神经内镜经蝶垂体腺瘤切除术中发生脑脊液漏时,脂肪填塞在进行鞍底重建中的作用。方法选取河北省人民医院神经外科2016年6月至2021年6月收治的96例行经鼻蝶神经内镜下切除垂体腺瘤术中并发脑脊液漏患者的临床资料采用历史性对照研究分析,根据患者手术时间及方法进行分组,其中观察组48例均于2019年及之后手术治疗,并采用脂肪填塞+明胶海绵+人工硬膜+鼻中隔黏膜瓣修复鞍底,其中脑脊液漏1级37例,脑脊液漏2级11例;对照组48例均于2019年之前进行手术治疗,采用明胶海绵+人工硬膜+鼻中隔粘膜瓣修复鞍底,其中脑脊液漏1级41例,脑脊液漏2级7例。根据患者术后及随访过程中脑脊液漏发生率,比较2组手术有效率,并进行随访15~26个月。结果术后观察组脑脊液漏整体发生率4.1%(2/48),其中脑脊液漏1级术后持续漏发生率2.7%(1/37),脑脊液漏2级术后持续漏发生率9.1%(1/11)。对照组整体发生率为16.7%(8/48),其中脑脊液漏1级术后持续漏发生率7.3%(3/41),脑脊液漏2级术后持续漏发生率71.4%(5/7)。2组术后脑脊液漏整体发生率差异均有统计学意义(P<0.05)。结论脂肪填塞在鞍底重建中具有重要作用,尤其对于术中即发生脑脊液漏2、3级患者,可有效降低术后脑脊液漏发生率,但对术中发生脑脊液漏1级患者,脂肪填塞重建鞍底是否仍具有显著效果需进一步研究。

Pituitary metastasis from lung adenocarcinoma:A case report

BACKGROUND Pituitary gland metastasis is an unusual event,and pituitary metastasis from lung adenocarcinoma is extremely rare and associated with poor prognosis.To date,approximately 15 cases have been reported.CASE SUMMARY Here,we present the case of a 64-year-old woman with pituitary metastasis derived from lung adenocarcinoma,which was difficult to distinguish from other sellar tumors.The patient presented to the neurosurgery clinic with blurred vision and intermittent headache.During hospitalization,brain computed tomography(CT)and magnetic resonance imaging revealed a pituitary macroadenoma.Chest CT revealed irregular nodules in the basal segment of the lower lobe of the left lung,which were likely lung cancer.Positron emission tomography-CT revealed a carbohydrate metabolism tumor in the lungs and sellar region,which was considered malignant.Postoperative pathological examination of the sellar tumor revealed lung adenocarcinoma.CONCLUSION Excision of pituitary metastases combined with radiotherapy and chemotherapy should be a priority treatment for patients with pituitary metastasis.

Predictive visual field outcomes after optic chiasm decompressive surgery by retinal vessels parameters using optical coherence tomography angiography

AIM:To evaluate the predictive value of superficial retinal capillary plexus(SRCP)and radial peripapillary capillary(RPC)for visual field recovery after optic cross decompression and compare them with peripapillary nerve fiber layer(pRNFL)and ganglion cell complex(GCC).METHODS:This prospective longitudinal observational study included patients with chiasmal compression due to sellar region mass scheduled for decompressive surgery.Generalized estimating equations were used to compare retinal vessel density and retinal layer thickness preand post-operatively and with healthy controls.Logistic regression models were used to assess the relationship between preoperative GCC,pRNFL,SRCP,and RPC parameters and visual field recovery after surgery.RESULTS:The study included 43 eyes of 24 patients and 48 eyes of 24 healthy controls.Preoperative RPC and SRCP vessel density and pRNFL and GCC thickness were lower than healthy controls and higher than postoperative values.The best predictive GCC and pRNFL models were based on the superior GCC[area under the curve(AUC)=0.866]and the tempo-inferior pRNFL(AUC=0.824),and the best predictive SRCP and RPC models were based on the nasal SRCP(AUC=0.718)and tempo-inferior RPC(AUC=0.825).There was no statistical difference in the predictive value of the superior GCC,tempo-inferior pRNFL,and tempo-inferior RPC(all P>0.05).CONCLUSION:Compression of the optic chiasm by tumors in the saddle area can reduce retinal thickness and blood perfusion.This reduction persists despite the recovery of the visual field after decompression surgery.GCC,pRNFL,and RPC can be used as sensitive predictors of visual field recovery after decompression surgery.