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Luis R Salgado, Arthur Cukiert, Elcio Machado, Alcione Sousa, Jose A Buratini, Joaquim Vieira, Bernardo Liberman, Jaime Goldman, Maria ER Silva, Katia Nogueira, Martha Huayllas.
Departments of Endocrinology and Neurosurgery, Hospital Brigadeiro, Sao Paulo SP, Brazil.
INTRODUCTION: Patients with pituitary stalk (PS) lesions may present with diabetes insipidus (DI). Surgical manipulation of the PS may leads to transient or permanent DI. Permanent DI is rare after transesphenoidal resections of pituitary tumors but is rather common after transcranial procedures. This paper describes the time course of the DI in patients submitted to transcranial lesionectomies in whom a complete PS section was documented intraoperatively.
METHODS: Nine patients were studied. Five patients had PS lesions (Group I): 1 with glioma, 2 with infundibulitis, 1 with infundibulo-hypophisitis and 1 with hystiocitosis. All of them (except the one with glioma) had DI preoperatively and were receiving DDAVP. All of them were submitted to a total transcranial resection of the PS by means of a cranial section at the level of the infundibulum and a caudal section just above the diafragma sellae. Four patients (Group II) have non-PS lesions: 2 with meningiomas and 2 with craniopharyngiomas. All patients were submitted to transcranial resection of their lesions. In the 2 patients with meningiomas, PS section occurred at the level of the diafragma sellae; in the 2 patients with craniopharyngioma, section occurred at the middle of the PS. No patient with meningioma had DI preoperatively. One patient with craniopharyngioma had DI preoperatively.
RESULTS: In Group I, the patient who had no DI developed it 18 hours postoperatively. Two of the 4 patients who had DI preoperatively disclosed no change in the clinical picture or in the need for DDAVP; on the other hand, 2 patients developed an inappropriate ADH secretion syndrome (IADHSS) intraoperatively that lasted 48 and 60 hours respectively. After these periods, one patients required the same DDAVP dosage as preoperatively but the second one needed a DDAVP dose reduction. In Group II, patients with meningioma and PS section had no postoperative DI. The patient with craniopharyngioma and preoperative DI remained with DI and the other developed DI 12 hours postoperatively.
DISCUSSION: Intraoperative PS section is not always followed by DI, especially when the section occurs near the diafragma sellae in patients with lesions outside the PS itself. The dose of DDAVP has to be carefully managed in patients with PS pathology since 40% of them may present with IADHSS intra- and postoperatively and administration of the habitual dose for these patients may represent overtreatment. We did not observe IADHSS in Group II patients.