Postoperative diabetes insipidus: how to define and grade this complication?

Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 1, general recommendations

Tumours of the anterior part of the pituitary gland represent just 1% of all childhood (aged <15 years) intracranial neoplasms, yet they can confer high morbidity and little evidence and guidance is in place for their management. Between 2014 and 2022, a multidisciplinary expert group systematically developed the first comprehensive clinical practice consensus guideline for children and young people under the age 19 years (hereafter referred to as CYP) presenting with a suspected pituitary adenoma to inform specialist care and improve health outcomes. Through robust literature searches and a Delphi consensus exercise with an international Delphi consensus panel of experts, the available scientific evidence and expert opinions were consolidated into 74 recommendations. Part 1 of this consensus guideline includes 17 pragmatic management recommendations related to clinical care, neuroimaging, visual assessment, histopathology, genetics, pituitary surgery and radiotherapy. While in many aspects the care for CYP is similar to that of adults, key differences exist, particularly in aetiology and presentation. CYP with suspected pituitary adenomas require careful clinical examination, appropriate hormonal work-up, dedicated pituitary imaging and visual assessment. Consideration should be given to the potential for syndromic disease and genetic assessment. Multidisciplinary discussion at both the local and national levels can be key for management. Surgery should be performed in specialist centres. The collection of outcome data on novel modalities of medical treatment, surgical intervention and radiotherapy is essential for optimal future treatment.

Importance of Intraoperative Factors in Postoperative Arginine Vasopressin Deficiency After Pituitary Adenoma Surgery

OBJECTIVE

Pituitary adenoma (PA) is the most frequent tumor in the sellar region. Arginine vasopressin deficiency (AVP-D), formerly known as central diabetes insipidus, is a common complication after pituitary surgeries. In this study, we reviewed patients with PAs after endoscopic transsphenoidal surgery, evaluated the incidence of postoperative AVP-D, and determined associated risk factors.

METHODS

We retrospectively studied 520 patients who underwent endoscopic transsphenoidal surgery for PAs and evaluated perioperative risk factors and their associations with postoperative AVP-D. Patients who developed AVP-D were categorized in 3 groups: (1) early AVP-D, (2) transient AVP-D, and (3) permanent AVP-D.

RESULTS

Of the 520 patients, 24.8% experienced early AVP-D, and 1.9% (n = 10) had transient AVP-D. Permanent AVP-D was observed in only 6 patients (1.1%). Gross total resection, hormonal remission, pituitary stalk manipulation, and intraoperative cerebrospinal fluid leak were significantly associated with a higher incidence of AVP-D (P = .027, P = .002, P < .001 and P < .001, respectively). All patients who developed permanent AVP-D had somatotroph adenomas. AVP-D was not found to be related with tumor size. The length of hospital stay was prolonged by AVP-D on average by 1.5 days (P = .018).

CONCLUSION

The reported incidence of AVP-D has a considerably wide range. A consistent definition and grading for AVP-D will increase consistency and comparability among studies. Nonetheless, most patients experience AVP-D on a temporary basis, and only a few require long-term treatment. Cerebrospinal fluid leak, gross total resection, and hormonal remission were identified as risk factors for postoperative AVP-D. We believe that the intraoperative risk factors play the main role in postoperative AVP-D. The course of surgery and operative findings help us plan selective postoperative patient monitoring and care.

Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: Clinical recommendations on the perioperative management of pituitary tumors

Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7%-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.

Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: clinical recommendations on the perioperative management of pituitary tumors

Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.

Copeptin analysis in endocrine disorders

Copeptin is cleaved from the same precursor as arginine vasopressin and is released in equimolar amounts with arginine vasopressin from the posterior pituitary in response to the same stimuli. Its level of stability in the blood, quick and simple analysis, and ease of automation make it much easier to analyze than arginine vasopressin, thereby offering a suitable alternative to measuring arginine vasopressin in endocrine disorders. Research has demonstrated the suitability of copeptin in adults for the differentiation of arginine vasopressin resistance and arginine vasopressin deficiency from primary polydipsia, in addition to the early identification of arginine vasopressin deficiency following pituitary surgery; however, further research is still required in the Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and the pediatric population.

Defining benchmark outcomes for transsphenoidal surgery of pituitary adenomas: a multicenter analysis

IMPORTANCE

Benchmarks aid in improve outcomes for surgical procedures. However, best achievable results that have been validated internationally for transsphenoidal surgery (TS) are not available.

OBJECTIVE

We aimed to establish standardized outcome benchmarks for TS of pituitary adenomas.

DESIGN

A total of 2685 transsphenoidal tumor resections from 9 expert centers in 3 continents were analyzed.

SETTING

Patients were risk stratified, and the median values of each center's outcomes were established. The benchmark was defined as the 75th percentile of all median values for a particular outcome. The postoperative benchmark outcomes included surgical factors, endocrinology-specific values, and neurology-specific values.

RESULTS

Of 2685 patients, 1149 (42.8%) defined the low-risk benchmark cohort. Within these benchmark cases, 831 (72.3%) patients underwent microscopic TS, and 308 (26.8%) patients underwent endoscopic endonasal resection. Of all tumors, 799 (29.8%) cases invaded the cavernous sinus. The postoperative complication rate was 19.6% with mortality between 0.0% and 0.8%. Benchmark cutoffs were ≤2.9% for reoperation rate, ≤1.9% for cerebrospinal fluid leak requiring intervention, and ≤15.5% for transient diabetes insipidus. At 6 months, benchmark cutoffs were calculated as follows: readmission rate: ≤6.9%, new hypopituitarism ≤6.0%, and tumor remnant ≤19.2%.

CONCLUSIONS

This analysis defines benchmark values for TS targeting morbidity and mortality and represents the best outcomes in the best patients in expert centers. These cutoffs can be used to assess different centers, patient populations, and novel surgical techniques. It should be noted that the benchmark values may influence each other and must be evaluated in their own context.

A Novel Magnetic Resonance Imaging-Based Radiomics and Clinical Predictive Model for the Regrowth of Postoperative Residual Tumor in Non-Functioning Pituitary Neuroendocrine Tumor

Background and Objectives: To develop a novel magnetic resonance imaging (MRI)-based radiomics-clinical risk stratification model to predict the regrowth of postoperative residual tumors in patients with non-functioning pituitary neuroendocrine tumors (NF-PitNETs). Materials and Methods: We retrospectively enrolled 114 patients diagnosed as NF-PitNET with postoperative residual tumors after the first operation, and the diameter of the tumors was greater than 10 mm. Univariate and multivariate analyses were conducted to identify independent clinical risk factors. We identified the optimal sequence to generate an appropriate radiomic score (Rscore) that combined pre- and postoperative radiomic features. Three models were established by logistic regression analysis that combined clinical risk factors and radiomic features (Model 1), single clinical risk factors (Model 2) and single radiomic features (Model 3). The models' predictive performances were evaluated using receiver operator characteristic (ROC) curve analysis and area under curve (AUC) values. A nomogram was developed and evaluated using decision curve analysis. Results: Knosp classification and preoperative tumor volume doubling time (TVDT) were high-risk factors (p < 0.05) with odds ratios (ORs) of 2.255 and 0.173. T1WI&T1CE had a higher AUC value (0.954) and generated an Rscore. Ultimately, the AUC of Model 1 {0.929 [95% Confidence interval (CI), 0.865-0.993]} was superior to Model 2 [0.811 (95% CI, 0.704-0.918)] and Model 3 [0.844 (95% CI, 0.748-0.941)] in the training set, which were 0.882 (95% CI, 0.735-1.000), 0.834 (95% CI, 0.676-0.992) and 0.763 (95% CI, 0.569-0.958) in the test set, respectively. Conclusions: We trained a novel radiomics-clinical predictive model for identifying patients with NF-PitNETs at increased risk of postoperative residual tumor regrowth. This model may help optimize individualized and stratified clinical treatment decisions.

Pituitary Stalk Morphology as a Predictor of New-Onset Adrenocortical Insufficiency and Arginine Vasopressin Deficiency after Transsphenoidal Resections of Pituitary Macroadenomas: A Retrospective Single-Center Study with a Focus on iMRI

BACKGROUND

A new-onset adrenocortical insufficiency (NAI) is the most critical postoperative endocrinological complication after transsphenoidal surgery for macroadenomas. Because of increased mortality risk, arginine vasopressin deficiency (AVP-D) is also a relevant postoperative complication. This study aimed to identify easy-to-acquire magnet resonance imaging (MRI) aspects of the pituitary stalk to predict these insufficiencies after transsphenoidal surgery.

METHODS

Pituitary stalk morphology was reviewed intraoperatively and three months postoperatively in the MRIs of 48 transsphenoidal surgeries for macroadenomas. NAI was validated in endocrinological follow-up controls 10-14 months post-surgery.

RESULTS

Intraoperative pituitary stalk diameters were 0.5 mm larger in patients who developed NAI and AVP-D. The odds ratio was 29 for NAI and 6 for AVP-D in binary regression analysis. A value of 2.9 mm was identified as the optimal cut-off for the minimal pituitary stalk diameter regarding NAI, with a high specificity of 89%. There was no difference in pituitary stalk diameter regarding these insufficiencies three months post-surgery.

CONCLUSIONS

We identified an increased pituitary stalk diameter in intraoperative MRIs as a predictive factor of NAI and AVP-D after transsphenoidal surgery. These findings might improve the early detection of NAI and, thus, optimal management. However, validating these retrospective findings in prospective studies is obligatory.

Skull base reconstruction using in situ bone flap in patients with pituitary adenomas treated by endoscopic endonasal approach

Objective

The objective of this study is to study the effect of in situ bone flap (ISBF) repositioning, a recently proposed rigid skull base reconstruction technique, on patients diagnosed with pituitary adenoma undergoing endoscopic endonasal approach (EEA).

Method

A retrospective analysis was conducted on 188 patients with pituitary adenomas who underwent EEA from February 2018 to September 2022. Patients were divided into the ISBF group and non-ISBF group, according to whether ISBF was used during skull base reconstruction.

Results

Of the 75 patients in the non-ISBF group, 6 had postoperative cerebrospinal fluid (CSF) leakage (8%), while only 1 of 113 patients in the ISBF group (0.8%) had postoperative CSF leakage, indicating that the incidence of postoperative CSF leakage in the ISBF group was significantly lower than that in the non-ISBF group (P = 0.033). In addition, we also found that the postoperative hospitalization days of patients in the ISBF group (5.34 ± 1.24) were significantly less than those in the non-ISBF group (6.83 ± 1.91, P = 0.015).

Conclusion

ISBF repositioning is a safe, effective, and convenient rigid skull base reconstruction method for patients with pituitary adenoma treated by EEA, which can significantly reduce the rate of postoperative CSF leakage and shorten postoperative hospital stays.

Pituitary Adenoma With Apoplexy Presenting As Unilateral Third Nerve Palsy

Pituitary adenomas are one of the most common intracranial tumors. Non-functioning macroadenomas are usually diagnosed when they cause symptoms due to the mass effect on surrounding structures. We present the case of a 48-year-old man who presented with a headache associated with ptosis of the right eye and right-sided blurry vision for three days. Initial computerized tomography (CT) scan of the head did not report a mass, acute infarct, or hemorrhage. He was given 325mg of aspirin for concern of a stroke while waiting for magnetic resonance imaging (MRI) of the brain, which was done the next day and revealed a pituitary macroadenoma with hemorrhage, mass effect, and compression of the optic chiasm consistent with pituitary apoplexy. He ultimately underwent trans-sphenoidal resection of the tumor; however, his surgery was delayed for five days as he had received a high dose of aspirin in the Emergency Room. His adrenocorticotropic hormone (ACTH), cortisol, and testosterone levels were found to be quite low. He was administered stress dose steroids peri-operatively and ultimately discharged on indefinite hydrocortisone therapy and endocrinology follow-up. Our case highlights a serious complication of pituitary adenomas that can occur called pituitary apoplexy which is caused by acute ischemic infarction or hemorrhage in the pituitary. It needs prompt identification and management. Our case also emphasizes the importance of recognizing pituitary apoplexy as one of the causes of sudden onset cranial nerve deficits, as it is a rare presentation of pituitary adenomas that can be taken for a stroke in the Emergency Department.

Sleep quality in patients with non-functioning pituitary adenoma: impact of replacement therapies with an emphasis on the time of hydrocortisone

PURPOSE

Sleep disturbances are widespread and associated with pituitary diseases, even those under long-term therapeutic management. The aim of this study was to investigate sleep quality in patients with non-functioning pituitary adenoma (NFPA) and determine the factors that might influence sleep quality, including the detailed features of replacement therapy.

METHODS

Eighty-two patients with NFPA and 82 age- and gender-matched control subjects were included. Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS) and International Physical Activity Questionnaire (IPAQ) were used.

RESULTS

In the NFPA group, 57.3% of patients had decreased sleep quality, compared to 35.4% in the control group (p=0.005). Although there was no relationship between the presence of hydrocortisone replacement and sleep quality (p>0.05), a strong positive correlation was observed between PSQI and morning hydrocortisone replacement time in patients with secondary adrenal insufficiency (r=0.834, p<0.001). Diabetes insipidus was found to be significantly higher in the group with decreased sleep quality (p=0.01). Moreover, there was a negative correlation between PSQI and IGF-1 in patients with NFPA (r=-0.259, p=0.01). A multivariate logistic regression model revealed that depression score and free T4 level in the upper half of the normal limit influence the sleep quality of patients with NFPA.

CONCLUSION

Our study indicated the presence of depression, and a free T4 level in the upper half of the normal range have an impact on the sleep quality of patients with NFPA. The time of hydrocortisone replacement might be important factor for improved sleep quality in patients with secondary adrenal insufficiency.

Copeptin levels in hospitalized infants and children with suspected vasopressin-dependent disorders: a case series

OBJECTIVES

There have been recent advances assessing copeptin levels in adults with suspected disorders of vasopressin release. Very limited data exits on copeptin levels in children and infants, especially in a critically-ill hospitalized population where hyper- and hypo-natremia are very common. Our objective is to describe the institutional experience assessing copeptin levels in hospitalized infants and children with hyper- or hypo-natremia.

METHODS

We performed a single-center retrospective case series of all infants, children, and adolescents who had an ultrasensitive plasma copeptin level obtained between 2019-2021.

RESULTS

A total of 29 critically ill patients (6 infants) were identified with 38 % of patients having copeptin levels after neurosurgical procedures for tumors or trauma. Approximately 13/17 children with hypernatremia had CDI to diagnose CDI, A copeptin level ≤ 4.9 pmol/L resulted in an 88 % sensitivity (95 % CI 47-99 %), and 66 % specificity (95 % CI 30-93 %). Amongst those with hyponatremia levels were more variable, 8/12 children had SIAD with copeptin levels ranging 4.7-72.6 pmol/L.

CONCLUSIONS

While difficult to conclude due to multiple limitations, this case series highlights that typical copeptin cutoffs used to diagnose DI in adults in an ambulatory setting may also translate to a critically-ill pediatric population. Large prospective studies are needed to confirm this observation. In addition, postoperative copeptin levels could potentially be utilized as an additional marker to predict permanent from transient DI, but much larger studies are needed. Further work is needed to establish normative copeptin levels in infants and patients with SIAD.

The importance of preserving the superior hypophyseal artery infundibular branch in craniopharyngioma surgery

PURPOSE

Postoperative pituitary dysfunction, a critical problem in the treatment of craniopharyngiomas, can occur even when the pituitary stalk is preserved. We hypothesized that compromise of the primary superior hypophyseal artery (pSHA) might be related to this occurrence.

METHODS

We performed a retrospective review of 131 patients with craniopharyngioma who underwent surgery from April 2009 to September 2021. The inclusion criteria were initial surgery, endoscopic transsphenoidal surgery, preoperative normal pituitary function or pituitary dysfunction in one axis, and morphological preservation of the pituitary stalk. The branches of the pSHA consist mainly of the chiasmatic branches (Cb), infundibular branches (Ib), and descending branches (Db). We analyzed the association between postoperative pituitary function and preservation of these branches.

RESULTS

Twenty patients met the criteria. Preoperative anterior pituitary function was normal in 18 patients, and there was isolated growth hormone deficiency in two patients. No patient had preoperative diabetes insipidus (DI). Anterior pituitary function was unchanged postoperatively in eight patients. Of these eight patients, bilateral preservation of pSHA Ib was confirmed in seven patients. Bilateral preservation of pSHA Ib was the only factor associated with preserved anterior pituitary function (p < 0.01). Fifteen patients were free of permanent DI, and the preservation of any given pSHA branch produced no significant difference in the postoperative occurrence of permanent DI.

CONCLUSIONS

Our study shows that bilateral preservation of pSHA Ib provides favorable postoperative anterior pituitary function in craniopharyngioma surgery; however, such preservation may have little effect on the postoperative occurrence of DI.

Endoscopic endonasal approach for infradiaphragmatic craniopharyngiomas: a multicentric Italian study

OBJECTIVE

Infradiaphragmatic craniopharyngiomas (ICs) represent a distinct subtype, harboring a sellar-suprasellar origin and generally growing in the extra-arachnoidal space contained by the diaphragma sellae. They have been considered ideal for surgical removal through the transsphenoidal approach since the 1960s. The authors present a multicentric national study, intending to selectively analyze IC behavior and the impact of the transsphenoidal endoscopic endonasal approach (EEA) on surgical outcomes.

METHODS

Craniopharyngiomas that were intraoperatively recognized as infradiaphragmatic and removed with standard EEA between 2000 and 2021 at 6 Italian neurosurgical departments were included in the study. Clinical, radiological, and surgical findings and outcomes were evaluated and reviewed.

RESULTS

In total, 84 patients were included, with 45.23% identified as pediatric cases and 39.28% as having recurrent tumors. The most common presenting symptoms were endocrine (75%), visual (59.52%), and hypothalamic (26.19%) disorders. ICs were classified as extending below (6 intrasellar and 41 occupying the suprasellar cistern) or above (26 obliterating the anterior recesses of the third ventricle and 11 extending up to the foramina of Monro) the chiasmatic cistern. Gross-total resection (GTR) was achieved in 54 cases (64.28%). Tumor extension above the chiasmatic cistern and calcifications were associated with lower likelihood of GTR. The cumulative rate of postoperative complications was 34.53%, with CSF leak being the most common (14.28%). Endocrine, visual, and hypothalamic functions deteriorated postoperatively in 41/78 patients (52.56%), 5/84 (5.95%), and 14/84 (16.67%), respectively. Twenty-eight patients (33.33%) had recurrence during follow-up (mean 63.51 months), with a mean 5-year progression-free survival (PFS) rate of 58%. PFS was greater in patients who achieved GTR than patients with other extent of resection.

CONCLUSIONS

This is the largest series in the literature to describe ICs removed with standard EEA, without the need for additional bone and dural opening over the planum sphenoidale. EEA provides a direct route to ICs, the opportunity to manage lesions extending up to the third ventricle without breaching the diaphragma, and high rates of GTR and satisfactory clinical outcomes. Increased surgical complexity and morbidity should be expected in patients with extensive suprasellar extension and involvement of the surrounding vital neurovascular structures.

Pituitary stalk changes on magnetic resonance imaging following pituitary adenoma resection using a transsphenoidal approach

Objective

We aimed to investigate the magnetic resonance imaging (MRI) findings and clinical significance of position and changes in morphology of the pituitary stalk following pituitary adenoma (PA) resection using a transsphenoidal approach.

Methods

We collected clinical and MRI data of 108 patients with PA after transsphenoidal surgery. Diameter, length, and coronal deviation of the pituitary stalk were measured pre-, post-, and mid-term post-operatively, to observe pituitary stalk morphology.

Results

Of 108 patients, 53 pituitary stalks were recognisable pre-operatively. The angle between the pituitary stalk and the median line was 7.22°-50.20° (average, 25.85°) in 22 patients with left-sided pituitary stalks and 5.32°-64.05° (average, 21.63°) in 20 patients with right-sided pituitary stalks. Of 42 patients with preoperative pituitary stalk deviation, 41 had an early postoperative recovery and 1 had increased deviation. In the mid-term postoperative period, 21 of 42 patients had pituitary stalks located centrally. In 53 patients, the pituitary stalk length was 1.41-11.74 mm (mean, 6.12 mm) pre-operatively, 3.61-11.63 mm (mean, 6.93 mm) in the early postoperative period, and 5.37-17.57 mm (mean, 8.83 mm) in the mid-term postoperative period. In the early postoperative period, 58 (53.70%) patients had posterior pituitary bright spots (PPBS) and 28 (25.92%) had diabetes insipidus (DI).

Conclusion

Pre-operatively, the pituitary stalk was compressed and thinned. Post-operatively, it could be stretched to a "normal state", and its position showed a gradual centring trend. Post-operatively, the length of the pituitary stalk gradually increased. The PPBS in the early postoperative period negatively correlated with postoperative DI.

New developments and concepts in the diagnosis and management of diabetes insipidus (AVP-deficiency and resistance)

Diabetes insipidus (DI) is a disorder characterised by the excretion of large amounts of hypotonic urine, with a prevalence of 1 per 25,000 population. Central DI (CDI), better now referred to as arginine vasopressin (AVP)-deficiency, is the most common form of DI resulting from deficiency of the hormone AVP from the pituitary. The less common nephrogenic DI (NDI) or AVP-resistance develops secondary to AVP resistance in the kidneys. The majority of causes of DI are acquired, with CDI developing when more than 80% of AVP-secreting neurons are damaged. Inherited/familial CDI causes account for approximately 1% of cases. Although the pathogenesis of NDI is unclear, more than 280 disease-causing mutations affecting the AVP2 protein or AVP V2 receptor, as well as in aquaporin 2 (AQP2), have been described. Although the cAMP/protein kinase A pathway remains the major regulatory pathway of AVP/AQP2 action, in vitro data have also revealed additional cAMP independent pathways of NDI pathogenesis. Diagnosing partial forms of DI, and distinguishing them from primary polydipsia, can be challenging, previously necessitating the use of the water deprivation test. However, measurements of circulating copeptin levels, especially after stimulation, are increasingly replacing the classical tests in clinical practice because of their ease of use and high sensitivity and specificity. The treatment of CDI relies on desmopressin administration, whereas NDI requires the management of any underlying diseases, removal of offending drugs and, in some cases, administration of diuretics. A better understanding of the pathophysiology of DI has led to novel evolving therapeutic agents that are under clinical trial.

Disorders of Salt and Water Balance After Pituitary Surgery

Transsphenoidal surgery is the first-line treatment for many clinically significant pituitary tumors and sellar lesions. Although complication rates are low when performed at high-volume centers, disorders of salt and water balance are relatively common postoperatively. Both, or either, central diabetes insipidus (recently renamed arginine vasopressin deficiency - AVP-D), caused by a deficiency in production and/or secretion of arginine vasopressin, and hyponatremia, most commonly secondary to the syndrome of inappropriate antidiuresis, may occur. These conditions can extend hospital stay and increase the risk of readmission. This article discusses common presentations of salt and water balance disorders following pituitary surgery, the pathophysiology of these conditions, and their diagnosis and management.

Serum copeptin levels at day two after pituitary surgery and ratio to baseline predict postoperative central diabetes insipidus

PURPOSE

Central diabetes insipidus is a complication that may occur after pituitary surgery and has been difficult to predict. This study aimed to identify the cutoff levels of serum copeptin and its optimal timing for predicting the occurrence of central diabetes insipidus in patients who underwent transsphenoidal surgery.

METHODS

This was a prospective observational study of patients who underwent transsphenoidal surgery for pituitary gland or stalk lesions. Copeptin levels were measured before surgery, 1 h after extubation, and on postoperative days 1, 2, 7, and 90.

RESULTS

Among 73 patients, 14 (19.2%) and 13 (17.8%) patients developed transient and permanent central diabetes insipidus, respectively. There was no significant difference in copeptin levels before surgery and 1 h after extubation; copeptin levels on postoperative days 1, 2, 7, and 90 were significantly lower in patients with permanent central diabetes insipidus than in those without central diabetes insipidus. Copeptin measurement on postoperative day 2 exhibited the highest performance for predicting permanent central diabetes insipidus among postoperative days 1, 2, and 7 (area under the curve [95% confidence interval] = 0.754 [0.632-0.876]). Serum copeptin level at postoperative day 2(< 3.1 pmol/L) showed a sensitivity of 92.3% and a negative predictive value of 97.1%. The ratio of copeptin at postoperative day 2 to baseline (< 0.94) presented a sensitivity of 84.6% and a negative predictive value of 94.9%. The copeptin levels > 3.4 and 7.5 pmol/L at postoperative day 2 and 7 may have ruled out the occurrence of CDI with a negative predictive value of 100%.

CONCLUSION

The copeptin level at postoperative day 2 and its ratio to baseline can predict the occurrence of permanent central diabetes insipidus after pituitary surgery.

Change in the pituitary stalk deviation angle after transsphenoidal surgery can predict the development of diabetes insipidus for pituitary adenomas

Purpose

We aimed to assess the factors influencing the development of diabetes insipidus after transsphenoidal surgery for pituitary adenomas.

Methods

A retrospective analysis was conducted on the clinical data of patients with pituitary adenomas who underwent transsphenoidal surgery. The predictors of postoperative diabetes insipidus were determined using statistical analysis.

Results

Of the 415 patients who underwent microscopic transsphenoidal surgery for pituitary adenomas, 196 experienced postoperative diabetes insipidus. The sinking depth of the diaphragma sellae and the difference between the preoperative and postoperative pituitary stalk deviation angles in the diabetes insipidus group were greater than those in the non-diabetes insipidus group. Logistic regression analysis showed that the risk of diabetes insipidus after transsphenoidal surgery was higher in patients with a larger difference in their pituitary stalk deviation angles (odds ratio = 2.407, 95% CI = 1.335-4.342; P = 0.004).

Conclusion

The difference in the pituitary stalk deviation angle could predict the onset of diabetes insipidus after transsphenoidal surgery for pituitary adenomas.

Safety of Withholding Perioperative Hydrocortisone for Patients With Pituitary Adenomas With an Intact Hypothalamus-Pituitary-Adrenal Axis: A Randomized Clinical Trial

IMPORTANCE

Pituitary adenoma is the second most common primary brain tumor. Perioperative hydrocortisone has been used for decades to avoid postoperative adrenal insufficiency. Recent studies suggest that withholding perioperative hydrocortisone may be safe for patients with an intact hypothalamus-pituitary-adrenal (HPA) axis.

OBJECTIVE

To assess the safety of withholding hydrocortisone during the perioperative period of pituitary adenoma surgery for patients with an intact HPA axis.

DESIGN, SETTING, AND PARTICIPANTS

A parallel-group, triple-masked, noninferiority randomized clinical trial was conducted at Peking Union Medical College Hospital from November 1, 2020, to January 31, 2022, among 436 patients aged 18 to 70 years with an intact HPA axis undergoing surgery for pituitary adenomas.

INTERVENTIONS

Hydrocortisone supplementation protocol (intravenous and subsequent oral hydrocortisone, using a taper program) or no-hydrocortisone protocol.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of new-onset adrenal insufficiency (morning cortisol level, <5 μg/dL with adrenal insufficiency-related symptoms) during the perioperative period (on the day of operation and the following 2 days). The secondary outcome was the incidence of adrenal insufficiency in postoperative month 3. Analysis was on an intention-to-treat basis.

RESULTS

Of the 436 eligible patients, 218 were randomly assigned to the hydrocortisone group (136 women [62.4%]; mean [SD] age, 45.4 [13.0] years) and 218 to the no-hydrocortisone group (128 women [58.7%]; mean [SD] age, 44.5 [13.8] years). All patients completed 3-month postoperative follow-up. The incidence of new-onset adrenal insufficiency during the perioperative period was 11.0% (24 of 218; 95% CI, 6.9%-15.2%) in the no-hydrocortisone group and 6.4% (14 of 218; 95% CI, 3.2%-9.7%) in the hydrocortisone group, with a difference of 4.6% (95% CI, -0.7% to 9.9%), meeting the prespecified noninferiority margin of 10 percentage points. The incidence of adrenal insufficiency at the 3-month follow-up was 3.7% (8 of 218) in the no-hydrocortisone group and 3.2% (7 of 218) in the hydrocortisone group (difference, 0.5%; 95% CI, -3.0% to 3.9%). Incidences of new-onset diabetes mellitus (1 of 218 [0.5%] vs 9 of 218 [4.1%]), hypernatremia (9 of 218 [4.1%] vs 21 of 218 [9.6%]), hypokalemia (23 of 218 [10.6%] vs 34 of 218 [15.6%]), and hypocalcemia (6 of 218 [2.8%] vs 19 of 218 [8.7%]) were lower in the no-hydrocortisone group than in the hydrocortisone group. Lower preoperative morning cortisol levels were associated with higher risks of the primary event (<9.3 µg/dL; odds ratio, 3.0; 95% CI, 1.5-5.9) and the secondary event (<8.8 µg/dL; odds ratio, 7.8; 95% CI, 2.6-23.4) events.

CONCLUSIONS AND RELEVANCE

This study found that withholding hydrocortisone was safe and demonstrated noninferiority to the conventional hydrocortisone supplementation regimen regarding the incidence of new-onset adrenal insufficiency among patients with an intact HPA axis undergoing pituitary adenomectomy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04621565.

Diagnosis and Management of Central Diabetes Insipidus in Adults

Central diabetes insipidus (CDI) is a clinical syndrome which results from loss or impaired function of vasopressinergic neurons in the hypothalamus/posterior pituitary, resulting in impaired synthesis and/or secretion of arginine vasopressin (AVP). AVP deficiency leads to the inability to concentrate urine and excessive renal water losses, resulting in a clinical syndrome of hypotonic polyuria with compensatory thirst. CDI is caused by diverse etiologies, although it typically develops due to neoplastic, traumatic, or autoimmune destruction of AVP-synthesizing/secreting neurons. This review focuses on the diagnosis and management of CDI, providing insights into the physiological disturbances underpinning the syndrome. Recent developments in diagnostic techniques, particularly the development of the copeptin assay, have improved accuracy and acceptability of the diagnostic approach to the hypotonic polyuria syndrome. We discuss the management of CDI with particular emphasis on management of fluid intake and pharmacological replacement of AVP. Specific clinical syndromes such as adipsic diabetes insipidus and diabetes insipidus in pregnancy as well as management of the perioperative patient with diabetes insipidus are also discussed.

Diagnosis and Management of New-Onset Central Diabetes Insipidus in Critically Ill Children Varies between Pediatric Critical Care Medicine and Pediatric Endocrinology Clinicians

The diagnosis and management of central diabetes insipidus in critically ill children is not standardized. Our objective was to characterize differences between Pediatric Critical Care Medicine (PCCM) and Pediatric Endocrinology (PE) clinicians in the diagnosis and management of new-onset CDI in the pediatric intensive care unit. We also sought to characterize knowledge gaps among general pediatrics (GP) residents. This is a scenario-based survey to assess patterns of diagnosis and management of new-onset CDI that was distributed to PCCM, PE, and GP clinicians who work in a quaternary care urban children's hospital. Of 275 PCCM, PE, and GP clinicians surveyed, 158 (57%) responded. More PCCM than PE clinicians relied on serum sodium levels (96 vs. 75%, p <0.01) and more PE than PCCM clinicians relied on serum osmolality (91 vs. 40%, p < .001) for diagnosis. Fewer PCCM than PE clinicians favored restricting IV fluids to two-thirds maintenance rate (4 vs. 37%, p <0.001). More PCCM than PE clinicians favored a starting dose of 0.5 milli-units/kg/h for IV vasopressin infusion (76 vs. 53%, p = 0.048). More PCCM clinicians than PE clinicians favored titrating the IV vasopressin infusion every 20 minutes (24 vs. 2%, p = 0.02), whereas more PE clinicians than PCCM clinicians favored titration every 60 minutes (38 vs. 14%, p = 0.03). GP residents earlier in training had greater self-reported gaps in knowledge. We observed substantial variability in the diagnosis and management of new-onset CDI in critically ill children among PCCM, PE, and GP clinicians. There is a need for greater standardization in care of these patients.

Predictive factors for delayed hyponatremia after transsphenoidal surgery in patients with Rathke’s cleft cysts

Purpose

We aimed to assess factors influencing the occurrence of delayed hyponatremia after transsphenoidal surgery in patients with Rathke’s cleft cysts (RCCs).

Methods

We retrospectively collected the clinical data of patients who underwent transsphenoidal surgery for RCCs from January 2014 to January 2022. Univariate and multivariate analyses were used to determine the factors influencing the occurrence of postoperative delayed hyponatremia.

Results

Of the 78 microscopic transsphenoidal surgery recipients with RCCs, 15 experienced postoperative delayed hyponatremia. There were 35 men and 43 women, and mean age was 43.75 ± 14.95 years. The clinical manifestations of RCCs were headache (62 cases, 79.5%), visual dysfunction (35 cases, 44.9%), endocrine dysfunction symptoms (12 cases, 15.4%). After transsphenoidal surgery, 93.5% (58/62) had improvements in headache, and 97.1% (34/35) had improved or resolved compressive visual symptoms. Delayed hyponatremia occurred on average on day 6.46 and lasted on average for 4.40 days. Logistic regression analysis showed that the independent influencing factor of delayed hyponatremia after transsphenoidal surgery in patients with RCCs was postoperative diaphragma sellae height.

Conclusion

Postoperative diaphragma sellae height was identified as an independent influencing factor for delayed hyponatremia after transsphenoidal surgery in patients with RCCs.

The Efficacy of Targeted Perioperative Management for Diabetic Patients with Traumatic Calcaneal Fractures

Objective

To assess the efficacy of targeted perioperative management for diabetic patients with traumatic calcaneal fractures.

Methods

Between April 2020 and December 2020, 100 diabetic patients with traumatic calcaneal fractures treated in our institution satisfying the inclusion criteria were enrolled and assigned to receive either conventional treatment with surgery or plaster fixation (observation group) or targeted treatment with surgery or plaster fixation (experimental group) via the random number table method, with 50 patients in each group. All eligible patients were followed up for 1 year postoperatively. Outcome measures included length of hospital stay, recovery time, fracture healing, duration of postoperative wound drainage, complication rate, blood glucose, and treatment satisfaction. The Maryland score was used for the assessment of foot function.

Results

The duration of postoperative wound drainage, length of hospital stay, and recovery time in the experimental group (3.63 ± 1.04 d, 12.13 ± 3.77 d, and 111.22 ± 16.24 d) were significantly shorter than those in the observation group (5.71 ± 2.34 d, 15.28 ± 4.42 d, 123.10 ± 22.82 d) (P < 0.01). The experimental group obtained a markedly higher complete healing rate versus the observation group (P < 0.001). A significantly lower complication rate was observed in the experimental group than in the observation group (P < 0.05). The Maryland scores results were dichotomized into good (≥75 points) and poor (<75 points). The experimental group showed significantly higher Maryland scores good rate and treatment satisfaction versus the observation group (P < 0.01). The experimental group patients were associated with better postoperative fasting glucose and 2 h postprandial glucose versus those in the observation group (P < 0.05).

Conclusion

Targeted treatment in the perioperative management of diabetic patients with traumatic calcaneal fractures significantly promotes the recovery of patients, reduces the incidence of complications, increases treatment satisfaction, and ameliorates the doctor-patient relationship.

Diabetes Insipidus after Vasopressin Withdrawal: A Scoping Review

Objectives

The objective of this study is to synthesize the current literature about the relationship between the occurrence of diabetes insipidus (DI), its diagnosis criteria, and management after withdrawal of vasopressin (VP) in critically ill.

Data sources

This scoping review followed the recommendations of Preferred Reporting Items for Systematic Review and Meta-Analyses for Scoping Review (PRISMA-ScR). The search literature was conducted in MEDLINE and EMBASE databases, until March 2022. A manual search was also conducted in order to include articles that were not identified in the initial search performed in the databases.

Study selection and data extraction

The selection of studies and extraction of data were carried out in a paired and independent manner. There was no restriction regarding the language of publication of the included manuscripts.

Data synthesis

The analysis included 17 studies (16 case reports and one retrospective cohort). All studies used VP, with a median time of drug infusion of 48 hours (IQR: 16-72) and DI incidence of 1.53%. The diagnosis of DI was based on diuresis output and concomitant hypernatremia or changes in serum sodium concentration, with median time to symptoms onset after discontinuation of VP of 5 hours (IQR: 3-10). The treatment of DI consisted mainly of fluid management and the use of desmopressin.

Conclusions

DI after VP withdrawal was present in 51 patients described in 17 studies, but diagnosis and management varied among each report. Using the available data, we propose a diagnosis suggestion and a flowchart for managing patients with DI after withdrawal of VP in the Intensive Care Unit. Multicentric collaborative research is urgently needed to obtain more quality data on this topic.

How to cite this article

Pérsico RS, Viana MV, Viana LV. Diabetes Insipidus after Vasopressin Withdrawal: A Scoping Review. Indian J Crit Care Med 2022;26(7):846-852.

Autoimmunity Related to Adipsic Hypernatremia and ROHHAD Syndrome

Specific antibody responses to subfornical organs, including Na_x antibody, have been reported in patients with adipsic hypernatremia of unknown etiology who do not have structural lesions in the hypothalamic–pituitary gland. The subfornical organ, also referred to as the window of the brain, is a sensing site that monitors sodium and osmotic pressure levels. On the other hand, ROHHAD syndrome is a rare disease for which the etiology of the hypothalamic disorder is unknown, and there have been some reports in recent years describing its association with autoimmune mechanisms. In addition, abnormal Na levels, including hypernatremia, are likely to occur in this syndrome. When comparing the clinical features of adipsic hypernatremia due to autoimmune mechanisms and ROHHAD syndrome, there are similar hypothalamic–pituitary dysfunction symptoms in addition to abnormal Na levels. Since clinical diagnoses of autoimmunological adipsic hypernatremia and ROHAD syndrome might overlap, we need to understand the essential etiology and carry out precise assessments to accurately diagnose patients and provide effective treatment. In this review, I review the literature on the autoimmune mechanism reported in recent years and describe the findings obtained so far and future directions.

Sevoflurane anesthesia rather than propofol anesthesia is associated with 3-month postoperative hypocortisolism in patients undergoing endoscopic transsphenoidal surgery for non-functional pituitary adenoma with preoperative normal hypothalamic-pituitary-adrenal axis

PURPOSE

The effects of anesthetic technique on intermediate-term postoperative adrenocorticotropic hormone (ACTH) functional outcomes have not been fully determined in non-functioning pituitary adenoma (NFPA) patients. Postoperative hypocortisolism is potentially life-threatening and requires steroid replacement after pituitary surgery. The present study determined whether sevoflurane anesthesia was predictive of 3-month postoperative hypocortisolism in NFPA patients with preoperative normal hypothalamic-pituitary-adrenal (HPA) axis.

METHODS

Demographics, preoperative pituitary hormone status, intraoperative data, and tumor characteristics were retrospectively collected from 429 NFPA patients, who had preoperative normal HPA axis and underwent endoscopic transsphenoidal surgery. Patients were divided into two groups based on intraoperative anesthetic technique: sevoflurane-based inhalation anesthesia group (n = 74) and propofol-based intravenous anesthesia group (n = 355). After propensity score matching, 73 patients were selected in each group and the incidence of 3-month postoperative hypocortisolism (primary outcome measure) was compared between the two groups.

RESULTS

The incidence of 3-month postoperative hypocortisolism was higher in the sevoflurane anesthesia group than the propofol anesthesia group before (n = 20[27.0%] vs. n = 49[13.8%], P = 0.008) and after (n = 20 [27.4%] vs. n = 5 [6.8%], P = 0.002) propensity score matching, respectively. Sevoflurane anesthetic use (odds ratio [95% CI] 5.37[1.80-15.98], P = 0.003) and postoperative steroid administration (2.89 [1.06-7.92], P = 0.039) were predictors of 3-month postoperative hypocortisolism.

CONCLUSION

In patients with preoperative normal HPA axis undergoing endoscopic transsphenoidal surgery for NFPA, sevoflurane anesthesia and postoperative steroid administration were associated with the development of 3-month postoperative hypocortisolism. A large-scale prospective study is needed to confirm the negative association between sevoflurane anesthesia and postoperative ACTH functional outcome.

Change in cephalocaudal tumor cavity diameter after transsphenoidal surgery is a predictor of diabetes insipidus in pituitary adenoma

Objective

To assess the factors influencing the development of diabetes insipidus after transsphenoidal surgery for pituitary adenomas.

Methods

We retrospectively analyzed the clinical data of patients with pituitary adenoma who underwent transsphenoidal surgery. The pituitary gland was assessed using a 3.0 T magnetic resonance imaging, and the predictors of postoperative diabetes insipidus were determined through univariate and multivariate analyses.

Results

A total of 212 eligible patients with pituitary adenomas were included; 82 (38.7%) cases developed postoperative diabetes insipidus while 130 cases (61.3%) did not. Diabetes insipidus was transient in 80 (37.7%) patients and permanent in 2 (0.9%) patients. The results of logistic regression analyses showed that the change in cephalocaudal tumor cavity diameter after transsphenoidal surgery was associated with the occurrence of postoperative diabetes insipidus.

Conclusions

Change in cephalocaudal tumor cavity diameter after transsphenoidal surgery may play an important role in predicting diabetes insipidus onset in patients with a pituitary adenoma.

The role of social networks in diabetes self‐care: A cross‐sectional study

Background

Patient involvement with diabetes self‐care is critical to reducing complications, morbidity, and mortality. Social media, as one of the most important forms of digital health, has always been available for diabetes self‐care, although the role of these media in supporting patient self‐care is unclear.

Aims

The aim of this study was to investigate the role of social networks in diabetes self‐care. In this study, the most important social networks used to receive self‐care services, diabetes self‐care behaviors, diabetes self‐care educations and benefits of using various services provided through social networks were identified.

Methods

The present study is a cross‐sectional study that was conducted through an electronic researcher‐made questionnaire in 2021. Two hundred and eighteen patients were selected to participate in the study from centers of diabetes of Fasa city, south of Iran. Sampling was performed by convenience sampling and in accordance with inclusion and exclusion criteria. Data were analyzed by descriptive statistics and analytical tests.

Results

In the data analysis section on Diabetes self‐care behaviors, there was no significant relationship between gender (p = 0.292), age (p = 0.49), type of diabetes (p = 0.909) and duration of diabetes (p = 0.076) with the use of self‐care services provided through social networks. There was a significant relationship between education level and the use of self‐care services provided through social networks (p = 0.01). “Recognizing diabetes and its complications,” “observing personal hygiene,” and “the impact of physical activity on diabetes control” were the most important educations. “Increasing patient knowledge and understanding about diabetes and its complications,” “reducing the consumption of high‐calorie foods and sugars,” and “observing personal and public health” were the most important social network's benefits, respectively.

Conclusions

Various self‐care educations and services provided through social networks can increase the in‐depth knowledge of diabetic patients about self‐care techniques and their effective role in controlling and managing diabetes and performing more self‐care processes.

Predicting the Need for Desmopressin Treatment During Inpatient and After Discharge Following Endoscopic Sellar Surgery

Introduction

Postoperative diabetes insipidus (DI) is a common complication following endoscopic sellar surgery. However, the requirement of desmopressin treatment for patients with DI are heterogenous. Although the predictors of postoperative DI have been reported, whether these patients required desmopressin treatment remained uninvestigated. Predicting the need of desmopressin can benefit clinical decision making more directly than predicting the occurence of postoperative DI. This study aimed to identify variables that predict the need for desmopressin treatment following sellar surgery.

Methods

Patients undergoing endoscopic sellar surgery between 2016 and 2019 were retrospectively reviewed. Twenty-three variables, characterized as potential predictors for requiring desmopressin treatment, were analyzed. To assess the capability to generalize the identified predictors, external validation with receiver operating characteristic (ROC) analysis was performed using a second series from 2019 to 2020.

Results

Postoperative DI occurred in 40 of 159 included patients. Twelve patients required inpatient desmopressin treatment and 20 patients needed desmopressin prescription after discharge. The potential predictors of requiring any desmopressin use included higher peak sodium (Na) level (p = 0.007), lower minimum Na level (p = 0.043), and higher peak urine output (p = 0.006), but these were not supported by external validation. The predictors of requiring desmopressin after discharge included higher peak Na (p = 0.040) and minimum Na levels (p = 0.048), which were supported by external ROC validation showing areas under curve of 0.787, 0.611, and 0.898 for peak Na (p = 0.036), minimum Na (p = 0.460), and peak Na – minimum Na levels (p < 0.001), respectively. A criterion of peak Na ≥ 150 mmol/L or peak Na – minimum Na ≥ 10 predicted the need of desmopressin prescription after discharge. A postoperative management algorithm was proposed.

Conclusion

The required treatments for patients with postoperative DI following endoscopic sellar surgery are heterogenous. Elevated peak Na and large peak Na—minimum Na levels in the perioperative period predicted requiring desmopressin after hospital discharge. Patients with peak Na <150 mmol/L and peak Na—minimum Na <10 can be safely discharged without desmopressin prescription.

Costs and Its Determinants in Pituitary Tumour Surgery

PURPOSE

Value-based healthcare (VBHC) provides a framework to improve care by improving patient outcomes and reducing healthcare costs. To support value-based decision making in clinical practice we evaluated healthcare costs and cost drivers in perioperative care for pituitary tumour patients.

METHODS

We retrospectively assessed financial and clinical data for surgical treatment up to the first year after surgery of pituitary tumour patients treated between 2015 and 2018 in a Dutch tertiary referral centre. Multivariable regression analyses were performed to identify determinants of higher costs.

RESULTS

271 patients who underwent surgery were included. Mean total costs (SD) were €16339 (13573) per patient, with the following cost determinants: surgery time (€62 per minute; 95% CI: 50, 74), length of stay (€1331 per day; 95% CI 1139, 1523), admission to higher care unit (€12154 in total; 95% CI 6413, 17895), emergency surgery (€10363 higher than elective surgery; 95% CI: 1422, 19305) and postoperative cerebrospinal fluid leak (€14232; 95% CI 9667, 18797). Intradural (€7128; 95% CI 10421, 23836) and combined transsphenoidal/transcranial surgery (B: 38494; 95% CI 29191, 47797) were associated with higher costs than standard. Further, higher costs were found in these baseline conditions: Rathke's cleft cyst (€9201 higher than non-functioning adenoma; 95% CI 1173, 17230), giant adenoma (€19106 higher than microadenoma; 95% CI 12336, 25877), third ventricle invasion (€14613; 95% CI 7613, 21613) and dependent functional status (€12231; 95% CI 3985, 20477). In patients with uncomplicated course, costs were €8879 (3210) and with complications €17551 (14250).

CONCLUSIONS

Length of hospital stay, and complications are the main drivers of costs in perioperative pituitary tumour healthcare as were some baseline features, e.g. larger tumors, cysts and dependent functional status. Costs analysis may correspond with healthcare resource utilization and guide further individualized care path development and capacity planning.

Novel Nomograms to Predict Delayed Hyponatremia After Transsphenoidal Surgery for Pituitary Adenoma

OBJECTIVE

This study aimed to develop a nomogram of clinical variables and magnetic resonance imaging scans to predict delayed hyponatremia after transsphenoidal surgery for pituitary adenoma.

METHODS

Patients who underwent transsphenoidal surgery for pituitary adenoma in Fuzong Clinical Medical College of Fujian Medical University between January 2012 and December 2020 were retrospectively investigated. Medical records, MRI findings, and laboratory examination results were recorded as candidate variable predictors of delayed hyponatremia. A nomogram to predict delayed hyponatremia was formulated based on the multivariable model of risk factors. The predictive accuracy and discriminative ability of the nomogram were assessed using the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analyses. The model underwent prospective validation in three medical centers with patients who underwent transsphenoidal surgery for pituitary adenoma between January 2021 and February 2022.

RESULTS

The model that incorporated the postoperative length of "measurable pituitary stalk," pituitary stalk deviation angle difference, postoperative diabetes insipidus, sinking depth of diaphragma sellae, and blood sodium level on the second postoperative day was developed and presented as the nomogram of the training cohort. The nomogram achieved area under the ROC curve (AUCs) of 0.806 and 0.849 for the training cohort and the testing cohort, respectively, and displayed good calibration. Decision curve analysis showed that the nomogram was clinically useful when the threshold probability was 13-96%.

CONCLUSIONS

We developed a nomogram to evaluate the individualized prediction of delayed hyponatremia after transsphenoidal surgery for pituitary adenomas.

Postoperative water and electrolyte disturbances after extended endoscopic endonasal transsphenoidal surgery

INTRODUCTION

Water and electrolyte disturbances are common after pituitary surgery and can generally be classified into transient hypotonic polyuria and transient or permanent diabetes insipidus (DI). The prevalence varies in the literature between 31-51% for transient hypotonic polyuria, 5.1-25.2% for transient DI, and 1-8.8% for permanent DI.

OBJECTIVE

The aim of this study was to identify the prevalence of water and electrolyte disturbances with polyuria and the preoperative and postoperative predictive factors in patients undergoing surgery with an extended endoscopic endonasal approach.

MATERIAL AND METHODS

This retrospective observational descriptive study included 203 patients with a diagnosis of pituitary adenoma who underwent their first transsphenoidal surgery via the extended endoscopic endonasal approach between April 2013 and February 2020. The diagnosis of water and electrolyte disturbances was based on the criterion for polyuria (>4 ml/kg/h). Postoperative polyuria was defined as those cases diagnosed during the immediate postsurgical period that resolved prior to discharge. Transient DI included all cases with a duration of less than 6 months but still present at hospital discharge, and permanent DI included cases lasting more than 6 months.

RESULTS

The overall prevalence of water and electrolyte disorders was 30.5% (62), and the prevalence of postoperative polyuria was 23.6% (48). The median number of desmopressin doses administered to patients with postoperative polyuria was one dose (interquartile range [IQR] 1-2), and thus the median duration of treatment was 0 days. The median initiation of desmopressin was the second day after surgery (IQR 1-2). The overall prevalence of DI was 6.89%. Among the patients with transient DI, the duration was less than 3 months in three patients (1.47%), and between 3 and 6 months in two (0.98%). Nine patients had permanent DI (4.43%). (4.43%).

CONCLUSIONS

The prevalence of electrolyte disturbances in our study was high, although similar to that found in the literature. Most of the cases were transient hypotonic polyuria that resolved within one day. The prevalence of transient DI in our cohort was lower than that described in the literature, while permanent DI was similar.

Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score

OBJECTIVE

To identify risk factors for the development of postoperative diabetes insipidus (DI) in a modern cohort of endoscopic endonasal transsphenoidal surgery.

METHODS

Analysis of prospectively collected data of 449 consecutive patients operated on for anterior skull base pathology. DI was defined as a polyuria (> 250 ml/h for ≥ 2 consecutive hours) polydipsia syndrome associated with hypotonic urine with or without hypernatraemia. Multivariate logistic regression was used to identify predictors of postoperative DI. A simple scoring system was then created.

RESULTS

Postoperative DI occurred in 46 (10.2%) patients. The development of DI did not affect quality of life. Predictors of DI on multivariate analysis included suprasellar extension (OR 2.2; p = 0.04), age < 50 years (OR 2.8; p = 0.003), craniopharyngioma histology (OR 6.7; p = 0.002), and Kelly grade 3 intraoperative CSF leak (OR 2.1; p = 0.04). The SALT score was created based on these characteristics, with one point awarded for each feature present, and predicted DI with fair to good predictive value in our cohort (AUROC 0.735 (95%CI 0.65-0.82)). The rates of postoperative DI were 4.0%, 6.5%, 15.0%. 36.8% and 85.7% for SALT scores of zero, one, two, three, and four, respectively.

CONCLUSIONS

The SALT score predicts postoperative DI with fair to good accuracy, and now requires prospective external validation. Improved prediction of DI could optimize resource allocation and facilitate individualised preoperative patient counselling. We also provide our algorithm for diagnosis and treatment of DI.

Increased oxytocin release precedes hyponatremia after pituitary surgery

PURPOSE

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a well-known complication of transsphenoidal pituitary surgery, related to inappropriate secretion of arginine vasopressin (AVP). Its diagnosis is based on hyponatremia, with a peak of occurrence around day 7 after surgery and, to date, no early marker has been reported. In particular, copeptin levels are not predictive of hyponatremia in this case. Oxytocin (OXT) is secreted into the peripheral blood by axon terminals adjacent to those of AVP neurons in the posterior pituitary. Besides its role in childbirth and lactation, recent evidences suggested a role for OXT in sodium balance. The contribution of this hormone in the dysnatremias observed after pituitary surgery has however never been investigated.

METHODS

We analyzed the urinary output of OXT in patients subjected to transsphenoidal pituitary surgery.

RESULTS

While OXT excretion remained stable in patients who presented a normonatremic postoperative course, patients who were later diagnosed with SIADH-related hyponatremia presented with a significantly increased urinary secretion of OXT 4 days after surgery.

CONCLUSION

Taken together, these results show for the first time that urinary OXT output remains normally stable after transsphenoidal pituitary surgery. OXT excretion however becomes abnormally high on or around 4 days after surgery in patients later developing hyponatremia, suggesting that this abnormal dynamics of OXT secretion might serve as an early marker for transsphenoidal surgery-related hyponatremia attributed to SIADH.