Elsevier

World Neurosurgery

Volume 110, February 2018, Pages e1072-e1077
World Neurosurgery

Original Article
Delayed Occurrence of Diabetes Insipidus After Transsphenoidal Surgery with Radiologic Evaluation of the Pituitary Stalk on Magnetic Resonance Imaging

https://doi.org/10.1016/j.wneu.2017.11.169Get rights and content

Background

Diabetes insipidus (DI) is a major complication of transsphenoidal surgery (TSS). DI usually occurs within a couple of days after TSS. Delayed occurrence of postoperative DI is rarely observed and its developing mechanisms remain unknown.

Methods

Six patients were identified as having postoperative delayed DI, which was defined as DI that first occurred 2 or more weeks after TSS. They consisted of 1 male and 5 females, and their mean age was 38.3 years (range, 10–76 years). Five patients were histologically diagnosed with Rathke cleft cyst (RCC), and one had RCC coexisting with prolactin-secreting adenoma. Sequential T1-weighted magnetic resonance imaging was evaluated for hyperintensity (HI) in the pituitary stalk and the posterior lobe, indicating the location of antidiuretic hormone.

Results

No patients had any DI before TSS. Delayed DI occurred 2 weeks to 3 months after TSS and persisted for 2 weeks to 5 months. T1-weighted magnetic resonance imaging showed that the HI in the posterior lobe became faint but did not disappear after DI occurrence, and their intensities increased with recovery from DI. In contrast, the HI in the pituitary stalk was found faintly preoperatively and turned clear postoperatively and decreased with recovery from DI. The morphologic patterns were dependent on DI duration.

Conclusions

In the delayed occurrence of DI, it was suggested that preoperative antidiuretic hormone transport was mildly congested yet not completely blocked when DI manifested postoperatively. Gradual spreading of inflammation to the infundibulum after RCC removal was considered as 1 possible mechanism of this delayed DI development.

Introduction

Transsphenoidal surgery (TSS) has become the main surgical procedure for sellar and parasellar lesions. Despite remarkable advances in operative techniques and instruments, including endoscopy, central-type diabetes insipidus (DI) remains a major complication of TSS. Because superconductive magnetic resonance imaging (MRI) has recently made it possible to visualize normal and pathologic anatomy, the pathophysiology of the infundibuloneurohypophyseal (INH) system and the mechanism underlying DI development have been gradually elucidated.1, 2, 3 Generally, postoperative DI occurs immediately after TSS4, 5, 6; however, rarely has it been observed occurring postoperatively after some extent of time.

The complex of antidiuretic hormone (ADH) and neurophysin (carrier protein) is packed within a phospholipid membrane and the existence of these neurosecretory granules is shown as hyperintensity (HI) in the posterior lobe of the pituitary gland on T1-weighted MRI.7, 8, 9 To preserve the function of the INH system normally, the transportation of the granules is maintained along the axon in the pituitary stalk to its terminal in the posterior lobe.7, 9, 10 The disappearance of the HI in the posterior lobe suggests the development of central-type DI.10, 11, 12, 13 In addition, the HI in the pituitary stalk indicates that the ADH transport is disturbed from the hypothalamus to the posterior lobe. At the proximal site of obstruction, ADH is congested in the pituitary stalk, leading to a lack of ADH in the posterior lobe.1, 14, 15, 16 Therefore, MRI can evaluate the function of the INH system, as well as providing a morphologic diagnosis.3, 7, 9, 17

Most cases of postoperative DI arise within a couple of days after TSS and are transient because the transport of ADH recovers after a period.4, 5, 6 However, few cases manifest permanent DI, requiring ADH replacement. In the current study, 6 cases of delayed occurrence of postoperative DI were analyzed from clinical and radiologic aspects. Assessment of the changes in HI, on T1-weighted images (WIs) in both the pituitary stalk and the posterior lobe, were useful to elucidate both the clinical pictures and the developing mechanisms of this unusual type of DI after TSS, which gives important suggestions for proper management.

Section snippets

Patient Characteristics

This study was approved by the Kanazawa University institutional review board. In this retrospective clinical study, 310 patients who underwent TSS for sellar and parasellar tumors between 2006 and 2016 at Kanazawa University Hospital were reviewed. Delayed occurrence of postoperative DI was defined as DI that first manifested more than 2 weeks after TSS. In our clinical database, we found 6 suitable patients (1.9%) who had delayed occurrence of postoperative DI. Pituitary tumors had been

Patient Characteristics

The patients consisted of 1 male and 5 females, with a mean age of 38.3 years (range: 10–76 years). Their histologic diagnoses were RCC in 5, and RCC coexisting with prolactin-secreting adenoma in 1. Their symptoms were headache in 4 patients, visual function disturbance in 3, and amenorrhea caused by prolactin-secreting adenoma in 1. No patients encountered any intraoperative or postoperative complications (Table 1).

Radiographic features of the patients in this study are described as follows:

Discussion

Postoperative transient DI has been reported in 10%–60% of patients who have undergone TSS.17 In most cases, DI occurs immediately after TSS but infrequently can remain permanent.4, 5, 6, 19 Because the delayed occurrence of postoperative DI is rarely observed, the clinical features and developing mechanisms have not been examined in detail. In the present study, 6 cases of delayed occurrence of postoperative DI were diagnosed and all recovered completely.

First, one of the notable points in

Conclusions

Preoperative ADH transport was mildly congested in patients with postoperative delayed DI and was not completely blocked even during DI manifestation. Moreover, if HI can be observed in the pituitary stalk, postoperative DI is self-limiting and the functional integrity of the INH system is maintained. The HI in the posterior lobe was preserved, although it became faint during the DI. In addition, 5 of 6 patients had RCC and RCC coexisted with pituitary adenoma in the remaining patient;

References (27)

  • I. Fukui et al.

    Significant improvement in chronic persistent headaches caused by small Rathke cleft cysts after transsphenoidal surgery

    World Neurosurg

    (2017)
  • S.J. Pawar et al.

    Rathke's cleft cyst presenting as pituitary apoplexy

    J Clin Neurosci

    (2002)
  • A.D. Elster

    Modern imaging of the pituitary

    Radiology

    (1993)
  • M.J. Naldich et al.

    Current approaches to imaging of the sellar region and pituitary

    Endocrinol Metab Clin North Am

    (1993)
  • S. Zucchint et al.

    Role of magnetic resonance imaging in hypothalamic pituitary disorders

    Horm Res

    (1995)
  • J. Hensen et al.

    Prevalence, predictors and patterns of postoperative polyuria and hyponatraemia in the immediate course after transsphenoidal surgery for pituitary adenomas

    Clin Endocrinol (Oxf)

    (1999)
  • E.C. Nemergut et al.

    Predictors of diabetes insipidus after transsphenoidal surgery: a review of 881 patients

    J Neurosurg

    (2005)
  • S. Shah et al.

    Diabetes insipidus after pituitary surgery: incidence after traditional versus endoscopic transsphenoidal approaches

    Am J Rhinol

    (2001)
  • I. Fujisawa

    Magnetic resonance imaging of the hypothalamic-neurohypophyseal system

    J Neuroendocrinol

    (2004)
  • C.A. Holder et al.

    Magnetization transfer imaging of the pituitary: further insights into the nature of the posterior “bright spot”

    J Comput Assist Tomogr

    (1997)
  • H. Kurokawa et al.

    Posterior lobe of the pituitary gland: correlation between signal intensity on T1-weighted MR images and vasopressin concentration

    Radiology

    (1998)
  • I. Fujisawa et al.

    Transection of the pituitary stalk: development of an ectopic posterior lobe assessed with MR imaging

    Radiology

    (1987)
  • N. Colombo et al.

    Posterior pituitary gland: appearance on MR images in normal and pathologic states

    Radiology

    (1987)
  • Cited by (7)

    • Sodium Perturbations After Pituitary Surgery

      2019, Neurosurgery Clinics of North America
      Citation Excerpt :

      In most cases, DI manifests shortly after pituitary surgery (1–3 days postoperatively), although delayed DI is also reported in patients with Rathke's cleft cyst.25 In such patients, the mechanism of delayed DI is not well understood, but it is thought to be related to the release of cyst contents causing inflammation near the neurohypophysis.26 Conversely, hypernatremia can rapidly ensue in the presence of thirst abnormalities such as adipsia or hypodipsia from hypothalamic osmoreceptor damage, or if the patient is unconscious or cognitively impaired.

    View all citing articles on Scopus

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    View full text