Original ArticleDelayed Occurrence of Diabetes Insipidus After Transsphenoidal Surgery with Radiologic Evaluation of the Pituitary Stalk on Magnetic Resonance Imaging
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;
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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.