Clinical syndromes of compression and surgical transection of the pituitary stalk

Background. The pituitary stalk (PS) is an anatomical structure consisting of the portal vessel system and axons of the hypothalamic nuclei terminating in the posterior pituitary lobe. Surgical injury or compression (by a tumor or another space-occupying process) of the PS can lead to hypopituitarism, diabetes insipidus, and hyperprolactinemia. However, the literature lacks studies on the extent of these disorders depending on PS injury or compression in clinical practice.

Aim. The study aim was to investigate pre- and postoperative endocrine disorders in patients with chiasmo-sellar region (CSR) tumors and the PS compressed and preserved or involuntarily transected during neurosurgery.

Material and methods. The PS compressed before surgery was preserved in 82 patients (41 patients with non-functioning endosuprasellar adenoma and 41 — with suprasellar meningioma). The PS was transected during transcranial surgery in 57 patients (46 patients with pituitary stalk craniopharyngioma and 11 patients with non-functioning endosupresellar pituitary adenoma). All patients underwent blood tests for prolactin (PRL), TSH, LH, FSH, free T4, cortisol, testosterone, or estradiol levels before and 6 months after surgery.

Results. Hyperprolactinemia was detected in 37.4% of patients with CSR tumors compressing the PS. Elimination of PS compression led to normalization of the PRL level in most patients and was not accompanied by worsening of hypopituitarism symptoms. Transection of the PS resulted in panhypopituitarism in 100% of patients and diabetes insipidus in 93% of cases. There was no evidence of hyperprolactinemia in 58.7% of patients with craniopharyngiomas and 81.9% of patients with non-functioning pituitary adenomas.

Conclusion. Given the difference in symptoms, we distinguished two syndromes: PS compression syndrome and PS transection syndrome. Syndrome of PS compression by a CSR tumor was characterized mainly by hyperprolactinemia (37.4% of cases); elimination of PS compression due to tumor resection led to normalization of the PRL level in most patients and was not accompanied by worsening of hypopituitarism symptoms. Syndrome of surgical PS transection in patients with craniopharyngioma (CP) and non-functioning pituitary adenoma (NFPA) manifested as panhypopituitarism in all patients and as permanent diabetes insipidus in most of them. The causes for the absence of hyperprolactinemia in many patients with the transected PS require further research. We can not exclude both adenohypophysis ischemia (due to its impaired blood supply) with partial or complete atrophy of lactotrophic cells and pituitary revascularization with restoration of dopamine transport.

пролактин, стебель (ножка) гипофиза, компрессия стебля гипофиза, хирургическое пересечение стебля гипофиза, несахарный диабет

1. Дедов И.И., Балаболкин М.И., Марова Е.И. Болезни органов эндокринной системы. — М.: Медицина; 2000. [Dedov II, Balabolkin MI, Marova EI. Bolezni organov endokrinnoy sistemy. Mоscоw: Meditsina; 2000. (In Russ.)].

2. Акмаев И.Г. Структурные основы механизмов гипоталамической регуляции эндокринных функций. — М.: Наука; 1979. [Akmaev IG. Strukturnye osnovy mekhanizmov gipotalamicheskoy regulyatsii endokrinnykh funktsiy. Mоscоw: Nauka; 1979. (In Russ.)].

3. Войткевич А.А., Дедов И.И. Ультраструктурные основы гипоталамической нейросекреции. — М.: Медицина; 1972. [Voytkevich AA, Dedov II. Ul’trastrukturnye osnovy gipotalamicheskoy neyrosekretsii. Moscow: Meditsina; 1972. (In Russ.)].

4. Бабичев В.Н. Основные представления о механизме функционирования системы «Гипоталамус—гипофиз—периферические эндокринные железы». В кн.: Аденомы гипофиза, клиника, диагностика, лечение. / Под ред. Кадашева Б.А. — Тверь; 2007. — С. 23—31. [Babichev VN. Osnovnye predstavleniya o mekhanizme funktsionirovaniya sistemy «Gipotalamus – gipofiz – perifericheskie endokrinnye zhelezy». In: Kadashev BA, editor. Adenomy gipofiza, klinika, diagnostika, lechenie. Tver’; 2007;23-31. (In Russ.)].

5. Netter FH. Atlas of human anatomy. Third Edition. New Jersey: Icon Learning Systems; 2002.

6. Melmed S. The pituitary. Second edition. Blackwell Science; 2002.

7. Fujisawa I, Kikuchi K, Nishimura K, et al. Transection of the pituitary stalk: development of an ectopic posterior lobe assessed with MR imaging. Radiology. 1987;165(2):487-489. doi: 10.1148/radiology.165.2.3659371

8. Gutch M, Kumar S, Razi SM, et al. Pituitary stalk interruption syndrome: Case report of three cases with review of literature. J Pediatr Neurosci. 2014;9(2):188-191. doi: 10.4103/1817-1745.139363

9. Pinto G, Netchine I, Sobrier ML, et al. Pituitary stalk interruption syndrome: a clinical-biological-genetic assessment of its pathogenesis. J Clin Endocrinol Metab. 1997;82(10):3450-3454. doi: 10.1210/jcem.82.10.4295

10. Guo Q, Yang Y, Mu Y, et al. Pituitary stalk interruption syndrome in Chinese people: clinical characteristic analysis of 55 cases. PLoS One. 2013;8(1):e53579. doi: 10.1371/journal.pone.0053579

11. Zhang F, Huang Y, Ding C, et al. The prevalence of hyperprolactinemia in non-functioning pituitary macroadenomas. Int J Clin Exp Med. 2015;8(10):18990-18997.

12. Kwancharoen R, Blitz AM, Tavares F, et al. Clinical features of sellar and suprasellar meningiomas. Pituitary. 2014;17(4):342-348. doi: 10.1007/s11102-013-0507-z

13. Halac I, Zimmerman D. Endocrine manifestations of craniopharyngioma.Childs Nerv Syst. 2005;21(8-9):640-648. doi: 10.1007/s00381-005-1246-x

14. Wildemberg LE, Vieira Neto L, Taboada GF, et al. Sellar and suprasellar mixed germ cell tumor mimicking a pituitary adenoma. Pituitary. 2011;14(4):345-350. doi: 10.1007/s11102-008-0161-z

15. Bouznad N, El Ansari N. Intra and latero-sellar carotid aneurysm mimicking a pituitary adenoma. Pan Afr Med J. 2015;22:150. doi: 10.11604/pamj.2015.22.150.8043

16. Астафьева Л.И., Марова Е.И., Кадашев Б.А., Коршунов А.Г. Сравнительное исследование пролактином и гормонально-неактивных аденом гипофиза с умеренной гиперпролактинемией. // Проблемы эндокринологии. — 2006. — Т. 52. — №3. — С. 30—33. [Astafyeva LI, Marova YI, Kadashev BA, Korshunov AG. Comparative study of prolactin-secreting and hormonally inactive pituitary adenomas in patients with moderate hyperprolactinemia. Problems of endocrinology. 2006;52(3):30-33. (In Russ.)].

17. Karavitaki N, Thanabalasingham G, Shore HC, et al. Do the limits of serum prolactin in disconnection hyperprolactinaemia need re-definition? A study of 226 patients with histologically verified non-functioning pituitary macroadenoma. Clin Endocrinol (Oxf). 2006;65(4):524-529. doi: 10.1111/j.1365-2265.2006.02627.x

18. Hong JW, Lee MK, Kim SH, Lee EJ. Discrimination of prolactinoma from hyperprolactinemic non-functioning adenoma. Endocrine. 2010;37(1):140-147. doi: 10.1007/s12020-009-9279-7

19. Arafah BM, Prunty D, Ybarra J, et al. The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas. J Clin Endocrinol Metab. 2000;85(5):1789-1793. doi: 10.1210/jcem.85.5.6611

20. Zayour DH, Selman WR, Arafah BM. Extreme elevation of intrasellar pressure in patients with pituitary tumor apoplexy: relation to pituitary function. J Clin Endocrinol Metab. 2004;89(11):5649-5654. doi: 10.1210/jc.2004-0884

21. Zaidi HA, Cote DJ, Castlen JP, et al. Time course of resolution of hyperprolactinemia after transsphenoidal surgery among patients presenting with pituitary stalk compression. World Neurosurg. 2017;97:2-7. doi: 10.1016/j.wneu.2016.09.066

22. Nomikos P, Ladar C, Fahlbusch R, Buchfelder M. Impact of primary surgery on pituitary function in patients with non-functioning pituitary adenomas — a study on 721 patients. Acta Neurochir (Wien). 2004;146(1):27-35. doi: 10.1007/s00701-003-0174-3

23. Adams JH, Daniel PM, Prichard MML. Some effects of transection of the pituitary stalk. Br Med J. 1964;2(5425):1619-1625. doi: 10.1136/bmj.2.5425.1619

24. Vaughan L, Carmel PW, Dyrenfurth I, et al. Section of the pituitry stalk in the rhesus monkey. Neuroendocrinology. 2008;30(2):70-75. doi: 10.1159/000122978

25. Anderson LL, Hard DL, Trenkle AH, Cho SJ. Long-term growth after hypophyseal stalk transection and hypophysectomy of beef calves. Endocrinology. 1999;140(5):2405-2414. doi: 10.1210/endo.140.5.6735

26. Adams JH, Daniel PM, Prichard MML. Transection of the pituitary stalk in man: anatomical changes in the pituitary glands of 21 patients. J Neurol Neurosurg Psychiatry. 1966;29(6):545-555. doi: 10.1136/jnnp.29.6.545

27. Honegger J, Buchfelder M, Fahlbusch R. Surgical treatment of craniopharyngiomas: endocrinological results. J Neurosurg. 1999;90(2):251-257. doi: 10.3171/jns.1999.90.2.0251

28. Hayashi Y, Kita D, Watanabe T, et al. Prediction of postoperative diabetes insipidus using morphological hyperintensity patterns in the pituitary stalk on magnetic resonance imaging after transsphenoidal surgery for sellar tumors. Pituitary. 2016;19(6):552-559. doi: 10.1007/s11102-016-0739-9

29. Fujisawa I. Magnetic resonance imaging of the hypothalamic-neurohypophyseal system. J Neuroendocrinol. 2004;16(4):297-302. doi: 10.1111/j.0953-8194.2004.01183.x

30. Arafah BM, Nekl KE, Gold RS, Selman WR. Dynamics of prolactin secretion in patients with hypopituitarism and pituitary macroadenomas. J Clin Endocrinol Metab. 1995;80(12):3507-3512. doi: 10.1210/jcem.80.12.8530591