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Neurosurgery > Ch. 9 - Pituitary Tumors > Flashcards

Ch. 9 - Pituitary Tumors Flashcards

(54 cards)

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1
Q

Incidence of pituitary tumors

A

8-10% of all intracranial tumors

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2
Q

Pituitary adenoma origin

A

From anterior lobe (adenohypophysis)

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3
Q

Microadenoma vs. macroadenoma

A

Micro: < 10mm

Macro: >10mm

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3
Q

Pituitary adenoma spread and consequences

A

Local invasion inferiorly through floor of sella (CSF rhinorrhea)

Superiorly to suprasellar cisterns (compression of optic chiasm, hypothalamus, 3rd ventricle)

Laterally to cavernous sinus (CN disturbance)

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4
Q

Lateral microadenomas are more likely to produce which hormones?

A

Prolactin and GH

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6
Q

Central microadenomas are more likely to produce which hormone?

A

ACTH

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7
Q

Effects of prolactin

A

Breast growth and promotion of lactation; important in spermatogenesis

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8
Q

How is prolactin secretion regulated?

A

Dopamine blocks prolactin secretion (UNLIKE ALL OTHER PITUITARY HORMONES)

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9
Q

Characteristic presentation of prolactinomas

A

Young females with amenorrhea and galactorrhea; males with impotence

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10
Q

Prolactin level suggestive of pituitary adenoma

A

>2000 ng/mL (nl 70-550)

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11
Q

Other pituitary adenomas associated with hyperprolactinemia

A

GH and null cell can cause hyperprolactinemia 2/2 mass effect blocking DA secretion

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12
Q

Consequences of ACTH adenoma

A

ACTH stimulates adrenal cortex to secrete cortisol = CUSHING’S DISEASE

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13
Q

Null cell adenoma histology

A

Chromophobic (no cytoplasmic granules) + accumulation of mitochondria (then called ‘oncocytomas’)

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14
Q

Null cell adenoma presentation

A

Aggressive and grow quickly = visual disturbances

Hormonally silent

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15
Q

Factors affecting presentation of pituitary adenomas

A

Size of tumor + endocrine fxn of secreted hormones

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16
Q

Visual field deficits a/w pituitary adenoma

A

Compression of optic chiasm -> bitemporal hemianopsia

Compression of optic tract -> homonymous hemianopsia

Compression of posterior chiasm -> bilateral central scotomas

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17
Q

Extraocular deficits a/w pituitary adenomas

A

CN3, 4, 6 palsies

CN5 damage 2/2 cavernous sinus invasion causes facial pain

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18
Q

Sxs of hypopituitarism

A

Pre-pubertal: retards development of 2ndary sex characteristics

Post-pubertal: fatigue, muscle weakness, anorexia –> episodic confusion/drowsiness (severe) can be precipitated by stressful events

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19
Q

Sxs of pituitary apoplexy

A

Spontaneous hemorrhage into pituitary tumor = sudden severe HA, transient LOC + extraocular muscle paralysis (looks like SAH + EOM involvement)

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20
Q

What do GH-secreting tumors cause?

A

Kids - gigantism

Adults (30-40) - acromegaly (enlarged hands/feet, coarse/greasy skin, sweat profusely, HTN, cardiac hypertrophy, diabetes)

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21
Q

Cushing’s disease

A

ACTH-producing pituitary adenoma (80% microadenomas)

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22
Q

Cushing’s disease mortality

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A

50% at 5 years

23
Q

Cushing’s disease sxs

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A

Obesity, thin skin, striae, fat redistribution (moon face, buffalo hump), easy bruising, acne, facial hair, weakness/muscle atrophy, osteoporosis, glucose intolerance

24
Q

Causes of Cushing’s syndrome

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A

90% of cases 2/2 Cushing’s disease (ACTH-producing pituitary adenoma)

OTHER: adrenal adenoma/carcinoma or ectopic ACTH (small cell lung CA)

25
Nelson-Salassa syndrome
ACTH-producing pituitary adenoma in pt w/ bilateral adrenalectomy -\> no negative feedback -\> accelerated growth of existing adenoma (usually macroadenoma)
26
Cutaneous findings of Nelson-Salassa syndrome
Hyperpigmentation 2/2 beta-MSH production (ACTH breakdown product)
27
How is GH-secreting tumor diagnosed?
Glucose suppression test - measure GH following glucose bolus (should suppress normally) IGF-1 levels - indicator of GH activity Other: measure GHRH or TRH
28
How is Cushing's disease diagnosed?
1. Hypercortisolemia on 24 hr urine cortisol 2. Dexamethasone suppression test (high-dose will suppress pituitary adenoma but NOT ectopic or adrenal ACTH source) 3. Administer CRH and measure differential ACTH level in periphery/pertrosal sinus
29
Scan of choice for pituitary adenomas?
High resolution CT/MRI with contrast
30
Appearance of pituitary micro vs. macroadenoma on CT?
Micro: hypodense, upward bulging, deviation of pituitary stalk, thinning of sella Macro: contrast-enhancing lesion in sella, best seen on coronal section
31
Appearance of pituitary micro vs. macroadenoma on MRI?
Micro: T1 - hypointense T2 - hyperintense Macro: T1 - isointense T2 - hyperintense
32
Ddx of pituitary adenoma
Craniopharyngioma (pituitary gland embryonic tissue) OR suprasellar meningioma (part of sella turcica) Uncommon: optic nerve/hypothalamus glioma, aneurysm, Rathke's cleft cysts
33
Indications for surgical excision of pituitary adenomas
1. Large tumors compressing adjacent structures (esp. visual pathways) 2. GH-secreting (causing acromegaly) 3. ACTH secreting (causing Cushing's) 4. Refractory prolactinomas
34
Surgical approaches to pituitary adenomas
Transphenoidal vs. transcranial excision
35
Post-operative management of pituitary excision
Fluid balance and hormonal status! Endocrine deficiency replacement with (1) parenteral hydrocortisone and (2) vasopressin for transient DI
36
Indications for postoperative radiotherapy in pituitary adenomas
Subtotal excision or residual hormone secretion
37
Medical tx of micro prolactinomas
Bromocriptine = dopamine agonist; significant side effects (n/v, postural hypotension)
38
Craniopharyngioma origin
Epithelial remnants of Rathke's pouch
39
Craniopharyngioma histology
Cystic tumor with yellow fluid (cholesterol crystals) 1. Adamantinous - all children have this type 2. Papillary - 1/3 of adults, rare in children
40
Craniopharyngioma presentation
1. Elevated ICP (3rd ventricular obstruction) - HA, vomiting, papilledema 2. Visual impairment - papilledema vs. chiasmal compression (direct) 3. Endocrine abnormalities - hypogonadism, stunted growth, DI
41
Craniopharyngioma appearance on CT
Cystic tumor in suprasellar region with curvilinear calcification
42
DDx of craniopharyngioma
Rathke's cleft cyst
43
Craniopharyngioma tx
Pterional craniotomy vs. bifrontal craniotomy (top-down approach since tumor is suprasellar)
44
Empty sella syndrome
Communicating extension of subarachnoid space into pituitary fossa 2/2 defect in diaphragma sella OR pituitary surgery/radiotherapy OR increased ICP = herniation of subarachnoid space Considered ANATOMICAL VARIANT
45
Classic pt with empty sella syndrome
Obese, hypertensive, middle-age woman
46
Sxs of empty sella syndrome
HA, spontaneous CSF rhinorrhea
47
Tx of empty sella syndrome with CSF rhinorrhea
Repair leak in floor of sella with crushed muscle and fascia lata + CSF shunt
48
Anterior pituitary lobe vs. posterior lobe development
Anterior lobe - Rathke's pouch Posterior lobe - infundibulum (floor of diencephalon)
49
Hormones released by anterior pituitary? Posterior pituitary?
Anterior - GH, TSH, ACTH, prolactin, LH, FSH Posterior - ADH, oxytocin
50
What is the most common pituitary adenoma?
Prolactinoma (40%) \> GH adenoma (20%) = non-secreting adenoma (20%) \> ACTH adenoma (15%)
51
Population most commonly affected by craniopharyngiomas
Children and young adults; almost half occur in first 20 years of life
52
Identify the lesion
Pituitary macroadenoma
53
Identify the lesion
Craniopharyngioma
54
Identify the lesion
Empty sella syndrome

Neurosurgery (21 decks)

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