Spontaneous Resolution of Diabetes Insipidus After Pituitary Stalk Sectioning During Surgery for Large Craniopharyngioma-Endocrinological Evaluation and Clinical Implications for Surgical Strategy-

Abstract

The mechanism of spontaneous resolution of diabetes insipidus (DI) was investigated after surgery for large craniopharyngioma. Twenty-two adult patients (mean age 48.9 years old), who underwent surgery via the anterior interhemispheric trans-lamina terminalis approach, were divided into three groups: Group I, the entire pituitary stalk was preserved (n ＝ 2); Group II, the stalk was dissected distally from the tumor but ultimately sacrificed (n ＝ 9); Group III, the stalk was not identified and was sacrificed (n ＝ 11). All patients were discharged without neurological deficits 1 month after surgery. Four patients underwent gamma-knife treatment for residual tumor or recurrence. Postoperative endocrinological functions were normal in Group I, and no replacement therapy was required. Hormonal replacement for pan-hypopituitarism and DI was necessary in Groups II and III (mean follow-up period 5.9 years). DI resolved at 2.7 ± 1.3 years after surgery in four patients in Group II, and a hypertonic saline infusion test revealed production of small amounts of intrinsic antidiuretic hormone (ADH). Urine osmolarity was high in the morning, and a significant increase in urinary osmolarity was noted after Pitressin injection. These results indicate induction of hypersensitivity of the distal renal tubules to small amounts of intrinsic ADH, resulting in decreased urinary output. Recovery from DI can be expected, despite permanent impairment of anterior pituitary function, if the pituitary stalk is dissected as distally as possible.

Association of pituitary stalk management with endocrine outcomes and recurrence in microsurgery of craniopharyngiomas: A meta-analysis

“…Of these patients, 46 were dropped from the analysis since there were no follow-up data [7]. Other patients were excluded, including 5 patients who received immediate radiotherapy after surgery [5,15], two patients undergoing both transcranial surgery and gamma knife surgery before the second operation, one patient having transcranial surgery three times [16], 10 cases without ambiguous statistics [10], 16 patients with stereotactically guided cyst puncture, and/or biopsy and/or cerebrospinal fluid shunt placement [11], and 64 patients without pituitary stalk identification [11,12]. There were total 420 patients making up the study population, including 185 patients who had their pituitary stalk maintained and 235 patients who had their pituitary stalk removed.…”

“…It was reported that the epithelial squamous cell nest of the pars tuberalis of the adenohypophysis is the major source of craniopharyngioma [8]. Therefore, the handling of the pituitary stalk during surgery is important but controversial [5][6][7][9][10][11][12][13][14][15][16]. Although several investigations showed that maintenance of the pituitary stalk could reduce the risk of altered endocrine function complication after surgery [6,[9][10][11], it was also frequently reported that the pituitary stalk might have lost its function due to the invasion of the craniopharyngioma [16][17][18].…”

Late Recovery of Cranial Diabetes Insipidus following Pituitary Surgery

“…Nishizawa et al [8] reported improvement in the symptoms of DI and reduced need for desmopressin among 4 of 22 adult patients 2.7 ± 1.3 years following resection of suprasellar craniopharyngioma. This case series is remarkable as none of the patients appeared to have DI preoperatively.…”

Pituitary stalk craniopharyngioma

“…It is worth preserving the pituitary stalk, even though it is very difficult in surgeries involving large craniopharingiomas. It may be sacrificed for total removal of the tumour 17. The resultant hypothalamic pituitary hypofunction may require cortisol and thyroid hormone replacement therapy 17.…”

“…It may be sacrificed for total removal of the tumour 17. The resultant hypothalamic pituitary hypofunction may require cortisol and thyroid hormone replacement therapy 17. Patients may also develop DI and thus require nasal administration of desmopressin 17…”