Predictive factors for delayed hyponatremia after transsphenoidal surgery in patients with pituitary adenomas

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Abstract

Objective

The aim of this study was to evaluate the incidence and duration of delayed hyponatremia and to assess the factors influencing the development of delayed hyponatremia after transsphenoidal surgery (TSS) in pituitary adenomas.

Methods

We retrospectively analyzed the clinical data of patients with pituitary adenoma who underwent TSS. Univariable and multivariable statistics were carried out to identify factors independently associated with the occurrence of delayed hyponatremia.

Results

Of the 285 patients with pituitary adenoma who underwent microscopic TSS, 44 (15.4%) developed postoperative-delayed hyponatremia and 241 (84.6%) did not. The onset of delayed hyponatremia occurred an average of 5.84 days post-surgery and persisted for an average of 5.36 days. Logistic regression analysis showed the highest risk of delayed hyponatremia in patients with significant change in tumor cavity height (odds ratio (OR), 1.158; 95% CI, 1.062, 1.262; P = 0.001), preoperative hypothalamus–pituitary–thyroid axis hypofunction (OR, 3.112; 95% CI, 1.481, 6.539; P = 0.003), and significant difference in blood sodium levels before and 2 days after TSS (OR, 1.101; 95% CI, 1.005, 1.206; P = 0.039).

Conclusions

Preoperative hypothyroidism, difference in blood sodium levels before and 2 days after TSS, and the change in tumor cavity height after TSS played important roles in predicting postoperative-delayed hyponatremia onset in patients with pituitary adenomas.

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Most cited references 24

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Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings.

E Knosp, E Steiner, K Kitz … (1993)

We present 25 pituitary adenomas that were confirmed surgically to have invaded the cavernous sinus space. The surgical results are compared with the preoperative magnetic resonance imaging findings. For comparable radiological criteria, we classified parasellar growth into five grades. This proposed classification is based on coronal sections of unenhanced and gadolinium diethylene-triamine-pentaacetic acid enhanced magnetic resonance imaging scans, with the readily detectable internal carotid artery serving as the radiological landmark. The anatomical, radiological, and surgical conditions of each grade are considered. Grades 0, 1, 2, and 3 are distinguished from each other by a medial tangent, the intercarotid line--through the cross-sectional centers--and a lateral tangent on the intra- and supracavernous internal carotid arteries. Grade 0 represents the normal condition, and Grade 4 corresponds to the total encasement of the intracavernous carotid artery. According to this classification, surgically proven invasion of the cavernous sinus space was present in all Grade 4 and Grade 3 cases and in all but one of the Grade 2 cases; no invasion was present in Grade 0 and Grade 1 cases. Therefore, the critical area where invasion of the cavernous sinus space becomes very likely and can be proven surgically is located between the intercarotid line and the lateral tangent, which is represented by our Grade 2. We also measured tumor growth rates, using the monoclonal antibody KI-67, which shows a statistically higher proliferation rate (P < 0.001) in adenomas with surgically observed invasion into the cavernous sinus space, as compared with noninvasive adenomas.

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Giant pituitary tumors: a study based on surgical treatment of 118 cases.

Atul Goel, Dhwani Desai, Umesh Phalke … (2004)

The aim of the study is to analyze the nature, extensions, and dural relationships of hormonally inactive giant pituitary tumors. The relevance of the anatomic relationships to surgery is analyzed. There were 118 cases of hormonally inactive pituitary tumors analyzed with the maximum dimension of more than 4 cm. These cases were surgically treated in our neurosurgical department from 1995 to 2002. Depending on the anatomic extensions and the nature of their meningeal coverings, these tumors were divided into 4 grades. The grades reflected an increasing order of invasiveness of adjacent dural and arachnoidal compartments. The strategy and outcome of surgery and radiotherapy was analyzed for these 4 groups. Average duration of follow-up was 31 months. There were 54 giant pituitary tumors, which remained within the confines of sellar dura and under the diaphragma sellae and did not enter into the compartment of cavernous sinus (Grade I). Transgression of the medial wall and invasion into the compartment of the cavernous sinus (Grade II) was seen in 38 cases. Elevation of the dura of the superior wall of the cavernous sinus and extension of this elevation into various compartments of brain (Grade III) was observed in 24 cases. Supradiaphragmatic-subarachnoid extension (Grade IV) was seen in 2 patients. The majority of patients were treated by transsphenoidal route. Giant pituitary tumors usually have a meningeal cover and extend into well-defined anatomic pathways. Radical surgery by a transsphenoidal route is indicated and possible in Grade I-III pituitary tumors. Such a strategy offers a reasonable opportunity for recovery in vision and a satisfactory postoperative and long-term outcome. Biopsy of the tumor followed by radiotherapy could be suitable for Grade IV pituitary tumors.

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Incidence, clinical manifestations, and course of water and electrolyte metabolism disturbances following transsphenoidal pituitary adenoma surgery: a prospective observational study.

G Neuloh, R Kristof, M Rother … (2009)

The authors prospectively studied the incidence, spectrum of clinical manifestations, course, and risk factors of water and electrolyte disturbances (WEDs) following transsphenoidal pituitary adenoma surgery. From the preoperative day to the 14th postoperative day, 57 successive patients undergoing transsphenoidal adenomectomy were monitored daily for body weight, balance of fluids, serum electrolytes, plasma osmolality, plasma antidiuretic hormone (ADH) levels, urinary sodium excretion, urinary osmolality, and subjective sensation of thirst. The type of adenoma operated on and the intraoperative manipulation of the neurohypophysis were also recorded. Fifty-seven patients (mean age 55 years, 61.4% females) harbored 30 clinically hormone-inactive and 27 hormone-secreting pituitary adenomas. Postoperative WED occurred in 75.4% of the patients: in 38.5% as isolated diabetes insipidus (DI); in 21% as isolated hyponatremia; and in 15.7% as combined DI-hyponatremia. The maximum of medians of diuresis (5.750 L) in patients with isolated DI occurred on postoperative Day 2. Nadir of medians of hyponatremia (132 mmol/L) in patients with isolated hyponatremia occurred on postoperative Day 9. In patients with combined DI-hyponatremia, maximum of medians of diuresis (5.775 L) occurred on the 2nd day and nadir of medians of hyponatremia (130 mmol/L) on the 10th postoperative day. Altogether, 8.7% of the patients had to be treated with desmopressin because of DI persisting for >3 months. Of all the patients with hyponatremia, 42.8% were treated by transient fluid-intake restriction due to an IH of <130 mmol/L with or without clinical symptomatology. Transient acute renal failure occurred in one of these patients. Generally, the occurrence of postoperative WEDs was linked to the intraoperative manipulation of the neurohypophysis. Increased thirst correlated significantly with DI (p=0.001 and 0.02, respectively) and decreased thirst with the hyponatremic episode in patients with combined DI-hyponatremia (p=0.003). Decreased urine osmolality correlated significantly with the presence of DI (p=0.023). Electrolyte-free water clearance and urinary Na+ excretion were not correlated with DI and hyponatremia. Antidiuretic hormone was not suppressed during hyponatremia. Water and electrolyte disturbances occurred in the majority of patients undergoing transsphenoidal adenomectomy and were usually transient. Diabetes insipidus is more frequent than hyponatremia. Diabetes insipidus usually occurs during the 1st postoperative day and resolves in the majority of cases within 10 days. In few patients, DI may persist and require therapy with ADH analogs. Hyponatremia usually occurs at the end of the 1st postoperative week and resolves in most cases within 5 days. Very few patients will need treatment other than fluid-intake restriction to avoid serious complications. Thus, careful monitoring of the WEDs in patients undergoing transsphenoidal pituitary adenoma surgery is mandatory for the first 10 postoperative days.

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Author and article information

Journal

Journal ID (nlm-ta): Endocr Connect

Journal ID (iso-abbrev): Endocr Connect

Journal ID (hwp): EC

Title: Endocrine Connections

Publisher: Bioscientifica Ltd (Bristol )

ISSN (Electronic): 2049-3614

Publication date (Electronic): 03 December 2021

Publication date Collection: 01 January 2022

Volume: 11

Issue: 1

Electronic Location Identifier: e210497

Affiliations

[1 ]Department of Neurosurgery , Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China

[2 ]Fuzong Clinical Medical College of Fujian Medical University , Fuzhou, China

[3 ]Department of Neurosurgery , Guiqian International General Hospital, Guiyang, China

[4 ]Department of Neurosurgery , 900th Hospital, Fuzhou, China

Author notes

Correspondence should be addressed to S Huang or S Wang: 1123228680@ 123456qq.com or wshsen1965@ 123456126.com

*(K Lin and L Lu contributed equally to this work)

Article

Publisher ID: EC-21-0497

DOI: 10.1530/EC-21-0497

PMC ID: 8789016

PubMed ID: 34860173

SO-VID: 7f053d87-47b2-4a32-a64c-d05d2651f0a6

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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Predictive factors for delayed hyponatremia after transsphenoidal surgery in patients with pituitary adenomas

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Bioscientifica Open Endocrinology

Most cited references 24

Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings.

Giant pituitary tumors: a study based on surgical treatment of 118 cases.

Incidence, clinical manifestations, and course of water and electrolyte metabolism disturbances following transsphenoidal pituitary adenoma surgery: a prospective observational study.

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