Pulmonary Atypical Carcinoid Tumor with Metastatic Involvement of the Pituitary Gland Causing Functional Hypopituitarism

ObjectiveTo report a unique case of a peripherally located pulmonary atypical carcinoid tumor with metastatic involvement of the pituitary, manifesting with evidence of functional hypopituitarism and compressive symptoms of dysarthria, bitemporal loss of vision, and ataxia.MethodsWe present a case report, including detailed laboratory, radiologic, and pathologic findings in a 50-year-old woman with a peripherally located pulmonary atypical carcinoid tumor and a lesion metastatic to the pituitary gland. The pertinent literature is also reviewed.ResultsA 50-year-old woman with a medical history of metastatic pulmonary atypical carcinoid tumor presented with symptoms of bitemporal hemianopia, ataxia, and dysarthria. Laboratory evaluation revealed functional hypopituitarism, and magnetic resonance imaging of the brain with use of gadolinium contrast demonstrated a pituitary lesion measuring 3.5 by 2.5 by 2.5 cm. Visual field testing revealed bitemporal superior quadrantanopia, consistent with a pituitary lesion of the chiasm. Computed tomographic angiography excluded the presence of an aneurysm of the internal carotid artery. Subsequently, the patient underwent subtotal transsphenoidal hypophysectomy. Findings on pathology examination were consistent with a lesion metastatic from the primary pulmonary atypical carcinoid tumor. The patient subsequently received monthly octreotide injections as well as chemotherapeutic regimens of capecitobine and temozolomide. At 18-month follow-up, disease had not recurred.ConclusionThis case of metastatic involvement of the pituitary gland from a peripherally located pulmonary atypical carcinoid tumor manifesting with evidence of functional hypopituitarism is highly uncommon. To our knowledge, such a case has not been previously reported. The presentation of an advanced pituitary metastatic lesion can be particularly dramatic, and the course can be potentially complicated. Therefore, heightened awareness of the possibility of a pituitary lesion metastatic from a pulmonary atypical carcinoid tumor is important. (Endocr Pract. 2007;13:291-295)     

Moyamoya syndrome following growth hormone-secreting pituitary adenoma

We report a case of Moyamoya syndrome developing in association with growth hormone-secreting pituitary adenoma. A 31-year-old female presented with acromegalic features. Magnetic resonance imaging revealed a 1 × 2 cm tumor in the sella turcica and MR angiography demonstrated unremarkable findings. Blood growth hormone and insulin-like growth factor I levels were elevated to 74.1 ng/ml and over 1 575 ng/ml, respectively. The diagnosis was growth hormone-secreting pituitary adenoma, and the tumor was removed through a transsphenoidal approach. Four years after surgery, she visited the outpatient department due to left side weakness for 2 months. Magnetic resonance images showed acute and old infarcted lesions in the basal ganglia and subcortical area and residual small pituitary adenoma in the sellar area. MR angiography demonstrated stenosis of the bilateral distal internal carotid arteries with basal collateral vessels. Conventional cerebral angiography showed complete obstruction in the right internal carotid artery and severe stenosis of the left internal carotid artery, middle cerebral artery, and anterior cerebral artery with basal collateral vessels. Her blood growth hormone and insulin-like growth factor I levels were 15.3 ng/ml and 1 055 ng/ml, respectively. We believe that excess systemic exposures of growth hormone and insulin-like growth factor I may participate in the development of Moyamoya syndrome.     

Kawasaki disease causing saccular aneurysms of the coronary arteries

A 22-year-old man was referred for treatment of a 45 mm saccular aneurysm of the right coronary artery (RCA) and a 15 mm saccular aneurysm of the left anterior descending artery (LAD). The patient developed Kawasaki disease in 1998. The aneurysms were diagnosed in 2002. The RCA showed thrombus formation. Until now the patient had remained asymptomatic. He now presented with effort angina. On coronary angiography and magnetic resonance imaging, an occluded aneurysm of the proximal RCA (45 mm) was seen with a second aneurysm more distally (22 mm).     

Hybrid repair of a very late, post-aortic coarctation surgery thoracic aneurysm: a case report

ABSTRACT: INTRODUCTION: Local aneurysms after surgical repair of coarctation of the aorta occur mainly in patients surgically treated by Dacron patch plasty during adulthood. The management of these patients is always problematic, with frequent complications and increased mortality rates. Percutaneous stent-graft implantation avoids the need for surgical reintervention. CASE PRESENTATION: We report a case involving the hybrid treatment by stent-graft implantation and transposition of the left subclavian artery to the left common carotid artery of an aneurysmal dilatation of the thoracic aorta that occurred in a 64-year-old Caucasian man, operated on almost 40 years earlier with a Dacron patch plasty for aortic coarctation. Our patient presented to our facility for evaluation with back pain and shortness of breath after minimal physical effort. A physical examination revealed stony dullness to percussion of the left posterior thorax, with no other abnormalities. The results of chest radiography, followed by contrast-enhanced computed tomography and aortography, led to a diagnosis of giant aortic thoracic aneurysm. Successful treatment of the aneurysm was achieved by percutaneous stent-graft implantation combined with transposition of the left subclavian artery to the left common carotid artery. His post-procedural recovery was uneventful. Three months after the procedure, computed tomography showed complete thrombosis of the excluded aneurysm, without any clinical signs of left lower limb ischemia or new onset neurological abnormalities. CONCLUSIONS: Our patient's case illustrates the clinical outcomes of surgical interventions for aortic coarctation. However, the very late appearance of a local aneurysm is rather unusual. Management of such cases is always difficult. The decision-making should be multidisciplinary. A hybrid approach was considered the best solution for our patient.     

Delay in diagnosis of hypopituitarism after traumatic head injury: a case report and review of the literature

Neuroendocrine complications are among important and frequently missed complications of traumatic brain injury. Hypopituitarism, the partial or complete insufficiency of anterior pituitary secretion may be underrecognized due to its subtle clinical manifestations in traumatic patients. We report a case of 14.5-year-old girl who was admitted due to growth failure and had been diagnosed to have multiple hypophyseal hormone deficiency including thyroid-stimulating hormone, gonadotropins, adrenocorticotropin hormone which developed years after traumatic head injury.     

Monophasic synovial sarcoma presenting as a primary ileal mass: a case report and review of the literature

Introduction

Iliocaval fistulas can complicate an iliac artery aneurysm. The clinical presentation is classically a triad of hypotension, a pulsatile mass and heart failure. In this instance, following presentation with multiorgan failure, management included the immediate use of an endovascular stent graft on discovery of the fistula.

Case presentation

A 62-year-old Caucasian man presented to our tertiary hospital for management of iatrogenic trauma due to the insertion of a central venous line into his right common carotid artery, causing transient ischemic attack. Our patient presented to a peripheral hospital with fever, nausea, vomiting, acute renal failure, acute hepatic dysfunction and congestive heart failure. A provisional diagnosis of sepsis of unknown origin was made. There was a 6.5 cm×6.5 cm right iliac artery aneurysm present on a non-contrast computed tomography scan. An unexpected intra-operative diagnosis of an iliocaval fistula was made following the successful angiographic removal of the central line to his right common carotid artery. Closure of the iliocaval fistula and repair of the iliac aneurysm using a three-piece endovascular aortic stent graft was then undertaken as part of the same procedure. This was an unexpected presentation of an iliocaval fistula.

Conclusion

Our case demonstrates that endovascular repair of a large iliac artery aneurysm associated with a caval fistula is safe and effective and can be performed at the time of the diagnostic angiography. The presentation of an iliocaval fistula in this case was unusual which made the diagnosis difficult and unexpected at the time of surgery. The benefit of immediate repair, despite hemodynamic instability during anesthesia, is clear. Our patient had two coronary angiograms through his right femoral artery decades ago. Unusual iatrogenic causes of iliocaval fistulas secondary to previous coronary angiograms with wire and/or catheter manipulation should be considered in patients such as ours.     

Traumatic aneurysm in persistent sciatic artery

A 59-year-old male patient admitted to our hospital with a pulsatile right gluteal mass with history of formation after blunt trauma. Persistent sciatic artery and its traumatic aneurysm was diagnosed after medical examination followed by peripheric digital substraction angiography. Surgery was performed under general anesthesia, and the patient was discharged from the hospital on postoperative day 7 without any problems. The sciatic artery, a continuation of the internal iliac artery into the popliteal-tibial vessels, represents the major blood supply to the lower limb in early embryologic development. Its persistence is very rare, and the aneurysmatic dilatation is the most common pathology diagnosed. Here, we present a rare case of persistent sciatic artery presenting with a traumatic aneurysm treated by iliopopliteal bypass surgery and ligation of the internal iliac artery proximal to the aneurysm.     

Remission of Acromegaly After Pituitary Apoplexy: Case Report and Review of Literature

ObjectiveTo identify and present cases of acromegaly in which pituitary apoplexy resulted in remission of acromegaly, with normalization of insulinlike growth factor-I and growth hormone levels.MethodsWe present a case history of a personal patient and review the related literature in PubMed and Ovid MEDLINE.ResultsA 34-year-old man with classic acromegaly had spontaneous pituitary apoplexy, resulting in remission of his acromegaly and diabetes. Moreover, we identified 21 other similar cases in the literature and analyze the clinical presentations, possible apoplexy triggers, and hormonal sequelae. All these patients were “cured” of acromegaly, and 68% of them experienced other pituitary hormone insufficiencies after pituitary apoplexy, including 2 cases of panhypopituitarism.ConclusionPituitary apoplexy can result in remission of acromegaly and in partial or complete anterior or posterior (or both) pituitary insufficiency. Thus, after suspected or confirmed pituitary apoplexy, pituitary hormone secretion must be reevaluated. This assessment may result in initiation of appropriate substitution therapy, a change in management of growth hormone overproduction, or both interventions. (Endocr Pract. 2009;15:725-731)     

Superiority of magnetic resonance imaging (MRI) over computerized tomography (CT) in diagnosis of hypopituitarism]

Hypopituitarism can be a result of various lesions of hypothalamus, pituitary stalk, or of the pituitary gland itself. The aim of the study was to assess the value of CT and MRI examinations in determination of the cause of hypopituitarism. Seventeen patients with hypopituitarism (9 women and 8 men) aged 22 to 61 years have been examined. In three cases growth deficiency was observed, 4 women had galactorrhoea, 4 patients had diabetes insipidus, 16 patients had supra-adrenal insufficiency, 14 had signs of hypogonadism and 10 hypothyroidism. In each case plasma concentrations of LH, FSH, PRL, TSH, alpha-subunit, ACTH before and after appropriate stimulation with TRH, metoclopramid, LH-RH, GRF or metyrapon were determined with RIA. Every patient was examined both with CT and MRI (0.5 T Toshiba MRT 50a). All 17 patients had abnormal MR images of hypothalamo-pituitary area, while only 10 of them had abnormalities in their CT scans. In remaining 7 patients the MRI revealed: three cases of congenital malformation of hypophyseal stalk, two cases of empty sella, one posttraumatic lesion of the stalk and one case of granulomatous infiltration of the stalk. We found MRI superior to CT in establishing the case of hypopituitarism.     

Reports of two cases of selective adrenocorticotropin (ACTH) and growth hormone (GH) deficiency: differential diagnosis from cases with isolated ACTH deficiency associated with transient GH insufficiency

An acquired partial pituitary insufficiency with selective ACTH and GH deficiency was demonstrated in two men aged 47 and 54, for which the clinical course over many years corresponds to Addison's disease. In one of the 2 cases, antibodies to anterior pituitary cell membrane, assayed by an immunofluorescence method with GH3 cells (rat GH and prolactin secreting cell) and AtT-20 cells (mouse ACTH secreting cell) as antigens, were positive. We also present a 55-year-old man with isolated ACTH deficiency associated with transient GH deficiency. In this case, hydrocortisone replacement corrected his subnormal, pre-therapy GH response to insulin tolerance and glucagon propranolol tests, although there was no response of serum GH to L-dops and arginine stimulation test before therapy. Selective ACTH and GH deficiency are very rare and the finding of transient GH insufficiency in a patient with isolated ACTH deficiency suggests that repeated testing while on hydrocortisone replacement therapy is of great diagnostic importance in order to distinguish between selective ACTH and GH deficiency and isolated ACTH deficiency accompanied by transient GH insufficiency.     

树鼩(Tupaia belangeri chinensis)的脑底动脉环

用25只树鼩,从升主动脉灌注带色的橡胶乳液,在解剖显微镜下进行解剖观察,用目测微尺进行测量。大多数树鼩(22只)有完整的脑底动脉环。由左、右大脑前动脉向内侧各发一前交通动脉组成大脑前总动脉。前交通动脉口径为大脑前动脉的75～85％。后交通动脉口径与大脑后动脉相近,连于颈内动脉与大脑后动脉(基底动脉的分支)之间。测量了组成脑底动脉环有关动脉的口径。由于后交通动脉足够粗大,只有中断左、右颈总动脉和左、右椎动脉,才能造成全脑缺血。     

Aneurysm Characteristics Associated with the Rupture Risk of Intracranial Aneurysms: A Self-Controlled Study

This study analyzed the rupture risk of intracranial aneurysms (IAs) according to aneurysm characteristics by comparing the differences between two aneurysms in different locations within the same patient. We utilized this self-controlled model to exclude potential interference from all demographic factors to study the risk factors related to IA rupture. A total of 103 patients were diagnosed with IAs between January 2011 and April 2015 and were enrolled in this study. All enrolled patients had two IAs. One IA (the case) was ruptured, and the other (the control) was unruptured. Aneurysm characteristics, including the presence of a daughter sac, the aneurysm neck, the parent artery diameter, the maximum aneurysm height, the maximum aneurysm width, the location, the aspect ratio (AR, maximum perpendicular height/average neck diameter), the size ratio (SR, maximum aneurysm height/average parent diameter) and the width/height ratio (WH ratio, maximum aneurysm width/maximum aneurysm height), were collected and analyzed to evaluate the rupture risks of the two IAs within each patient and to identify the independent risk factors associated with IA rupture. Multivariate, conditional, backward, stepwise logistic regression analysis was performed to identify the independent risk factors associated with IA rupture. The multivariate analysis identified the presence of a daughter sac (odds ratio [OR], 13.80; 95% confidence interval [CI], 1.65–115.87), a maximum aneurysm height ≥7 mm (OR, 4.80; 95% CI, 1.21–18.98), location on the posterior communicating artery (PCOM) or anterior communicating artery (ACOM; OR, 3.09; 95% CI, 1.34–7.11) and SR (OR, 2.13; 95% CI, 1.16–3.91) as factors that were significantly associated with IA rupture. The presence of a daughter sac, the maximum aneurysm height, PCOM or ACOM locations and SR (>1.5±0.7) of unruptured IAs were significantly associated with IA rupture.     

Hypophyseal angioarchitecture of common tree shrew (Tupaia glis) revealed by scanning electron microscopy study of vascular corrosion casts.

The vascular corrosion cast technique in conjunction with scanning electron microscopy (SEM) was used for the study of pituitary microvascularization in the common tree shrew (Tupaia glis). The pituitary vascular casts were obtained by infusion of low viscosity methyl methacrylate plastic (Batson's no.17) mixture. It was found that the blood supplies to the pituitary complex were from branches of the circle of Willis and could be divided into two groups. The first group consisted of two to four superior hypophyseal arteries (SHAs) branching off from the internal carotid artery supplying each half of the median eminence (ME), infundibular stalk (IS), and pars distalis (PD). The SHAs supplying the ME branched into internal and external capillary plexi. The internal plexus had a larger capillary size (approximately 15 microns in diameter), was deeper in position, and had denser and more complex capillary loops than those in the external plexus. The capillaries of the external plexus were approximately 10 microns in diameter. The two plexi drained into 15-20 hypophyseal portal veins (HPVs) which were located mainly along the ventral and ventrolateral surfaces of the IS before breaking up into large capillaries (approximately 18 microns in diameter) with an anteroposterior arrangement within the PD. The second group consisted of one inferior hypophyseal artery (IHA) on each side branching off from the internal carotid artery. These arteries gave off branches to pierce the dorsolateral and ventrolateral aspects of infundibular process (IP) before branching off to form a capillary network. They also gave rise to radiating capillaries to supply the pars intermedia (PI) surrounding the cortical area of the IP. The hypophyseal cleft separating the PI from the PD was clearly seen with very few blood vessels. The capillaries in both PD and IP joined to form confluent hypophyseal veins draining the blood into the cavernous sinus.     

手术夹闭与介入栓塞治疗对前交通动脉瘤患者认知功能的影响

目的:探讨前交通动脉瘤手术夹闭与介入栓塞两种治疗方法对前交通动脉瘤患者认知功能的影响。方法:采用简易精神状态量表(MMSE)对206例前交通动脉瘤患者进行分析对照,其中开颅动脉瘤夹闭患者125例,介入栓塞患者81例,另取正常组40例作为对照组。结果:前交通动脉瘤患者术前即有认知功能障碍发生,术后患者认知功能障碍发生率增高(P<0.01)。患者组的术后认知功能障碍发生率明显高于对照组,而患者组中的介入组的术后认知功能障碍发生率明显小于手术夹闭组(P<0.05)。结论:前交通动脉瘤患者术前既有认知功能障碍发生,两种治疗手段对术前即出现的认知功能障碍无改善作用,并且可能增加认知功能障碍的发生率及加重认知功能障碍的程度,而介入栓塞术在认知障碍的发生率及出现认知功能障碍的程度方面都优于开颅动脉瘤夹闭术。     

Expérience clinique avec une épreuve de réserve hypophysaire

A test of pituitary reserve was used in the investigation of 14 children with retarded growth and 15 adults with endocrine disorders. Mepyrapone (Metopiron), 500 mg. every four hours, was administered orally for 48 hours. The pituitary response was determined by the amount of 17-hydroxycorticosteroid in a 24-hour urine sample (by a modification by Peterson of the Porter-Silber method). Pituitary reserve was decreased in four patients who were pituitary dwarfs, one who had retarded growth, two patients with Sheehan''s syndrome, three with pituitary tumours, one who had panhypopituitarism without a tumour, and one case of limited adrenal reserve (confirmed by a negative response to ACTH stimulation). The pituitary reserve was normal in three patients with gonadal dysgenesis, three who exhibited retarded growth, one case of diabetes insipidus, one cretin, one patient treated by steroids, three with psychogenic amenorrhea, and five normal controls. It is concluded that this test of pituitary reserve is useful in the assessment of children with growth retardation and in establishing the diagnosis of pituitary insufficiency in adults.     

FALSE ANEURYSM OF THE LEFT VENTRICLE: CASE REPORT WITH PRE- AND POSTOPERATIVE EVALUATION

A 66-year-old woman developed chronic congestive heart failure after myocardial infarction of the anterior wall of the left ventricle. Angiographic studies revealed total proximal occlusion of the left anterior descending coronary artery and a large saccular aneurysm located on the anteroapical aspect of the left ventricle. Resection of a false aneurysm at operation resulted in improved cardiac function, and the patient made an uneventful recovery. Repeat evaluation six months later confirmed normal cardiac hemodynamics and left ventricular angiographic characteristics. To our knowledge, this is the first documented case of normalized heart function resulting from resection of a false aneurysm of the left ventricle. Functional classification according to the New York Heart Association improved dramatically, rising from Class IV preoperatively to Class I after operation.     

Amaurosis fugax and carotid artery disease: indications for angiography.

A prospective study of 80 patients presenting with amaurosis fugax was performed in an attempt to relate clinical features to angiographic findings in the internal carotid artery. Carotid bruit, transient cerebral ischaemic attacks, hypertension, and claudication were associated with a high prevalence of angiographic abnormality. Every patient who showed all these features had an operable lesion, as did 88% of those who had three features. In patients over 50 years of age carotid stenosis and atheromatous ulceration were occasionally found in the absence of bruit and transient cerebral ischaemia, but only one patient aged under 50 had an operable lesion and no associated features. Clinical features were therefore valuable in predicting the outcome of angiography, but it seems prudent to restrict angiography to patients aged over 50, who are most likely to benefit from surgery on the carotid artery.     

Carotid artery injury with cerebral infarction following head and neck blunt trauma: report of a case

Blunt injury to the carotid artery is rare but may produce a devastating outcome with longterm morbidity. Initial recognition by clinicians is often difficult because of the diverse clinical manifestations, the delay in presentation of symptoms, and the associated multi-organ system injuries that accompany carotid injury. Early diagnosis and successful management of traumatic carotid artery injury require a high index of clinical suspicion. We report herein a 20-year-old male victim of internal carotid artery injury induced by a motorcycle accident, who initially presented with a clear consciousness and had normal computed tomogram (CT) of brain. Two days after injury, the patient suffered from left hemiplegia and coma. The follow-up brain CT showed acute infarction of right cerebrum and severe cerebral edema. Emergency craniotomy for brain decompression and anticoagulation therapy was carried out. After a three-month treatment, he was discharged and underwent regular follow-up in the outpatient department. Six months later, the patient had intact awareness but remained in a left-sided hemiparetic state.     

Blood vessel size of circulus arteriosus cerebri (circle of Willis): a statistical research on 100 human subjects

The brain weight of 100 fresh cadavers of Italian subjects (60 males and 40 females), aged between 17 and 84 years, was obtained and the corrected circumference of the following blood vessels was measured: basilar artery, internal carotid arteries, anterior and posterior cerebral arteries, and anterior and posterior communicating arteries. The cerebral 'potential flow' was expressed in each case by adding the circumference of the basilar artery to that of the internal carotid arteries. Moreover, the sides and the perimeter of the circle of Willis as well as the length of the basilar artery were calculated. The statistical analysis of the obtained data yielded the following main results: (1) the brain weight decreases with aging, is lower in females than in males and and is statistically correlated neither with the circumferences of the considered arteries and the 'potential flow' nor with the perimeter of the arterial polygon (circle of Willis); (2) the arteries of the left side appear to be larger than those of the right one; (3) no significant difference exists in the circumference and length of the arteries between males and females; (4) the increase of the perimeter of the arterial polygon is achieved by means of a harmonious increase of all its sides; (5) the anterior and posterior communicating arteries have an anarchic pattern, because of the relatively frequent anomalies and the lack of a correlation between their circumference and that of the vessel of origin or of outlet.     

MYOCARDIAL INFARCTION FOLLOWING CAROTID ENDARTERECTOMY

Myocardial infarction has been the major cause of mortality following operation for cerebrovascular insufficiency. In our institution, a clinical diagnosis of coronary artery disease was made in 37 of 125 (29.6%) consecutive male patients having carotid endarterectomy. Six of these 37 patients developed postoperative myocardial infarction. In contrast, none of the 88 patients without coronary artery disease developed myocardial infarction. A more recently treated group of 20 patients who had undergone carotid artery surgery and had previously undergone coronary artery bypass for angina did not develop postoperative myocardial infarction. These data suggest that in patients with both coronary artery and carotid artery disease, prior or concomitant coronary artery bypass should be considered. Myocardial infarction has been the leading cause of early and late death following operation for cerebrovascular insufficiency.(1) DeBakey(2) found operative mortality in patients having surgery for cerebrovascular insufficiency directly related to the incidence of coronary artery disease. An increased operative mortality due to reinfarction has been found in patients recovering from recent myocardial infarction.(3) Cooley(4) found that in patients having aortocoronary bypass there was no increased operative mortality 30 days after myocardial infarction and this may apply to patients having carotid endarterectomy. Subendocardial postoperative infarction associated with minor T wave changes and slight enzyme elevation had a better prognosis than did transmural infarction causing significant Q waves, sequential ST and T wave changes and marked enzyme elevations.(5) The purpose of this study was to document our experience with myocardial infarction in patients undergoing carotid artery operation for clinical coronary artery disease. Consideration of the role of saphenous vein bypass in those patients with coronary artery disease was the background for this review even though the evidence that myocardial infarction can be prevented with saphenous vein bypass operation is only preliminary at the present time.(6)