CC BY
42
was observed in 15 infants (75%) LDL - 17 (80%) and TG - in 13 children (60%) of the group. Reduction of HDL was found in 6 children (40%).
After 12 months of therapy with metformin was found a significant reduction in total cholesterol to 6.1 ± 0.28 mmol/l to 5.3 ± 0.22 mmol/l (P < 0.001), 6 months later these figures with 5.3 ± 0.22 mmol/l decreased to 4.2 ± 0.22 mmol/l. LDL before treatment averaged 2.8 ± 0.8 mmol/l, and after 3 months was 2.6 ± 0.2 mmol/l, and after 6 months 2.4 ± 0.2 mmol/l (P < 0.001). TG levels were also significantly decreased from 1.2 ± 0.7 mmol/l, after 6 months there was a significant decline in 1.1 ± 0.5 mmol/l.
Against the background of the treatment in 16 children (80%) decreased triglyceride levels, and 3 children (20%) managed to reach the target level.
The results of our work had a predominant influence on therapy with metformin, a standard treatment in the clinical and metabolic parameters in children with asthma. This effect is related to indicators, carbohydrate and fat metabolism, and had a statistically significant effect in children with MS.
Conclusions
1. Recommended treatment regimens that include reducing insulin resistance - metformin, the correction of body weight, recovery of carbohydrate and lipid metabolism, and normalization of all components of MS, advanced mode of physical activity, subcalorie diet bronchial asthma in school-age children have a positive effective lead in achieving long-term remission and improving prognosis of disease.
References:
1. Вавилова Н. Н. Способ восстановительного лечения больных бронхиальной астмой с избыточной массой тела//Бюллетень, Выпуск 35. - 2010. - С. 21-25.
2. Александров О. В., Алёхина Р. М., Григорьев С. П. Метаболический синдром//Российский медицинский журнал. - М., 2006. -№ 6. - С. 50-55.
3. Астафьева Н. Г., Гамова И. В., Удовиченко Е. Н., Перфилова И. А. Ожирение и бронхиальная астма//Лечащий врач. - 2014. -C. 63-68.
4. Балыкова Л. А., Солдатов О. М., Самошкина Е. С. Метаболический синдром у детей и подростков//Педиатрия. - М., 2010. -№ 3. - С. 127-134.
5. Ровда Ю. И., Миняйлова H. H., Сундукова Е. Л. Вопросы лечения и профилактики метаболического синдрома у детей и под-ростков//Педиатрия. - 2010. - Том. 89, № 5. - С. 150-155.
6. Pervanidou P., Aralestos A., Bastaki D. Increased circulating concentrations in children and adolescents obesity and the metabolic syndrome: a marker for early cardiac damage//Metabolism. - 2013. - Том. 62. - Р. 527-531.
Azizov Miralim Mirabidovich, post-graduate researcher of neurosurgery of a Republican Research Center of Emergency Medicine, Tashkent, Republic of Uzbekistan. E-mail: miralimazizov@gmail.com
Results of surgical treatment of patient with pituitary tumor apoplexy
Abstract:
Objective: Apoplexy in pituitary tumor, resulting from the acute hemorrhage or infarction mainly in pituitary adenomas, is a rare yet major clinical event with neurological, ophthalmological and hormonal urgent consequences. The authors describe their surgical experience with a series of 89 cases of pituitary apoplexy.
Methods: The 205 patients with pituitary tumor operated via transsphenoidal approach in our hospital between 20052015 and 89 cases with pituitary apoplexy were retrospectively analyzed. The indications for urgent transsphenoidal surgery were as follows: mental deterioration, rapid visual loss and pituitary insufficiency.
Results: The mean age of patients (39 male and 50 female) was 38 years. Pituitary apoplexy occurred as an initial manifestation of pituitary adenoma in all patients. Headache was the most common presenting symptom (88.7 %). Visual disturbance was found in 49.4 % of patients. 39.3 % of the patients had hypopituitarism. On magnetic resonance imaging (MRI), this catastrophic event accompanied with macroadenoma in a mean size of 26.5 mm. There was no specific complication in any of these patients.
Conclusion: The differential approach based on the account of features of a clinical case, possible increase already available pathologic infringements and high level of technics of operative intervention is a basis for favorable results of treatment at pituitary adenomas.
Keywords: pituitary adenoma, pituitary tumor apoplexy, transsphenoidal approach, hypothalamic syndrome.
Introduction meningism, and/or decreased level of consciousness, often with in-
Pituitary tumor apoplexy (PA) refers to the abrupt onset of volvement of optic nerves, chiasm and CN III, IV VI. The PA is po-a severe headache frequently accompanied with nausea, vertigo, tentially a life threatening pathology when the hemorrhage and/or
necrosis results to significant sudden increase in mass of the tumor [8, 4-6; 9, 160-164]. The incidence of apoplexy in pituitary adenomas occurs in 6-31 % patients. Asymptomatic (subclinic) forms consist 25 % from all operated of severe pituitary adenomas [5, 278-280; 6, 181-188; 7, 65-72; 8, 4-6.].
The biggest influence on the clinical picture of pituitary adenomas is rendered on the pathological processes developing in the tumor [4, 22-25]. Pituitary apoplexy irrespective of size of a clinical current is accompanied with vasospasm which can be the starting factor to development of fatal ischemia of the brain [2, 363-373; 3, 114-118; 1, 602-609; 10, 109-115].
Patients with pituitary adenomas consist the special group among sick of tumors of sella areas and in the absence of adequate treatment can lead to frequency increase fatal outcome, that it is necessary to consider at their management [2, 363-373].
The authors performed a retrospective analysis to evaluate clinical presentation, postoperative courses, and pathological findings in
a series of patients surgically treated for symptomatic pituitary apoplexy during last 10 years.
Clinical Material and Methods. Based on brain tumor database, 205 pituitary adenomas had been operated between 2005 and 2015. During this period, 89 patients (39 male and 50 female) were surgically treated for acute or subacute presentation of pituitary apoplexy. Using retrospective analysis of 89 patients, the reviewed the details of clinical presentations, radiologic findings, endocrine studies, pathologic findings, postoperative complication and outcomes (Fig. 1).
All patients underwent assessment of anterior pituitary function on admission and subsequent follow-up in department of endocrinology. Assessment of anterior pituitary function was made by measuring random serum levels of PRL, ACTH, cortisol, GH Free T4, T3, TSH, FSH and IGF-1. The presence of hypopituitarism was defined by proven biochemical deficiency of at least one endocrine axis. The degree of visual disturbance was assessed by Snellen visual acuity and automated visual field testing.
Fig. 1. The patients with invasive pituitary tumor complicated with intratumoral hemorrhage and total ophtalmoplegia
Surgical Management
In all patients the surgical treatment was a primary method of treatment. The pituitary decompression by transseptal-transs-phenoidal approach was performed within different period after apoplexy.
The technique was as follows: the patient is on a table in a supine position. All stages of operation were spent under the microscope and fluoroscope control. The operative microscope was used as the primary instrument for tumor visualization. Only one (right) nostril
was used in all patient. At the closing stage, the free fat graft was laid in the tumor resection cavity if a CSF leak encountered intraoperatively sphenoid sinus was paced with an absorbable sponge to provide additional support to the fat graft. On intraoperation, hemorrhage and necrosis was obtained in 50 (56.1 %) cases, in 39 (43.8 %) patients revealed massive intratumoral hemorrhage (fig. 3). For revealing of the feature pituitary apoplexy, it had been considered the early postoperative period and the nearest results of treatment are analysed. The scheme of sellar stage is shown in fig. 2.
Fig. 2. The scheme of sellar stage
Fig. 3. Removed tumor fragments
Results
Clinical features
The main presenting symptoms and signs are listed in the Table 1. Headache, typically of sudden onset, was the most common complaint, occurring in all but one patient. Headache was frequently in 96 % of patients associated with nausea, vomiting and visual symptoms. Neuroophthalmological evaluation was performed in all cases and revealed visual disturbance in 44 of cases. On visual field examination, bitemporal hemianopsia was found in 29 patients included 18 case of right temporal hemianopsia and left anopsia and 11 case of both temporal upper quadrantanopsia. Decreased visual acuity was recognized in 44 cases. 19 patient demonstrated altered consciousness (Table 1).
Table 1. - Common presenting symptoms and signs in 145 patients with pituitary apoplexy
Table 2. - Hormonal secretion characteristics in patient with pituitary apoplexy
Hormone secretion No
Hiperfuntion 39
GH 11
Prolactin 19
ACTH 9
Hipofunction 30
ACTH 6
TSH 4
GH 20
Normal function 15
Panhypopituitarism 5
Symptom and signs Number of patients ( %)
Headache 79 (88.7 %)
Altered consciousness 19 (21.3 %)
Nausea/vomiting 17 (19.1 %)
Decreaced visual acuity 44(49.4 %)
Visual field deficite 29 (32.5 %)
Ocular palsy 9 (10.1 %)
Endocrine and pathologic findings
The results of pituitary function test at presentation were available in all patients. In considerable portion of apoplectic patients, preoperative assessments of pituitary hormone were substituted by measurement of random serum levels of hormone because the patients were needed urgent operation. 66 patients had clinically nonfunctioning pituitary adenomas. 35 patients showed deficiency of one or more pituitary hormones; corticotropin deficiency was found in 6, thyrotrophin deficiency with adrenal insufficiency in 4, grow hormone deficiency in 20 and panhypopituitarism in 5. 15 patients had normal pituitary functions, and 39 patients had hyperpituitarism; hyperprolactinemia was found in 19 patient (Table 2).
Radiologic features and operative findings
All patients with apoplexy underwent MRI as a primary investigation (Fig. 1). All the tumors were macroadenomas, with an average size of 26.5 mm. According to Hardy classification, IIA, IIIA and IIB types were the most common ones (Tab. 5). Definitive hemorrhagic changes on MRI study were found in 57 cases; early subacute stage of hemorrhage in 17, late subacute stage of hemorrhage in 50. The cystic or necrotic degeneration ofpituitary adenoma was in 32 (Table 3, Fig. 4). Table 3. - Radiologic classification of size and extension in patients with pituitary apoplexy (based on the classification system by Hardy, modified by Wylson)
——^^^Extrasellar extention Destruction of sella turcica —— A B C D E
I 9 3 5 1 -
II 19 9 - 3 1
III 17 6 - - 2
IV 7 4 - - 3
In table 3 sella turcica destruction: I - local bulginig; II - diffuse bulding; III - focal destruction; IV - diffuse destruction. Extrasellar extention: A - suprasellar cistern only; B - up to 3rd ventricle floor; C - in or above 3rd ventical; D - intradural lateral extention; E - ex-tradural lateral extention.
■ ^
l
it,
^U- * 1
H ir Jb '.J h<-J , _ _ L
n
f ¿k
w n
fill ^
iJIHH c<
Fig. 4. MRI scans of a 24-year-old man who presented with headache, left ptosis and hipopituitarsm. A, B, C: Preoperative MRI scans show a 2.9 x 1.9 x 2.5 cm. sized pituitary macroadenoma with supra-para-infrasellar extension with intratumoral hemorrhage; D, E, F: Postoperative MRI scans was obtained 3 months later revealing decompression of optic nerve and nearly total removal of tumor
Outcomes
The average length offollow-up in this series was 10 days and there were 5 death cases. Patient's most recent clinical state at follow-up was assessed and divided into the following groups: no symptoms in 12 patients; non-disabling symptoms (requiring hormonal replacement) in 5 patients. Visual acuity was assessed after 3 month in 80 patients and was improved but not normal in 31, unchanged 9 and 4 was worse. Visual fields improved in 23, unchanged in 4 and were worse in 2 patients. Cranial nerve palsy regressed in 77.7 % of patients (Table 4). Data on postoperative endocrine function were available in all patients (Table 5). Among 15 patients with normal endocrine function before operation, 2 showed postoperative hypopituitarism. Among 35 patients who showed preoperative hypopituitarism, 5 needed continuous hormonal replacement. 12 patients had remnant mass after 3 and 6 month imaging study. All of them received radiotherapy and was managed with dopamine receptor agonist.
Table 4. - Postsurgical outcomes of visual and cranial nerve function of patient with PA
Improved Unchanged Worse
Visual acuity 31 (70.4 %) 9 (20.4 %) 4(9 %)
Visual field 23 (79.3 %) 4(13.7 %) 2 (6.8 %)
Ocular nerve palsy 7 (77.7 %) 2 (28.7 %) 0
Table 5. - Postsurgical endocrine outcomes of patients with pituitary apoplexy
Initial endocrine function Follow-up endocrine function
Hyperpituitarism Normal function Hypopituitarism
Hyperpituitarism (n = 39) 10 44 4
Hypopituitarism (n = 35) 0 0 35
Normal function (n = 15) 0 13 2
Complications of surgical treatment
For an estimation of results of treatment we used gradation of complications of the early postoperative period according to the recommendations developed in the Scientific Research Centre of Neurosurgery named after N. N. Burdenko. Postoperative complications have been divided into 3 degrees. Of complications in the postoperative period, headache was more frequent and occured in 25 (17 %) patient; moderately increase hypopituitarism in 6 (6.7 %); diabetes insipidus in 11 (12.3 %); CSF leak in 5 (5.6 %) cases; visual deterioration 15 (16.8 %). In majority of them regressed by the discharge moment from hospital. In our series (2 cases), abdominal fat graft were placed in the sella when postoperative CSF leak was encountered.
Huge complications have been related by brain blood circulation infringement. The mass effect produced by the infarct and oedematous brain, usually caused mortality in these cases. A 26 year old female presented with history of sudden onset of headache,
vomiting, ophthalmoplegia and rapid deterioration of vision in the right eye 3 week prior to admission at our hospital. She mentioned total loss of vision and decreased level of consciousness following admission. CT scan showed a hyperdense sellar mass with right parasellar extension. On steroids background she underwent an emergency transnasal transsphenoidal decompression of sellar cavity. At surgery, the tumor was necrotic with hemorrhage and was excised except for a small portion invading the right cavernous sinus. Afterwards, the patient was electively ventilated and follow-up CT scan [11] showed a large infarction in the right internal carotid artery territory with mass effect and midline shift. He developed signs of progressive brainstem dysfunction and diabetes insipidus, which was treated with desmopressin. Patient died on the tenth post operative day. The biopsy showed a pituitary adenoma with hemorrhage and necrosis. Autopsy showed an infarction in the right internal carotid artery territory. Coronal sections through the sella and parasellar region showed the evidence of compression of the right intracavernous internal carotid artery by the tumor.
In preoperative and postoperative period all patients re-cieved intensive therapy. Depending on prevalence of this or that kind of complication, the following medicine were included: microcirculation improves colloid solutions, glucocorticoids, desmopres-sine, neuroleptics and etc. Rapid hipotalamic syndrome (hipothal-amo-hipophiseal disfunction) developed in the early postoperative period, demanded immediate and active medical actions directed toward careful management of fluid and electrolyte balance.
Conclutions
The patients with pituitary apoplexy consist a special group among tumors of sellar area, and it is necessary to take into account at their diagnostics and management. The sudden headache, progressing ophthalmologic infringements, mental deteriorations should suggest the expert about pituitary apoplexy and to timely rendering of emergency specialised medical aid.
The mass effect produced by the infarction and oedematous brain, is usual cause of mortality in these cases. Methods of preventive maintenance ofpostoperative hemorrhages after subtotal surgical removal are as follow: local application of haemostatic means, control and correction of functions (mainly, arterial blood pressure and external breath) and indicators of system of haemo-coagulation.
According to our data, the favorable outcome is possible due to adequate preoperative and postoperative conservative therapy directed on correction of haemodynamic infringements and maintenance of the homeostasis.
Thus, the differential approach based on taking into account features of a clinical case, possible increasing of already available infringements and high level of technics of operative intervention are a mandatory terms for favorable results of treatment at pituitary apoplexy. Early transsphenoidal decompression with high-dose corticosteroid replacement result to good outcome for these patient.
References:
1. Bills D. C., Meyer F. B., Laws E. R. et al. A retrospective analysis of pituitary apoplexy. Clinical study//Neurosurgery. - 1993. - Vol. 33. -P. 602-609.
2. Cardoso E. R., Petersen E. W. Pituitary apoplexy: a review//Neurosurgery. - 1984. - Vol. 14. - P. 363-373.
3. Grigoriev A. U. Complication in early terms after operation at patients with pituitary adenomas. Dissertation. - Moscow. - P. 114-118.
4. Kadashev B. A. Tumors of sellar areas: neuro-endocrinology aspects//Materials of conference «Replaceable therapy hipotalamo-hipophiseal insufficiency». - M., 2001. - P. 22-25.
5. Mokry M. Pituitary apoplexy//Neurosurgery-96. Manual of Neurosurgery/Ed. by J. D. Palmer. - 1996. - P. 278-280.
6. Randeva H. S., Schoebel J., Byrne J., Esiri M., Adams C. B., Wass J. A. Classical pituitary apoplexy: clinical features, management and outcome//Clin Endocrinol (Oxf). - 51: 1999. - P. 181-188.
7. Semple P. L., Webb M. K., de Villiers J. C., Laws E. R. Jr. Pituitary apoplexy//Neurosurgery. - 56: 2005. - P. 65-72.
8. Ugryumov V. M. Surgery of the Central Nervous System//J. Medicine. - Leningrad, 1969. - P. 4-6.
9. VainshenkerJ. I. Syndrome ofpituitary apoplexy. Dissertation. - St.-Petersburg, 2001. - P. 160-164.
10. Weisberg L. A. Pituitary apoplexy: Association of degenerative change in pituitary adenoma with radiotherapy and detection by cerebral computed tomography//Am. J. Med. - 1977. - Vol. 63. - P. 109-115.
11. [Electronic resource]. - Available from: http://www.neurologyindia.com/article.asp?issn=0028-3886; year=2001; volume=49; issue=2; spage=191; epage=3; aulast=Lath.
Aliev Mansur Abdukholikovich, Samarkand State Medical Institute, Senior researcher, Department of Neurosurgery E-mail: dr.mansoor1982@mail.ru Mamadaliev Abdurakhmon Mamatkulovich, Doctor of Medical Sciences, Professor, Department of Neurosurgery
E-mail: mam412000@mail.ru Mamadalieva Saodat Abdurakhmonovna, Neurosurgeon, Clinic of Neurosurgery E-mail: saodat973@gmail.com
The study of the improved complex neurosurgical treatment in patients with posttraumatic chronic subdural hematomas and hygromas
Abstract: The article about improved complex neurosurgical treatment in patients with posttraumatic chronic subdural hematomas and hygromas use of endolumbally insufflation of ozone after operation. Received the positive results — improved clinical and neurological status in GOSE.
Keywords: chronic, subdural, hematoma, hygroma, ozone, GOSE.
For the present time among general traumatism cranio-cere-bral traumas (CCT) make 30-50 % and according to World Health Organization data every year this index has been on average in 2 %. The disability index after cranio-cerebral traumas has been examined in 25-30 % of patients and this index shows the actuality of the problem [8; 9; 11]. Among the consequences of CCT under acute and chronic subdural hematomas (CSH), also hygromas have a separate neurosurgical importance as nosologic unit.
Based on the literature data in the development of chronic subdural hematomas it requires time from 1 week to 4 months [5; 18; 1; 12; 13; 14; 19]. As a result of the received materials during surgical operations and morphologic investigations CSH-s have been developed after capsulated traumas or spontaneous rupture of blood vessels during the period of two weeks and exactly this period gives us the opportunity to divide hematomas into under acute and chronic forms [9; 12; 13]. To determine the formation period of CSH capsule is very difficult, because this process depends on the many individual features, such as premorbid status and properties of reactivity. It should been separately emphasized that after formation
of capsule, development and evolution process of this one require several months and several years [17; 6; 14].
According to the data of some investigators the probability of CSH development after CCT is 1.1-8 % i. e. in every 100 000 of population it has been occurred in 1.72 cases [2; 7]. Among all subdural hematomas chronic forms have been occurred in 8-63 % of cases and besides that among all intracranial chronic hematomas CSH has been occurred in 82-86 % of cases [2; 15]. Among all intracranial hemorrhages bilateral CSH-s have been occurred in 0.57 % of cases and only among CHS-s this index is 5-18 % [15; 16].
The aim of the scientific investigation was to improve the methods and results of complex treatment of posttraumatic subdural hematomas and subdural hygromas.
Material and methods of investigations. Scientific investigations have been carried out on the basis of assessment of 167 patients with the diagnosis of posttraumatic chronic and under acute subdural hematomas and hygromas (Fig. 1) who had surgical operations in the neurosurgical clinic of Samarkand State Medical Institute for the period of2003-2014 years.
Fig. 1. a) Bilateral chronic posttraumatic hygroma in the fronto-temporal regions of the brain (MRI);
b) Chronic posttraumatic chronic hematoma in the left fronto-temporal region of the brain (CT);
c) Chronic posttraumatic common subdural hematoma in the left hemisphere of the brain (MRI)
