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Journal of the Royal Society of Medicine Volume 84 March 1992
fluid and electrolyte balance, that regular reappraisal of postoperative requirements should occur4. This can only be achieved by regular reference to fluid balance charts, clinical examination (including serial body weights) and, if necessary, biochemical analysis of urine and plasma5. Whilst we agree that prescription of postoperative intravenous fluids is often suboptimal, the mere availability of dextrose-saline solution cannot possibly be deemed causal. S COCKROFT M K BAXTER
Anaesthetics Unit
The Royal London Hospital Whitechapel, London El 1BB
References 1 British National Formulary, vol 21. London: BMA, 1991:303 2 Vaughan RS, Lunn JN. Potassium and the anaesthetist. Anaesthesia 1973;28:118-31 3 Moore FD, Ball MD. The metabolic response to surgery. Springfield, Illinois: Thomas, 1952 4 Jenkins MT, Giesecke AH, Johnson ER The postoperative patient and his fluid requirements. Br J Anaesth 1975; 47:143-50 5 Sweny P. Is postoperative oliguria avoidable? Br J Anaesth 1991;67:137-45
Cerebrospinal fluid rhinorrhoea in patients with pituitary adenoma treated medically We read with interest the article by Shone et al. (March 1991 JRSM, p 140). In their review of 35 patients with non-secretory pituitary adenomas treated by transethmoidal sellotomy, they reported that three patients developed cerebrospinal fluid (CSF) rhinorrhoea in the postoperative period. Similarly, Gransden et al.V reported that nine of their 114 patients developed CSF rhinorrhoea within 3 weeks of treatment with transsphenoidal hypophysectomy. However, CSF rhinorrhoea can occur as a delayed complication of surgical treatment of pituitary adenoma24. In addition, CSF rhinorrhoea can occur in patients with untreated pituitary adenoma5 or as a complication of medical treatment4'6. Aronoff et al.6 reported CSF rhinorrhoea occurring 5 weeks post treatment with bromocriptine for prolactin secreting pituitary adenoma6. This may be of serious consequence as in a patient reported by the authors4 in whom a large prolactinoma was treated with bromocriptine resulting in tumour shrinkage, unplugging of a bony defect in the sella floor and the development of CSF rhinorrhoea which led to meningitis. We now report an additional patient treated for a non-functioning pituitary adenoma with bromocriptine in whom CSF rhinorrhoea developed after 2 weeks. None of our three patients who developed rhinorrhoea brought this to medical attention spontaneously. We conclude that CSF rhinorrhoea which may antedate the diagnosis of pituitary adenoma or more commonly may occur as an immediate or late complication of surgical treatment, can also occur as a complication of medical treatment. During long-term follow-up, it is recommended that patients who are treated either medically or surgically for a pituitary adenoma, be warned to report the occurrence of CSF leak which carries the risk of meningitis. T M FIAD T J McKENNA
Department of Endocrinology and Diabetes Mellitus St Vincents Hospital, Elm Park, Dublin 4, Ireland
References 1 Gransden WR, Wickstead M, Eykyn SJ. Meningitis after transsphenoidal excision of pituitary tumours. JLaryngol Otol 1988;102:33-6 2 Ciric I, Mikhael M, Stafford T, Lawson L, Garces R. Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow up results. J Neurosurg 1983;59:395-401 3 Wilson CB, Dempsey LC. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 1978; 48:13-22 4 Fiad TM, McKenna TJ. Meningitis as a late complication of surgically and medically treated pituitary adenoma. Clin Endocrinol (in press) 5 Rothrock JF, Laguna JF, Reynolds AF. CSF rhinorrhoea from untreated pituitary adenoma. Arch Neurol 1982; 39:442-3 6 Aronoff SL, Daughaday WH, Laws ER. Bromocriptine treatment of prolactinomas (letter). N Engl J Med 1979;300:1391
Cardiogenic dementia I enjoyed reading the editorial on 'cardiogenic dementia' by Lane (October 1991 JRSM, p 577) which reiterated the close connection between the heart and the brain. The cardiac dysrhythmias resulting in 'cardiogenic dementia' can be either bradyrhythmias or tachyrhythmias. The most common example ofthe latter is atrial fibrillation with rapid ventricular response which has been called in the past 'delirium cordis' . One special form of delirium cordis is delirium tremens cordis which is seen among the alcoholics2. Although the disordered heart function can affect the brain, the reverse may also hold true. The altered mental state may render the diagnosis and treatment of acute myocardial infarction and early stages of congestive heart failure difficult or in some cases impossible. Furthermore, as indicated by the significant finding of cardiac rupture in nearly three-quarters of cases (16/22) of myocardial infarction in a psychiatric hospital3, demented cardiac patients may be more prone to catastrophic complications. Therefore, the importance of heart-brain and brainheart relationships received reinforced support from this excellent editorial. While the cardiologist must consider the cerebral consequences of cardiac disease, the neurologist cannot ignore the heart4. As the Chinese saying goes, 'heart is the seat ofthe soul but brain is the seat of the mind'. T 0 CHENG
Division of Cardiology, George Washington University Medical Center, Washington DC 20037, USA
References 1 White PD. Heart disease, 4th edn. New York: Macmillan, 1951:895 2 Cheng TO. Delirium tremens cordis. N Engl J Med 1973;289:593 3 Jetter WW, White PD. Rupture of the heart in patients in mental institutions. Ann Intern Med 1944;21:783802 4 Sherman DG, Hart RG, Shi F. Heart-brain interactions: neurocardiology or cardioneurology comes of age. Mayo Clin Proc 1987;62:1158-60
Journal of the Royal Society of Medicine Volume 84 March 1992
fluid and electrolyte balance, that regular reappraisal of postoperative requirements should occur4. This can only be achieved by regular reference to fluid balance charts, clinical examination (including serial body weights) and, if necessary, biochemical analysis of urine and plasma5. Whilst we agree that prescription of postoperative intravenous fluids is often suboptimal, the mere availability of dextrose-saline solution cannot possibly be deemed causal. S COCKROFT M K BAXTER
Anaesthetics Unit
The Royal London Hospital Whitechapel, London El 1BB
References 1 British National Formulary, vol 21. London: BMA, 1991:303 2 Vaughan RS, Lunn JN. Potassium and the anaesthetist. Anaesthesia 1973;28:118-31 3 Moore FD, Ball MD. The metabolic response to surgery. Springfield, Illinois: Thomas, 1952 4 Jenkins MT, Giesecke AH, Johnson ER The postoperative patient and his fluid requirements. Br J Anaesth 1975; 47:143-50 5 Sweny P. Is postoperative oliguria avoidable? Br J Anaesth 1991;67:137-45
Cerebrospinal fluid rhinorrhoea in patients with pituitary adenoma treated medically We read with interest the article by Shone et al. (March 1991 JRSM, p 140). In their review of 35 patients with non-secretory pituitary adenomas treated by transethmoidal sellotomy, they reported that three patients developed cerebrospinal fluid (CSF) rhinorrhoea in the postoperative period. Similarly, Gransden et al.V reported that nine of their 114 patients developed CSF rhinorrhoea within 3 weeks of treatment with transsphenoidal hypophysectomy. However, CSF rhinorrhoea can occur as a delayed complication of surgical treatment of pituitary adenoma24. In addition, CSF rhinorrhoea can occur in patients with untreated pituitary adenoma5 or as a complication of medical treatment4'6. Aronoff et al.6 reported CSF rhinorrhoea occurring 5 weeks post treatment with bromocriptine for prolactin secreting pituitary adenoma6. This may be of serious consequence as in a patient reported by the authors4 in whom a large prolactinoma was treated with bromocriptine resulting in tumour shrinkage, unplugging of a bony defect in the sella floor and the development of CSF rhinorrhoea which led to meningitis. We now report an additional patient treated for a non-functioning pituitary adenoma with bromocriptine in whom CSF rhinorrhoea developed after 2 weeks. None of our three patients who developed rhinorrhoea brought this to medical attention spontaneously. We conclude that CSF rhinorrhoea which may antedate the diagnosis of pituitary adenoma or more commonly may occur as an immediate or late complication of surgical treatment, can also occur as a complication of medical treatment. During long-term follow-up, it is recommended that patients who are treated either medically or surgically for a pituitary adenoma, be warned to report the occurrence of CSF leak which carries the risk of meningitis. T M FIAD T J McKENNA
Department of Endocrinology and Diabetes Mellitus St Vincents Hospital, Elm Park, Dublin 4, Ireland
References 1 Gransden WR, Wickstead M, Eykyn SJ. Meningitis after transsphenoidal excision of pituitary tumours. JLaryngol Otol 1988;102:33-6 2 Ciric I, Mikhael M, Stafford T, Lawson L, Garces R. Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow up results. J Neurosurg 1983;59:395-401 3 Wilson CB, Dempsey LC. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 1978; 48:13-22 4 Fiad TM, McKenna TJ. Meningitis as a late complication of surgically and medically treated pituitary adenoma. Clin Endocrinol (in press) 5 Rothrock JF, Laguna JF, Reynolds AF. CSF rhinorrhoea from untreated pituitary adenoma. Arch Neurol 1982; 39:442-3 6 Aronoff SL, Daughaday WH, Laws ER. Bromocriptine treatment of prolactinomas (letter). N Engl J Med 1979;300:1391
Cardiogenic dementia I enjoyed reading the editorial on 'cardiogenic dementia' by Lane (October 1991 JRSM, p 577) which reiterated the close connection between the heart and the brain. The cardiac dysrhythmias resulting in 'cardiogenic dementia' can be either bradyrhythmias or tachyrhythmias. The most common example ofthe latter is atrial fibrillation with rapid ventricular response which has been called in the past 'delirium cordis' . One special form of delirium cordis is delirium tremens cordis which is seen among the alcoholics2. Although the disordered heart function can affect the brain, the reverse may also hold true. The altered mental state may render the diagnosis and treatment of acute myocardial infarction and early stages of congestive heart failure difficult or in some cases impossible. Furthermore, as indicated by the significant finding of cardiac rupture in nearly three-quarters of cases (16/22) of myocardial infarction in a psychiatric hospital3, demented cardiac patients may be more prone to catastrophic complications. Therefore, the importance of heart-brain and brainheart relationships received reinforced support from this excellent editorial. While the cardiologist must consider the cerebral consequences of cardiac disease, the neurologist cannot ignore the heart4. As the Chinese saying goes, 'heart is the seat ofthe soul but brain is the seat of the mind'. T 0 CHENG
Division of Cardiology, George Washington University Medical Center, Washington DC 20037, USA
References 1 White PD. Heart disease, 4th edn. New York: Macmillan, 1951:895 2 Cheng TO. Delirium tremens cordis. N Engl J Med 1973;289:593 3 Jetter WW, White PD. Rupture of the heart in patients in mental institutions. Ann Intern Med 1944;21:783802 4 Sherman DG, Hart RG, Shi F. Heart-brain interactions: neurocardiology or cardioneurology comes of age. Mayo Clin Proc 1987;62:1158-60
