Accepted Manuscript Neurosurgical endocrinology, endocrinological neurosurgery and interdisciplinary work Morten Lund-Johansen, M.D., Ph.D PII:
S1878-8750(14)00150-8
DOI:
10.1016/j.wneu.2014.02.020
Reference:
WNEU 2273
To appear in:
World Neurosurgery
Received Date: 10 November 2013 Accepted Date: 11 February 2014
Please cite this article as: Lund-Johansen M, Neurosurgical endocrinology, endocrinological neurosurgery and interdisciplinary work, World Neurosurgery (2014), doi: 10.1016/j.wneu.2014.02.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Neurosurgical endocrinology, endocrinological neurosurgery and interdisciplinary work
Morten Lund-Johansen M.D., Ph.D. Department of Neurosurgery
RI PT
Haukeland University Hospital And Department of Clinical medicine
SC
University of Bergen Bergen, Norway
M AN U
[email protected]
“Give someone a hammer and he will find nails everywhere”
AC C
EP
TE D
Hyperspecialization is increasingly evolving in Western medicine. We organize clinical units where professionals with perfectionate skills within a specified field of medicine treat patients with a narrow specter of conditions. Most patients would like to meet a doctor who is particularly experienced in treating a case like their own. This high-level specialization is mandatory for our work but may despite its advantages lead to problems. If patients suffer from something else than what they got admitted for, there is a risk of misdiagnosis and wrong treatment. There are many imitators in clinical medicine and a doctor with little exposure to a wide panorama of disease may be less likely to suspect a diagnosis different from the one he knows even if symptoms may seem a little unfamiliar. The price of hyperspecialization is loss of general knowledge. I did my internship in a small Norwegian county hospital nearly 30 years ago where the clinical director in the Department of Internal Medicine had been in charge for many decades and did clinical rounds most mornings. He had impressive diagnostic skills. I remember in particular one case of a young man who was admitted in the evening from a general practitioner with the clinical diagnosis of “being ill”. Without hesitating he diagnosed Addison’s disease on the basis of a short case history, a glance at the patient and the electrolyte levels. I was awestruck. In tribute to my first boss and to Dr House, the skill of making a correct diagnosis from taking a history and examining the patient is the basis for good clinical work. That skill is less well developed in many of us nowadays, and we need to be extra cautious when we face something that we do not quite recognize when treating a patient.
ACCEPTED MANUSCRIPT
RI PT
Within the field of endocrinology there are several diagnoses such as adrenal failure, where symptoms may initially be vague, non-specific and easily ascribed to many other conditions. In the current issue of WNS Kronvall and coworkers present a prospective study on pituitary outcomes in SAH patients (1). In months following SAH, patients often complain about lethargy, fatigue, cognitive failure, lack of energy and reduced daily performance. Usually the gradual improvement leads on to a lower performance level than prior to the bleed. This is well known and usually correctly ascribed to brain damage caused by the haemorrhage, vasospasm and hydrocephalus. It is important to keep in mind other potential causes for such complaints and pituitary failure may be one.
M AN U
SC
Pituitary failure may have many different causes. Neurosurgeons occupied with pituitary surgery are familiar with those caused by tumors in the sellar region and their treatment, but it is less recognized if SAH regularly leads to long-term pituitary failure. In the acute phases, dysregulation of posterior lobe function is usually recognized, and it is important to distinguish between Diabetes Insipidus and syndrome of inappropriate ADH secretion. As pointed out by the authors, anterior lobe failure in the early phase is common and may be regarded as a response to acute severe illness. In the acute stage there was a significant preponderance for pituitary failure to occur in patients with aneurysms within the Circle of Willis. Interestingly, after six months this difference was no longer found. The six-months’ high occurrence of failures within the somatotroph and corticotroph axes found in this study were according to the authors likely ascribable to hypothalamic damage and were associated with a poor GOS around the time of ictus and at follow-up.
AC C
EP
TE D
The pituitary is an organ familiar to neurosurgeons. As a pituitary surgeon I have enjoyed collaboration with endocrinologists for many years and recognized the importance of a close discussion about each case before undertaking surgery. Assessing pituitary function is not at all easy, and we should not hesitate to consult our colleagues in endocrinology when in doubt about pituitary function. From the present study, we may conclude that pituitary failure is to be expected in a significant proportion of patients after SAH. This may be pointed out in discharge reports, and should be kept in mind in outpatient follow-up of SAH patients. Still, whether or not endocrine tests should be part of the follow-up routine for SAH is yet to be established. The study by Kronvall and associates is not the first to report on pituitary failure in SAH patients. There are several others, and quite recently a group from a closely situated geographic region advised against routine testing for pituitary failure during follow-up for SAH, as their study identified very few cases (2). The present study and the one by Klose and coworkers both emerge from groups of authors with merits in joint neuroendocrine and neurovascular research. Thus, we seem to be in need of more high-quality, preferably multicenter studies. At present, we should keep pituitary failure in mind when treating patients who have undergone SAH. This should be communicated to doctors and personnel who take over the care for the patients. If suspected, the collaboration of neurosurgeon and endocrinologist is the one way to secure proper diagnosis and treatment.
ACCEPTED MANUSCRIPT Literature 1: Kronvall E, Valdemarsson S, Säveland H, Nilsson OG. Pituitary dysfunction after aneurysmal subarachnoid hemorrhage is associated with impaired early outcome. World Neurosurg. 2013 Oct 16. S1878-8750(13)01363-6.[Epub ahead of print]
AC C
EP
TE D
M AN U
SC
RI PT
2: Klose M, Brennum J, Poulsgaard L, Kosteljanetz M, Wagner A, Feldt-Rasmussen U.Hypopituitarism is uncommon after aneurysmal subarachnoid haemorrhage. Clin Endocrinol (Oxf). 2010 Jul;73(1):95-101.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1878-8750(14)00150-8
DOI:
10.1016/j.wneu.2014.02.020
Reference:
WNEU 2273
To appear in:
World Neurosurgery
Received Date: 10 November 2013 Accepted Date: 11 February 2014
Please cite this article as: Lund-Johansen M, Neurosurgical endocrinology, endocrinological neurosurgery and interdisciplinary work, World Neurosurgery (2014), doi: 10.1016/j.wneu.2014.02.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Neurosurgical endocrinology, endocrinological neurosurgery and interdisciplinary work
Morten Lund-Johansen M.D., Ph.D. Department of Neurosurgery
RI PT
Haukeland University Hospital And Department of Clinical medicine
SC
University of Bergen Bergen, Norway
M AN U
[email protected]
“Give someone a hammer and he will find nails everywhere”
AC C
EP
TE D
Hyperspecialization is increasingly evolving in Western medicine. We organize clinical units where professionals with perfectionate skills within a specified field of medicine treat patients with a narrow specter of conditions. Most patients would like to meet a doctor who is particularly experienced in treating a case like their own. This high-level specialization is mandatory for our work but may despite its advantages lead to problems. If patients suffer from something else than what they got admitted for, there is a risk of misdiagnosis and wrong treatment. There are many imitators in clinical medicine and a doctor with little exposure to a wide panorama of disease may be less likely to suspect a diagnosis different from the one he knows even if symptoms may seem a little unfamiliar. The price of hyperspecialization is loss of general knowledge. I did my internship in a small Norwegian county hospital nearly 30 years ago where the clinical director in the Department of Internal Medicine had been in charge for many decades and did clinical rounds most mornings. He had impressive diagnostic skills. I remember in particular one case of a young man who was admitted in the evening from a general practitioner with the clinical diagnosis of “being ill”. Without hesitating he diagnosed Addison’s disease on the basis of a short case history, a glance at the patient and the electrolyte levels. I was awestruck. In tribute to my first boss and to Dr House, the skill of making a correct diagnosis from taking a history and examining the patient is the basis for good clinical work. That skill is less well developed in many of us nowadays, and we need to be extra cautious when we face something that we do not quite recognize when treating a patient.
ACCEPTED MANUSCRIPT
RI PT
Within the field of endocrinology there are several diagnoses such as adrenal failure, where symptoms may initially be vague, non-specific and easily ascribed to many other conditions. In the current issue of WNS Kronvall and coworkers present a prospective study on pituitary outcomes in SAH patients (1). In months following SAH, patients often complain about lethargy, fatigue, cognitive failure, lack of energy and reduced daily performance. Usually the gradual improvement leads on to a lower performance level than prior to the bleed. This is well known and usually correctly ascribed to brain damage caused by the haemorrhage, vasospasm and hydrocephalus. It is important to keep in mind other potential causes for such complaints and pituitary failure may be one.
M AN U
SC
Pituitary failure may have many different causes. Neurosurgeons occupied with pituitary surgery are familiar with those caused by tumors in the sellar region and their treatment, but it is less recognized if SAH regularly leads to long-term pituitary failure. In the acute phases, dysregulation of posterior lobe function is usually recognized, and it is important to distinguish between Diabetes Insipidus and syndrome of inappropriate ADH secretion. As pointed out by the authors, anterior lobe failure in the early phase is common and may be regarded as a response to acute severe illness. In the acute stage there was a significant preponderance for pituitary failure to occur in patients with aneurysms within the Circle of Willis. Interestingly, after six months this difference was no longer found. The six-months’ high occurrence of failures within the somatotroph and corticotroph axes found in this study were according to the authors likely ascribable to hypothalamic damage and were associated with a poor GOS around the time of ictus and at follow-up.
AC C
EP
TE D
The pituitary is an organ familiar to neurosurgeons. As a pituitary surgeon I have enjoyed collaboration with endocrinologists for many years and recognized the importance of a close discussion about each case before undertaking surgery. Assessing pituitary function is not at all easy, and we should not hesitate to consult our colleagues in endocrinology when in doubt about pituitary function. From the present study, we may conclude that pituitary failure is to be expected in a significant proportion of patients after SAH. This may be pointed out in discharge reports, and should be kept in mind in outpatient follow-up of SAH patients. Still, whether or not endocrine tests should be part of the follow-up routine for SAH is yet to be established. The study by Kronvall and associates is not the first to report on pituitary failure in SAH patients. There are several others, and quite recently a group from a closely situated geographic region advised against routine testing for pituitary failure during follow-up for SAH, as their study identified very few cases (2). The present study and the one by Klose and coworkers both emerge from groups of authors with merits in joint neuroendocrine and neurovascular research. Thus, we seem to be in need of more high-quality, preferably multicenter studies. At present, we should keep pituitary failure in mind when treating patients who have undergone SAH. This should be communicated to doctors and personnel who take over the care for the patients. If suspected, the collaboration of neurosurgeon and endocrinologist is the one way to secure proper diagnosis and treatment.
ACCEPTED MANUSCRIPT Literature 1: Kronvall E, Valdemarsson S, Säveland H, Nilsson OG. Pituitary dysfunction after aneurysmal subarachnoid hemorrhage is associated with impaired early outcome. World Neurosurg. 2013 Oct 16. S1878-8750(13)01363-6.[Epub ahead of print]
AC C
EP
TE D
M AN U
SC
RI PT
2: Klose M, Brennum J, Poulsgaard L, Kosteljanetz M, Wagner A, Feldt-Rasmussen U.Hypopituitarism is uncommon after aneurysmal subarachnoid haemorrhage. Clin Endocrinol (Oxf). 2010 Jul;73(1):95-101.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
