Posttraumatic pituitary dysfunction and intrasellar bony Spur 1% t) M.Parizc:l. C

ßru.ssnnrd. J. d e Moor, and A . M. D(:Schepper

Kcy words

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Staiidard radiographs o l the skull rcvealed a liriear I'racturc. involving the riglit frontal sinus androiitinuing into base oTthe skull arid through the sella.

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Sellaturcica.CT--SellaLurcica, ti'aiirna-Pi-

Recausc of thc persistirig CSF rhinorrhoca. a tuitai-y~hy~opiLuiLarisn'-Pit~'itary~lraui"a iicuros~irgicalintervenl.ioii was planncd on day 10 after tlic acci-

Schlüsselwörter .~ - -

derii.. ~ r a c t u r c so f thc ethrnoid arid splieiioid sinuses, as well as laceration of tlic dura. wcrc discovered and surgically repaired.

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H y p o p h y s a r e i ) y s l i i r i k t i o i i - Sella t i i r c i c a Trauma -

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Post-Lraurnnlic pituitary glancl dysf'uiiclion is a well-dociinieiitcd cornplication of sever+? hcad traunia. 111 iiiosi. cascs. i t is attributed to ruptiirp of t h r piliiitnry s t a k and/or to Iiypothnlarnic injury. withoiit fracturc throiigli tIi(2 sella turcica We report on n paticnt w i t h posttrauiiintic diabctcs insipidiis niid dclaycd paiiliypopituitarism. i n whorri a i i upwardly hinged iiitinscllar bony spur was docurncntcd by conventioiial skull radiograplis and by (3'.'l'herefore, w r proposc an alternative rriechnnism o f posttrauiiiatic pituitary dysliinclioii. dircct dcstriiction o f tlie hypophysis and/or srciion o f t h c pitiiitary strilk l)y iipwnrd m i gra.tioii o i a hone fragmcnt frorri t l i r sellar floor. Post-iraiiiiiatic dinbctes insipidus ([)I) aiid dclayed paii11yl)opituitarisrn are uiicoiiiiiioii cornplicatioiis iii savcrc craniofacial iiijiiric*~.Ilowcvcr. with iiicreasing survival ratcs i n paticnts witli hcad irijiiri12s. thcsc post-traurnaiic eiiclocriiic dysiurici.ioiis are bccoming more f'reqiieiit. In iriosi docurncntcd cases ur pariliypopituilarisrii, iio ahiiorrnal findings o f t h r selln turcica arc dcscribed. Wc rcport on a pai.ieiit with a n unusual hoiiy spiir on thc floor o f the seIIa turcica causing posi.lraiirnntic panhypopitiiitarisiii.

Case report

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A 22-ycar-old iriaii was ndrnittcd to the eriiergeiicy roorn followirig a violent hcad injui-y i r i a iiintoi'cyclr accident. Tlic paticnt was uncoriscioiis. l'hcrc was cvidence o i a sevcrc rnaxillofacial traiinin. Blood-stained walery dischargc from tlie iiose was prcsciit: tlic fliiid was idcntificd as cerehrospinal fluid ((:SI;). Tlic (:Sr rhinorrhoea was presi~rncdto bc a rnariifeslalinn o f a l)asal skull frnciurc.

'I'hr paliciii. rcgaincd consciuusiii~ss aller Bh hours. Opliilialninlogical cxamirialiuii discloscd cornpletr loss of visinn i n thc riglit. c~yewith i'ctinal ocdt.rnii iri IIie papillornac~ilar rcginn. c\ transscction ofllit! right nptic ncrvc was siispni:lc!tl. Fig. 1 Lateral (a)andAP(b) skull filinsdemonstrate a postiraumatic bony spur within the sella tiircica (arrows).The lateral film shows loss of cortical alignment ol the sellar floor (arrowhead).Note the boundariesof the frontal craniolomy defect prolectedon the AP film.

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Dnpari.menl.oiRndiology. Ilniversii.iiir %ickciihiiisAntwerpe,ii. Uiii\~ersilyol'ibtwerp. Edegeiii. Belgiurii

188 Forlschr. Rönlgenstr. 15.?,4

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Demonstration of a posllrüiimatic boiiy spiir within thc sclla. originating frorn thc scllar fioor. is rnost iinusual. I r i oiir patieiit. this boiiy Spur was causcd by a cornn~inutcdbasal skull fraciiire witti an iipwardly hinged fragineiitofthv sellar floor. 'rhc adjaccnt bony dcfcct is wcll dernonstratcd on thc coronal (3' iiiiages (Fig. 2). .Th(: d i k r e n t i a l diagnosis should bc madc with a prornirient rniddlt! cliiioid process (3) arid witti the so-called sellar spinc ( 4 . 5 ) .Howcver. the i r r e p l a r and blistered appearance of the I ~ o i i yspur nnd tho adjaccnt bony dcfcct of thc scllar fioor strongly suggesl a postlrauiiialic origiii. presiiiriably as a resiilt o f n c:oiiiniinutcd fracturc with ~ipivardhinging of a borie fragment.

Fig. 2 Contrast-enhancedcoronal CTscan section(widewindow, bone algorithrn)confirms the presence of an upwardly hinged bone fragment (arrows) frorn thesellarfloor, resultingfrorna comminuted skull base fracture.There is an adjacent bone defect in the sellar floor (arrowhead).Note the presence of a secondfracture line in the baseof the sphenoid bone.

I n the postoperative period. the paticnt dcvclopcd a right frontal brain abscess. well dociiiiieiited by CT ruarniiiatioiis. A second ncurosurgical intervention was perforrned on day 24 alter tlie traurnn and thc absccss was draincd. Shortly aftcrwards. the patient developed diabetes iiisipidus, presiiiriably rellecting a traumatic rupturc of thc pituitary stalk. Cornplete hormonal replaceriient was stnrted irnrnediatcly. Thrcc ycars latcr. thc patient was readrnitted tu the ernergericy rooin iii a subcomntose statc. Thc physical cxamination upon admission revealed signs o i detiydratioii. Iiypotherniia (body temporaturc: 34.5" C). bradycardia (50 beatshninute) and hypotensiori (1 00/50 iriin I lg). Thcre was cvidcncc of scvcrc diabctes insipidus (polyurizl). The ionograiri sliowed a sliglit hypokalnemia (3.1 rnrnol/l). Adcquatc trcatment was started and the patient recovered well. A careiiil history rcvcalcd that thc syrnptoms had been caused by poor ttierspy coiiipliarire. 'rhe patient lind severc crnotional and rclational problerns, linked to a decreased lihido. Standard X-rayso i thc skull and the sella turcica displayed a bony spiir iiear the llonr nl' thn sclla. A contrastcnhanccd Ci' cxamination of the pitiiitary glarid was obtained. using thiri contiguous 1.5 rnrn coronal scans (General klectric CE CT/l' 9800). Tlie CT scati conlirined thc prcscncc of an upwardly hingcd bony spur within the sella turcica and attactied to ttie sellar Iloor. TIie Spur originated i n thc right postcro-inferior part of the sellar fioor arid was djrected roslrnlly. Taking into account thc prcvious history of trauma and skull base fractiires. tlie spur was believed 1.0 be posttraurnatic i n origin. and was presurned to have caused (partial) destriictiori of tlie hypophysis andlor trnnsscction of thc pituitary stalk.

Tlie nccurrence of DI and panhypopituitarism following severe head injiiry is well dociirneiited. I i i rnost cnses this occurs without a concornitant skull base fracture. 'l'he rnechanisrn is believed to be a rupture or elongation ofthc pituitary stalk (G. 7). Associated neurological ahnorrnalities are coninion. the rnost i'requent ol'thesc bcing various visiial field defects and even blindness, iollowed by lesioiis of tlie crnnial ncrvcs wjthin thc sinus cavcrnosus (2). A CSF leük tliroiigti i.lie iiose (rliiiiorrhoea) caiised hy a dilral tcar is also a frcquent complication (2). Ilural lacerütion riiay he coniplicatrd by inkction. as secn i n our paticnt.

Seciiori ofttie pitiiiiary stalk Iiiis beeil reporte~It n causc dcvasciilarisation ofthc anterior pituitary resulting in extcsrisivc riecrosis ('I). Iii our pnticnt. it is likely that thc DI and panhypopituitarisrn werc caiised iiol oiily by riiptiire of tlir pitiiitary stalk. but also by destruction of the hypophysis by an upwardly displaced hone l'rngrnent. ßoth mcchanisrns can account b r thc loss of pitiiitary tissiie evidencecl by CT. T l i r decreased heiglit ol' the hypophysis prcsurnably explains the downward herniation of the suprasellilr cistcrii irilo thc sclln turcica. rc!sulting i n a "partially ernpty sella". Finally. persistirig Dl iriay indicate tlie piesence ol' concornitant lcsions i n thc hypothalamic nuclei. [ii coiicliisioii. tliis report preseiils aii alteriiativc rncchaiiisrn Tor thc developrncnt of posttrauinatic pituitary dysfiinclioii. I n addition to thc rupturc of thc pituitary stalk with subseqiient riecrosis olttie Iiypophysis. a siriiilar el'ieci iiiay result I'ioiii dircct dostruction of the pituitary gland by upward rnigration ol'a hone l'ragnicnt I'rom thc scllar floor.

HeferencesL

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ßonief. P. M . . M. M. 1.. Prichnrd. P. H . .Schurr: Extcnt of thc

infarct in the aiiterior lohe oll.lie Iiuiiiari pituii.ary aflcr si.nlk section. Lancet l(1958) 1101-1 103 V d l u n r d s . 0. .\I,. J . U /I. Clark: Post-traiimatic hypopitiiiiarisrii lsix cascs and a rcvicw of thc litcraturc). Mcdicinc 65(5) (1986) 281 -290 :' Kcats. '1: E.: Atlas of normal roentgen variant5 that rnay siniiils1.r disclnsc (41h Edition). Ycar Book Mcdical Yublishcrs. Chicago

1988 1,nng. J.: Structiirr and postiialal orgariizalioii of lierel.ofi~re

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uninvcstigatcd and infrcqucnt ossification of thc sella turcica regiori. Ac1.a Aiint. (I

Posttraumatic pituitary dysfunction and intrasellar bony spur.

Posttraumatic pituitary dysfunction and intrasellar bony Spur 1% t) M.Parizc:l. C ßru.ssnnrd. J. d e Moor, and A . M. D(:Schepper Kcy words -- Sta...
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