Pituitary Adenomas Sellar region pathologies and treatment
The Sellar region in the skull base and the pituitary gland, are among the most sophisticated anatomical regions of the human skull and brain, which are very hard to reach. Proximity to complex important structures such as the cavernous sinus and it’s contents, the optic chiasma and various vital vasculature makes the anatomy of this region very complex and challenging. Various different pathologies exist In these regions which require experts attention and treatment.
Most common pathologies include pituitary adenomas which are usually benign tumors that can be functional or non functional. Since the pituitary gland is responsible for the production of most hormones in our body, functional masses can cause disturbances of this function, meaning they can cause over secretion or diminishing the normal production of these hormones. Due to hormonal imbalances signs and symptoms such as problem with menstrual cycles in women, lactation both in males and females, disproportional growth of body parts, skin alterations and many other signs and symptoms can be an alarming and indicator of hormonal problems
Nonfunctional adenomas are usually not disturbing the normal function of the pituitary gland the and the hormone levels are not disturbed, however they can have space occupying effect and this can cause damage to the pituitary gland or surrounding structures (cranial nerves and vasculature) and cause neurological signs and symptoms as well as deficits. The most common neurological signs and symptoms in case of space occupying lesions are vision loss, loss of peripheral visual field and problem with eyeball and eyelid movements.
Other groups of adenomas, known as microadenomas are very hard to visualize and identify on MRI scans, they are usually active and disturb the normal function of the pituitary gland. Diagnosing microadenomas might require very special diagnostic procedures such as sampling of the petrosal and cavernous sinuses and analyzing hormone levels of the blood samples of these regions. Such diagnostic procedures are very sophisticated and are not available in all centers.
Other pathologies such as inflammatory diseases, other cancerous alterations and congenital or acquired defects of skull base can be mentioned as common pathologies of this region.
All these pathologies require extensive multidisciplinary team decisions and treatment, most importantly a close collaboration between neurosurgeons, endocrinologists, oncologists, radio-surgeons and ophthalmologists are required to diagnose and treat these patients.
In our institute we have treated more than XXXXXX patients with pituitary adenomas and pathologies of sellar region.
In our center a very professional team consisting of Neurosurgeons, Endocrinologists, Oncologists and ophtalmologists work in a multidisciplinary setting to ensure the best care for the patient.
In general diagnosing a patient follows a route as below:
- Suspicion of hormonal disturbances or presence of neurological deficits such as visual field loss, loss of visual acuity and problem with eyeball movements.
- Examination by Endocrinologist or a Neurologist to rule out or diagnose suspected disease.
- Baseline lab tests among hormonal examinations
- Proper neurological examination
- Proper ophthalmological examination
- If needed contrast material enhanced brain MRI scans
- If MRI scans do suggest the presence of a mass in the sellar regions then referral to a Neurosurgeon is needed
- Examination and evaluation of results by neurosurgeon and deciding about treatment options. Surgical vs non-surgical treatments
- Mases which do not have space occupying effects and are non functional or their hormone production can be controlled by oral medications are not surgical candidates at the first step.
- Mases causing damage to vital structures and/or producing high level of hormones which cannot be controlled by medications are surgical candidates
- Refractory hormonal problems or adenomas which show progressive growth on follow up MRI scans can turn into surgical cases if necessary.
These steps are simplified in the following flowchart:
Once the decision to treat the patient by surgery is made , the patient goes through the following step for pre-operative preparations:
- Pre-operative evaluation of hormonal status (if not done prior to diagnosis)
- Pre-operative visual field assessment (if not done prior to diagnosis)
- Evaluation of the patient by an anesthesiologist
- Admission to hospital one day prior to the operation and assessment by neurosurgeon , going through the operation and treatment plan once again, presenting the consent forms and signing them.
- Operation
- Post-operative regular CBC follow ups to check Na and K levels , as well as checking fluid intake-output balance.
- Post-operative hormone work up
- Referral to the endocrinology ward for medication assessment and dosage reconsiderations
- Discharge
Simplified Schematic of surgical treatment:
In some cases patients might have to spend a day or two after surgery in the intensive care unit for monitoring , although generally the patients are transported to the recovery room after surgery and then admitted to the sub-intensive care unit of the neurosurgical ward.
A more detailed medical protocol regarding the skullbase and sellar region can be found on our website ………………..
Pre-operative consent forms can be found here :
Consent forms ………..