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【脑瘤案例】85岁垂体瘤经典案例分析

患者男,85岁,因头痛、呕吐、双眼进行性视力丧失5天就诊。否认体重下降、惊厥、肢体或面部不适等。有高血压、腹主动脉瘤、甲状腺功能减退和良性前列腺肥大。胶质瘤资讯网提示:目前
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  患者男,85岁,因“头痛、呕吐、双眼进行性视力丧失5天”就诊。否认体重下降、惊厥、肢体或面部不适等。有高血压、腹主动脉瘤、甲状腺功能减退和良性前列腺肥大。胶质瘤资讯网提示:目前国际上治疗垂体瘤最有效的方法是手术治疗。

垂体瘤案例图片

  血压110/75 mm Hg,心律齐 80次/分,格拉斯哥昏迷评分 (GCS) 15。周围神经系统检查未见明显异常。颅神经检查提示双颞侧偏盲,眼底检查未见明显异常。
  钠 126 mmol/L(参考范围135-145),钾 3.6 mmol/L (3.5-5),尿素 5.6 mmol/L (2.5-6.7),肌酐 101 ?mol/L (70-150),C反应蛋白(CRP) 66 mg/L (<10)。全血细胞计数和肝功能是正常的。
  CT:垂体窝有个肿块。MRI:鞍区肿块压迫视交叉,信号变化提示肿块内出血。如下图:
  患者表现为双颞侧偏盲,需要考虑的诊断有:垂体腺瘤、垂体卒中、颅咽管瘤、脑膜瘤、胶质瘤、颅内动脉瘤。
  结合患者临床表现和辅助检查,垂体瘤卒中的可能性最大。垂体瘤卒中指预先存在的垂体肿瘤发生出血或梗塞,垂体腺瘤发生卒中的风险为2-7%。垂体腺瘤比微腺瘤患者发生卒中的风险更大。
  脑垂体位于刚性壁内,快速增长导致鞍内压力增高,以致于出现一系列临床表现:头痛(可以伴有恶心、呕吐);正常血管受压,导致垂体功能低下,垂体前叶促肾上腺皮质激素分泌受损,进而导致皮质醇不足;视交叉受压,导致视野缺损和视力下降;海绵窦内结构受压,导致颅神经麻痹。
  垂体卒中患者出现日益恶化的体重或GCS减小,均是外科急诊切除肿瘤的指征;病情稳定的患者可以选择保守治疗,但如果不改善,可能需要进行手术治疗。
  所有垂体卒中患者应该在首次发病后的4-8周进行随访;每年要去内分泌科随访;发病后3-6个月进行头颅MRI检查,此后每年行一次头颅MRI检查连续5年,然后每2年进行一次头颅MRI检查。
  本例中的患者成功的接受了内镜下经蝶切除垂体瘤,激素水平恢复到正常,右眼视力得到改善,但是左眼视力恢复差。
  原始出处:
  Ramdeep Bajwa, Paven Preet Kaur, Headaches and hormones: a potentially lethal combination.BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.h6752
  The patient, 85 years old, was hospitalized for "headache, vomiting and progressive visual loss of both eyes for 5 days".
  Deny weight loss, convulsions, physical or facial discomfort, etc. There are hypertension, abdominal aortic aneurysm, hypothyroidism and BPH.
  Blood pressure 110 / 75 mm Hg, arrhythmia 80 times / min, Glasgow Coma Score (GCS) 15. No obvious abnormality was found in peripheral nervous system. Cranial nerve examination showed that bilateral temporal hemianopia and fundus examination showed no obvious abnormality.
  Sodium 126 mmol / L (reference range 135-145), potassium 3.6 mmol / L (3.5-5), urea 5.6 mmol / L (2.5-6.7), creatinine 101? Mol / L (70-150), C-reactive protein (CRP) 66 mg / L (< 10). The whole blood cell count and liver function were normal.
  CT: there is a mass in the pituitary fossa. MRI: the sellar mass compressed the optic chiasm, and the change of signal indicated the hemorrhage in the mass. As shown below:
  The patients presented with bilateral temporal hemianopia. The diagnosis to be considered included pituitary adenoma, pituitary apoplexy, craniopharyngioma, meningioma, glioma and intracranial aneurysm.
  Combined with the clinical manifestations and auxiliary examination, pituitary apoplexy is the most likely. Pituitary apoplexy refers to bleeding or infarction of preexisting pituitary tumor, and the risk of pituitary adenoma apoplexy is 2-7%. Pituitary adenomas are at a higher risk of stroke than microadenomas.
  The pituitary gland is located in the rigid wall, and the rapid growth leads to the increase of the pressure in the sella, resulting in a series of clinical manifestations: headache (may be accompanied by nausea and vomiting); normal blood vessels are compressed, resulting in hypophysis function, the secretion of adrenocorticotropic hormone in the anterior pituitary gland is damaged, resulting in the insufficiency of cortisol; optic chiasmal compression, resulting in visual field defect and visual acuity decline; cavernous sinus node Compression of structures leads to paralysis of cranial nerves.
  Patients with pituitary apoplexy have worsening weight or decreased GCS, which is the indication of surgical emergency tumor resection; patients with stable condition can choose conservative treatment, but if not improved, may need surgical treatment.
  All patients with pituitary apoplexy should be followed up in 4-8 weeks after the first onset of the disease; they should go to the endocrine department for follow-up every year; after the onset of the disease, they should have MRI examination of the head for 3-6 months, and then they should have MRI examination of the head once a year for 5 years, and then every 2 years.
  In this case, the patient successfully received endoscopic transsphenoidal resection of pituitary tumor, the hormone level returned to normal, the vision of the right eye was improved, but the vision of the left eye was poor.
  Original source:
  Ramdeep Bajwa, Paven Preet Kaur, Headaches and hormones: a potentially lethal combination.BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.h6752
TAGS: 垂体瘤

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