Hideki Kanai

Pituitary apoplexy after pituitary function test: A report of two cases and review of the literature.

BACKGROUND Although most of pituitary apoplexy occur spontaneously, some precipitating factors have been reported. We experienced two cases of pituitary apoplexy after a pituitary function test. METHODS In order to clarify the causal relation between the pituitary function test and apoplexy, we presented our two cases and reviewed 20 cases in the literature. RESULTS (Case 1) A 48-year-old man with a pituitary macroadenoma received an injection of 500 micrograms thyrotropin-releasing hormone (TRH), 100 micrograms gonadotropin-releasing hormone (GnRH), and 0.1U/kg insulin as a preoperative test of pituitary function. Fifteen minutes later, he complained of diminished vision and headache. (Case 2) A 54-year-old man with a large cystic adenoma had an administration of 500 micrograms TRH and 100 micrograms GnRH. Ten minutes later, he complained of blurring of his left eye and headache. Although, in both cases, CT scans showed neither intratumoral hemorrhage nor infarction, the surgical specimen showed necrotic and hemorrhagic adenoma. The patients made excellent clinical recoveries after surgical decompression. Twenty-two reports including our two cases were reviewed. In 15 cases (68%), TRH was associated with apoplectic events and seemed to be the agent most likely to have an etiologic role because of its vasoactive properties. Eighteen patients (82%) had pituitary macroadenomas with suprasellar extension. In 72% of 18 surgical cases, some recovery of visual function was obtained. CONCLUSIONS An apparent relationship between the test and the apoplectic events raises the possibility of the development of pituitary apoplexy after a pituitary function test. Unless there is a specific indication, pituitary function test should be avoided especially in patients with a large pituitary tumor.

A large aneurysm of the persistent primitive hypoglossal artery.

An aneurysm of a persistent primitive hypoglossal artery (PHA) particularly at its junction with the basilar artery, often poses therapeutic problems. This is attributable not only to the size and location of the aneurysm but also to the fact that the persistent PHA is functionally the single artery providing blood in posterior circulation. We report a 31-year-old man with a large aneurysm of the persistent PHA at its junction with the basilar artery and review the existing literature. We clipped the broad neck of the aneurysm through a lateral suboccipital craniectomy; however, the patient suffered a second episode of subarachnoid hemorrhage. Angiography disclosed a slipped clip incompletely obstructing the persistent PHA. He received no further treatment for the aneurysm because of his deteriorating condition. Direct surgical treatment, although it failed to obliterate the aneurysm neck in our patient, should be recommended for a persistent PHA aneurysm.

Immature teratoma producing alpha-fetoprotein without components of yolk sac tumor in the pineal region

Abstract A case of pineal region tumor in a 9-year-old boy with a high serum alpha fetoprotein (AFP) level is reported. The serum levels of beta-human chorionic gonadotropin (HCG) and placental alkaline phosphatase (PLAP) were not elevated. The tumor was composed of radiologically different components and was removed surgically. Postoperative radiation therapy was performed and the serum level of AFP gradually declined to the normal range. The pathological diagnosis was immature teratoma, and no elements of yolk sac tumor or embryonal carcinoma were found. In the immunohistochemical study, AFP was detected in the cytoplasm of gastrointestinal-type epithelium and primitive neuroepithelial element. This is considered a rare case of intracranial immature teratoma in which AFP was detected immunohistochemically in the columnar epithelium and immature neural tissue.

A typical moyamoya disease associated with brain tumor

A 4-year-old boy with right retinal hemorrhage, mental retardation, and multiple minor anomalies was referred to our hospital. Computed tomography scanning revealed a cystic brain tumor at the vermis. Angiography showed stenosis of both internal carotid arteries at the supraclinoid portion and the Moyamoya vessels. The right ophthalmic artery was dilated as wide as the internal carotid artery. Stenosis of the basilar artery was also observed. Collateral circulation via the posterior inferior cerebellar artery and Moyamoya vessels in the area of the posterior cerebral artery was observed.

Nucleolar organizing regions in primary intracranial malignant lymphomas

Twenty-two non-immunocompromised patients with primary intracranialmalignant lymphomas were examined on surgical material by using anargyrophilic method for the demonstration of nucleolar organizer regions asAg-NORs. The histopathological classifications of 22 patients included 3small lymphocytic, 7 small cleaved, 9 large cell, 1 mixed large and small,and 2 small non-cleaved type. The numbers of Ag-NOR of malignant lymphomapatients varied from 1.36 to 5.02 (mean 3.46 ± 0.25). The mean Ag-NORnumbers in the histopathological subtypes were small lymphocytic 1.63, smallcleaved 3.18, large 4.21, mixed large and small 3.47, and small non-cleaved3.78. The number of Ag-NORs in small lymphocytic type was significantly lessthan small cleaved or large cell type (p < 0.05). The small cleaved typealso had a smaller Ag-NOR number than the large cell type (p < 0.05).Except for two patients who had postoperative deterioration, 20 patientsreceived postoperative irradiation ranging from 36 to 54 Gy (median, 46 Gy).Sixteen patients had complete response to radiotherapy, and 4 had goodpartial response. Ten patients had tumor recurrence within the remissionperiod of 3 months to 7 years and 10 months (median 4.8 months). Threepatients with intracranial relapse at a remote site had a significantlylonger remission period (mean 57.3 months) than 7 with local relapse (mean6.29 months), p < 0.05. The mean Ag–NOR number of the short andlong remission period were 3.13 ± 0.34 and 3.81 ± 0.80,respectively. No significant difference was found between these two groups.The survival period was 3.2 months to 12 years (median 20 months). TheAg-NOR numbers of survival period less than or more than 20 months were 3.62± 0.40 and 3.27 ± 0.37, respectively. The Ag-NOR numbers didnot correlate with either the remission or the survival period. Theseresults indicate that Ag-NOR numbers may correlate with the histopathologictypes, but not with the prognosis of primary intracranial malignantlymphomas.