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SRNA3AdvancedPatho2 > Pituitary Disorders > Flashcards

Pituitary Disorders Flashcards

1
Q

Pituitary gland location

A

Sella turcica within sphenoid bone

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2
Q

Relationship of pituitary to hypothalamus

A

Inferior

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3
Q

Pituitary in close proximity to

A

Close proximity to:
– Optic Chiasm
– Carotid Arteries
– C.N. III, IV, V, VI

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4
Q

CRH

A

ACTH Cortisol

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5
Q

TRH

A

TSH T3, T4

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6
Q

GnRH

A

FSH,LH Sex Hormones

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7
Q

GHRH

A

GH IGF

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8
Q

PRF

A

Prolactin Lactation

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9
Q

Dopamine

A

↓ Prolactin ↓ Lactation

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10
Q

Somatostatin

A

↓ GH ↓ IGF

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11
Q

2 types of pituitary tumors

A

Two Basic Types:
• Functional (hormone secreting “microadenoma”)
• Non-Functional (non-secreting “macroadenoma”)

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12
Q

Hormone secreting is

A

Functional, “microadenoma”

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13
Q

Non-secreting

A

Nonfunction, macroadenoma

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14
Q

Functional (Micro-adenomas)

A

– Hypersecretion of usually one hormone
– Multiple hormones rare, most common
combination is GH & Prolactin
– Account for approximately 55% of pituitary tumors

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15
Q

Non-Functional (Macro-adenomas)

– Signs/Symptoms due to___________

A

Compression
• pituitary gland itself or surrounding structures
• HA, visual disturbances, CN deficits, Hypopituitarism
– Account for approximately 45% of pituitary tumors

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16
Q

Non-Functional Tumors Compression of:

A 
Optic Chiasm
Third Ventricle
Cranial Nerves II – VI
Carotid Arteries
Hypophyseal Portal System & Infundibulum
Pituitary gland itself
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17
Q

Optic chiasm compression

A

Light from lateral (“temporal”) visual fields strikes medial
retina.
Medial axons cross at O.C.
Injury to O.C. results in loss of lateral visual fields.

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18
Q

With transphenoidal surgery

A

may have deficit to trigeminal nerve

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19
Q

Only _______cristcross, Lateral fibers_____

A

Medial fibers cristcross; does not

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20
Q

Image on Lateral retinal axons travel straight back.

A

retina is flipped – Lateral light strikes medial retina.

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21
Q

Medial retinal axons

A

carrying lateral image info cross over at O.C.

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22
Q

Early enlargement compresses

A

inferior O.C. first, resulting in superiolateral visual loss

quadrantanopia

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23
Q

in Optic chiasm compression Later,

A

all axons compressed – results in full loss of lateral visual
fields (BITEMPORAL hemianopia).

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24
Q

Further Superior Extension of Tumor

A
  • Compression/impingement of Third Ventricle
  • Can cause obstruction of CSF flow
  • Results in Obstructive Hydrocephalus leading to increased ICP.
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25
Q

Pre-operative Intracranial Hypertension may present with:

A
  • N/V
  • Altered Mental Status
  • HA (bifrontal or bitemporal)
  • Papilledema
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26
Q

Increased ICP Papilledema means

A 
• Papilledema (optic disc swelling)*
– HA
– Enlarged blind spot
– Visual disturbances
– Vision loss
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27
Q

Papilledema is associated with

A

Blurred Disc Margins

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28
Q

Anesthesia Considerations in Increased ICP : Pre-Op sedation should be

A

carefully administered as these pt.s may be sensitive to

sedative drugs.

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29
Q

Anesthesia Considerations in Increased ICP

Drug induced hypoventilation can

A

exacerbate intracranial hypertension due to hypercapnia

induced cerebral vasodilation.

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30
Q

Anesthesia Considerations in Increased ICP

Anesthesia induction agents should be carefully

A

titrated to avoid hypotension.

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31
Q

Anesthesia Considerations in Increased ICP

2 meds that can increase ICP.

A

Ketamine and high-dose volatile anesthetics

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32
Q

Lateral Expansion of Tumor

A
  • Invasion of cavernous sinus
  • Compression of Cranial Nerves II – VI
  • Compression of Carotid Artery
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33
Q

Cranial Nerve Compression Losses II

A

visual function (especially lateral fields)

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34
Q

Cranial Nerve Compression Losses III

A

pupillary constriction

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35
Q

Cranial Nerve Compression Losses III, IV, VI

A

extra-ocular movements

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36
Q

Cranial Nerve Compression Losses V

A

facial sensation (first & second branches)

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37
Q

Hypopituitarism Pituitary Failure, Caused by Tumor Compression of:

A
  • Pitutary gland itself
  • Infundibulum (stalk)
  • Hypophyseal Portal System
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38
Q

Hypopituitary changes in hormones

A

Results in: ↓GH,ACTH,TSH,FSH/LH,ADH,OT, ↑PRL (because of dopamine) (prolactin inhibiting factor)

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39
Q

Hypophyseal Portal Compression Hypothalamic releasing factors cannot

A

reach target cells in the pituitary

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40
Q

PIF

A

Prolactin Inhibiting Factor (Dopamine)

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41
Q

Pituitary Failure can be Acute or Chronic
Acute Failure leads to
–________ failure
– __________have short half-lives

A

acute adrenal insufficiency
HPA axis
ACTH and Cortisol 10 mins. and 90 mins. respectively

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42
Q

Symptoms of Pituitary Failure:

A

Nausea, dilutional hyponatremia (from ↓aldosterone), profound hypotension or shock

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43
Q

Treatment of pituitary Failure with

A

corticosteroids can be life-saving

44
Q

Chronic Failure initially and later

A

– ↓ GH initially

– ↓ ACTH, ↓TSH later

45
Q

Functional Tumors

• ↑GH –

A

Acromegaly/Gigantism

46
Q

• ↑ PRL

A

Hyperprolactinemia

47
Q

• ↑ TSH

A

Pituitary Hyperthyroidism

48
Q

↑ Gonadotropins similar to what kind of tumor (micro/macro)

A

similar to non-functional, usually asymptomatic

49
Q

• MEN-1 (Multiple endocrine neoplasia type 1) a.k.a. “

A

Wermer’s syndrome”.

50
Q

What happens in MEN-1

A

Pituitary tumor presents with neoplasms in PT and Pancreas – leads to hypercalcemia & hypoglycemia

51
Q

↑ GH - Acromegaly/Gigantism Clinical Manifestations:

A
  • ↑growth of hands and feet (ring, glove, shoe)
  • Peripheral Neuropathies/Carpal Tunnel
  • Thickening of facial bones/prognathism
  • Thickening of skin and soft tissues
  • Enlargement of all internal organs (except brain and nerves)
  • Cardiac Hypertrophy
  • HTN
  • Peripheral Neuropathy
52
Q

Anesthesia Considerations in Acromegaly/Gigantism

• Mask ventilation

A

difficult due to enlarged mandible and facial bones.

53
Q

Anesthesia Considerations in Acromegaly/Gigantism

• Mandibular hypertrophy

A

increased distance from lips to vocal cords.

54
Q

Anesthesia Considerations in Acromegaly/Gigantism

Direct laryngoscopy difficult due to

A

enlarged

tongue, epiglottis and glottic structures.

55
Q

Anesthesia Considerations in Acromegaly/Gigantism Hoarseness/stridor may indicate

A

stretching of laryngeal nerve and impaired mobility of cricoarytenoid joints – smaller diameter tracheal tube
may be required.

56
Q

Anesthesia Considerations in Acromegaly/Gigantism

Larger than normal

A

tidal volumes from ventilator

may be required (CAD common in these pts).

57
Q

Anesthesia Considerations in Acromegaly/Gigantism

A

Avoid positioning extremities in a manner that may
exacerbate altered nerve function.– ie. Pt.’s elbows should remain extended to minimize
tension on ulnar nerve.

58
Q

Anesthesia Considerations in Acromegaly/Gigantism Extension of Pt.’s hands should

A

be avoided to preclude stretching of ulnar and median nerves.

59
Q

Anesthesia Considerations in Acromegaly/Gigantism

ECG and arrhythmias

A

Arrhythmias and ECG changes are common – 12-lead

ECG helpful to detect new-onset changes.

60
Q

Anesthesia Considerations in Acromegaly/Gigantism
• High incidence of
• High incidence of_____

A

Peripheral Neuropathy –

Obstructive sleep apnea – monitor for airway obstruction Alterations in BP/cardiac function post-operatively.

61
Q

↑ PRL - Hyperprolactinemia

Can Cause those symptoms

A

galactorrhea, amonorrhea, infertility,
decreased libido, osteopenia, impotence and
erectile dysfunction

62
Q

PRL Normally controlled by

A

Hypothalamic Dopamine

63
Q

↑ PRL - Hyperprolactinemia• Usually treated with

A

Dopamine agonist

64
Q

↑ PRL - Hyperprolactinemia caused by

A

• ↑ PRL caused by functional prolactin secreting mass
or
• Non-functional tumor compressing and blocking
Hypothalamic Dopamine

65
Q

Anesthesia Considerations in Hyperprolactinemia

• Dopamine agonist side effects -

A

hallucinations, drowsiness, nausea, orthostatic hypotension

• Can be exacerbated by General Anesthesia

66
Q

↑ TSH – Pituitary Hyperthyroidism

• Causes ↑T4,T3 =

A

palpitations, nervousness, heat intolerance, tremor and/or arrhythmias

67
Q

↑TSH Pituitary Hyperthyroidism secreting tumors usually

A

large and invasive – can present with compression effects (HA, visual changes, C.N. palsies)

68
Q

↑TSH Pituitary Hyperthyroidism tumors can also co-secrete 3 hormones? what is the significance of that

A

co-secrete GH, PRL & ACTH, therefore acromegaly, hyperprolactinemia or Cushing’s disase may coexist.

69
Q

↑ TSH – Pituitary Hyperthyroidism

• Treated with

A

somatostatin analogue (ex. Octreotide) – reduces TSH production

70
Q

↑ TSH – Pituitary Hyperthyroidism used to control tachycardia

A

Beta-antagonist

71
Q

↑ TSH – Pituitary Hyperthyroidism Some pt.s may have been initially treated for

A

primary hyperthyroidism/Grave’s disease (instead of pituitary hyperthyroidism) with removal of thyroid
– In this case, pt. may be clinically hypothyroid and
require thyroid hormone replacement

72
Q

Anesthesia Considerations in Pituitary Hyperthyroidism

A

• Hypothyroid pt.s should continue to receive thyroid hormone in peri-operative period.
• Potential for intra-operative thyroid storm in
pituitary hyperthyroid possible, (but unlikely).

73
Q

↑ Gonadotropins

A

Overproduction of FSH/LH

74
Q

↑ Gonadotropins • Usually manifest as

A

disorders with sexual function and reproduction.

75
Q

↑ Gonadotropins Largely present as

A

Macro-adenomas with symptoms related to mass effect.

76
Q

Peri-operative anesthetic management↑ Gonadotropins

similar to

A

non-secreting pituitary tumors.

77
Q

Posterior Pituitary Disorders

• ↑ ADH

A

SIADH (Syndrome of Inappropriate ADH)

78
Q

Posterior Pituitary Disorders

• ↓ ADH

A

DI (Diabetes Inspidus)

79
Q

Posterior Pituitary Disorders

ADH or “Vasopressin” binds to:

A

V1 receptors in blood vessels = vasoconstriction
V2 receptors in kidney = reabsorption of H2O
Increases blood pressure; decreases blood osmolarity

80
Q

SIADH Causes

A

Hypo-osmolality and Hyponatremia

81
Q

SIADH Symptoms:

A

– Nausea
– HA
– Lethargy
– Confusion

82
Q

If Na+ level below 120 symptoms

A

– Stupor
– Seizures
– coma

83
Q

SIADH

• Acute hyponatremia treatment:

A

– Hypertonic saline (3%)
– In pt.s with mild neurologic symptoms, given at
0.5mEq/L/h
– In pt.s with severe neurologic symptoms, given at
1-2 mEq/L/h

84
Q

• Infusion rate can be estimated using formula:

A

Vol. 3% NaCl/h = wgt (kg) x expected change in serum Na level.
Example: 70 ml NaCl/h = 70kg x 1 mEq/L/h

85
Q

SIADH

• Correcting serum sodium too rapidly

A

associated with central pontine myelinolysis
(osmotic demyelination syndrome)
Damage to CNS (Pons) as brain cells compensate

86
Q

SIADH Tx In asymptomatic

A 
pt.s, water restriction and/or
loop diuretics (ex. Furosemide)
87
Q

SIADH treatment:

A

vasopressin receptor antagonists (ex. Conivaptan)

88
Q

DI Causes

A

hypernatremia and hypovolemia

89
Q

Two types of DI: =

A

Central DI and Nephrogenic DI

90
Q

Central DI

A

failure of posterior pituitary

91
Q

Nephrogenic DI

A

Lack of kidney response to ADH

92
Q

DI Correction of hypernatremia is

A

with 0.9% saline. Plasma Na+ correction should not decrease by more than 1 mEq/L q 2 hrs.
Otherwise could cause cerebral edema

93
Q

• Treatment of DI:

A

Desmopressin

94
Q

Pituitary Surgrery: What is the most common approach?

A

Transnasal approach is most commonly used technique.

95
Q

Pituitary Surgery

Intra-operative complications:

A

– Bleeding because of close proximity to venous
CAVERNOUS SINUS and CAROTID
– HTN if a vasoconstrictor is added to submucosal
anesthetic

96
Q

Large-bore intravenous access and availability of

A

blood products should be considered

97
Q

Gastric accumulation of blood could

A

increase risk of post-op N/V

98
Q

Pituitary Surgery and CSF what can occur?

A
  • CSF leak could occur.
  • Some surgeons may request placement of lumbar CSF drain catheter.
  • (CSF can be drained or air can be injected to displace sellar contents, but will also cause transient change in ICP.)
99
Q

Pituitary Surgery: examination post op

A

Post-op cranial nerve examination often performed to assess gross visual function

100
Q

Most common symptom of pituitary surgery tumor and post CN issues? What causes it?

A

diplopia due to dysfunction of extra-ocular muscles

101
Q

If air is injected via lumbar catheter, NO2

A

should not be used given its effect on volume
of gases in closed spaces. (NO2 passes easily
from blood into gas filled spaces causing
increased volume expansion).

102
Q

What should be performed after pituitary surgery?

A

Gross neurological exam should be performed

103
Q

With acromegaly, what is the exception as far as organ enlargement?

A

Nerves and Brain

104
Q

Lateral movement muscles are

A

Lateral rectus (CN VI) (9am)

105
Q

Superior Oblique is

A

CN IV

106
Q

Inferior MEDIAL movement muscles are

A

Superior oblique CN IV (5pm)

SRNA3AdvancedPatho2 (15 decks)

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