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Abstract: A 36-year-old female patient presented to the clinic with a headache accompanied by decreased menstruation, and an examination suggested a pituitary adenoma. Due to the poor results of oral medication, surgery was recommended and the patient agreed. The patient underwent neuroendoscopic assisted transsphenoidal pituitary adenoma resection after completing all the preoperative tests, and with drug treatment, her condition was significantly controlled.
Basic information】Female, 36 years old
Type of disease】Pituitary adenoma
Hospital】Shanghai First People’s Hospital
Date of Consultation】March 8, 2022
Treatment plan】Surgical treatment (neuroendoscopy-assisted transsphenoidal pituitary adenoma resection) + medication (Ceftriaxone sodium for injection, white brow snake venom hemagglutinase for injection, compound acetaminophen tablets (II), metoclopramide tablets, posterior pituitary injection, desmopressin acetate tablets)
[Treatment Period] Hospitalization for 7 days, rechecked after 1 month
Treatment effect] The disease was significantly controlled, headache disappeared, prolactin level normalized, and menstruation basically returned to normal.
I. Initial consultation
A 36-year-old middle-aged woman found that her menstrual flow started to decrease half a year ago. Because of her usual work intensity, she thought it was an endocrine disorder caused by fatigue and did not pay attention to it. Later, she was recommended by the gynecology department to the endocrinology department to check the systemic hormone level and found that the level of prolactin was increased. She had taken bromocriptine mesylate tablets for 2 months, but there were side effects such as dizziness and nausea, and she could not tolerate them for a long time and stopped taking them. After explaining to the patient that the treatment effect of bromocriptine mesylate tablets was not good and surgery was needed to remove the tumor, the patient agreed to undergo surgery, so the patient was admitted to the ward for further treatment.
II. Treatment process
After admission, the patient underwent gross visual field measurements and ophthalmologic examination, and was found to have no visual acuity loss or visual field narrowing, and no papillary overflow. The patient underwent routine blood, blood biochemistry, coagulation, four infectious diseases, and a full set of endocrine hormone examination, and found no abnormalities except for increased prolactin, and no abnormalities in routine abdominal ultrasound and electrocardiogram. Since the tumor was small in size and completely below the saddle diaphragm, a neuroendoscopic-assisted transnasal pituitary adenomectomy was performed. Postoperatively, injectable ceftriaxone sodium was given to prevent infection, and injectable whitebrow snake venom hemagglutinase was given to control the nasal cavity and blood leakage in the operative area. The patient had headache and vomiting symptoms in the first 2 days after surgery, which were considered as possible surgical injury and anesthetic reaction, and was given compound acetaminophen tablets (II) and metoclopramide tablets. The patient also had transient increase in urine volume and decrease in urine specific gravity, which were controlled by subcutaneous injection of posterior pituitary injection and oral desmopressin acetate tablets for 5 days and then normalized. The tumor was well resected, and the hormone prolactin level was decreased and the rest of the hormones were not abnormal. One month later, the patient came to the hospital for endoscopic nasal exploration to check the healing of the nasal mucosa and the mucosal flap of the saddle base, and to clear the nasal secretion.
III. Treatment effect
The patient’s postoperative headache was relieved, and the transient uropygias were controlled. There was no fever, cerebrospinal fluid leakage or recurrent nasal leakage. The imaging examination showed no significant blood leakage from the operated area, and the tumor was satisfactorily resected, and the laboratory results indicated that the patient’s prolactin level decreased to normal. Three months after the operation, the patient came back to the hospital for a follow-up examination. The MRI of the saddle area did not indicate recurrence, the headache disappeared, the prolactin level continued to be normal, and the menstruation basically returned to normal.
IV. Notes
We are glad that the patient’s headache symptoms disappeared after treatment. Patients should eat cold fluids after surgery to avoid nasal capillary dilation caused by high temperature resulting in nasal bleeding. If postoperative patients have low hormone levels, they need long-term hormone replacement therapy. Postoperative transient increase in urine volume is one of the common symptoms, and attention needs to be paid to control the daily urine volume not exceeding 2500 ml with medication, appropriate water restriction and attention to maintain electrolyte balance. Patients are recommended to come to the hospital for nasal exploration 1 month after discharge to check the healing of nasal mucosa and saddle base mucosal flap and to remove nasal secretions. The complete set of hormone levels and saddle area enhancement MRI are usually reviewed every 3-6 months to clarify whether there is any rebound of hormone levels and tumor recurrence, while coughing, nose blowing and nose pulling should be avoided. Patients should keep their bowels open to prevent constipation and avoid spicy and stimulating diet, such as spicy hotpot and spicy hot pot.
V. Personal insight
Pituitary adenoma can be divided into microadenoma, macroadenoma and macroadenoma according to size, and functional pituitary adenoma such as prolactin type, growth hormone type, adrenocorticotropic hormone type and mixed type, and non-functional pituitary adenoma with normal hormones. However, the patient was unable to tolerate long-term use of bromocriptine mesylate tablets, so surgery was given. Depending on the size, morphology and invasion of the tumor, the type of surgery includes simple transsphenoidal approach, simple open cranial approach and combined nasocranial approach. For tumors that are not completely resected, treatment options such as second stage re-excision, gamma knife and drugs are available.