Post-traumatic pituitary apoplexy--two case reports.
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A 60-year-old female and a 66-year-old male presented with post-traumatic pituitary apoplexy associated with clinically asymptomatic pituitary macroadenoma manifesting as severe visual disturbance that had not developed immediately after the head injury. Skull radiography showed a unilateral linear occipital fracture. Magnetic resonance imaging revealed pituitary tumor with dumbbell-shaped suprasellar extension and fresh intratumoral hemorrhage. Transsphenoidal surgery was performed in the first patient, and the visual disturbance subsided. Decompressive craniectomy was performed in the second patient to treat brain contusion and part of the tumor was removed to decompress the optic nerves. The mechanism of post-traumatic pituitary apoplexy may occur as follows. The intrasellar part of the tumor is fixed by the bony structure forming the sella, and the suprasellar part is free to move, so a rotational force acting on the occipital region on one side will create a shearing strain between the intra- and suprasellar part of the tumor, resulting in pituitary apoplexy. Recovery of visual function, no matter how severely impaired, can be expected if an emergency operation is performed to decompress the optic nerves. Transsphenoidal surgery is the most advantageous procedure, as even partial removal of the tumor may be adequate to decompress the optic nerves in the acute stage. Staged transsphenoidal surgery is indicated to achieve total removal later. (+info)
Significance of vomiting after head injury.
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OBJECTIVES: To determine whether the presence and severity of post-traumatic vomiting can predict the risk of a skull vault fracture in adults and children. METHODS: Data were analysed relating to a consecutive series of 5416 patients including children who presented to an emergency service in the United Kingdom during a 1 year study period with a principal diagnosis of head injury. Characteristics studied were age, sex, speed of impact, level of consciousness on arrival, incidence of skull fracture, and the presence and severity of post-traumatic vomiting. RESULTS: The overall incidence of post-traumatic vomiting was 7% in adults and 12% in children. In patients with a skull fracture the incidence of post-traumatic vomiting was 28% in adults and 33% in children. Post-traumatic vomiting was associated with a fourfold increase in the relative risk for a skull fracture. Nausea alone did not increase the risk of a skull fracture and multiple episodes of vomiting were no more significant than a single episode. In patients who were fully alert at presentation, post-traumatic vomiting was associated with a twofold increase in relative risk for a skull fracture. CONCLUSION: These results support the incorporation of enquiry about vomiting into the guidelines for skull radiography. One episode of vomiting seems to be as significant as multiple episodes. (+info)
Value of radiological diagnosis of skull fracture in the management of mild head injury: meta-analysis.
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OBJECTIVES: Head injury is a common event. Most patients sustain a mild head injury (MHI), and management depends on the risk of an intracranial haemorrhage (ICH). The value of a plain skull radiograph as a screening tool for ICH is controversial. The aim of this meta-analysis was to estimate and explain differences in reported sensitivity and specificity of the finding of a skull fracture for the diagnosis of ICH, in order to assess the value of the plain skull radiograph in the investigation of patients with MHI, and to estimate the prevalence of ICH in these patients. METHOD: After a systematic literature search 20 studies were selected that reported data on the prevalence of ICH after MHI and/or data on the diagnostic value of skull fracture for the diagnosis of ICH. The mean prevalence of ICH weighted for the sample size was determined. The sensitivity and specificity of different studies were combined using a summary receiver operator characteristic curve. Correlation analysis was used to determine factors that could explain the reported differences between studies. RESULTS: The weighted mean prevalence of ICH after MHI is 0.083. The potential for verification bias and the percentage of patients who had suffered loss of consciousness or post-traumatic amnesia were the most significant factors explaining interstudy differences in sensitivity and specificity. Based on studies wherein at least 50% of patients had a CT study of the brain, the estimated sensitivity of a radiographic finding of skull fracture for the diagnosis of ICH is 0.38 with a corresponding specificity of 0.95. CONCLUSION: The plain skull radiograph is of little value in the initial assessment of MHI patients. (+info)
Pituitary insufficiency after penetrating injury to the sella turcica.
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We report a 28-year-old male patient with a pituitary insufficiency after a simple fracture of the sella turcica. He was injured by a long nail that punctured the lower jaw. No fracture other than that of the sella turcica was detected. An endocrinological examination revealed both anterior and pituitary dysfunction and diabetes insipidus that continued for about two months. (+info)
Acute identification of cranial burst fracture: comparison between CT and MR imaging findings.
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BACKGROUND AND PURPOSE: Scalp swelling associated with cranial burst fracture, a widely diastatic skull fracture of infants associated with dural laceration and acute cerebral extrusion, may be confused with that of a simple subgaleal hematoma. Both conditions can also be associated with hemorrhagic shock. We sought to improve the early evaluation of infants believed to have sustained cranial burst fracture by including MR imaging, since this study clearly delineates the dural-cortical interface, the site of injury. METHODS: Seven infants aged 1 through 11 months who sustained cranial burst fractures, all initially imaged with skull radiography and CT, were studied or treated from 1992 through 1996. MR imaging was obtained after resuscitation and stabilization. RESULTS: Surgery or autopsy confirmed MR findings (dural laceration and extracalvarial cerebral tissue) in all seven infants. CONCLUSION: MR imaging allows early diagnosis of skull fracture associated with acute cerebral extrusion. (+info)
Fracture of the occipital condyle: the forgotten part of the neck.
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A case of occipital condylar fracture in a multiply injured and unconscious motorcyclist is reported. This injury was clinically unsuspected but found on the lowest cuts of head computed tomography. It is shown that this site is often inadequately imaged when scanning the head and neck in victims of trauma. The Anderson and Montesano classification of occipital condylar fracture is described. It is noted that types 1 and 2 are stable injuries but type 3 is potentially unstable. A retrospective analysis of 30 head computed tomography scans in trauma cases revealed that in only 16 were the occipital condyles adequately imaged. It is emphasised that vigilance is required to detect fractures of the occipital condyle and that it should be standard practice to include this area when performing computed tomography of the head in trauma victims. (+info)
Significance of shock in head-injured patients with skull fracture.
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The clinical differences between patients with skull base and convexity fractures were retrospectively investigated in 324 patients, of whom 110 had suffered head injury resulting in skull fracture. These 110 patients were divided into the skull base and convexity groups. There were no significant differences between the groups with respect to sex, age, Glasgow Coma Scales, injury severity scores, pupil abnormalities, and outcomes. Automobile collisions were the most common causes in the skull base group, and falls in the convexity group. Traumatic Coma Data Bank diffuse 1 type injuries were more frequent in the skull base group and evacuated masses were more frequent in the convexity group. Multiple injuries, shock on admission, lower hemoglobin concentrations, and increased transfusion requirements were evident in the skull base group. Controlling for shock, the outcomes in the skull base group were favorable. Convexity fractures were usually associated with isolated severe head injuries and require brain protection therapy. Skull base fractures were caused by a significant force distributed over a large area of the body with a tendency to induce shock, and require a multidisciplinary approach to treatment. (+info)
Central diabetes insipidus in children and young adults.
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BACKGROUND: Central diabetes insipidus is rare in children and young adults, and up to 50 percent of cases are idiopathic. The clinical presentation and the long-term course of this disorder are largely undefined. METHODS: We studied all 79 patients with central diabetes insipidus who were seen at four pediatric endocrinology units between 1970 and 1996. There were 37 male and 42 female patients whose median age at diagnosis was 7.0 years (range, 0.1 to 24.8). All patients underwent magnetic resonance imaging (MRI) and periodic studies of anterior pituitary function. The median duration of follow-up was 7.6 years (range, 1.6 to 26.2). RESULTS: The causes of the central diabetes insipidus were Langerhans-cell histiocytosis in 12 patients, an intracranial tumor in 18 patients, a skull fracture in 2 patients, and autoimmune polyendocrinopathy in 1 patient; 5 patients had familial disease. The cause was considered to be idiopathic in 41 patients (52 percent). In 74 patients (94 percent) the posterior pituitary was not hyperintense on the first MRI scan obtained, and 29 patients (37 percent) had thickening of the pituitary stalk. Eighteen patients had changes in the thickness of the pituitary stalk over time, ranging from normalization (six patients) or a decrease in thickness (one patient) to further thickening (seven patients) or thickening of a previously normal stalk (four patients). Anterior pituitary hormone deficiencies, primarily growth hormone deficiency, were documented in 48 patients (61 percent) a median of 0.6 year (range, 0.1 to 18.0) after the onset of central diabetes insipidus. CONCLUSIONS: Most children and young adults with acquired central diabetes insipidus have abnormal findings on MRI scans of the head, which may change over time, and at least half have anterior pituitary hormone deficiencies during follow-up. (+info)