Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score

Castle-Kirszbaum, Mendel; Fuller, Peter J.; Wang, Yi Yuen; King, James; Goldschlager, Tony

doi:10.1007/s11102-021-01159-y

Cited by 26 publications

(24 citation statements)

References 39 publications

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“…The incidence of CDI was higher in patients who underwent craniotomy when compared to TSS. Previous studies have reported an incidence of transient CDI of 18-38.5% among the patients with pituitary surgery (8,9,11,16,26,27). Our study showed a comparable incidence of CDI with TSS patients, but much higher incidence among craniotomy patients, which possibly can be attributed to the surgical approach itself and increased handling leading to damage of the posterior pituitary or the stalk.…”

Section: Post-operative Polyuriasupporting

confidence: 62%

“…The incidence of hyponatremia after surgeries in sellar/ suprasellar region has been reported to be16-23%, with most common aetiology being syndrome of inappropriate anti-diuretic-hormone (SIADH) (1)(2)(3)(4)(5). The other causes for hyponatremia in this context are secondary hypocortisolism, over-treatment with desmopressin, excessive uid intake and cerebral salt wasting (CSW) (2,6,7) Polyuria is another complication following these surgeries, which is usually due to diuresis of the intravenous uid administered during intra-operative period, followed by cranial diabetes insipidus (CDI), with an incidence of 10-58% (8)(9)(10). Post-operative CDI in these patients can be, transient, permanent or triphasic (11).…”

Section: Introductionmentioning

confidence: 99%

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Sodium and water imbalances following sellar and suprasellar surgeries in Sri Lanka; a descriptive cross-sectional study

Wijewickrama¹,

Ambawatte²,

Sumanatilleke

et al. 2022

Preprint

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Background Water and sodium imbalances are common following sellar/suprasellar surgeries. The aim of the current study was to analyse the incidence, associations and management of sodium and water imbalances following sellar/ suprasellar surgeries in Sri Lanka. Methods A prospective cross-sectional study carried out in the National Hospital of Sri Lanka over 18 months from September 2019. All patients undergoing sellar/suprasellar surgeries fulfilling the inclusion criteria were followed up to 7 days after surgery, to collect clinical, biochemical and intake-output parameters. Results Out of 139 patients, 108 were trans-sphenoidal surgeries (TSS), 31 had craniotomies. Majority had non-functioning pituitary adenomas (NFPA) (n=81,58.2%) followed by craniopharyngioma (n=22,15.8%), acromegaly (n=20,14.3%), Cushing’s-disease (n=9,6.4%), suprasellar meningioma (n=6,4.3%) and prolactinoma (n=1,0.7%). Post-operative hyponatremia occurred in 18.5% TSS and 38.7% craniotomy patients, with syndrome-of-inappropriate-ADH-secretion (SIADH) being the commonest cause. First surgery (p:0.004, Adjusted-OR:1.38(1.23-1.53)), craniotomy compared to TSS (p:0.001, Adjusted-OR:2.61(1.86-4.66)), tumour size>3cm (p:<0.001, Adjusted-OR:2.81(2.21-4.05), pre-operative dexamethasone (p:<0.001, Adjusted-OR:3.60(1.84-7.36)) and, craniopharyngioma (p:0.001, Adjusted-OR:3.69(1.71-6.9)) were identified as risk factors for post-operative SIADH. No patients with Cushing’s disease or acromegaly developed SIADH. Mainstay of management of SIADH was fluid restriction. Post-operative polyuria was detected in 75 (53.9%) with 50 having cranial diabetes insipidus (CDI) and the rest having transient-polyuria due to other causes. Re-operation (p:<0.001, Adjusted-OR:3.02(1.81-5.89)), suprasellar location of the tumour (p:<0.001, Adjusted-OR:7.89(2.99-20.62)), craniotomy (p:0.004, Adjusted-OR 2.41:(1.36-4.55)), tumour size>2cm (p:0.018, Adjusted-OR:1.29(1.01-1,62)), craniopharyngioma (p:<0.001, Adjusted-OR:2.93(2.11-4.21)), and post-operative dexamethasone (p:0.008, Adjusted-OR:1.7(1.23-2.66)) were identified as risk factors for post-operative CDI. For patients who had transient polyuria, but not CDI, acromegaly was the only identified association (p:<0.001, Adjusted-OR 7.81 (4.12-13.99)). Only 4 patients went on to have permanent CDI. Mainstay of management of CDI was desmopressin as needed, along with fluid management. Conclusion Diagnosis and management of water and sodium imbalances following sellar/suprasellar surgeries is challenging, needing specialist endocrinology input. Post-operative hyponatremia, SIADH, transient polyuria and transient CDI are common. This is the first study carried out in Sri Lanka to analyse the patterns of sodium and water disorders following sellar/ suprasellar surgeries. These findings highlight that certain pre-operative characteristics could predict post-operative water and sodium imbalances and will be useful in early identification of high-risk patients.

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Section: Post-operative Polyuriasupporting

confidence: 62%

Section: Introductionmentioning

confidence: 99%

Sodium and water imbalances following sellar and suprasellar surgeries in Sri Lanka; a descriptive cross-sectional study

Wijewickrama¹,

Ambawatte²,

Sumanatilleke

et al. 2022

Preprint

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“…Apart from the incidence of postoperative DI, we investigated the treatment required in these patients. Although the incidence rates and risk factors of DI occurrence were reported in previous publications, the percentage of patients requiring inpatient or prolonged desmopressin treatment was rarely reported and the descriptions of the desmopressin management strategies were unclear ( 13 , 14 , 22 – 27 ). In the present study, we highlighted that the clinical course and required treatment for patients with transient DI were heterogenic.…”

Section: Discussionmentioning

confidence: 99%

“…Clinicians must be vigilant about sudden electrolyte fluctuations and knowledgeable in the course of postoperative DI to avoid potential complications. Although the predictors of postoperative DI have been reported and there is evidence on the treatment of postoperative DI ( 2 , 3 , 7 , 13 , 14 ), whether a patient with DI may require desmopressin therapy and the strategy for desmopressin discontinuation are not yet investigated. Determining an optimal indication and duration of desmopressin treatment may improve patient care and prevent complications associated with suboptimal treatment duration, such as rebounding of DI symptoms and iatrogenic hyponatremia ( 15 ).…”

Section: Introductionmentioning

confidence: 99%

Predicting the Need for Desmopressin Treatment During Inpatient and After Discharge Following Endoscopic Sellar Surgery

et al. 2022

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IntroductionPostoperative diabetes insipidus (DI) is a common complication following endoscopic sellar surgery. However, the requirement of desmopressin treatment for patients with DI are heterogenous. Although the predictors of postoperative DI have been reported, whether these patients required desmopressin treatment remained uninvestigated. Predicting the need of desmopressin can benefit clinical decision making more directly than predicting the occurence of postoperative DI. This study aimed to identify variables that predict the need for desmopressin treatment following sellar surgery.MethodsPatients undergoing endoscopic sellar surgery between 2016 and 2019 were retrospectively reviewed. Twenty-three variables, characterized as potential predictors for requiring desmopressin treatment, were analyzed. To assess the capability to generalize the identified predictors, external validation with receiver operating characteristic (ROC) analysis was performed using a second series from 2019 to 2020.ResultsPostoperative DI occurred in 40 of 159 included patients. Twelve patients required inpatient desmopressin treatment and 20 patients needed desmopressin prescription after discharge. The potential predictors of requiring any desmopressin use included higher peak sodium (Na) level (p = 0.007), lower minimum Na level (p = 0.043), and higher peak urine output (p = 0.006), but these were not supported by external validation. The predictors of requiring desmopressin after discharge included higher peak Na (p = 0.040) and minimum Na levels (p = 0.048), which were supported by external ROC validation showing areas under curve of 0.787, 0.611, and 0.898 for peak Na (p = 0.036), minimum Na (p = 0.460), and peak Na – minimum Na levels (p < 0.001), respectively. A criterion of peak Na ≥ 150 mmol/L or peak Na – minimum Na ≥ 10 predicted the need of desmopressin prescription after discharge. A postoperative management algorithm was proposed.ConclusionThe required treatments for patients with postoperative DI following endoscopic sellar surgery are heterogenous. Elevated peak Na and large peak Na—minimum Na levels in the perioperative period predicted requiring desmopressin after hospital discharge. Patients with peak Na <150 mmol/L and peak Na—minimum Na <10 can be safely discharged without desmopressin prescription.

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“…The pituitary metastasis was asymptomatic before the biopsy surgery. As postoperative DI has been observed in 10.2% of endoscopic transsphenoidal surgery [ 11 ], the thalamic metastasis, as opposed to the pituitary metastasis, was selected as a biopsy target to preserve pituitary function. Nonetheless, postoperative pituitary dysfunction was observed, as evidenced by the unexpected DI and panhypopituitarism.…”

Section: Discussionmentioning

confidence: 99%

Masked diabetes insipidus in pituitary metastasis from breast cancer after thalamic biopsy: a case report

et al. 2022

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Background Symptomatic pituitary metastasis is rare; furthermore, it can result in diabetes insipidus and panhypopituitarism. Since diabetes insipidus is masked by concurrent panhypopituitarism, it can impede the diagnosis of pituitary dysfunction. Case presentation A 68-year-old Japanese female suffering from pituitary and thalamic metastases caused by untreated breast cancer, underwent a biopsy targeting the thalamus, not the pituitary. She lacked prebiopsy pituitary dysfunction symptoms; however, these symptoms unexpectedly occurred after biopsy. Diabetes insipidus was masked by corticosteroid insufficiency, and she showed normal urinary output and plasma sodium levels. Upon commencement of glucocorticoid replacement therapy, the symptoms of diabetes insipidus appeared. Conclusions In this case, thalamic biopsy, as opposed to pituitary biopsy, was performed to preserve pituitary function. However, pituitary dysfunction could not be avoided. Caution is necessary for asymptomatic patients with pituitary metastases as invasive interventions, such as surgery, may induce pituitary dysfunction. Moreover, with respect to masked diabetes insipidus, there is a need to carefully consider pituitary dysfunction to avoid misdiagnosis and delayed treatment.

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Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score

Cited by 26 publications

References 39 publications

Sodium and water imbalances following sellar and suprasellar surgeries in Sri Lanka; a descriptive cross-sectional study

Sodium and water imbalances following sellar and suprasellar surgeries in Sri Lanka; a descriptive cross-sectional study

Predicting the Need for Desmopressin Treatment During Inpatient and After Discharge Following Endoscopic Sellar Surgery

Masked diabetes insipidus in pituitary metastasis from breast cancer after thalamic biopsy: a case report

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