Abstract
Object
Headache is the most common symptom of both primary and metastatic brain tumor, and is generally considered the primary symptom in patients with large pituitary adenomas. However, patients with small pituitary adenomas rarely complain of intractable headache, and neurosurgeons are unsure whether such small adenomas actually contribute to headache. If conventional medical treatments for headache prove ineffective, surgical removal of the adenoma can be considered as an alternative management strategy.
Methods
We conducted a retrospective review of 180 patients who underwent transsphenoidal surgery (TSS) for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. Patients with acute phase intratumoral hemorrhage were excluded. We identified nine patients with intractable headache as the chief complaint associated with small pituitary adenoma (diameters 15.8 ± 2.6 mm, 11–20 mm), non-functioning in eight, and prolactin-secreting in one. The preoperative neuroradiological studies and headache characteristics were assessed retrospectively, and the intrasellar pressure evaluation was performed during TSS in the last seven patients.
Results
All nine patients had complete or substantial resolution of their formerly intractable headache after TSS. Headaches consisted of ocular pain ipsilateral to the adenoma localization within the sella in four cases and bifrontal headache in five. Magnetic resonance imaging of these patients revealed small diaphragmatic foramen, which were so narrow that only the pituitary stalk could pass. Computed tomography scans showed ossification beneath the sellar floor in the sphenoid sinus, presellar type in six cases, and choncal type in three. The adenomas included cysts in seven cases. There was no cavernous sinus invasion. Intrasellar pressure measurements averaged 41.5 ± 8.5 mmHg, range 34–59, significantly higher than in control patients without headache (n = 12), namely 22.2 ± 10.6 mmHg (16–30).
Conclusion
In this study, the authors demonstrated the validity of TSS in the treatment of intractable headache associated with pituitary adenoma. The presence of ocular pain, especially ipsilateral to the adenoma, integrity of the diaphragm sella, and ossification in the sphenoid sinus, cyst or hemorrhage and the absence of cavernous sinus invasion were the indications for TSS for patients complaining of intractable headache and having pituitary adenomas.
Similar content being viewed by others
Abbreviations
- ACTH:
-
Adrenocorticotropic hormone
- CRH:
-
Corticotropin-releasing hormone
- CT:
-
Computed tomography
- FIESTA:
-
Fast imaging employing steady state acquisition
- HIT:
-
Headache impact test
- ISP:
-
Intrasellar pressure
- MRI:
-
Magnetic resonance imaging
- PRL:
-
Prolactin
- TSS:
-
Transsphenoidal surgery
References
Fleseriu M, Yedinak C, Campbell C, Delashaw JB (2009) Significant headache improvement after transsphenoidal surgery in patients with small sellar lesions. J Neurosurg 110(2):354–358. doi:10.3171/2008.8.JNS08805
Levy MJ, Jager HR, Powell M, Marthau MS, Meeran K, Goadsby PJ (2004) Pituitary volume and headache: size is not everything. Arch Neurol 61:721–725. doi:10.1001/archneur.61.5.721
Suwanwela N, Phanthumchinda K, Kaoropthum S (1994) Headache in brain tumor: a cross-sectional study. Headache 34(7):435–438
Abe T, Matsumoto K, Kuwazawa J, Toyoda I, Sasaki K (1998) Headache associated with pituitary adenomas. Headache 38(10):782–786. doi:10.1046/j.1526-4610.1998.3810782.x
Shah AK, Freij W (1999) Dramatic headache relief after sumatriptan in a patient with a pituitary macroadenoma. Headache 39(6):443–445. doi:10.1046/j.1526-4610.1999.3906443.x
Arafah BN, Prunty D, Ybarra J, Hiavin ML, Seiman WR (2000) The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headache in patients with pituitary adenomas. J Clin Endocrinol Metabol 85(5):1789–1793. doi:10.1210/jcem.85.5.6611
Evans RW, Levy MJ (2008) Expert opinion: headache and pituitary tumors. Headache 48:280–283. doi:10.1111/j.1526-4610.2007.01020
Gondim JA, de Almeida JP, Freitas de Albuquerque LA, Schops M, Gomes E, Ferraz T (2009) Headache associated with pituitary tumors. J Headache Pain 10:15–20. doi:10.1007/s10194-008-0084-0
Freitas Tda S, Ferreira IC, Pereira Neto A, Neto OR, Gomes Gdo V, da Mota LA, Naves LA, Azevedo MF (2011) Treatment of severe trigeminal headache in patients with pituitary adenomas. Neurosurgery 68(5):1300–1308. doi:10.1227/NEU.0b013e31820c6c9e
Piebes SK, Snyder AR, Bay RC, Valovich McLeod TC (2011) Measurement properties of headache-specific outcomes scales in adolescent athletes. J Sport Rehabil 20:129–142
Nomura M, Tachibana O, Yamashima T, Yamashita J, Suzuki M (2002) MRI evaluation of the diaphragmal opening: using MRI parallel to the transsphenoidal surgical approach. J Clin Neurosci 9(2):175–177. doi:10.1054/jocn.2000.0920
Gondim JA, Tella OI Jr, Schops M (2006) Intrasellar pressure and tumor volume in pituitary tumor. Arq Neuropsiquiatr 64:971–975
Koskinen LO, Olivecrona M (2005) Clinical experience with the intraparenchymal intracranial pressure monitoring Codman MicroSensor system. Neurosurgery 56(4):693–698. doi:10.1227/01.NEU.0000156609.95596.24
Levy MJ, Matharu MS, Meeran K, Powell M, Goadsby PJ (2005) The clinical characteristics of headache in patients with pituitary tumours. Brain 128:1921–1930. doi:10.1093/brain/awh525
Destrieux C, Kakou MK, Velut S, Lefrancq T, Jan M (1998) Microanatomy of the hypophyseal fossa boundaries. J Neurosurg 88(4):743–752. doi:10.3171/jns.1998.88.4.0743
Lees PD, Pichard JD (1987) Hyperprolactinemia, intrasellar pituitary tissue pressure, and the pituitary stalk compression syndrome. J Neurosurg 67:192–196
Lees PD, Fahlbusch R, Zrinzo A, Pickard JD (1994) Intrasellar pituitary tissue pressure, tumour size and endocrine status—an international comparison in 107 patients. Br J Neurosurg 8:313–318
Ramakrishnan VR, Suh JD, Lee JY, O’Malley BW Jr, Grady MS, Palmer JN (2013) Sphenoid sinus anatomy and suprasellar extension of pituitary tumors. J Neurosurg 119(3):669–674. doi:10.3171/2013.3.JNS122113
Zada G, Agarwalla PK, Mukundan S Jr, Dunn I, Golby AJ, Laws ER Jr (2011) The neurosurgical anatomy of the sphenoid sinus and sellar floor in endoscopic transsphenoidal surgery. J Neurosurg 114(5):1319–1330. doi:10.3171/2010.11.JNS10768
Gondim JA, Schops M, Tella OI Jr (2003) Transnasal endoscopic surgery of the sellar region: study of the first 100 cases. Arq Neuropsiquiatr 61:836–841
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All authors have no conflict of interests.
Rights and permissions
About this article
Cite this article
Hayashi, Y., Kita, D., Iwato, M. et al. Significant improvement of intractable headache after transsphenoidal surgery in patients with pituitary adenomas; preoperative neuroradiological evaluation and intraoperative intrasellar pressure measurement. Pituitary 19, 175–182 (2016). https://doi.org/10.1007/s11102-015-0696-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11102-015-0696-8