Anaesthesia and pituitary tumors

1. PITUITARY
TUMORS AND
ANAESTHETIC
CONSIDERATIONS
PRESENTOR : Dr. Agalya (III Year Resident )
MODERATOR : Dr. Kiwi Ma’am
Department of Anaesthesia , SPMC

2. PITUITARY GLAND
❖ Pituitia - Latin for Pleghm (functions unknown )
❖ 1910 : Harvey Cushing related Acromegaly to
Pituitary gland and later on its true functions
identified
❖ Master Hormonal gland : Owing to
Innumerable influences over physiological
homeostasis
2

3. PITUITARY GLAND -ANATOMY
❖ Pea shaped , weight : 0.5-1gm
, 1cm horizontal and 8mm
vertical length
❖ Lies in the Sella Turcica
❖ Sella turcica : lined by Dura
reflected superiorly as
Diaphragma sella
accommodating pituitary Stalk
3

4. ❖ Surrounding structures and Significance :

5. NEURODEVELOPMENT OF GLAND
❖ Known as Hypophysis
❖ Three substructures
I) Anterior lobe - Rathkes pouch :
ADENOHYPOPHYSIS
II) Posterior lobe - Infundibular process :
NEUROHYPOPHYSIS
III) Intermediate lobe - Morphologically
different , function uncertain
5

6. SUBSTRUCTURES AND BLOOD
SUPPLY

7. HYPOTHALAMUS AND PITUITARY
RELATION ?
7

8. PITUITARY HORMONES

9. FEEDBACK SYSTEMS

10. PITUITARY TUMORS

11. PITUITARY TUMORS -
INTRODUCTION
❖ Incidence : 10-15% of all Intracranial tumors
❖ Anterior Lobe - Most Common site of Pituitary Adenomas
❖ Intermediate lobe - Rathkes pouch cysts & Craniopharyngiomas
❖ Posterior Lobe -Very Rare
❖ Risk Factors : MEN-I , Carney Complex , Isolated Familial Acromegaly

12. TUMOR - CLASSIFICATION
RADIOANATOMICAL PATHOLOGICAL MORPHOLOGICAL
1.Microadenomas < 10mm. 1.Functioning(Hypersecreting ) 1. Benign
2. Macroadenomas >10mm. 2. Non-functioning 2. Malignant
WILSON -HARDY
CLASSIFICATION

13. INDIVIDUAL TUMORS -
HYPERSECRETING ADENOMAS
[>60%]

14. PROLACTINOMAS
❖Prolactin - secreted by Anterior pituitary , down regulated by Dopamine
❖Most frequently observed Hyperfunctioning pituitary Adenoma (20-30%), predominant in women
PRESENATION :
❖Signs : Mass effect , Amennorhea , Galactorrhea , Loss of Libido , Impotence
❖Serum prolactin levels : 50 - 300ng/ml (N : 3-20ng/ml )
MANAGEMENT :
❖Medical : Dopamine Agonists - Bromocriptine, Cabergoline, Pergolide
❖Surgical : 90% Response to medical management , few patients require surgical excision
ANAESTHETIC RELEVANCE :
❖Fewer Anaesthetic specific ramifications
❖Focus on Mass effects and peri-operative management

15. GH SECRETING TUMORS -
ACROMEGALY
❖ Growth Hormone secreted by
Anterior pituitary , Inhibited by
GHIH
❖ Excessive Secretion of GH >
10ng/ml (N : 2-5 ng/ml) -
Prepubertal age : Gigantism
-Adults : Acromegaly
❖ Diagnosis : 24 hour GH levels
,GH Suppression tests

16. ❖ PRESENTATION :

17. MANAGEMENT :
❖ Medical : Dopamine agonists ( Bromocriptine , Cabergoline ) , Somatostatin
Analouge ( Octreotide, Lanreotide) , GH Receptor Antagonist ( Pegvisomant)
❖ Surgical Resection [Cure rate : 70 %]
ANAESTHETIC RELEVANCE :

18. ACTH SECRETING TUMORS-CUSHING’S
DISEASE
❖ ACTH secreted from Anterior Pituitary and Down
regulated by Glucocorticoids
❖ Condition of Glucorticoid excess : Due to
Supraphysiologic secretion of ACTH from tumors
❖ Cushing’s Syndrome [Hypercortisolim] : Due to Excessive
Cortisol levels , can be ACTH dependant or ACTH
independent .
❖ Incidence : 1-2% of all pituitary adenomas
❖ Female : Male ratio = 8 : 1 , peak incidence : 3rd - 4th
decades
❖ Diagnosis : Late night salivary cortisol levels, Urinary free
cortisol levels, Serum ACTH levels , Low and High dose
dexamethasone suppression test

19. PRESENTATION :

20. MANAGEMENT : Surgical resection of tumor
ANAESTHETIC RELEVANCE :
❖ Hypertension - 80% Cushing’s patients have systemic
hypertension & 50% have diastolic BP > 100mmHg
❖ Glucose Intolerance : DM in 1/3rd of Cushings patients
❖ Difficult Airway
❖ Easy chances of Bruising : Careful handling while
positioning
❖ Proximal muscle myopathies
❖ Osteoporosis : Potential difficult CNB
❖ Perioperative Steriod therapy ( discussed in upcoming
slides )

21. TSH /GLYCOPEPTIDE SECRETING
TUMORS
❖ Extremely rare tumors
THYROTROPHIC ADENOMAS :
Pituitary Hyperthyroidism (Elevated TSH , T3, T4 Levels )
Locally invasive macro adenomas
Needs Surgical excision (30-40% Cure Rate )
GONADOTROPH ADENOMAS : C/F - Precocius puberty , Menstruation in
Post-menopausal women , Elevated Prolactin levels.

22. NON- SECRETING TUMORS
❖ Nonfunctioning Adenomas : Null cell Adenomas - Second Most Common
pituitary tumors ( 20-25%)
❖ Includes Craniopharyngiomas and Rathkes cleft cysts( extremely rare ) :
PRESENTATION :
❖ Should be screened for Hypopituitarism & Adrenal insufficiency (Tumors are
often large at time of diagnosis due to late presentation )
❖ Only Mass effects will be present (no hypersecreting features )

23. TUMORS- SPECIAL EFFECTS ?
PITUITARY APOPLEXY :
❖ Hemorrhage / Infarction within pituitary gland/tumor
❖ SHEEHAN SYNDROME : Pituitary infarction following obstetric hemorrhage
❖ Sudden onset of headache , visual disturbance , ocular paresis , vomiting
❖ Presentation is similar to SAH - should be ruled out by radiographic studies
DIAGNOSIS :
❖ Sheehans : Failure to start postpartum lactation , fatigue, cold intolerance , hypotension
unresponsive to volume/pressors
❖ Expanding pituitary mass on CT/MRI . Needs Urgent Surgical Decompression

24. STALK EFFECT :
❖ Phenomenon of Hyperprolactinemia in association with
suppression of Pituitary stalk function
❖ Large adenomas creating mass effect /destruction of
pituitary stalk . Downregulating dopamine and thereby
decreased inhibition of prolactin secretion from anterior
pituitary
❖ Clinical Significance : Not all Hyperprolactinemia
represent prolactin secreting tumor .

25. ANAESTHETIC CONSIDERATIONS &
MANAGEMENT

26. ❖ PRE-OPERATIVE ASSESMENT
❖ INDIVIDUAL TUMORS & ANAESTHETIC CONCERNS
❖ PRE-OPERATIVE SUPPLEMENTATION
❖ INTRA-OPERATIVE CONSIDERATIONS & MANAGEMENT
❖ POSTOPERATIVE COMPLICATIONS & MANAGEMENT

27. PRE-OPERATIVE ASSESMENT
HISTORY & EVALUATION :
❖ A thorough routine history
❖ History for mass effects : Headache , Visual disturbances, Vomiting ,
Evidence of increased ICP , Cranial nerve palsies
❖ Evaluate for : Hypertension , Glucose Intolerance , Peripheral nerve / artery
entrapments , skeletal muscle weakness , Typical facies .
❖ Airway Examination : Look for glottic / subglottic stenosis , nasal turbinate
enlargement , vocal cord thickening , recurrent laryngeal nerve involvement

28. PREOP- WORKUP
❖ Routine laboratory tests : CBC, Liver
and Renal function tests ,
Electrolytes ,Coagulation profile ,
Urinanalysis
❖ Cardiac Evaluation : ECG, ECHO
❖ Cranial Evaluation : CT , MRI
❖ Ophthalmic evaluation
❖ Evidence of raised ICP

29. HORMONAL PROFILE :
❖ Thyroid profile : TSH, T3, T4
❖ Serum Cortisol and ACTH levels
❖ Prolactin
❖ ILGF-1
❖ Testosterone, LH , FSH
❖ NOTE : Women presenting with secondary amenorrhea should always have a pregnancy test done

30. INDIVIDUAL TUMORS &
ANAESTHETIC CONCERNS

31. ACROMEGALY & ANESTHESIA

32. ACROMEGALY AND AIRWAY :

33. CUSHING’S & ANAESTHESIA

34. OTHER PITUITARY ADENOMAS &
ANAESTEHSIA
❖ PROLACTINOMAS :
No specific
anaesthetic concerns
except for mass
effects and
cardiovascular side
effects from
Dopamine Agonists
❖ TSH Adenomas :
Euthyroid state to be
achieved

35. NONSECRETING / HYPOPITUITARISM AND
CONCERNS
❖ Perioperative supplementation of steroids essential to maintain HPA Axis

36. INTRAOPERATIVE CONCERNS AND
MANAGEMENT

37. INTRAOPERATIVE
CONSIDERATIONS
PRE-OPERATIVE PREPARATION
❖ Glucocorticoid replacement if appropriate
❖ Antibiotic and Antiaspiration prophylaxis
❖ Antianxiety : Benzodiazepines
❖ GIVE INSTRUCTIONS TO PATIENTS ABOUT MOUTH BREATHING IN THE
POSTOPERATIVE PERIOD
❖ PRE-MEDICATION :
❖ Anti- sialogouge : Glycopyrrolate 20mcg/kg iv (must in awake fibre-optic intubation)
❖ Blunt Intubation reflexes : Lidocaine 1.5mg/kg iv 90 seconds prior to intubation

38. INDUCTION :
❖ TECHNIQUE :
- Routine Iv induction with : Thiopentone 3-5mg/kg iv ,
Fentanly 1-2mcg/kg iv Ketamine (Avoided ) .
❖ AIRWAY MANAGEMENT : Anticipate Difficult airway
- Acromegaly : Significant Airway Anatomical changes :
Keep Difficult airway preparations and Difficult Airway Cart
ready ( Awake techniques provide greater margin of safety )
-Cushings : OSA , Obesity , DM (Inc. GERD) : Consider
RSI
- RAE oral tubes preferred : Facilities good working space
for surgeons.
- Pharyngeal packing done ( To prevent cough and emesis
)

39. POSITIONING :

40. INTRAOPERATIVE MONITORING :
❖ Routine monitors : NIBP , SpO2, Pulse rate , ECG , EtCO2
❖ Temperature / Neuromuscular monitoring
❖ Urine output monitoring
❖ Arterial line : IBP for uncontrolled Hypertensive patients ( Acromegalic
patients - Femoral artery preferred )
❖ CVP : Rarely required
❖ Visual Evoked potential monitoring

41. MAINTENANCE :
❖ Fentanyl (1-2mcg/kg) and Vecuronium given as intermittent boluses
❖ Maintain Deep Plane of Anaesthesia with adequate Muscle relaxants and Volatile
Anaesthetics
❖ Choice of Anaesthetics - Low blood solubility and rapidly cleared drugs to be used
owing to the desire for rapid emergence : Sevo/Isoflurane reasonable choices
(N20 Avoided if Air Pneumo-encephalography planned )
❖ Hemodynamic stability : Hypotensive anaesthesia techniques preferred
ICA injury (potential risk but rare )
❖ Assisting Tumor removal : Permissive Hypercapnia , Lumbar drain catheters
❖ Post-resection : Valsalva Maneuver used to test CSF leaks

42. EMERGENCE FROM ANAESTHESIA
❖ Smooth and Rapid Emergence : Essential for early neurological assessment
❖ For reversal Neostigmine 0.05mg/kg with Glycopyrolate 0.02mcg/kg iv
❖ Removal of Pharyngeal packs and thorough suctioning
❖ Fully awake extubation in propped up position when : Conscious and obeys
commands, Stable hemodynamics , Normothermia , TOF > 0.7
❖ Avoid Coughing
❖ OSA Patients : Post-extubation - Consider CPAP ( CSF leak and meningitis
risk present ) , Oral Airways safer alternative

43. ANAESTHETIC MANAGEMNT - SUM
UP
❖ Hemodynamic stability
❖ Maintenance of Cerebral oxygenation
❖ Facilitate Surgical conditions
❖ Prevention of intra-operative complications
❖ Rapid Smooth emergence to facilitate early Neurological assessment

44. POSTOPERATIVE COMPLICATIONS

45. POSTOPERATIVE COMPLICATIONS
❖Nausea and Vomiting
❖Pain
❖Cranial nerve dysfunction and CSF leakage , Meningitis
❖Disorders of water balance
SIADH
Diabetes Insipidus
❖Hypopituitarism

46. 1. NAUSEA AND VOMITING : Most common ( 40%) , Routine pharmacological prophylaxis to
be given - Vomiting casuses Detrimental effect on ICP
2. PAIN : Headache (MC) , Treated with Narcotics , NSAIDs such as ketorolac , Acetaminophen
3. SURGERY RELATED COMPLICATIONS :
❖ CN dysfunction : Proximity of CN II-VI , Post-op cranial nerve palsy feared complication -
Necessiates Immediate Visual assessment , CT/MRI and re-exploration
❖ CSF Leakage : Some Leakage acceptable , Continuous fluid Leakage with Headache
necessities further investigation & Operative re-packing with Autologous fat
4. DISORDERS OF WATER BALANCE : DI And SIADH

47. DIABETES INSIPIDUS
❖ Common Complication of Transphenoidal
surgery (0.5-25%) - Usually transient
❖ Acute Postoperative complication : Manifests 24-
48 hours post-op
❖ PRESENTATION : Polyuria , Polydipsia ,
Hypovolemia , Hypernatremia
❖ DIAGNOSTIC HALLMARK :
1. Serum osmolarity > 300mosm/kg
2. Serum Sodium > 145mmol/L
3. Urine Osmolarity < 300mosm/kg(usually <200)
4. Urine Specific Gravity < 1.005

48. DI-Management

49. SIADH
❖Syndrome of Inappropriate secretion of ADH : 9-25% post -pituitary surgery
❖Manifests in the Late post-operative period
❖Free water intake > Free water excretion
PRESENATION : Headache , Nausea/Vomiting , Seizures
DIAGNOSTIC HALLMARK :
1.Serum Sodium < 135 mEq/L
2.Urinary Sodium excretion > 20mEq/L
3.Serum Osmolarity < 275 mosm/kg
MANAGEMNT :
❖Fluid Restriction limited to 700-1000ml/day
❖Severe Symptomatic Hyponatremia< 120meq/l - Sodium repletion necessary with 3% or 1.8 % NaCl
supplementation (Target Correction : 0.5-1meq/L/hour increase )

50. DI AND SIADH

51. TO SUM UP !
1. Pituitary gland disorders : MYRIAD PATHOLOGICAL CONDITION . Proper care can be
provided only with the understanding of potential consequences of both
ENDOCRINOPATHIES & MASS EFFECTS
2. Discussions to be held with Surgical team which includes Endocrinologists , Neurosurgeons ,
ENT specialists regarding patients Hypothalamo- pituitary Axis, warranting peri-operative
steroid therapy for a better overall morbidity and mortality rates
3. Complex anatomical location and potential endocrine derangements needs intra-operative
active collaboration of anaesthesiologists with the surgeon throughout the procedure
4. Early diagnosis of post-operative complications and management should be done
5. LASTLY TEAM WORK IS THE UTMOST NEED AT EACH STEP .

52. REFERENCES
1. Miller’s Anesthesia : Ninth Edition
2. Cottrell and Patel’s Neuroanesthesia : Sixth Edition , Chapter 27 (Pg 458-
467)
3. Nemergut EC, et al . Anesth Analg. 2005 ; 101 : 1170
4. Menon, Rashmi & Murphy, Paul & Lindley, Andrew. (2011). Anaesthesia and
pituitary disease. Continuing Education in Anaesthesia, Critical Care & Pain.
11. 133-137. 10.1093/bjaceaccp/mkr014.

53. THANK YOU