垂体瘤卒中个体化治疗与多学科协作的临床转归

目的探讨垂体瘤卒中的临床表现、手术时机及最优治疗方法。方法回顾性分析2017年11月—2018年11月间南京大学医学院附属鼓楼医院收治的30例垂体瘤卒中患者，治疗方法因病情而异，对于病情稳定者采取多学科协作诊疗模式，由内分泌科根据患者激素检查水平制定出详细激素调节补充方案，力求达到正常水平范围内，同时积极纠正电解质紊乱；影像学检查同期进行，待所有检查结果回报后进行多学科讨论会，内分泌科给出围手术期激素调整方案，影像科根据磁共振检查结果指导阅片，而后由神经外科提出手术治疗方案。对于急性发病视力出现急剧下降、急性脑积水致意识障碍者采取个体化治疗方案，急诊行影像学检查并经验性给予补充激素一剂（氢化可的松100 mg 静脉滴注），同时行急诊手术治疗。手术方法均为经鼻蝶神经内镜鞍区占位切除术，术后标本均经HE染色确定为肿瘤组织合并缺血坏死组织。结果30例患者中，出现1例术后鼻腔延迟出血，余29例预后良好，所有术前表现为头痛者术后均不同程度好转；术前视力视野障碍患者，术后视力视野情况均得到一定程度恢复；术前表现为垂体前叶功能减退者，术后经过激素替代治疗症状均有所改善。结论根据垂体瘤卒中患者不同分型、不同分期需采取多学科协作、个体化治疗方案。除非失明或急性脑积水致意识障碍者采取急诊手术外，其余均需先内分泌科调整激素，纠正电解质紊乱，同时内分泌科、影像科及神经外科多学科讨论患者实际临床表现，个体化确定具体手术时机，所以多学科协作及制定个体化治疗方案对于患者的治疗及预后有极大指导意义。

Objective To investigate the clinical manifestations, operative timing and optimal treatment of pituitary apoplexy. Methods 30 patients with pituitary apoplexy admitted to the Department of Neurosurgery, Drum Tower Hospital-The Affiliated Hospital of Nanjing University Medical School from November 2017 to November 2018 were analyzed retrospectively, including 12 males and 18 females, with an average age of 47 years. The treatment varied with the condition. For those with stable condition, a multidisciplinary collaborative diagnosis and treatment model was adopted. The endocrinology department formulated a detailed hormone adjustment and supplement plan according to the hormone examination level of the patient, striving to reach the normal level and actively correcting electrolyte disorder at the same time. Imaging examination was conducted at the same time, and multidisciplinary discussion was conducted after all examination results were returned. Endocrinology department gave the perioperative hormone adjustment plan, and radiology department guided the film reading according to magnetic resonance examination results, and then department of neurosurgery proposed the surgical treatment plan. For patients with acute visual loss and consciousness disorder caused by acute hydrocephalus, individualized treatment was performed,emergency imaging examination was performed, and one dose of supplementary hormone(hydrocortisone 100 mg intravenous drip) was given empirically, and emergency surgical treatment was performed simultaneously. The operative methods were transsphenoidal endoscopic sellar region mass resection. All the postoperative specimens were confirmed to be tumor tissue with ischemic necrosis by HE staining. Results One of the 30 patients had delayed postoperative nasal bleeding, and the prognosis of the remaining 29 cases was good without obvious complications. All the patients who presented headache before operation were improved in different degrees after operation. All preoperative visually impaired patients got visual acuity recovered to varying degrees after surgery. The ones who showed anterior pituitary dysfunction preoperative acquired improvement after surgery. Conclusions According to the different types and stages of pituitary apoplexy patients, multidisciplinary collaboration and individualized treatment regimen should be adopted. Unless blindness or acute hydrocephalus leads to consciousness disorder requiring emergency surgery, endocrinology should first adjust hormones to correct electrolyte imbalances. At the same time, endocrinology, imaging and department of neurosurgery discuss the actual clinical manifestations of the patients, and determine the specific timing of surgery. Therefore, multidisciplinary collaboration and the formulation of individualized treatment plan have great guiding significance for the treatment and prognosis of patients.