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Table of Contents    
EDITORIAL DEBATE
Year : 2015  |  Volume : 63  |  Issue : 5  |  Page : 659-660

Postoperative diabetes insipidus in craniopharyngiomas: Effective management by adherence to a strict protocol


Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1295, Japan

Date of Web Publication6-Oct-2015

Correspondence Address:
Kiyoshi Saito
Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1295
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.166572

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How to cite this article:
Saito K. Postoperative diabetes insipidus in craniopharyngiomas: Effective management by adherence to a strict protocol. Neurol India 2015;63:659-60

How to cite this URL:
Saito K. Postoperative diabetes insipidus in craniopharyngiomas: Effective management by adherence to a strict protocol. Neurol India [serial online] 2015 [cited 2019 Aug 19];63:659-60. Available from: http://www.neurologyindia.com/text.asp?2015/63/5/659/166572


Craniopharyngiomas are surgically challenging tumors. I believe that total removal and adequate postoperative management are basically required, especially in pediatric patients. Although many patients have pituitary insufficiency after surgery, effective long-term endocrinological replacements are achieved at most institutes. On the other hand, hypothalamic dysfunction is still difficult to control. We need further analysis and studies to prevent or to treat manifestations of hypothalamic dysfunction such as obesity, hyperphagia, or disturbances of thermoregulation.

Postoperative diabetes insipidus (DI) is another difficult issue, especially in an acute phase after surgical removal of tumors. Inadequate control of DI could induce excessive hypernatremia or hyponatremia and cause secondary damage of the central nervous system. Pratheesh et al., have proposed a strict protocol for the management of DI after removal of craniopharyngiomas and confirmed the efficacy of their protocol.[1]

In our institute, we have selected a bifrontal basal interhemispheric approach[2],[3] or recently, an endonasal endoscopic approach.[4],[5] Although we could achieve total removal in most patients, 70–80% of the patients showed hypopituitarism and/or DI postoperatively. When I was a chief resident, late Prof. Kenichiro Sugita usually performed total removal of craniopharyngiomas. As shown in this paper, postoperative management of the patients without an adequate protocol was not easy. Many patients had hypernatremia and/or hyponatremia. Then, I made a protocol. After that we have been using our protocol to manage postoperative DI for more than 20 years. I introduce some important points existing in our protocol.

As the authors suggested, an input-output balance is not enough to assess for the water balance. Serum sodium (Na) measurement is mandatory.[6] We also check the daily body weight of the patients to detect either an over- or under-corrected water balance.

During the 5–10 days after resection of the pituitary stalk, the patients develop the syndrome of inappropriate antidiuretic hormone (SIADH). We call it a tri-phasic DI.[5] In the first phase, the patients develop DI due to paralysis of ADH release from the posterior pituitary lobe. In the second phase, the urine volume decreases due to SIADH because of an uncontrolled release of ADH from the posterior pituitary lobe. Then, the patients have a persistent DI due to depletion of ADH in the third phase. It is important to predict the second phase and to prevent hyponatremia during this phase. Patients with preoperative DI do not have the second phase because there is no ADH storage in the posterior lobe. After total removal of the tumor along with the intrasellar component including the posterior lobe, the patients develop a mono-phasic DI. All other patients may have the tri-phasic DI after damage to the pituitary stalk occurs.

To prevent hyponatremia during the SIADH phase, an over-corrected water balance should be avoided during the first phase. We keep the serum Na at 145–150 mEq/L during the first phase. We should not over-infuse the fluids and should ask the patients to drink water according to their thirst. We should use a minimal dose of vasopressin. At this point, we use a different protocol from that suggested by the authors. Five Unit intravenous bolus of pitressin is usually recommended but this is not a physiological dose. To control DI using a bolus injection of pitressin is not easy. We use intravenous infusion of pitressin infusing the dose of 1-5 mUnit/h to keep the urine output within 50–150 ml/h. A pitressin ampule contains 20 Unit of vasopressin in 1 ml. We dilute it 20,000 times to make a solution of 1 mUnit/ml. Usually we start from 3 ml/h (3 mUnit/h) and increase the dose by 0.5 ml with the urine volume increase >150 ml/h, or decrease the dose by 0.5 ml with the urine volume decrease <50 ml/h. This is much lower than the recommended volume of the medication but we have confirmed the effect of this microdose. Since the effect of vasopressin immediately disappears by stopping the infusion, we can prevent hyponatremia during the transition from the first to the second phase.

After the second phase or after confirming a mono-phasic DI, we change the microinfusion of pitressin to oral 1-Desamino-8d-Arginine Vasopressin (DDAVP) or the nasal spray of DDAVP.

 
  References Top

1.
Pratheesh R, Swallow DMA, Joseph M, Natesan D, Rajaratnam S, Jacob KS, et al. Evaluation of a protocol-based treatment strategy for postoperative diabetes insipidus in craniopharyngioma. Neurol India 2015;63:712-7.  Back to cited text no. 1
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2.
Shibuya M, Takayasu M, Suzuki Y, Saito K, Sugita K. Bifrontal basal interhemispheric approach to craniopharyngioma resection with or without division of the anterior communicating artery. J Neurosurg 1996;84:951-6.  Back to cited text no. 2
    
3.
Sinha S, Kumar A, Sharma BS. Bifrontal basal interhemispheric approach for midline suprasellar tumors: Our experience with forty-eight patients. Neurol India 2013;61:581-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A. Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 2007;61:219-27.  Back to cited text no. 4
    
5.
Sankhla SK, Jayashankar N, Khan GM. Endoscopic endonasal transplanum transtuberculum approach for retrochiasmatic craniopharyngiomas: Operative nuances. Neurol India 2015;63:405-13.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Timmons RL, Dugger GS. Water and salt metabolism following pituitary stalk section. Neurology 1969;19:790-800.  Back to cited text no. 6
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