原发性空蝶鞍的垂体功能变化及影像学特点分析

发布时间：2018-07-03 19:53

本文选题：原发性空蝶鞍 + 垂体功能减退　；参考：《天津医科大学》2017年硕士论文

【摘要】：研究背景空蝶鞍(Empty Sella,ES)系指由于各种原因所致的鞍上蛛网膜下腔疝入蝶鞍内,使鞍内填充以脑脊液,而正常的垂体组织受压变扁,伴或不伴蝶鞍扩大。空蝶鞍按病因不同分为原发性空蝶鞍和继发性空蝶鞍。一般来讲,继发性空蝶鞍(Secondary Empty Sella,SES)可找到明确病因,如:鞍区手术、外伤、肿瘤、放疗等,而原发性空蝶鞍(Primary Empty Sella,PES)则病因尚不十分明确。既往原发性空蝶鞍被认为是鞍区的一种生理性改变,很少引起垂体功能减退,也无需治疗。近年随着老龄化社会的到来及影像学技术的不断提高,原发性空蝶鞍的检出率逐年增加,空蝶鞍所致垂体功能减退的报道越来越多,有关其带来的健康危害也日益受到关注。研究目的回顾性分析108例PES患者的临床及影像学资料,探讨PES的发病机制、临床特点、垂体功能及影像学变化情况,以提高对本病的进一步认识。研究方法收集2011年1月至2016年10月于天津医科大学总医院内分泌代谢科住院108例初次确诊为PES患者的病例资料,包括:年龄、性别、体重指数、临床症状及体征、女性月经史及妊娠史、合并症(如:高血压、糖尿病、冠心病等)、内分泌激素评估水平以及治疗情况。并于影像科收集患者的MRI资料,由影像科专业医师测量垂体矢状位高径、前后径、冠状位高径、宽径及蝶鞍矢状位高径、前后径、冠状宽径及矢状位面积。纳入标准:影像学显示鞍上蛛网膜下腔疝入蝶鞍内,垂体受压后变扁紧贴于蝶鞍底部,伴或不伴蝶鞍扩大,并且无鞍区手术、外伤、放疗、药物、感染等病史。排除标准:无内分泌激素评估、缺乏影像学资料、泌乳素(prolactin,PRL)大于100ng/ml、血清生长激素或皮质醇分泌增多等。根据垂体-靶腺轴功能是否减退,将108例PES患者分为垂体功能正常组和垂体功能减退组。以脑脊液充填蝶鞍50%为界,若超过50%,且垂体高度2 mm定义为完全性ES,否则为部分性ES,将108例PES患者分为完全性ES组和部分性ES组。并选取同期年龄、性别与PES患者相匹配,且下丘脑-垂体区域无先天或后天性疾病及垂体功能评估无异常的43例健康查体者作为正常对照组。结果1.一般情况:本组108例PES患者,男性43例,女性65例,男女比例为1:1.5,平均年龄61.5±12.9岁,占我科同期住院总人数的1.4%,并以50-69岁女性多见。96.9%(63/65)女性患者有妊娠史,其中2次及以上妊娠史占60.3%(38/63)。2.临床表现:乏力59例(54.6%),头痛40例(37.0%),食欲减退29例(26.9%),皮肤干燥伴畏寒16例(14.8%),男性性欲减退12例(27.9%),女性性腺功能减退12例(18.5%),视力障碍11例(10.2%),垂体危象4例(3.7%)。因多尿、烦渴、多饮确诊为中枢性尿崩症11例(10.2%)。10例(18.2%)糖尿病患者因血糖波动较大、易出现低血糖行MRI检查发现PES。3.垂体功能:56.5%(61/108)患者腺垂体功能正常,而43.5%(47/108)出现不同程度的腺垂体功能减退。其中,垂体-性腺轴、垂体-甲状腺轴和垂体-肾上腺皮质轴功能减退发生率分别为33.3%、18.5%、13.9%。男性出现腺垂体功能减退(60.5%)比例明显高于女性(32.3%)(P0.05)。完全性ES(60.7%)较部分性ES(21.3%)更易出现腺垂体功能减退(P0.05)。在无症状的PES患者中发现20.5%(8/39)存在不同程度垂体-靶腺轴功能减退。另外,8.3%(9/108)患者合并高泌乳素血症,10.2%(11/108)合并中枢性尿崩症。4.影像学特征:108例PES患者的MRI主要表现为:蝶鞍内呈长T1长T2脑脊液样信号,垂体不同程度受压变扁,而垂体内信号无异常。通过测量垂体及蝶鞍大小显示:正常对照人群的垂体平均体积为284.96±56.34 mm3,而PES患者仅为104.29±48.55 mm3(P0.05);垂体功能减退组的垂体体积(79.71±43.11mm3)明显小于垂体功能正常组(123.22±44.05mm3)(P0.05),并且,完全性ES组的垂体功能减退率(60.7%)明显高于部分性ES组(21.3%)(P0.05);PES组的蝶鞍深径、前后径、宽径、蝶鞍面积均大于正常对照组(P0.05);分别比较垂体功能正常组与垂体功能减退组以及完全性ES组与部分性ES组的蝶鞍径线,结果显示两不同分组中蝶鞍大小差异无统计学意义(P0.05)。5.垂体大小与功能的相关性:垂体高径分别与血Cor、ACTH、FT3、FT4、T(男)、FSH(女)、LH(女)呈正相关,垂体体积分别与血Cor、ACTH、FT3、FT4、FSH(女)、LH(女)呈正相关。6.随访:对74例PES患者的垂体功能随访26±14个月,发现8.1%(6/74)患者新发不同程度垂体-靶腺轴功能减退。结论1.PES在女性中的发病率明显多于男性,尤以中老年女性最多见,但男性空蝶鞍患者更易出现垂体功能减退。2.PES的临床表现不典型,多以乏力、头痛、内分泌紊乱、视力障碍等为主诉。故凡有上述症状者,应及时排查有无空蝶鞍。对于PES合并糖尿病者需注意降糖药的选择及其剂量调整。3.近半的PES患者可出现垂体功能减退症,因此,对于确诊为空蝶鞍的患者,无论有无临床症状、分型如何,一经诊断,均需全面评估垂体功能,对功能损害者,及时给予激素替代治疗。因PES有病情进展的风险,应需长期随访,并定期评估垂体功能,防止垂体危象发生。4.空蝶鞍不仅可引起垂体外形改变,还可致垂体体积缩小。并且,空蝶鞍引起的垂体功能改变与垂体的高度及大小呈正相关。一部分空蝶鞍可伴蝶鞍扩大,但蝶鞍的改变与垂体功能及垂体大小无关。
[Abstract]:Background Empty Sella (ES) refers to the subarachnoid hernia in the saddle of the saddle caused by various causes, which is filled with cerebrospinal fluid in the saddle, and the normal pituitary tissue is compressed, with or without the enlargement of the saddle. The empty sella is divided into primary empty sella and secondary empty sella according to the causes. Generally speaking, secondary empty sella ( Secondary Empty Sella, SES) can find clear causes, such as sellar area surgery, trauma, tumor, radiotherapy and so on, and the primary empty sella (Primary Empty Sella, PES) is not yet very clear. The former primary empty sella is considered a physiological change in the saddle area, rarely causing hypophysis dysfunction, and no treatment. In recent years, it is not necessary to treat. The arrival of society and the continuous improvement of imaging technology, the detection rate of primary empty sella increased year by year, more and more reports of hypopituitarism caused by empty sella were reported, and the health hazards caused by the sella were more and more concerned. The purpose of this study was to review the clinical data of 108 cases of PES patients and explore the pathogenesis of PES. Bed characteristics, pituitary function and imaging changes in order to improve the further understanding of the disease. The methods collected from January 2011 to October 2016 were collected from 108 patients with PES in the Endocrinology Department of General Hospital Affiliated to Tianjin Medical University, including age, sex, body mass index, clinical symptoms and signs, and female menstrual history. And pregnancy history, complications (such as hypertension, diabetes, coronary heart disease, etc.), the level of endocrine hormone assessment and treatment. The MRI data of the patients were collected in the imaging department, and the sagittal height diameter, the anterior and posterior diameter, the height of the coronal position, the width of the sella sagittal position, the front and back diameter, the coronary width and the sagittal area were measured by the imaging department. Inclusion criteria: imaging showed that the subarachnoid hernia was inserted into the saddle of the saddle, and the pituitary gland was compressed into the bottom of the sella, accompanied or without the enlargement of the saddle, and no saddle surgery, trauma, radiotherapy, drug, infection and other diseases. Exclusion criteria: no endocrine hormone assessment, lack of imaging data, prolactin, PRL greater than 100ng/ml, serum Growth hormone or cortisol secretion increased. 108 cases of PES patients were divided into normal pituitary function group and hypophyseal dysfunction group according to the function of pituitary target gland axis. The sella 50% was bounded by cerebrospinal fluid, if more than 50%, and the pituitary height 2 mm was defined as complete ES, otherwise, partial ES was divided into complete ES group, 108 cases of PES patients were divided into complete ES group. And partial ES group, and select the age of the same period, sex with PES patients, and the hypothalamus pituitary region without congenital or postnatal diseases and pituitary function evaluation of 43 healthy subjects as normal control group. Results 1. general case: 108 cases of PES patients, male 43 cases, female 65 cases, male and female ratio of 1:1.5, the average age 61.5 12.9 years of age, accounting for 1.4% of the total number of inpatients in the same period of our department, and female patients with.96.9% (63/65) more than 50-69 years old, 2 and above were 60.3% (38/63).2., 59 cases (54.6%), 40 headache (37%), 29 cases of anorexia (26.9%), dry skin with fear of cold 16 cases (14.8%), male sexual hypothyroidism in 12 cases, 12 cases of female hypogonadism (18.5%), 11 cases of visual impairment (10.2%), 4 cases of pituitary crisis (3.7%), 11 cases of central diabetes insipidus (10.2%) diagnosed as polyuria, polydipsia and polydipsia (10.2%).10 (18.2%) patients with diabetes due to high blood glucose fluctuations, easy to appear hypoglycemia and MRI detection of PES.3. pituitary function: 56.5% (61/108) patients with normal adenohypophysis, and 43. 5% (47/108) had a varying degree of hypogonadohypophysis. Among them, the incidence of pituitary adenohypophysis axis, pituitary thyroid axis and pituitary adrenocortical axis hypofunction was 33.3%, 18.5%, and 13.9%. male hypophysis dysfunction (60.5%) was significantly higher than that of women (32.3%) (P0.05). Complete ES (60.7%) was more likely than partial ES (21.3%). Hypophyseal dysfunction (P0.05). In asymptomatic PES patients, 20.5% (8/39) was found to have different degrees of pituitary - target gland dysfunction. In addition, 8.3% (9/108) patients were combined with hyperprolactinemia, 10.2% (11/108) combined with central diabetes insipidus in.4. imaging features: 108 cases of PES patients showed a long T1 long T2 cerebrospinal fluid sample in the sella sphenae. In the pituitary and sella, the pituitary volume was 284.96 + 56.34 mm3, and the PES patient was only 104.29 + 48.55 mm3 (P0.05), and the pituitary volume (79.71 + 43.11mm3) in the hypophyseal hypofunction group was significantly smaller than that of the pituitary function group (123 .22 + 44.05mm3) (P0.05), and the hypophyseal dysfunction rate (60.7%) in the complete ES group was significantly higher than that of the partial ES group (21.3%) (P0.05). The depth of the sella, anterior and posterior diameter, the width of the sella turcica in the PES group were all larger than that of the normal control group (P0.05), and the pituitary function was compared with the hypophyseal dysfunction group, the complete ES group and the partial ES group respectively. The saddle diameter line, the results showed that there was no significant difference in the size of sella sphenae in two different groups (P0.05) the correlation of.5. pituitary size and function: the pituitary height was positively correlated with blood Cor, ACTH, FT3, FT4, T (male), FSH (female), and LH (female), and the pituitary volume was positively correlated with the blood Cor, ACTH, FT3, female and female. The body function was followed up for 26 + 14 months, and 8.1% (6/74) patients were found to have different degrees of pituitary - target gland dysfunction. Conclusion the incidence of 1.PES in women was more than that of men, especially in middle aged and elderly women, but male empty sella patients were more likely to appear hypophyseal dysfunction.2.PES, with anatypical, headache and endocrine disorder. All those with the above symptoms should be checked in time with or without empty sella. For patients with PES with diabetes, the choice of hypoglycemic drugs and the dose adjustment of.3. in the near half of PES patients may appear hypophyseal dysfunction. Therefore, for patients diagnosed with empty sella, whether or without clinical symptoms, classification, and diagnosis It is necessary to evaluate the function of the pituitary in an all-round way and give hormone replacement therapy to those who have impaired function. Because of the risk of the progression of the disease, PES should be followed up for a long time and evaluate the function of the pituitary to prevent the hypophysis.4. empty sella not only to cause the pituitary shape change, but also to reduce the pituitary volume, and the pituitary function caused by the empty sella. There was a positive correlation between the changes and the height and size of the pituitary gland. Part of the empty sella can be enlarged with sella turcica, but the sella changes are not related to pituitary function and pituitary size.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R584;R742

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