Background: Disorders of water and electrolyte balance, hyper- and hyponatremia, are common postoperative complications of transsphenoidal neurosurgical interventions and are found in up to 30–40% of cases. At the same time, delayed hyponatremia is the main cause of repeated hospitalizations of patients, and the risk factors/pathogenetic mechanisms responsible for the development of postoperative hyponatremia have not been fully investigated. Aim: To determine the frequency of water-electrolyte disturbances and to identify predictors of dysnatriemia states in patients after transnasal adenomectomy. Materials and methods: A retrospective single-site study included an analysis of electronic medical records of patients who underwent transnasal neurosurgical interventions for benign tumors of the pituitary gland ( n = 416). The diagnostic and prognostic factors for the development of postoperative water-electrolyte disorders were evaluated. Results: The prevalence of hyponatremia in the total group of patients was 7.2%, and for hypernatremia it was 3 times higher – 24.3%, with these indicators being kept stable through the years of surgery ( p > 0.05; χ 2 with the Yeats correction). 66 (16%) of the operated patients, the sodium level in the early (0–5 day) and 157 (38%) patients in the later (6+ day) postoperative period was not determined, which may underestimate the identification of the most dangerous delayed postoperative hyponatremia. When analyzing the main clinical and laboratory characteristics of patients with hypo-, normo- and hypernatremia, no statistically significant differences were found between the parameters characterizing natremia, the osmolality of blood and urine, the frequency of determining blood sodium in different time intervals of the postoperative period. Complications of the main diagnosis (diabetes mellitus, coronary heart disease and arterial hypertension), selected parameters of pathological examination (identification of neurohypophysis cells, adenohypophysis, oxyphilic, basophilic or chromophobic cells, as well as other structures that are not part of the pituitary gland) and the operation protocol (bleeding, coagulation of sellar structures, liquorrhea, excision of the pituitary gland), did not differ between groups. In the hypernatremia group, the tumor volume in quantitative representation was lower than in the normo- and hyponatremia groups (1.0 ml vs. 1.5 and 1.5 ml, respectively). The number of neurosurgical interventions performed in a patient did not differ between the study groups. Conclusions: After transnasal adenomectomy, hypo- and hypernatremia occur in 7.2% and 24.3%, respectively, and do not depend on the presence of complications of the underlying disease, the parameters of the pathomorphological protocol, the appearance of postoperative hypopituitarism or the course of the operation itself. For the timely detection of disorders of water and electrolyte metabolism, the implementation of blood sodium testing in the early and late (6+ day) postoperative period is necessary in management of patients after transnasal adenomectomy.

Background. Cushing’s disease (СD) is а severe neuroendocrine disease that can rapidly progress with the development of severe complications of hypercorticism requiring immediate treatment. The main method of treatment is a neurosurgical operation, the effectiveness of which at the present time can reach 80% or more, however, about a quarter of patients after successful neurosurgical treatment experience reccurence. Aim. The analysis of prognostic factors potentially affecting the occurrence of recurrence of CD after successful primary transnasal adenomectomy. Material and methods. A retrospective monocenter comparative study of treatment outcomes in 219 patients (32 men, 187 women) with confirmed diagnosis of Cushingas disease who underwent endoscopic transsphenoidal adenomectomy between 2007 and 2014 was performed. The inclusion criteria were: the absence of previous pathogenetic treatment for this disease and the development of remission of the disease in the early postoperative period. The duration of follow-up period was three years and more. We used methods of statistical comparison of groups, including survival analysis and ROC-analysis. Results. Within 3 years the remission was preserved in 172 patients, the recurrence of Cushingas disease developed in 47 patients (21.5% [16%; 28%]). The probability of CD recurrence was associated with morning levels of ACTH and cortisol and evening ACTH in the early postoperative period. As a result of the ROC-analysis for morning ACTH and cortisol, the optimal cutting points were 7 pg/ml and 123 nmol/l respectively. In patients with ACTH level less than 7 pg/ml, three years recurrence appeared to be 7%, 95% CI [3%, 14%], while at the level of ≥7 pg/ml recurrence was observed in 31% [23%, 40%] cases, RR 0.22 [0.09; 0.51], ОR – 0.16 [0.06; 0.43]. In patients with cortisol level below 123 nmol/l the recurrence developed in 13% [9%, 20%] of cases, while in patients with cortisol level ≥123 nmol/l, recurrence was equal to 45% [32%, 59%], RR 0.29 [0.18; 0.50], ОR – 0.19 [0.09; 0.39]. Conclusion. The development of adrenal insufficiency (a decrease in ACTH level less than 7 pg/ml and cortisol level less than 123 nmol/l) statistically significantly reduces the probability of the recurrence of CD within three years after surgery.

We do not recommend population screening for diabetes insipidus (DI) (B3). We recommend to perform diagnostic testing for central diabetes insipidus (CDI) in patients who underwent neurosurgery, after skull and brain trauma, subarchnoid hemorrhage (B3). We recommend excluding thirst impairment during all stages of diagnostic assessment (С3). We recommend excluding DI in cases of persistent hypotonic polyuria: excretion of more than 3 L. or more than 40 mL/kg of urine daily; urine osmolality less than 300 mOsm/kg or urinary specific gravity less than 1004 g/L in all urine samples or during Zimnitsky test (В3). After hypotonic polyuria is confirmed, we recommend excluding of the main causes of nephrogenic diabetes insipidus (NDI) (B3). We recommend simultaneous measurement of urine osmolality and blood osmolality/sodium level in order to confirm DI. Blood hyperosmolality (more than 300 mOsm/kg) and/or hypernatremia with low urine osmolality (less than 300 mOsm/kg) confirms DI (B2). If testing does not reveal these findings, we recommend performing a fluid deprivation test to exclude primary polydipsia (PP) (B2). Desmopressin test is recommended to distinguish CDI and NDI (B2). In cases of CDI we recommend to perform head MRI with contrast (B3). In cases of NDI we recommend assessing renal structure and function and possible electrolyte disturbances (C3). In cases of PP we recommend to refer a patient to psychiatrist (B3). We recommend treating CDI with synthetic vasopressin analogue – desmopressin (B1). We recommend an individual approach in choosing desmopressin dosage form (B2). As the initial dose is difficult to predict when starting desmopressin treatment, we recommend titrating the dosage using two approaches: “the average dose” and “as required” (C4). We recommend educating the patients to ensure knowledge of the features of various desmopressin dosage forms (C4). To decrease the risk of water intoxication, we recommend educating the patients to the water intake regimen adherence (С4). When CDI is accompanied by thirst impairment, we recommend titrating the dose in a clinical setting, with assessment of blood sodium, bodyweight and/or urine volume (C4).

Objective : to popularization the knowledge about hemostasis in patients with chiasmosellar tumors during conduction of endoscopic transnasal transsphenoid neurosurgical operations. Material and methods . The analysis of literature data dedicated to mechanism of action and area of application of modern hemostatic materials to solve the problem of hemostasis on endonasal surgery; our own material including more than 2000 patients operated during 10 years. Results: nowadays the principles of surgery in patients with chiasmosellar tumors had been totally changed thanks to endoscopic technologies. The appearance of new hemostatic materials and new methods of their application allow recommending them in various clinical situations. Conclusion : the usage of modern hemostatic materials allows conducting endoscopic transnasal interventions with minimal blood loss as well as decreasing the numbers of complications and expenses involved in blood transfusion.

Objectives. The aim of this research was to study the dynamic changes of intra- and early postoperative hormonal parameters (ACTH and cortisol) as predictors of hypercorticism remission. Material and methods. 50 patients with confirmed Cushing`s disease (CD) were sampled for this research. The patients were divided into 3 groups depending on the outcome of the operation. The first group – patients with secondary adrenal insufficiency confirmed by clinical picture and the level of cortisol less than 50 nmol/l; the second group – with normalization of levels of ACTH and cortisol; the third – with the persistence of the CD. The results of intraoperative studies during the transnasal adenomectomy were then studied. The group sample consisted of 38 women and 12 men, aged 15–66 years. To assess the levels of ACTH and cortisol blood sampling was performed from a peripheral vein. The first sample was taken during the incision of the Dura mater, the second – immediately after removal of the tumor and the last – 20 minutes after the removal of the adenoma. Then, 1 day after the surgery the hormones mentioned above were studied in all patients. The levels of ACTH and cortisol were measured by immunochemiluminescent analysis on the automated system Cobas 6000 (Roche, France). Reference intervals ACTH 0–30 ng/ml, cortisol123–626 nmol/l. Results. The analysis of the obtained data did not suggest a relationship between the changes of intraoperative indicators of hormonal status and the likelihood of disease remission (p > 0.125). In the postoperative period, of the 50 patients, 41 (82%) developed adrenal insufficiency, 5 (10%) showed normalization and in 4 patients (8%) adrenal insufficiency was not observed. The results of the hormonal research after 1 day had a correlation with the frequency of postoperative remission (p < 0.125). Conclusion. Intraoperative measurement of levels of ACTH and cortisol is not appropriate and cannot serve as guidance for further tactics of the surgeon to define the totality of tumor removal.

The remission rate of Cushing’s disease in patients after neurosurgery varies from 59 to 94%, while the recurrence rate is 3 to 46%. Aim — to evaluate the five-year outcome in neurosurgery patients with Cushing’s disease (CD), depending on preoperative MRI-based identification of pituitary adenoma. Material and methods . The study included 105 neurosurgery patients with histologically confirmed CD. CD remission was confirmed by the development of adrenal insufficiency and/or normalization of serum cortisol and 24-hour urinary free cortisol (24h UFC) levels, as well as by clinical remission. Results . Pituitary adenoma was not visualized by gadolinium MRI in 35 cases. The size of visualized pituitary adenoma varied from 0.3 to 29 mm. After first neurosurgery, remission was achieved in 87 (82.8%) patients. After second neurosurgery, remission occurred in 12 patients. Radiation therapy was conducted in 24 patients. Six patients had bilateral adrenalectomy. Two patients died during remission: one patient died from stroke two years after neurosurgery, and the other patient died due to surgery complications. During five-year follow-up after neurosurgery, remission continued in 76 (72.8%) patients, including 27 (77%) of 35 patients without MRI-detected adenoma and 49 (70%) of 70 patients with MRI-detected pituitary adenoma, p=0.15. Sixty-six patients developed recurrence, and 14 patients had active hypercortisolism. Conclusion . There was no correlation between the rate of preoperative MRI-based detection of pituitary adenoma and the rate of remission in neurosurgery patients with Cushing’s disease during the five year follow-up. The size of pituitary adenoma was a risk factor for adenoma recurrence.

Endogenous hypercortisolism (EH) is a rare endocrine disorder, one of the most frequent manifestations of which is obesity. Due to the high prevalence of the metabolic syndrome and the similarity of the clinical manifestations, EH may remain undiagnosed. However, prompt diagnosis and treatment can effectively promote complete cure of the patient. We describe the clinical case of a patient К., 58 years old, who suffered from morbid obesity, diabetes, uncontrolled hypertension and dyslipidemia. The CT examination revealed bilateral adrenal incidentalomas. The further follow-up let us to establish Cushing's disease. The adrenal tumors in this case may be the results of a long-term stimulation of the adrenal glands by ACTH. There is a possibility that the first manifestation of the disease began at the age of 30 years after the second pregnancy, when she observed weight gain and poorly controlled hypertension. When remission was achieved after neurosurgical treatment, we could observe significant improvements (reduction in body weight of 10 kg, improved glucose levels), but without the full normalization of all complications and symptoms. Conclusion: EH may cause the development of obesity and metabolic syndrome or significantly exacerbate its course. In cases of doubt, weight gain and poorly controlled manifestations of metabolic syndrome screening is justified to exclude EH.

Introduction. The state of pelvic and retroperitoneal lymph nodes is an important prognostic factor for cervical cancer. Lymph node size is the most widely used CT and MR criteria for assessing lymph node status. Lymph nodes measuring more than 1cm in the short axis diameter are considered malignant. However this criterion (nodal size) is not foolproof because of a high percentage of diagnostic errors. The purpose of the study was to develop objective MRI criteria for assessing lymph node metastasis in patients with cervical cancer by measuring the short- and the long-axis diameters of lymph nodes, short axis/long axis ratio (configuration index) and to evaluate their diagnostic value. Materials and methods. The prospective study included 31 patients with histologically confirmed cervical cancer, who underwent radical surgery with standard lymph node dissection. Sixty removed lymph nodes were evaluated. MRI examinations were performed using a 1.5 T scanner in T2- weighted images (T2-WI), T1-WI and T2 weighted sequences with fatty tissue signal suppressing and diffusionweighted MRI. Results. Lymph nodes measuring ≥0.8 cm in the short axis diameter were considered suspicious for metastatic disease. The sensitivity and specificity with a cutoff of ≥0.8cm were 68 % (CI 48.3‑82.9) and 80 % (CI 63.8‑90.3), respectively; the positive and negative predictive values were 71 % and 78 %, respectively; and the accuracy was 75 % (CI 62.7‑84.3). The short axis/long axis ratio (configuration index) of <1.47 indicated a likelihood of pathology in the lymph node. The absence of the hypointense signal from the fatty hilum of lymph nodes was considered as a predictor of lymph node metastasis. The analysis of this criterion showed 80 % sensitivity (CI 60.4‑91.6), 85.7 % specificity (60.4‑91.6), 80 % PPV, 85.1 % NPV and 83.3 % accuracy (CI 60.4‑91.6). Conclusion. Lymph node size of ≥0.8 cm in the short axis diameter and the short axis/long axis ratio (configuration index) of <1.47 appeared to be significant MRI criteria in the assessment of lymph node metastasis. The additional use of MRI criterion such as the absence of the hypointense signal from the fatty hilum of the lymph node made it possible to improve diagnostic accuracy up to 92 % (CI 80.9–97.4).

This article discusses such complication of transnasal surgical treatment of pituitary adenomas as intraoperative bleeding from intercavernous sinuses. The MRI images of hypertrophic intercavernous sinuses (IS), technical features of surgery at such patients as well as methods of hemostasis and adenoma removal under conditions of bleeding are presented.

Objective. To estimate the outcomes of repeated transsphenoidal adenomectomy (RTA) at patients with relapse and persistent course of Itsenko-Kushing disease and to optimize the limits of surgical intervention at such patients. Material and methods. The analysis of RTA results at 50 patients (42 women and 8 men at the age from 16 till 64 years old) with confirmed Itsenko-Kushing disease was conducted. The mean time of RTA performance was 36 months. All patients underwent endoscopic surgery. Results. The remission after RTA was seen at 28 (56%) patients, among them 20 (69%) suffered from developing adrenocortical insufficiency, the recovery of hormonal state was revealed at 8 (31%). The hypercorticoidism remained at 22 (44%) patient. Follow-up after RTA was 6 months with following examination at 30 patients which revealed remaining hypercorticoidism at 14 (47%) persons, complete remission - at 14 (47%) patients and disease relapse - at 2 (6%) patients. Conclusion. The repeated transsphenoidal adenomectomy is relatively safe and effective treatment method at patients with relapse and residual course of Itsenko-Kushing disease while performed under conditions of specialized department. The clear predictors for persistence development or relapse of ACTH-dependent hypercorticoidism were not revealed. The limits of repeated neurosurgical intervention are necessary to determine on a case by case basis.