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Hypothalamic and Pituitary Injury J Clin Pathol: First Published As 10.1136/Jcp.S3-4.1.178 on 1 January 1970

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Hypothalamic and Pituitary Injury J Clin Pathol: First Published As 10.1136/Jcp.S3-4.1.178 on 1 January 1970 J. clin. Path., 23, Suppl. (Roy. Coll. Path.), 4, 178-186 Hypothalamic and pituitary injury J Clin Pathol: first published as 10.1136/jcp.s3-4.1.178 on 1 January 1970. Downloaded from C. S. TREIP Cambridge The hypothalamic-pituitary axis is recognized Hypothalamic Lesions to an increasing extent as a physiological unit which influences and is influenced by endocrine The lesions described in this paper are based on and autonomic function. Anatomically, however, a personal series of 15 cases of fatal head injury, a clear distinction is to be drawn, with regard to surviving from three to over 300 days, in which both cellular and vascular anatomy, betweenthe serial histological sections of the hypothalamus neural (hypothalamus and neurohypophysis) and were examined. The lesions may for conveniencecopyright. the glandular epithelial (pars distalis) components be divided into four anatomical groups: (1) of the axis. The anatomical situation of lesions lesions of the supraoptic and paraventricular which may cause physiological disturbances nuclei; (2) lesions of the infundibulum; (3) of the hypothalamic-pituitary axis has to be lesions in and around the third ventricle; and considered, as it appears in some cases at least (4) lesions of the mamillary bodies. Lesions of all that a precise location may be required to disrupt four areas are commonly found in one brain the physiological integrity of the axis. Despite and sometimes in association with pituitary present-day refinements of biochemical diagnosis, lesions; not infrequently, however, the pituitary the final word regarding the correlation of clinical gland is histologically intact. Injury of the brainhttp://jcp.bmj.com/ findings with anatomical lesions still rests with the elsewhere is almost always present (Vonderahe, histopathologist. In the present paper the infundi- 1940) and fracture of the base of the skull is bulum is considered with the hypothalamus and often, but not invariably, found. the pituitary stalk and neurohypophysis with the pituitary gland, for although these structures form an anatomical continuum the interposition of the THE SUPRAOPTIC AND diaphragma sellae between the infundibulum and PARAVENTRICULAR NUCLEI on October 6, 2021 by guest. Protected neurohypophysis results in the development of The supraoptic nucleus is the most vulnerable different lesions in these two areas after head area of the hypothalamus and haemorrhages of injury. varying size, mostly petechial, were present in The effects of trauma on the hypothalamic- one or both nuclei in nearly every one of the pituitary axis have been observed and recorded acutely injured patients (dying within 30 days of for nearly a century, one of the oldest observa- injury). Acute neuronal damage, such as pykno- tions being that of Kahler (1886), who reported sis, is rare; central chromatolysis is difficult polyuria following a basal fracture which ran to assess with certainty (Daniel, 1966). Acute through the pituitary fossa. Most of the reports, cell loss is also uncommon, but may be seen if however, have been clinical, without pathological there is direct injury to the nucleus; such injury correlation. The few published pathological is seen when there is tearing or distortion of the reports have been concerned mainly with the optic chiasma or of the optic tracts (Figs. 1 and changes in the pituitary gland in long survivors 2). Neurosecretory material persists in the (for references see Daniel and Treip, 1961 and damaged nucleus, but may be diminished in 1966a). Even fewer descriptions of post-trau- amount. Abscess formation and infarction within matic hypothalamic changes are available (Von- the nucleus may be seen if there is meningitis or derahe, 1940; Henzi, 1952; Goldman and extensive haemorrhage nearby. Cell loss result- Jacobs, 1960; Orthner and Meyer, 1967). ing from retrograde atrophy is seen in long Hypothalamic and pituitary injury 179 J Clin Pathol: first published as 10.1136/jcp.s3-4.1.178 on 1 January 1970. Downloaded from Fig. 3a Normal supraoptic nucleus. Nissl x 40. Fig. 1 Male, aged 17 years. Survived three days. Base ofbrain, showing tearing of left optic tract copyright. (arrow), with chiasmal distortion. The stump of the (transected) pituitary stalk is haemorrhagic x 1J5. http://jcp.bmj.com/ on October 6, 2021 by guest. Protected Fig. 2 Same case as in Figure 1. Coronal section through hypothalamus to show tearing of left optic tract and supraoptic nucleus (arrow), which contain Fig. 3b Male, aged 23 years. Survived 10 months. recent haemorrhages (on right offigure). The supraoptic nucleus (within dotted line) contains Haemorrhages are also present in the periventricular very few neurons and is partly replaced superiorily region and right supraoptic nucleus. Luxol fast bluel by an infarct containing many macrophages. cresyl violet x 5. Nissl x 40. C. S. Treip 180 survivors (Fig. 3a and b) (Henzi, 1952; Goldman,J Clin Pathol: first published as 10.1136/jcp.s3-4.1.178 on 1 January 1970. Downloaded from and Jacobs, 1960). The atrophy is a slow process and may not be apparent for weeks or months (Orthner and Meyer, 1967). Similar changes, of a less conspicuous nature, are found in the paraventricular nucleus, with the exception of direct tears, which are not seen. The paraventri- cular nucleus sometimes shows a striking loose- ness of texture, possibly oedema, associated with petechial haemorrhages (Fig. 4). The vulnerability of the supraoptic nucleus to injury may perhaps be explained in the follow- ing way. The optic nerve is tethered rostrally at the optic foramen by the dural sheath which closely invests it. Caudally it forms with the lamina terminalis an angle within which the superior portion of the supraoptic nucleus lies, separated from the surface by a thin layer of neuropil. As one side of the angle is fixed, sudden movements of the brain such as occur with trauma, could readily result in abrupt changes of the angle and tearing or compression of the supraoptic nucleus (Fig. 5). The rich supply of thin-walled blood vessels to this nucleus (Daniel, 1966) accounts for its predisposition to haemor- 1-ig. 4 Same case as in Figure 1. Haemorrhages rhage. and oedema within the paraventricular nucleus. Haematoxylin and eosin. x 40. THE INFUNDIBULAR REGION copyright. Infarction is the commonest lesion in the infundi- bulum, taking the form of small areas of necrosis, usually in the midline of the tuber cinereum or upper infundibular stem (Fig. 6). Characteristic of these infarcts are the pooling of neurosecretory material around their periphery and the presence of axonal swellings adjacent to them (Orthner and Meyer, 1967). Similar accumulations of neurosecretory material and axonal swellingshttp://jcp.bmj.com/ are seen after experimental section of the pituitary stalk (Beck and Daniel, 1961). Linear and pete- chial haemorrhages are also seen in this region, where they are in a position to interrupt the supraoptico-hypophysial tract. Scarring of the infundibulum was seen in one long-surviving patient (Fig. 7). Haemorrhages into the ventro- on October 6, 2021 by guest. Protected medial nuclei may occur and, occasionally, bilateral infarction of these nuclei is seen (Fig. 8). The vulnerability of the lower infundibulum may to some extent be explained by the traction exerted on it and its blood vessels by the pituitary stalk, which is tethered below by the diaphragma Fig. 5 Diagram to illustrate possible mechanisms sellae (Fig. 5). of hypothalamic and pituitary damage. (1) Dural tethering of the optic nerve at the optic foramen results in tearing of the supraoptic nucleus with THE THIRD VENTRICLE sudden movements of the brain. (2) High transection Subependymal haemorrhages around the third of the pituitary stalk results in rupture of the tuberal ventricle are of common occurrence and may and infundibular vessels, the portal vessels to the impinge"upon the paraventricular nuclei. Haemor- pars distalis escaping injury. (3) Low stalk transection rhages and infarcts in the floor of the ventricle results in rupture of the long portal vessels to the Purulent ventri- pars distalis. I1 = optic nerve. DS = diaphragma merge with infundibular lesions. sellae. IHA = inferior hypophysial artery. NH culitis may occur as a consequence of skull neurohypophysis. PD = pars distalis. SHA = fractures. In long survivors a granular ependy- superior hypophysial artery. SON = supraopt.c nucleus. mitis may develop, with a macrophage (sidero- Hypothalamic and pituitary injury 181 Fig. 6 Male, aged 41 years. Suirvived 27 days; severe hypernatraemia. Acute infundibular infarction J Clin Pathol: first published as 10.1136/jcp.s3-4.1.178 on 1 January 1970. Downloaded from immediately above pituitary stalk (arrow). Haema- toxylin and eosin v 6. Fig. 7 Male, aged 23 years. Sur vived 10 months. Diabetes insipidus for one month. One side of the infundibuluim (tuber) is scarred and puckered (arrow ). Nissl x 6. Fig. 8 Same case as in Figure 6. Bilateral acute infarction of the ventromedial nuclei (arrows). Hlaematoxylin and eosin 6. phore) reaction to intraventricular haemorrhage and marginal gliosis. The readiness with which ependyma reacts to damage was noted by Russell (1949). Fig. 6. THE MAMILLARY BODIES Petechial and larger haemorrhages, which may occupy half of the medial mamillary nucleus, are not uncommonly found in association with lesions elsewhere in the hypothalamus. Infarcts occur less frequently and gliosis and loss of neu- rones may be seen in longstanding cases. Elsewhere in the hypothalamus infarction of the lateral hypothalamic area may be seen when copyright. there are extensive haemorrhages or infarction involving structures nearer the midline (Fig. 9). ,s.S 4 ^ Pituitary Lesions V)-.*.s .S Scattered pathological reports of traumatic http://jcp.bmj.com/ Fi.b .- 7 , pituitary damage were reviewed by Daniel and Treip (1961 and 1966a). Larger series have been studied by Ceballos (1966-102 cases) and by Daniel and Treip (1966a 156 cases). Orthner and Meyer (1967) review much of the relevant literature with particular reference to diabetes insipidus.
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