Hypothalamic Pituitary Axis

Gerardo Carmelo B. Salazar, MD

3rd Year LPUSC School of Health Sciences
Copyrights apply
Copyrights apply
Copyrights apply
HPAxis

• A complex set of direct influences and

feedback interactions among three
components: the hypothalamus, the
pituitary gland and the effector glands
Copyrights apply
Raised Intracranial Pressure
MJ 15 Male
• CC: headaches
• Noticed to be gaining weight at age 14 yrs old with occasional fatigue and cold intolerance
• Dull, continuous headaches of 4/5 relieved with paracetamol. Headaches are worse on lying
down and on turning to sides.
• Upon getting out of bed, had feeling of blacking out. He is also noticed to be moving his tablet
horizontally when reading.
• He claims to be urinating frequently
• Because of the progressive headaches becoming 7-8/10 the past week with episodes of vomiting.
Complete the above case
• Is there a neurologic problem?
• If yes, what level is the neurologic problem?
• Localize
• What is the temporal profile?
• Etiologic DDX
Differentials
• Pituitary Gland Tumor ( Macroadenoma)
• Brainstem glioma/tumor
• Giant carotid aneurysm
• Cavernous sinus syndrome
• Migraine
Work up
• IMAGING
• Brain MRI with and without contrast is the gold standard.
• ENDOCRINE EVALUATION
• Baseline serum electrolytes, serum and urine osmolality, thyroid studies, morning and evening cortisol levels, growth
hormone levels, and luteinizing and follicle-stimulating hormone levels, in pediatric as well as adult patients.
• In emergent cases, hormonal testing should be limited to diagnosing diabetes insipidus, hypoadrenalism, and
hypothyroidism, as these hormones require the initiation of treatment prior to surgery.
• HISTOLOGIC
• Three main types: adamantinomas, papillary craniopharyngiomas, and mixed tumors.
• The MIB-1 labeling index is a measure of the disease’s proliferative activity. It is determined by using an
immunohistochemical method with monoclonal antibody MIB-1 and may be useful for the planning of adjuvant
therapy. One study reported that an MIB-1 labeling index of greater than 7% predicted regrowth/recurrence.
Diabetes Insipidus
versus SIADH
T1 Weighted Images
Adamantinomatous
craniopharyngioma
Papillary
craniopharyngiomas
Craniopharyngioma
• Slow-growing, extra-axial, epithelial-squamous, calcified, and cystic tumor arising from
remnants of the craniopharyngeal duct and/or Rathke cleft and occupying the
sellar/suprasellar region
Craniopharyngioma
• Rare malformational tumours of low histological malignancy arising along the craniopharyngeal duct.
• Benign but locally invasive tumours of the sellar region that arise from ectopic embryonic remnants of Rathke's pouch,
• The two histological subtypes, adamantinomatous craniopharyngioma (ACP) and papillary craniopharyngioma (PCP),
differ in genesis and age distribution.
• ACPs are diagnosed with a bimodal peak of incidence (5–15 years and 45–60 years), whereas PCPs are restricted to
adults mainly in the fifth and sixth decades of life.
• ACPs are driven by somatic mutations in CTNNB1 (encoding β-catenin) that affect β-catenin stability and are
predominantly cystic in appearance.
• PCPs frequently harbour somatic BRAFV600E mutations and are typically solid tumours.
• Clinical manifestations due to increased intracranial pressure, visual impairment and endocrine deficiencies should
prompt imaging investigations, preferentially MRI.
Craniopharyngioma
• Most frequently arise in the pituitary stalk and project into the hypothalamus. They extend horizontally
along the path of least resistance in various directions, as follows:
• Anteriorly - Into the prechiasmatic cistern and subfrontal spaces
• Posteriorly - Into the prepontine and interpeduncular cisterns, cerebellopontine angle, third ventricle, [3] posterior
fossa, and foramen magnum
• Laterally - Toward the subtemporal spaces
• Clinical behavior and the choice of surgical approach are dictated by the primary location of the tumor
and its extension pattern.
• Prechiasmatic craniopharyngiomas (extending into the subfrontal spaces)
• Retrochiasmatic craniopharyngiomas (expanding into the posterior fossa) may become large before being diagnosed.
Treatment Approach
1. attempt a gross total resection
2. perform a planned subtotal resection followed by radiotherapy or some other adjuvant therapy.

Successful management is determined by the ability to preserve independent social functioning,

prevent symptomatic recurrence, and increase survival rate.
There has been significant debate in recent years regarding the outcomes of GTR (Gross total removal)
in the pediatric population given the high risk for hypothalamic injury and deficits, which can be life-
altering in children (i.e., extreme obesity, deterioration in educational abilities).
Prognosis
• Neuropsychological deficits represent the major limiting factor for independent social
functioning because
• (1) patients often can overcome minor neurologic deficits and
• (2) hormone replacement therapies are widely available.
• The degree of psychosocial impairment correlates directly with the degree of hypothalamic
injury sustained at the time of surgery.

(antidepressants)
• Selective serotonin reuptake inhibitors (SSRIs).
Doctors often start by prescribing an SSRI. These
medications generally cause fewer bothersome side
effects and are less likely to cause problems at higher
therapeutic doses than other types of antidepressants
are. SSRIs include fluoxetine (Prozac), paroxetine
(Paxil, Pexeva), sertraline (Zoloft), citalopram
(Celexa) and escitalopram (Lexapro).
• Serotonin and norepinephrine reuptake
inhibitors (SNRIs). Examples of SNRI medications
include duloxetine (Cymbalta), venlafaxine (Effexor
XR), desvenlafaxine (Pristiq) and levomilnacipran
(Fetzima).
• Atypical antidepressants. These medications don't fit neatly into any
of the other antidepressant categories. More commonly prescribed
antidepressants in this category include trazodone, mirtazapine
(Remeron), vortioxetine (Trintellix), vilazodone (Viibryd) and
bupropion (Wellbutrin SR, Wellbutrin XL, others). Bupropion is one
of the few antidepressants not frequently associated with sexual side
effects.
• Tricyclic antidepressants. Tricyclic antidepressants — such as
imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin
and desipramine (Norpramin) — tend to cause more side effects than
newer antidepressants. So tricyclic antidepressants generally aren't
prescribed unless you've tried other antidepressants first without
improvement.
• Monoamine oxidase inhibitors (MAOIs). MAOIs — such as
tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid
(Marplan) — may be prescribed, often when other medications haven't
worked, because they can have serious side effects. Using an MAOI
requires a strict diet because of dangerous (or even deadly)
interactions with foods — such as certain cheeses, pickles and wines
— and some medications, including pain medications, decongestants
and certain herbal supplements. Selegiline (Emsam), an MAOI that
you stick on your skin as a patch, may cause fewer side effects than
other MAOIs. These medications can't be combined with SSRIs.
(anxiolytics)
• Benzodiazepines
• Ca channel inhibitors
• Antihistamine