發(fā)布時間：2018-07-03 19:53

  本文選題：原發(fā)性空蝶鞍 + 垂體功能減退�。� 參考：《天津醫(yī)科大學》2017年碩士論文

【摘要】：研究背景空蝶鞍(Empty Sella,ES)系指由于各種原因所致的鞍上蛛網膜下腔疝入蝶鞍內,使鞍內填充以腦脊液,而正常的垂體組織受壓變扁,伴或不伴蝶鞍擴大。空蝶鞍按病因不同分為原發(fā)性空蝶鞍和繼發(fā)性空蝶鞍。一般來講,繼發(fā)性空蝶鞍(Secondary Empty Sella,SES)可找到明確病因,如:鞍區(qū)手術、外傷、腫瘤、放療等,而原發(fā)性空蝶鞍(Primary Empty Sella,PES)則病因尚不十分明確。既往原發(fā)性空蝶鞍被認為是鞍區(qū)的一種生理性改變,很少引起垂體功能減退,也無需治療。近年隨著老齡化社會的到來及影像學技術的不斷提高,原發(fā)性空蝶鞍的檢出率逐年增加,空蝶鞍所致垂體功能減退的報道越來越多,有關其帶來的健康危害也日益受到關注。研究目的回顧性分析108例PES患者的臨床及影像學資料,探討PES的發(fā)病機制、臨床特點、垂體功能及影像學變化情況,以提高對本病的進一步認識。研究方法收集2011年1月至2016年10月于天津醫(yī)科大學總醫(yī)院內分泌代謝科住院108例初次確診為PES患者的病例資料,包括:年齡、性別、體重指數、臨床癥狀及體征、女性月經史及妊娠史、合并癥(如:高血壓、糖尿病、冠心病等)、內分泌激素評估水平以及治療情況。并于影像科收集患者的MRI資料,由影像科專業(yè)醫(yī)師測量垂體矢狀位高徑、前后徑、冠狀位高徑、寬徑及蝶鞍矢狀位高徑、前后徑、冠狀寬徑及矢狀位面積。納入標準:影像學顯示鞍上蛛網膜下腔疝入蝶鞍內,垂體受壓后變扁緊貼于蝶鞍底部,伴或不伴蝶鞍擴大,并且無鞍區(qū)手術、外傷、放療、藥物、感染等病史。排除標準:無內分泌激素評估、缺乏影像學資料、泌乳素(prolactin,PRL)大于100ng/ml、血清生長激素或皮質醇分泌增多等。根據垂體-靶腺軸功能是否減退,將108例PES患者分為垂體功能正常組和垂體功能減退組。以腦脊液充填蝶鞍50%為界,若超過50%,且垂體高度2 mm定義為完全性ES,否則為部分性ES,將108例PES患者分為完全性ES組和部分性ES組。并選取同期年齡、性別與PES患者相匹配,且下丘腦-垂體區(qū)域無先天或后天性疾病及垂體功能評估無異常的43例健康查體者作為正常對照組。結果1.一般情況:本組108例PES患者,男性43例,女性65例,男女比例為1:1.5,平均年齡61.5±12.9歲,占我科同期住院總人數的1.4%,并以50-69歲女性多見。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.臨床表現(xiàn):乏力59例(54.6%),頭痛40例(37.0%),食欲減退29例(26.9%),皮膚干燥伴畏寒16例(14.8%),男性性欲減退12例(27.9%),女性性腺功能減退12例(18.5%),視力障礙11例(10.2%),垂體危象4例(3.7%)。因多尿、煩渴、多飲確診為中樞性尿崩癥11例(10.2%)。10例(18.2%)糖尿病患者因血糖波動較大、易出現(xiàn)低血糖行MRI檢查發(fā)現(xiàn)PES。3.垂體功能:56.5%(61/108)患者腺垂體功能正常,而43.5%(47/108)出現(xiàn)不同程度的腺垂體功能減退。其中,垂體-性腺軸、垂體-甲狀腺軸和垂體-腎上腺皮質軸功能減退發(fā)生率分別為33.3%、18.5%、13.9%。男性出現(xiàn)腺垂體功能減退(60.5%)比例明顯高于女性(32.3%)(P0.05)。完全性ES(60.7%)較部分性ES(21.3%)更易出現(xiàn)腺垂體功能減退(P0.05)。在無癥狀的PES患者中發(fā)現(xiàn)20.5%(8/39)存在不同程度垂體-靶腺軸功能減退。另外,8.3%(9/108)患者合并高泌乳素血癥,10.2%(11/108)合并中樞性尿崩癥。4.影像學特征:108例PES患者的MRI主要表現(xiàn)為:蝶鞍內呈長T1長T2腦脊液樣信號,垂體不同程度受壓變扁,而垂體內信號無異常。通過測量垂體及蝶鞍大小顯示:正常對照人群的垂體平均體積為284.96±56.34 mm3,而PES患者僅為104.29±48.55 mm3(P0.05);垂體功能減退組的垂體體積(79.71±43.11mm3)明顯小于垂體功能正常組(123.22±44.05mm3)(P0.05),并且,完全性ES組的垂體功能減退率(60.7%)明顯高于部分性ES組(21.3%)(P0.05);PES組的蝶鞍深徑、前后徑、寬徑、蝶鞍面積均大于正常對照組(P0.05);分別比較垂體功能正常組與垂體功能減退組以及完全性ES組與部分性ES組的蝶鞍徑線,結果顯示兩不同分組中蝶鞍大小差異無統(tǒng)計學意義(P0.05)。5.垂體大小與功能的相關性:垂體高徑分別與血Cor、ACTH、FT3、FT4、T(男)、FSH(女)、LH(女)呈正相關,垂體體積分別與血Cor、ACTH、FT3、FT4、FSH(女)、LH(女)呈正相關。6.隨訪:對74例PES患者的垂體功能隨訪26±14個月,發(fā)現(xiàn)8.1%(6/74)患者新發(fā)不同程度垂體-靶腺軸功能減退。結論1.PES在女性中的發(fā)病率明顯多于男性,尤以中老年女性最多見,但男性空蝶鞍患者更易出現(xiàn)垂體功能減退。2.PES的臨床表現(xiàn)不典型,多以乏力、頭痛、內分泌紊亂、視力障礙等為主訴。故凡有上述癥狀者,應及時排查有無空蝶鞍。對于PES合并糖尿病者需注意降糖藥的選擇及其劑量調整。3.近半的PES患者可出現(xiàn)垂體功能減退癥,因此,對于確診為空蝶鞍的患者,無論有無臨床癥狀、分型如何,一經診斷,均需全面評估垂體功能,對功能損害者,及時給予激素替代治療。因PES有病情進展的風險,應需長期隨訪,并定期評估垂體功能,防止垂體危象發(fā)生。4.空蝶鞍不僅可引起垂體外形改變,還可致垂體體積縮小。并且,空蝶鞍引起的垂體功能改變與垂體的高度及大小呈正相關。一部分空蝶鞍可伴蝶鞍擴大,但蝶鞍的改變與垂體功能及垂體大小無關。
[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.
【學位授予單位】：天津醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R584;R742

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