Courtney C Hamish, McAllister Andrew S, Bell Patrick M, McCance David R, Leslie Hilary, Sheridan Brian, Atkinson A Brew
Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast BT12 6BA, United Kingdom.
J Clin Endocrinol Metab. 2004 Apr;89(4):1712-7. doi: 10.1210/jc.2003-031577.
The optimal means of assessing the integrity of the hypothalamic-pituitary-adrenal (HPA) axis after pituitary surgery remains controversial. We compared low-dose (1 micro g iv) and standard-dose (250 micro g im) corticotropin tests performed 1 and 4-6 wk after pituitary surgery with an insulin hypoglycemia test performed at 4-6 wk. Forty-one patients (21 male and 20 female; median age, 52 yr; range, 23-73 yr) who had undergone pituitary surgery were studied (Cushing's disease excluded). Twenty-two of the 41 patients had normal cortisol responses to all tests both at 1 and 4-6 wk after surgery. Eight patients had subnormal cortisol responses to all tests. Of the 11 patients with discrepant results, seven had subnormal responses only after the low-dose corticotropin test; the remaining four patients had borderline responses to one or more tests. At 4-6 wk after surgery, subjects with a 30-min serum cortisol after standard-dose corticotropin of less than 350 nmol/liter (12.7 micro g/dl) consistently had a subnormal response to hypoglycemia, and those with a serum cortisol greater than 650 nmol/liter (23.6 micro g/dl) had a normal response to hypoglycemia. Definitive testing of the HPA axis using the standard-dose corticotropin test can be carried out provided it is performed at least 4 wk after pituitary surgery. A 30-min cortisol level greater than 650 nmol/liter (23.6 micro g/dl) indicates adequacy of the HPA axis, and a level of less than 350 nmol/liter (12.7 micro g/dl) indicates ACTH deficiency. No further testing is then required. An intermediate level of 350-650 nmol/liter (12.7-23.6 micro g/dl) warrants further assessment using the insulin hypoglycemia test.
垂体手术后评估下丘脑 - 垂体 - 肾上腺（HPA）轴完整性的最佳方法仍存在争议。我们比较了垂体手术后1周以及4 - 6周时进行的低剂量（静脉注射1μg）和标准剂量（肌肉注射250μg）促肾上腺皮质激素试验与4 - 6周时进行的胰岛素低血糖试验。对41例接受垂体手术的患者（排除库欣病）进行了研究（21例男性和20例女性；年龄中位数52岁；范围23 - 73岁）。41例患者中有22例在术后1周以及4 - 6周时对所有试验的皮质醇反应均正常。8例患者对所有试验的皮质醇反应均低于正常水平。在11例结果不一致的患者中，7例仅在低剂量促肾上腺皮质激素试验后反应低于正常水平；其余4例患者对一项或多项试验的反应处于临界状态。术后4 - 6周时，标准剂量促肾上腺皮质激素注射后30分钟血清皮质醇低于350nmol/L（12.7μg/dl）的受试者对低血糖的反应始终低于正常水平，而血清皮质醇大于650nmol/L（23.6μg/dl）的受试者对低血糖的反应正常。如果在垂体手术后至少4周进行标准剂量促肾上腺皮质激素试验，则可以对HPA轴进行确定性检测。30分钟皮质醇水平大于650nmol/L（23.6μg/dl）表明HPA轴功能正常，而水平低于350nmol/L（12.7μg/dl）表明促肾上腺皮质激素缺乏。此时无需进一步检测。皮质醇水平在350 - 650nmol/L（12.7 - 23.6μg/dl）之间则需要使用胰岛素低血糖试验进行进一步评估。
