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==Overview== | ==Overview== | ||
Hypopituitarism is believed to be caused mainly due to [[ischemia]] of the [[pituitary gland]]. This ischemia can be due to [[hemorrhage]], [[tumors]], or [[brain injury]]. Compression of the [[blood vessels]] is one of the mechanisms that cause ischemia to the pituitary gland and leads to hypopituitarism. [[Pituitary adenomas]] cause compression to the [[Hypophyseal portal system|hypophyseal]] | Hypopituitarism is believed to be caused mainly due to [[ischemia]] of the [[pituitary gland]]. This ischemia can be due to [[hemorrhage]], [[tumors]], or [[brain injury]]. Compression of the [[blood vessels]] is one of the mechanisms that cause [[ischemia]] to the [[pituitary gland]] and leads to hypopituitarism. [[Pituitary adenomas]] cause compression to the [[Hypophyseal portal system|hypophyseal vessels]] leading to interruption in the pituitary gland function. [[Traumatic brain injury]] either primary or secondary also leads to [[pituitary gland]] dysfunction. | ||
==Pathophysiology== | ==Pathophysiology== | ||
===Background on pituitary gland blood supply=== | ===Background on pituitary gland blood supply=== | ||
*In order to understand the pathophysiology of hypopituitarism, it is necessary to know the [[blood]] supply of the [[pituitary gland]] as | *In order to understand the pathophysiology of hypopituitarism, it is necessary to know the [[blood]] supply of the [[pituitary gland]] as hypopituitarism occurs mainly by [[ischemia]] through different mechanisms like [[hemorrhage]], [[tumors]] or [[brain injury]].<ref name="pmid18481181">{{cite journal| author=Dusick JR, Wang C, Cohan P, Swerdloff R, Kelly DF| title=Pathophysiology of hypopituitarism in the setting of brain injury. | journal=Pituitary | year= 2012 | volume= 15 | issue= 1 | pages= 2-9 | pmid=18481181 | doi=10.1007/s11102-008-0130-6 | pmc=4170072 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18481181 }}</ref><ref name="pmid17467517">{{cite journal| author=Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, Stalla GK, Ghigo E| title=Hypopituitarism. | journal=Lancet | year= 2007 | volume= 369 | issue= 9571 | pages= 1461-70 | pmid=17467517 | doi=10.1016/S0140-6736(07)60673-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17467517 }}</ref> | ||
*The [[pituitary gland]] is composed of two parts anterior ([[adenohypophysis]]) and posterior ([[neurohypophysis]]). Both parts are supplied by the [[carotid arteries]]. | *The [[pituitary gland]] is composed of two parts anterior ([[adenohypophysis]]) and posterior ([[neurohypophysis]]). Both parts are supplied by the [[carotid arteries]]. | ||
*Adenohypophysis: It receives blood supply from the long and short hypophyseal arteries which arise from the [[internal carotid artery]] and the anterior of the [[circle of Willis]]. | *[[Adenohypophysis]]: It receives [[blood]] supply from the [[Hypophyseal portal system|long and short hypophyseal arteries]] which arise from the [[internal carotid artery]] and the anterior of the [[circle of Willis]]. | ||
*Neurohypophysis: It receives the blood supply from the inferior and middle [[Hypophyseal portal system|hypophyseal arteries]]. | *[[Neurohypophysis]]: It receives the blood supply from the inferior and middle [[Hypophyseal portal system|hypophyseal arteries]]. | ||
[[Image: Gray1180.png|500 px|center|link=https://www.wikidoc.org/index.php/File:Gray1180.png]] | [[Image: Gray1180.png|500 px|center|link=https://www.wikidoc.org/index.php/File:Gray1180.png]] | ||
===Pathogenesis=== | ===Pathogenesis=== | ||
*Hypopituitarism pathogenesis is mainly due to the destruction of the [[pituitary gland]] cells by different ways like [[ischemia]], [[inflammation]] or [[Infiltration (medical)|infiltration]]. However, ischemia is believed to be the cornerstone of hypopituitarism pathogenesis caused via different ways.<ref name="pmid12675508">{{cite journal| author=Arafah BM| title=Medical management of hypopituitarism in patients with pituitary adenomas. | journal=Pituitary | year= 2002 | volume= 5 | issue= 2 | pages= 109-17 | pmid=12675508 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12675508 }}</ref><ref name="Vance1994">{{cite journal|last1=Vance|first1=Mary Lee|title=Hypopituitarism|journal=New England Journal of Medicine|volume=330|issue=23|year=1994|pages=1651–1662|issn=0028-4793|doi=10.1056/NEJM199406093302306}}</ref> | *Hypopituitarism pathogenesis is mainly due to the destruction of the [[pituitary gland]] cells by different ways like [[ischemia]], [[inflammation]] or [[Infiltration (medical)|infiltration]]. However, ischemia is believed to be the cornerstone of hypopituitarism pathogenesis caused via different ways.<ref name="pmid12675508">{{cite journal| author=Arafah BM| title=Medical management of hypopituitarism in patients with pituitary adenomas. | journal=Pituitary | year= 2002 | volume= 5 | issue= 2 | pages= 109-17 | pmid=12675508 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12675508 }}</ref><ref name="Vance1994">{{cite journal|last1=Vance|first1=Mary Lee|title=Hypopituitarism|journal=New England Journal of Medicine|volume=330|issue=23|year=1994|pages=1651–1662|issn=0028-4793|doi=10.1056/NEJM199406093302306}}</ref> | ||
*Compression of the blood vessels:<ref name="pmid10843153">{{cite journal| author=Arafah BM, Prunty D, Ybarra J, Hlavin ML, Selman WR| title=The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas. | journal=J Clin Endocrinol Metab | year= 2000 | volume= 85 | issue= 5 | pages= 1789-93 | pmid=10843153 | doi=10.1210/jcem.85.5.6611 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10843153 }}</ref> | *Compression of [[Blood vessels|the blood vessels]]:<ref name="pmid10843153">{{cite journal| author=Arafah BM, Prunty D, Ybarra J, Hlavin ML, Selman WR| title=The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas. | journal=J Clin Endocrinol Metab | year= 2000 | volume= 85 | issue= 5 | pages= 1789-93 | pmid=10843153 | doi=10.1210/jcem.85.5.6611 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10843153 }}</ref> | ||
**[[Pituitary adenoma]], secretory or nonsecretory, is one of the common causes that lead to loss of the pituitary | **[[Pituitary adenoma]], secretory or nonsecretory, is one of the common causes that lead to loss of the pituitary dysfunction by compression on the [[Hypophyseal portal system|hypophyseal vessels]] resulting in ischemia. | ||
**Large [[adenomas]] (more than 1.5 cm) cause loss of function more than [[Microadenoma of the pituitary gland|microadenomas]]. They cause compression on the pituitary stalk and the hypophyseal portal vessels which supply the gland with blood. | **Large [[adenomas]] (more than 1.5 cm) cause loss of function more than [[Microadenoma of the pituitary gland|microadenomas]]. They cause compression on the [[pituitary stalk]] and the hypophyseal portal vessels which supply [[Pituitary gland|the pituitary gland]] with [[blood]]. | ||
**The [[tumor]] growth in the gland participates in increasing the intrasellar pressure which causes a decrease in the [[Hypophyseal circulation|hypophyseal]] [[blood flow]] which ends up by a decrease of [[hormonal]] delivery from the [[hypothalamus]] to the [[Pituitary gland|pituitary gland.]] | **The [[tumor]] growth in the pituitary gland participates in increasing the intrasellar pressure which causes a decrease in the [[Hypophyseal circulation|hypophyseal]] [[blood flow]] which ends up by a decrease of [[hormonal]] delivery from the [[hypothalamus]] to the [[Pituitary gland|pituitary gland.]] | ||
**Other lesions lead to compression includes [[carotid artery]] [[aneurysm]], [[meningioma]], and [[craniopharyngioma]]. | **Other lesions lead to compression includes [[carotid artery]] [[aneurysm]], [[meningioma]], and [[craniopharyngioma]]. | ||
*[[Traumatic brain injury|Traumatic brain injury (TBI)]]: | *[[Traumatic brain injury|Traumatic brain injury (TBI)]]: | ||
**Hypopituitarism occurs either by the following factors: | **Hypopituitarism occurs either by the following factors: | ||
***Primary brain injury | ***[[Brain injury|Primary brain injury]] | ||
***[[Brain injury]] due to other secondary events like [[hypotension]] or [[hypoxia]] | ***[[Brain injury]] due to other secondary events like [[hypotension]] or [[hypoxia]] | ||
***[[Medication]] effects | ***[[Medication]] effects | ||
Revision as of 15:45, 11 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2], Iqra Qamar M.D.[3]
Overview
Hypopituitarism is believed to be caused mainly due to ischemia of the pituitary gland. This ischemia can be due to hemorrhage, tumors, or brain injury. Compression of the blood vessels is one of the mechanisms that cause ischemia to the pituitary gland and leads to hypopituitarism. Pituitary adenomas cause compression to the hypophyseal vessels leading to interruption in the pituitary gland function. Traumatic brain injury either primary or secondary also leads to pituitary gland dysfunction.
Pathophysiology
Background on pituitary gland blood supply
- In order to understand the pathophysiology of hypopituitarism, it is necessary to know the blood supply of the pituitary gland as hypopituitarism occurs mainly by ischemia through different mechanisms like hemorrhage, tumors or brain injury.[1][2]
- The pituitary gland is composed of two parts anterior (adenohypophysis) and posterior (neurohypophysis). Both parts are supplied by the carotid arteries.
- Adenohypophysis: It receives blood supply from the long and short hypophyseal arteries which arise from the internal carotid artery and the anterior of the circle of Willis.
- Neurohypophysis: It receives the blood supply from the inferior and middle hypophyseal arteries.
Pathogenesis
- Hypopituitarism pathogenesis is mainly due to the destruction of the pituitary gland cells by different ways like ischemia, inflammation or infiltration. However, ischemia is believed to be the cornerstone of hypopituitarism pathogenesis caused via different ways.[3][4]
- Compression of the blood vessels:[5]
- Pituitary adenoma, secretory or nonsecretory, is one of the common causes that lead to loss of the pituitary dysfunction by compression on the hypophyseal vessels resulting in ischemia.
- Large adenomas (more than 1.5 cm) cause loss of function more than microadenomas. They cause compression on the pituitary stalk and the hypophyseal portal vessels which supply the pituitary gland with blood.
- The tumor growth in the pituitary gland participates in increasing the intrasellar pressure which causes a decrease in the hypophyseal blood flow which ends up by a decrease of hormonal delivery from the hypothalamus to the pituitary gland.
- Other lesions lead to compression includes carotid artery aneurysm, meningioma, and craniopharyngioma.
- Traumatic brain injury (TBI):
- Hypopituitarism occurs either by the following factors:
- Primary brain injury
- Brain injury due to other secondary events like hypotension or hypoxia
- Medication effects
- Critical illness
- The anatomical sitting of the pituitary gland increases its susceptibility to getting injured from trauma.
- It is believed that tissue necrosis results in the release of sequestered antigens, precipitating autoimmunity of the Pituitary gland and hypopituitarism in Sheehan's syndrome.[6][7][8]
- Hypopituitarism occurs either by the following factors:
Genetics
Hypopituitarism is caused by a mutation in any one of the following genes.[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]
| Isolated
hormone abnormalities |
Gene | Inheritance | Phenotype |
|---|---|---|---|
| GH1 | AR, AD | Isolated GH deficiency | |
| GHRHR | AR | Isolated GH deficiency | |
| TSHB | AR | Isolated TSH deficiency | |
| TRHR | AR | Isolated TSH deficiency | |
| TPIT | AR | Isolated ACTH deficiency | |
| GnRHR | AR | HH | |
| PC1 | AR | ACTH deficiency, hypoglycemia, HH, obesity | |
| POMC | AR | ACTH deficiency, obesity, red hair | |
| DAX1 | XL | Adrenal hypoplasia congenital and HH | |
| CRH | AR | CRH deficiency | |
| KAL1 | XL | Kallman syndrome, renal agenesis, synkinesia | |
| FGFR1 | AD, AR | Kallman syndrome, cleft lip and palate, facial dysmorphism | |
| Leptin | AR | HH, obesity | |
| Leptin-R | AR | HH, obesity | |
| GPR54 | AR | HH | |
| Kisspeptin | AR | HH | |
| FSHB | AR | Primary amenorrhea, defective spermatogenesis | |
| LHB | AR | Delayed puberty | |
| PROK2 | AD | Kallman syndrome, severe sleep disorder, obesity | |
| PROKR2 | AD, AR | Kallman syndrome | |
| AVP-NPII | AR, AD | Diabetes insipidus | |
| Combined pituitary hormone deficiency | POU1F1 | AR, AD | GH, TSH, and prolactin deficiencies |
| PROP1 | AR | GH, TSH, LH, FSH, prolactin, and evolving ACTH deficiencies | |
| Specific syndromes | HESX1 | AR, AD | Septo-optic dysplasia |
| LHX3 | AR | GH, TSH, LH, FSH, prolactin deficiencies, limited neck rotation | |
| LHX4 | AD | GH, TSH, ACTH deficiencies with cerebellar abnormalities | |
| SOX3 | XL | Hypopituitarism and mental retardation | |
| GLI2 | AD | Holoprosencephaly and multiple midline defects | |
| SOX2 | AD | Anophthalmia, hypopituitarism, oesophageal atresia | |
| GLI3 | AD | Pallister-Hall syndrome | |
| PITX2 | AD | Rieger syndrome |
References
- ↑ Dusick JR, Wang C, Cohan P, Swerdloff R, Kelly DF (2012). "Pathophysiology of hypopituitarism in the setting of brain injury". Pituitary. 15 (1): 2–9. doi:10.1007/s11102-008-0130-6. PMC 4170072. PMID 18481181.
- ↑ Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, Stalla GK, Ghigo E (2007). "Hypopituitarism". Lancet. 369 (9571): 1461–70. doi:10.1016/S0140-6736(07)60673-4. PMID 17467517.
- ↑ Arafah BM (2002). "Medical management of hypopituitarism in patients with pituitary adenomas". Pituitary. 5 (2): 109–17. PMID 12675508.
- ↑ Vance, Mary Lee (1994). "Hypopituitarism". New England Journal of Medicine. 330 (23): 1651–1662. doi:10.1056/NEJM199406093302306. ISSN 0028-4793.
- ↑ Arafah BM, Prunty D, Ybarra J, Hlavin ML, Selman WR (2000). "The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas". J Clin Endocrinol Metab. 85 (5): 1789–93. doi:10.1210/jcem.85.5.6611. PMID 10843153.
- ↑ Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N (2002). "Pituitary autoimmunity in patients with Sheehan's syndrome". J. Clin. Endocrinol. Metab. 87 (9): 4137–41. doi:10.1210/jc.2001-020242. PMID 12213861.
- ↑ "AUTOANTIBODIES IN SHEEHAN'S SYNDROME - ScienceDirect".
- ↑ Falorni A, Minarelli V, Bartoloni E, Alunno A, Gerli R (2014). "Diagnosis and classification of autoimmune hypophysitis". Autoimmun Rev. 13 (4–5): 412–6. doi:10.1016/j.autrev.2014.01.021. PMID 24434361.
- ↑ Carvalho LR, Woods KS, Mendonca BB, Marcal N, Zamparini AL, Stifani S, Brickman JM, Arnhold IJ, Dattani MT (2003). "A homozygous mutation in HESX1 is associated with evolving hypopituitarism due to impaired repressor-corepressor interaction". J. Clin. Invest. 112 (8): 1192–201. doi:10.1172/JCI18589. PMC 213489. PMID 14561704.
- ↑ Sobrier ML, Maghnie M, Vié-Luton MP, Secco A, di Iorgi N, Lorini R, Amselem S (2006). "Novel HESX1 mutations associated with a life-threatening neonatal phenotype, pituitary aplasia, but normally located posterior pituitary and no optic nerve abnormalities". J. Clin. Endocrinol. Metab. 91 (11): 4528–36. doi:10.1210/jc.2006-0426. PMID 16940453.
- ↑ Netchine I, Sobrier ML, Krude H, Schnabel D, Maghnie M, Marcos E, Duriez B, Cacheux V, Moers A, Goossens M, Grüters A, Amselem S (2000). "Mutations in LHX3 result in a new syndrome revealed by combined pituitary hormone deficiency". Nat. Genet. 25 (2): 182–6. doi:10.1038/76041. PMID 10835633. Vancouver style error: initials (help)
- ↑ Machinis K, Pantel J, Netchine I, Léger J, Camand OJ, Sobrier ML, Dastot-Le Moal F, Duquesnoy P, Abitbol M, Czernichow P, Amselem S (2001). "Syndromic short stature in patients with a germline mutation in the LIM homeobox LHX4". Am. J. Hum. Genet. 69 (5): 961–8. PMC 1274372. PMID 11567216.
- ↑ Wu W, Cogan JD, Pfäffle RW, Dasen JS, Frisch H, O'Connell SM, Flynn SE, Brown MR, Mullis PE, Parks JS, Phillips JA, Rosenfeld MG (1998). "Mutations in PROP1 cause familial combined pituitary hormone deficiency". Nat. Genet. 18 (2): 147–9. doi:10.1038/ng0298-147. PMID 9462743.
- ↑ Pellegrini-Bouiller I, Bélicar P, Barlier A, Gunz G, Charvet JP, Jaquet P, Brue T, Vialettes B, Enjalbert A (1996). "A new mutation of the gene encoding the transcription factor Pit-1 is responsible for combined pituitary hormone deficiency". J. Clin. Endocrinol. Metab. 81 (8): 2790–6. doi:10.1210/jcem.81.8.8768831. PMID 8768831.
- ↑ Pfäffle RW, DiMattia GE, Parks JS, Brown MR, Wit JM, Jansen M, Van der Nat H, Van den Brande JL, Rosenfeld MG, Ingraham HA (1992). "Mutation of the POU-specific domain of Pit-1 and hypopituitarism without pituitary hypoplasia". Science. 257 (5073): 1118–21. PMID 1509263.
- ↑ Turton JP, Reynaud R, Mehta A, Torpiano J, Saveanu A, Woods KS, Tiulpakov A, Zdravkovic V, Hamilton J, Attard-Montalto S, Parascandalo R, Vella C, Clayton PE, Shalet S, Barton J, Brue T, Dattani MT (2005). "Novel mutations within the POU1F1 gene associated with variable combined pituitary hormone deficiency". J. Clin. Endocrinol. Metab. 90 (8): 4762–70. doi:10.1210/jc.2005-0570. PMID 15928241.
- ↑ Bhangoo AP, Hunter CS, Savage JJ, Anhalt H, Pavlakis S, Walvoord EC, Ten S, Rhodes SJ (2006). "Clinical case seminar: a novel LHX3 mutation presenting as combined pituitary hormonal deficiency". J. Clin. Endocrinol. Metab. 91 (3): 747–53. doi:10.1210/jc.2005-2360. PMID 16394081.
- ↑ Cogan JD, Wu W, Phillips JA, Arnhold IJ, Agapito A, Fofanova OV, Osorio MG, Bircan I, Moreno A, Mendonca BB (1998). "The PROP1 2-base pair deletion is a common cause of combined pituitary hormone deficiency". J. Clin. Endocrinol. Metab. 83 (9): 3346–9. doi:10.1210/jcem.83.9.5142. PMID 9745452.
- ↑ Flück C, Deladoey J, Rutishauser K, Eblé A, Marti U, Wu W, Mullis PE (1998). "Phenotypic variability in familial combined pituitary hormone deficiency caused by a PROP1 gene mutation resulting in the substitution of Arg-->Cys at codon 120 (R120C)". J. Clin. Endocrinol. Metab. 83 (10): 3727–34. doi:10.1210/jcem.83.10.5172. PMID 9768691.
- ↑ Rosenbloom AL, Almonte AS, Brown MR, Fisher DA, Baumbach L, Parks JS (1999). "Clinical and biochemical phenotype of familial anterior hypopituitarism from mutation of the PROP1 gene". J. Clin. Endocrinol. Metab. 84 (1): 50–7. doi:10.1210/jcem.84.1.5366. PMID 9920061.
- ↑ Pernasetti F, Toledo SP, Vasilyev VV, Hayashida CY, Cogan JD, Ferrari C, Lourenço DM, Mellon PL (2000). "Impaired adrenocorticotropin-adrenal axis in combined pituitary hormone deficiency caused by a two-base pair deletion (301-302delAG) in the prophet of Pit-1 gene". J. Clin. Endocrinol. Metab. 85 (1): 390–7. doi:10.1210/jcem.85.1.6324. PMID 10634415.
- ↑ Lee JK, Zhu YS, Cordero JJ, Cai LQ, Labour I, Herrera C, Imperato-McGinley J (2004). "Long-term growth hormone therapy in adulthood results in significant linear growth in siblings with a PROP-1 gene mutation". J. Clin. Endocrinol. Metab. 89 (10): 4850–6. doi:10.1210/jc.2003-031816. PMID 15472175.
- ↑ Yamamoto M, Iguchi G, Takeno R, Okimura Y, Sano T, Takahashi M, Nishizawa H, Handayaningshi AE, Fukuoka H, Tobita M, Saitoh T, Tojo K, Mokubo A, Morinobu A, Iida K, Kaji H, Seino S, Chihara K, Takahashi Y (2011). "Adult combined GH, prolactin, and TSH deficiency associated with circulating PIT-1 antibody in humans". J. Clin. Invest. 121 (1): 113–9. doi:10.1172/JCI44073. PMC 3007153. PMID 21123951.
- ↑ Vallette-Kasic S, Brue T, Pulichino AM, Gueydan M, Barlier A, David M, Nicolino M, Malpuech G, Déchelotte P, Deal C, Van Vliet G, De Vroede M, Riepe FG, Partsch CJ, Sippell WG, Berberoglu M, Atasay B, de Zegher F, Beckers D, Kyllo J, Donohoue P, Fassnacht M, Hahner S, Allolio B, Noordam C, Dunkel L, Hero M, Pigeon B, Weill J, Yigit S, Brauner R, Heinrich JJ, Cummings E, Riddell C, Enjalbert A, Drouin J (2005). "Congenital isolated adrenocorticotropin deficiency: an underestimated cause of neonatal death, explained by TPIT gene mutations". J. Clin. Endocrinol. Metab. 90 (3): 1323–31. doi:10.1210/jc.2004-1300. PMID 15613420.
- ↑ Yang Y, Guo QH, Wang BA, Dou JT, Lv ZH, Ba JM, Lu JM, Pan CY, Mu YM (2013). "Pituitary stalk interruption syndrome in 58 Chinese patients: clinical features and genetic analysis". Clin. Endocrinol. (Oxf). 79 (1): 86–92. doi:10.1111/cen.12116. PMID 23199197.
- ↑ Wang W, Wang S, Jiang Y, Yan F, Su T, Zhou W, Jiang L, Zhang Y, Ning G (2015). "Relationship between pituitary stalk (PS) visibility and the severity of hormone deficiencies: PS interruption syndrome revisited". Clin. Endocrinol. (Oxf). 83 (3): 369–76. doi:10.1111/cen.12788. PMID 25845766.
- ↑ Mendonca BB, Osorio MG, Latronico AC, Estefan V, Lo LS, Arnhold IJ (1999). "Longitudinal hormonal and pituitary imaging changes in two females with combined pituitary hormone deficiency due to deletion of A301,G302 in the PROP1 gene". J. Clin. Endocrinol. Metab. 84 (3): 942–5. doi:10.1210/jcem.84.3.5537. PMID 10084575.
- ↑ De Marinis L, Bonadonna S, Bianchi A, Maira G, Giustina A (2005). "Primary empty sella". J. Clin. Endocrinol. Metab. 90 (9): 5471–7. doi:10.1210/jc.2005-0288. PMID 15972577.