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Table 5.

1 Summary of anatomy and function of the hypothalamic nuclei


Nuclei
Medial

Function
Supraoptic

Tuberal

Mammillary

Paraventricular (PVN)

Secretes vasopressin and oxytocin; large neurones


pass through the pituitary stalk as the supraoptichypothalamic tract to the posterior pituitary where
the nerve terminals contain storage granules
Secretes corticotrophin-releasing hormone (CRH)

Supraoptic (SON)

Vasopressin and oxytocin secretion (like PVN)

Suprachiasmatic (SCN)

Biological clock functions (e.g. wake-sleep cycle);


receives input from retina

Ventromedial (VMN)

Satiety; lesions cause overeating (hyperphagia)


Mood

Arcuate

Secretes multiple releasing hormones, somatostatin


and
dopamine
from
nerve
terminals
in
the
median
eminence
into
capillary
network
for
delivery
to
the
anterior
pituitary;
overlapping
function
with
PVN
and
other nuclei

Mammillary

No known endocrine function; role in memory

Posterior

Thermoregulation
Blood pressure

Lateral

Hunger; lesions cause anorexia


Thirst

Hormone axes and functions are detailed in the relevant sections of this chapter and later organ-specific chapters. Not all nuclei play endocrine
roles and some functions remain incompletely understood. However, general appreciation of the diverse function is important as disruption (e.g.
from space-occupying lesions or radiation damage) can have pronounced effects for patients attending endocrinology clinics.

(Table 5.2). Involvement of each nerve can give


rise
to characteristic forms of diplopia (double
vision),
exacerbated by looking away from the action of
the
paralyzed muscle. Laterally, tumour can also
envelop

the internal carotid artery in the cavernous


sinus, after which restricted access and the
dangers of operating around major vessels
makes curative surgery impossible.

Case history 5.1


A 65-year-old man had attended the optician for new reading glasses when a routine
assessment revealed loss of the entire lateral half of the visual fields on both sides.
What is the precise description for this visual deficit?
What is the likely cause?
How would it be best imaged?
If imaging of the pituitary gland is abnormal, why should this person be referred urgently to an endocrinologist?
Answers, see p. 96

70 / Chapter 5: The hypothalamus and pituitary gland

Box 5.1 Pituitary tumours


Two issues must be considered:
Potential hormone excess from the tumour
cell type (see following sections)
Physical pressure on local structures and
other pituitary cell types:
ranial nerve palsies (see below and

Table
C 5.2)

oss of pituitary hormones, either

Lindividually or in combination, causing


hypopituitarism (see later sections)

Local anatomy at risk from expanding pituitary tumours


Superiorly - optic chiasm:
ompression causes loss of vision

(commonly
C
bitemporal; Figure 5.3)
Laterally - cavernous sinuses:

ompression of cranial nerves III, IV and

VIC(Table 5.2)

ncasing of the internal carotid artery;

does
E no harm but prevents curative
surgery

Antero-inferiorly

sphenoid

sinus

(the

route for transsphenoidal surgery):


erebrospinal

fluid

(CSF)

rhinorrhoea

secondary
C
to tumour erosion is rare
Categorization of tumour size

>1 cm diameter=macroadenoma
<1 cm diameter=microadenoma

Other more generalized symptoms of


pituitary
masses include headache (especially
frontal/retroorbital) from stretching of the meninges
or
obstruction to CSF drainage. Very rarely,
tumours
extend
anteriorly through the sphenoid sinus to
cause
CSF
leakage
through
the
nose
(CSF
rhinorrhoea).
Not
all
pituitary
masses
are
adenomas.
The
differential diagnosis includes metastasis,
meningi-

oma,
lymphoma,
sarcoid,
histiocytosis,
or
an
unusual
tumour
called
a
craniopharyngioma
that
more commonly presents to the
paediatric
endocrinologist. Histologically, this tumour
is
benign,
but it is still invasive. It most likely
arises from the

epithelial cells that lined Rathkes pouch


and can cause coincident diabetes
insipidus (deficiency of vasopressin, see
later).

Treating pituitary tumours


Pharmacological treatment is available
for some hormone-secreting tumours (see
sections
on
growth
hormone
and
prolactin). For all others, and where drug
treatment proves inadequate, there are
three choices (Box 5.2).
Compression of the optic chiasm is a
neurosurgical emergency. Even profound visual
loss
can
recover quickly by relieving pressure on
the
chiasm.
In this scenario, surgery is advantageous
over
radiotherapy, which is less invasive, but would
damage
optic neurones, can take up to 10 years
for
its
complete effect, mildly increases the risk of
cerebrovascular ischaemic events and frequently
results
in
hypopituitarism because of the death
of
other
hormone-secreting cell types.

The hypothalamus
The hypothalamus is a critical part of the
brain

linking diverse aspects of the endocrine


system
to
the CNS and vice versa in health and
disease.
For
example, depression is associated with
altered
function
of
the
hypothalamic-anterior
pituitary
adrenocortical axis. In many situations it
functions
as
a
rheostat (e.g. like the thermostat on a
heating
system), regulating the stimulation or
suppression
of a variety of processes such as hunger
or
thirst.
It
lies below the thalamus and above the
pituitary
gland as a series of nuclei categorized
anatomically
as medial (plus subdivisions) and lateral
(see Table
5.1). Many of the nuclei interact with
peripheral
endocrine organs either dependent on or
independent of the hormone axes of the anterior
pituitary
(see next section). The hypothalamic
role
in
appetite control is covered in Chapter 15.
It
is
also
involved in the bodys counter-regulatory
hormone
response to hypoglycaemia (Chapter
12).
The hypothalamus is responsible for
temperature control and the regulation of
several
circadian
rhythms and biological clock functions
(e.g. the

abcdfreeer 5: The hypothalamus and pituitary gland / 71


LEFT EYE

RIGHT EYE

Figure 5.3 Visual field assessment. There is a bitemporal loss of the lower quadrants (black areas) caused by a
pituitary tumour compressing the optic chiasm. More commonly the upper quadrants are lost first; however,
such clinical variation is not unusual.

Table 5.2 Cranial nerves in the cavernous sinus


Cranial nerve

Function

Consequences of compression

Oculomotor nerve (III)

Innervation of suprapalpebral
muscles

Ptosis (most obvious feature)

Associated with parasympathetic


nerve fibres from the EdingerWestphal nucleus

Fixed, dilated pupil and loss of


accommodation

Innervation of all extraocular


muscles except those supplied by
IV and VI

Downward and outward-looking vision


(unopposed actions of superior oblique
and lateral rectus)
Double vision (if ptotic eye lid is raised)

Trochlear nerve (IV)

Innervation of the superior oblique


muscle

Weak downward and inward gaze


Double vision on walking down stairs

Abducent nerve (VI)

Innervation of the lateral rectus


muscle

Inward (medial)-looking gaze


Double vision most pronounced on
looking to affected side

targeted
at
pituitary gland.
wake-sleep
cycle).
Occasionally,
despite
careful
monitoring of radiation dose, some
patients
consider that these latter functions become
disturbed
after external beam radiotherapy

the

In regulating thirst, the hypothalamus


receives
endocrine signals from circulating atrial
natriuretic

peptide (ANP) and angiotensin amongst


other
hormones, and has neurones that are
receptive
to
sodium concentration and osmolality.
These inputs

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