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Akakın A, Yılmaz B, Ekşi MŞ, Kılıç T. A case of pituitary apoplexy following posterior lumbar fusion surgery. J Neurosurg Spine 2015; 23:598-601. [DOI: 10.3171/2015.3.spine14792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pituitary adenoma is a common primary brain neoplasm. Pituitary apoplexy (PA) is a rare complication of pituitary adenoma and occurs as the result of sudden tumor growth and following different comorbidities. The authors describe the first case of PA following posterior lumbar fusion surgery performed while the patient was prone. In patients with a preexisting pituitary adenoma, thorough clinical and laboratory investigations should be conducted using an interdisciplinary approach before any planned surgery. In unknown cases of pituitary adenoma, PA should be kept in mind for the differential diagnosis in a case with headache, nausea, vomiting, ophthalmoplegia, visual loss, and electrolyte imbalance concurrent with an ongoing disease state.
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Affiliation(s)
- Akın Akakın
- 1Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey; and
| | - Baran Yılmaz
- 1Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey; and
| | - Murat Şakir Ekşi
- 2Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Türker Kılıç
- 1Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey; and
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Zhan R, Li X, Li X. Endoscopic Endonasal Transsphenoidal Approach for Apoplectic Pituitary Tumor: Surgical Outcomes and Complications in 45 Patients. J Neurol Surg B Skull Base 2015; 77:54-60. [PMID: 26949589 DOI: 10.1055/s-0035-1560046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 06/25/2015] [Indexed: 12/12/2022] Open
Abstract
Objective To assess the safety and effectiveness of the endoscopic endonasal transsphenoidal approach (EETA) for apoplectic pituitary adenoma. Design A retrospective study. Setting Qilu Hospital of Shandong University; Brain Science Research Institute, Shandong University. Participants Patients admitted to Qilu Hospital of Shandong University who were diagnosed with an apoplectic pituitary tumor and underwent EETA for resection of the tumor. Main Outcome Measures In total 45 patients were included in a retrospective chart review. Data regarding patient age, sex, presentation, lesion size, surgical procedure, extent of resection, clinical outcome, and surgical complications were obtained from the chart review. Results In total, 38 (92.7%) of 41 patients with loss of vision obtained visual remission postoperatively. In addition, 16 patients reported a secreting adenoma, and postsurgical hormonal levels were normal or decreased in 14 patients. All other symptoms, such as headache and alteration of mental status, recovered rapidly after surgery. Two patients (4.4%) incurred cerebrospinal fluid leakage. Six patients (13.3%) experienced transient diabetes insipidus (DI) postoperatively, but none of these patients developed permanent DI. Five patients (11.1%) developed hypopituitarism and were treated with replacement of hormonal medicine. No cases of meningitis, carotid artery injury, or death related to surgery were reported. Conclusion EETA offers a safe and effective surgical option for apoplectic pituitary tumors and is associated with low morbidity and mortality.
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Affiliation(s)
- Rucai Zhan
- Department of Neurosurgery, Qilu Hospital of Shandong University, Brain Science Research Institute, Shandong University, Jinan, China; Department of Neurosurgery, Jinan Third People's Hospital, Jinan, Shandong, China
| | - Xueen Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Brain Science Research Institute, Shandong University, Jinan, China
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Brain Science Research Institute, Shandong University, Jinan, China
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Xu K, Yuan Y, Zhou J, Yu J. Pituitary adenoma apoplexy caused by rupture of an anterior communicating artery aneurysm: case report and literature review. World J Surg Oncol 2015. [PMID: 26220796 PMCID: PMC4518590 DOI: 10.1186/s12957-015-0653-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pituitary adenoma combined with intracranial aneurysm is not rare. Some aneurysms are located inside pituitary adenomas, and most do not rupture. Pituitary apoplexy caused by aneurysm rupture is rare and is easily misdiagnosed as simple pituitary adenoma apoplexy. CASE PRESENTATION In this study, we report one case of rare pituitary adenoma apoplexy caused by the rupture of an anterior communicating artery aneurysm. The patient was a 49-year-old male who had an untreated pituitary adenoma for 3 years. The patient experienced a sudden headache; computed tomography (CT) and magnetic resonance imaging (MRI) revealed pituitary adenoma apoplexy and significant subarachnoid hemorrhage. Cranial CT angiography (CTA) showed a communicating artery aneurysm. Supratentorial intracranial aneurysm clipping and pituitary adenoma resection were performed. The aneurysm was a ruptured aneurysm located inside the pituitary adenoma. During the surgery, the aneurysm was clipped, and the majority of the tumor was resected. The patient recovered well after the surgery and received radiotherapy. CONCLUSIONS This rare case demonstrates that when pituitary adenoma apoplexy is combined with subarachnoid hemorrhage, the possibility of a combined intrasellar aneurysm should be considered. During transsphenoidal tumor resection, aneurysm rupture should be avoided to prevent disastrous consequences.
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Affiliation(s)
- Kan Xu
- Department of Neurosurgery, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China.
| | - Yongjie Yuan
- Department of Neurosurgery, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China.
| | - Jing Zhou
- Department of Neurosurgery, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China.
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, China.
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Abstract
OBJECT Pituitary adenomas occasionally undergo infarction, apoplexy, which often destroys much of the tumor. It is well known that apoplexy can be precipitated by several acute factors, including cardiac surgery, other types of surgery, trauma, insulin infusion, and stimulation with administration of hypothalamic releasing factors. METHODS The prior focus on mechanisms underlying pituitary apoplexy has been on these acute events. Less attention has been given to the endogenous features of pituitary tumors that make them susceptible to spontaneous infarction, despite that most pituitary apoplexy occurs in the absence of a recognized precipitating event. The authors examine intrinsic features of pituitary adenomas that render them vulnerable to apoplexy-features such as high metabolic demand, paucity of angiogenesis, and sparse vascularity, qualities that have previously not been linked with apoplexy-and argue that it is these features of adenomas that underlie their susceptibility to spontaneous infarction. The sensitivity of freshly cultured pituitary adenomas to hypoglycemia is assessed. RESULTS Adenomas have high metabolic demand, limited angiogenesis, and reduced vessel density compared with the normal gland. Pituitary adenoma cells do not survive in the presence of reduced or absent concentrations of glucose. CONCLUSIONS The authors propose that the frequent ischemic infarction of pituitary adenomas is the product of intrinsic features of these tumors. These endogenous qualities create a tenuous balance between high metabolic demand and marginal tissue perfusion. Thus, the tumor is vulnerable to spontaneous infarction or to acute ischemia by any event that acutely alters the balance between tumor perfusion and tumor metabolism, events such as acute systemic hypotension, abruptly decreased supply of nutrients, hypoglycemia with insulin administration, or increase in the tumor's metabolic demand due to administration of hypothalamic releasing factors. It may be possible to take advantage of these intrinsic features of pituitary adenomas by using aspects of this vulnerability for development of new approaches for treatment.
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Affiliation(s)
- Edward H Oldfield
- 1Department of Neurological Surgery, University of Virginia Health Sciences Center, University of Virginia, Charlottesville, Virginia; and.,2Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Marsha J Merrill
- 2Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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55
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Johnston PC, Hamrahian AH, Weil RJ, Kennedy L. Pituitary tumor apoplexy. J Clin Neurosci 2015; 22:939-44. [PMID: 25800143 DOI: 10.1016/j.jocn.2014.11.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 11/23/2014] [Accepted: 11/25/2014] [Indexed: 11/20/2022]
Abstract
We review the etiology, investigations, management and outcomes of pituitary tumor apoplexy. Pituitary tumor apoplexy is a clinical syndrome which typically includes the acute onset of headache and/or visual disturbance, cranial nerve palsy and partial or complete endocrine dysfunction. It is associated with either infarction or hemorrhage of a pre-existing pituitary adenoma and is associated with significant morbidity and potential fatality. Not all patients will present with classic signs and symptoms, therefore it is pertinent to appreciate the clinical spectrum in which this condition can present.
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Affiliation(s)
- Philip C Johnston
- Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, UK; Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Amir H Hamrahian
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert J Weil
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
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56
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Abstract
Pituitary apoplexy (PA) is a rare clinical syndrome caused by sudden hemorrhaging and/or infarction of the pituitary gland, generally within a pituitary adenoma. The main symptom is sudden-onset severe headache, associated with visual disorders or ocular palsy. Corticotropic deficiency may be life-threatening if left untreated. Computed tomography (CT) or MRI confirms the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. PA used to be considered a neurosurgical emergency but a conservative approach is increasingly used in selected patients, as it yields similar outcomes. Glucocorticoid treatment must always be started immediately after onset.
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Affiliation(s)
- Claire Briet
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Department of Endocrinology and Reproductive Diseases, Le Kremlin-Bicêtre F-94275, France; Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Department of Endocrinology and Reproductive Diseases, Le Kremlin-Bicêtre F-94275, France
| | - Sylvie Salenave
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Department of Endocrinology and Reproductive Diseases, Le Kremlin-Bicêtre F-94275, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Department of Endocrinology and Reproductive Diseases, Le Kremlin-Bicêtre F-94275, France; Univ Paris-Sud, School of Medicine, Orsay F-91405, France; Insitut National de la Santé et de la Recherche Médicale, Unit 693, Le Kremlin-Bicêtre, F-94276, France.
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57
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Miller BA, Ioachimescu AG, Oyesiku NM. Contemporary indications for transsphenoidal pituitary surgery. World Neurosurg 2015; 82:S147-51. [PMID: 25496626 DOI: 10.1016/j.wneu.2014.07.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 07/25/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze current indications for transsphenoidal pituitary surgery. METHODS The current literature regarding transsphenoidal surgery for all subtypes of pituitary adenomas and other sellar lesions was examined. Alternate approaches for pituitary surgery were also reviewed. RESULTS Transsphenoidal surgery continues to be the mainstay of surgical treatment for pituitary tumors, and has good outcomes in experienced hands. Pre- and postoperative management of pituitary tumors remains an important part of the treatment of patients with pituitary tumors. CONCLUSIONS Even as medical and surgical treatment for pituitary tumors evolves, transsphenoidal surgery remains a mainstay of treatment. Outcomes after transshenoidal surgery have improved over time. Neurosurgeons must be aware of the indications, risks and alternatives to transsphenoidal pituitary surgery.
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Affiliation(s)
- Brandon A Miller
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Nelson M Oyesiku
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
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58
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Jho DH, Biller BM, Agarwalla PK, Swearingen B. Pituitary Apoplexy: Large Surgical Series with Grading System. World Neurosurg 2014; 82:781-90. [DOI: 10.1016/j.wneu.2014.06.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 03/10/2014] [Accepted: 06/04/2014] [Indexed: 11/15/2022]
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Abstract
Visual failure of any kind is a common clinical presentation and indication for neuroimaging. Monocular deficits should concentrate the search to the anterior (prechiasmatic) visual pathway. Bitemporal hemianopia suggests a chiasmatic cause, whereas retrochiasmatic lesions characteristically cause homonymous hemianopic defects. Quadrantanopias usually arise from lesions in the optic radiations. Disorders of visual perception can be broadly divided into "where" and "what" problems caused by lesions in the parietal and temporal lobes, respectively, and their associated white matter tracts. Visualization of the retrochiasmatic visual and visual association pathways is aided by diffusion tensor imaging.
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Affiliation(s)
| | - Adam G Thomas
- Imaging Department, Leicester Royal Infirmary, Leicester, UK; Department of Neuroradiology, Queens Medical Centre, Nottingham, UK.
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60
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Chao CC, Lin CJ. Pituitary apoplexy in a teenager--case report. Pediatr Neurol 2014; 50:648-51. [PMID: 24842258 DOI: 10.1016/j.pediatrneurol.2014.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/30/2014] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pituitary apoplexy is a rare clinical emergency which results from hemorrhage or infarction in the pituitary gland. PATIENT We present a 14-year-old girl with pituitary apoplexy and review the literature. RESULTS Our patient experienced blurred vision, nausea, and headache. Her best-corrected visual acuity was 20/200 and 20/20. Confrontation test visual field testing revealed bitemporal hemianopsia. Brain imaging demonstrated a suprasellar mass. The microscopic endonasal transsphenoidal approach only found 5-10 mL brownish fluid-like material. Pathology confirmed no malignancy. Pituitary apoplexy was diagnosed. Her nausea and headache gradually improved. Six months after operation, her best-corrected visual acuity had improved to 20/30 and 20/20. CONCLUSIONS Although pituitary apoplexy is rare in pediatric patients, prompt evaluation including detailed ophthalmic examination, biochemical evaluation, endocrine workup, and image study are very important.
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Affiliation(s)
- Chen-Cheng Chao
- Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan; Department of Ophthalmology, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
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62
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Abstract
PURPOSE OF REVIEW This review summarizes safety concerns associated with diagnostic neuroimaging in patients who are of childbearing age, focusing on diagnostic modalities and radiologic features of neurologic conditions encountered by pregnant women. RECENT FINDINGS During pregnancy, women experience a range of physiologic changes that can affect neurologic function. These include endocrine, hemodynamic, endothelial, immunologic, and coagulopathic changes that can alter susceptibility to stroke, subarachnoid hemorrhage, demyelination, venous thrombosis, and other neurologic conditions. Unique safety concerns are associated with imaging procedures performed to diagnose neurologic conditions that occur during pregnancy. SUMMARY This review discusses the use of diagnostic neuroimaging, including administration of IV contrast, in pregnant women and in nonpregnant women of childbearing age.
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63
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Garg MK, Pathak HC, Singh G. Subclinical pituitary apoplexy with preserved pituitary functions. Indian J Endocrinol Metab 2014; 18:122-123. [PMID: 24701449 PMCID: PMC3968724 DOI: 10.4103/2230-8210.126597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- M. K. Garg
- Department of Endocrinology, Command Hospital (Southern Command), Pune, Maharashtra, India
| | - H. C. Pathak
- Department of Neurosurgery, Command Hospital (Southern Command), Pune, Maharashtra, India
| | - Giriraj Singh
- Department of Radiology, Command Hospital (Southern Command), Pune, Maharashtra, India
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Vicente A, Lecumberri B, Gálvez MÁ. Guía de práctica clínica para el diagnóstico y tratamiento de la apoplejía hipofisaria. ACTA ACUST UNITED AC 2013; 60:582.e1-582.e12. [DOI: 10.1016/j.endonu.2013.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 04/04/2013] [Accepted: 04/10/2013] [Indexed: 11/29/2022]
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65
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Jahangiri A, Clark AJ, Han SJ, Kunwar S, Blevins LS, Aghi MK. Socioeconomic factors associated with pituitary apoplexy. J Neurosurg 2013; 119:1432-6. [DOI: 10.3171/2013.6.jns122323] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Object
Pituitary apoplexy is associated with worse outcomes than are pituitary adenomas detected without acute clinical deterioration. The association between pituitary apoplexy and socioeconomic factors that may limit access to health care has not been examined in prior studies.
Methods
This study involved retrospectively evaluating data obtained in all patients who underwent surgery for nonfunctioning pituitary adenoma causing visual symptoms between January 2003 and July 2012 at the University of California, San Francisco. Patients were grouped into those who presented with apoplexy and those who did not (“no apoplexy”). The 2 groups were compared with respect to annual household income, employment status, health insurance status, and whether or not the patient had a primary health care provider. Associations between categorical variables were analyzed by chi-square test and continuous variables by Student t-test. Multivariate logistic regression was also performed.
Results
One hundred thirty-five patients were identified, 18 of whom presented with apoplexy. There were significantly more unmarried patients and emergency room presentations in the apoplexy group than in the “no apoplexy” group. There was a nonsignificant trend toward lower mean household income in the apoplexy group. Lack of health insurance and lack of a primary health care provider were both highly significantly associated with apoplexy. In a multivariate analysis including marital status, emergency room presentation, income, insurance status, and primary health care provider status as variables, lack of insurance remained associated with apoplexy (OR 11.6; 95% CI 1.9–70.3; p = 0.008).
Conclusions
The data suggest that patients with limited access to health care may be more likely to present with pituitary apoplexy than those with adequate access.
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66
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Sudden death in custody due to pituitary apoplexy during long restriction in a sitting position: A case report and review of the literature. J Forensic Leg Med 2013; 20:812-5. [DOI: 10.1016/j.jflm.2013.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 04/30/2013] [Accepted: 06/24/2013] [Indexed: 11/19/2022]
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Mir SA, Masoodi SR, Bashir MI, Wani AI, Farooqui KJ, Kanth B, Bhat AR. Dissociated hypopituitarism after spontaneous pituitary apoplexy in acromegaly. Indian J Endocrinol Metab 2013; 17:S102-S104. [PMID: 24251123 PMCID: PMC3830269 DOI: 10.4103/2230-8210.119518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pituitary apoplexy is an uncommon event and usually occurs in non-functioning pituitary tumors. Among the functioning tumors, prolactinomas are the ones most likely to apoplexy. Apoplexy in growth hormone (GH) producing adenomas is a very rare event with less than thirty cases reported worldwide. OBJECTIVE To describe a case of spontaneous pituitary apoplexy in acromegaly. CASE REPORT A 55 year old smoker male presented to the our outpatient clinic in 2004 with complaints of gradual onset increase in the size of hands and feet, bilateral knee pain, increased sweating and blurring of vision. Investigations uncovered diabetes mellitus by a casual blood glucose of 243 mg/dl and HbA1c of 8.5%. Growth hormone suppression test using 75 gram oral glucose showed a 60 minute growth hormone of 105 ng/ml. Magnetic resonance imaging of the sellar region showed a 12.0 mm × 10.0 mm pituitary adenoma. The patient was planned for transsphenoidal tumor decompression. However, the patient was lost to follow up. Eight-years later, he presented in the emergency department of our institute with sudden onset headache, vomiting and decreased level of consciousness of one day duration. CT scan of the head with focus on the sella was suggestive of apoplexy which was later confirmed by the MRI of the sellar region. CONCLUSION Although acromegaly can remit following apoplexy of the responsible pituitary adenoma, long term follow up is needed for early detection of the development of deficiency of pituitary hormones which may occur over years following the event as well as to detect tumor regrowth which again may occur several years later.
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Affiliation(s)
- Shahnaz Ahmad Mir
- Department of Endocrinology, Sheri-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Shariq Rashid Masoodi
- Department of Endocrinology, Sheri-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Mir Iftikhar Bashir
- Department of Endocrinology, Sheri-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Arshad Iqbal Wani
- Department of Endocrinology, Sheri-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Khalid Jamal Farooqui
- Department of Endocrinology, Sheri-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Basharat Kanth
- Department of Neurosurgery, Sheri-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Abdul Rashid Bhat
- Department of Neurosurgery, Sheri-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
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A case of acromegaly complicated with diabetic ketoacidosis, pituitary apoplexy, and lymphoma. Kaohsiung J Med Sci 2013; 29:687-90. [PMID: 24296058 DOI: 10.1016/j.kjms.2013.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/08/2012] [Indexed: 11/22/2022] Open
Abstract
Acromegaly is always complicated with comorbidities and increased mortality. The disease activity and mortality outcomes are highly correlated to the level of growth hormone and insulin-like growth factor 1. A variety of clinical manifestations of acromegaly have been reported. We present a unique case where a 49-year-old male was diagnosed with acromegaly with a first manifestation as an episode of diabetic ketoacidosis. Because he refused any suggestion of treatment, a recurrent episode of diabetic ketoacidosis with pituitary apoplexy occurred. A huge B-cell lymphoma displaying as a huge facial mass followed within 1 year of the diagnosis of acromegaly. Death from advanced cancer ensued 3 years later. This clinical experience strongly reinforces the urgency of controlling growth hormone and insulin-like growth factor 1 as soon as possible once acromegaly is diagnosed.
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69
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Hojo M, Goto M, Miyamoto S. Chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy. Surg Neurol Int 2013; 4:41. [PMID: 23607063 PMCID: PMC3622356 DOI: 10.4103/2152-7806.109654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 03/05/2013] [Indexed: 11/19/2022] Open
Abstract
Background: Enlargement of intracerebral hematoma without rebleeding in chronic phase is a rare but well-known clinical condition, and is well-described as chronic expanding intracerebral hematoma. However, chronic enlargement of pituitary hematoma without rebleeding after pituitary apoplexy is extremely rare. Case Description: We report a case of chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy. A 29-year-old male presented with sudden onset of headache and vomiting. Magnetic resonance imaging (MRI) demonstrated a pituitary mass lesion with hematoma, consistent with pituitary apoplexy. Neuro-ophthalmological examination revealed no visual field defect, and endocrinological evaluations showed an elevated prolactin level. Pituitary apoplexy due to a prolactinoma was the most likely diagnosis. He was conservatively treated because he exhibited no visual disturbance. Three weeks after the onset, he gradually began to complain of blurred vision and neuro-ophthalamological examination revealed bitemporal upper quadrant hemianopsia. MRI showed enlargement of the pituitary hematoma without any finding suggestive of rebleeding. This enlarged mass lesion compressed the chiasm. The patient was operated on via transsphenoidal approach. After dural opening, xanthochromic fluid spouted out, but no fresh clot could be detected within the cyst. After the operation, the visual field disturbance resolved completely. The possible mechanism of hematoma enlargement is considered to be expansion due to the serum exudation from capillaries of the hematoma capsule. This pathogenetic mechanism is common in enlargement of chronic subdural hematoma. Conclusions: This case is the first report of chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy.
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Affiliation(s)
- Masato Hojo
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
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70
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Abstract
Intracerebral hemorrhage (ICH) remains a life-threatening disease that carries significant morbidity and mortality despite recent diagnostic and management advances. Various conditions are associated with increased risk of intracerebral hemorrhage. Understanding the etiology of these conditions and their pathophysiological contribution to ICH will likely lead to better therapeutic and preventative measures and improve the morbidity and mortality associated with intracerebral hemorrhage. We will review the current literature regarding important etiologies/risk factors of intracerebral hemorrhage.
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71
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Kim E. A Rathke's Cleft Cyst Presenting with Apoplexy. J Korean Neurosurg Soc 2012; 52:404-6. [PMID: 23133732 PMCID: PMC3488652 DOI: 10.3340/jkns.2012.52.4.404] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 09/15/2012] [Accepted: 10/10/2012] [Indexed: 11/27/2022] Open
Abstract
The occurrence of symptomatic pituitary hemorrhage into a Rathke's cleft cyst (RCC) is extremely rare. The author reports an interesting case of intra- and suprasellar RCC presented with features of pituitary apoplexy. This 62-year-old woman suffered acute headache, mental confusion, and partial hypopituitarism. The characteristics of the magnetic resonance imaging seemed most compatible with a hemorrhagic pituitary adenoma. Transsphenoidal drainage of the cyst contents confirmed the diagnosis of hemorrhagic RCC and resolved the symptoms. All published data on this rare clinical entity are extracted and reviewed.
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Affiliation(s)
- Ealmaan Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea
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72
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Fraser CL, Biousse V, Newman NJ. Visual outcomes after treatment of pituitary adenomas. Neurosurg Clin N Am 2012; 23:607-19. [PMID: 23040747 DOI: 10.1016/j.nec.2012.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Pituitary adenomas frequently manifest with neuro-ophthalmic symptoms and signs. The location of the pituitary gland makes involvement of both the visual pathways and the ocular motor cranial nerves likely when there is adenomatous expansion. A sudden expression of visual loss or diplopia commonly accompanies pituitary apoplexy. Several preoperative neuro-ophthalmic indicators help predict posttreatment outcomes and help determine the best intervention. Treatments themselves may also cause neuro-ophthalmic complications. The current literature and avenues of future research are reviewed.
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Affiliation(s)
- Clare Louise Fraser
- Department of Neuro-Ophthalmology, Emory Eye Center, Emory University School of Medicine, Emory University, Atlanta, GA 30322, USA
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Antonopoulou M, Sharma R, Farag A, Banerji MA, Karam JG. Hypopituitarism in the elderly. Maturitas 2012; 72:277-85. [PMID: 22727068 DOI: 10.1016/j.maturitas.2012.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 05/06/2012] [Indexed: 11/25/2022]
Abstract
Pituitary dysfunction in elderly can represent a true diagnostic and therapeutic challenge to clinicians caring for these patients. Symptoms associated with partial or total hypopituitarism, such as fatigue, lower muscle strength and decreased libido, are nonspecific and can be often attributed to normal aging. Gold standard pituitary diagnostic testing carries higher risks in elderly and is classically replaced by alternative testing. Furthermore, the benefits and safety of selective pituitary hormonal replacement, specifically sexual and growth hormone replacement, remain subject of controversy in this group of patients. Recognizing and appropriately treating hypopituitarism in elderly is crucial for the survival and well being of the older patients with this disease.
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74
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Gradual onset of left-sided temporal headache and ptosis. JAAPA 2012; 25:63-4. [DOI: 10.1097/01720610-201204000-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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75
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Ferreira-González L, Trigás-Ferrín M, Rubin EP, Sesma P. Pituitary apoplexy after myocardial perfusion scintigraphy. ACTA ACUST UNITED AC 2012; 59:606-8. [PMID: 22424596 DOI: 10.1016/j.endonu.2011.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 12/22/2011] [Accepted: 12/23/2011] [Indexed: 10/28/2022]
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76
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Diagnosis and minimally invasive surgery for the pituitary abscess: a review of twenty nine cases. Clin Neurol Neurosurg 2012; 114:957-61. [PMID: 22402201 DOI: 10.1016/j.clineuro.2012.02.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Revised: 12/24/2011] [Accepted: 02/12/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to better determine the salient signs and symptoms for diagnosis of a pituitary abscess as well as the determination of the most appropriate treatment. METHODS A retrospective analysis was performed using clinical presentations, imaging features, diagnosis and treatment of 29 patients with pituitary abscess in our hospital. RESULTS We made the correct diagnosis of pituitary abscess before surgery only in 2 cases (13.3%) out of 15 patients between January 2004 and January 2008. While 12 cases (85.7%) out of 14 patients were correctly diagnosed before surgery between January 2008 and June 2010. All of the patients underwent transnasal-transsphenoidal surgery assisted by the microscope or endoscope. The antibiotic therapy and hormonal replacement were routinely administrated. The postoperative courses were uneventful and all symptoms of the patients were gradually improved one week to six months after surgery. None of the 29 cases were recurrent during the follow-up. CONCLUSION With the increased clinical experience, the correct diagnosis rate of pituitary abscess before surgery has been greatly improved in recent three years. The microsurgical drainage, proper antibiotics and hormonal replacement are the keys to the treatment of pituitary abscess.
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Lee JS, Park YS, Kwon JT, Nam TK, Lee TJ, Kim JK. Radiological apoplexy and its correlation with acute clinical presentation, angiogenesis and tumor microvascular density in pituitary adenomas. J Korean Neurosurg Soc 2011; 50:281-7. [PMID: 22200007 DOI: 10.3340/jkns.2011.50.4.281] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 07/26/2011] [Accepted: 10/17/2011] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Pituitary apoplexy is life-threatening clinical syndrome caused by the rapid enlargement of a pituitary tumor due to hemorrhage and/or infarction. The pathogenesis of pituitary apoplexy is not completely understood. We analyzed the magnetic resonance imaging (MRI) of pituitary tumors and subsequently correlated the radiological findings with the clinical presentation. Additionally, immunohistochemistry was also performed to determine whether certain biomarkers are related to radiological apoplexy. METHODS Thirty-four cases of pituitary adenoma were enrolled for retrospective analysis. In this study, the radiological apoplexy was defined as cases where hemorrhage, infarction or cysts were identified on MRI. Acute clinical presentation was defined as the presence of any of the following symptoms: severe sudden onset headache, decreased visual acuity and/or visual field deficit, and acute mental status changes. Angiogenesis was quantified by immunohistochemical expression of fetal liver kinase 1 (Flk-1), neuropilin (NRP) and vascular endothelial growth factor (VEGF) expression, while microvascular density (MVD) was assessed using Endoglin and CD31. RESULTS Clinically, fourteen patients presented with acute symptoms and 20 for mild or none clinical symptoms. Radiologically, fifteen patients met the criteria for radiological apoplexy. Of the fifteen patients with radiologic apoplexy, 9 patients presented acute symptoms whereas of the 19 patient without radiologic apoplexy, 5 patients presented acute symptoms. Of the five biomarkers tracked, only VEGF was found to be positively correlated with both radiological and nonradiological apoplexy. CONCLUSION While pituitary apoplexy is currently defined in cases where clinical symptoms can be histologically confirmed, we contend that cases of radiologically identified pituitary hemorrhages that present with mild or no symptoms should be designated subacute or subclinical apoplexy. VEGF is believed to have a positive correlation with pituitary hemorrhage. Considering the high rate of symptomatic or asymptomatic pituitary tumor hemorrhage, additional studies are needed to detect predictors of the pituitary hemorrhage.
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Affiliation(s)
- Jung-Sup Lee
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
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78
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Abstract
Pituitary apoplexy is rare endocrine emergency which can occur due to infarction or haemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. There is conflicting data regarding which type of pituitary adenoma is prone for apoplexy. Some studies showed predominance of non-functional adenomas while some other studies showed a higher prevalence in functioning adenomas amongst which prolactinoma have the highest risk. Although pituitary apoplexy can occur without any precipitating factor in most cases, there are some well recognizable risk factors such as hypertension, medications, major surgeries, coagulopathies either primary or following medications or infection, head injury, radiation or dynamic testing of the pituitary. Patients usually present with headache, vomiting, altered sensorium, visual defect and/or endocrine dysfunction. Hemodynamic instability may be result from adrenocorticotrophic hormone deficiency. Imaging with either CT scan or MRI should be performed in suspected cases. Intravenous fluid and hydrocortisone should be administered after collection of sample for baseline hormonal evaluation. Earlier studies used to advocate urgent decompression of the lesion but more recent studies favor conservative approach for most cases with surgery reserved for those with deteriorating level of consciousness or increasing visual defect. The visual and endocrine outcomes are almost similar with either surgery or conservative management. Once the acute phase is over, patient should be re-evaluated for hormonal deficiencies.
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Affiliation(s)
- Salam Ranabir
- Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Manash P. Baruah
- Department of Endocrinology, Excel Center, Guwahati, Assam, India
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Valle Feijoo ML, Fernández Fernández FJ, Muñoz López F, de la Fuente Aguado J. [Pituitary apoplexy due to macroadenoma bleeding]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2011; 58:317-318. [PMID: 21497570 DOI: 10.1016/j.endonu.2011.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 01/26/2011] [Accepted: 01/27/2011] [Indexed: 05/30/2023]
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Endoscopic Surgical Treatment for Pituitary Apoplexy in Three Elderly Patients over the Age of 80. INTRACEREBRAL HEMORRHAGE RESEARCH 2011; 111:429-33. [DOI: 10.1007/978-3-7091-0693-8_74] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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