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Kajal S, Ahmad YES, Halawi A, Gol MAK, Ashley W. Pituitary apoplexy: a systematic review of non-gestational risk factors. Pituitary 2024; 27:320-334. [PMID: 38935252 DOI: 10.1007/s11102-024-01412-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Pregnancy is a known risk factor for Pituitary Apoplexy (PA) but there is a lack of consistency in the literature regarding non-gestational risk factors responsible for PA. METHODS We did a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify the non-gestational risk factors associated with the development of PA in adult patients with pituitary adenoma. Also, we discuss here a case of an elderly female with pituitary macroadenoma who was initially planned for pituitary resection electively but underwent emergency surgery after she developed PA. RESULTS As per screening and eligibility criteria, seven studies with 4937 study participants were included in this systematic review out of which 490 (9.92%) patients had PA, including asymptomatic subclinical PA (SPA) and symptomatic clinical PA (CPA). The macroadenomas and negative staining of the tumor were found to be a significant risk factor consistently in multivariate analysis in three and two retrospective studies, respectively. However, the results were varied for any significant difference in the risk factors for apoplexy between SPA and CPA. Similarly, there was no consistency among the studies for risk factors significantly responsible for CPA or PA compared to controls. CONCLUSION No single non-gestational risk factor is solely responsible for the development of PA in a pituitary adenoma compared to the control population. Tumor size (macroadenoma) and the non-functioning status of the adenoma are the only significant factors contributing independently toward an apoplectic event in most patients. Such patients can be prioritized for early pituitary tumor resection.
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Affiliation(s)
- Smile Kajal
- MedStar Health Union Memorial Hospital, Baltimore, MD, 21218, USA.
| | | | - Akaber Halawi
- MedStar Health Union Memorial Hospital, Baltimore, MD, 21218, USA
- LifeBridge Health Sinai Hospital, Baltimore, MD, 21215, USA
- Maryland ENT Center, Baltimore, MD, 21218, USA
| | - Mohammad Abraham Kazemizadeh Gol
- MedStar Health Union Memorial Hospital, Baltimore, MD, 21218, USA
- LifeBridge Health Sinai Hospital, Baltimore, MD, 21215, USA
- Maryland ENT Center, Baltimore, MD, 21218, USA
| | - William Ashley
- LifeBridge Health Sinai Hospital, Baltimore, MD, 21215, USA
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Yildiz Y, Lauber A, Char NV, Bozinov O, Neidert MC, Hostettler IC. Subarachnoid hemorrhage due to pituitary adenoma apoplexy-case report and review of the literature. Neurol Sci 2024; 45:997-1005. [PMID: 37872321 DOI: 10.1007/s10072-023-07130-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/07/2023] [Indexed: 10/25/2023]
Abstract
Pituitary apoplexy (PA) may be complicated by development of subarachnoid hemorrhage (SAH). We conducted a literature review to evaluate the rate of PA-associated tumor rupture and SAH. We conducted a systematic literature search (PubMed, Web of Science, Medline) for patients with PA-associated SAH and report a case SAH following PA. Suitable articles, case series, and case reports were selected based on predefined criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). We reviewed included publications for clinical, radiological, surgical, and histopathological parameters.We present the case of a patient with PA developing extensive SAH whilst on the MRI who underwent delayed transsphenoidal resection. According to our literature review, we found 55 patients with a median age of 46 years; 18 (32.7%) were female. Factors associated with PA-related SAH were hypertension, diabetes mellitus, prior trauma, anticoagulant, and/or antiplatelet therapy. The most common presenting symptoms included severe headache, nausea and/or vomiting, impaired consciousness, and meningeal irritation. Acute onset was described in almost all patients. Twenty-two of the included patients underwent resection. In patients with available outcome, 45.1% had a favorable outcome, 10 (19.6%) had persisting focal neurological deficits, 7 developed cerebral vasospasms (12.7%), and 18 (35.3%) died. Mortality greatly differed between surgically (9.1%) and non-surgically (44.8%) treated patients. PA-associated SAH is a rare condition developing predominantly in males with previously unknown macroadenomas. Timely surgery often prevents aggravation or development of severe neuro-ophthalmological defects and improves clinical outcome.
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Affiliation(s)
- Yesim Yildiz
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Arno Lauber
- Department of Neuroradiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Natalia Velez Char
- Department of Neuropathology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Isabel Charlotte Hostettler
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland.
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Nabulsi O, Abouelleil M, Lyons L, Walsh M, Singer J. Immune Thrombocytopenic Purpura Presenting with Pituitary Apoplexy: A Case Report and Literature Review. J Neurol Surg Rep 2023; 84:e61-e64. [PMID: 37213415 PMCID: PMC10195162 DOI: 10.1055/a-2072-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 01/26/2023] [Indexed: 05/23/2023] Open
Abstract
Background Pituitary apoplexy is a rare condition that usually occurs in the setting of a pituitary adenoma. It can present with symptoms of visual disturbances, vertigo, headache, and neurological impairments. Computed tomography (CT) scans can aid in identifying pituitary apoplexy and ruling out other diseases. We present a unique case of pituitary apoplexy in the setting of immune thrombocytopenic purpura (ITP). Case Description A 61-year-old man with a past medical history significant for myocardial infarction presented to the emergency department with symptoms of diplopia and headache 36 hours after onset. The patient was found to have severe thrombocytopenia with a platelet count below 20,000. A CT of the head revealed a possible pituitary adenoma with compression of the optic chiasm. The patient's platelet count continued to decrease throughout his admission and dropped below 7,000 on day 2 of admission. The patient was given platelet transfusion along with intravenous immunoglobulins. The patient underwent endoscopic transsphenoidal resection of the pituitary mass. Pathology of the mass revealed immature platelets characteristic of immune ITP in the setting of pituitary apoplexy. Conclusion While ITP in the setting of pituitary apoplexy is a rare entity, we believe that clinicians should have pituitary apoplexy on their differential diagnosis in patients with ITP.
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Affiliation(s)
- Omar Nabulsi
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
- Address for correspondence Omar Nabulsi, BA Department of NeurosurgerySpectrum Health, 25 Michigan St. NE, Grand Rapids, MI 49503-2560United States
| | - Mohamed Abouelleil
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
| | - Leah Lyons
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
| | - Meggen Walsh
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
| | - Justin Singer
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
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Pituitary apoplexy in the setting of double umbilical cord hematopoietic cell transplant and pancytopenia: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Ambrose C, Sarma S, Banerjee R, Myers S. Pituitary apoplexy and associated cranial nerve palsies secondary to bleeding caused by immune thrombocytopaenia in a patient with known pituitary macroadenoma. BMJ Case Rep 2021; 14:14/5/e240105. [PMID: 34059534 DOI: 10.1136/bcr-2020-240105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An 84-year-old man presented with a frontal headache and easy bruising. He had a background history of a pituitary macroadenoma, diagnosed incidentally a year earlier. Investigations showed haemorrhage into the pituitary macroadenoma leading to a diagnosis of pituitary apoplexy in the context of low platelet count secondary to immune thrombocytopaenia. He was treated with intravenous hydrocortisone, platelet transfusion, intravenous immunoglobulin and high-dose steroid. Neurosurgical intervention was not indicated initially. Five days into his admission, he developed bilateral ptosis and ophthalmoplegia. MRI confirmed further haemorrhage associated with compression of the optic chiasm. He was transferred to a tertiary neurosurgical centre where he underwent urgent surgical decompression. To date, there has been minor improvement in his neurological symptoms. Management of this patient required considerable multidisciplinary teamwork between the clinics of endocrinology, haematology, neurosurgery, ophthalmology and geriatrics.
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Affiliation(s)
- Christopher Ambrose
- Department of Medicine for the Elderly, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - Sruthi Sarma
- Department of Medicine for the Elderly, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - Ritwick Banerjee
- Department of Diabetes and Endocrinology, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - Sam Myers
- Department of Medicine for the Elderly, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
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Maki Y, Kurosaki Y, Uchino K, Ishibashi R, Chin M, Yamagata S. Pituitary Apoplexy in Long-Term Cabergoline User During Thrombocytopenia Due to Chemotherapy for Chronic Myelocytic Leukemia. World Neurosurg 2018; 120:290-295. [PMID: 30189305 DOI: 10.1016/j.wneu.2018.08.187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pituitary apoplexy (PA) is a life-threatening syndrome. The usage of a dopamine agonist, such as bromocriptine or cabergoline, is considered a predisposing factor for PA, which commonly occurs 1.5 years within commencement. CASE DESCRIPTION A 64-year-old female with a >15-year history of cabergoline therapy for pituitary prolactinoma was referred to our department of neurosurgery after complaining of headache, blurred vision, diplopia, and ptosis for 3 days during hospital admission for chemotherapy of chronic myelocytic leukemia. Computed tomography and magnetic resonance imaging revealed findings indicative of PA. As the patient was experiencing thrombocytopenia related to chemotherapy, blood transfusion was preceded, and after a platelet count of 15.0 × 104/μL was confirmed, transnasal neuroendoscopic surgery was performed 5 days from the onset of symptoms. The majority of the prolactinoma was removed, and the prolactinoma in the cavernous sinus was intentionally left. The postoperative course was generally good. The ptosis and diplopia improved, and the blurred vision resolved. CONCLUSIONS PA related to dopamine agonist therapy can occur in cases of elevated bleeding tendency, even in long-term users, suggesting that attention should be paid in the administration of a dopamine agonist in the patient experiencing thrombocytopenia. Surgical intervention should be performed after the preoperative platelet number and adequate response to transfusion are confirmed, and the aggressive removal of prolactinoma in the cavernous sinus should be avoided to reduce the risk of hemorrhagic complications.
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Affiliation(s)
- Yoshinori Maki
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan.
| | | | - Kaori Uchino
- Department of Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Ryota Ishibashi
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
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Tan SK, Seow CJ, Tan E, Chau YP, Dalan R. Pituitary apoplexy secondary to thrombocytopenia due to dengue hemorrhagic fever: a case report and review of the literature. Endocr Pract 2016; 20:e58-64. [PMID: 24325998 DOI: 10.4158/ep13319.cr] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present a case of pituitary apoplexy secondary to thrombocytopenia associated with dengue hemorrhagic fever (DHF). METHODS In this case study, we review the presentation, evaluation, diagnosis, and management of a case of pituitary apoplexy in the setting of DHF. We also searched the literature for cases of pituitary apoplexy associated with thrombocytopenia and review their clinical presentation, management, and outcome. RESULTS A 53-year-old man presented with fever, lethargy, and worsening headache. Routine investigations revealed thrombocytopenia secondary to dengue fever. He developed symptoms of a cavernous sinus lesion the next day. Urgent magnetic resonance imaging revealed pituitary apoplexy in a pituitary macroadenoma. A transsphenoidal surgery was done and histology was consistent with apoplexy in a prolactin/follicle-stimulating hormone macroadenoma. Subsequently, the patient developed permanent deficits of anterior pituitary hormones. We review 8 other cases of pituitary apoplexy associated with thrombocytopenia reported in the literature. CONCLUSION Thrombocytopenia due to various causes may be a predisposing factor for pituitary apoplexy in a patient with underlying pituitary disease. In view of the tendency for bleeding associated with thrombocytopenia, the risks of surgical intervention have to be carefully weighed against the potential benefits. Indications for surgery would include progressive alteration of consciousness, visual disturbances, and opthalmoplegia despite conservative management. Patients with underlying pituitary macroadenomas with optic chiasm compression have a worse prognosis, and the chances of recovery, even with early surgery, are limited.
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Affiliation(s)
| | | | - Eberta Tan
- Department of Endocrinology Changi General Hospital, Tan Tock Seng Hospital
| | | | - Rinkoo Dalan
- Yong Loo Lin School of Medicine, DUKE-NUS Graduate Medical School, National University Singapore
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Giammattei L, Mantovani G, Carrabba G, Ferrero S, Di Cristofori A, Verrua E, Guastella C, Pignataro L, Rampini P, Minichiello M, Locatelli M. Pituitary apoplexy: considerations on a single center experience and review of the literature. J Endocrinol Invest 2016; 39:739-46. [PMID: 26733212 DOI: 10.1007/s40618-015-0424-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 12/11/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE To present a single-center experience on pituitary tumor apoplexy and a review of literature focusing on predisposing and precipitating factors. METHODS Clinical presentation of our series of cases. Contemporary published literature is also reviewed. RESULTS The definition of this syndrome has not been consistent although now the majority of authors agree to definite it as an acute condition caused by hemorrhage or infarction of a pre-existing pituitary adenoma. Different predisposing and precipitating factors have been described in literature; among these antithrombotic and anticoagulant drugs, seem to play relevant roles. The clinical cases observed in our clinic confirm these data and suggest a probable association between elderly patients taking anticoagulant therapy and pituitary apoplexy adenoma. CONCLUSION Pituitary tumor apoplexy remains a challenging disease in relation to difficulties in correct diagnosis and thus in appropriate treatment. Antithrombotic/anticoagulant therapy may have an important role as precipitating factor. When a pituitary disorder is known, great care should be taken in the prescription of anticoagulant therapy.
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Affiliation(s)
- L Giammattei
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy
| | - G Mantovani
- Unit of Endocrinology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - G Carrabba
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - S Ferrero
- Unit of Pathology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - A Di Cristofori
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy
| | - E Verrua
- Unit of Endocrinology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Guastella
- Unit of Otolaringology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - L Pignataro
- Unit of Otolaringology - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - P Rampini
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Minichiello
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy.
| | - M Locatelli
- Unit of Neurosurgery - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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9
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Abstract
Pituitary apoplexy, a rare clinical syndrome secondary to abrupt hemorrhage or infarction, complicates 2%-12% of pituitary adenomas, especially nonfunctioning tumors. Headache of sudden and severe onset is the main symptom, sometimes associated with visual disturbances or ocular palsy. Signs of meningeal irritation or altered consciousness may complicate the diagnosis. Precipitating factors (increase in intracranial pressure, arterial hypertension, major surgery, anticoagulant therapy or dynamic testing, etc) may be identified. Corticotropic deficiency with adrenal insufficiency may be life threatening if left untreated. Computed tomography or magnetic resonance imaging confirms the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. Formerly considered a neurosurgical emergency, pituitary apoplexy always used to be treated surgically. Nowadays, conservative management is increasingly used in selected patients (those without important visual acuity or field defects and with normal consciousness), because successive publications give converging evidence that a wait-and-see approach may also provide excellent outcomes in terms of oculomotor palsy, pituitary function and subsequent tumor growth. However, it must be kept in mind that studies comparing surgical approach and conservative management were retrospective and not controlled.
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Affiliation(s)
- Claire Briet
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Sylvie Salenave
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Jean-François Bonneville
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Edward R Laws
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Philippe Chanson
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
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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: 33] [Impact Index Per Article: 3.7] [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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Barvalia U, Eliades M, Melhem L. Concomitant Pituitary Apoplexy and Acute Fatty Liver of Pregnancy Complicated With Disseminated Intravascular Coagulation. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14436.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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12
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Kruljac I, Cerina V, Pećina HI, Pažanin L, Matić T, Božikov V, Vrkljan M. Pituitary metastasis presenting as ischemic pituitary apoplexy following heparin-induced thrombocytopenia. Endocr Pathol 2012; 23:264-7. [PMID: 23129546 DOI: 10.1007/s12022-012-9224-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pituitary apoplexy (PA) typically results from infarction or hemorrhage in a pituitary adenoma, while PA in nonadenomatous pituitary gland is uncommon. Prothrombotic states have never been recognized as precipitating factors for PA. The authors report a case of an elderly female who received prophylactic fractionated heparin therapy due to sepsis, consequent rhabdomyolysis, and overt disseminated intravascular coagulation. On the seventh day of heparin therapy, she reported sudden vision loss, ptosis, diplopia, and severe headache. Severe thrombocytopenia and positive antibodies to the complex of platelet factor 4 and heparin confirmed heparin-induced thrombocytopenia type 2 (HIT). Magnetic resonance imaging disclosed a homogenous pituitary tumor mass with pronounced sphenoid sinus mucosa thickening and two hypointense zones within the tumor mass on contrast-enhanced images consistent with focal ischemic necrosis. The tumor was confirmed to be squamous cell carcinoma with no signs of necrosis. Ischemic necrosis was found within marginal pituitary tissue. This is the first reported case of ischemic PA associated with pituitary metastasis and the first case in which HIT triggered PA. Our case demonstrates that prothrombotic states such as HIT can precipitate ischemic PA. Pituitary metastasis can present with ischemic PA, but radiological features differ from those described in pituitary adenomas. Segregated low-signal intensity zones within the tumor mass on postcontrast images indicate partial infarction of the tumor, which could be a special feature of ischemic PA in pituitary metastasis and has never been described in pituitary adenomas. These are all novel findings and might enlighten the pathogenesis of PA.
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Affiliation(s)
- Ivan Kruljac
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", University of Zagreb Medical School, Zagreb, Croatia.
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Leyer C, Castinetti F, Morange I, Gueydan M, Oliver C, Conte-Devolx B, Dufour H, Brue T. A conservative management is preferable in milder forms of pituitary tumor apoplexy. J Endocrinol Invest 2011; 34:502-9. [PMID: 20811169 DOI: 10.3275/7241] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Our objective was to report a single-center experience of the management of pituitary tumor apoplexy. PATIENTS AND METHODS We retrospectively analyzed a series of 44 patients hospitalized for pituitary apoplexy between January 1996 and March 2008 at the Timone Hospital, Marseille, France. RESULTS Most frequent presenting symptoms were headaches (93%), visual impairment (85%) and vomiting (59%). Hypopituitarism was present at diagnosis in 88% of patients, with a high incidence of corticotroph deficiency (70%). A risk factor was found in 52% of patients, mostly hypertension. Apoplexy occurred in a previously undiagnosed pituitary adenoma in 32/44 cases (73%). The apoplectic event concerned 12 secreting, 27 non-functioning, 4 uncharacterized adenomas and one Rathke's pouch cyst. Nineteen patients underwent surgery within the first month, and one patient had conventional radiotherapy. Twenty-four patients, who had no ophthalmic or neurological signs, were conservatively treated in first intention; among them, 6 received high dose corticosteroids. After a median follow-up of 21 months, there was no significant difference in terms of endocrine or visual recovery between the operated and the conservatively treated groups, nor between patients treated with corticosteroids or not. Panhypopituitarism was observed in 52% of patients, but partial or complete visual recovery was present in the majority of patients (91%), whatever the therapeutic approach. CONCLUSION The outcome of patients treated with or without surgery for pituitary apoplexy without severe neuro-ophthalmic deficits seems to be identical, pleading for a conservative management of pituitary apoplexy in the absence of visual emergency.
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Affiliation(s)
- C Leyer
- Department of Endocrinology, Timone Hospital, 204, Rue Saint-Pierre, 13385 Marseille Cedex 05, France
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Serramito-García R, García-Allut A, Arcos-Algaba A, Castro-Bouzas D, Santín-Amo J, Gelabert-González M. Apoplejía pituitaria. Revisión del tema. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70005-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rajasekaran S, Vanderpump M, Baldeweg S, Drake W, Reddy N, Lanyon M, Markey A, Plant G, Powell M, Sinha S, Wass J. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol (Oxf) 2011; 74:9-20. [PMID: 21044119 DOI: 10.1111/j.1365-2265.2010.03913.x] [Citation(s) in RCA: 214] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Classical pituitary apoplexy is a medical emergency and rapid replacement with hydrocortisone maybe life saving. It is a clinical syndrome characterized by the sudden onset of headache, vomiting, visual impairment and decreased consciousness caused by haemorrhage and/or infarction of the pituitary gland. It is associated with the sudden onset of headache accompanied or not by neurological symptoms involving the second, third, fourth and sixth cranial nerves. If diagnosed patients should be referred to a multidisciplinary team comprising, amongst others, a neurosurgeon and an endocrinologist. Apart from patients with worsening neurological symptoms in whom surgery is indicated, it is unclear currently for the majority of patients whether conservative or surgical management carries the best outcome. Post apoplexy, there needs to be careful monitoring for recurrence of tumour growth. It is suggested that further trials be carried out into the management of pituitary apoplexy to optimize treatment.
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Carolei A, Sacco S. Headache attributed to arteritis, cerebral venous thrombosis, and other vascular intracranial disturbances. HANDBOOK OF CLINICAL NEUROLOGY 2010; 97:529-540. [PMID: 20816454 DOI: 10.1016/s0072-9752(10)97048-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Headache with variable characteristics and associated signs and symptoms may occur in all forms of arteritis. Giant cell arteritis, one of the most common forms, involves branches of the external and, more rarely, of the internal carotid arteries. It occurs in patients over the age of 50 and is characterized by fever, new-onset headache, prominence and tenderness of the temporal artery, claudication of the masticatory muscles on chewing, amaurosis fugax, and visual loss. Headache is the initial symptom in 48% of patients and is present in 90%. Primary central nervous system angiitis is a rare and highly fatal disease in which headache is one of the most frequent symptoms despite the fact that, given its non-specific characteristics, it is of little diagnostic relevance. Headache may also be attributed to several secondary central nervous system arteritides such as Behçet's disease, Takayasu disease, polyarteritis nodosa, Kawasaki disease, Wegener's granulomatosis, systemic lupus erythematosus, and vasculitits caused by viruses, bacteria, fungi, rickettsiae, and protozoa. Thrombosis of the cerebral veins and sinuses is a distinct cerebrovascular disorder that, unlike arterial stroke, most often affects young adults and children. Headache is the most frequent but least specific symptom of venous sinus thrombosis, being present in more than 90% of patients. Headache can also be attributed to other vascular intracranial disorders such as cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), benign (or reversible) angiopathy of the central nervous system, and pituitary apoplexy.
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Affiliation(s)
- Antonio Carolei
- Department of Neurology, University of L'Aquila, L'Aquila, Italy.
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Semple PL, Jane JA, Laws ER. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosurgery 2008; 61:956-61; discussion 961-2. [PMID: 18091272 DOI: 10.1227/01.neu.0000303191.57178.2a] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The pathogenesis of pituitary apoplexy and the role of precipitating factors in pituitary apoplexy are poorly understood. Most of the published cases are in the form of case reports. We assessed the presumed precipitating factors in a series of patients treated surgically for pituitary apoplexy and reviewed the contemporary published literature. METHOD Thirty-eight consecutive patients with pituitary apoplexy were treated surgically by the Department of Neurosurgery at the University of Virginia, Charlottesville, VA, between January 1996 and March 2006. Their medical records were retrospectively reviewed. Contemporary published cases from 1990 to 2006 were also reviewed. RESULTS Nine patients (24%) were identified as having precipitating factors for pituitary apoplexy. The factors identified were coronary artery surgery (two patients), other major surgery (two patients), pregnancy (two patients), gamma knife irradiation, anticoagulant therapy, and coagulopathy secondary to liver failure. The presentation, histology, and outcome were compared between those patients with a precipitating factor and those in whom none was identified. A review of the published literature showed that coronary artery surgery, pituitary stimulation, and coagulopathy were the most common precipitating factors. CONCLUSION A minority of patients with pituitary apoplexy will have precipitating factors. The majority of patients with precipitating factors will have histopathology showing hemorrhagic infarction or hemorrhage. The most common precipitating factors are pituitary stimulation, surgery, particularly coronary artery surgery, and coagulopathy. Caution in doing endocrine investigation, surgery, or anticoagulation in patients with a known pituitary tumor is advised. Patients with no diagnosed pituitary tumor but with a known precipitating factor who have neuro-ophthalmological deterioration or endocrine failure should undergo prompt magnetic resonance image scans and endocrine investigation and endocrine replacement as indicated.
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Affiliation(s)
- Patrick L Semple
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
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Balarini Lima GA, Machado EDO, Dos Santos Silva CM, Filho PN, Gadelha MR. Pituitary apoplexy during treatment of cystic macroprolactinomas with cabergoline. Pituitary 2008; 11:287-92. [PMID: 17570067 DOI: 10.1007/s11102-007-0046-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pituitary apoplexy is a rare and life-threatening clinical condition caused by hemorrhage and/or infarction of the pituitary gland or adenoma. Although pituitary apoplexy is usually spontaneous, it has been associated with numerous precipitating factors, such as bromocriptine use. However, reports of pituitary apoplexy during cabergoline therapy are scarce. We report three patients with cystic macroprolactinomas who developed pituitary apoplexy during cabergoline treatment.
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Affiliation(s)
- Giovanna Aparecida Balarini Lima
- Division of Endocrinology, Clementino Fraga Filho University Hospital/Federal University of Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, no. 255, Cidade Universitária - Ilha do Fundão, Rio de Janeiro, RJ, Brazil
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