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Fleseriu M, Christ-Crain M, Langlois F, Gadelha M, Melmed S. Hypopituitarism. Lancet 2024; 403:2632-2648. [PMID: 38735295 DOI: 10.1016/s0140-6736(24)00342-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 05/14/2024]
Abstract
Partial or complete deficiency of anterior or posterior pituitary hormone production leads to central hypoadrenalism, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency, or arginine vasopressin deficiency depending on the hormones affected. Hypopituitarism is rare and likely to be underdiagnosed, with an unknown but rising incidence and prevalence. The most common cause is compressive growth or ablation of a pituitary or hypothalamic mass. Less common causes include genetic mutations, hypophysitis (especially in the context of cancer immunotherapy), infiltrative and infectious disease, and traumatic brain injury. Clinical features vary with timing of onset, cause, and number of pituitary axes disrupted. Diagnosis requires measurement of basal circulating hormone concentrations and confirmatory hormone stimulation testing as needed. Treatment is aimed at replacement of deficient hormones. Increased mortality might persist despite treatment, particularly in younger patients, females, and those with arginine vasopressin deficiency. Patients with complex diagnoses, pregnant patients, and adolescent pituitary-deficient patients transitioning to adulthood should ideally be managed at a pituitary tumour centre of excellence.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health and Science University, Portland, OR, USA; Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, USA; Pituitary Center, Oregon Health and Science University, Portland, OR, USA.
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l'Estrie, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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2
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Garcia-Feijoo P, Perez Lopez C, Paredes I, Acitores Cancela A, Alvarez-Escola C, Calatayud M, Lagares A, Librizzi MS, Rodriguez Berrocal V, Araujo-Castro M. Exploring risk factors of severe pituitary apoplexy: Insights from a multicenter study of 71 cases. Endocrine 2024:10.1007/s12020-024-03918-w. [PMID: 38850439 DOI: 10.1007/s12020-024-03918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE To identify clinical and radiological factors associated with a higher risk of developing a severe pituitary apoplexy (PA). METHODS Multicenter retrospective study of patients presenting with clinical PA in three Spanish tertiary hospitals of Madrid between 2008 and 2022. We classified PA as severe when presenting with an altered level of consciousness (Glasgow Coma Scale (GCS) < 15) or visual involvement. RESULTS A total of 71 PA cases were identified, of whom 80.28% (n = 57) were classified as severe PA. The median age was 60 (18 to 85 years old) and 67.6% (n = 48) were male. Most patients had macroadenomas, except for one patient with a microadenoma of 9 mm. Headache was the most common presenting symptom (90.1%) and anticoagulation was the most frequent predisposing risk factor, but it was not associated with a higher risk for severe PA (odds ratio [OR] 1.13 [0.21-5.90]). Severe cases were associated with male gender (OR 5.53 [1.59-19.27]), tumor size >20 mm (OR 17.67 [4.07-76.64]), and Knosp grade ≥2 (OR 9.6 [2.38-38.73]). In the multivariant analysis, the only variables associated with a higher risk for severe PA were tumor size and Knosp grade. Surgery was more common in severe PA than in non-severe (91.2% vs. 64.3%, P = 0.009). CONCLUSION A tumor size >20 mm and cavernous sinus invasion are risk factors for developing a severe PA. These risk factors can stratify patients at a higher risk of a worse clinical picture, and subsequently, more need of decompressive surgery.
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Affiliation(s)
| | - Carlos Perez Lopez
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, Hospital Universitario Doce de Octubre, Facultad de Medicina, Departamento de Cirugía, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | | | - Maria Calatayud
- Department of Endocrinology & Nutrition, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Hospital Universitario Doce de Octubre, Facultad de Medicina, Departamento de Cirugía, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Maria Soledad Librizzi
- Department of Endocrinology & Nutrition, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Victor Rodriguez Berrocal
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Neurosurgery, Hospital Universitario Puerta del Sur, Madrid, Spain
| | - Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal. Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
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Whyte E, Nezu M, Chik C, Tateno T. Update on Current Evidence for the Diagnosis and Management of Nonfunctioning Pituitary Neuroendocrine Tumors. Endocrinol Metab (Seoul) 2023; 38:631-654. [PMID: 37964483 PMCID: PMC10764990 DOI: 10.3803/enm.2023.1838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/29/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023] Open
Abstract
Pituitary neuroendocrine tumors (PitNETs) are the third most frequently diagnosed intracranial tumors, with nonfunctioning PitNETs (nfPitNETs) accounting for 30% of all pituitary tumors and representing the most common type of macroPitNETs. NfPitNETs are usually benign tumors with no evidence of hormone oversecretion except for hyperprolactinemia secondary to pituitary stalk compression. Due to this, they do not typically present with clinical syndromes like acromegaly, Cushing's disease or hyperthyroidism and instead are identified incidentally on imaging or from symptoms of mass effects (headache, vision changes, apoplexy). With the lack of effective medical interventions, first-line treatment is transsphenoidal surgical resection, however, nfPitNETs often have supra- or parasellar extension, and total resection of the tumor is often not possible, resulting in residual tumor regrowth or reoccurrence. While functional PitNETs can be easily followed for recurrence using hormonal biomarkers, there is no similar parameter to predict recurrence in nfPitNETs, hence delaying early recognition and timely management. Therefore, there is a need to identify prognostic biomarkers that can be used for patient surveillance and as therapeutic targets. This review focuses on summarizing the current evidence on nfPitNETs, with a special focus on potential new biomarkers and therapeutics.
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Affiliation(s)
- Elizabeth Whyte
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Masahiro Nezu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Constance Chik
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Toru Tateno
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Yamamuro S, Yoshino A, Nishide T, Negishi H, Kumagawa T. A case report of pituitary neuroendocrine tumor manifesting as severe conjunctival chemosis. BMC Ophthalmol 2023; 23:479. [PMID: 37993825 PMCID: PMC10666417 DOI: 10.1186/s12886-023-03224-5] [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: 07/23/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Conjunctival chemosis (CC) is an extremely rare symptom of pituitary neuroendocrine tumor (PitNET). We report an extremely rare case of PitNET manifesting as severe CC. CASE PRESENTATION A 48-year-old male was admitted to our hospital with severe CC, proptosis, and ptosis of the right eye. Magnetic resonance imaging demonstrated the tumor mass invading the cavernous sinus (CS) with cystic lesion. The patient underwent emergent endoscopic transsphenoidal surgery, and the pathological diagnosis was PitNET. CC of the right eye remarkably improved after the surgery. Glucocorticoid therapy was performed for right oculomotor nerve palsy, which rapidly improved. The postoperative course was uneventful and the patient was discharged from our hospital without hormone replacement. CONCLUSIONS CC caused by CS invasion of PitNET can be cured by early surgical treatment. Therefore, PitNET is important to consider in the differential diagnosis of CC.
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Affiliation(s)
- Shun Yamamuro
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan.
| | - Atsuo Yoshino
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Takuma Nishide
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Hiroshi Negishi
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Takahiro Kumagawa
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
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Wu J, Li S, Huang Y, Zeng Z, Mei T, Wang S, Wang W, Zhang F. MRI features of pituitary adenoma apoplexy and their relationship with hypoxia, proliferation, and pathology. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023. [PMID: 37235536 DOI: 10.1002/jcu.23492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/20/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE We aim to study the MRI features of pituitary adenoma (PA) apoplexy and their relationship with hypoxia, proliferation, and pathology. METHODS Sixty-seven patients with MRI signs of PA apoplexy were selected. According to the MRI signs, they were divided into the parenchymal group and the cystic group. The parenchymal group had a low signal area on T2WI without cyst >2 mm and this area was not significantly enhanced on the corresponding TW1 enhancement. The cystic group had a cyst >2 mm on T2WI, and the cyst showed liquid stratification on T2WI or high signal on T1WI. The relative T1WI (rT1WI) enhancement value and relative T2WI (rT2WI) value of non-apoplexy areas were measured. Protein levels of hypoxia-inducible factor-1 (HIF-1α), pyruvate dehydrogenase kinase 1 (PDK1), and Ki67 were detected with immunohistochemistry and Western blot. Nuclear morphology was observed with HE staining. RESULTS The rT1WI enhancement average value, rT2WI average value, Ki67 protein expression level, and the number of abnormal nuclear morphology of non-apoplexy lesions in the parenchymal group were significantly lower than those in the cystic group. The protein expression levels of HIF-1α and PDK1 in the parenchymal group were significantly higher than those in the cystic group. HIF-1α protein was positively correlated with PDK1 but negatively correlated with Ki67. CONCLUSION When there is PA apoplexy, the ischemia and hypoxia of the cystic group are lesser than those of the parenchymal group, but the proliferation is stronger.
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Affiliation(s)
- Jianwu Wu
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Songyuan Li
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Yinxing Huang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Zihuan Zeng
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Tao Mei
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen, People's Republic of China
| | - Shousen Wang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Wei Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Fangfang Zhang
- Department of Endocrinology, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, People's Republic of China
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Gheorghe AM, Trandafir AI, Stanciu M, Popa FL, Nistor C, Carsote M. Challenges of Pituitary Apoplexy in Pregnancy. J Clin Med 2023; 12:jcm12103416. [PMID: 37240522 DOI: 10.3390/jcm12103416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012-December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal-fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample-case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal-fetal outcomes from multidisciplinary insights.
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Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra-Ioana Trandafir
- Department of Endocrinology, Doctoral School of "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 50169 Sibiu, Romania
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy & Thoracic Surgery Department, "Dr. Carol Davila" Central Emergency University Military Hospital, 013058 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, "Carol Davila" University of Medicine and Pharmacy & "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
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Fatigue and Its Contributing Factors in Chinese Patients with Primary Pituitary Adenomas. JOURNAL OF ONCOLOGY 2023; 2023:9876422. [PMID: 36968639 PMCID: PMC10033214 DOI: 10.1155/2023/9876422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/05/2022] [Accepted: 01/29/2023] [Indexed: 03/17/2023]
Abstract
Background. Pituitary adenomas (PAs) refers to a group of benign tumors that develop in the pituitary gland and are often characterized by fatigue. However, fatigue has not been documented in any Chinese research involving people with primary PA. The study sought to examine the prevalence, predictors, and correlation of fatigue with the quality of life (QoL) among PA patients in China. Methods. In total, 203 primary PA patients were included in this cross-sectional study. A series of questionnaires were administered, including the Multidimensional Fatigue Inventory (MFI), M. D. Anderson Symptom Inventory Brain Tumor (MDASI-BT), Short-Form 36 Health Survey (SF-36), Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS). Data analysis was accomplished by Pearson or Spearman correlations, linear regression, and simple path analysis. Results. Severe fatigue prior to the initial diagnosis and preparation for surgery affected 50% of PA patients. Depression, sleep disturbance, and MDASI-BT symptom total scores were independently able to predict patient fatigue. Sleep disturbance mediates the influence of depression on fatigue (IE sleep = 0.296, 95% CI: LB = 0.148 to UB = 0.471). Conclusions. Chinese patients with primary PA often report experiencing fatigue. Depression and poor sleep quality were shown to be significant contributors to PA patients’ fatigue. Depression affects PA patients’ fatigue directly or indirectly. Medical professionals should take a proactive approach to PA patients suffering from fatigue before initial diagnosis and preoperative preparation to determine necessary interventions early, thus reducing fatigue and ultimately enhancing their QoL.
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Sharifi G, Ohadi MAD, Abedi M, Khajavi M, Shahjouei S, Moradi A, Bahranian A, Dilmaghani NA. Surgical anatomic findings of sphenoid sinus in 1009 Iranian patients with pituitary adenoma undergoing endoscopic transsphenoidal surgery. Eur Arch Otorhinolaryngol 2023; 280:2985-2991. [PMID: 36705727 DOI: 10.1007/s00405-022-07818-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/28/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The most common surgical technique for the management of pituitary adenomas is the endoscopic endonasal transsphenoidal approach (EEA). preoperative neuroimaging along with detecting surgical landmarks of the sphenoid sinus during surgery is important for making a successful operation. METHOD This study includes 1009 patients with pituitary adenomas who underwent EEA between 2013 and 2020. We evaluated the anatomical features of the sphenoid sinus through a panel of items obtained from imaging and intra-operative findings. RESULTS Our result includes 57.38% nonfunctional, 8.42% cushing, 12.39% prolactinoma, and 21.8% acromegaly patients who had undergone endoscopic endonasal transsphenoidal surgery. The mean age of the patients was 45 with a male to female ratio of 1.2:1. Sellar sphenoid type was the most common (91.8%) with only 12% symmetrical inter sphenoid septa, Internal carotid artery dehiscence was found in 1.7% of the cases. Apoplexy was present in 6.3% of patients, which was found more prevalent in nonfunctional adenomas (9.67%, Odds ratio: 4.85, 95% CI 2.24-11.79) and further investigation revealed a significant association between apoplexy and sphenoid mucosal edema and hemorrhage (Odds ratio: 43.0, 95% CI 22.50-84.26), and between apoplexy and cystic lesions (OR = 4.14, 95% CI 1.87-8.45, P-value < 0.0001). Acromegaly is associated with the increased number of lateral recces (Odds ratio: 11.41, 95% CI 7.54-17.52), septation of the sphenoid sinus (Marginal mean: 3.92, 95% CI 3.69-4.14), edematous sinonasal mucosa (Odds ratio: 6.7; 95% CI 4.46-10.08), and higher bony (OR: 4.81, 95% CI 2.60-8.97, P-value < 0.001) and cavernous (OR: 1.7, 95% CI 1.13-2.46, P-value < 0.01) invasion. CONCLUSION The present study provides anatomical data about the sphenoid sinus and its adjacent vital structures with adenomal specific changes that are necessary to prevent complications during endoscopic advanced transsphenoidal surgery.
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Affiliation(s)
- Guive Sharifi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Dabbagh Ohadi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abedi
- Department of Otolaryngology, Head and Neck Surgery, Loghman Hakim Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahdi Khajavi
- Department of Otolaryngology, Head and Neck Surgery, Loghman Hakim Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shima Shahjouei
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Alireza Moradi
- Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arefe Bahranian
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nader Akbari Dilmaghani
- Department of Otolaryngology, Head and Neck Surgery, Skull Base Research Center, Loghman Hakim Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Liu J, Huang P, Zhang X, Chen Y, Zheng X, Shen R, Tang X, Yang H, Li S. Differences in Clinical Characteristics and Surgical Outcomes of Patients with Ischemic and Hemorrhagic Pituitary Adenomas. J Korean Neurosurg Soc 2023; 66:72-81. [PMID: 36625014 PMCID: PMC9837490 DOI: 10.3340/jkns.2022.0071] [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: 04/06/2022] [Accepted: 07/19/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Ischemia and hemorrhage of pituitary adenomas (PA) caused important clinical syndrome. However, the differences on clinical characteristics and surgical outcomes between these two kinds apoplexy were less reported. METHODS A retrospective analysis was made of patients with pituitary apoplexy between January 2013 and June 2018. Baseline and clinical characteristics before surgery were reviewed. All patients underwent transsphenoidal surgery and were followed up at least 1 year. RESULTS Total 67 cases (5.8%) among 1147 pituitary tumor patients were enrolled, which consisted of 28 (~2.4%) ischemic PA and 39 (~3.4%) hemorrhagic PA. There were more male patients in the ischemic group compared with hemorrhagic group (78.6% vs 53.8%, p=0.043). However, the mean age, tumor size and functional tumor ratio were significant higher in the hemorrhagic group. Headache was more common in ischemic PA (82.1%) than that of hemorrhagic PA (51.3%, p=0.011). Magnetic resonance imaging findings found that mucosal thickening and enhancement of the sphenoid sinus was observed in 15 ischemic PA patients (n=27, 55.6%), but none in patients with hemorrhagic PA (n=38, p<0.0001). It was worth noting that the rate of pre-surgical hypopituitarism in ischemic PA patients were seemed higher than that in hemorrhagic PA patients, but not significant. The two groups got a total tumor resection rate at 94.1% and 92.9%, independently. No significant difference on the operative time, blood loss in operation and complications in perioperative period was observed in two groups. After operation, cranial nerve symptoms recovered to normal at 81.8% of ischemic PA patients and 82.6% of hemorrhagic PA patients. Importantly, the incidence of postoperative hypopituitarism partially decreased in both groups, among which the rate of hypothyroidism in ischemic PA patients significantly decreased from 46.4% to 18.5% (p=0.044). CONCLUSION Patients with ischemic PA presented different clinical characteristics to the hemorrhagic ones. Transsphenoidal surgery should be considered for the patients with neuro-ophthalmic deficits and might benefit for pituitary function recovery of the apoplectic adenoma patients, especially pituitary thyroid axis in ischemic PA patients.
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Affiliation(s)
- Jingpeng Liu
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Peng Huang
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Xiaoqing Zhang
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Yong Chen
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Xin Zheng
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Rufei Shen
- Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Department of Endocrinology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xuefeng Tang
- Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Department of Pathology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hui Yang
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Address for correspondence : Hui Yang Department of Neurosurgery, Xinqiao Hospital, Army Medical University, 183th Xinqiao Main Street, Shapingba District, Chongqing 400037, China Tel : +86-02368763513, Fax : +86-02368763513, E-mail :
| | - Song Li
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Address for correspondence : Hui Yang Department of Neurosurgery, Xinqiao Hospital, Army Medical University, 183th Xinqiao Main Street, Shapingba District, Chongqing 400037, China Tel : +86-02368763513, Fax : +86-02368763513, E-mail :
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10
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Popov D, Hadzhiyanev A. Pituitary apoplexy associated with COVID-19 infection: review and a case report. BIOTECHNOL BIOTEC EQ 2022. [DOI: 10.1080/13102818.2022.2051738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Deyan Popov
- Neurosurgery Department, University Hospital “St. Ivan Rilski,” Medical University of Sofia, Sofia, Bulgaria
| | - Asen Hadzhiyanev
- Neurosurgery Department, University Hospital “St. Ivan Rilski,” Medical University of Sofia, Sofia, Bulgaria
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11
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Donegan D, Erickson D. Revisiting Pituitary Apoplexy. J Endocr Soc 2022; 6:bvac113. [PMID: 35928242 PMCID: PMC9342855 DOI: 10.1210/jendso/bvac113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Pituitary apoplexy (PA) is a rare clinical syndrome due to pituitary hemorrhage or infarction. It is characterized by the sudden onset of one or more of the following: severe headache, visual disturbance, nausea/vomiting, and or altered mental status. Most commonly, PA occurs in an underlying pituitary adenoma. The pathophysiology is not fully understood, but it is thought to involve elements of increased metabolic demand and/or compromise to the vasculature of the pituitary or pituitary tumor. Several risk factors have been described. Stabilization of the patient on presentation, replacement of hormonal deficiencies, and reversal of electrolyte abnormalities are the recommended initial steps in the management of patients with PA. Surgical decompression of the mass effect had been the recommended treatment for patients with PA; however, retrospective studies of patients with PA have demonstrated similar outcomes when a conservative approach is applied. This suggests that in highly selected clinical scenarios (mild visual deficit and improving symptoms), conservative management is possible. Further studies, however, are necessary to better stratify patients but are limited by the rarity of the condition and the acuity.
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Affiliation(s)
- Diane Donegan
- Division of Endocrinology, Diabetes and Metabolism, Indiana University , Indianapolis, Indiana 46220 , USA
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic Minnesota , Rochester, Minnesota 55905 , USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic Minnesota , Rochester, Minnesota 55905 , USA
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12
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Puglisi V, Morini E, Biasini F, Vinciguerra L, Lanza G, Bramanti P. Neurological Presentation of Giant Pituitary Tumour Apoplexy: Case Report and Literature Review of a Rare but Life-Threatening Condition. J Clin Med 2022; 11:jcm11061581. [PMID: 35329907 PMCID: PMC8953299 DOI: 10.3390/jcm11061581] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/11/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Giant pituitary adenomas are benign intracranial tumours with a diameter ≥4 cm. Even if hormonally non-functional, they may still cause local extension, leading to symptoms that include mostly gland dysfunction, mass effects, and, much less frequently, apoplexy due to haemorrhage or infarction. Neurological presentation of giant pituitary tumour apoplexy is even more rare and has not been systematically reviewed. Case Presentation: An 81-year-old woman was admitted to the Emergency Department because of acute onset headache, bilateral visual deficit, and altered consciousness. Computed tomography showed a giant mass lesion (>5.5 cm diameter) expanding upward to the suprasellar cistern, optic chiasm, and third ventricle, over-running the sphenoid sinus, and with lateral invasion of the cavernous sinus. Laboratory investigations revealed central adrenal and hypothyroidism insufficiency, while magnetic resonance imaging confirmed a voluminous suprasellar tumour (~6 cm diameter), with signs of pituitary tumour apoplexy. Neurological manifestations and gland-related deficits improved after hormonal replacement therapy with a high dose of intravenous hydrocortisone, followed by oral hydrocortisone and levo-thyroxine. The patient declined surgical treatment and follow-up visit. Conclusions: Giant pituitary tumour apoplexy is a rare but potentially life-threatening condition. Prompt diagnosis and multidisciplinary management may allow a remarkable clinical improvement, as seen in this case.
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Affiliation(s)
- Valentina Puglisi
- Department of Neurology and Stroke Unit, Istituti Ospitalieri, ASST Cremona, Viale Concordia 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Elisabetta Morini
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (E.M.); (P.B.)
| | - Fiammetta Biasini
- Unit of Neurology and Neuromuscular Diseases, Policlinico University Hospital “G. Martino”, Via Consolare Valeria 1-2, 98124 Messina, Italy;
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, Istituti Ospitalieri, ASST Cremona, Viale Concordia 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018 Troina, Italy
- Correspondence: ; Tel.: +39-095-3782448
| | - Placido Bramanti
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (E.M.); (P.B.)
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13
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Abstract
The epidemiology of male hypogonadism has been understudied. Of the known causes of endogenous androgen deficiency, only Klinefelter syndrome is common with a likely population prevalence of greater than 5:10,000 men (possibly as high as 10-25:10,000). Mild traumatic injury might also be a common cause of androgen deficiency (prevalence 5-10:10,000 men), but large, long-term studies must be completed to confirm this prevalence estimation that might be too high. The classic causes of male androgen deficiency-hyperprolactinemia, pituitary macroadenoma, endogenous Cushing syndrome, and iron overload syndrome-are rare (prevalence < 10,000 men).
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Affiliation(s)
- Arthi Thirumalai
- Department of Medicine, University of Washington School of Medicine, Box 356420, 1959 Northeast Pacific Avenue, Seattle, WA 98195, USA
| | - Bradley D Anawalt
- Department of Medicine, University of Washington School of Medicine, Box 356420, 1959 Northeast Pacific Avenue, Seattle, WA 98195, USA.
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14
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Taneja C, Fazeli PK, Gardner PA, Wang EW, Snyderman CH, Mahmud H. Rapidly Progressive Pituitary Apoplexy in a Patient with COVID-19 Disease Treated with Endoscopic Endonasal Surgery. J Neurol Surg Rep 2022; 83:e8-e12. [PMID: 35028278 PMCID: PMC8747894 DOI: 10.1055/s-0041-1742104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 09/20/2021] [Indexed: 01/06/2023] Open
Abstract
This report describes a case of pituitary apoplexy with rapidly evolving hemorrhage in a 74-year-old female with coronavirus disease 2019 (COVID-19) disease. The patient presented with severe headache and mild respiratory symptoms, with laboratories concerning for pituitary hypofunction. Brain imaging demonstrated a sellar mass concerning for a pituitary adenoma with ischemic apoplexy. She subsequently developed visual deficits within 24 hours of presentation, and repeat imaging demonstrated evolving hemorrhage and new mass effect on the optic chiasm. She was successfully managed with urgent endoscopic endonasal surgery despite her COVID-19 positive status by taking special intraoperative precautions to mitigate SARS-CoV2 transmission risk. Only a handful of cases of pituitary apoplexy have been reported in association with COVID-19 disease, and even fewer reports exist of endonasal procedures in such cases. We discuss the potential implication of COVID-19 in the occurrence of pituitary apoplexy, in addition to the safety and success of endonasal surgery in this population.
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Affiliation(s)
- Charit Taneja
- Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Pouneh K Fazeli
- Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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15
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Drissi Oudghiri M, Motaib I, Elamari S, Laidi S, Chadli A. Pituitary Apoplexy in Geriatric Patients: A Report of Four Cases. Cureus 2021; 13:e20318. [PMID: 35028217 PMCID: PMC8748001 DOI: 10.7759/cureus.20318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/18/2022] Open
Abstract
Pituitary apoplexy (PA) is a rare clinical syndrome related to abrupt hemorrhage and/or infarction of the pituitary gland, usually occurring in patients with preexisting pituitary disease. It is an endocrine emergency requiring rapid diagnosis and appropriate management. This is a literature review and a retrospective study reporting the observation of four patients that have suffered from pituitary macroadenomas. These observations illustrate the particularities of this pathology in the elderly. The symptoms may be truncated and lead to a late diagnosis with its repercussions on management, without forgetting the particularity of the fragile and multisystemic terrain, which may contraindicate the usual surgical treatment. A rapid diagnosis and appropriate management can limit the occurrence of irreversible complications.
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16
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Lamback EB, Wildemberg LE, Gadelha MR. Current opinion on the diagnosis and management of non-functioning pituitary adenomas. Expert Rev Endocrinol Metab 2021; 16:309-320. [PMID: 34678108 DOI: 10.1080/17446651.2021.1988851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/30/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Non-functioning pituitary adenomas (NFPAs) are clinically silent tumors and the second most common pituitary adenoma. Surgery is the mainstay of treatment as there is, as yet, no effective medical treatment. AREAS COVERED We present current knowledge on the clinical diagnosis, histopathological classification, molecular data, and management strategies in NFPA. EXPERT OPINION NFPA is a heterogeneous group of tumors, in respect to their origin and clinical course. In recent years, research on pathology and molecular biology have advanced our knowledge of NFPA pathogenesis. NFPA exhibit, in the majority of cases, an indolent behavior, with satisfactory response to treatment. In aggressive cases, multimodal management is needed; however, even this approach may be insufficient, so the development of new treatments is warranted for better management. In this setting, the understanding of the mechanisms involved in the genesis and progression of NFPA is crucial for the identification and development of directed treatments with higher chances of response.
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Affiliation(s)
- Elisa B Lamback
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio De Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual Do Cérebro Paulo Niemeyer, Rio De Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual Do Cérebro Paulo Niemeyer, Rio De Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio De Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual Do Cérebro Paulo Niemeyer, Rio De Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual Do Cérebro Paulo Niemeyer, Rio De Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio De Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual Do Cérebro Paulo Niemeyer, Rio De Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual Do Cérebro Paulo Niemeyer, Rio De Janeiro, Brazil
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17
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Wildemberg LE, Fialho C, Gadelha MR. Prolactinomas. Presse Med 2021; 50:104080. [PMID: 34687915 DOI: 10.1016/j.lpm.2021.104080] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 08/31/2021] [Accepted: 10/12/2021] [Indexed: 12/28/2022] Open
Abstract
Hyperprolactinemia, defined by a level of serum prolactin above the standard upper limit of normal range, is a common finding in clinical practice and prolactinomas are the main pathological cause. Prolactinomas lead to signs and symptoms of hormone oversecretion, such as galactorrhea and hypogonadism, as well as symptoms of mass effect, including visual impairment, headaches and intracranial hypertension. Diagnosis involves prolactin measurement and sellar imaging, but several pitfalls are involved in this evaluation, which may difficult the proper management. Treatment is medical in the majority of cases, consisting of dopamine agonists, which present high response rates, with a very favorable safety profile. Major adverse effects that should be monitored consist of cardiac valvulopathy and impulse control disorders. Other treatment options include surgery and radiotherapy. Temozolomide may be used for aggressive or malignant carcinomas. Finally, pregnancy outcomes are similar to general population even when dopamine agonist treatment is maintained.
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Affiliation(s)
- Luiz Eduardo Wildemberg
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Christhiane Fialho
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica R Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
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18
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Guarda FJ, Yu X, Shiraliyeva N, Haines MS, Bradbury M, Saylor PJ, Nachtigall LB. GnRH agonist-associated pituitary apoplexy: a case series and review of the literature. Pituitary 2021; 24:681-689. [PMID: 33835355 DOI: 10.1007/s11102-021-01143-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To examine the clinical presentation and longitudinal outcome of Pituitary Apoplexy (PA) after gonadotropin-releasing hormone agonist (GnRHa) in a series of patients and compare to prior reports. METHODS A retrospective chart review was performed on seven patients receiving GnRHa who developed PA. Prior reported cases were analyzed. RESULTS Six men (median age 72 years) with prostate cancer and one woman (aged 22 years) undergoing oocyte donation presented with PA between 1990 and 2020. Most presented with within 24 h of the first dose, but two developed PA 1 to 5 months after GnRHa initiation. The main clinical manifestations were headache (100%), nausea and vomiting (86%). While no patients had a previously known pituitary tumor, all had imaging demonstrating sellar mass and/or hemorrhage at presentation. Among those surgically treated (5/7), 80% (4/5) of patients had pathologic specimens that stained positive for gonadotropins; the remaining patient's pathologic specimen was necrotic. At the time of PA, the most common pituitary dysfunction was hypocortisolism. Central adrenal insufficiency and central hypothyroidism were reversible in a subset. Pituitary imaging remained stable. CONCLUSIONS This is the first report of a case series with PA after GnRHa administration with longitudinal follow-up. Although infrequent, PA can be life-threatening and should be suspected among patients receiving GnRHa, with or without a known pituitary adenoma, who develop acute headache, nausea and/or vomiting. Since hypopituitarism was reversible in a subset, ongoing pituitary function testing may be indicated.
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Affiliation(s)
- Francisco J Guarda
- Department of Endocrinology and Center for Translational Endocrinology (CETREN-UC), School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Pituitary Tumor Program. Red de Salud UC-CHRISTUS, Santiago, Chile
| | - Xiaoling Yu
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA
| | - Naila Shiraliyeva
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA
| | - Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA
| | - Michael Bradbury
- Department of Ophthalmology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Philip J Saylor
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lisa B Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA.
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19
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Sowka JW, Wu TH. Case Report: Polyneuropathy Pituitary Apoplexy with Normal Perimetry and Initially Normal Neuroimaging. Optom Vis Sci 2021; 98:1139-1142. [PMID: 34629437 DOI: 10.1097/opx.0000000000001786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SIGNIFICANCE Pituitary apoplexy is a syndrome with a varied appearance, which carries a significant risk of morbidity and mortality. It is important to recognize the potential numerous symptoms and clinical findings, urgently investigate with the proper neuroimaging tests, and coordinate care with the appropriate specialists without delay. PURPOSE This study aimed to describe a patient with worsening headache and ophthalmoparesis attributable to pituitary apoplexy who initially had reportedly a normal neuroimaging result and were diagnosed with migraine. CASE REPORT A 39-year-old Hispanic man with a history of migraine developed a new and worsening headache. He presented to a hospital emergency department where he underwent a non-contrast-enhanced computed tomography and MRI, whose results were subsequently interpreted as normal. His headache was attributed to migraine, and he was medicated as such and discharged. Three days later, he developed horizontal and vertical diplopia and sought a second opinion. His visual acuity and visual fields were normal. He manifested a right pupil-sparing, external partial cranial nerve III palsy and concurrent right sixth nerve palsy. He also complained of worsening headache and lethargy. He was immediately referred for contrast-enhanced MRI and magnetic resonance angiography with suspicion of pituitary apoplexy. Subsequent imaging revealed a hemorrhagic pituitary macroadenoma consistent with pituitary apoplexy that was expanding laterally into the right cavernous sinus. He underwent immediate neurosurgical surgical repair. CONCLUSIONS New or worsening headache with signs and symptoms of hypopituitarism should immediately be investigated for pituitary apoplexy. Other possible findings include involvement of cranial nerves III through VI because of cavernous sinus involvement and visual deficits if the optic chiasm or intracranial portion of the optic nerve is involved. However, growth may be lateral, and no visual deficits may be found, as in this case. Multiple concurrent cranial neuropathies should increase suspicion for cavernous sinus involvement.
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Affiliation(s)
| | - Tsung-Hao Wu
- Marciano Family Optometric, West Palm Beach, Florida
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20
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Sun, MD Z, Cai, MD X, Li, MD Y, Shao, MD D, Jiang, PhD Z. Endoscopic Endonasal Transsphenoidal Approach for the Surgical Treatment of Pituitary Apoplexy and Clinical Outcomes. Technol Cancer Res Treat 2021; 20:15330338211043032. [PMID: 34486456 PMCID: PMC8422825 DOI: 10.1177/15330338211043032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: This study investigated the clinical manifestations, surgical method, and treatment outcomes of patients with pituitary apoplexy and evaluated the safety and effectiveness of the endoscopic endonasal transsphenoidal approach in the treatment of pituitary adenomas. Patients and methods: In this retrospective study, were analyzed the data of patients with symptomatic pituitary apoplexy who received surgical treatment by endoscopic endonasal transsphenoidal approach from January 2017 to June 2020 at the Department of Neurosurgery of the First Affiliated Hospital of Bengbu Medical College. Patients were followed up through outpatient visits and telephone interviews. Results: Data for 24 patients including 13 males and 11 females with an average age of 46.46 years were analyzed. Headache (83.33%) and visual disturbances (75.00%) were the most common preoperative manifestations. In the 24 patients, 21 (87.50%) tumors were completely removed and 3 (12.50%) were partly removed. Intractable headache improved in all patients over a mean follow-up time of 25.16 months, and postoperative improvement in visual acuity was achieved in 17 of 18 patients (94.44%) with vision defects. Four patients (16.67%) experienced transient urinary collapse after the operation. No intracranial infection, carotid artery injury, or death occurred. Conclusion: The endoscopic endonasal transsphenoidal approach is a safe and effective method for the treatment of pituitary apoplexy.
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Affiliation(s)
- Zhixiang Sun, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Xintao Cai, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yu Li, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Dongqi Shao, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Zhiquan Jiang, PhD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Zhiquan Jiang, Department of Neurosurgery, First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Road, Bengbu, Anhui 233004, China.
Email
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21
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Fialho C, Barbosa MÁ, Lima CHA, Wildemberg LEA, Gadelha MR, Kasuki L. Apoplexy in sporadic pituitary adenomas: a single referral center experience and AIP mutation analysis. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:295-304. [PMID: 33909377 PMCID: PMC10065329 DOI: 10.20945/2359-3997000000358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations. Methods The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced. Results Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort. Conclusion Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.
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Affiliation(s)
- Christhiane Fialho
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Monique Álvares Barbosa
- Unidade de Radiologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Carlos Henrique Azeredo Lima
- Laboratório de Neuropatologia e Genética Molecular, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Luiz Eduardo Armondi Wildemberg
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Mônica R Gadelha
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.,Laboratório de Neuropatologia e Genética Molecular, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Leandro Kasuki
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil, .,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil.,Seção de Endocrinologia, Hospital Federal de Bonsucesso, Rio de Janeiro, RJ, Brasil
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22
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Prodam F, Caputo M, Mele C, Marzullo P, Aimaretti G. Insights into non-classic and emerging causes of hypopituitarism. Nat Rev Endocrinol 2021; 17:114-129. [PMID: 33247226 DOI: 10.1038/s41574-020-00437-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/11/2022]
Abstract
Hypopituitarism is defined as one or more partial or complete pituitary hormone deficiencies, which are related to the anterior and/or posterior gland and can have an onset in childhood or adulthood. The most common aetiology is a sellar or suprasellar lesion, often an adenoma, which causes hypopituitarism due to tumour mass effects, or the effects of surgery and/or radiation therapy. However, other clinical conditions, such as traumatic brain injury, and autoimmune and inflammatory diseases, can result in hypopituitarism, and there are also genetic causes of hypopituitarism. Furthermore, the use of immune checkpoint inhibitors to treat cancer is increasing the risk of hypopituitarism, with a pattern of hormone defects that is different from the classic patterns and depends on mechanisms that are specific for each drug. Moreover, autoantibody production against the pituitary and hypothalamus has been demonstrated in studies investigating the development or worsening of some cases of hypopituitarism. Finally, evidence suggests that posterior pituitary damage can affect oxytocin secretion. The aim of this Review is to summarize current knowledge on non-classic and emerging causes of hypopituitarism, so as to help clinicians improve early identification, avoid life-threatening events and improve the clinical care and quality of life of patients at risk of hypopituitarism.
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Affiliation(s)
- Flavia Prodam
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Marina Caputo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Chiara Mele
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Paolo Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Division of General Medicine, I.R.C.C.S. Istituto Auxologico Italiano, Ospedale San Giuseppe, Verbania, Italy
| | - Gianluca Aimaretti
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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Falhammar H, Tornvall S, Höybye C. Pituitary Apoplexy: A Retrospective Study of 33 Cases From a Single Center. Front Endocrinol (Lausanne) 2021; 12:656950. [PMID: 33935971 PMCID: PMC8082680 DOI: 10.3389/fendo.2021.656950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/24/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Acute symptomatic pituitary apoplexy is a rare and potentially life-threatening condition. However, pituitary apoplexy can also present with milder symptoms and stable hemodynamics. Due to the rarity of this inhomogeneous condition, clinical studies are important to increase the knowledge. METHODS We retrospectively reviewed all consecutive cases of pituitary apoplexy being admitted between January 1st, 2005 and December 31st, 2019 at the Karolinska University Hospital, Stockholm, Sweden, for symptoms, results of magnetic resonance (MRI), biochemistry, management and mortality. RESULTS Thirty-three patients were identified with pituitary apoplexy, 18 were men (55%) and mean age was 46.5 (17.2) years. The incidence of symptomatic pituitary apoplexy was 1.6 patients/year (0.76 patients/1,000,000 inhabitants/year). The majority presented with headache (n=27, 82%) and hormonal deficiencies (n=18, 55%), which were most frequent in men. ACTH deficiency was present in nine patients (27% but 50% of those with hormonal deficiencies). All had the characteristic findings on MRI. Only three patients (9%) required acute pituitary surgery, while eight were operated after more than one week. Seven (21%) were on antithrombotic therapy. None of the patients died in the acute course. During follow-up (7.6 ± 4.3 years) none of the hormonal deficiencies regressed and 3 patients died from non-related causes. CONCLUSION Our study confirmed the rarity and the symptoms of this condition. Surprisingly, only 3 patients needed acute neurosurgical intervention, perhaps due to milder cases and a general intensified treatment of precipitating factors. An early awareness and in severe cases decision on pituitary surgery is of utmost importance to avoid severe complications.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Sofia Tornvall
- Department of Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Charlotte Höybye
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- *Correspondence: Charlotte Höybye,
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Lamback EB, Guterres A, Barbosa MA, Lima CHDA, Silva DA, Camacho AHDS, Chimelli L, Kasuki L, Gadelha MR. Cyclin A in nonfunctioning pituitary adenomas. Endocrine 2020; 70:380-387. [PMID: 32621052 DOI: 10.1007/s12020-020-02402-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Assess cyclin A in nonfunctioning pituitary adenomas (NFPA) and compare its expression in non-invasive and non-proliferative tumors with invasive and proliferative tumors (12× higher risk of recurrence). METHODS Quantitative real time polymerase chain reaction to analyze cyclin A using normal pituitary gland as reference. Fold change (FC) > 1 was considered as increased. Tumor invasion was based on Knosp criteria (grades 3-4 considered invasive) and proliferation on the presence of at least two of three criteria: Ki-67 ≥ 3%; mitoses > 2/10; positive p53. Both groups were compared with Mann-Whitney test considering p value < 0.05 as statistically significant. RESULTS Thirty-one patients with NFPA were included. Tumors were mainly of gonadotrophic origin (74.2%), followed by corticotrophic (19.4%) and lactotrophic (3.2%) origins and null-cell adenomas (3.2%). Median tumor diameter was 3.5 cm (1.8-8.0) and Ki-67 was 3.0% (0.3-11%). Sixteen patients had tumors classified as non-invasive and non-proliferative and 15 as invasive and proliferative. Median FC was 0.31 in all tumors (0.13-1.94). Cyclin A was not related to invasion or proliferation (FC 0.41 in non-invasive and non-proliferative tumors and FC 0.30 in invasive and proliferative tumors; p = 0.968). Four (12.9%) patients had tumors that exhibited increased cyclin A [median FC of 1.04 (1.02-1.94)]-three of gonadotrophic origin and one null-cell adenoma, with two tumors classified as non-invasive and non-proliferative and two tumors classified as invasive and proliferative. Median tumor diameter in these samples was 3.4 cm (2.4-3.6) and Ki-67 was 5.1% (2-11%). CONCLUSIONS Cyclin A was increased in a minority of NFPA and does not seem to be related to invasion or proliferation.
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Affiliation(s)
- Elisa B Lamback
- Neuroendocrinology Research Center/ Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alexandro Guterres
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | | | - Debora Aparecida Silva
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Aline Helen da Silva Camacho
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Pathology Division, Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | - Leila Chimelli
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center/ Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Endocrinology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/ Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
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Siwakoti K, Omay SB, Inzucchi SE. SPONTANEOUS RESOLUTION OF PRIMARY HYPERCORTISOLISM OF CUSHING DISEASE AFTER PITUITARY HEMORRHAGE. AACE Clin Case Rep 2020; 6:e23-e29. [PMID: 32984518 DOI: 10.4158/accr-2019-0292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/14/2019] [Indexed: 02/01/2023] Open
Abstract
Objective To describe a case of spontaneous resolution of primary hypercortisolism from Cushing disease (CD) due to pituitary apoplexy (PA). Methods Clinical, laboratory, and pathologic information are described. Results A 59-year-old female presented with a headache, a 2.3 cm sellar mass with a questionable hemorrhagic component, and clinical signs of hypercortisolism. On further evaluation, she had an increased 24-hour urine free cortisol, abnormal serum cortisol during a low dose dexamethasone suppression test, and an elevated plasma adrenocorticotropic hormone (ACTH), consistent with pituitary CD. As she was being prepared for surgical resection, she was noted to have spontaneous biochemical remission associated with resolution of her symptoms of hypercortisolism, and a repeat magnetic resonance imaging scan showed shrinkage of the sellar mass. She has been managed conservatively since and remains in clinical/biochemical remission until present time, 18 months following her initial presentation. Conclusion We report a case of spontaneous resolution of CD from symptomatic hemorrhage within an ACTH-secreting pituitary adenoma, or PA. This has been rarely reported in the medical literature. The fact that she did not pass through a phase of adrenal withdrawal, makes us suspect a residual functional adenoma within or around the sella which may eventually grow, causing her disease to recur, as has been reported. Hence, continued monitoring will be required.
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Chapman PR, Singhal A, Gaddamanugu S, Prattipati V. Neuroimaging of the Pituitary Gland: Practical Anatomy and Pathology. Radiol Clin North Am 2020; 58:1115-1133. [PMID: 33040852 DOI: 10.1016/j.rcl.2020.07.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The pituitary gland is a small endocrine organ located within the sella turcica. Various pathologic conditions affect the pituitary gland and produce endocrinologic and neurologic abnormalities. The most common lesion of the pituitary gland is the adenoma, a benign neoplasm. Dedicated MR imaging of the pituitary is radiologic study of choice for evaluating pituitary gland and central skull region. Computed tomography is complimentary and allows for identification of calcification and adjacent abnormalities of the osseous skull base. This review emphasizes basic anatomy, current imaging techniques, and highlights the spectrum of pathologic conditions that affect the pituitary gland and sellar region.
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Affiliation(s)
- Philip R Chapman
- Department of Radiology, School of Medicine, University of Alabama Birmingham, 619 19th Street South, JT N419, Birmingham, AL 35249-6830, USA.
| | - Aparna Singhal
- Department of Radiology, School of Medicine, University of Alabama Birmingham, 619 19th Street South, JT N419, Birmingham, AL 35249-6830, USA
| | - Siddhartha Gaddamanugu
- Department of Radiology, School of Medicine, University of Alabama Birmingham, 619 19th Street South, JT N419, Birmingham, AL 35249-6830, USA
| | - Veeranjaneyulu Prattipati
- Department of Radiology, School of Medicine, University of Alabama Birmingham, 619 19th Street South, JT N419, Birmingham, AL 35249-6830, USA
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Shijo K, Yoshimura S, Mori F, Yamamuro S, Sumi K, Oshima H, Yoshino A. Pituitary Apoplexy Accompanying Temporal Lobe Seizure as a Complication. World Neurosurg 2020; 138:153-157. [PMID: 32147553 DOI: 10.1016/j.wneu.2020.02.148] [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] [Received: 11/10/2019] [Revised: 02/23/2020] [Accepted: 02/24/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pituitary apoplexy is an acute clinical syndrome caused by infarction and/or hemorrhage of pituitary adenoma, which typically presents with severe headache, visual deterioration, and endocrine abnormalities. However, temporal lobe seizure (and temporal lobe epilepsy) has not been viewed as a symptom of pituitary apoplexy in the literature. CASE DESCRIPTION To elucidate further such a rare complication of temporal lobe seizure, we describe here the rare clinical manifestations of a 55-year-old previously healthy man with pituitary apoplexy harboring headache, combined palsies involving cranial nerves III to VI, endocrinologic disturbances, and temporal lobe seizure. In addition, we discuss the temporal lobe seizure (and temporal lobe epilepsy) associated with pituitary adenoma based on the literature. CONCLUSIONS Although further accumulation of clinical data is needed, we would like to emphasize the importance of recognition of temporal lobe seizure caused by pituitary apoplexy, and to suggest that early surgery could be considered as an option in patients displaying such a rare complication.
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Affiliation(s)
- Katsunori Shijo
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Sodai Yoshimura
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Fumi Mori
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shun Yamamuro
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Koichiro Sumi
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Oshima
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Atsuo Yoshino
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan.
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Lee IH, Kim HK, Ahn DJ. Concurrent pituitary apoplexy and posterior reversible encephalopathy syndrome in a patient with end-stage renal disease on hemodialysis: A case report. Medicine (Baltimore) 2020; 99:e18987. [PMID: 32000433 PMCID: PMC7004754 DOI: 10.1097/md.0000000000018987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Pituitary apoplexy (PA) and posterior reversible encephalopathy syndrome (PRES) are rare neurologic diseases that show acute neuro-ophthalmologic symptoms such as headache, decreased visual acuity, and altered consciousness. These diseases are rarely found in patients with end-stage renal disease (ESRD) on hemodialysis, and simultaneous occurrence of these 2 diseases has not been reported. PATIENT CONCERNS The patient was a 75-year-old man with a history of hypertension, diabetes mellitus, and non-functioning pituitary macroadenoma. He had been receiving hemodialysis for ESRD for 3 months before his presentation to the emergency room. The patient complained of headache, vomiting, and dizziness that started after the previous day's hemodialysis. The patient had voluntarily discontinued his antihypertensive medication 2 weeks before presentation and had high blood pressure with marked fluctuation during hemodialysis. Complete ptosis and ophthalmoplegia on the right side suggested 3rd, 4th, and 6th cranial nerve palsies. DIAGNOSES Magnetic resonance imaging of the brain revealed a pituitary tumor, intratumoral hemorrhage within the sella, and symmetric vasogenic edema in the subcortical white matter in the parieto-occipital lobes. Based on these findings, the patient was diagnosed with PA and PRES. INTERVENTIONS Intravenous administration of hydrocortisone (50 mg every 6 hours after a bolus administration of 100 mg) was initiated. Although surgical decompression was recommended based on the PA score (5/10), the patient declined surgery. OUTCOMES Headache and ocular palsy gradually improved after supportive management. The patient was discharged on the 14th day of hospitalization with no recurrence 5 months post-presentation. Current therapy includes antihypertensive agents, oral prednisolone (7.5 mg/day), and maintenance hemodialysis. LESSONS Neurologic abnormalities developed in a patient with ESRD on hemodialysis, suggesting the importance of prompt diagnosis and treatment in similar instances.
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Affiliation(s)
| | - Ho Kyun Kim
- Department of Radiology, Daegu Catholic University School of Medicine
| | - Dong Jik Ahn
- Department of Internal Medicine, HANSUNG Union Internal Medicine Clinic and Dialysis Center, Daegu, Republic of Korea
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Zhu B, Gao M, Zhang L, Wang J, Wang L, Qin LL, Kang XX, Zhao ZG. Association of PTTG1 polymorphism rs1895320, rs2910200 and rs6882742 with non-functioning pituitary adenomas in Chinese Han population: a case-control study. Metab Brain Dis 2019; 34:841-846. [PMID: 30607824 DOI: 10.1007/s11011-018-0364-6] [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] [Received: 09/27/2018] [Accepted: 12/04/2018] [Indexed: 11/26/2022]
Abstract
Due to absence of clinical manifestations of hormonal hyper secretion, the treatment of Nonfunctioning pituitary adenoma (NFPA) was always delayed. PTTG1 was reported to be overexpressed in most of pituitary tumors, however, the polymorphism of PTTG1 rs1895320, rs2910200 and rs6882742 with NFPA were still not fully elucidated in NFPA. Thus, a hospital based case control study which included 79 patients and 142 healthy control participants were conducted. DNA was extracted from peripheral blood samples and genotyped by Mass Array methods. In addition, a meta-analysis of rs2910200 was also employed to further testify the conclusion. Significant difference were observed between patients and healthy controls under rs2910200 locus between allelic genotype (p = 0.0219). However, no other significant difference was observed in rs1895329 and rs6882742. In addition, a logistic regression analysis showed that the dominant model of rs2910200 were closely correlated with the NFPA susceptibility (OR = 1.951, 95% CI:1.075-3.542, p = 0.028). While no significant difference was observed in the rs1895320 and rs6882742 under dominant model, recessive model and additive model The meta-analysis results showed that the dominant model and heterozygote model can significantly increase the risk of PA (p = 0.007, OR = 1.57, 95% CI:1.14-2.18; p = 0.009, OR = 1.57, 95% CI:1.12-2.19). Whereas no significant difference were observed under the homozygous model and recessive model. In conclusion, the polymorphism of PTTG1 rs2910200 dominant model and T allelic might increase the risk of NFPA.
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Affiliation(s)
- Bin Zhu
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Ming Gao
- Laboratory Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Lei Zhang
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100050, China
| | - Juan Wang
- Education research evaluation center, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Lei Wang
- Department of endocrinology, Third affiliated hospital of Beijing university of Chinese medicine, Beijing, 100029, China
| | - Ling Ling Qin
- Technology Department, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Xi Xiong Kang
- Laboratory Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhi Gang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.
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30
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Ogiwara T, Nagm A, Nakamura T, Mbadugha T, Horiuchi T, Hongo K. Significance and Indications of Surgery for Asymptomatic Nonfunctioning Pituitary Adenomas. World Neurosurg 2019; 128:e752-e759. [PMID: 31077893 DOI: 10.1016/j.wneu.2019.04.250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/27/2019] [Accepted: 04/29/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The availability of magnetic resonance imaging (MRI) has led to an increase in the detection of pituitary incidentaloma (PI). However, there are no robust data on surgical treatment of PI on which to base therapeutic recommendations. This study was performed to investigate the significance of surgery for asymptomatic nonfunctioning pituitary adenoma (NFPA) among PIs. METHODS A total of 180 patients that underwent tumor resection of pituitary adenoma via the transsphenoidal approach between 2005 and 2017 were reviewed. Thirty-three consecutive patients with subjectively asymptomatic NFPA were included in this study. Our surgical indications for asymptomatic NFPAs were categorized as follows: macroadenoma with optic chiasma compression (group A, n = 14), solid tumor ≥2 cm in size (group B, n = 7), and tumor growth on follow-up MRI (group C, n = 12). The clinical outcomes were analyzed accordingly. RESULTS Seven patients (50%) in group A showed subjective improvement of visual function after tumor resection even though they had no complaints preoperatively. On the other hand, no changes occurred in any cases in group B or group C. Although there were no critical complications in this series, the incidence of nonnegligible nasal complications was relatively high (24.2%) and may decrease the patient's quality of life. CONCLUSIONS Surgery should be recommended for asymptomatic NFPA with optic chiasma compression to improve visual outcome. On the other hand, immediate intervention for other asymptomatic NFPA to reduce the likelihood of the appearance of tumor-related symptoms remains questionable considering its invasiveness to the nose.
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Affiliation(s)
- Toshihiro Ogiwara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Alhusain Nagm
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan; Department of Neurosurgery, Al-Azhar University Faculty of Medicine-Nasr city, Cairo, Egypt
| | - Takuya Nakamura
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tobechi Mbadugha
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan; Unit of Neurosurgery, Memfys Hospital for Neurosurgery, Enugu, Nigeria
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
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Yang D, Newman SK, Katz K, Agrawal N. Central diabetes insipidus emerging after steroid replacement in pituitary apoplexy. CMAJ 2019; 191:E501-E504. [PMID: 31061075 DOI: 10.1503/cmaj.181475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Dixon Yang
- Departments of Neurology (Yang) and Medicine (Newman, Katz, Agrawal), New York University School of Medicine, New York, NY
| | - Samantha K Newman
- Departments of Neurology (Yang) and Medicine (Newman, Katz, Agrawal), New York University School of Medicine, New York, NY
| | - Karin Katz
- Departments of Neurology (Yang) and Medicine (Newman, Katz, Agrawal), New York University School of Medicine, New York, NY
| | - Nidhi Agrawal
- Departments of Neurology (Yang) and Medicine (Newman, Katz, Agrawal), New York University School of Medicine, New York, NY
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Zhang R, Wang Z, Gao L, Guo X, Feng C, Deng K, Lian W, Yao Y, Feng M, Bao X, Wang R, Xing B. Clinical Characteristics and Postoperative Recovery of Hypopituitarism in Patients with Nonfunctional Pituitary Adenoma. World Neurosurg 2019; 126:e1183-e1189. [PMID: 30880207 DOI: 10.1016/j.wneu.2019.03.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the clinical characteristics of hypopituitarism and its reversibility after surgery for nonfunctional pituitary adenoma (NFPA); analyze the correlation between tumor size and hypopituitarism incidence; and predict hypopituitarism by tumor volume and maximum diameter. METHODS We retrospectively reviewed 164 patients with NFPA who underwent surgical treatment at Peking Union Medical College Hospital from January 2016 to December 2016. Demographic, imaging, and endocrine data were collected during preoperative, postoperative, and long-term follow-up (21.1 ± 3.3 months) periods. Differences in hormone levels were analyzed by paired and independent samples t-tests. The cut-off values of tumor size and volume to predict hypopituitarism were calculated by receiver operating characteristic curves. RESULTS In total, 80.4% (132/164) of patients had anterior pituitary hypofunction and 48.4% patients had hypogonadism; the recovery rate of luteinizing hormone was 80.9%, and follicular-stimulating hormone was 60%. In total, 36.5% of patients had hypothyroidism; the recovery rate of thyroxine was 85%, free thyroxine was 87.8%, and thyroid-stimulating hormone was 100.0%. Finally, 27.4% of patients had insulin-like growth factor 1 (IGF-1)/growth hormone (GH) hypofunction, and the recovery rate of IGF-1 was 77.8%. The preoperative free thyroxine, thyroxine, GH, IGF-1, follicular-stimulating hormone, and luteinizing hormone levels were significantly lower in the giant adenoma group (n = 43) than in the large adenoma group (n = 121). The hypopituitarism predictive cut-off value of tumor volume was 3105.1 mm3 and that of tumor diameter was 23.5 mm. CONCLUSIONS NFPA has a significant influence on gonadal hormone, IGF-1/GH, and thyroid hormone. NFPA can cause single- or multiple-hormone reduction in each pituitary target gland. Tumor size is positively correlated with the incidence and degree of hypopituitarism. NFPA-induced hypopituitarism is significantly recovered after surgical treatment.
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Affiliation(s)
- Ruopeng Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zihao Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenzhe Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Rengzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China; Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China.
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Wang Z, Gao L, Wang W, Guo X, Feng C, Lian W, Li Y, Xing B. Coagulative necrotic pituitary adenoma apoplexy: A retrospective study of 21 cases from a large pituitary center in China. Pituitary 2019; 22:13-28. [PMID: 30390276 DOI: 10.1007/s11102-018-0922-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE Coagulative necrotic pituitary apoplexy (CNPA) is a clinical entity with unique intraoperative and histopathological manifestations. We aimed to improve the knowledge of this rare disease through the largest case series published to date. METHODS A retrospective review of 21 CNPA patients was performed from among 5095 patients who underwent surgery for pituitary adenomas at a single institution between January 2009 and June 2017. The demographic, clinical, endocrine, neuroimaging, intraoperative, and histopathological findings, management and prognosis were summarized. RESULTS Headache was the most common symptom that was observed in 21 patients, followed by visual disturbances (17/21, 81.0%), nausea and vomiting (16/21, 76.2%), electrolyte disturbance (13/21, 61.9%), and oculomotor palsies (10/21, 47.6%). Hypopituitarism with at least one anterior pituitary deficiency, especially panhypopituitarism (10/21, 47.6%), was present in 81.0% of patients. Most patients (81.0%) showed typical MRI appearances. All 21 patients underwent transsphenoidal surgery (TSS), and 16 patients had total tumor resection demonstrated by postoperative MRI. Cottage cheese-like necrosis was observed in 16 patients (76.2%) intraoperatively. Histopathology showed large areas of pink, acellular, coagulative necrotic areas in the central zone, and a pseudocapsule in the border zone. After follow-up for 4.3 ± 2.3 years, only 28.6% of patients still suffered from corticotropic deficiency, and 9.5% of patients had gonadotropic deficiency. These patients were administered the appropriate corresponding hormones for life. CONCLUSIONS CNPA can be correctly diagnosed preoperatively by typical clinical and MRI characteristics. Early surgery combined with hyperbaric oxygen therapy early postoperatively usually yields satisfactory endocrine and neuro-ophthalmic outcomes.
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Affiliation(s)
- Zihao Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lu Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wenze Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Chenzhe Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wei Lian
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Yongning Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
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Fan Y, Bao X, Wang R. Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature. Clin Interv Aging 2018; 13:1981-1985. [PMID: 30349217 PMCID: PMC6188166 DOI: 10.2147/cia.s181109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA. Case description We describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient’s poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family’s wishes, we continued the conservative treatment and watched closely for any changes in the patient’s condition. After 6 months of conservative treatment, the patient’s symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient’s hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone. Conclusion In older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients’ condition closely and continue conservative treatment, which may yield good results.
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Affiliation(s)
- Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
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