A case of pituitary apoplexy in a child

Pituitary apoplexy after cardiac surgery in a 14-year-old girl with Carney complex: a case report

A 14-year-old girl was referred to our department because of headache and visual impairment following the resection of recurrent cardiac myxoma. Head magnetic resonance imaging (MRI) scan detected an intra- and supra-sellar tumor. Moreover, the patient showed the presence of spotty skin pigmentations on her cheeks and lower lip. Blood examination revealed hypothyrotropinemia, and ultrasonography results revealed multiple thyroid nodules. She was diagnosed with Carney complex (CNC). Her pituitary tumor was suspected as growth hormone (GH)-secreting adenoma, because overgrowth was observed in the patient. However, biochemical examinations, including oral glucose tolerance test, failed to show the characteristic findings of GH-secreting adenoma. In contrast, insulin tolerance test showed GH deficiency. Her visual impairment improved without performing decompression surgery, and the tumor size decreased, as per the MRI findings. Based on clinical course, the patient was diagnosed with pituitary apoplexy in pituitary adenoma, following which she was discharged. At 3 months after discharge, thyrotropin-releasing hormone loading test performed revealed low thyrotropin-stimulating hormone and thyroid hormone levels, and the patient was in a depressed mood. Therefore, l-T4 replacement was initiated, following which her GH secretory capacity gradually improved. Here, we report, to the best of our knowledge, the first case of a patient with pituitary apoplexy in CNC. Such condition must be identified in young patients with recurrent cardiac myxoma, and examinations, such as head MRI, must be performed.

Pituitary Adenoma Apoplexy in an Adolescent: A Case Report and Review of the Literature

We present a 13-year-old boy who was admitted with complaints of a state of progressive sleepiness and a sudden headache with vomiting and fever. Laboratory testing showed hypoglycemia, multiple pituitary hormonal deficiencies, and an elevated C-reactive protein level. A cranial magnetic resonance imaging (MRI) showed an opaque sphenoid sinus and an intrasellar mass suggesting hemorrhage, so that we suspected pituitary apoplexy (PA) originating from a non-functioning adenoma, although a pituitary abscess could not completely be excluded. The boy was treated with antibiotics, hydrocortisone, and levothyroxine. Due to his rapid clinical improvement, no surgery was performed and we considered the diagnosis of PA as confirmed. At follow-up, the MRI scan showed a small residual lesion. Pituitary deficiencies of growth hormone, adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone, and vasopressin persisted. A literature search of all well-documented cases of PA in children or adolescents (n=30, 13 boys and 17 girls) indicated that this condition is rare below 20 years of age but must be considered when a patient experiences headache with or without visual disturbances, even in the presence of clinical and laboratory signals suggestive of pituitary abscess. MRI neuroimaging is helpful in the differential diagnosis. In both conditions, the possibility of ACTH deficiency should always be considered, investigated, and treated. In cases without severe neuro-ophthalmological deficits and/or with a rapid and positive response to acute medical management, one can abstain from surgical treatment.

Pituitary apoplexy in residual pituitary adenoma following surgical treatment in the follow-up period: management strategy

Pituitary apoplexy is a rare clinical event, used to occur spontaneously. Although, some predisposing factors for pituitary apoplexy is reported ie. head injury, digital cerebral angiography, bromocriptine therapy, coughing, lumbar puncture for CSF drainage, pneumoventriculography, even during surgery, in the immediate postoperative period and raised intracranial tension. Although pituitary apoplexy occurring following radiotherapy as primary treatment modality is reported, however, apoplexy occurring in residual adenoma following surgery, receiving adjuvant radiation therapy for residual adenoma is not reported in the literature. Authors reports two-cases of pituitary apoplexy, which occurred in the residual pituitary adenoma after a varying period in the follow-up period. These patients were previously operated by transcranial approach for decompression of the pituitary adenoma. The pituitary apoplexy occurred in one case after an interval of one and half years following surgical intervention for pituitary adenoma decompression and next case developed after five years. Both the cases had also received radiotherapy in the postoperative period for residual pituitary adenoma.

Pituitary adenomas in childhood and adolescence with a focus on intratumoral hemorrhage

Pituitary adenomas in childhood and adolescence are relatively rare. In the present study we investigated intratumoral hemorrhage in pituitary adenomas and examined cases of intratumoral hemorrhage using adult patients for comparison. From 1975 to 2012, 38 consecutive patients operated for pituitary adenoma and one patient treated with medication alone, were enrolled in this study. Their ages were less than 18 years old at the initial diagnosis (mean age 15.3 ± 2.9 years). The comparison group consisted of 209 consecutive adult patients (>18 years old). The incidence and characteristics of intratumoral hemorrhage in pituitary adenomas were evaluated, based on magnetic resonance imaging (MRI) findings (28 cases) and on operative findings. The incidence of pituitary adenomas in childhood and adolescence was 38/1,073 (3.5 %) patients operated. Functioning pituitary adenomas (82.1 %) were common and non-functioning pituitary adenomas (17.9 %) were rare. Although no significant difference in tumor size was found and Knosp grade did not differ between young (≤18 years old) and adult (>18 years old) patients, indications of intratumoral hemorrhage on MRI was common in young patients (42.9 %). Based on both MRI and operative findings, intratumoral hemorrhage was significantly more likely to occur in young patients, compared with adult patients.

Pituitary Apoplexy

OBJECTIVE:

Pituitary apoplexy is a rare yet potentially fatal disease. We reviewed the combined experience of the University of Virginia in Charlottesville, VA, and Groote Schuur Hospital, University of Cape Town, South Africa, with 62 cases of pituitary apoplexy.

METHODS:

An Internet web site with a database was constructed, and the records of 62 patients were entered into the database from both institutions and then systematically analyzed.

RESULTS:

The average age of patients was 51.1 years; 60% were male, and the average length of follow-up was 55 months. The average time of presentation was 14.2 days after the ictus, and 81% had no previous history of pituitary tumor. Headache was the most common presenting symptom (87%). Diminished visual acuity was found in 56% of patients, bitemporal hemianopia in 34%, ocular palsies in 45%, and diminished level of consciousness in 13%. Seventy-three percent of the patients had laboratory evidence of hypopituitarism, and 8% had diabetes insipidus. Fifty-eight patients underwent surgery, 3 were treated conservatively, and 1 died before intervention. Histological examination revealed hemorrhagic infarction in 47%, simple infarction in 40%, and frank hemorrhage in 8%. Seventy-nine percent had a good outcome, although 83% required subsequent hormonal replacement therapy.

CONCLUSION:

Pituitary apoplexy is often misdiagnosed because the majority of patients have undetected pituitary adenomas, and the presentation is often mistaken for subarachnoid hemorrhage. Most cases of pituitary apoplexy occur spontaneously, although precipitating factors have been suggested. Magnetic resonance imaging is the imaging modality of choice. Treatment includes high-dose corticosteroid administration and surgery. Transsphenoidal surgery is indicated in patients with diminished levels of consciousness, hypothalamic dysfunction, and visual deterioration. Conservative management for patients with isolated cranial nerve palsies has been advocated but remains controversial.

[Pituitary apoplexy followed by endocrine remission. Report of two cases]

Pituitary apoplexy is rare and endocrine remission in patients with apopletic secreting pituitary adenomas is even rarer. This study reports on two patients with pituitary macroadenomas (one with Cushing's disease and the other with acromegaly) in whom endocrine remission occurred after apoplexy. The first patient had Cushing's disease and had an ictus of headache and vomiting after which she started a progressive remission of hypercortisolism. A post-apoplexy MRI disclosed persistence of a sellar and supra-sellar mass. She was submitted to transesphenoidal surgery. An hypertensive hemorrhagic cyst was found with no tumor. The second patient had acromegaly. While performing a LHRH-stimulation test he had an ictus of headache, vomiting, no visual loss and appearance of diabetes insipidus. A CT scan disclosed an intrasellar hematoma. Despite the size of the tumor and since there was no visual impairment, this patient was followed up without surgery. Imaging follow-up showed a progressive shrinkage and disappearance of the mass, which was corroborated by endocrine remission. A high rate of recurrence is reported in such patients in the literature. Both patients are being currently followed-up on a long-term basis.