1
|
Karaca Z, Unluhizarci K, Kelestimur F. Hypoprolactinemia. Does it matter? Redefining the hypopituitarism and return from a mumpsimus : "Absence of proof is not the proof of absence". Rev Endocr Metab Disord 2023:10.1007/s11154-023-09847-9. [PMID: 37875774 DOI: 10.1007/s11154-023-09847-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 10/26/2023]
Abstract
Prolactin (PRL) is secreted by the lactotroph cells in the anterior pituitary gland which is under inhibitory control of dopamine. The mature human PRL has more than 300 physiological actions including lactation, reproduction, homeostasis, neuroprotection, behavior, water and electrolyte balance, immunoregulation and embryonic and fetal development. PRL is involved in the growth and development of mammary gland, preparation of the breast for lactation in the postpartum period, synthesis of milk, and maintenance of milk secretion. Abnormalities in the synthesis and secretion of PRL may result in hyperprolactinemia or hypoprolactinemia. Although hyperprolactinemia has been extensively investigated in the literature, because of the subtle or unclearly defined symptoms, hypoprolactinemia is a less-known and neglected disorder. Failure of lactation is a well-known clinical manifestation of hypoprolactinemia. Recent studies reveal that hypoprolactinemia may have some effects beyond lactation such as increased risk for metabolic abnormalities including insulin resistance, abnormal lipid profile, obesity and sexual dysfunction. Very low level of PRL is suggested to be avoided in patients receiving dopamin agonist treatment to prevent unwanted effects of hypoprolactinemia. Another important point is that hypoprolactinemia is not included in the classification of hypopituitarism. Anterior pituitary failure is traditionally classified as isolated, partial and complete (panhypopituitarism) hypopituitarism regardless of prolactin level. Therefore, there are two kinds of panhypopituitarism: panhypopituitarism with normal or high PRL level and panhypopituitarism with low PRL level. In this review, we present two personal cases, discuss the diagnosis of hypoprolactinemia, hypoprolactinemia associated clinical picture and suggest to redefine the classification of hypopituitarism.
Collapse
Affiliation(s)
- Zuleyha Karaca
- Faculty of Medicine, Department of Endocrinology Kayseri, Erciyes University, Talas/Kayseri, Turkey
| | - Kursad Unluhizarci
- Faculty of Medicine, Department of Endocrinology Kayseri, Erciyes University, Talas/Kayseri, Turkey
| | - Fahrettin Kelestimur
- Faculty of Medicine, Department of Endocrinology İstanbul, Yeditepe University, Ataşehir/İstanbul, Turkey.
| |
Collapse
|
2
|
Woelfel CW, Mariani CL, Nolan MW, Keenihan EK, Topulos SP, Early PJ, Muñana KR, Musulin SE, Olby NJ. Presumed pituitary apoplexy in 26 dogs: Clinical findings, treatments, and outcomes. J Vet Intern Med 2023; 37:1119-1128. [PMID: 37084035 DOI: 10.1111/jvim.16703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Pituitary apoplexy refers to hemorrhage or infarction within the pituitary gland resulting in acute neurological abnormalities. This condition is poorly described in dogs. OBJECTIVES To document presenting complaints, examination findings, endocrinopathies, magnetic resonance imaging (MRI), treatments, and outcomes of dogs with pituitary apoplexy. ANIMALS Twenty-six client-owned dogs with acute onset of neurological dysfunction. METHODS Retrospective case series. Dogs were diagnosed with pituitary apoplexy if MRI or histopathology documented an intrasellar or suprasellar mass with evidence of hemorrhage or infarction in conjunction with acute neurological dysfunction. Clinical information was obtained from medical records and imaging reports. RESULTS Common presenting complaints included altered mentation (16/26, 62%) and gastrointestinal dysfunction (14/26, 54%). Gait or posture changes (22/26, 85%), mentation changes (18/26, 69%), cranial neuropathies (17/26, 65%), cervical or head hyperpathia (12/26, 46%), and hyperthermia (8/26, 31%) were the most frequent exam findings. Ten dogs (38%) lacked evidence of an endocrinopathy before presentation. Common MRI findings included T1-weighted hypo- to isointensity of the hemorrhagic lesion (21/25, 84%), peripheral enhancement of the pituitary mass lesion (15/25, 60%), brain herniation (14/25, 56%), and obstructive hydrocephalus (13/25, 52%). Fifteen dogs (58%) survived to hospital discharge. Seven of these dogs received medical management alone (median survival 143 days; range, 7-641 days) and 8 received medications and radiation therapy (median survival 973 days; range, 41-1719 days). CONCLUSIONS AND CLINICAL IMPORTANCE Dogs with pituitary apoplexy present with a variety of acute signs of neurological disease and inconsistent endocrine dysfunction. Dogs that survive to discharge can have a favorable outcome.
Collapse
Affiliation(s)
- Christian W Woelfel
- Veterinary Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Christopher L Mariani
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
- Comparative Neuroimmunology and Neuro-Oncology Laboratory, North Carolina State University, Raleigh, North Carolina, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Michael W Nolan
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Erin K Keenihan
- Veterinary Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Sophia P Topulos
- Veterinary Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Peter J Early
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Karen R Muñana
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Sarah E Musulin
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Natasha J Olby
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| |
Collapse
|
3
|
Spinelli CP, Iwanaga J, Hur MS, Dumont AS, Tubbs RS. Discovery of a trans-sellar vascular supply for the pituitary gland. Anat Cell Biol 2022; 55:124-129. [PMID: 35599459 PMCID: PMC9256484 DOI: 10.5115/acb.21.255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/11/2022] [Accepted: 03/03/2022] [Indexed: 11/27/2022] Open
Abstract
The vasculature of the pituitary gland is discussed briefly and the details of an anatomical discovery of the vessels supplying the pituitary gland provided. Twenty latex injected cadaveric heads were dissected. Any vessels that were found to penetrate the sella turcica and travel to the pituitary gland were documented and measured. Additionally, 25 adult skulls were evaluated for the presence, size, and sites of bony foramina in the floor of sella turcica. Trans-sellar vessels were identified in 65% of specimens. There was a mean of 1.5 vessels per specimen consisting usually of a mixture of veins and arteries. The mean diameter of these vessels was 0.3 mm and the mean length from the sella turcica to the pituitary gland was 2.3 mm. These vessels were concentrated in the most concave part of the sella turcica. In bony specimens, the mean number of trans-sellar foramina was four. The diameter of these foramina ranged from 0.3 to 0.6 mm in size. The trans-sellar foramina were concentrated near the center part of the sella turcica and had no regular pattern. The pituitary gland receives at least some blood supply and drainage via vessels traveling along the septum of the sphenoidal sinuses and through the sella turcica. Knowledge of such vessels might lead to a better understanding of the vascular supply and drainage of the pituitary gland and would be useful during skull base approaches such as trans-nasal approaches to the pituitary gland.
Collapse
Affiliation(s)
- Casey P Spinelli
- Tulane University & Ochsner Clinic Neurosurgery Program, Tulane University School of Medicine, New Orleans, LA, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mi-Sun Hur
- Department of Anatomy, Catholic Kwandong University College of Medicine, Gangneung, Korea
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada.,Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA.,University of Queensland, Brisbane, Australia
| |
Collapse
|
4
|
Chen Y, Hu F, Wang J, Huang K, Liu W, Tan Y, Zhao K, Xiao Q, Lei T, Shu K. Clinical Features of Craniopharyngioma With Tumoral Hemorrhage: A Retrospective Case-Controlled Study. Front Surg 2022; 9:845273. [PMID: 35360427 PMCID: PMC8963871 DOI: 10.3389/fsurg.2022.845273] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCraniopharyngioma (CP) with tumoral hemorrhage is a very rare syndrome presenting with various manifestation and unfavorable outcomes. The current retrospective study was performed to summarize the clinical features of CP with tumoral hemorrhage.MethodsIn this study, 185 patients with pathological diagnosis of CP (18 patients with hemorrhage) were enrolled. Clinical characteristics, radiological and surgical treatments, and post-operative complications were analyzed. In addition, the correlations between sexual hormones and tumor volume were explored.ResultsDrowsiness, acute syndrome, and pituitary deficiency were more frequent in patients with hemorrhage patients. Prothrombin time (PT) were higher in patients with hemorrhage. Luteinizing hormone (LH) and testosterone (T) were lower in male patients with hemorrhage. Post-operative electrolyte disturbances, hypothalamic syndrome, and death appeared more frequently in the hemorrhage group. Moreover, prolactin (PRL) and cortisol 8AM were found to be correlated with the volume of the tumor and the hematoma, respectively.ConclusionThe current study presented the clinical features of CP apoplexy from the aspects of clinical characteristics, radiography, surgical treatment, and post-operative complications. Patients with CP apoplexy could benefit from the proper processing of peritumoral hemorrhage and post-operative monitoring of the electrolyte.
Collapse
|
5
|
Cabuk B, Kaya NS, Polat C, Geyik AM, Icli D, Anik I, Ceylan S. Outcome in pituitary apoplexy patients, stratified by delay between symptom appearance and surgery: A single center retrospective analysis. Clin Neurol Neurosurg 2021; 210:106991. [PMID: 34700278 DOI: 10.1016/j.clineuro.2021.106991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/17/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are surgical and conservative management strategies in pituitary apoplexy patients. The use of both methods may lead to delayed surgery in the treatment of pituitary apoplexy. The aim of this study was to evaluate the surgical indications and outcomes of a series of patients with pituitary apoplexy according to delay between surgery and symptom onset. METHODS A retrospective analysis was performed of 2711 cases with sellar pathologies treated with endoscopic transsphenoidal surgery in a single centre. Inclusion criteria were histopathological confirmation of haemorrhage or necrosis, acute onset and at least one of the following: symptoms of endocrine dysfunction; visual impairment; ophtalmoplegia; headache; or altered consciousness. Patients were divided into three groups based on the number of days from initial symptoms to surgery: early (1-7 day), delayed (8-21 days) and late (>21 day). The indication for and outcome of surgery was reviewed according to symptoms and timing of surgery. RESULTS Ninety-one patients with pituitary apoplexy underwent surgery. The median time from ictus until surgery was 16 days (1-120 days). Headache was the most common presenting symptom. Visual impairment and ophtalmoplegia were found in 26.4% and 23.1% of patients, respectively. Surgical intervention was successful in treatment of headache in 82 (97,6%) patients. In patients in the early or delayed groups a significant improvement was found between pre- and post-operative headache, ocular palsy, visual impairment, and hormone deficiencies. Patients in the late group also had a significant improvement in headache and visual symptoms after surgery. CONCLUSION Surgery was sufficient in headache, endocrine, and neuro-ophthalmic outcomes at first 21 days (early and delayed groups). Beyond 21 days (late group), surgery was not effective on recovery of pituitary function.
Collapse
Affiliation(s)
- Burak Cabuk
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Necdet Selim Kaya
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Caner Polat
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Abidin Murat Geyik
- Gaziantep University, School of Medicine, Department of Neurosurgery, Gaziantep, Turkey
| | - Dilek Icli
- KocaeliUniversity, School of Medicine, Department of Anesthesiology, Kocaeli, Turkey
| | - Ihsan Anik
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Savas Ceylan
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey.
| |
Collapse
|
6
|
Cruz-Flores S. Neurological Complications of Endocrine Emergencies. Curr Neurol Neurosci Rep 2021; 21:21. [PMID: 33709163 DOI: 10.1007/s11910-021-01105-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Endocrine disorders are the result of insufficient or excessive hormonal production. The clinical course is long, and the manifestations are nonspecific due to the systemic effect of hormones across many organs and systems including the nervous system. This is a narrative review of the recent evidence of the diagnosis and treatment approach of these medical and neurological emergencies. RECENT FINDINGS With the possible exception of diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia, endocrinological emergencies are complex, uncommon yet life-threatening conditions with protean and often nonspecific early clinical signs. They frequently are the first manifestation of the endocrine derangement. The systemic effects of hormones extend to the nervous system and as such, these conditions can present with neurological complications manifested, in most cases, by a diffuse dysfunction of the brain in the form of encephalopathy, delirium, seizures, and coma; or specific and peculiar syndromes such as hemichorea, hemiballism, and epilepsia partialis continua. The severity of these conditions often necessitates management in the intensive care unit requiring substantial supportive care in addition to specific targeted therapy to correct the hormonal metabolic abnormalities while at the same time blocking hormonal activity, in cases of excessive function, or supplementing hormonal deficiencies. Endocrine emergencies and their neurological complications are infrequent. The major challenge for most is early recognition. Their morbidity and mortality are high and their diagnosis requires high index of suspicion. The neurological complication most often improves with the correction of the metabolic derangement and their acuity and severity require admission to the intensive care unit.
Collapse
Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA.
| |
Collapse
|
7
|
Shaker L, Ripper J, Murano T. 55-year-old Woman with Headache, Vomiting, and Visual Disturbance. Clin Pract Cases Emerg Med 2020; 4:116-120. [PMID: 32426650 PMCID: PMC7219986 DOI: 10.5811/cpcem.2019.12.45546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/26/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022] Open
Abstract
Case Presentation A 55-year-old woman with a past medical history of hypertension, hyperlipidemia, and iron deficiency anemia presented to the emergency department with three days of headache, nausea, vomiting, and visual changes. Her vital signs were within normal limits. She was noted to have a left cranial nerve six palsy on exam. Results Her laboratory testing revealed leukocytosis, hyponatremia, and hypokalemia. A non-contrast computed tomography scan of the head revealed an enlarged sella turcica and pituitary gland with hemorrhage and deviation of the optic chiasm. Conclusion Her symptoms improved and she was discharged from the hospital in stable condition.
Collapse
Affiliation(s)
- Lana Shaker
- Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, New Jersey
| | - Jill Ripper
- Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, New Jersey
| | - Tiffany Murano
- Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, New Jersey
| |
Collapse
|
8
|
Kelly PD, Fernando SJ, Malenke JA, Chandra RK, Turner JH, Chambless LB. The Effect of Timing of Surgery in Pituitary Apoplexy on Continuously Valued Visual Acuity. J Neurol Surg B Skull Base 2020; 82:e70-e78. [PMID: 34306919 DOI: 10.1055/s-0040-1701217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/29/2019] [Indexed: 10/25/2022] Open
Abstract
Background Pituitary apoplexy is often treated urgently, but this is based on studies which assess vision categorically and dichotomizes the time interval between symptom onset and surgery which may introduce bias in measuring an association between the two. Objective This study was aimed to assess for a relationship between continuously valued surgery delay and visual acuity recovery after pituitary apoplexy. Methods In this retrospective study, all patients presenting with symptomatic pituitary apoplexy between 2004 and 2016 were identified from an institutional database. The primary endpoint was visual acuity improvement, measured as the difference in acuity from the pre- to postoperative period, and measured in Logarithm of the Minimal Angle of Resolution (LogMAR) units. Analysis was performed using continuous values of time delay and visual acuity to assess for an underlying association. Results Thirty-two pituitary apoplexy patients were identified. Visual acuity deficits were reported in 81%. The median visual acuity was 0.35 LogMAR (Snellen's fraction 20/40) preoperatively, and 0.1 (20/25) postoperatively ( p < 0.01). The time between symptom onset and surgery was not associated with improvement in visual acuity ( p = 0.46). When the time delay and visual outcome were intentionally dichotomized, patients undergoing surgery within 2 days of symptom onset had 0.21 times the odds of a good visual outcome (95% confidence interval [CI]: 0.04-1.05). Conclusion When assessed as continuously valued measures, the time from symptom onset to surgical intervention and the improvement in visual acuity are not associated, although intentional dichotomization of data produced conflicting results.
Collapse
Affiliation(s)
- Patrick D Kelly
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Shanik J Fernando
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Jordan A Malenke
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Rakesh K Chandra
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Justin H Turner
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| |
Collapse
|
9
|
Solari D, Pivonello R, Caggiano C, Guadagno E, Chiaramonte C, Miccoli G, Cavallo LM, Del Basso De Caro M, Colao A, Cappabianca P. Pituitary Adenomas: What Are the Key Features? What Are the Current Treatments? Where Is the Future Taking Us? World Neurosurg 2020; 127:695-709. [PMID: 31266132 DOI: 10.1016/j.wneu.2019.03.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
Pituitary tumors are a heterogeneous group of lesions (usually benign) and proper understanding of the anatomy, physiology, and pathology of the hypothalamic/pituitary region is essential to make an accurate diagnosis and define the essential treatment options (i.e., surgery, medical therapies, and radiotherapy, alone or in combination). Surgery is the primary treatment for acromegaly, Cushing disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing mass effect. Medical and radiation therapy are reserved in cases in which surgery is not possible or does not provide a complete cure. In the last decades, tremendous innovations (i.e., targeted drugs and refined surgical tools and techniques) have expanded the treatment strategies for pituitary adenomas. We herein report the current indications for and depiction of the surgical techniques in pituitary surgery, review current medical treatments, and provide a glimpse of future possibilities.
Collapse
Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Rosario Pivonello
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Chiara Caggiano
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Carmela Chiaramonte
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Miccoli
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Annamaria Colao
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| |
Collapse
|
10
|
Almeida JP, Sanchez MM, Karekezi C, Warsi N, Fernández-Gajardo R, Panwar J, Mansouri A, Suppiah S, Nassiri F, Nejad R, Kucharczyk W, Ridout R, Joaquim AF, Gentili F, Zadeh G. Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature. World Neurosurg 2019; 130:e988-e999. [PMID: 31302273 DOI: 10.1016/j.wneu.2019.07.055] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Pituitary apoplexy is associated with visual, cranial nerve, and endocrine dysfunction. In this article, the results of surgical and conservative management of pituitary apoplexy in a single center are evaluated and a review of the literature is presented. METHODS A retrospective analysis was made of patients with pituitary apoplexy who underwent surgery or conservative management at our center between January 2007 and June 2017. Surgery was typically selected for patients who presented with acute deterioration of visual status and/or level of consciousness. Patients with no visual field deficit and those who had medical contraindications to undergo a surgical procedure because of previous comorbidities typically had conservative treatment. Baseline characteristics and clinical and radiologic outcomes were reviewed. A review of the literature (1990-2018) was performed according to PRISMA guidelines. Studies comparing the results of conservative and surgical management were identified. Visual, cranial nerve, and endocrine outcomes and tumor recurrence were analyzed. RESULTS Forty-nine patients (73.1%) were managed surgically and 18 (26.9%) conservatively. After careful case selection, patients underwent surgical or conservative treatment. Patients who underwent conservative treatment had fewer visual deficits. At diagnosis, visual deficit (38.8% vs. 75.5%; P = 0.008) and cranial nerve palsy (27.7% vs. 51%; P = 0.058) were less common in the conservative group. Conservative and surgical treatments had similar visual and cranial nerve improvement rates (75% vs. 58.3%, P = 0.63 and 75% vs. 69.2%, P = 1.0, respectively). In the conservative group, tumor shrinkage was observed in 76.4% of cases. The systematic review retrieved 11 studies. No significant difference between conservative and surgical treatment for clinical outcomes (visual field recovery, odds ratio [OR], 1.45; 95% confidence interval [CI], 0.72-2.92; cranial nerve recovery, OR, 2.30; 95% CI, 0.93-5.65; and hypopituitarism, OR, 1.05; 95% CI, 0.64-1.74) or tumor recurrence (OR, 0.68; 95% CI, 0.20-2.34) was observed. CONCLUSIONS A tailored approach to pituitary apoplexy, one that does not include an absolute need for surgery, is appropriate. Conservative management is appropriate in selected patients presenting without visual deficits.
Collapse
Affiliation(s)
- Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Department of Neurology, State University of Campinas (UNICAMP), Campinas, Brazil.
| | - Miguel Marigil Sanchez
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Claire Karekezi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nebras Warsi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Jyoti Panwar
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Suganth Suppiah
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Romina Nejad
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - Rowena Ridout
- Division of Endocrinology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrei F Joaquim
- Division of Neurosurgery, Department of Neurology, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Harju T, Alanko J, Numminen J. Pituitary apoplexy following endoscopic nasal surgery: A case report. SAGE Open Med Case Rep 2019; 7:2050313X19855867. [PMID: 31217974 PMCID: PMC6558528 DOI: 10.1177/2050313x19855867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 05/15/2019] [Indexed: 11/24/2022] Open
Abstract
Pituitary apoplexy develops as a consequence of acute haemorrhage and/or
infarction in a pre-existing pituitary adenoma. Typical symptoms include sudden
onset headache, visual acuity/field defects, and ocular palsies. We report a
male patient with a known pituitary macroadenoma who underwent a right-sided
endoscopic nasal surgery. Preoperatively, thickening of sphenoid mucosa was seen
in computed tomography and magnetic resonance imaging. The patient developed
pituitary apoplexy postoperatively. The presented report indicates that in
patients with a pituitary adenoma, nasal surgery – like any other kind of
surgery – is a possible precipitating factor for pituitary apoplexy. Isolated
thickening of sphenoid mucosa is associated with pituitary apoplexy. It may also
precede an apoplectic event.
Collapse
Affiliation(s)
- Teemu Harju
- Department of Otorhinolaryngology, Tampere University Hospital, Tampere, Finland
| | - Juha Alanko
- Valkeakoski District Hospital, Valkeakoski, Finland
| | - Jura Numminen
- Department of Otorhinolaryngology, Tampere University Hospital, Tampere, Finland
| |
Collapse
|
12
|
Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) and Subsequent Central Diabetes Insipidus: A Rare Presentation of Pituitary Apoplexy. Case Rep Endocrinol 2019; 2019:7592648. [PMID: 31061738 PMCID: PMC6466927 DOI: 10.1155/2019/7592648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/21/2019] [Indexed: 12/24/2022] Open
Abstract
Pituitary apoplexy (PA) is a rare endocrine emergency that occasionally presents with sodium disturbances. Here we present a rare case with a previously healthy 41-year-old female who presented with acute onset headache and nausea without visual impairment or overt pituitary dysfunction. Plasma sodium concentrations declined abruptly during the first two days of admission to a nadir of 111 mmol/l. Urine and blood chemistry were consistent with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Magnetic resonance imaging revealed recent bleeding into a pituitary cystic process. Hyponatremia was successfully corrected with fluid restriction and both visual function and anterior pituitary function remained intact. Subsequently, the patient developed central diabetes insipidus (CDI), which responded well to desmopressin substitution. To our knowledge, this is the first case of PA presenting predominantly with posterior pituitary dysfunction that transitioned from SIADH to permanent CDI.
Collapse
|
13
|
Abbara A, Clarke S, Eng PC, Milburn J, Joshi D, Comninos AN, Ramli R, Mehta A, Jones B, Wernig F, Nair R, Mendoza N, Sam AH, Hatfield E, Meeran K, Dhillo WS, Martin NM. Clinical and biochemical characteristics of patients presenting with pituitary apoplexy. Endocr Connect 2018; 7:EC-18-0255. [PMID: 30139818 PMCID: PMC6198188 DOI: 10.1530/ec-18-0255] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/16/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE To review the clinical and biochemical characteristics and clinical outcome of patients presenting with pituitary apoplexy to a tertiary centre. METHODS We retrospectively reviewed the clinical features, predisposing factors, biochemistry and clinical outcome of patients presenting with pituitary apoplexy to Imperial College Healthcare NHS Trust between 1991 to 2015. RESULTS We identified 64 patients with pituitary apoplexy (more complete clinical records were available in 52 patients). The median age at presentation was 46.7 years (IQR 31.5-57.0 years). Pituitary apoplexy was the first presentation of pituitary disease in 38/52 of patients and predisposing factors were identified in 28/52. Pituitary apoplexy predominantly occurred in patients with non-functioning pituitary adenomas (47/52). Headache was most commonly described as sudden-onset, severe, lateralising to the frontal or temporal regions. Symptoms of meningeal irritation were reported in 7/18 and visual abnormalities in 22/35. A pre-treatment serum cortisol <100nmol/l was recorded in 12/31 of patients. All patients with visual disturbance had some resolution of their visual symptoms whether managed surgically (14/14) or conservatively (5/5), although pituitary endocrine function did not fully recover in any patient. CONCLUSIONS In conclusion, these data describe the clinical features of pituitary apoplexy to aid the clinician in diagnosing this rare emergency presentation of pituitary disease. Prospective multicentre studies of the presentation of pituitary apoplexy are required to further characterise presentation and outcomes.
Collapse
Affiliation(s)
- Ali Abbara
- A Abbara, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Sophie Clarke
- S Clarke, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Pei Chia Eng
- P Eng, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - James Milburn
- J Milburn, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Devavrata Joshi
- D Joshi, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Alexander N Comninos
- A Comninos, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Rozana Ramli
- R Ramli, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Amrish Mehta
- A Mehta, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Brynmor Jones
- B Jones, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Florian Wernig
- F Wernig, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Ramesh Nair
- R Nair, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Nigel Mendoza
- N Mendoza, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Amir H Sam
- S Amir, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Emma Hatfield
- E Hatfield, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Karim Meeran
- K Meeran, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Waljit Singh Dhillo
- W Dhillo, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Niamh M Martin
- N Martin, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
14
|
Salehi N, Firek A, Munir I. Pituitary Apoplexy Presenting as Ophthalmoplegia and Altered Level of Consciousness without Headache. Case Rep Endocrinol 2018; 2018:7124364. [PMID: 29854489 PMCID: PMC5966706 DOI: 10.1155/2018/7124364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 03/28/2018] [Indexed: 11/18/2022] Open
Abstract
Background. Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The typical clinical presentation of PA includes acute onset of severe headache, visual disturbance, cranial nerve palsy, and altered level of consciousness. Case Report. A 78-year-old man presented to the emergency department with one-day history of ptosis and diplopia and an acute-onset episode of altered level of consciousness which was resolving. He denied having headache, nausea, or vomiting. Physical examination revealed third-cranial nerve palsy and fourth-cranial nerve palsy both on the right side. Noncontrast computed tomography (CT) scan of the head was unremarkable. Brain magnetic resonance imaging (MRI) showed a pituitary mass with hemorrhage (apoplexy) and extension to the right cavernous sinus. The patient developed another episode of altered level of consciousness in the hospital. Transsphenoidal resection of the tumor was done which resulted in complete recovery of the ophthalmoplegia and mental status. Conclusion. Pituitary apoplexy can present with ophthalmoplegia and altered level of consciousness without having headache, nausea, or vomiting. A CT scan of the head could be negative for hemorrhage. A high index of suspicion is needed for early diagnosis and timely management of pituitary apoplexy.
Collapse
Affiliation(s)
- Nooshin Salehi
- Department of Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Anthony Firek
- Division of Endocrinology, Department of Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Iqbal Munir
- Division of Endocrinology, Department of Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| |
Collapse
|
15
|
Seo Y, Kim YH, Dho YS, Kim JH, Kim JW, Park CK, Kim DG. The Outcomes of Pituitary Apoplexy with Conservative Treatment: Experiences at a Single Institution. World Neurosurg 2018; 115:e703-e710. [PMID: 29709755 DOI: 10.1016/j.wneu.2018.04.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Pituitary apoplexy is an unpredictable complication caused by hemorrhage or infarction in a pituitary adenoma. We retrospectively analyzed the radiologic and clinical outcomes of patients with conservatively managed pituitary apoplexy. METHODS A total of 32 patients who had undergone conservative treatment with high-dose corticosteroid replacement were enrolled in this study. This cohort study consisted of 20 male and 12 female patients. The median patient age was 60 years. Five patients had a previously diagnosed pituitary tumor, and one third of the patients had a history of hypertension. RESULTS The median follow-up duration was 50 months. The median tumor volumes at the initial and final assessments were 2.75 cm3 (range, 0.32-10.7 cm3) and 0.64 cm3 (range, 0-8.74 cm3), respectively. Complete radiographic regression occurred in 9 of the 32 patients, partial regression occurred in 14 patients, and no change in size or progression occurred in 9 patients. Eighteen of the 32 patients had visual disturbances at the initial presentation; in this subgroup, 17 patients showed improvement over the course of the study. One patient had newly developed diplopia related to tumor progression. Nineteen of the 32 patients had ≥1 hormonal deficiency at the initial assessment, 8 of whom recovered to normal endocrine status. Three patients developed a new hormonal deficiency during the follow-up, and 3 patients experienced tumor recurrence. CONCLUSIONS This study showed the regression of tumors related to pituitary apoplexy, with favorable ophthalmologic and endocrinologic recovery. Conservative management should be considered in patients without severe or progressive neuro-ophthalmic deficits.
Collapse
Affiliation(s)
- Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Yun-Sik Dho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
16
|
Delgado-López PD, Pi-Barrio J, Dueñas-Polo MT, Pascual-Llorente M, Gordón-Bolaños MC. Recurrent non-functioning pituitary adenomas: a review on the new pathological classification, management guidelines and treatment options. Clin Transl Oncol 2018; 20:1233-1245. [PMID: 29623588 DOI: 10.1007/s12094-018-1868-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 03/26/2018] [Indexed: 11/25/2022]
Abstract
At least 50% of surgically resected non-functioning pituitary adenomas (NFPA) recur. Either early or late adjuvant radiotherapy is highly efficacious in controlling recurrent NFPA but associates potentially burdensome complications like hypopituitarism, vascular complications or secondary neoplasm. Reoperation is indicated in bulky tumor rests compressing the optic pathway. To date, no standardized medical therapy is available for recurrent NFPA although cabergoline and temozolomide show promising results. Guidelines on the management of recurrent NFPAs are now available. The new 2017 WHO pituitary tumor classification, based on immunohistochemistry and transcription factor assessment, identifies a group of aggressive NFPA variants that may benefit from earlier adjuvant therapy. Nevertheless, NFPA patients exhibit a reduced overall life expectancy largely due to hypopituitarism and treatment-related morbidity. The management of recurrent NFPA benefits from a multidisciplinary teamwork of surgeons, endocrinologists, radiation oncologists, ophthalmologists, pathologists and neuro-radiologists in order to provide individualized therapy and anticipate deterioration.
Collapse
Affiliation(s)
- P D Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain.
| | - J Pi-Barrio
- Servicio de Endocrinología Y Nutrición, Hospital Universitario de Burgos, Burgos, Spain
| | - M T Dueñas-Polo
- Servicio de Oncología Radioterápica, Hospital Universitario de Burgos, Burgos, Spain
| | - M Pascual-Llorente
- Servicio de Anatomía Patológica, Hospital Universitario de Burgos, Burgos, Spain
| | - M C Gordón-Bolaños
- Servicio de Oftalmología, Hospital Universitario de Burgos, Burgos, Spain
| |
Collapse
|
17
|
Hari Kumar K, Nachankar A. Dumbbell Tumor With Apoplexy. Endocr Pract 2018; 24:395. [DOI: 10.4158/ep-2017-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
18
|
Abstract
Pituitary apoplexy is an uncommon event, occurring due to the infarction and/or haemorrhage usually of a previously unknown pituitary adenoma. It can occur in all adenoma subtypes but is more common in nonfunctioning pituitary adenomas. The physiopathology is not completely clear, and precipitating factors, such as major surgeries, anticoagulant use or pituitary dynamic tests, can be found in up to 40% of patients. The clinical presentation is characterized by a rapid onset with a headache as the main symptom, but visual disturbances can also be present as well as meningism and intracranial hypertension. The diagnosis is based on imaging evaluations, mainly using magnetic resonance imaging, which can show various patterns depending on the timeframe following the occurrence of the apoplectic event. Pituitary hormonal deficits are also common, and the evaluation of hormonal levels is mandatory. Pituitary apoplexy can be managed by surgery or conservative treatment, and a multidisciplinary team is essential for the decision-making process. The outcome is usually positive with both surgical and conservative approaches, but surveillance is needed due to the risk of re-bleeding or tumour recurrence.
Collapse
Affiliation(s)
- Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9F - Sala de Pesquisa em Neuroendocrinologia, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9F - Sala de Pesquisa em Neuroendocrinologia, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil.
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
| |
Collapse
|
19
|
Hayashi Y, Sasagawa Y, Kita D, Fukui I, Oishi M, Tachibana O, Ueda F, Nakada M. Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage. Pituitary 2017; 20:531-538. [PMID: 28616673 DOI: 10.1007/s11102-017-0814-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Although hemorrhage within pituitary adenomas frequently exacerbates the symptoms, there are many grades of severity. Moreover, the contributing factors for symptom severity are still controversial. METHODS This retrospective study included 82 patients who underwent transsphenoidal surgery for pituitary adenomas with intratumoral hemorrhage. The grades of preoperative symptoms were classified into group A, asymptomatic or minor symptoms; group B, moderate symptoms sufficient for complain; and group C, severe symptoms disturbing daily life. RESULTS The hemorrhage volume within an adenoma was significantly higher in group C (92.6%) than in groups A (48.6%) and B (58.7%). Both headache and diplopia were dominant in group C, occurring in 72.2% and 27.8% of the patients, respectively. In group C, there was no significant difference in frequency between adenoma extensions into the sphenoid sinus (0%) and involvement of the cavernous sinus of Knosp grade 4 (0%), and extensions into the suprasellar region were not common (38.9%). The most distinctive feature was that "no extrasellar extension" was found only in group C (41.2%), and "multidirectional extension" was not detected in this group (0%). Multiple regression analysis revealed that the most powerful determining factors were the high frequencies of intratumoral hemorrhage and lack of extrasellar and multidirectional extensions. CONCLUSION Rapid volume expansion of a hematoma and lack of extension or unidirectional extension might lead to significant compression of the sellar and surrounding structures. Of note, the integrity of the sellar dura might contribute to the acute onset of symptom manifestations caused by hemorrhage in pituitary adenomas.
Collapse
Affiliation(s)
- Yasuhiko Hayashi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Yasuo Sasagawa
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Daisuke Kita
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Issei Fukui
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Masahiro Oishi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Osamu Tachibana
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Fumiaki Ueda
- Department of Radiology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| |
Collapse
|
20
|
Rahman SH, Chittibonia P, Quezado M, Patronas N, Stratakis CA, Lodish MB. Delayed Diagnosis of Cushing's Disease in a Pediatric Patient due to Apparent Remission from Spontaneous Apoplexy. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2017; 2:30-34. [PMID: 28848696 DOI: 10.1016/j.jecr.2016.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report here a pediatric patient whose Cushing's Disease was diagnosed late because of her cyclical presentation, presumably due to subclinical pituitary apoplexy. Starting at age 8, she presented with observable signs of Cushing's but was not clinically assessed for Cushing's Syndrome until the age of 15. Initial tests at age 15 were consistent with Cushing's Disease, however, the patient presented with spontaneous remission of hypercortisolemia just a few short months later. Her cushingoid features never subsided, and at age 17, her MRI showed a partially empty sella; this finding of an empty sella contributed evidence to our suspicion of asymptomatic apoplexy, especially since the patient never reported an episode of acute headache. Pituitary apoplexy in corticotroph adenomas is very uncommon, but even more rare in microadenomas, making this case very unusual. Lost to follow-up, she was not reevaluated for Cushing's Disease until age 25, and her laboratory tests were consistent with an adrenocorticotrophic-dependent pituitary tumor; Pituitary magnetic resonance imaging revealed a 9 mm X 6 mm X 8 mm mass projecting on the superior aspect of pituitary and abutting the wall of the right cavernous sinus. The patient had a transsphenoidal surgery to remove the microadenoma and is planned to undergo radiation therapy. To the best of our knowledge, this is the first report of subclinical apoplexy of a microadenoma in a pediatric patient with Cushing's Disease. It brings to light the importance of long term follow up for pediatric patients presenting with clinical symptoms of Cushing's Syndrome.
Collapse
Affiliation(s)
- Sara H Rahman
- Clinical Center of the National Institutes of Health (NIH) 10 Center Dr, Bethesda, MD 20814.,Frank H. Netter SOM, Quinnipiac University
| | - Prashant Chittibonia
- Clinical Center of the National Institutes of Health (NIH) 10 Center Dr, Bethesda, MD 20814
| | - Martha Quezado
- Clinical Center of the National Institutes of Health (NIH) 10 Center Dr, Bethesda, MD 20814
| | - Nicholas Patronas
- Clinical Center of the National Institutes of Health (NIH) 10 Center Dr, Bethesda, MD 20814
| | | | - Maya B Lodish
- Clinical Center of the National Institutes of Health (NIH) 10 Center Dr, Bethesda, MD 20814
| |
Collapse
|
21
|
Mercado M, Melgar V, Salame L, Cuenca D. Clinically non-functioning pituitary adenomas: Pathogenic, diagnostic and therapeutic aspects. ACTA ACUST UNITED AC 2017; 64:384-395. [PMID: 28745610 DOI: 10.1016/j.endinu.2017.05.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/26/2017] [Accepted: 05/29/2017] [Indexed: 12/15/2022]
Abstract
Clinically non-functioning pituitary adenomas (NFPAs) are among the most common tumors in the sellar region. These lesions do not cause a hormonal hypersecretion syndrome, and are therefore found incidentally (particularly microadenomas) or diagnosed based on compressive symptoms such as headache and visual field defects, as well as clinical signs of pituitary hormone deficiencies. Immunohistochemically, more than 45% of these adenomas stain for gonadotropins or their subunits and are therefore called gonadotropinomas, while 30% of them show no immunostaining for any hormone and are known as null cell adenomas. The diagnostic approach to NFPAs should include visual field examination, an assessment of the integrity of all anterior pituitary hormone systems, and magnetic resonance imaging of the sellar region to define tumor size and extension. The treatment of choice is transsphenoidal resection of the adenoma, which in many instances cannot be completely accomplished. The recurrence rate after surgery may be up to 30%. Persistent or recurrent adenomas are usually treated with radiation therapy. In a small proportion of these cases, drug treatment with dopamine agonists and, to a lesser extent, somatostatin analogs may achieve reduction or at least stabilization of the tumor.
Collapse
Affiliation(s)
- Moises Mercado
- Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico; Neurological Center, American British Cowdray Medical Center, Mexico City, Mexico.
| | - Virgilio Melgar
- Neurological Center, American British Cowdray Medical Center, Mexico City, Mexico
| | - Latife Salame
- Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
| | - Dalia Cuenca
- Department of Medicine, American British Cowdray Medical Center, Mexico City, Mexico
| |
Collapse
|
22
|
Abstract
OBJECTIVES To assess the etiology of cerebrospinal fluid (CSF) pleocytosis in critical care patients with seizure(s) or status epilepticus (SE). Many previous studies, some performed decades ago, concluded that CSF pleocytosis may be entirely attributable to seizure activity. METHODS We undertook a retrospective chart review of adult patients with an admitting or acquired diagnosis of seizure(s) or SE in critical care units at the Winnipeg Health Sciences Centre between 2009 and 2012. Patients were identified through a critical care information database at a tertiary care center. We limited our study to patients who had lumbar punctures at our center within 5 days of seizure(s) or SE. RESULTS Of 426 patients with seizures in critical care units, 51 met the inclusion criteria. Seizure subtypes included focal seizures (5 or 10%), generalized seizures (14 or 27%), and SE (32 or 63%). Twelve (seven with SE) of the 51 (24%) were found to have CSF pleocytosis. A probable etiological cause for the CSF pleocytosis was identified in all 12 cases. CONCLUSIONS We conclude that seizures do not directly induce a CSF pleocytosis. Instead, the CSF pleocytosis more likely reflects the underlying acute or chronic brain process responsible for the seizure(s). This was not readily apparent in early studies without magnetic resonance imaging (MRI) of the brain and currently available laboratory investigations. An etiological cause of CSF pleocytosis must always be sought when patients present with seizures and it should never be assumed that seizures are the cause.
Collapse
|
23
|
Zamora C, Castillo M. Sellar and Parasellar Imaging. Neurosurgery 2016; 80:17-38. [DOI: 10.1093/neuros/nyw013] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 10/18/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
The skull base is a complex anatomical region that harbors many important neurovascular structures in a relatively confined space. The pathology that can develop at this site is varied, and many disease processes may present with similar clinical and neuroimaging findings. While computed tomography maintains a role in the evaluation of many entities and can, for instance, delineate osseous erosion with great detail and characterize calcified tumor matrices, magnetic resonance imaging (MRI) is the mainstay in the neuroimaging assessment of most pathology occurring at the skull base. Various MRI sequences have proven to be robust tools for tissue characterization and can provide information on the presence of lipids, paramagnetic and diamagnetic elements, and tumor cellularity, among others. In addition, currently available MRI techniques are able to generate high spatial resolution images that allow visualization of cranial nerves and their involvement by adjacent pathology. The information obtained from such examinations may aid in the distinction of these disease processes and in the accurate delineation of their extent prior to biopsy or treatment planning.
Collapse
|
24
|
Abstract
Hypopituitarism refers to deficiency of one or more hormones produced by the anterior pituitary or released from the posterior pituitary. Hypopituitarism is associated with excess mortality, a key risk factor being cortisol deficiency due to adrenocorticotropic hormone (ACTH) deficiency. Onset can be acute or insidious, and the most common cause in adulthood is a pituitary adenoma, or treatment with pituitary surgery or radiotherapy. Hypopituitarism is diagnosed based on baseline blood sampling for thyroid stimulating hormone, gonadotropin, and prolactin deficiencies, whereas for ACTH, growth hormone, and antidiuretic hormone deficiency dynamic stimulation tests are usually needed. Repeated pituitary function assessment at regular intervals is needed for diagnosis of the predictable but slowly evolving forms of hypopituitarism. Replacement treatment exists in the form of thyroxine, hydrocortisone, sex steroids, growth hormone, and desmopressin. If onset is acute, cortisol deficiency should be replaced first. Modifications in replacement treatment are needed during the transition from paediatric to adult endocrine care, and during pregnancy.
Collapse
Affiliation(s)
- Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK; Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephen M Shalet
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK; Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| |
Collapse
|
25
|
Glezer A, Bronstein MD. Pituitary apoplexy: pathophysiology, diagnosis and management. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 59:259-64. [PMID: 26154095 DOI: 10.1590/2359-3997000000047] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 05/29/2015] [Indexed: 11/21/2022]
Abstract
Pituitary apoplexy is characterized by sudden increase in pituitary gland volume secondary to ischemia and/or necrosis, usually in a pituitary adenoma. Most cases occur during the 5th decade of life, predominantly in males and in previously unknown clinically non-functioning pituitary adenomas. There are some predisposing factors as arterial hypertension, anticoagulant therapy and major surgery. Clinical picture comprises headache, visual impairment, cranial nerve palsies and hypopituitarism. Most cases improve with both surgical and expectant management and the best approach in the acute phase is still controversial. Surgery, usually by transsphenoidal route, is indicated if consciousness and/or vision are impaired, despite glucocorticoid replacement and electrolyte support. Pituitary function is impaired in most patients before apoplexy and ACTH deficiency is common, which makes glucocorticoid replacement needed in most cases. Pituitary deficiencies, once established, usually do not recover, regardless the treatment. Sellar imaging and endocrinological function must be periodic reevaluated.
Collapse
Affiliation(s)
- Andrea Glezer
- Hospital das Clinicas, Medical School, University of Sao Paulo, São Paulo, SP, Brazil
| | - Marcello D Bronstein
- Hospital das Clinicas, Medical School, University of Sao Paulo, São Paulo, SP, Brazil
| |
Collapse
|
26
|
Management of clinically non-functioning pituitary adenoma. ANNALES D'ENDOCRINOLOGIE 2015; 76:239-47. [PMID: 26072284 DOI: 10.1016/j.ando.2015.04.002] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/29/2015] [Indexed: 11/20/2022]
Abstract
Clinically NFPA is currently the preferred term for designing all the pituitary adenomas which are not hormonally active (in other words, not associated with clinical syndromes such as amenorrhea-galactorrhea in the context of prolactinomas, acromegaly, Cushing's disease or hyperthyroidism secondary to TSH-secreting adenomas). They account for 15-30% of pituitary adenomas. Diagnosis is usually made either in the context of mass effect due to a macroadenoma or, increasingly, fortuitously during imaging performed for some unrelated purpose; the latter case is known as pituitary incidentaloma. Surgery is indisputably indicated in case of tumoral syndrome, but other aspects of NFPA (hormonal work-up, follow-up, and especially postoperative follow-up, management of remnant or recurrence, the special case of incidentaloma, or apoplexy) remain controversial. The French Endocrinology Society (SFE) therefore set up an expert working group of endocrinologists, neurosurgeons, ophthalmologists, neuroradiologists, pathologists and biologists to draw up guidelines, at the 2012 SFE Congress in Toulouse, France. The present article presents the guidelines suggested by this group of French-speaking experts.
Collapse
|