1
|
Moscona-Nissan A, Sidauy-Adissi J, Hermoso-Mier KX, Glick-Betech SS, Chávez-Vera LDJ, Martinez-Mendoza F, Delgado-Casillas OM, Taniguchi-Ponciano K, Marrero-Rodríguez D, Mercado M. Diagnosis and Treatment of Pituitary Apoplexy, A True Endocrine Emergency. Arch Med Res 2024; 55:103001. [PMID: 38703639 DOI: 10.1016/j.arcmed.2024.103001] [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: 03/05/2024] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024]
Abstract
Pituitary apoplexy (PA) is a clinical syndrome resulting from a hemorrhagic infarction of the pituitary gland. It is characterized by the sudden onset of visual disturbances, nausea, vomiting, headache and occasionally, signs of meningeal irritation and an altered mental status. The exact pathogenesis of PA remains to be elucidated, although tumor overgrowth of its blood supply remains the most popular theory. Main risk factors for the development of PA include systemic, iatrogenic, and external factors as well as the presence of an underlying pituitary tumor. The diagnostic approach of PA includes both neuroimaging and evaluation of pituitary secretory function. PA is a potentially life-threatening condition which should be managed with hemodynamic stabilization, correction of electrolyte abnormalities and replacement of hormonal deficiencies. PA treatment should be individualized based on the severity of the clinical picture which may vary widely. Treatment options include conservative management with periodic follow-up or neurosurgical intervention, which should be decided by a multidisciplinary team. We conducted a systematic review of the literature to unveil the frequency of PA predisposing factors, clinical and biochemical presentations, management strategies and outcomes.
Collapse
Affiliation(s)
- Alberto Moscona-Nissan
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Jessica Sidauy-Adissi
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Karla Ximena Hermoso-Mier
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Shimon Shlomo Glick-Betech
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Leonel de Jesús Chávez-Vera
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Florencia Martinez-Mendoza
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Oscar Mario Delgado-Casillas
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Keiko Taniguchi-Ponciano
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Daniel Marrero-Rodríguez
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Moisés Mercado
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| |
Collapse
|
2
|
Buchta M, Krainz H, Grimm J, Kraus T, Griessenauer CJ, Schwartz C, Ueberschaer MF, Dejaco M, Otto F. Pituitary Apoplexy in Macroadenoma After Minor Surgery: An Unusual Case and Literature Review. Cureus 2024; 16:e57912. [PMID: 38725789 PMCID: PMC11081411 DOI: 10.7759/cureus.57912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2024] [Indexed: 05/12/2024] Open
Abstract
Pituitary apoplexy is a rare and severe complication of pituitary adenoma that may present with new-onset headache, ocular palsy, visual disturbances, life-threatening electrolyte imbalance, and endocrinological disturbances due to pituitary hemorrhage and/or infarction. We report the case of a 58-year-old previously healthy patient who developed isolated mild oculomotor nerve palsy of the left eye following osteosynthesis of a traumatic right distal radius fracture. Initial cerebral magnetic resonance imaging showed a pituitary macroadenoma without characteristic signs of pituitary infarction or hemorrhage. The patient presented to the neurology department on the fifth postoperative day with malaise and fatigue due to pituitary insufficiency, deteriorated rapidly and required intensive care monitoring. Clinical stabilization was achieved through the administration of hydrocortisone, and transsphenoidal resection of the pituitary lesion was performed on the 10th day after acute symptom onset. Histological examination revealed a necrotic pituitary adenoma. Pituitary apoplexy may occur after minor surgery in patients with pituitary adenoma. Clinicians should pay particular attention to laboratory signs of pituitary insufficiency in new-onset oculomotor nerve palsy associated with sellar lesions, as cerebral imaging may miss pituitary apoplexy and therefore delay diagnosis and treatment. In our case, delayed decompressive transsphenoidal resection resulted in the normalization of the oculomotor nerve palsy while the pituitary insufficiency persisted. The potential impact of an earlier surgical intervention on the outcome of pituitary function remains uncertain.
Collapse
Affiliation(s)
- Melanie Buchta
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Herbert Krainz
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Jochen Grimm
- Neuroradiology, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Theo Kraus
- Pathology, University Hospital Salzburg, Paracelsus Private Medical University, Salzburg, AUT
| | - Christoph J Griessenauer
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Christoph Schwartz
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Moritz F Ueberschaer
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Martin Dejaco
- Otolaryngology - Head and Neck Surgery, University Hospital Salzburg, Paracelsus Private Medical University, Salzburg, AUT
| | - Ferdinand Otto
- Neurology, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
- Neurology, Centre for Cognitive Neuroscience, Salzburg, AUT
| |
Collapse
|
3
|
Miller MJ, Charoenkijkajorn C, Pakravan M, Mortensen PW, Chen JJ, Lee AG. Myelin Oligodendrocyte Glycoprotein Antibody-Associated Optic Neuritis Mimicking Pituitary Apoplexy With Bitemporal Field Loss. J Neuroophthalmol 2024; 44:e73-e75. [PMID: 36542667 DOI: 10.1097/wno.0000000000001761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Matthew J Miller
- Baylor College of Medicine (MJM), Houston, Texas; Department of Ophthalmology (CC, MP, PWM, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; Department of Ophthalmology (JJC), Mayo Clinic, Rochester, Minnesota; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; Texas A and M College of Medicine (AGL), Bryan, Texas; Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa; and Departments of Ophthalmology (AGL), Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York
| | | | | | | | | | | |
Collapse
|
4
|
Alshahrani AM, Al Bshabshe A, Al Shahrani MB. Pituitary Apoplexy After a Major Abdominal Surgery: A Case Report. Cureus 2024; 16:e52966. [PMID: 38406091 PMCID: PMC10894319 DOI: 10.7759/cureus.52966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Pituitary apoplexy is a major complication of pituitary adenoma, and the diagnosis might be challenging if the patient presents with signs of meningeal irritation or electrolyte imbalance. It can be fatal if not diagnosed and treated appropriately. Apoplexy is the first clinical presentation in the majority of pituitary adenoma cases. The pathophysiology of pituitary apoplexy involves bleeding and/or ischemia of pituitary enlargement. In this case report, we present a case of pituitary apoplexy that developed after a major abdominal surgery. The patient presented with headache, hypertension, and visual loss. After confirming the diagnosis through a CT scan, the patient underwent a transsphenoidal surgical decompression.
Collapse
Affiliation(s)
| | - Ali Al Bshabshe
- Intensive Care Unit, Aseer Central Hospital, Abha, SAU
- Medicine, King Khalid University, Abha, SAU
| | | |
Collapse
|
5
|
Naik R, Avula S, Palleti SK, Gummadi J, Ramachandran R, Chandramohan D, Dhillon G, Gill AS, Paiwal K, Shaik B, Balachandran M, Patel B, Gurugubelli S, Mariswamy Arun Kumar AK, Nanjundappa A, Bellamkonda M, Rathi K, Sakhamuri PL, Nassar M, Bali A. From Emergence to Endemicity: A Comprehensive Review of COVID-19. Cureus 2023; 15:e48046. [PMID: 37916248 PMCID: PMC10617653 DOI: 10.7759/cureus.48046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 11/03/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), later renamed coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China, in early December 2019. Initially, the China office of the World Health Organization was informed of numerous cases of pneumonia of unidentified etiology in Wuhan, Hubei Province at the end of 2019. This would subsequently result in a global pandemic with millions of confirmed cases of COVID-19 and millions of deaths reported to the WHO. We have analyzed most of the data published since the beginning of the pandemic to compile this comprehensive review of SARS-CoV-2. We looked at the core ideas, such as the etiology, epidemiology, pathogenesis, clinical symptoms, diagnostics, histopathologic findings, consequences, therapies, and vaccines. We have also included the long-term effects and myths associated with some therapeutics of COVID-19. This study presents a comprehensive assessment of the SARS-CoV-2 virology, vaccines, medicines, and significant variants identified during the course of the pandemic. Our review article is intended to provide medical practitioners with a better understanding of the fundamental sciences, clinical treatment, and prevention of COVID-19. As of May 2023, this paper contains the most recent data made accessible.
Collapse
Affiliation(s)
- Roopa Naik
- Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
- Internal Medicine/Hospital Medicine, Geisinger Health System, Wilkes Barre, USA
| | - Sreekant Avula
- Diabetes, Endocrinology, and Metabolism, University of Minnesota, Minneapolis, USA
| | - Sujith K Palleti
- Nephrology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Jyotsna Gummadi
- Internal Medicine, MedStar Franklin Square Medical Center, Baltimore, USA
| | | | | | - Gagandeep Dhillon
- Physician Executive MBA, University of Tennessee, Knoxville, USA
- Internal Medicine, University of Maryland Baltimore Washington Medical Center, Glen Burnie, USA
| | | | - Kapil Paiwal
- Oral & Maxillofacial Pathology, Daswani Dental College & Research Center, Kota, IND
| | - Bushra Shaik
- Internal Medicine, Onslow Memorial Hospital, Jacksonville, USA
| | | | - Bhumika Patel
- Oral Medicine and Radiology, Howard University, Washington, D.C., USA
| | | | | | | | - Mahita Bellamkonda
- Hospital Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Kanika Rathi
- Internal Medicine, University of Florida, Gainesville, USA
| | | | - Mahmoud Nassar
- Endocrinology, Diabetes, and Metabolism, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Atul Bali
- Internal Medicine/Nephrology, Geisinger Medical Center, Danville, USA
- Internal Medicine/Nephrology, Geisinger Health System, Wilkes-Barre, USA
- Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
| |
Collapse
|
6
|
Mattogno PP, Zoli M, D’Alessandris QG, Bongetta D, Caccavella VM, Rigante M, Della Pepa GM, Mazzatenta D, Lauretti L, Olivi A, Spena G, Zoia C. Ultra-Early Treatment of Neurosurgical Emergencies with Endoscopic Endonasal Approach: Experience from Three Italian Referral Centers. J Clin Med 2023; 12:5471. [PMID: 37685541 PMCID: PMC10487769 DOI: 10.3390/jcm12175471] [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: 08/02/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE the aim of this multicenter study is to preliminarily assess the role of the Endoscopic Endonasal Approach (EEA) in ultra-early (i.e., within 12 h) management of selected neurosurgical emergencies in terms of clinical and radiological outcomes. METHODS 26 patients affected by sellar/parasellar pathologies with rapid progression of symptoms were managed with EEA within 12 h from diagnosis in three Italian tertiary referral Centers from January 2016 to December 2019. Both clinical and radiological data have been collected preoperatively as well as post-operatively in order to perform retrospective analysis. RESULTS The average time from admission to the operating room was 5.5 h (±2.3). The extent of resection was gross-total in 20 (76.9%), subtotal in 6 (23.1%) patients. One patient experienced re-bleeding after a subtotal removal of a hemorrhagic lesion. Patients with a longer time from admission (>4 h) to the operatory room (OR) experienced stable impairment of the visual acuity (p = 0.033) and visual field (p = 0.029) in the post-operative setting. CONCLUSIONS The Endoscopic Endonasal Approach represents a safe, effective technique that can be efficiently used with good results in the management of selected neurosurgical emergencies in centers with adequate experience.
Collapse
Affiliation(s)
- Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Matteo Zoli
- Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Institute of Neurological Sciences of Bologna, 40121 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40121 Bologna, Italy
| | | | - Daniele Bongetta
- Department of Neurosurgery, ASST Fatebenefratelli Sacco, 20100 Milan, Italy
| | - Valerio Maria Caccavella
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Mario Rigante
- Department of Otolaryngology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Diego Mazzatenta
- Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Institute of Neurological Sciences of Bologna, 40121 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40121 Bologna, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Giannantonio Spena
- Neurosurgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cesare Zoia
- Neurosurgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| |
Collapse
|
7
|
Tanaka H, Nishimura F, Nakase K, Yokoyama S, Nakagawa I, Yamada S, Tamura K, Matsuda R, Takeshima Y, Kotsugi M, Park YS, Nakase H. Case report: Giant pituitary neuroendocrine tumor presented along with acute visual loss due to pituitary apoplexy after receiving COVID-19 vaccination. Front Surg 2023; 10:1220098. [PMID: 37576925 PMCID: PMC10413133 DOI: 10.3389/fsurg.2023.1220098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 08/15/2023] Open
Abstract
Objective A case of giant pituitary neuroendocrine tumor presented along with acute visual loss due to pituitary apoplexy after receiving a COVID-19 vaccination is reported. Case presentation A 45-year-old man was referred for a giant pituitary tumor with bitemporal hemianopsia. A surgical procedure was planned and then delayed due to the COVID-19 outbreak in Japan, with a Pfizer/BioNTech vaccine administered while awaiting surgery. Three days after the second COVID-19 vaccination the patient noted a progressively worsening headache that caused pituitary apoplexy and then a decrease in vision. Emergency surgery was thus performed. Conclusion Pituitary apoplexy is a rare and life-threatening complication that may occur after undergoing a COVID-19 vaccination.
Collapse
|
8
|
Chang CWJ, Provencio JJ, Pascual J, Heavner MS, Olson D, Livesay SL, Kaplan LJ. State-of-the-Art Evaluation of Acute Adult Disorders of Consciousness for the General Intensivist. Crit Care Med 2023; 51:948-963. [PMID: 37070819 DOI: 10.1097/ccm.0000000000005893] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES To provide a concise review of knowledge and practice pertaining to the diagnosis and initial management of unanticipated adult patient disorders of consciousness (DoC) by the general intensivist. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing adult patient acute DoC diagnostic evaluation and initial management strategies including indications for transfer. STUDY SELECTION Descriptive and interventional studies that address acute adult DoC, their evaluation and initial management, indications for transfer, as well as outcome prognostication. DATA EXTRACTION Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for adult critical care practice. DATA SYNTHESIS Acute adult DoC may be categorized by etiology including structural, functional, infectious, inflammatory, and pharmacologic, the understanding of which drives diagnostic investigation, monitoring, acute therapy, and subsequent specialist care decisions including team-based local care as well as intra- and inter-facility transfer. CONCLUSIONS Acute adult DoC may be initially comprehensively addressed by the general intensivist using an etiology-driven and team-based approach. Certain clinical conditions, procedural expertise needs, or resource limitations inform transfer decision-making within a complex care facility or to one with greater complexity. Emerging collaborative science helps improve our current knowledge of acute DoC to better align therapies with underpinning etiologies.
Collapse
Affiliation(s)
| | | | - Jose Pascual
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - DaiWai Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern, Dallas, TX
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
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
|
11
|
Gheorghe AM, Trandafir AI, Ionovici N, Carsote M, Nistor C, Popa FL, Stanciu M. Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET). Biomedicines 2023; 11:biomedicines11030680. [PMID: 36979658 PMCID: PMC10044830 DOI: 10.3390/biomedicines11030680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.
Collapse
Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra Ioana Trandafir
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Nina Ionovici
- Department of Occupational Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy & “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy & Thoracic Surgery Department, “Carol Davila” Central Emergency University Military Hospital, 013058 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania
| |
Collapse
|
12
|
Targeting the Tumor Immune Microenvironment Could Become a Potential Therapeutic Modality for Aggressive Pituitary Adenoma. Brain Sci 2023; 13:brainsci13020164. [PMID: 36831707 PMCID: PMC9954754 DOI: 10.3390/brainsci13020164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/20/2023] Open
Abstract
OBJECT This study aimed to explore the relationship between the aggressiveness and immune cell infiltration in pituitary adenoma (PA) and to provide the basis for immuno-targeting therapies. METHODS One hundred and three patients with PA who underwent surgery at a single institution were retrospectively identified. The infiltration of macrophages and T-lymphocytes was quantitatively assessed. RESULTS The number of CD68+ macrophages was positively correlated with Knosp (p = 0.003) and MMP-9 expression grades (p = 0.00). The infiltration of CD163+ macrophages differed among Knosp (p = 0.022) and MMP-9 grades (p = 0.04). CD8+ tumor-infiltrating lymphocytes (TILs) were also positively associated with Knosp (p = 0.002) and MMP-9 grades (p = 0.01). Interestingly, MGMT expression was positively correlated with MMP-9 staining extent (p = 0.000). The quantities of CD8+ TILs (p = 0.016), CD68+ macrophages (p = 0.000), and CD163+ macrophages (p = 0.043) were negatively associated with MGMT expression levels. The number of CD68+ macrophages in the PD-L1 negative group was significantly more than that in the PD-L1 positive group (p = 0.01). The rate of PD-L1 positivity was positively correlated with the Ki-67 index (p = 0.046) and p53 expression (p = 0.029). CONCLUSION Targeted therapy for macrophages and CD8+ TILs could be a helpful treatment in the future for aggressive PA. Anti-PD-L1 therapy may better respond to PAs with higher Ki-67 and p53 expression and more infiltrating CD68+ macrophages. Multiple treatment modalities, especially combined with immunotherapy could become a novel therapeutic strategy for aggressive PA.
Collapse
|
13
|
Carlos Rodrigues Junior J, Ely Bortolin da Silva V, Rossi Ujvari M, Alberto Aguillar Condori L, Batista de Sousa A. Laparoscopic Surgery-Induced Pituitary Apoplexy. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
|
14
|
Biagetti B, Sarria-Estrada S, Cordero Asanza E, Chaachou-Charradi A, Ng-Wong YK, Cicuendez M, Hernandez I, Rojano-Toimil A, Costa P, Martinez-Saez E, Casteràs A, Simò R. Risk Factors, Radiological and Clinical Outcomes in Subclinical and Clinical Pituitary Apoplexy. J Clin Med 2022; 11:jcm11247288. [PMID: 36555904 PMCID: PMC9786023 DOI: 10.3390/jcm11247288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/25/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pituitary apoplexy (PA) can be symptomatic, namely acute apoplexy (APA), or asymptomatic or subclinical (SPA). OBJECTIVE To describe the clinical characteristics and evolution of the patients with APA compared to SPA Patients and methods: Retrospective, longitudinal database analysis. RESULTS We identified 58 patients with PA, and 37 accomplished the inclusion criteria (17 men, median age 47.7 years). A total of 29 (78.4%) had APA (17 underwent surgery, and 12 were conservatively managed), and 8 (21.6%) had SPA. The presence of non-functioning pituitary adenoma (NFPA) odds ratio (OR): 29.36 (95% confidence interval (CI): 1.86-462.36) and the largest size OR 1.10 (95% CI: 1.01-1.2) elevated the risk of having surgery. Hypopituitarism developed in 35.1% without significant differences between APA and SPA. In non-surgical patients, adenoma volume shrunk spontaneously at one year magnetic resonance imaging (MRI), without statistical differences between the conservatively treated and SPA group. CONCLUSIONS APA is more frequent in larger NFPAs, and this subset of patients has a higher risk of surgery. Hypopituitarism is quite frequent even in patients with SPA, and, therefore, long-term follow-up is mandatory. In the non-surgical group, the pituitary tumour shrinkage is clinically relevant after one year of PA. Consequently, surgery indication in NFPA should be delayed and reassessed if patients remain asymptomatic.
Collapse
Affiliation(s)
- Betina Biagetti
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
| | - Silvana Sarria-Estrada
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Esteban Cordero Asanza
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | | | - Yiken Karelys Ng-Wong
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Marta Cicuendez
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Irene Hernandez
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Alba Rojano-Toimil
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Pilar Costa
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Elena Martinez-Saez
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Anna Casteràs
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
| | - Rafael Simò
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
| |
Collapse
|
15
|
Pineyro MM, Diaz L, Guzzetti M, Risso M, Pereda J. Acute Sheehan's Syndrome Presenting with Hyponatremia Followed by a Spontaneous Pregnancy. Case Rep Endocrinol 2022; 2022:9181365. [PMID: 36465526 PMCID: PMC9718624 DOI: 10.1155/2022/9181365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Acute Sheehan's syndrome is rare, as well as hyponatremia as its initial manifestation. In addition, spontaneous pregnancy in patients after Sheehan's syndrome is unusual. To our knowledge, no cases of spontaneous pregnancy after acute Sheehan's syndrome have been reported. We describe a case of Sheehan's syndrome that presented with acute hyponatremia and a spontaneous pregnancy. CASE A 34-year-old female developed blood loss during delivery, which required a blood transfusion. On day seven postpartum, she presented with headaches, lethargy, and difficulty in breastfeeding. The workup showed hyponatremia (118 mEq/l), secondary hypothyroidism, and low prolactin levels. Magnetic resonance imaging showed pituitary necrosis. She was treated with NaCl, hydrocortisone (cortisol results were not available), and levothyroxine. Laboratory tests six weeks after discharge showed low IGF-1 and 8 AM cortisol and normal FT4, LH, FSH, and PRL levels. She was able to partially breastfeed until 4 months postpartum. Regular menstrual cycles started three months later. She became spontaneously pregnant one year later. CONCLUSION Acute Sheehan's syndrome should be considered in the evaluation of postpartum patients with suggestive symptoms. Physicians should be aware that hyponatremia could be an initial manifestation of Sheehan's syndrome, which requires a high index of suspicion for diagnosis. Spontaneous pregnancy can occur after acute Sheehan's syndrome.
Collapse
Affiliation(s)
- Maria M. Pineyro
- Clinica de Endocrinología y Metabolismo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Leonardo Diaz
- Clinica de Endocrinología y Metabolismo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Macarena Guzzetti
- Clinica de Endocrinología y Metabolismo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Mariana Risso
- Clinica de Endocrinología y Metabolismo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Jimena Pereda
- Clinica de Endocrinología y Metabolismo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| |
Collapse
|
16
|
Pituitary Apoplexy: Risk Factors and Underlying Molecular Mechanisms. Int J Mol Sci 2022; 23:ijms23158721. [PMID: 35955859 PMCID: PMC9369054 DOI: 10.3390/ijms23158721] [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: 06/27/2022] [Revised: 07/31/2022] [Accepted: 08/04/2022] [Indexed: 12/02/2022] Open
Abstract
Pituitary apoplexy is a rare syndrome, graded from asymptomatic subclinical apoplexy to a life-threatening condition due to pituitary ischemia or haemorrhage of an enlarged pituitary gland. The risk factors and the molecular underlying mechanisms are yet to be elucidated. We provide an overview of the general concepts, the potential factors associated with pituitary adenoma susceptibility for apoplectic events and the molecular mechanisms that could be involved such as HIF-1α/VEGF pathways and metalloproteinases activation, among others. The knowledge of the molecular mechanisms that could participate in the pathogenesis of pituitary apoplexy is crucial to advancement in the identification of future diagnostic tools and therapeutic targets in this rare but sometimes fatal condition.
Collapse
|
17
|
Chow O, Pham T, He B, Hort A, Gibson D, Olsson G. Prolactinoma with apoplexy in the context of thrombocytopaenia: A case report. Int J Surg Case Rep 2022; 95:107228. [PMID: 35617738 PMCID: PMC9133765 DOI: 10.1016/j.ijscr.2022.107228] [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] [Received: 04/13/2022] [Revised: 05/17/2022] [Accepted: 05/17/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction and importance Pituitary apoplexy is a clinical syndrome that occurs secondary to abrupt haemorrhage or infarction and can cause a presentation with headache, visual disturbances, and various neurological deficits. Pituitary apoplexy is a rare clinical syndrome that is often misdiagnosed or discovered late in its clinical course due to its relatively nonspecific clinical presentation. Case presentation The case describes patient with a giant prolactinoma which developed haemorrhagic progression in the context of previously undiagnosed coagulopathy from idiopathic thrombocytopaenia. Transcranial (rather than transnasal) surgery was performed for evacuation and debulking. Conclusion The case highlights the management of an exceedingly large adenoma in the context of coagulopathy contributing to rapid clinical progression, as well as a positive clinical outcome in a patient with restored vision and pituitary function. Apoplexy is a rare-sight threatening condition that must be considered in the context of undiagnosed endocrine deficiencies. A transcranial approach may be required over trans-nasal in the context of massive pituitary tumours. Early evacuation of haemorrhage allows for medical management of pituitary adenoma with good patient outcomes.
Collapse
Affiliation(s)
- Oliver Chow
- Westmead Hospital Plastics and Reconstructive Department, Australia
| | - Therese Pham
- Liverpool Hospital Plastics and Reconstructive Department, Australia
| | - Brandon He
- University of New South Wales, Australia
| | - Amy Hort
- Westmead Hospital General Surgical Department, Australia
| | | | - Gemma Olsson
- Westmead Hospital Neurosurgery Department, Australia
| |
Collapse
|
18
|
Oertel J, Teping F. Editorial "pituitary apoplexy-are visual deficits the only indication for emergent surgical intervention?". Acta Neurochir (Wien) 2022; 164:1125-1126. [PMID: 35067785 PMCID: PMC8967756 DOI: 10.1007/s00701-022-05120-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 01/01/2023]
|
19
|
Guijt MC, Zamanipoor Najafabadi AH, Notting IC, Pereira AM, Verstegen MJT, Biermasz NR, van Furth WR, Claessen KMJA. Towards a pituitary apoplexy classification based on clinical presentation and patient journey. Endocrine 2022; 76:132-141. [PMID: 35067902 PMCID: PMC8986731 DOI: 10.1007/s12020-022-02983-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The condition of pituitary apoplexia contains the clinical spectre from life-threatening emergency to asymptomatic self-limiting course, which partly determines diagnostic delay and management. Outcome evaluation of course and management of pituitary apoplexia is hampered by the diverse presentation of this condition and requires appraisal. This study aimed to describe the patient journey, clinical presentation, and management of various types of pituitary apoplexy in a new classification to facilitate future outcome evaluation and identify unmet needs in the care process. METHODS A single-center retrospective patient chart study was conducted between 2005-2021 (N = 98). Outcome measures were clinical symptoms at first presentation in hospital, being headache, consciousness, visual acuity, visual field defects (VFD), ophthalmoplegia, nausea, vomiting, fever, and hypopituitarism and care process characteristics. RESULTS Mean age was 47.6 ± 16.6 years (51.0% male). We describe their patient journey and identified three different types, differing in clinical presentation, in-hospital route, and final treatment, e.g., Acute (type A, 52%), Subacute (type B, 22.5%), and Non-acute (type C, 25.5%). Type A generally presents with acute onset headaches, VFD, or ophthalmoplegia emergency setting, with lowest mean visual acuity of both eyes and frequent hypocortisolism. CONCLUSIONS Pituitary apoplexy can be approached as a spectrum of disease with 3 main subtypes, with a different initial presentation, different in-hospital route resulting in different management. Acknowledging subtypes with particular needs for (emergency) referrals to Pituitary Tumors Center of Excellence (PTCOE) will serve patient care improvements, outcome evaluations and address areas for improvement.
Collapse
Affiliation(s)
- M C Guijt
- Dept. of Medicine, Division of Endocrinology, and Centre for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, the Netherlands
| | - A H Zamanipoor Najafabadi
- Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospitals, University Neurosurgical Center Holland, Leiden and The Hague, the Netherlands
| | - I C Notting
- Dept. of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Dept. of Medicine, Division of Endocrinology, and Centre for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, the Netherlands
| | - M J T Verstegen
- Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospitals, University Neurosurgical Center Holland, Leiden and The Hague, the Netherlands
| | - N R Biermasz
- Dept. of Medicine, Division of Endocrinology, and Centre for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospitals, University Neurosurgical Center Holland, Leiden and The Hague, the Netherlands
| | - K M J A Claessen
- Dept. of Medicine, Division of Endocrinology, and Centre for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, the Netherlands.
| |
Collapse
|
20
|
Frara S, Loli P, Allora A, Santini C, di Filippo L, Mortini P, Fleseriu M, Giustina A. COVID-19 and hypopituitarism. Rev Endocr Metab Disord 2022; 23:215-231. [PMID: 34387832 PMCID: PMC8363093 DOI: 10.1007/s11154-021-09672-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 02/07/2023]
Abstract
Besides the pulmonary manifestations caused by severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2), an emerging endocrine phenotype, which can heavily impact on the severity of the syndrome, has been recently associated with coronavirus disease 2019 (COVID-19). Patients with pituitary diseases or the pituitary gland itself may also be involved in COVID-19 clinical presentation and/or severity, causing pituitary apoplexy.Moreover, hypopituitarism is frequently burdened by several metabolic complications, including arterial hypertension, hyperglycemia, obesity and vertebral fractures, which have all been associated with poor outcomes and increased mortality in patients infected by SARS-CoV-2.This review will discuss hypopituitarism as a condition that might have a bidirectional relationship with COVID-19 due to the frequent presence of metabolic comorbidities, to the direct or indirect pituitary damage or being per se a potential risk factor for COVID-19. Finally, we will address the current recommendations for the clinical management of vaccines in patients with hypopituitarism and adrenal insufficiency.
Collapse
Affiliation(s)
- Stefano Frara
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Paola Loli
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Agnese Allora
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Santini
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Pietro Mortini
- Neurosurgery Department and Radiosurgery Unit, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Maria Fleseriu
- Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| |
Collapse
|
21
|
Elshimy G, Raj R, Jacob A, Correa R. Late onset of pituitary apoplexy following gonadotropin-releasing hormone agonist for prostate cancer treatment. BMJ Case Rep 2022; 15:e248523. [PMID: 35256375 PMCID: PMC8905893 DOI: 10.1136/bcr-2021-248523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/04/2022] Open
Abstract
Pituitary apoplexy (PA) is a clinical condition characterised by a sudden increase in pituitary gland volume secondary to ischaemia and/or necrosis. Most cases occur in non-functioning pituitary adenoma but can also occur in functioning adenoma. Certain predisposing factors can result in PA and the use of gonadotropin-releasing hormone (GnRH) agonists for prostate cancer (PCa) is one such condition. Once diagnosed, both surgical and conservative management has been used for the treatment of PA. We present a case of a man in his late 50s who developed PA following treatment of PCa with leuprolide. His symptoms developed insidiously and he presented 6 months after symptom onset. Anterior pituitary hormone workup along with pituitary MRI confirmed the diagnosis of PA and patient was subsequently treated with adequate replacement of pituitary hormone with significant improvement in his symptoms. It is very important to keep a high index of suspicion for PA, especially among elderly patients receiving GnRH agonist treatment for PCa.
Collapse
Affiliation(s)
- Ghada Elshimy
- Endocrinology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - Rishi Raj
- Endocrinology, Diabetes and Metabolism, Pikeville Medical Center, Pikeville, Kentucky, USA
- Endocrinology, Diabetes and Metabolism, University of Pikeville Kentucky College of Osteopathic Medicine, Pikeville, Kentucky, USA
| | - Aasems Jacob
- Hematology and Oncology, Pikeville Medical Center, Pikeville, Kentucky, USA
| | - Ricardo Correa
- Endocrinology, Diabetes and Metabolism, The University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| |
Collapse
|
22
|
Andriuskeviciute A, Cossu G, Ameti A, Papadakis G, Daniel RT, Dunet V, Messerer M. Potential Association Between Anabolic Androgenic Steroid Abuse and Pituitary Apoplexy: A Case Report. Front Endocrinol (Lausanne) 2022; 13:890853. [PMID: 35937816 PMCID: PMC9354695 DOI: 10.3389/fendo.2022.890853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Pituitary apoplexy (PA) is a rare, and potentially life-threatening condition, caused by hemorrhage or infarction into the pituitary gland with a rapid expansion of the contents of the sella turcica, associated with sudden intense headache, neurological and endocrinological deterioration. The identification of risk factors is crucial for prevention and optimal management. Herein we report a case of PA occurring 1 month after the initiation of anabolic androgenic steroid abuse for bodybuilding. CASE REPORT A 40-year-old male patient presents with abrupt onset headache associated with left partial third cranial nerve palsy. The MRI shows a sellar lesion involving left cavernous sinus with a heterogenous anterior aspect of the lesion with hemorrhagic zones in favor of PA. Endocrine work-up shows high testosterone level in patient who was using exogenous testosterone without a medical prescription for a month. CONCLUSION We report a case of PA of a pituitary neuroendocrine tumor occurring shortly after AAS. The association between PA and AAS should be considered as a potential risk.
Collapse
Affiliation(s)
- Agne Andriuskeviciute
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Adelina Ameti
- Department of Endocrinology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Georgios Papadakis
- Department of Endocrinology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Vincent Dunet
- Department of Radiology, Neuroradiology division, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
- *Correspondence: Mahmoud Messerer,
| |
Collapse
|
23
|
Abstract
The sellar and parasellar region is complex, with a unique meningeal, neural, vascular, and bony anatomy. Understanding the imaging anatomy is critical for accurate imaging interpretation. resonance (MR) imaging is the primary modality for pituitary imaging, whereas computed tomography may be used when MR imaging is contraindicated, and provides complementary bony anatomic information. This article reviews embryology and anatomy of the sellar and parasellar region. Imaging appearances of pituitary adenomas, Rathke cleft cysts, meningiomas, craniopharyngiomas, arachnoid cysts, vascular disorders, infectious abnormalities, and pituitary apoplexy are discussed and illustrated.
Collapse
Affiliation(s)
- Claudia F E Kirsch
- Department of Radiology, Northwell Health, Zucker Hofstra School of Medicine at Northwell Health, Northshore University Hospital, 300 Community Drive, New York, NY 11030, USA.
| |
Collapse
|
24
|
Nys C, Versyck G, Buelens E, Engelborghs K, Cornips E, Van Leeuwen-Wintjens H, Vankelecom H, Weyns F, Peuskens D. Transnasal transsphenoidal pituitary surgery in a large tertiary hospital, a retrospective study. Acta Chir Belg 2021; 123:272-280. [PMID: 34590931 DOI: 10.1080/00015458.2021.1988231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Pituitary adenomas (PAs), although being small tumours, can have quite an impact on patients' lives causing hormonal and visual disturbances, for which surgery must be performed. As a large peripheral hospital with specialists in pituitary surgery, an assessment of the efficacy and safety of transnasal transsphenoidal pituitary surgery was made. METHODS A retrospective analysis of neurosurgical reports as well as pre and postoperative imaging was made to evaluate the presenting symptoms, tumoural variables, peri-operative morbidity, and long-term outcome. RESULTS This cohort included 105 patients who were operated for PAs over a 9-year period, with a slight male predominance. Adenomas had a mean maximum diameter of almost 25 mm, with one-third of tumours presenting with a Knosp-grade 3 or 4. As expected, most patients presented with either visual (32.4%) or hormonal (40.0%) disturbances. After surgery, 85.3% had complete resolution of visual deficits, and 97.1% had normalisation of hormonal hypersecretion. Postoperative hormonal insufficiency requiring substitution was observed in 43.1% and was significantly more frequent in males and in non-functioning pituitary adenomas (NFAs). Postoperative cerebrospinal fluid (CSF) leakage was observed in 2.9%, and merely one patient developed meningitis. Tumour recurrence was significantly more frequent in patients with partial resection as compared to complete resection (25.6 vs. 7.9%). CONCLUSIONS This study demonstrates that transnasal transsphenoidal pituitary surgery can be performed safely and effectively in a large non-university hospital, improving visual and/or hormonal disturbances as well as providing long-term tumour control. Patients with larger adenomas are at an increased risk to develop postoperative hypopituitarism.
Collapse
Affiliation(s)
- Charlotte Nys
- Department of Development and Regeneration, Laboratory of Tissue Plasticity in Health and Disease, Cluster of Stem Cell and Developmental Biology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Georges Versyck
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Eveleen Buelens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Koen Engelborghs
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Erwin Cornips
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | | | - Hugo Vankelecom
- Department of Development and Regeneration, Laboratory of Tissue Plasticity in Health and Disease, Cluster of Stem Cell and Developmental Biology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Frank Weyns
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Diederik Peuskens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| |
Collapse
|
25
|
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.
Collapse
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.
| |
Collapse
|
26
|
Ohata H, Shinde B, Nakamura H, Teranishi Y, Morisako H, Ohata K, Goto T. Pituitary apoplexy in a puberal child: A case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
27
|
LaRoy M, McGuire M. Pituitary apoplexy in the setting of COVID-19 infection. Am J Emerg Med 2021; 47:329.e1-329.e2. [PMID: 33658149 PMCID: PMC7901271 DOI: 10.1016/j.ajem.2021.02.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/04/2021] [Accepted: 02/18/2021] [Indexed: 01/05/2023] Open
Affiliation(s)
- Michael LaRoy
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States.
| | - Morgan McGuire
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States
| |
Collapse
|
28
|
MR-Based Radiomics for Differential Diagnosis between Cystic Pituitary Adenoma and Rathke Cleft Cyst. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:6438861. [PMID: 34422095 PMCID: PMC8373489 DOI: 10.1155/2021/6438861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022]
Abstract
Background It is often tricky to differentiate cystic pituitary adenoma from Rathke cleft cyst with visual inspection because of similar MRI presentations between them. We aimed to design an MR-based radiomics model for improving differential diagnosis between them. Methods Conventional diagnostic MRI data (T1-,T2-, and postcontrast T1-weighted MR images) were obtained from 215 pathologically confirmed patients (105 cases with cystic pituitary adenoma and the other 110 cases with Rathke cleft cyst) and were divided into training (n = 172) and test sets (n = 43). MRI radiomics features were extracted from the imaging data, and semantic imaging features (n = 15) were visually estimated by two radiologists. Four classifiers were used to construct radiomics models through 5-fold crossvalidation after feature selection with least absolute shrinkage and selection operator. An integrated model by combining radiomics and semantic features was further constructed. The diagnostic performance was validated in the test set. Receiver operating characteristic curve was used to evaluate and compare the performance of the models at the background of diagnostic performance by radiologist. Results In test set, the combined radiomics and semantic model using ANN classifier obtained the best classification performance with an AUC of 0.848 (95% CI: 0.750-0.946), accuracy of 76.7% (95% CI: 64.1-89.4%), sensitivity of 73.9% (95% CI: 56.0-91.9%), and specificity of 80.0% (95% CI: 62.5-97.5%) and performed better than multiparametric model (AUC = 0.792, 95% CI: 0.674-0.910) or semantic model (AUC = 0.823, 95% CI: 0.705-0.941). The two radiologists had an accuracy of 69.8% and 74.4%, respectively, sensitivity of 69.6% and 73.9%, and specificity of 70.0% and 75.0%. Conclusions The MR-based radiomics model had technical feasibility and good diagnostic performance in the differential diagnosis between cystic pituitary adenoma and Rathke cleft cyst.
Collapse
|
29
|
Martinez-Perez R, Kortz MW, Carroll BW, Duran D, Neill JS, Luzardo GD, Zachariah MA. Coronavirus Disease 2019 and Pituitary Apoplexy: A Single-Center Case Series and Review of the Literature. World Neurosurg 2021; 152:e678-e687. [PMID: 34129968 PMCID: PMC8196470 DOI: 10.1016/j.wneu.2021.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/23/2022]
Abstract
Background Pituitary apoplexy (PA) is a rare, but life-threatening, condition characterized by pituitary infarction and hemorrhage, most often in the setting of a preexisting adenoma. The risk factors and mechanisms associated with PA are poorly understood. Although neurovascular manifestations of coronavirus disease 2019 (COVID-19) infection have been documented, its association with PA has not yet been determined. Methods From a prospectively collected database of patients treated at a tertiary care center for pituitary adenoma, we conducted a retrospective medical record review of PA cases during the COVID-19 pandemic from March 2020 to December 2020. We also conducted a literature review to identify other reported cases. Results We identified 3 consecutive cases of PA and concomitant COVID-19 infection. The most common symptoms at presentation were headache and vision changes. The included patients were successfully treated with surgical decompression and medical management of the associated endocrinopathy, ultimately experiencing improvement in their visual symptoms at the latest follow-up examination. COVID-19 infection in the perioperative period was corroborated by polymerase chain reaction test results in all the patients. Conclusions With the addition of our series to the literature, 10 cases of PA in the setting of COVID-19 infection have been confirmed. The present series was limited in its ability to draw conclusions about the relationship between these 2 entities. However, COVID-19 infection might represent a risk factor for the development of PA. Further studies are required.
Collapse
Affiliation(s)
| | - Michael W Kortz
- Department of Neurological Surgery, University of Colorado, Aurora, Colorado, USA
| | - Benjamin W Carroll
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Daniel Duran
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - James S Neill
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Gustavo D Luzardo
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Marcus A Zachariah
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
30
|
Abstract
BACKGROUND Despite COVID-19 being identified as severe respiratory viral infection, progressively many relevant endocrine manifestations have been reported greatly contributing to the severity of the clinical presentation. Systemic involvement in COVID-19 is due to the ubiquitous expression of angiotensin-converting enzyme 2 (ACE2) receptor, responsible for the entry in the cells of SARS-CoV-2, Several reports in humans and animal models showed a significant ACE2 mRNA expression in hypothalamus and pituitary cells. Moreover, higher mortality and poorer outcomes have been widely described in COVID-19 patients with obesity, diabetes and vertebral fractures, which are all highly prevalent in subjects with pituitary dysfunctions. AIM To review the main endocrine manifestations of COVID-19 with their possible implications for pituitary diseases, the possible direct and indirect involvement of the pituitary gland in COVID-19, the impact of COVID-19 on the management of established pituitary diseases which can be already at increased risk for worse outcomes and on neurosurgical activities as well as vaccination. CONCLUSIONS Our review underlines that there could be a specific involvement of the pituitary gland which fits into a progressively shaping endocrine phenotype of COVID-19. Moreover, the care for pituitary diseases need to continue despite the restrictions due to the emergency. Several pituitary diseases, such as hypopituitarism and Cushing disease, or due to frequent comorbidities such as diabetes may be a risk factor for severe COVID-19 in affected patients. There is the urgent need to collect in international multicentric efforts data on all these aspects of the pituitary involvement in the pandemic in order to issue evidence driven recommendations for the management of pituitary patients in the persistent COVID-19 emergency.
Collapse
Affiliation(s)
- Stefano Frara
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCC Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Agnese Allora
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCC Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Laura Castellino
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCC Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCC Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Paola Loli
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCC Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCC Hospital, Via Olgettina 60, 20132, Milan, Italy.
| |
Collapse
|
31
|
Penner F, Grottoli S, Lanotte MMR, Garbossa D, Zenga F. Pituitary surgery during Covid-19: a first hand experience and evaluation. J Endocrinol Invest 2021; 44:635-636. [PMID: 32651894 PMCID: PMC7351547 DOI: 10.1007/s40618-020-01354-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/04/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE During the Covid-19 pandemic every hospital has had to change its internal organization. Different institutions have highlighted the risks connected with endoscopic endonasal surgery. The goal of this paper is to illustrate the feasibility of pituitary region surgery during the SARS-CoV-2 pandemic. METHODS After two negative Covid tests were obtained, three patients with macro GH-secreting tumors, and two patients with micro ACTH-secreting tumors resistant to medical treatment underwent surgery during the pandemic. During the surgery, every patient was treated as if they were positive. RESULTS Neither operator, nor patient have developed Covid symptoms. The two neurosurgeons performing the operations underwent two Covid swab, which resulted negative. CONCLUSIONS Pituitary surgery is a high risk non-urgent surgery. However, the method described has so far been effective and is safe for both patients and healthcare providers.
Collapse
Affiliation(s)
- F Penner
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy.
| | - S Grottoli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital, Cleveland, USA
| | - M M R Lanotte
- Department of Neuroscience "Rita Levi Montalcini", Stereotactic and Functional Neurosurgical Unit, University of Turin, Turin, Italy
| | - D Garbossa
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - F Zenga
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| |
Collapse
|
32
|
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.
Collapse
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,
| |
Collapse
|
33
|
Chan JL, Gregory KD, Smithson SS, Naqvi M, Mamelak AN. Pituitary apoplexy associated with acute COVID-19 infection and pregnancy. Pituitary 2020; 23:716-720. [PMID: 32915365 PMCID: PMC7484495 DOI: 10.1007/s11102-020-01080-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE We report a case of a pregnant female presenting with pituitary apoplexy and simultaneous SARS-CoV-2 infection with a focus on management decisions. CLINICAL HISTORY A 28-year-old G5P1 38w1d female presented with 4 days of blurry vision, left dilated pupil, and headache. She tested positive for SARS-CoV-2 on routine nasal swab testing but denied cough or fever. Endocrine testing demonstrated an elevated serum prolactin level, and central hypothyroidism. MRI showed a cystic-solid lesion with a fluid level in the pituitary fossa and expansion of the sella consistent with pituitary apoplexy. Her visual symptoms improved with corticosteroid administration and surgery was delayed to two weeks after her initial COVID-19 infection and to allow for safe delivery of the child. A vaginal delivery under epidural anesthetic occurred at 39 weeks. Two days later, transsphenoidal resection of the mass was performed under strict COVID-19 precautions including use of Powered Air Purifying Respirators (PAPRs) and limited OR personnel given high risk of infection during endonasal procedures. Pathology demonstrated a liquefied hemorrhagic mass suggestive of pituitary apoplexy. She made a full recovery and was discharged home two days after surgery. CONCLUSION Here we demonstrate the first known case of successful elective induction of vaginal delivery and transsphenoidal intervention in a near full term gravid patient presenting with pituitary apoplexy and acute SARS-CoV-2 infection. Further reports may help determine if there is a causal relationship or if these events are unrelated. Close adherence to guidelines for caregivers can greatly reduce risk of infection.
Collapse
Affiliation(s)
- Julie L Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kimberly D Gregory
- Cedars-Sinai Medical Center, Maternal Fetal Medicine, Los Angeles, CA, USA
| | - Sarah S Smithson
- Cedars-Sinai Medical Center, Maternal Fetal Medicine, Los Angeles, CA, USA
| | - Mariam Naqvi
- Cedars-Sinai Medical Center, Maternal Fetal Medicine, Los Angeles, CA, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Araujo-Castro M, Berrocal VR, Pascual-Corrales E. Pituitary tumors: epidemiology and clinical presentation spectrum. Hormones (Athens) 2020; 19:145-155. [PMID: 31933100 DOI: 10.1007/s42000-019-00168-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
Pituitary tumors (PTs) are a heterogeneous group of lesions of the central nervous system that are usually benign. Most of them occur sporadically, but 5% can do so within family syndromes, usually at a young age. There are differences by sex, age, race, and genetic factors in the prevalence of different tumor cell types and clinical presentation. Functioning-PTs (FPTs) are usually diagnosed earlier than non-functioning PTs (NFPTs). However, this depends on the PT type. Headaches and visual disturbances are the most frequent mass-effect symptoms, but seizures or hydrocephalus may also occur. Pituitary apoplexy is another possible mode of presentation, and it requires special attention because of its potential severity. PTs in pregnancy, childhood, and old age present a series of clinical peculiarities that must be taken into account when evaluating these patients. Ectopic PTs (EPTs) are uncommon and share the same clinical-epidemiological data as eutopic PTs, but, depending on their location, other types of clinical manifestations may appear. Silent PTs are often detected as an incidentaloma or due to neurologic symptoms related to mass-effect. Aggressive PTs and pituitary carcinomas (PCs), which are very rare, are characterized by multiple local recurrences and metastases, respectively. This review addresses the epidemiology and clinical presentation of PTs, from the classical hormonal and mass-effect symptoms to the different rare presentations, such as pituitary apoplexy, hydrocephalus, or diabetes insipidus. Moreover, special situations of the presentation of PTs are discussed, namely, PTs in pregnancy, childhood, and the elderly, EPTs, silent and aggressive PTs, and PCs.
Collapse
Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology Unit, Endocrinology Department, Ramón y Cajal University Hospital, Madrid, Spain.
| | | | - Eider Pascual-Corrales
- Neuroendocrinology Unit, Endocrinology Department, Ramón y Cajal University Hospital, Madrid, Spain
| |
Collapse
|