Pituitary apoplexy: a complication of cardiac surgery

Oculomotor nerve palsy following coronary artery bypass graft surgery: can pituitary apoplexy complicate the post-operative course of cardiac surgery?

Oculomotor nerve palsy, due to pituitary apoplexy, has been previously reported in the literature. However, the association with coronary artery bypass graft surgery (CABG) is rarely investigated. This article reports a case of pituitary apoplexy presenting with oculomotor nerve palsy following CABG. A 65-year-old male, known to have ischemic heart disease, diabetes mellitus and hypertension, presented with ptosis, diplopia and anisocoria that developed after 1 day of CABG. Radiological imaging demonstrated a pituitary adenoma with acute/subacute hemorrhage causing mild mass effect on the cavernous sinus. Considering the acute state of bypass surgery and pre-existing cardiac co-morbidities, expectant management was considered. The visual acuity and palsy gradually improved. Pituitary apoplexy, following CABG, is a rare phenomenon in the post-operative period. High index of suspicious is required to promptly identify high-risk patients to avoid further neurological sequelae.

[Pituitary apoplexy following coronary bypass surgery: A case report and literature review]

INTRODUCTION

Pituitary apoplexy is a >rare entity that presents with a sudden onset of headache associated with visual and endocrinological disturbances due to pituitary hemorrhage or infarction. It usually occurs in patients with an unknown pituitary adenoma. Cardiac surgery, and especially coronary artery bypass grafting, can be a precipitating factor in these patients.

CASE REPORT

We report an 82-year-old male patient who presented with sudden headache and delirium, a right sixth cranial nerve palsy, a right temporal hemianopsia, and a severe loss of left eye visual acuity in the immediate post-operative course of a coronary artery bypass surgery. Pituitary apoplexy was demonstrated on both MRI and CT-scan. Trans-sphenoidal surgical decompression was performed 13 days after coronary artery bypass grafting, with immediate beneficial effect on the delirium and a partial recovery of visual disturbances.

CONCLUSION

Pituitary apoplexy is a rare and life-threatening complication that may occur after cardiac surgery (coronary artery bypass, cardiac valve surgery), often precipitated by the use of cardiopulmonary bypass. It can occur after other surgical procedures (orthopedic, digestive, thoracic). The diagnosis must be considered during the early postoperative period in the presence of unusual and severe headache associated with visual disturbances.

Urgent Surgery for Pituitary Adenoma Bleeding After Coronary Bypass Surgery

Pituitary gland adenoma bleeding is an uncommon complication after coronary artery surgery. Clinical presentation may be variable. We report a case of hemorrhagic complication of a pituitary gland adenoma requiring urgent surgery in a 60-year-old male patient who underwent coronary artery bypass grafting operation.

Pituitary apoplexy following lumbar fusion surgery in prone position: A case report

RATIONALE

Pituitary apoplexy (PA) is a syndrome caused by acute hemorrhage or infarction of the pituitary gland, generally within a pituitary adenoma. PA following spinal surgery is a very rare complication and may be difficult to diagnose. However, early diagnosis of PA is essential for the timely treatment of pan-hypopituitarism and prevention of severe neurologic complications.

PATIENT CONCERNS

A 73-year-old man had a posterior lumbar fusion surgery over a period of 8 hours on prone position. The patient complained of severe intractable headache accompanied by ophthalmalgia and ptosis on right eye 2 days after the surgery.

DIAGNOSIS

Brain magnetic resonance imaging revealed a 1.3 × 2.6 × 2 cm mass in the sellar fossa and suprasellar region and the laboratory tests indicated pan-hypopituitarism.

INTERVENTIONS

High-dose intravenous steroid therapy and trans-sphenoidal hypophysectomy were performed.

OUTCOMES

Pathological evaluation of the surgical specimen revealed a pituitary adenoma with total necrosis, indicating that the PA occurred because of tumor infarction. The patient recovered fully after resection of the pituitary adenoma and hormonal therapy.

LESSONS

Even though the incidence is low, PA has been related to blood pressure fluctuations or vasospasm during surgery. PA should be considered during differential diagnosis in cases of postoperative severe headache or ophthalmic complications.

Pituitary Apoplexy

Pituitary apoplexy, a rare clinical syndrome secondary to abrupt hemorrhage or infarction, complicates 2%-12% of pituitary adenomas, especially nonfunctioning tumors. Headache of sudden and severe onset is the main symptom, sometimes associated with visual disturbances or ocular palsy. Signs of meningeal irritation or altered consciousness may complicate the diagnosis. Precipitating factors (increase in intracranial pressure, arterial hypertension, major surgery, anticoagulant therapy or dynamic testing, etc) may be identified. Corticotropic deficiency with adrenal insufficiency may be life threatening if left untreated. Computed tomography or magnetic resonance imaging confirms the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. Formerly considered a neurosurgical emergency, pituitary apoplexy always used to be treated surgically. Nowadays, conservative management is increasingly used in selected patients (those without important visual acuity or field defects and with normal consciousness), because successive publications give converging evidence that a wait-and-see approach may also provide excellent outcomes in terms of oculomotor palsy, pituitary function and subsequent tumor growth. However, it must be kept in mind that studies comparing surgical approach and conservative management were retrospective and not controlled.

Pituitary apoplexy following mitral valvuloplasty

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome caused by the sudden enlargement of a pituitary adenoma secondary to hemorrhage or infarction. Pituitary apoplexy after cardiac surgery is a very rare perioperative complication. Factors associated with open heart surgery that may lead to pituitary apoplexy include hemodynamic instability during cardiopulmonary bypass and systemic heparinization. We report a case of pituitary apoplexy after mitral valvuloplasty with cardiopulmonary bypass. After early pituitary tumor resection and hormonal replacement therapy, the patient made a full recovery.

Management of endocrine disease: pituitary tumour apoplexy

Pituitary tumour apoplexy (PA) is a rare clinical syndrome that occurs as a result of acute haemorrhage and/or infarction within a frequently undiagnosed pituitary tumour. The sudden enlargement of the pituitary mass undergoing PA is responsible for a wide range of acute symptoms/signs (severe headache, visual loss, diplopia, hypopituitarism, impaired consciousness) which, together with the radiological evidence of a pituitary lesion, establish the diagnosis. The optimal care of PA requires involvement of a multidisciplinary team including endocrinologist, neurosurgeon, neuroophthalmologist and the management strategy that depends on the clinical manifestations, as well as the presence of co-morbidities. Prompt surgical decompression is initially indicated in cases with severe or progressive impairment of the visual acuity or the visual fields or with altered mental state and leads to visual and neurological recovery in most of the patients. The patients with mild, stable clinical picture (including those with isolated ocular palsies) can be managed conservatively (support of fluid and electrolyte balance and stress doses of steroids in most cases) with favourable visual and neurological outcome. Frequent reassessment is mandatory because the clinical course can be unpredictable; if progression of symptoms occurs, later elective surgery is indicated and is beneficial, especially in terms of visual outcome. The endocrinological outcome is less favourable, irrespective of the treatment option, with many patients remaining on long-term replacement therapy. Despite the above guidelines, clear proof of optimal outcomes in the form of randomised controlled trials is lacking. Regrowth of the pituitary tumour years after a PA episode is possible and patients require long-term surveillance.

Iatrogenic diplopia [corrected]

Diplopia is a very disturbing condition that has been reported as a complication of several surgical procedures. The following review aims to identify the ocular and nonocular surgical techniques more often associated with this undesirable result. Diplopia is reported as an adverse outcome of some neurosurgical procedures, dental procedures, endoscopic paranasal sinus surgery, and several ophthalmic procedures. The most common patterns and some recommendations in order to prevent and treat this frustrating outcome are also given.

Neurologic complications of cardiac surgery and interventional cardiology

A wide array of neurologic complications can occur in relation to cardiac surgical procedures, most of which are transient and do not result in permanent sequelae. Specific neurologic insults can occur depending on the type of cardiac procedure and are an important cause of morbidity and mortality. Neurologists practicing in the hospital setting as well as outpatient neurologists should be familiar with the cardiac surgical procedures currently available. Prompt identification of neurologic deficits is important in order to plan an appropriate systematic evaluation and initiate possible treatments in a timely manner. This chapter provides a comprehensive overview of all facets of neurologic complications after cardiac surgical procedures.

Waking up from coronary bypass surgery and one eye does not move right

INTRODUCTION

Complications of coronary artery bypass graft surgery (CABG) include acute oculomotor nerve palsy secondary to ischemic stroke and pituitary apoplexy. These can present with impairment of extraocular muscle function as well as involvement or sparing of the pupil.

CASE REPORT

We report the case of a 58-year-old male admitted for elective CABG surgery for severe coronary artery disease and found to have a pupil-sparing partial oculomotor palsy post-procedure. Neurological examination revealed left pupil-sparing isolated medial rectus and levator palpebrae superioris paresis. Magnetic resonance imaging demonstrated acute midbrain infarction.

CONCLUSION

Acute pupil-sparing partial oculomotor nerve palsy should be recognized as a neurological complication of cardiac surgery. Pupillary involvement can be helpful in identifying the underlying etiology.

Hypopituitarism in the elderly

Pituitary dysfunction in elderly can represent a true diagnostic and therapeutic challenge to clinicians caring for these patients. Symptoms associated with partial or total hypopituitarism, such as fatigue, lower muscle strength and decreased libido, are nonspecific and can be often attributed to normal aging. Gold standard pituitary diagnostic testing carries higher risks in elderly and is classically replaced by alternative testing. Furthermore, the benefits and safety of selective pituitary hormonal replacement, specifically sexual and growth hormone replacement, remain subject of controversy in this group of patients. Recognizing and appropriately treating hypopituitarism in elderly is crucial for the survival and well being of the older patients with this disease.

Perioperative visual loss in ocular and nonocular surgery

Incidence estimates for perioperative vision loss (POVL) after nonocular surgery range from 0.013% for all surgeries up to 0.2% following spine surgery. The most common neuro-ophthalmologic causes of POVL are the ischemic optic neuropathies (ION), either anterior (AION) or posterior (PION). We identified 111 case reports of AION following nonocular surgery in the literature, with most occurring after cardiac surgery, and 165 case reports of PION following nonocular surgery, with most occurring after spine surgery or radical neck dissection. There were an additional 526 cases of ION that did not specify if the diagnosis was AION or PION. We also identified 933 case reports of central retinal artery occlusion (CRAO), 33 cases of pituitary apoplexy, and 245 cases of cortical blindness following nonocular surgery. The incidence of POVL following ocular surgery appears to be much lower than that seen following nonocular surgery. We identified five cases in the literature of direct optic nerve trauma, 47 cases of AION, and five cases of PION following ocular surgery. The specific pathogenesis and risk factors underlying these neuro-ophthalmic complications remain unknown, and physicians should be alert to the potential for loss of vision in the postoperative period.

Pituitary Apoplexy and CABG: Should We Change Our Strategy?

Patients with pituitary adenoma that had coronary artery bypass grafting with cardiopulmonary bypass had pituitary apoplexy develop with neurologic deficits and even death. Four patients with pituitary adenoma underwent coronary artery bypass grafting operations (3 patients had coronary artery bypass grafting on bypass, 1 of them with known pituitary adenoma. All of them had pituitary apoplexy develop with neurologic deficits). One patient with known pituitary adenoma who had a coronary artery bypass grafting operation off pump was neurologically intact. Our recommendation is to consider operating on patients with pituitary adenoma who need coronary artery bypass grafting operation off pump, and to prevent pituitary apoplexy that cardiopulmonary bypass may cause.

Silent Pituitary Infarction After Coronary Artery Bypass Grafting Procedure: Case Report and Review of Literature

OBJECTIVE

To report a case of silent pituitary infarction that occurred after a coronary artery bypass grafting procedure and review the relevant literature.

METHODS

We describe a female patient with silent pituitary infarction several months after a coronary artery bypass operation and discuss her presentation, clinical findings, and laboratory evaluation. We also review similar cases in the literature.

RESULTS

A 73-year-old woman presented with generalized fatigue, weakness, and an elevated creatine kinase level several months after she had undergone a coronary artery bypass procedure. The findings on laboratory evaluation were consistent with hypogonadism, growth hormone deficiency, central hypothyroidism, and adrenal insufficiency. Magnetic resonance imaging of the pituitary fossa showed an empty sella turcica and no sellar enlargement. The patient had no headaches, no neuro-ophthalmologic symptoms, and no focal neurologic deficits. The presentation was slow and insidious. The patient received glucocorticoid and thyroid hormone replacement therapy, after which her clinical status improved substantially. Silent pituitary infarction after coronary artery bypass grafting has been reported previously in 3 male patients, but our current case is the first such report in a female patient.

CONCLUSION

Silent pituitary infarction can be a complication of a coronary artery bypass grafting procedure, with a delayed and insidious presentation.

Ptosis postcardiac surgery: a case of pituitary apoplexy

We present a patient in whom ptosis and third cranial nerve palsy developed postcoronary artery bypass grafting, and discuss the management of pituitary apoplexy postcardiac surgery.

Pituitary gland macroadenoma: a cause of transient blindness after cardiac surgery

Pituitary gland macroadenoma complicating cardiac surgery is an uncommon condition of spectacular clinical presentation that is generally treated by surgery. We report here on an unusual presentation of this condition that was successfully managed by medical treatment.

Two Cases of Hemorrhage in Benign Brain Tumors during Systemic Heparinization. Case Reports

SUMMARY

Anticoagulant therapy is usually used after endovascular operations like coil embolization of aneurysms, or for thromboembolic diseases such as myocardial infarction. Few data exist regarding hemorrhage from benign brain tumors during systemic heparinization with the exception of pituitary adenomas (1,2). We experienced two cases of hemorrhage from benign brain tumors during systemic heparinization. The first patient had an unruptured aneurysm in her suprasellar tumor. She underwent coil embolization to prevent hemorrhage during the subsequent tumorectomy. During and after the endovascular operation, she was heparinized and she suffered a hemorrhage from the tumor on the first postoperative day. The second patient had a suprasellar tumor and was heparinized prophylactically for myocardial infarction. He had an intratumoral hemorrhage on the fifth day after the start of the heparinization. This small series suggests that systemic heparinization with brain tumors, even when they are benign, is very dangerous, and further studies with a larger patient base are warranted.

Perioperative management of a patient requiring surgery for pituitary apoplexy and severe angina pectoris

We describe the management of a 71-yr-old man with pituitary apoplexy and severe angina pectoris who underwent treatment of an intra-cranial haemorrhage and open-heart surgery requiring anticoagulant therapy within a very short period. Subtotal removal of the pituitary tumour was undertaken under stable cardiovascular conditions. But ventricular fibrillation occurred after the neurosurgery in the intensive care unit. After the patient was defibrillated, intra-aortic balloon pumping was necessary to assist coronary artery blood flow. Twenty hours after neurosurgery, oozing from the surgical wound stopped and coronary artery bypass grafting with full heparinization was performed uneventfully.

Heparin therapy for myocardial infarction: an unusual trigger for pituitary apoplexy

A 68-year-old man with coronary artery disease was admitted for chest pain and ventricular tachycardia. After electric cardioversion, therapeutic heparinization was started for myocardial ischemia and nontransmural infarction. On day 3, headache and fever developed, followed by an altered sensorium and hyponatremia. Infectious etiology for the fever was excluded, and results of computed tomography of the brain were normal. Later magnetic resonance imaging (Day 10) demonstrated a pituitary macroadenoma with hemorrhage. Treatment for panhypopituitarism with stress-dose steroids stabilized the patient, and the fever and hyponatremia resolved. Transsphenoidal resection of the pituitary adenoma was performed without incident. This is the first reported case of pituitary apoplexy after heparin anticoagulation for acute myocardial infarction, although chronic anticoagulation in other settings has been reported as a precipitant of apoplexy. The uncommon presentation of a "central" fever and confusion in a patient with previously undiagnosed adenoma posed a diagnostic challenge. Subtle presentations of panhypopituitarism, knowledge of which should lead to suspicion and early diagnosis of pituitary apoplexy, will prevent anticoagulant-induced central nervous system catastrophes and potential fatalities.

Hypopituitarism following coronary artery bypass surgery

Coronary artery bypass surgery (CABS) is a common operation, which is often complicated by neurological sequelae. Disturbances of cerebral blood flow have been reported up to eight days after surgery and pituitary apoplexy has previously been reported. We report a case of hypopituitarism without pituitary apoplexy, which developed after a period of sustained arterial hypotension, during coronary artery bypass surgery.

Pituitary adenomas complicating cardiac surgery: summary and review of 11 cases

From the literature and our own experience, 11 cases of hemorrhage or infarction of a pituitary adenoma associated with cardiac surgery have been identified over a 13-year period. Males outnumbered females by 10 to 1. Symptoms observed were headache, lethargy, confusion, obtundation, unilateral ptosis, meiosis, and opthalmoplegia involving cranial nerves III, IV, and VI, visual field deficits, and hemiparesis. Diagnosis in most recent cases has been confirmed with computerized tomography or magnetic resonance imaging. All patients received adrenocortical steroid therapy initially. Eight patients underwent transsphenoidal hypophysectomy and all survived. One patient underwent decompression craniotomy and died. Intracranial surgery was deferred in 1 patient who survived and in another who died of a massive stroke. Residual neurological deficits were noted to be either absent, minimal, or resolving in 7 of the 9 patients who survived their initial hospitalization. While numerous mechanisms have been proposed to explain the hemorrhage and necrosis of a pituitary adenoma during heart surgery, no direct cause has been clearly identified. Surgical treatment is commonly necessary since untreated pituitary apoplexy is often fatal. Transsphenoidal hypophysectomy with decompression is the preferred method of treatment with a low perioperative mortality and fairly good long-term prognosis.

Pituitary apoplexy following coronary artery bypass surgery

Pituitary apoplexy is a syndrome with variable clinical manifestations depending on which parasellar structures (such as the optic nerves and chiasm, cavernous and sphenoid sinuses, or the hypothalamus) are compressed when the pituitary undergoes rapid enlargement. Factors associated with cardiopulmonary bypass that may lead to pituitary apoplexy include ischemia, hemorrhage, edema, and positive pressure ventilation. Seven cases of pituitary apoplexy following cardiopulmonary bypass have been reported, including the present case. Transsphenoidal surgical decompression in the present case and those previously reported appears to be safe after cardiac surgery and may be helpful in amelioration of compression of nearby structures. Pituitary apoplexy should be considered as a diagnostic possibility in patients who develop visual disturbances or ophthalmoplegia following open heart surgery.