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Ciavarra B, McIntyre T, Kole MJ, Li W, Yao W, Guttenberg KB, Blackburn SL. Antiplatelet and anticoagulation therapy and the risk of pituitary apoplexy in pituitary adenoma patients. Pituitary 2023:10.1007/s11102-023-01316-5. [PMID: 37115294 DOI: 10.1007/s11102-023-01316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Pituitary apoplexy can be a life threatening and vision compromising event. Antiplatelet and anticoagulation use has been reported as a contributing factor in pituitary apoplexy (PA). Utilizing one of the largest cohorts in the literature, this study aims to determine the risk of PA in patients on antiplatelet/anticoagulation (AP/AC) therapy. METHODS A single center, retrospective study was conducted on 342 pituitary adenoma patients, of which 77 patients presented with PA (23%). Several potential risk factors for PA were assessed, including: patient demographics, tumor characteristics, pre-operative hormone replacement, neurologic deficits, coagulation studies, platelet count, and AP/AC therapy. RESULTS Comparing patients with and without apoplexy, there was no significant difference in the proportion of patients taking aspirin (45 no apoplexy vs. 10 apoplexy; p = 0.5), clopidogrel (10 no apoplexy vs. 4 apoplexy; p = 0.5), and anticoagulation (7 no apoplexy vs. 3 apoplexy; p = 0.7). However, male sex (p-value < 0.001) was a predictor for apoplexy while pre-operative hormone treatment was a protective factor from apoplexy (p-value < 0.001). A non-clinical difference in INR was also noted as a predictor for apoplexy (no apoplexy: 1.01 ± 0.09, apoplexy: 1.07 ± 0.15; p < 0.001). CONCLUSIONS Although pituitary tumors have a high risk for spontaneous hemorrhage, the use of aspirin is not a risk for hemorrhage. Our study did not find an increased risk of apoplexy with clopidogrel or anticoagulation, but further investigation is needed with a larger cohort. Confirming other reports, male sex is associated with an increased risk for PA.
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Affiliation(s)
- Bronson Ciavarra
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Timothy McIntyre
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Matthew J Kole
- The Vivian L Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Wen Li
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - William Yao
- Department of Otorhinolaryngology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Katie B Guttenberg
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Spiros L Blackburn
- The Vivian L Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA.
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Ghosh R, Chatterjee S, Roy D, Dubey S, Lavie CJ. Panhypopituitarism in acute myocardial infarction. Ann Afr Med 2021; 20:145-149. [PMID: 34213484 PMCID: PMC8378457 DOI: 10.4103/aam.aam_66_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
While hypopituitarism is known to be associated with increased cardiovascular morbidity and mortality, panhypopituitarism as a complication of myocardial infarction (MI) is very rare. Here, we report a case of rapidly developing empty sella syndrome with florid manifestations of panhypopituitarism after MI (due to critical stenosis in the left anterior descending artery) complicated by cardiogenic shock in a 65-year-old man. The patient was initially stabilized with conservative management of non-ST-elevated MI and cardiogenic shock, but after initial improvement, he again deteriorated with refractory shock (not adequately responding to vasopressors), seizures, hypoglycemia, hyponatremia, hyperkalemia, and metabolic acidosis. After ruling out recurrent cardiogenic shock or other causes of refractory hypotension, panhypopituitarism was diagnosed with the help of hormonal assays and imaging. With no prior evidence of hypopituitarism, we suspect that panhypopituitarism developed due to acute pituitary apoplexy secondary to initial cardiogenic shock. The patient was successfully survived by the emergency endocrine management followed by secondary coronary angioplasty.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Devlina Roy
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Carl J Lavie
- Department of Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, LA, USA
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Kamel WA, Najibullah M, Saleh MS, Azab WA. Coronavirus disease 2019 infection and pituitary apoplexy: A causal relation or just a coincidence? A case report and review of the literature. Surg Neurol Int 2021; 12:317. [PMID: 34345458 PMCID: PMC8326077 DOI: 10.25259/sni_401_2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Pituitary tumor apoplexy (PA) is an emergency condition caused by hemorrhage or infarction of the preexisting adenoma. Many factors are currently well-known to predispose to PA. However, during the period of coronavirus disease 2019 (COVID-19) pandemic, case reports of PA associated with COVID-19 infection have been sequentially published. To the best of our knowledge, four cases have been reported so far in the English literature. We herein report the fifth case of this association and review the pertinent literature. Case Description: A 55-year-old male patient with confirmed COVID-19 infection presented by progressive decrease in visual acuity and oculomotor nerve palsy. His medical history is notable for diabetes mellitus, hypertension, and pituitary macroadenoma resection 11 years ago. He was on hormonal replacement therapy for panhypopituitarism that complicated the surgery. Previous magnetic resonance (MR) imaging studies were consistent with enlarging residual pituitary adenoma. During the current hospitalization, computed tomography revealed hyperdensity of the sellar and suprasellar areas. MR imaging revealed PA in a recurrent large adenoma. Endoscopic endonasal transsphenoidal resection was uneventfully undertaken with near total excision of the adenoma and partial improvement of visual loss and oculomotor palsy. Histopathological examination demonstrated classic features of PA. However, his chest condition progressed and he had to be transferred to COVID-19 intensive care unit in the referring hospital where he was intubated and put on mechanical ventilation. One week later, the patient unfortunately passed away due to complications of severe COVID-19 pneumonia. Conclusion: We report the fifth case of PA associated with COVID-19 infection. Based on our patient’s clinical findings, review of the other reported cases, as well as the available literature, we put forth a multitude of pathophysiological mechanisms induced by COVID-19 that can possibly lead to the development of PA. In our opinion, the association between both conditions is not just a mere coincidence. Although the histopathological features of PA associated with COVID-19 are similar to PA induced by other etiologies, future research may disclose unique pathological fingerprints of COVID-19 virus that explains its capability of inducing PA.
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Affiliation(s)
- Walaa A Kamel
- Department of Neurology, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait.,Department of Neurology, Beni-Suef University, Egypt
| | - Mustafa Najibullah
- Department of Neurosurgery, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait
| | - Mamdouh S Saleh
- Department of Neurosurgery, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait
| | - Waleed A Azab
- Department of Neurosurgery, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait
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Heparin-Induced Pituitary Apoplexy Presenting as Isolated Unilateral Oculomotor Nerve Palsy: A Case Report and Literature Review. Case Rep Endocrinol 2019; 2019:5043925. [PMID: 31687223 PMCID: PMC6803741 DOI: 10.1155/2019/5043925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/25/2019] [Accepted: 09/05/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Pituitary apoplexy (PA) is a rare and potentially life-threatening clinical syndrome resulting from pituitary gland hemorrhage and/or infarction. Anticoagulation is a risk factor for triggering PA. Isolated oculomotor nerve palsy is an atypical presentation of PA. Case Presentation A 65-year-old African American female with no past medical history of pituitary disease presented to the emergency department (ED) with nonspecific abdominal pain that was thought to be secondary to fecal stasis and subsequently improved with laxatives. She also reported atypical chest pain that was concerning for unstable angina. She was started on aspirin, clopidogrel, and intravenous (IV) heparin. Later, coronary catheterization showed no significant coronary artery disease (CAD). Twelve hours after the procedure, the patient developed acute complete left oculomotor nerve palsy with a severe headache. Magnetic resonance imaging (MRI) of the head showed a large pituitary mass. Pituitary apoplexy was suspected and the patient eventually underwent a successful trans-sphenoidal pituitary resection. Discussion We report a case of PA manifesting as isolated left oculomotor nerve palsy without visual field defects in the setting of using dual antiplatelet therapy (DAPT) and IV heparin for acute coronary syndrome. To the best of our knowledge, this unique combination has not been previously reported.
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Vargas G, Gonzalez B, Guinto G, Mendoza V, López-Félix B, Zepeda E, Mercado M. Pituitary apoplexy in nonfunctioning pituitary macroadenomas: a case-control study. Endocr Pract 2019; 20:1274-80. [PMID: 25100377 DOI: 10.4158/ep14120.or] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Pituitary apoplexy (PA) is an endocrinologic emergency characterized by headache, visual abnormalities, and hemodynamic instability in the context of hemorragic infarction of a pituitary adenoma. Our goal was to estimate the incidence, precipitating factors, clinical characteristics, and outcome of PA in a cohort of patients with nonfunctioning pituitary macroadenomas (NFPMAs). METHODS A retrospective, case-control study of 46 patients with PA and 47 controls matched for age, gender, and tumor invasiveness. Clinical, hormonal, and tumoral charactersitics, as well as the presence of potential precipitating factors and long-term outcome were evaluated using both bivariate and multivariate analysis. RESULTS The prevalence of PA was 8%. Cases and controls were similar in regards to the prevalence of diabetes, hypertension, use of antiplatelet agents, and the presence of headaches and visual field defects. Oculomotor paralysis was present in 18% of cases and in none of the controls (P = .001). Prior use of dopamine agonists was significantly more frequent among cases than in controls on both bivariate and multivariate analysis. Pituitary hormone deficiencies were more common among cases than in controls on bivariate but not on multivariate analysis. Early and late surgical treatment was carried out in 11 and 25 patients, respectively; 11 patients were managed conservatively. Visual and endocrine outcomes were similar among the 3 groups. CONCLUSION PA represents a life-threatening medical emergency. Prior use of dopamine agonists and the presence of oculomotor abnormalities clearly distinguished patients with NFPMA who developed PA from those who did not.
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Affiliation(s)
| | - Baldomero Gonzalez
- Endocrinology Service/Experimental Endocrinology Unit Neurological Center, American British Cowdray Medical Center, Mexico City, Mexico
| | - Gerardo Guinto
- Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Neurosurgery Service Neurological Center, American British Cowdray Medical Center, Mexico City, Mexico
| | | | - Blas López-Félix
- Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Neurosurgery Service
| | - Erick Zepeda
- Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Neurosurgery Service
| | - Moisés Mercado
- Endocrinology Service/Experimental Endocrinology Unit Neurological Center, American British Cowdray Medical Center, Mexico City, Mexico
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McAninch EA, Kim BW. Symptomatic Syndrome of Inappropriate Antidiuretic Hormone Secretion in Pituitary Apoplexy: A Case Report and Literature Review. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15755.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
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.
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Affiliation(s)
- Claire Briet
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Sylvie Salenave
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Jean-François Bonneville
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Edward R Laws
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Philippe Chanson
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
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Abstract
Pituitary apoplexy is rare endocrine emergency which can occur due to infarction or haemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. There is conflicting data regarding which type of pituitary adenoma is prone for apoplexy. Some studies showed predominance of non-functional adenomas while some other studies showed a higher prevalence in functioning adenomas amongst which prolactinoma have the highest risk. Although pituitary apoplexy can occur without any precipitating factor in most cases, there are some well recognizable risk factors such as hypertension, medications, major surgeries, coagulopathies either primary or following medications or infection, head injury, radiation or dynamic testing of the pituitary. Patients usually present with headache, vomiting, altered sensorium, visual defect and/or endocrine dysfunction. Hemodynamic instability may be result from adrenocorticotrophic hormone deficiency. Imaging with either CT scan or MRI should be performed in suspected cases. Intravenous fluid and hydrocortisone should be administered after collection of sample for baseline hormonal evaluation. Earlier studies used to advocate urgent decompression of the lesion but more recent studies favor conservative approach for most cases with surgery reserved for those with deteriorating level of consciousness or increasing visual defect. The visual and endocrine outcomes are almost similar with either surgery or conservative management. Once the acute phase is over, patient should be re-evaluated for hormonal deficiencies.
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Affiliation(s)
- Salam Ranabir
- Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Manash P. Baruah
- Department of Endocrinology, Excel Center, Guwahati, Assam, India
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Une complication inhabituelle d’un traitement anticoagulant : l’hémorragie hypophysaire. Rev Med Interne 2010; 31:e1-2. [DOI: 10.1016/j.revmed.2010.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 12/10/2009] [Accepted: 01/11/2010] [Indexed: 11/18/2022]
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Semple PL, Jane JA, Laws ER. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosurgery 2008; 61:956-61; discussion 961-2. [PMID: 18091272 DOI: 10.1227/01.neu.0000303191.57178.2a] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The pathogenesis of pituitary apoplexy and the role of precipitating factors in pituitary apoplexy are poorly understood. Most of the published cases are in the form of case reports. We assessed the presumed precipitating factors in a series of patients treated surgically for pituitary apoplexy and reviewed the contemporary published literature. METHOD Thirty-eight consecutive patients with pituitary apoplexy were treated surgically by the Department of Neurosurgery at the University of Virginia, Charlottesville, VA, between January 1996 and March 2006. Their medical records were retrospectively reviewed. Contemporary published cases from 1990 to 2006 were also reviewed. RESULTS Nine patients (24%) were identified as having precipitating factors for pituitary apoplexy. The factors identified were coronary artery surgery (two patients), other major surgery (two patients), pregnancy (two patients), gamma knife irradiation, anticoagulant therapy, and coagulopathy secondary to liver failure. The presentation, histology, and outcome were compared between those patients with a precipitating factor and those in whom none was identified. A review of the published literature showed that coronary artery surgery, pituitary stimulation, and coagulopathy were the most common precipitating factors. CONCLUSION A minority of patients with pituitary apoplexy will have precipitating factors. The majority of patients with precipitating factors will have histopathology showing hemorrhagic infarction or hemorrhage. The most common precipitating factors are pituitary stimulation, surgery, particularly coronary artery surgery, and coagulopathy. Caution in doing endocrine investigation, surgery, or anticoagulation in patients with a known pituitary tumor is advised. Patients with no diagnosed pituitary tumor but with a known precipitating factor who have neuro-ophthalmological deterioration or endocrine failure should undergo prompt magnetic resonance image scans and endocrine investigation and endocrine replacement as indicated.
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Affiliation(s)
- Patrick L Semple
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
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Levy E, Korach A, Merin G, Feinsod M, Glenville B. Pituitary Apoplexy and CABG: Should We Change Our Strategy? Ann Thorac Surg 2007; 84:1388-90. [PMID: 17889010 DOI: 10.1016/j.athoracsur.2007.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 05/05/2007] [Accepted: 05/07/2007] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Eli Levy
- Division of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel.
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Tan TMM, Caputo C, Mehta A, Hatfield ECI, Martin NM, Meeran K. Pituitary macroadenomas: are combination antiplatelet and anticoagulant therapy contraindicated? A case report. J Med Case Rep 2007; 1:74. [PMID: 17761001 PMCID: PMC2018712 DOI: 10.1186/1752-1947-1-74] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 08/30/2007] [Indexed: 12/04/2022] Open
Abstract
Background Pituitary apoplexy is a life-threatening endocrine emergency that is caused by haemorrhage or infarction of the pituitary gland, commonly within a pituitary adenoma. Patients classically present with headache, ophthalmoplegia, visual field defects and altered mental state, but may present with a typical symptoms such as fever and altered conscious level. Case presentation A 57-year-old female with a known pituitary macroadenoma was treated for suspected acute coronary syndrome with aspirin, clopidogrel and full dose enoxaparin. She developed a severe and sudden headache, nausea and vomiting and visual deterioration. A CT scan showed haemorrhage into the pituitary macroadenoma. She underwent neurosurgical decompression. Post-operatively her visual fields and acuity returned to baseline. She was continued on hydrocortisone and thyroxine replacement on discharge. Conclusion This case illustrates the risks of anticoagulation in a patient with a known pituitary macroadenoma, and raises the issue of whether these tumours present a relative contraindication to the use of dual antiplatelet and anticoagulation in acute coronary syndrome.
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Affiliation(s)
- Tricia MM Tan
- Endocrine Unit, Hammersmith Hospitals NHS Trust, Imperial College Faculty of Medicine, London, UK
| | - Carmela Caputo
- Endocrine Unit, Hammersmith Hospitals NHS Trust, Imperial College Faculty of Medicine, London, UK
| | - Amrish Mehta
- Department of Radiology, Hammersmith Hospitals NHS Trust, Imperial College Faculty of Medicine, London, UK
| | - Emma CI Hatfield
- Endocrine Unit, Hammersmith Hospitals NHS Trust, Imperial College Faculty of Medicine, London, UK
| | - Niamh M Martin
- Endocrine Unit, Hammersmith Hospitals NHS Trust, Imperial College Faculty of Medicine, London, UK
| | - Karim Meeran
- Endocrine Unit, Hammersmith Hospitals NHS Trust, Imperial College Faculty of Medicine, London, UK
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Simó O, Castells I, Recasens A, Yetano V. Apoplejía hipofisaria secundaria al tratamiento del síndrome coronario agudo. Med Clin (Barc) 2006; 127:477. [PMID: 17040638 DOI: 10.1157/13093063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Dubuisson AS, Beckers A, Stevenaert A. Classical pituitary tumour apoplexy: clinical features, management and outcomes in a series of 24 patients. Clin Neurol Neurosurg 2006; 109:63-70. [PMID: 16488532 DOI: 10.1016/j.clineuro.2006.01.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Revised: 01/13/2006] [Accepted: 01/16/2006] [Indexed: 11/18/2022]
Abstract
We retrospectively analysed the incidence, clinical presentation, endocrinological and radiological findings, medical and surgical management of pituitary apoplexy in our department (single-centre study), having a large experience in pituitary surgery. Among 1540 pituitary lesions, 24 patients presented with pituitary apoplexy. Their charts were retrospectively reviewed. The symptoms included headache (92%), nausea and vomiting (54%), visual deficit (50%), oculomotor paresis (54%) and/or an altered mental state (42%). Skull X-rays (n = 14) demonstrated an enlarged sella turcica in all cases; CT-scan and/or MRI always revealed a sellar and suprasellar expanding lesion. Panhypopituitarism was present on admission in 70% of the patients. Urgent therapeutic management included high-dose cortisone treatment in all but one patients and CSF drainage in three. Three patients were treated conservatively. Nine patients were operated on rapidly, within hours or a few days because of severe visual deficit and/or altered level of consciousness. Nineteen patients were operated by the trans-sphenoidal approach; one of them required a second operation by craniotomy. There were two deaths related to the illness and one to an ill-defined reason at 4 months. Among the other patients 95% made a good recovery. All but two patients required a substitutive treatment with adrenal (83%), thyroid (68%), gonadal (42%) and/or growth (16%) hormones. The preoperative visual deficits recovered in all but one patients (92%) whereas the oculomotor pareses improved in all but two patients (85%). In conclusion, pituitary tumour apoplexy is a rare event, complicating in our series 1.6% of 1540 pituitary adenomas. Even in severe cases, complete recovery is possible if the diagnosis is rapidly obtained and adequate management is initiated in time. Surgical results after trans-sphenoidal approach are in the majority of cases very satisfactory.
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Affiliation(s)
- Annie S Dubuisson
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium.
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Maïza JC, Bennet A, Thorn-Kany M, Lagarrigue J, Caron P. Pituitary apoplexy and idiopathic thrombocytopenic purpura: a new case and review of the literature. Pituitary 2004; 7:189-192. [PMID: 16328568 DOI: 10.1007/s11102-005-1760-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pituitary apoplexy can occur as a complication of idiopathic thrombocytopenic purpura. We report here a new case of such association. A male patient aged 59 years, complaining of decreased libido for one year, was referred to the emergency department for purpura and severe thrombocytopenia (4000 platelets/mm3). 24 hours after the cutaneous rash the patient presented with clinical symptoms of bilateral cavernous sinus compression comprising ptosis, bilateral ophtalmoplegia and right supraorbital hypoesthesia. Cranial CT scan showed an enlarged sella and a pituitary mass with signs of intrapituitary haemorrhage. Hormonal evaluation showed hyperprolactinemia (50 ng/mL) and hypopituitarism, and the patient needed substitution with hydrocortisone and levothyroxine. Immunoglobulins and corticosteroids were given to the patient to treat thrombocytopenia, then worsening of neurological and ophtalmological symptoms led to pituitary surgery. Histopathological examination found necrotical pituitary tissue. Immunostaining with an anti-prolactin antibody was positive in several groups of cells. Neurological symptoms subsided and thrombocytopenia was corrected by treatment. In conclusion, we report a case of pituitary apoplexy due to severe thrombocytopenia occurring as a complication of a preexisting macroprolactinoma.
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Affiliation(s)
- J C Maïza
- Department of Endocrinology, Centre Hospitalo-Universitaire Rangueil, Toulouse, France
| | - A Bennet
- Department of Endocrinology, Centre Hospitalo-Universitaire Rangueil, Toulouse, France
| | - M Thorn-Kany
- Department of Neuroradiology, Centre Hospitalo-Universitaire Rangueil, Toulouse, France
| | - J Lagarrigue
- Department of Neurosurgery, Centre Hospitalo-Universitaire Rangueil, Toulouse, France
| | - Ph Caron
- Department of Endocrinology, Centre Hospitalo-Universitaire Rangueil, Toulouse, France.
- Department of Endocrinology and Metabolic Diseases, Centre Hospitalo-Universitaire Rangueil, TSA 50032, 31059, Toulouse, France.
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Skljarevski V, Khoshyomn S, Fries TJ. Pituitary Apoplexy in the Setting of Coronary Angiography. J Neuroimaging 2003. [DOI: 10.1111/j.1552-6569.2003.tb00192.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Taylor HC, McLean S, Monheim K. Resolution of Cushing's disease followed by secondary adrenal insufficiency after anticoagulant-associated pituitary hemorrhage: report of a case and review of the literature. Endocr Pract 2003; 9:147-51. [PMID: 12917078 DOI: 10.4158/ep.9.2.147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the 12th well-documented case of spontaneous resolution of pituitary Cushing's disease due to pituitary hemorrhage and to review data on the previous 11 such patients described in the literature. METHODS We present the longitudinal clinical, endocrinologic, and radiographic data in a 41-year-old woman with Cushing's disease before and after pituitary hemorrhage and summarize similar data in 11 previous reports of patients who convincingly appear to demonstrate the same syndrome. RESULTS A 41-year-old woman with classic features of Cushing's disease had an overnight dexamethasone suppressed serum cortisol level of 23 mg/dL. Five months later, symptomatic pituitary hemorrhage developed in conjunction with characteristic pituitary magnetic resonance imaging findings and a serum cortisol value of 2.2 mg/dL. During the ensuing 8 months, she lost her Cushing's habitus, demonstrated improvement in her secondary adrenal insufficiency, and developed an empty right sella turcica, which remained unchanged on 1-year follow-up magnetic resonance imaging of the pituitary. An overnight metyrapone test 3 months later yielded normal results. CONCLUSION Spontaneous remission in pituitary Cushing's disease, with or without later recurrence, has now been well documented in 12 patients. These findings (1) compel a reassessment of whether previously described patients experiencing spontaneous remission in association with medical therapy may have actually sustained asymptomatic pituitary hemorrhage and (2) raise the question of whether, in selected patents with microadenomas, medical treatment of Cushing's disease should be considered more often.
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Nakagawa T, Onozuka S, Mayanagi K. Two Cases of Hemorrhage in Benign Brain Tumors during Systemic Heparinization. Case Reports. Interv Neuroradiol 2001; 7:127-30. [PMID: 20663338 DOI: 10.1177/159101990100700206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2001] [Accepted: 03/25/2001] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- T Nakagawa
- Department of Neurosurgery; Keio University School of Medicine, Japan -
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Wongpraparut N, Pleanboonlers N, Suwattee P, Rerkpattanapipat P, Turtz A, Moster M, Gala I, Kim YN. Pituitary apoplexy in a patient with acute myeloid leukemia and thrombocytopenia. Pituitary 2000; 3:113-6. [PMID: 11141694 DOI: 10.1023/a:1009909908942] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We describe a 72-year-old woman with a history of acute myeloid leukemia who developed pituitary apoplexy associated with thrombocytopenia secondary to chemotherapy. She presented with new onset severe headache, nausea, vomiting and blurred vision. Initial physical examination was unremarkable. CT scan of the head was initially negative. Upon admission for further work up, She developed a high-grade fever, hypotension and obtundation. Subsequent physical examination revealed bitemporal visual fields defects and decreased visual acuity. Repeat imaging of head revealed a hemorrhagic pituitary mass compressing the optic chiasm. Laboratory results were compatible with the diagnosis of pan-hypopituitary syndrome. She received high dose steroids and was transferred for transnasal sphenoidotomy decompression surgery. The visual defects improved postoperatively. A literature review of Pituitary apoplexy is presented. Pituitary apoplexy secondary to thrombocytopenia has never been reported.
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Affiliation(s)
- N Wongpraparut
- Department of Medicine, Albert Einstein Medical Center, 5401 Old York Road, Philadelphia, PA 19141, USA.
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