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Yildiz Y, Lauber A, Char NV, Bozinov O, Neidert MC, Hostettler IC. Subarachnoid hemorrhage due to pituitary adenoma apoplexy-case report and review of the literature. Neurol Sci 2024; 45:997-1005. [PMID: 37872321 DOI: 10.1007/s10072-023-07130-y] [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: 07/04/2023] [Accepted: 10/07/2023] [Indexed: 10/25/2023]
Abstract
Pituitary apoplexy (PA) may be complicated by development of subarachnoid hemorrhage (SAH). We conducted a literature review to evaluate the rate of PA-associated tumor rupture and SAH. We conducted a systematic literature search (PubMed, Web of Science, Medline) for patients with PA-associated SAH and report a case SAH following PA. Suitable articles, case series, and case reports were selected based on predefined criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). We reviewed included publications for clinical, radiological, surgical, and histopathological parameters.We present the case of a patient with PA developing extensive SAH whilst on the MRI who underwent delayed transsphenoidal resection. According to our literature review, we found 55 patients with a median age of 46 years; 18 (32.7%) were female. Factors associated with PA-related SAH were hypertension, diabetes mellitus, prior trauma, anticoagulant, and/or antiplatelet therapy. The most common presenting symptoms included severe headache, nausea and/or vomiting, impaired consciousness, and meningeal irritation. Acute onset was described in almost all patients. Twenty-two of the included patients underwent resection. In patients with available outcome, 45.1% had a favorable outcome, 10 (19.6%) had persisting focal neurological deficits, 7 developed cerebral vasospasms (12.7%), and 18 (35.3%) died. Mortality greatly differed between surgically (9.1%) and non-surgically (44.8%) treated patients. PA-associated SAH is a rare condition developing predominantly in males with previously unknown macroadenomas. Timely surgery often prevents aggravation or development of severe neuro-ophthalmological defects and improves clinical outcome.
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Affiliation(s)
- Yesim Yildiz
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Arno Lauber
- Department of Neuroradiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Natalia Velez Char
- Department of Neuropathology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Isabel Charlotte Hostettler
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland.
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Funari A, Jeong SS, Pecorari IL, Flaquer I, Anderson CL, Agarwal V. Infarctive Apoplexy of Previously Healthy Pituitary Glands: A Small Case Series and Literature Review. J Neurol Surg Rep 2023; 84:e71-e79. [PMID: 37492614 PMCID: PMC10365896 DOI: 10.1055/s-0043-1770788] [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: 09/22/2022] [Accepted: 01/26/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction We present two cases of suspected pituitary apoplexy found instead to be infarcted pituitary glands without histopathologic evidence of neoplastic cells, likely resulting from spontaneous infarction of previously healthy pituitary glands. Case Presentations The first case is a 55-year-old man who presented with a pulsating headache, nausea, and several months of decreased libido, polyuria, and polydipsia. Magnetic resonance imaging (MRI) revealed a rim-enhancing sellar/suprasellar mass with evidence of recent hemorrhage on the right. Testosterone, follicle-stimulating hormone, and luteinizing hormone levels were suppressed. Analysis of the resected specimen showed fibrocollagenous tissue with evidence of old hemorrhage and microscopic focus of necrotic tissue. The second case is a 56-year-old man who presented with a throbbing headache, associated nausea, and 6 weeks of polyuria and polydipsia. Testosterone levels were found to be low, and 8-hour water deprivation test showed evidence for partial diabetes insipidus. MRI revealed a mass on the right side of the pituitary gland, with evidence of likely hemorrhage on the left. Analysis of the resected specimen showed necrotic tissue without neoplastic cells. Conclusion When evaluating small pituitary lesions in patients presenting with indolent onset of pituitary insufficiency, there should be a high degree of suspicion for an infarcted pituitary gland.
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Affiliation(s)
- Abigail Funari
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Seth S. Jeong
- Department of Otolaryngology—Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Isabella L. Pecorari
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Isabella Flaquer
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Cassidy L. Anderson
- Department of Otolaryngology—Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Vijay Agarwal
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Otolaryngology—Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
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Suspected Pituitary Apoplexy: Clinical Presentation, Diagnostic Imaging Findings and Outcome in 19 Dogs. Vet Sci 2022; 9:vetsci9040191. [PMID: 35448689 PMCID: PMC9026492 DOI: 10.3390/vetsci9040191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 02/01/2023] Open
Abstract
In human medicine, pituitary apoplexy (PA) is a clinical syndrome characterised by the sudden onset of neurological signs because of haemorrhage or infarction occurring within a normal or tumoral pituitary gland. The diagnosis is usually performed combining neurological signs and imaging findings. The aim of the present study is to describe the abnormal neurological signs, the diagnostic imaging findings, based on Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI), and the outcome in a population of dogs with suspected PA. Clinical cases were retrospectively reviewed. Nineteen cases of suspected PA were included. The majority of dogs showed behavioural abnormalities (11/19). Neurological signs more frequently identified were obtundation (7/19), vestibular signs (7/19) and epileptic seizures (6/19). The onset of neurological signs was per-acute in 14 out of 19 cases. Data regarding CT and MRI were available in 18 and 9 cases, respectively. Neurological signs resolved in less than 24 h in seven patients. The short-term prognosis was defined as favourable in the majority of our study population. The median survival time was of 7 months from the time of PA diagnosis. This is the first description of neurological signs, imaging findings and outcome in a large group of dogs with PA.
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Taweesomboonyat C, Oearsakul T. Factors predicting neuro-endocrine recovery following transsphenoidal surgery in pituitary apoplexy patients. World Neurosurg 2021; 159:e40-e47. [PMID: 34861451 DOI: 10.1016/j.wneu.2021.11.111] [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: 09/27/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pituitary apoplexy is a rare clinical syndrome. Only a few studies have examined factors associated with recovery of neuro-endocrine functions following transsphenoidal surgery. This study aimed to identify factors associated with neuro-endocrine recovery following surgery for pituitary apoplexy. METHODS The records of pituitary apoplexy patients who underwent transsphenoidal surgery at Songklanagarind Hospital between January 2005 and December 2020 were retrospectively reviewed. The primary outcomes were the recoveries of preoperative visual acuity (VA), visual field (VF), cranial nerve function, and pituitary hormone deficits. Using logistic regression analysis, various factors were analyzed for their associations with recovery of neuro-endocrine functions. RESULTS The study included 98 patients. Multivariate analysis showed that older age and greater suprasellar extension were associated with no recovery of VA (P = 0.042 and P = 0.018, respectively). Only 33% of patients aged > 55 years and suprasellar extension of lesion ≥ 25 mm gained recovery of VA, while 100% of patients with neither of these factors had recovery. Underlying hypertension was associated with no recovery of preoperative VF defect (P = 0.027). Wilson-Hardy classification-invasion grades 3-4 and lower preoperative serum prolactin level were associated with no recovery from preoperative hypoadrenalism and hypothyroidism (P = 0.016 and P = 0.007, respectively). CONCLUSIONS Older age, higher suprasellar extension, and hypertension were poor prognostic factors for visual recovery. Wilson-Hardy inferior invasion grade 3-4 and lower preoperative serum prolactin level were poor prognostic factors for recovery from hypopituitarism. Stratifying patients according to these prognostic factors may assist in selecting patients for surgery.
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Affiliation(s)
- Chin Taweesomboonyat
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Thakul Oearsakul
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Solorio-Pineda S, Almendárez-Sánchez CA, Tafur-Grandett AA, Ramos-Martínez GA, Huato-Reyes R, Ruiz-Flores MI, Sosa-Najera A. Pituitary macroadenoma apoplexy in a severe acute respiratory syndrome-coronavirus-2-positive testing: Causal or casual? Surg Neurol Int 2020; 11:304. [PMID: 33093981 PMCID: PMC7568102 DOI: 10.25259/sni_305_2020] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/05/2020] [Indexed: 01/06/2023] Open
Abstract
Background: In December 2019, in Wuhan, a new virus emerged, causing severe acute respiratory syndrome (SARS) secondary to infection by a type of coronavirus, causing coronavirus disease (COVID-19). The pandemic caused by the new coronavirus has had implications in the central nervous system. COVID-19 is known to be characterized by coagulation activation and endothelial dysfunction, causing ischemic and hemorrhagic vascular syndromes. Case Description: A 27-year-old male patient case with progressive decrease in visual acuity, associated with respiratory symptoms and intense headache. Multilobar infiltrate with a reticulonodular pattern is evident on chest CT scan. Brain CT scan with pituitary macroadenoma apoplexy was shown. SARS-Cov2 was confirmed, and respiratory support initiated. However, the patient died shortly afterward, secondary to pulmonary complications. Conclusion: The angiotensin-converting enzyme (ACE) II receptor is expressed in circumventricular organs and in cerebrovascular endothelial cells, which play a role in vascular autoregulation and cerebral blood flow. For this reason, is rational the hypothesize that brain ACE II could be involved in COVID-19 infection. Underlying mechanisms require further elucidation in the future.
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Affiliation(s)
- Saúl Solorio-Pineda
- Department of Neurosurgery, Centro Medico "Lic. Adolfo López Mateos", Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Toluca - 50010, Estado de México, México
| | - César Adán Almendárez-Sánchez
- Department of Neurosurgery, Centro Medico "Lic. Adolfo López Mateos", Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Toluca - 50010, Estado de México, México
| | - Abrahan Alfonso Tafur-Grandett
- Department of Neurosurgery, Centro Medico "Lic. Adolfo López Mateos", Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Toluca - 50010, Estado de México, México
| | - Gabriel Arturo Ramos-Martínez
- Department of Neurosurgery, Centro Medico "Lic. Adolfo López Mateos", Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Toluca - 50010, Estado de México, México
| | - Raúl Huato-Reyes
- Department of Neurosurgery, Centro Medico "Lic. Adolfo López Mateos", Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Toluca - 50010, Estado de México, México
| | - Milton Inocencio Ruiz-Flores
- Department of Neurosurgery, Centro Medico "Lic. Adolfo López Mateos", Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Toluca - 50010, Estado de México, México
| | - Antonio Sosa-Najera
- Department of Neurosurgery, Centro Medico "Lic. Adolfo López Mateos", Instituto de Salud del Estado de México, Av. Nicolás San Juan s/n Ex Hacienda La Magdalena, Toluca - 50010, Estado de México, México
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Chandra PS. We Stand on the Shoulders of Our Teachers … So that We Can See Further …. Neurol India 2019; 67:964-965. [DOI: 10.4103/0028-3886.266286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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O'Connor G, Dinn J, Farrell M, Phillips J, Stack J, Eustace P. Pituitary Apoplexy in an Ectopic Pituitary Tumour. Eur J Ophthalmol 2018; 1:33-8. [PMID: 1821196 DOI: 10.1177/112067219100100107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A case report of a patient with unilateral visual loss, due to infarction in an ectopic pituitary tumour, is presented. Good return of vision followed surgical removal of the tumour.
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Affiliation(s)
- G O'Connor
- Department of Neuro-Opthalmology and Neurosurgery, Beaumont Hospital, Ireland
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Subclinical haemorrhage in non-functional adenomas. Neurochirurgie 2018; 64:44-48. [PMID: 29428407 DOI: 10.1016/j.neuchi.2017.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 11/27/2017] [Accepted: 12/08/2017] [Indexed: 11/22/2022]
Abstract
AIM The prevalence and risk factors of subclinical haemorrhage on non-functional adenomas (NFA) remain controversial. The primary aim of our study was to assess the incidence of subclinical haemorrhage (SH) and the secondary objectives were to evaluate the risk factors of SH and the impact of SH on pituitary function at diagnosis. PATIENTS AND METHODS This retrospective transversal analysis included 95 patients between January 2012 and December 2014. The patients included in this series were all adults (>18 years of age), who presented a non-functional adenoma confirmed by an endocrinological evaluation and on dedicated MRI pituitary imaging. Sixty-four patients were eligible for this study. Subclinical haemorrhage was defined by the presence of haemorrhage within pituitary adenoma confirmed by pituitary MRI with no clinical symptoms. A senior neuroradiologist blinded to the diagnosis reviewed all MRI. The population was prospectively divided into two groups based on MRI results (SH group vs. group control) to determine risk factors. RESULTS SH was diagnosed in 22 patients (34.38%). No risk factors (age, sex, tumor size, chronic hypertension, diabetes mellitus, malignant disease, the use of anticoagulation or antithrombotic medication or Cabergoline treatment) were involved as regards the SH. At the diagnosis, pituitary deficiency was statistically significantly more frequent in the SH group (45.45%) than in the control group (19.04%) (P=0.04). CONCLUSION The SH within NFA was observed in 34.38% of cases without an association of risk factors.
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9
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Kim YJ, Kim CH, Cheong JH, Kim JM. Relationship between expression of vascular endothelial growth factor and intratumoral hemorrhage in human pituitary adenomas. TUMORI JOURNAL 2018; 97:639-46. [DOI: 10.1177/030089161109700517] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Although pituitary adenoma is a primary brain tumor that occasionally accompanies intratumoral hemorrhage, there are little reports about the molecular mechanism of intratumoral bleeding in pituitary adenoma. Vascular endothelial growth factor (VEGF) plays an important role in angiogenesis and vascular permeability of various brain tumors. The authors studied the relationship between intratumoral hemorrhage and the expression of VEGF in human pituitary adenomas. Methods VEGF expression was assessed by reverse transcriptase polymerase chain reaction (RT-PCR) in 71 pituitary adenomas. Clinical factors to investigate were age, gender, hormonal functioning, and radiological findings of pituitary adenomas. Radiological findings which were investigated by magnetic resonance (MR) images were intratumoral hemorrhage, cystic change, tumor size, and cavernous sinus invasion. The relationship between these factors and VEGF expression was statistically analyzed. Results VEGF was expressed in 25 cases (35.2%). Functioning tumors, hemorrhage, cystic change, and cavernous sinus invasion were 32 (45.1%), 18 (25.4%), 12 (16.9%), and 21 (29.6%) respectively. The expression of VEGF showed a significant relationship with the intratumoral hemorrhage of the adenomas (P <0.001). However, age, gender, tumor size, hormonal functioning, cyst formation, and cavernous sinus invasion had no relationship with VEGF expression (P >0.05). Conclusions This study suggests that VEGF expression may be responsible for intratumoral hemorrhage of pituitary adenomas. Therefore, VEGF can be a novel target to prevent a catastrophic apoplexy in pituitary adenomas and to establish roles in angiogenesis-based therapeutics of pituitary adenomas.
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Affiliation(s)
- Young Jin Kim
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan
| | - Choong Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Myla M, Lewis J, Beach A, Sylejmani G, Burge MR. A Perplexing Case of Pituitary Apoplexy Masquerading as Recurrent Meningitis. J Investig Med High Impact Case Rep 2018; 6:2324709618811370. [PMID: 30480002 PMCID: PMC6243406 DOI: 10.1177/2324709618811370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/12/2018] [Accepted: 09/23/2018] [Indexed: 11/29/2022] Open
Abstract
In this article, we present an exceptional case of pituitary apoplexy in which a patient presented with meningeal symptoms of headache, stiff neck, and nausea rather than the classical findings of ophthalmoplegia and/or vision loss. The patient has had 2 similar presentations with cerebrospinal fluid showing neutrophilic pleocytosis, as well as a computed tomography scan showing a prominent pituitary gland. On current presentation, the patient's vital signs were stable and the physical examination was remarkable for nuchal rigidity. Magnetic resonance imaging of the head revealed an expansile pituitary gland lesion measuring 2.0 × 1.7 × 1.5 cm with upward displacement of the overlying optic chiasm. Cerebrospinal fluid showed neutrophilic pleocytosis, low glucose, high protein content, and negative bacterial and fungal cultures. Surgical decompression subsequently revealed findings consistent with pituitary apoplexy. This is the first known case in which a patient had recurrent episodes of meningitis due to pituitary apoplexy in the absence of a clinical deterioration. Early identification of apoplexy masquerading as meningitis will allow early surgical intervention, if necessary, to prevent complications, recurrence, and morbidity. As such, the presence of sterile meningitis in patients with a known pituitary adenoma should be considered for prompt surgical evaluation.
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Affiliation(s)
- Madhura Myla
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jeremy Lewis
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Alan Beach
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Gresa Sylejmani
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Mark R. Burge
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Ogawa Y, Niizuma K, Mugikura S, Tominaga T. Ischemic pituitary adenoma apoplexy-Clinical appearance and prognosis after surgical intervention. Clin Neurol Neurosurg 2016; 148:142-6. [PMID: 27449534 DOI: 10.1016/j.clineuro.2016.07.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several retrospective investigations have recommended more passive surgical indications for intratumoral hemorrhage of pituitary adenomas due to probable spontaneous resolution. However, no definitive analyses have compared pituitary adenomas with hemorrhagic apoplexy and intratumoral hemorrhage without evident apoplectic symptoms or pituitary adenoma infarction. METHODS This study retrospectively identified 43 patients with symptomatic pituitary apoplexy among 1067 patients with pituitary adenomas initially treated by surgery at a single institute between April 2005 and May 2015, with 27 cases of hemorrhagic (2.53%) and 16 cases of ischemic apoplexy (1.50%). The inclusion criteria involved evident and sudden onset of symptoms and simultaneous histological confirmation as hemorrhagic or ischemic pituitary apoplexy. Diagnostic differentiation with magnetic resonance (MR) imaging was performed to examine the agreement between MR imaging and histological findings, and the clinical appearance and mid-term prognosis were compared for ischemic pituitary apoplexy and hemorrhagic apoplexy. RESULTS Diagnostic matching with MR imaging could be performed in 41 of 43 patients (25 with hemorrhagic and 16 with ischemic apoplexy). Agreement with the histological finding was found in 32 of 41 patients overall (78%), 23 of 25 patients with hemorrhagic apoplexy (92%), and 9 of 16 patients with ischemic apoplexy (56%). The main reason for diagnostic discrepancy was thought to be the difficulty in identifying ischemic lesion. All patients in the ischemic group suffered progression of symptoms from initial onset including various cranial nerve palsies, aseptic meningitis, and decreased level of consciousness, whereas the hemorrhagic group suffered progression in 4 of 27 patients. Ischemic group showed a statistically stronger tendency to disease progression than the hemorrhagic group (P<0.001). Endocrinological examinations showed 4 patients required no hormone supplement therapies but the other 11 patients had persistent hypopituitarism and required hormone supplementation in the ischemic group, whereas 2 of 25 patients required hormone supplementation in the hemorrhagic group. Endocrinological recovery showed a significant difference between the ischemic group and hemorrhagic group (P<0.01). CONCLUSIONS Ischemic pituitary adenoma apoplexy has a more severe clinical course than hemorrhagic apoplexy. Development of preoperative diagnostic technology to differentiate ischemic from hemorrhagic apoplexy is required to improve the low rate of agreement between the histological and MR imaging findings in patients with ischemic apoplexy.
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Affiliation(s)
- Yoshikazu Ogawa
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan.
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan, Japan
| | - Shunji Mugikura
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai. Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan, Japan
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Albani A, Ferraù F, Angileri FF, Esposito F, Granata F, Ferreri F, Cannavò S. Multidisciplinary Management of Pituitary Apoplexy. Int J Endocrinol 2016; 2016:7951536. [PMID: 28074095 PMCID: PMC5198093 DOI: 10.1155/2016/7951536] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 10/19/2016] [Accepted: 11/06/2016] [Indexed: 11/17/2022] Open
Abstract
Pituitary apoplexy is a rare clinical syndrome due to ischemic or haemorrhagic necrosis of the pituitary gland which complicates 2-12% of pituitary tumours, especially nonfunctioning adenomas. In many cases, it results in severe neurological, ophthalmological, and endocrinological consequences and may require prompt surgical decompression. Pituitary apoplexy represents a rare medical emergency that necessitates a multidisciplinary approach. Modalities of treatment and times of intervention are still largely debated. Therefore, the management of patients with pituitary apoplexy is often empirically individualized and clinical outcome is inevitably related to the multidisciplinary team's skills and experience. This review aims to highlight the importance of a multidisciplinary approach in the management of pituitary apoplexy and to discuss modalities of presentation, treatment, and times of intervention.
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Affiliation(s)
- Adriana Albani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Ferraù
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- *Francesco Ferraù:
| | - Filippo Flavio Angileri
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Felice Esposito
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Francesca Granata
- Unit of Neuroradiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Felicia Ferreri
- Unit of Ophthalmology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Salvatore Cannavò
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Johnston PC, Hamrahian AH, Weil RJ, Kennedy L. Pituitary tumor apoplexy. J Clin Neurosci 2015; 22:939-44. [PMID: 25800143 DOI: 10.1016/j.jocn.2014.11.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 11/23/2014] [Accepted: 11/25/2014] [Indexed: 11/20/2022]
Abstract
We review the etiology, investigations, management and outcomes of pituitary tumor apoplexy. Pituitary tumor apoplexy is a clinical syndrome which typically includes the acute onset of headache and/or visual disturbance, cranial nerve palsy and partial or complete endocrine dysfunction. It is associated with either infarction or hemorrhage of a pre-existing pituitary adenoma and is associated with significant morbidity and potential fatality. Not all patients will present with classic signs and symptoms, therefore it is pertinent to appreciate the clinical spectrum in which this condition can present.
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Affiliation(s)
- Philip C Johnston
- Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, UK; Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Amir H Hamrahian
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert J Weil
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
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Pituitary apoplexy associated with cabergoline therapy. J Clin Neurosci 2013; 20:1637-43. [DOI: 10.1016/j.jocn.2013.02.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 02/10/2013] [Indexed: 11/22/2022]
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Kurisu K, Kawabori M, Niiya Y, Ohta Y, Mabuchi S, Houkin K. Pituitary apoplexy manifesting as massive intracerebral hemorrhage. Case report. Neurol Med Chir (Tokyo) 2012; 52:587-90. [PMID: 22976142 DOI: 10.2176/nmc.52.587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 68-year-old man presented with severe conscious disturbance caused by pituitary apoplexy resulting in massive intracerebral hemorrhage (ICH). He had been periodically followed up for asymptomatic pituitary adenoma at another hospital for 8 years. Neuroimaging examination revealed pituitary apoplexy and massive ICH located in the left frontal lobe, and the ICH was directly connected to the intratumoral hemorrhage. The diagnosis was massive ICH from pituitary apoplexy. The patient underwent emergent evacuation of hematoma and removal of the pituitary adenoma via bi-frontal craniotomy. Postoperatively, he continued to exhibit deep consciousness disturbance and died 1 month after the operation. Pituitary apoplexy is usually characterized by intra-tumoral hemorrhage. The treatment strategy for asymptomatic pituitary adenoma is still controversial. This case shows that we should always consider the risk of pituitary apoplexy manifesting as ICH which may cause a fatal outcome.
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Affiliation(s)
- Kota Kurisu
- Department of Neurosurgery, Otaru Municipal Medical Center, Hokkaido, Japan.
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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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Seuk JW, Kim CH, Yang MS, Cheong JH, Kim JM. Visual outcome after transsphenoidal surgery in patients with pituitary apoplexy. J Korean Neurosurg Soc 2011; 49:339-44. [PMID: 21887391 DOI: 10.3340/jkns.2011.49.6.339] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 04/06/2011] [Accepted: 05/30/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Pituitary apoplexy is one of the most serious life-threatening complications of pituitary adenoma. The purpose of this study is to investigate the visual outcome after early transsphenoidal surgery for the patients with pituitary apoplexy. METHODS We retrospectively reviewed the 31 patients with pituitary apoplexy who were admitted due to acute visual acuity or field impairment and treated by transsphenoidal surgery. Five patients were excluded because of the decreased conscious level. The visual acuity of each individual eye was evaluated by Snellen's chart. Visual fields were also checked using automated perimetry. To compare the visual outcome according to the surgical timing, we divided the patients into 2 groups. The first group, 21 of the patients have been undertaken transsphenoidal approach (TSA) within at least 48 hours after admission. The second group included 8 patients who have been undertaken TSA beyond 48 hours. All patients were monitored at least 12 months after surgery. RESULTS Patients were 21 males and 8 females (M : F=2.6 : 1) with the mean age of 42.4 years. Among the enrolled 29 patients, 26 patients presented with decreased visual acuity and 23 patients revealed the defective visual field respectively. Postoperatively, improvement in the visual acuity was seen in 15 patients (83.3%) who underwent surgery within the first 48 hours of presentation, as compared to those in whom surgery was delayed beyond 48 hours (n=5; 62.5%) (p=0.014). Improvement in the visual field deficits was observed in 15 (88.2%) of patients who had been operated on within the first 48 hours of presentation, as compared to those in whom surgery was delayed beyond 48 hours (n=3; 50.0%) (p=0.037). CONCLUSION This study suggests that rapid transsphenoidal surgery is effective to recover the visual impairment in patients with pituitary apoplexy. If there are associated abnormalities of visual acuity or visual fields in patients with hemorrhagic pituitary apoplexy, early neurosurgical intervention within 48 hours should be also required to recover visual impairment.
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Affiliation(s)
- Ju-Wan Seuk
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Valle Feijoo ML, Fernández Fernández FJ, Muñoz López F, de la Fuente Aguado J. [Pituitary apoplexy due to macroadenoma bleeding]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2011; 58:317-318. [PMID: 21497570 DOI: 10.1016/j.endonu.2011.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 01/26/2011] [Accepted: 01/27/2011] [Indexed: 05/30/2023]
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Zhang X, Zhang W, Fu LA, Cheng JX, Liu BL, Cao WD, Fei Z, Zhang JN, Liu WP, Zhen HN. Hemorrhagic pituitary macroadenoma: characteristics, endoscopic endonasal transsphenoidal surgery, and outcomes. Ann Surg Oncol 2010; 18:246-52. [PMID: 20703818 DOI: 10.1245/s10434-010-1243-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE This study aims to assess the effect of endoscopic endonasal transsphenoidal surgery (EETSS) of hemorrhagic pituitary macroadenoma (HPMA). PATIENTS AND METHODS We retrospectively reviewed 52 cases with HPMA collected from the Xijing Hospital from April 1995 to April 2009. There were 39 males and 13 females, ranging in age from 18 to 79 years (average 51.6 years). Patients presented with headache or acute ophthalmological symptoms after adenoma hemorrhage. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed pituitary macroadenoma with hemorrhage in all cases. Twenty-eight adenomas showed marked suprasellar extension, 19 showed moderate extension, and another 5 showed slight extension. All patients were promptly treated by emergency EETSS, usually within 24 h after hospitalization. RESULTS Total removal of tumor was achieved in 46 cases (88.5%), and subtotal removal in 6 cases (11.5%). Postoperative radiotherapy and reoperation of the tumor were required in five patients with either residual or relapsed tumors. Follow-up ranged from 8 to 93 months (mean 41.6 months) for 43 cases. Visual acuity and visual field recovery and improvement was recorded in 92.1% and 94.3% of patients who had preoperative visual symptoms, respectively. CONCLUSIONS The majority of macroadenomas are hemorrhagic, and they often occur in middle-aged, male subjects. Detection by imaging in the setting of pituitary apoplexy accurately predicts the nature of the apoplectic process and helps to guide the type and timing of surgery. Early EETSS is the most effective therapy and significantly improves visual outcomes and systemic conditions.
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Affiliation(s)
- Xiang Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, People's Republic of China.
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Marouf R, Mohr G, Assimakopoulos P, Glikstein R. [Apoplectic macroadenomas: the outcome of the residual pituitary gland]. Neurochirurgie 2010; 56:324-30. [PMID: 20096427 DOI: 10.1016/j.neuchi.2009.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 06/18/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this retrospective study was to assess the MRI aspects and the function of the residual pituitary gland (RPG) after surgical decompression of an apoplectic pituitary macroadenoma, and to attempt to answer the question of whether an intra-adenomatous apoplexy necessarily leads to hypophyseal apoplexy. METHODS Between 1992 and 2008, 150 pituitary macroadenomas were surgically treated via the trans-sphenoidal approach, 19 of which presented an apoplectic feature (13%). They were subdivided into three groups: pure hemorrhage, hemorrhagic infarction, and ischemic infarction. The imaging was studied after surgery to identify the RPG and establish a correlation with the endocrine status. RESULTS After surgery five of 19 patients had normal adenohypophyseal function (27%), eight (42%) had panhypopituitarism, and six (31%) complete or partial corticotropic hypopituitarism. The RPG was identified on MRI in 13 patients (69%), four of them (31%) with normal adenohypophyseal function. The RPG was clearly identified intraoperatively in nine patients (47%), four of whom (44%) had normal adenohypophyseal function. One patient presented preoperative diabetes insipidus, which disappeared immediately after surgery, and two other patients developed postoperative diabetes insipidus: in one patient it quickly declined and in the other one it persisted, requiring replacement. According to the radiological classification of Hardy and Vezina modified by the Mohr (Mohr et Hardy, 1982) grade, the patients were subdivided up as follows: one grade II-0, four grade II-A, 11 grade II-B, two grade C, and one grade IV-B+D. CONCLUSION The repercussions of adenomatous apoplexy on the RPG is significant: only 27% of the patients retained normal pituitary function. Furthermore, although the RPG was identified on the MRI in more than two-thirds of the cases, more than half had adenohypophyseal failure: therefore, the visualization of a RPG does not mean that its functions are preserved. The involvement of the neurohypophysis is much rarer: one patient of 19 (5%). The implications of the ischemic or compressive damage on the normal pituitary gland are discussed.
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Affiliation(s)
- R Marouf
- Bureau 924, service de neurochirurgie, hôpital général juif, Sir Mortimer-B-Davis, 3755 Chemin de la Cote Sainte-Catherine, Montréal, Québec, H3T 1E2, Canada.
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Bahuleyan B, Menon G, Nair S, Rao B, Easwer H, Krishna K. Non-surgical management of cystic prolactinomas. J Clin Neurosci 2009; 16:1421-4. [DOI: 10.1016/j.jocn.2009.03.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Revised: 03/16/2009] [Accepted: 03/18/2009] [Indexed: 11/15/2022]
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24
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Altered consciousness associated with brain neoplasms. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18631828 DOI: 10.1016/s0072-9752(07)01715-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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Nawar RN, AbdelMannan D, Selman WR, Arafah BM. Pituitary tumor apoplexy: a review. J Intensive Care Med 2008; 23:75-90. [PMID: 18372348 DOI: 10.1177/0885066607312992] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pituitary tumor apoplexy is an uncommon syndrome resulting often spontaneously from hemorrhage or infarction of a pre-existing pituitary adenoma. As the primary event involves the adenoma, the syndrome should be referred to as pituitary tumor apoplexy and not as pituitary apoplexy. The sudden increase in sellar contents compresses surrounding structures and portal vessels, resulting in sudden, severe headache, visual disturbances, and impairment in pituitary function. Initial management of patients with pituitary tumor apoplexy includes supportive therapy (intravenous fluids and corticosteroids), following which many patients exhibit clinical improvement. Because those patients can be effectively managed with supportive measures, many who remain clinically and neurologically unstable might benefit from urgent surgical decompression by an experienced neurosurgeon. All patients presenting with this syndrome require long-term follow-up to treat any residual tumor and/or pituitary dysfunction. Close interaction between members of the management team is necessary for optimal patients' outcome.
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Affiliation(s)
- Rita N Nawar
- Division of Clinical and Molecular Endocrinology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Muthukumar N, Rossette D, Soundaram M, Senthilbabu S, Badrinarayanan T. Blindness following pituitary apoplexy: timing of surgery and neuro-ophthalmic outcome. J Clin Neurosci 2008; 15:873-9. [PMID: 18502643 DOI: 10.1016/j.jocn.2007.08.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Accepted: 08/21/2007] [Indexed: 11/30/2022]
Abstract
The aim of this study is to report the neuro-ophthalmic outcome in patients who underwent transsphenoidal decompression for unilateral or bilateral blindness that was due to pituitary apoplexy. Four patients who were rendered blind (with an absence of light perception) unilaterally or bilaterally as a result of pituitary apoplexy were studied. Neuro-ophthalmic evaluation was performed pre- and post-operatively. Patients underwent CT and MRI pre-operatively and CT post-operatively. All four patients underwent transethmoidal decompression of the pituitary adenoma. One patient underwent a second transcranial procedure to remove the remaining suprasellar component of the tumor. Visual acuity, visual fields and extra-ocular movements were documented during the follow-up period. There were three males and one female. Ages ranged from 40 to 68 years. Three patients had unilateral blindness and one was blind in both eyes. Two of the four patients had associated ophthalmoplegia. All the four patients presented within one week of ictus. One patient underwent surgery within the first week, two patients underwent surgery two and three weeks after ictus and the other patient underwent surgery two months after ictus. The patient who was operated on within the first week recovered from bilateral blindness to a visual acuity of 6/9 and 6/12 with superior quadrantic field defects. The two patients who were operated on two and three weeks after ictus improved to 6/60 in the affected eyes and the patient who was operated on after two months improved to 1/60 in the affected eye. Both the patients with ophthalmoplegia improved completely even though the surgery was delayed by two months for one patient. Although blindness following pituitary apoplexy is rare, visual acuity improves in most patients following transsphenoidal surgery. Early surgery within the first week after ictus leads to excellent visual outcome when compared with surgery that is performed at a later stage. In contrast to visual outcome, ophthalmoplegia improves even if surgical decompression is delayed.
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Affiliation(s)
- Natarajan Muthukumar
- Departments of Neurosurgery and Ophthalmology, Madurai Medical College, Madurai, India.
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Dev R, Singh SK, Sharma MC, Khetan P, Chugh A. Post traumatic pituitary apoplexy with contiguous intra cerebral hematoma operated through endonasal route--a case report. Pituitary 2007; 10:291-4. [PMID: 17318441 DOI: 10.1007/s11102-007-0015-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pituitary apoplexy is a clinical syndrome occurring as a consequence of fulminant expansion of pituitary tumor due to massive infarction, necrosis, and hemorrhage. Its association with head injury is rare and only few reports are available. Shear forces on stalk and arterial vasospasm have been proposed to be the possible reasons. The clinical picture is characterized by sudden onset headache, visual symptoms, multiple cranial nerves involvement, meningismus, altered mental status, and hormonal dysfunction. Transsphenoidal decompression is the standard treatment but suprasellar and widespread extension of hematoma may need intracranial approach. We are reporting a rare association of head injury with pituitary apoplexy, where endonasal surgery proved to be a simple useful approach to evacuate contiguous intra-cerebral hematoma with excision of apoplectic pituitary adenoma.
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Affiliation(s)
- Ravi Dev
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India.
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Kim HJ, Cho WH. Optic tract hemorrhage after pituitary apoplexy. AJNR Am J Neuroradiol 2007; 28:141-2. [PMID: 17213443 PMCID: PMC8134098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Subarachnoid hemorrhage following pituitary apoplexy is rare, and optic tract hemorrhage after the apoplexy is extremely rare. We report a case of optic tract hemorrhage after apoplexy that is not associated with hematologic disorders.
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Affiliation(s)
- H J Kim
- Department of Radiology, Medical Research Institute, Pusan National University College of Medicine, Pusan, South Korea.
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Shahlaie K, Olaya JE, Hartman J, Watson JC. Pituitary apoplexy associated with anterior communicating artery aneurysm and aberrant blood supply. J Clin Neurosci 2006; 13:1057-62. [PMID: 17071092 DOI: 10.1016/j.jocn.2006.01.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Accepted: 01/17/2006] [Indexed: 11/18/2022]
Abstract
Pituitary apoplexy is an uncommon condition typically caused by acute, hemorrhagic expansion of the pituitary gland in patients with an adenoma that undergoes infarction. Although various risk factors have been described, the vascular events leading to apoplexy are not well understood. Disruption of microvascular blood flow is a well-known cause of morbidity from hemorrhage of an intracranial aneurysm, but pituitary apoplexy is rarely associated with aneurysmal subarachnoid hemorrhage. We report here a 46-year-old woman with pituitary apoplexy who developed subarachnoid hemorrhage from rupture of an anterior communicating artery aneurysm. Intraoperatively, she was found to have an unusual, large recurrent artery originating at the junction of the aneurysm and the A2 segment of the anterior cerebral artery that traveled to the suprasellar cistern and along the pituitary stalk. This recurrent hypophyseal artery established a direct vascular relationship between an intracerebral aneurysm and the pituitary gland.
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Affiliation(s)
- Kiarash Shahlaie
- Department of Neurological Surgery, University of California at Davis Medical Center, Sacramento, California, USA
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Nakahara K, Oka H, Utsuki S, Iida H, Kurita M, Mochizuki T, Fujii K. Pituitary Apoplexy Manifesting as Diffuse Subarachnoid Hemorrhage-Case Report-. Neurol Med Chir (Tokyo) 2006; 46:594-7. [PMID: 17185885 DOI: 10.2176/nmc.46.594] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 46-year-old woman presented with hemorrhage from a non-functioning pituitary adenoma manifesting as sudden onset of severe headache. Computed tomography demonstrated diffuse subarachnoid hemorrhage (SAH) and a suprasellar mass with intratumoral hematoma. The patient underwent transnasal transsphenoidal removal of the pituitary adenoma. This type of SAH with intratumoral hematoma simulates rupture of an anterior cerebral artery aneurysm.
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Affiliation(s)
- Kuniaki Nakahara
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan.
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Ayuk J, McGregor EJ, Mitchell RD, Gittoes NJL. Acute management of pituitary apoplexy--surgery or conservative management? Clin Endocrinol (Oxf) 2004; 61:747-52. [PMID: 15579190 DOI: 10.1111/j.1365-2265.2004.02162.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE The rarity of pituitary apoplexy renders it a difficult subject for audit; hence there are no evidence-based standards of optimum care for such patients. The key controversy in management relates to the role of acute neurosurgical intervention. In recent years we have adopted a relatively conservative approach towards patients presenting with pituitary apoplexy. Against this background, we aimed to determine whether our less-interventional approach affected long-term clinical outcome in these patients. PATIENTS AND DESIGN A retrospective analysis was performed to evaluate clinical presentation, management and clinical outcomes in a cohort of patients who presented acutely with pituitary apoplexy during the period 1994-2004. Data from 33 patients (13 female) were included, with a mean age of 52 (range 27-79) years and mean follow-up duration of 3.7 (0.4-10.1) years. RESULTS The most common presenting symptoms were headache (97%), visual deficits (82%) and nausea/vomiting (78%). Fifteen patients (46%) underwent transsphenoidal surgery while 18 were managed conservatively. Indications for surgery were deteriorating visual deficit (n = 13), hemiparesis (n = 1) and altered conscious level (n = 1). Eight patients in the surgical group had ocular paresis that resolved in 63% following surgery, and seven had visual field defects with recovery in 57% postsurgery. Conservative management was reserved for patients with absent, or evidence of resolving, visual deficits at presentation. In this group, seven presented initially with ocular paresis and six with visual field defects but all made full recoveries. Of the patients managed neurosurgically, 87% required long-term glucocorticoid replacement and 60% required long-term thyroid hormone replacement. Conservatively managed patients required glucocorticoid replacement in 72% and thyroid hormone replacement in 72% of cases (P = NS between the two groups). Sex steroid replacement was required in 67% and 83% of patients managed neurosurgically and conservatively respectively (P = NS). At latest follow-up one patient in the conservatively managed group had required surgery and one in the surgically managed group had received pituitary radiotherapy, in both instances due to evidence of tumour regrowth on magnetic resonance imaging (MRI). CONCLUSION Our findings suggest that patients presenting with pituitary apoplexy in whom visual deficits are stable or improving may be managed expectantly as there is no identifiable deleterious effect on visual or endocrine outcome. One patient from each group experienced tumour regrowth that necessitated further treatment intervention, highlighting the importance of long-term follow-up in patients with pituitary apoplexy.
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Affiliation(s)
- John Ayuk
- Division of Medical Sciences, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK
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Abstract
Pituitary apoplexy is a rare clinical syndrome caused by sudden haemorrhaging or infarction of the pituitary gland, generally within a pituitary adenoma. Headache of sudden and severe onset is the main symptom, associated with visual disturbances or ocular palsy. Signs of meningeal irritation or altered consciousness may complicate the diagnosis. Corticotropic deficiency (secondary adrenal failure) may be life-threatening if untreated. Computed tomography (CT) or magnetic resonance imaging (MRI) confirm the diagnosis by revealing a pituitary tumour with haemorrhagic and/or necrotic components: CT is most useful in the acute setting (24 - 48 h), MRI is useful for identifying blood components in the subacute setting (4 days to 1 month). Owing to the highly variable course of this syndrome and the limited individual experience, the optimal management of acute pituitary apoplexy is controversial. Some authors advocate early transphenoidal surgical decompression for all patients, whereas others adopt a more conservative approach for selected patients (those without visual acuity or field defects and with normal consciousness). Glucocorticoid treatment must always be initiated immediately, at a dose of hydrocortisone 50 mg every 6 h.
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Affiliation(s)
- Philippe Chanson
- Bicetre University Hospital and University Paris XI, Department of Endocrinology, Assistance Publlique - Hopitaux de Paris, 78 rue du General Leclerc, F-94275 Le Kremlin-Bicetre, France.
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Verrees M, Arafah BM, Selman WR. Pituitary tumor apoplexy: characteristics, treatment, and outcomes. Neurosurg Focus 2004; 16:E6. [PMID: 15191335 DOI: 10.3171/foc.2004.16.4.7] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pituitary tumor apoplexy is an uncommon event heralded by abrupt onset of severe headache, restriction of visual fields, deterioration of visual acuity, and weakness of ocular motility frequently coupled with clinical indications of decreased endocrine function. Hemorrhage into or necrosis of a preexisting sellar mass, usually a pituitary macroadenoma, produces an expansion of sellar contents. Compression of adjacent structures elicits the variable expression of symptoms referable to displacement of the optic nerves and chiasm and impingement of the third, fourth, and sixth cranial nerves. Damage to or destruction of the anterior pituitary leads to multiple acute and/or chronic hormone deficiencies in many patients. Medical management may be used in rare cases in which the signs and symptoms are mild and restricted to meningismus or ophthalmoplegia deemed to be stable. In patients with visual or oculomotor lability or an altered level of consciousness, expeditious surgical decompression, accomplished most commonly through a transsphenoidal approach, should be performed to save life and vision and to optimize the chance of regaining or maintaining pituitary function.
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Affiliation(s)
- Meg Verrees
- Department of Neurosurgery and Division of Endocrinology, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio 44106, USA.
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Sibal L, Ball SG, Connolly V, James RA, Kane P, Kelly WF, Kendall-Taylor P, Mathias D, Perros P, Quinton R, Vaidya B. Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases. Pituitary 2004; 7:157-163. [PMID: 16010459 DOI: 10.1007/s11102-005-1050-3] [Citation(s) in RCA: 162] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review clinical presentation, management and outcomes following different therapies in patients with pituitary apoplexy. METHODS Retrospective analysis of case-records of patients with classical pituitary apoplexy treated in our hospitals between 1983-2004. RESULTS Forty-five patients (28 men; mean age 49 years, range 16-72 years) were identified. Only 8 (18%) were known to have pituitary adenomas at presentation. Thirty-four (81%) patients had hypopituitarism at presentation. CT and MRI identified pituitary apoplexy in 28% and 91% cases, respectively. Twenty-seven (60%) patients underwent surgical decompression, whilst 18 (40%) were managed conservatively. Median time from presentation to surgery was 6 days (range 1-121 days). Patients with visual field defects were more likely than those without these signs to be managed surgically (p = 0.01). Complete or near-complete resolution occurred in 93% (13/14), 94% (15/16) and 93% (13/14) of the surgically treated patients with reduced visual acuity, visual field deficit and ocular palsy, respectively. All patients with reduced visual acuity (4/4), visual field deficit (4/4) and ocular palsy (8/8) in the conservative group had complete or near-complete recovery. Only 5 (19%) patients in the surgical group and 2 (11%) in the conservative group had normal pituitary function at follow up. One (4%) patient in the surgical group and 4 (22%) in the conservative group had a recurrence of pituitary adenoma. CONCLUSIONS This large series suggests that the patients with classical pituitary apoplexy, who are without neuro-ophthalmic signs or exhibit mild and non-progressive signs, can be managed conservatively in the acute stage.
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Affiliation(s)
- Latika Sibal
- Department of Endocrinology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, UK
| | - Steve G Ball
- Department of Endocrinology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, UK
| | - Vincent Connolly
- Department of Endocrinology, The James Cook University Hospital, Middlesbrough, UK
| | - Robert A James
- Department of Endocrinology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, UK
| | - Philip Kane
- Department of Neurosurgery, The James Cook University Hospital, Middlesbrough, UK
| | - William F Kelly
- Department of Endocrinology, The James Cook University Hospital, Middlesbrough, UK
| | - Pat Kendall-Taylor
- Department of Endocrinology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, UK
| | - David Mathias
- Departments of Otonasolaryngology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, UK
| | - Petros Perros
- Department of Endocrinology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, UK
| | - Richard Quinton
- Department of Endocrinology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, UK
| | - Bijay Vaidya
- Department of Endocrinology, The James Cook University Hospital, Middlesbrough, UK.
- Department of Endocrinology, Diabetes & Vascular Medicine, Peninsula Medical School, Royal Devon & Exeter Hospital, Exeter, EX2 5DW, UK.
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Long SN, Michieletto A, Anderson TJ, Williams A, Knottenbelt CM. Suspected pituitary apoplexy in a German shorthaired pointer. J Small Anim Pract 2003; 44:497-502. [PMID: 14635962 DOI: 10.1111/j.1748-5827.2003.tb00110.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pituitary apoplexy is a syndrome which has been described in humans caused by acute haemorrhage or infarction within a pituitary tumour or a non-tumorous pituitary gland. This report describes the authors' observations of a dog in which vomiting, visual disturbances, seizures, altered consciousness and diencephalic dysfunction occurred in association with haemorrhage originating from a pituitary macroadenoma. The clinical signs were thought to be consistent with disruption of the hypothalamus and brainstem, together with raised intracranial pressure due to intraventricular haemorrhage. These signs, and the pathological findings, bear a striking resemblance to those associated with the syndrome of pituitary apoplexy, seen in humans.
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Affiliation(s)
- S N Long
- Department of Veterinary Clinical Studies, University of Glasgow Veterinary School, Bearsden Road, Bearsden, Glasgow G61 1QH
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Fukui S, Otani N, Nawashiro H, Yano A, Nomura N, Tokumaru AM, Miyazawa T, Ohnuki A, Tsuzuki N, Katoh H, Ishihara S, Shima K, Ooigawa H. The association of the expression of vascular endothelial growth factor with the cystic component and haemorrhage in pituitary adenoma. J Clin Neurosci 2003; 10:320-4. [PMID: 12763337 DOI: 10.1016/s0967-5868(03)00013-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Vascular endothelial growth factor (VEGF) is known to be a mediator of angiogenesis and vascular permeability. A cystic component and haemorrhage are often found in pituitary adenomas. We assessed the VEGF expression based on immunohistochemical examinations in 48 pituitary adenomas. All the adenomas showed some VEGF immunoreactivity mainly in the cytoplasm of tumour cells. Of the 48 adenoma-cases, 16 cases had a strong VEGF immunoreactivity, 26 cases had a moderate one, and 6 cases had a weak one. On the MR images, a cystic component was found in 16 cases (33.3%), and a haemorrhage was found in 18 cases (37.5%). The VEGF immunoreactivity had a significant relationship with the cystic component but not the haemorrhage, size, recurrence, or HE classification. These findings suggest that VEGF plays any potential role in the pathogenesis of cystic formation in pituitary adenomas.
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Affiliation(s)
- Shinji Fukui
- Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Saitama 359-8513, Tokorozawa, Japan.
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Randeva HS, Schoebel J, Byrne J, Esiri M, Adams CB, Wass JA. Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinol (Oxf) 1999; 51:181-8. [PMID: 10468988 DOI: 10.1046/j.1365-2265.1999.00754.x] [Citation(s) in RCA: 334] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The term classical pituitary apoplexy describes a clinical syndrome characterized by sudden headache, vomiting, visual impairment and meningismus caused by the rapid enlargement of a pituitary adenoma usually due to haemorrhagic infarction of the tumour. Most published reports looking at the clinical features and management of pituitary apoplexy have not differentiated between patients with clinical and subclinical apoplexy, the latter diagnosed at surgery. Furthermore, little is reported on the clinical outcome, in particular visual and endocrinological, and the role of radiotherapy. The purpose of this study was to observe not only the clinical presentation but also the possible predisposing events, investigations, management, clinical outcome as well as the role of radiotherapy in patients presenting with classical pituitary apoplexy. PATIENTS AND DESIGN In a retrospective analysis 1985-96, the medical records of 21 male and 14 female patients (mean age 49.8 years, range 30-74) with classical pituitary apoplexy were reviewed. This represents all patients seen with this condition over the stated period. MEASUREMENTS In all patients, pre- and post- operative measurements were made of FT4, FT3, TSH, PRL, LH, FSH, cortisol (0900 h), GH, oestradiol (females) and testosterone (males). Pituitary imaging was by computerized tomography (CT) scan, magnetic resonance imaging (MRI) or both. RESULTS Patients were followed for up to 11 years (mean 6.3 years: range 0.5-11). Headache (97%) was the commonest presenting symptom, followed by nausea (80%) and a reduction of visual fields (71%). Hypertension, defined as a systolic > 160 mmHg and/or a diastolic > 90 mmHg, was seen in 26% of patients. MRI correctly identified pituitary haemorrhage in 88% (n = 7), but CT scanning identified haemorrhage in only 21% (n = 6). By immunostaining criteria, null-cell adenomas were the most common tumour type (61%). Transsphenoidal surgery resulted in improvement in visual acuity in 86%. Complete restoration of visual acuity occurred in all patients operated on within 8 days but only in 46% of patients operated on after this time (9-34 days). Long-term steroid or thyroid hormone replacement was necessary in 58% and 45% of patients, respectively. Of the male patients, 43% required testosterone replacement, and long-term desmopressin therapy was required in 6%. Only two patients (6%) with tumour recurrence after transsphenoidal surgery for the initial apoplectic event, subsequently required radiotherapy. CONCLUSIONS In classical pituitary apoplexy, headache is the commonest presenting symptom and hypertension may be an important predisposing factor. MRI is the imaging method of choice. Transsphenoidal surgery is safe and effective. It is indicated if there are associated abnormalities of visual acuity or visual fields because, when performed within 8 days, it resulted in significantly greater improvement in visual acuity and fields than if surgery was performed after this time. Radiotherapy is not indicated immediately as the risk of tumour recurrence is small, but careful follow-up initially with annual imaging is indicated in this group.
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Affiliation(s)
- H S Randeva
- Department of Endocrinology, Radcliffe Infirmary, Oxford, UK
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Pinheiro MM, Cukiert A, Salgado LR, Nery M, Goldman J, Pimentel F, Liberman B. [Subclinical apoplexy in pituitary tumors]. ARQUIVOS DE NEURO-PSIQUIATRIA 1999; 57:74-7. [PMID: 10347728 DOI: 10.1590/s0004-282x1999000100014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Acute pituitary apoplexy is a rare event, even in patients with pituitary macroadenomas. On the other hand, the presence of necrotic/hemorrhagic areas, especially in macroadenomas, seems to be more common than earlier reported in the CT period. After the introduction of MR in the presurgical workup of these patients, these apopleptic areas have been more easily diagnosed preoperatively. Forty consecutive patients with pituitary macroadenomas were studied with high-resolution 1.5 T T1 coronal, sagittal and axial slices over the sellar region. Special attention was paid in the detection of necrotic, cystic and hemorrhagic areas within these tumors. Ten patients had hemorrhagic/necrotic areas within their tumors, without any sign or symptom of acute apoplexy. These areas varied from small (2 mm) to very large (30 mm) ones. Seven patients had non-secreting tumors, 2 GH and 1 prolactin secreting tumors, which is the same profile of secretory pattern for the whole series (40 patients). The clinical picture included (other than that caused by endocrine secretion) slowly progressive (but not acute) visual loss (n = 8) and headache (n = 3). After surgical decompression of the surrounding structures and visual apparatus, which was facilitated by the presence of the necrotic areas, there was visual improvement in 6 patients and headache resolution in 2. The presence of asymptomatic apopletic areas in these macroadenomas and their absence in microadenomas as can be seen in the literature suggest that they are related more to the size of the tumor than to its endocrine secretion pattern. This is in agreement with a vascular insufficiency hypothesis in the pathogenesis of these lesions.
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Affiliation(s)
- M M Pinheiro
- Serviço de Neurocirurgia, Hospital Brigadeiro, São Paulo, Brasil
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Miranda M, Barros L, Knopfelmacher M, Augusto EC, Jacomossi A, Cukiert A, Salgado LR, Nery M, Goldman J, Liberman B. [Pituitary apoplexy followed by endocrine remission. Report of two cases]. ARQUIVOS DE NEURO-PSIQUIATRIA 1998; 56:449-52. [PMID: 9754427 DOI: 10.1590/s0004-282x1998000300015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pituitary apoplexy is rare and endocrine remission in patients with apopletic secreting pituitary adenomas is even rarer. This study reports on two patients with pituitary macroadenomas (one with Cushing's disease and the other with acromegaly) in whom endocrine remission occurred after apoplexy. The first patient had Cushing's disease and had an ictus of headache and vomiting after which she started a progressive remission of hypercortisolism. A post-apoplexy MRI disclosed persistence of a sellar and supra-sellar mass. She was submitted to transesphenoidal surgery. An hypertensive hemorrhagic cyst was found with no tumor. The second patient had acromegaly. While performing a LHRH-stimulation test he had an ictus of headache, vomiting, no visual loss and appearance of diabetes insipidus. A CT scan disclosed an intrasellar hematoma. Despite the size of the tumor and since there was no visual impairment, this patient was followed up without surgery. Imaging follow-up showed a progressive shrinkage and disappearance of the mass, which was corroborated by endocrine remission. A high rate of recurrence is reported in such patients in the literature. Both patients are being currently followed-up on a long-term basis.
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Affiliation(s)
- M Miranda
- Departamento de Endocrinologia, Hospital Brigadeiro, São Paulo
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Abstract
The sella and parasellar region may be affected by a variety of disease states. Diseases of this region often result in visual disturbances because of the proximity of the sella to the optic pathways and cranial nerves. Knowledge of the pathological conditions affecting the sella and surrounding structures is important for the orbital imager.
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Affiliation(s)
- C E Swallow
- Department of Radiology, University of Utah Medical Center, Salt Lake City 84132, USA
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Yokoyama S, Goto M, Hirano H, Hirakawa W, Noguchi S, Hirahara K, Kadota K, Asakura T. Pituitary Adenoma with Cholesterol Clefts. Endocr Pathol 1998; 9:91-95. [PMID: 12114666 DOI: 10.1007/bf02739956] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Histologically, cholesterol clefts are often observed in craniopharyngioma, Rathke's cleft cyst, and various granulomas. However, pituitary adenomas with cholesterol clefts are rare. A 46-year-old woman developed visual field disturbance. She had no history of severe headache that would suggest pituitary apoplexy. She presented with homonymous bitemporal hemianopsia and galactorrhea. Blood prolactin level was 63.1 ng/mL Other hypophysial hormone levels were within normal range. Magnetic resonance imaging revealed a pituitary tumor with intratumoral cyst. The cyst showed high intensity on T1- and T2-weighted images. The tumor was demonstrated with iso intensity on T1-weighted image and with high intensity on 12-weighted image. She underwent trans-sphenoidal surgery. The tumor was soft, with yellowish, oily fluid, probably the cyst content. By light microscopy with hematoxylin and eosin staining, a typical chromophobic adenoma of the pituitary was identified. Immunostaining revealed immunoreactivity for ACTH in several cells. Many cholesterol clefts and several hemosiderin pigment containing macrophages were observed. Electron microscopy demonstrated a pituitary adenoma with sparse and small secretory granules and numerous lysosomes. The cyst was most likely caused by focal hemorrhagic infarction, followed by the formation of cholesterol crystals, the appearance of hemosiderin containing macrophages, foreign body product cells, and accumulation of lysosomes.
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Abstract
The pituitary gland has been termed the 'master gland' because of the myriad of hormones that emanate from it that are vital for normal homeostasis as well as growth and development. Primary tumors of this region are frequent and account for up to 10% of intracranial tumors. Pituitary tumors are monoclonal in origin, and may arise from any of the different cell types of the pituitary gland. Hence, these tumors may be manifest by their hormonal secretions. This may lead to profound and striking physiological changes attributable, for example, to prolactin, growth hormone, or ACTH excess. The central location of the pituitary gland also leads to characteristic compressive symptoms. This review will explore the clinical presentations of growth hormone, ACTH, and prolactin secreting tumors as well as the non-secreting pituitary tumors. Advances in neuroimaging and neuropharmacology have resulted in changes in our treatment of these tumors. Treatment modalities including surgical, medical, and radiation therapy will be addressed. The treatment of choice is dictated by the type of tumor and the nature of the excessive hormonal expression. Outcomes and efficacy of treatment are discussed.
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Affiliation(s)
- P J Yeh
- Department of Surgery, The University of Texas Medical Branch, Galveston 77555-0517, USA
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Goel A, Nadkarni T. Surgical management of giant pituitary tumours--a review of 30 cases. Acta Neurochir (Wien) 1996; 138:1042-9. [PMID: 8911540 DOI: 10.1007/bf01412306] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
An experience with surgical management of 30 giant pituitary tumours is analysed in this report. The clinical features, anatomical spread and relationship of these tumours with the cavernous sinus and other parasellar and basal forebrain structures is analysed. The problem encountered in the surgical treatment are reviewed. An unusual feature in the management was an intra-operative and post-operative tumour swelling and acute elevation of the intracranial pressure in 5 patients. Despite the technical problems encountered during surgery and in the post-operative period it was observed that a significant resection and adequate decompression of the visual apparatus offered a reasonable opportunity for recovery in vision and a satisfactory outcome. Complete resection of the tumour was not possible in this series. A contralateral subfrontal route was seen to be most suitable for resection of the part of the tumour that invaded the cavernous sinus.
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Affiliation(s)
- A Goel
- Department of Neurosurgery, K.E.M. Hospital, Bombay, India
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Wakai S, Sato A, Nagai M. Expanding intracerebral hematoma from pituitary adenoma: case report. Neurosurgery 1995; 37:807-8; discussion 808-9. [PMID: 8559311 DOI: 10.1227/00006123-199510000-00026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
We report the case of a 53-year-old man presenting with a headache of sudden onset and blurred vision secondary to hemorrhage from a nonfunctioning pituitary adenoma, which had been treated 25 years previously by transcranial surgery and postoperative irradiation. The intratumoral and intracerebral hematoma expanded to three times its initial size because of a recurrent hemorrhage that occurred during a 2-day period while the patient awaited surgery. The mechanisms of hematoma expansion and the management strategy in such a case are discussed, and a review of the pertinent literature is presented.
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Affiliation(s)
- S Wakai
- Department of Neurosurgery, Dokkyo University School of Medicine, Tochigi, Japan
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45
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Expanding Intracerebral Hematoma from Pituitary Adenoma. Neurosurgery 1995. [DOI: 10.1097/00006123-199510000-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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47
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Bills DC, Meyer FB, Laws ER, Davis DH, Ebersold MJ, Scheithauer BW, Ilstrup DM, Abboud CF. A retrospective analysis of pituitary apoplexy. Neurosurgery 1993; 33:602-8; discussion 608-9. [PMID: 8232799 DOI: 10.1227/00006123-199310000-00007] [Citation(s) in RCA: 174] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Thirty-seven patients with pituitary apoplexy were analyzed with an emphasis on clinical presentation and visual outcome. Their mean age was 56.6 years, with a male to female ratio of 2:1. Presenting symptoms included headache (95%), vomiting (69%), ocular paresis (78%), and reduction in visual fields (64%) or acuities (52%). Computed tomographic scanning correctly identified pituitary hemorrhage in only 46% of those scanned. Thirty-six patients underwent transsphenoidal decompression. By immunostaining criteria, null-cell adenomas were the most frequent tumor type (50%). Long-term steroid or thyroid hormone replacement therapy was necessary in 82% and 89% of patients, respectively. Long-term desmopressin therapy was required in 11%, and 64% of the male patients required testosterone replacement therapy. Surgery resulted in improvement in visual acuity deficits in 88%, visual field deficits in 95%, and ocular paresis in 100%. Analysis of the degree of improvement in preoperative visual deficits with the timing of the surgery demonstrated that those who underwent surgery within a week of apoplexy had significant recovery in their visual acuities. In the stable, conscious patient with residual vision in each eye, surgical decompression should be performed as soon as possible, because delays beyond 1 week may retard the return of visual function.
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Affiliation(s)
- D C Bills
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Saito K, Takayasu M, Akabane A, Okabe H, Sugita K. Primary chronic intrasellar haematoma: a case report. Acta Neurochir (Wien) 1992; 114:147-50. [PMID: 1580195 DOI: 10.1007/bf01400605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This report describes a rare case of primary intrasellar haematoma in a 66 year-old man with hypopituitarism. Computerized tomography (CT) and magnetic resonance imaging (MRI) showed an intrasellar cystic lesion with small suprasellar extension. Transsphenoidal surgery revealed that the lesion was a chronic haematoma, without evidence of a tumour or vascular anomaly. Pathological diagnosis confirmed this. This is the first report of a chronic intrasellar haematoma, which is probably primary.
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Affiliation(s)
- K Saito
- Department of Neurosurgery, Nagoya University School of Medicine, Japan
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49
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Lundin P, Nyman R, Burman P, Lundberg PO, Muhr C. MRI of pituitary macroadenomas with reference to hormonal activity. Neuroradiology 1992; 34:43-51. [PMID: 1553037 DOI: 10.1007/bf00588432] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In 115 patients with pituitary macroadenomas, the findings on mid-field MRI were correlated with the hormonal activity of the tumours. Adenomas secreting growth hormone (GH), prolactin (PRL) and clinically nonsecretory adenomas were studied. Tumour size, invasiveness and signal intensity patterns were recorded. Relaxation times and ratios of signal intensity and proton density (relative to the corpus callosum) were analysed in areas of apparently solid tissue in a subgroup of 59 previously untreated patients. Invasiveness was more common in PRL- and GH-secreting adenomas than in the nonsecreting ones. Diffuse invasion of the base of the skull was most common in prolactinomas, and associated with a lower frequency of suprasellar tumour extension. In prolactinomas, a correlation was found between the maximum serum PRL level and tumour size. Haemorrhagic, cystic or necrotic areas were less common in GH-secreting tumours than in the other types. Haemorrhage was more common in prolactinomas than in nonsecreting tumours. MR parameters were similar in prolactinomas and nonsecreting adenomas, but indicated a smaller amount of water in GH-secreting tumours.
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Affiliation(s)
- P Lundin
- Department of Diagnostic Radiology, Uppsala University, Akademiska sjukhuset, Sweden
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50
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Lunardi P, Rizzo A, Missori P, Fraioli B. Pituitary apoplexy in an acromegalic woman operated on during pregnancy by transphenoidal approach. Int J Gynaecol Obstet 1991; 34:71-4. [PMID: 1671026 DOI: 10.1016/0020-7292(91)90542-d] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- P Lunardi
- Department of Neurological Sciences, University La Sapienza, Rome, Italy
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