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Wesley SR, Vates GE, Thornburg LL. Neurologic Emergencies in Pregnancy. Obstet Gynecol 2024; 144:25-39. [PMID: 38626451 DOI: 10.1097/aog.0000000000005575] [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: 12/03/2023] [Accepted: 02/29/2024] [Indexed: 04/18/2024]
Abstract
Neurologic emergencies in pregnancy require prompt evaluation and early, focused intervention to improve neurologic outcomes for the affected person and to avoid further injury. Neurologic events in pregnancy, although rare, present a time of extreme risk of permanent injury for the person who is pregnant. Therefore, obstetric clinicians should be well versed in the risk factors for potential neurologic events and understand the symptoms and events that should prompt evaluation for a neurologic event. In addition, they should support other specialties in aggressive and early neurologic care for the patient to improve outcomes while assessing fetal well-being and care optimization for the dyad. Obstetric clinicians can uniquely provide knowledge of changes in pregnancy physiology that can increase the risk of neurologic events, as well as change the treatment of these events. For all patients with neurologic events, "time is brain." Therefore, it is important to be aware of changes in common presenting pregnancy concerns that should prompt evaluation for other pathogeneses. Finally, pregnancy care teams should be prepared to begin the initial stabilization and management of acute neurologic emergencies, including seizure, stroke, and meningitis, while seeking aid from other medical and neurologic specialists who can support their care and interventions. Early and aggressive interventions for individuals with neurologic events during pregnancy and postpartum are critical to the overall well-being of the dyad.
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Affiliation(s)
- Shaun R Wesley
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, and the Division of Neuroendocrine Disorders, Department of Neurosurgery, University of Rochester, Rochester, New York
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Buchta M, Krainz H, Grimm J, Kraus T, Griessenauer CJ, Schwartz C, Ueberschaer MF, Dejaco M, Otto F. Pituitary Apoplexy in Macroadenoma After Minor Surgery: An Unusual Case and Literature Review. Cureus 2024; 16:e57912. [PMID: 38725789 PMCID: PMC11081411 DOI: 10.7759/cureus.57912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2024] [Indexed: 05/12/2024] Open
Abstract
Pituitary apoplexy is a rare and severe complication of pituitary adenoma that may present with new-onset headache, ocular palsy, visual disturbances, life-threatening electrolyte imbalance, and endocrinological disturbances due to pituitary hemorrhage and/or infarction. We report the case of a 58-year-old previously healthy patient who developed isolated mild oculomotor nerve palsy of the left eye following osteosynthesis of a traumatic right distal radius fracture. Initial cerebral magnetic resonance imaging showed a pituitary macroadenoma without characteristic signs of pituitary infarction or hemorrhage. The patient presented to the neurology department on the fifth postoperative day with malaise and fatigue due to pituitary insufficiency, deteriorated rapidly and required intensive care monitoring. Clinical stabilization was achieved through the administration of hydrocortisone, and transsphenoidal resection of the pituitary lesion was performed on the 10th day after acute symptom onset. Histological examination revealed a necrotic pituitary adenoma. Pituitary apoplexy may occur after minor surgery in patients with pituitary adenoma. Clinicians should pay particular attention to laboratory signs of pituitary insufficiency in new-onset oculomotor nerve palsy associated with sellar lesions, as cerebral imaging may miss pituitary apoplexy and therefore delay diagnosis and treatment. In our case, delayed decompressive transsphenoidal resection resulted in the normalization of the oculomotor nerve palsy while the pituitary insufficiency persisted. The potential impact of an earlier surgical intervention on the outcome of pituitary function remains uncertain.
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Affiliation(s)
- Melanie Buchta
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Herbert Krainz
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Jochen Grimm
- Neuroradiology, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Theo Kraus
- Pathology, University Hospital Salzburg, Paracelsus Private Medical University, Salzburg, AUT
| | - Christoph J Griessenauer
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Christoph Schwartz
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Moritz F Ueberschaer
- Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
| | - Martin Dejaco
- Otolaryngology - Head and Neck Surgery, University Hospital Salzburg, Paracelsus Private Medical University, Salzburg, AUT
| | - Ferdinand Otto
- Neurology, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, AUT
- Neurology, Centre for Cognitive Neuroscience, Salzburg, AUT
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Zhang Z, Li S, Wang Y, Wang Z, Wang X, Wang B, Yang Z, Liu P, Li P. Visual outcomes and optimal timing for repeat surgery in cases of postoperative hematoma following transsphenoidal surgery for pituitary neuroendocrine tumors: A retrospective cohort study. Acta Neurochir (Wien) 2024; 166:127. [PMID: 38460009 DOI: 10.1007/s00701-024-06027-9] [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: 01/08/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE To investigate the visual outcomes and optimal timing for repeat surgery in cases of postoperative hematoma following transsphenoidal surgery for pituitary neuroendocrine tumors (PitNETs). METHODS A retrospective study was conducted on 28 patients who developed evident postoperative hematoma out of a total of 9,010 patients. The hematomas were classified into three types based on their CT appearance. Type 1a - mild high density with no tension, Type 1b - thin-layer high density; Type 2a - solid high density with large empty cavities, Type 2b - solid high density with small empty cavities; Type 3 -solid high density with no cavity showing high tension. Patient data were collected for analysis. RESULTS The study cohort comprised 10 female and 18 male patients, with a mean age of 51.5±11.9 years. Most patients presented with large adenomas (median diameter 36mm). Postoperative visual sight improved in 12 patients, remained stable in 11 patients, and worsened in 5 patients. Notably, no patients experienced worsened visual sight beyond twenty-four hours after the operation. Among the five patients with visual deterioration, four had CT type 3 hematoma (4/6, 66.7%), and one had CT type 2b hematoma (1/9, 11.1%). Patients in the type 3 CT group were significantly more prone to experience visual deterioration compared to those in the type 2 group (odds ratio [OR] 2.154 [95% CI 1.858-611.014], P=.027). Four patients underwent repeat surgery after visual deterioration, resulting in visual improvement following a prolonged recovery period. Postoperative hematoma had limited impact on pituitary dysfunction and hyponatremia. CONCLUSION Our study reveals a significant association between postoperative hematoma CT types and visual deterioration. For patients with stable visual sight and type 1 or 2a hematoma, conservative strategies may be considered. Conversely, type 2b and 3 patients are at higher risk of visual deterioration, especially within the first 24 hours after the operation. Consequently, early reoperation before vision worsens may be a prudent approach to reduce risks and improve visual outcomes, particularly in type 3 patients.
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Affiliation(s)
- Zhe Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shiwei Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Wang
- Neural Reconstruction Department, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zhenmin Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingchao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Peng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Cheng W, Liu J, Jiang T, Li M. The application of functional imaging in visual field defects: a brief review. Front Neurol 2024; 15:1333021. [PMID: 38410197 PMCID: PMC10895022 DOI: 10.3389/fneur.2024.1333021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/31/2024] [Indexed: 02/28/2024] Open
Abstract
Visual field defects (VFDs) represent a prevalent complication stemming from neurological and ophthalmic conditions. A range of factors, including tumors, brain surgery, glaucoma, and other disorders, can induce varying degrees of VFDs, significantly impacting patients' quality of life. Over recent decades, functional imaging has emerged as a pivotal field, employing imaging technology to illustrate functional changes within tissues and organs. As functional imaging continues to advance, its integration into various clinical aspects of VFDs has substantially enhanced the diagnostic, therapeutic, and management capabilities of healthcare professionals. Notably, prominent imaging techniques such as DTI, OCT, and MRI have garnered widespread adoption, yet they possess unique applications and considerations. This comprehensive review aims to meticulously examine the application and evolution of functional imaging in the context of VFDs. Our objective is to furnish neurologists and ophthalmologists with a systematic and comprehensive comprehension of this critical subject matter.
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Affiliation(s)
- Wangxinjun Cheng
- Department of Rehabilitation, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Queen Mary College, Nanchang University, Nanchang, China
| | - Jingshuang Liu
- Department of Rehabilitation, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Queen Mary College, Nanchang University, Nanchang, China
| | - Tianqi Jiang
- The First Clinical Medical College, Nanchang University, Nanchang, China
| | - Moyi Li
- Department of Rehabilitation, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Salle H, Cane M, Rocher M, Auditeau E, Teissier MP, Raverot G, Salle L. Pituitary apoplexy score, toward standardized decision-making: a descriptive study. Pituitary 2024; 27:77-87. [PMID: 38150169 DOI: 10.1007/s11102-023-01372-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 12/28/2023]
Abstract
Pituitary apoplexy (PA), a rare and life-threatening complication of pituitary adenomas, prompts urgent glucocorticoid administration. The optimal surgical approach is debated, and the Pituitary Apoplexy Score (PAS) aids decision-making. Our retrospective study (2003-2022) assesses variables in PA patient groups (surgical vs. non-surgical), applying PAS to establish a significant threshold for surgical decisions. Additionally, we aim to compare the rates of ophthalmological and endocrine deficit between both groups and identify any associated variables. PAS discrepancies were observed, with averages of 1.7 ± 1.7 (p < 0.0001) for conservative and 3.9 ± 1.7 (p < 0.0001) for surgical groups, confirmed by multivariate analysis (p = 0.009). A PAS threshold of 5, showing over 80% positive predictive value, was established. Patients with low prolactin levels (< 5 ng/ml) had higher corticotropic deficiency prevalence at 3-month and 1-year follow-ups (p = 0.017 and 0.027). Our study supports PAS as a valuable PA management tool, suggesting potential variable adjustments. Multicenter studies are crucial due to PA's low incidence.
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Affiliation(s)
- Henri Salle
- Neurosurgery, CHU Limoges, Limoges, France.
- CAPTuR, Inserm, University of Limoges, CHU Limoges, Limoges, France.
| | | | | | - Emilie Auditeau
- Inserm U1094, IRD U270, EpiMaCT, University of Limoges, CHU Limoges, Limoges, France
| | | | - Gerald Raverot
- Endocrinology, Hospices Civils de Lyon and Lyon 1 University, Lyon, France
| | - Laurence Salle
- Endocrinology, CHU Limoges, Limoges, France
- Inserm U1094, IRD U270, EpiMaCT, University of Limoges, CHU Limoges, Limoges, France
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Yamamuro S, Yoshino A, Nishide T, Negishi H, Kumagawa T. A case report of pituitary neuroendocrine tumor manifesting as severe conjunctival chemosis. BMC Ophthalmol 2023; 23:479. [PMID: 37993825 PMCID: PMC10666417 DOI: 10.1186/s12886-023-03224-5] [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: 07/23/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Conjunctival chemosis (CC) is an extremely rare symptom of pituitary neuroendocrine tumor (PitNET). We report an extremely rare case of PitNET manifesting as severe CC. CASE PRESENTATION A 48-year-old male was admitted to our hospital with severe CC, proptosis, and ptosis of the right eye. Magnetic resonance imaging demonstrated the tumor mass invading the cavernous sinus (CS) with cystic lesion. The patient underwent emergent endoscopic transsphenoidal surgery, and the pathological diagnosis was PitNET. CC of the right eye remarkably improved after the surgery. Glucocorticoid therapy was performed for right oculomotor nerve palsy, which rapidly improved. The postoperative course was uneventful and the patient was discharged from our hospital without hormone replacement. CONCLUSIONS CC caused by CS invasion of PitNET can be cured by early surgical treatment. Therefore, PitNET is important to consider in the differential diagnosis of CC.
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Affiliation(s)
- Shun Yamamuro
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan.
| | - Atsuo Yoshino
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Takuma Nishide
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Hiroshi Negishi
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Takahiro Kumagawa
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
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Kharel M, Hossain MF. Pituitary apoplexy associated with bacterial meningitis: Diagnostic dilemma. Clin Case Rep 2023; 11:e7887. [PMID: 37670816 PMCID: PMC10475759 DOI: 10.1002/ccr3.7887] [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: 06/04/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/07/2023] Open
Abstract
Pituitary apoplexy is a rare entity, which is characterized by severe neurological, ophthalmological, and endocrinological complications, with acute adrenal crisis being a major concern. The diagnosis of pituitary apoplexy is challenging, particularly in cases where it coexists with bacterial meningitis, leading to a diagnostic dilemma and delay in treatment. We report a case of a 23-year-old female diagnosed with pituitary apoplexy with concurrent bacterial meningitis.
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Hadj Kacem F, Trimeche O, Gargouri I, Ben Salah D, Charfi N, Rekik N, Mnif F, Mnif M, Elleuch M, Abid M. Diagnosis and management of pituitary apoplexy: a Tunisian data. Chin Neurosurg J 2023; 9:17. [PMID: 37391784 DOI: 10.1186/s41016-023-00331-6] [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: 11/13/2022] [Accepted: 06/12/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Pituitary apoplexy (PA) is defined as the hemorrhage or the infraction of a pituitary adenoma. Aiming to determine the epidemiological, clinical, paraclinical characteristics as well as management and outcomes of PA in our population, we conducted this cross-sectional study. METHODS This cross-sectional study was conducted at the Department of Endocrinology of Hedi chaker university hospital, Sfax. Data was collected from medical charts of patients with pituitary apoplexy admitted in our department between 2000 and 2017. RESULTS We included 44 patients with PA. Their mean age was 50 ± 12.6 years. Among them, 31.8% had a known pituitary adenoma, and it was in all cases a macroadenoma, predominantly a prolactin secreting tumor (42.8%). A triggering factor of PA was encountered in 31.8% of cases and it was mainly: head trauma, dopamine antagonists, and hypertension. The clinical presentation of PA encompassed headaches (84.1%), visual disturbances (75%), and neurological signs (40.9%). Gonadotropin deficiency was the most frequent form of hypopituitarism noted (59.1%), followed by corticotropin deficiency (52.3%), thyrotropin deficiency (47.7%), and somatotropin deficiency (2.3%). Hormonal assessment at PA onset, concluded that 23 had a secreting adenoma: 18 prolactinomas, 3 ACTH-secreting adenomas, and 2 GH-secreting adenomas. In the 21 remaining cases, the tumor was non-functioning (47.7%). Pituitary MRI was performed in 42 cases (95.5%), revealing infraction and or hemorrhage in the pituitary gland in 33 cases; a heterogenous signal or a fluid level within the adenoma, in nine cases. Urgent administration of intra venous hydrocortisone was required in 19 cases. Mannitol administration was mandatory in a patient who had severe intracranial hypertension. Surgical management of the PA was imperative in 24 patients (54.5%): 15 suffered from severe visual impairment, 4 had an intracranial hypertension, 2 cases demonstrated an impaired consciousness, 2 patients experienced a tumor enlargement and one case had a severe Cushing's disease. Operative complications found were rhinorrhea attributable to cerebral spinal fluid leakage, insipidus diabetes associated with rhinorrhea, isolated insipidus diabetes, and hydrocephalus in one case each. Long-term follow-up concluded that headaches persisted in five cases, owing to the tenacity of a macroprolactinoma regardless of cabergoline treatment in one case, the recurrence of an adenoma in two cases and its persistence despite the medical and the surgical treatment in two patients. Concerning the visual acuity defects, only two patients had persistent diminished visual acuity at long-term follow-up. Among 25 patients, 13 were diagnosed with definitive thyrotropin deficiency. Similarly, 14 patients had persistent corticotropin deficiency (CD). Additionally, CD was de novo diagnosed in two patients. Otherwise, gonadotropin deficiency prevailed in all cases. Persistent prolactin deficiency was seen in two patients. Disappearance of the pituitary tumor was encountered in 11 out of 24 cases at long-term follow-up. Overall, surgery was associated with better outcome than conservative management. Pituitary apoplexy is a challenging condition due to its variable course, its diagnosis difficulty and management, as gaps remain to determine the best approach to treat this condition. CONCLUSIONS To conclude, pituitary apoplexy is a challenging condition due to its variable course, its diagnosis difficulty and management, as gaps remain to determine the best approach to treat this condition. Further studies are thus needed.
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Affiliation(s)
| | | | | | | | | | | | - Fatma Mnif
- Hedi Chaker Hospital, 3029, Sfax, Tunisia
| | - Mouna Mnif
- Hedi Chaker Hospital, 3029, Sfax, Tunisia
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Fadul A, Demir G, Safieh M, Lebbe A, Falamrz F, Alhassan AT, Abdalla ELM, Fadul MH, Elawad M, Akbar RA. Isolated Sixth Cranial Nerve Palsy as Initial Presentation of Pituitary Apoplexy: A Case Report. Cureus 2023; 15:e41154. [PMID: 37525778 PMCID: PMC10386906 DOI: 10.7759/cureus.41154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/02/2023] Open
Abstract
Pituitary apoplexy is a serious condition, which if left untreated, might lead to irreversible life-long complications. Hence, pituitary apoplexy should always be included in the differential diagnoses of a patient with an isolated sixth cranial nerve (CN) palsy. This report highlights the case of a patient presenting with isolated CN palsy associated with pituitary apoplexy. Although pituitary adenomas are common, they seldom present with isolated abducent nerve palsy without any other CN involvement. The 47-year-old female patient presented with acute right eye pain, diplopia, and a squint. Examination revealed an isolated unilateral sixth CN palsy. Brain MRI showed a sellar and suprasellar mass suggestive of hemorrhagic pituitary apoplexy. The patient was transferred to neurosurgery and underwent transsphenoidal resection of a pituitary macroadenoma. Postoperative follow-up showed clinical improvement. It is, thus, imperative for physicians to have the knowledge to recognize an isolated sixth cranial nerve palsy and its associated causes.
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Affiliation(s)
- Abdalla Fadul
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Gokhan Demir
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | | | | | | | | | | | | | | | - Raza A Akbar
- Internal Medicine, Hamad General Hospital, Doha, QAT
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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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Tsukamoto T, Miki Y. Imaging of pituitary tumors: an update with the 5th WHO Classifications-part 1. Pituitary neuroendocrine tumor (PitNET)/pituitary adenoma. Jpn J Radiol 2023:10.1007/s11604-023-01400-7. [PMID: 36826759 PMCID: PMC10366012 DOI: 10.1007/s11604-023-01400-7] [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: 12/23/2022] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
The pituitary gland is the body's master gland of the endocrine glands. Although it is a small organ, many types of tumors can develop within it. The recently revised fifth edition of the World Health Organization (WHO) classifications (2021 World Health Organization Classification of Central Nervous System Tumors and 2022 World Health Organization Classification of Endocrine and Neuroendocrine Tumors) revealed significant changes to the classification of pituitary adenomas, the most common type of pituitary gland tumor. This change categorized pituitary adenomas as neuroendocrine tumors and proposed the name to be revised to pituitary neuroendocrine tumor (PitNET). The International Classification of Diseases for Oncology behavior code for this tumor was previously "0" for benign tumor. In contrast, the fifth edition WHO classification has changed this code to "3" for primary malignant tumors as same to neuroendocrine tumor in other organs. Because the WHO classification made an important and significant change in the fundamental concept of the disease, in this paper, we will discuss the imaging diagnosis (magnetic resonance imaging, computed tomography, and positron emission tomography) of PitNET/pituitary adenoma in detail, considering these revisions as per the latest version of the WHO classification.
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Affiliation(s)
- Taro Tsukamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan.
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Tanaka S, Suzuki S, Oishi M, Soeta S, Namiki R, Hara Y. Adrenocorticotropic hormone-producing pituitary adenoma with pituitary apoplexy treated by surgical decompression: a case report. BMC Vet Res 2022; 18:397. [PMID: 36369011 PMCID: PMC9652851 DOI: 10.1186/s12917-022-03502-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Pituitary-dependent hypercortisolism (PDH) is one of the most common endocrine disorders in veterinary medicine. However, there are few reports on pituitary tumor apoplexy (PTA) in dogs and no reports on its surgical intervention in veterinary medicine. Accordingly, the appropriate treatment is unknown. Herein, a case of PDH and PTA in a dog treated surgically is described. Case presentation A mongrel female dog (spayed; age, 8 years and 8 months; weight, 6.1 kg) with persistently elevated alkaline phosphatase underwent adrenocorticotropic hormone (ACTH) stimulation testing (post-stimulation cortisol: 20.5 μg/dL), abdominal ultrasonography (adrenal gland thickness: left, 5.7 mm; right, 8.1 mm), and brain magnetic resonance imaging (MRI) (pituitary-to-brain ratio [PBR], 0.61) at the referral hospital, resulting in a diagnosis of PDH (day 0). On day 9, the dog visited XXXX for the preparation of pituitary surgery to treat PDH. However, on days 10–15, the dog developed a loss of energy and appetite, bloody diarrhea, vomiting, and a decreased level of consciousness. However, on day 16, the dog’s condition recovered. A preoperative MRI scan performed on day 52 (the day of surgery) showed apoplexy in the dorsal pituitary region (PBR, 0.68). Based on the PTA findings, the risks of surgery were described to the owner, and approval was obtained. At the time of trans-sphenoidal surgery, a partial pituitary resection was performed with preservation of the PTA area due to adhesions between the PTA area of the right side of the pituitary and surrounding tissues. The resected pituitary tissue was diagnosed as an ACTH-producing adenoma, with necrotic and hemorrhagic findings. As of day 290, endogenous ACTH and cortisol levels did not exceed the reference range. Conclusions The acute signs that occurred on days 10–15 were most likely caused by PTA. Therefore, when signs similar to those detected in acute hypoadrenocorticism are observed in dogs with PDH, it is necessary to include PTA as a differential diagnosis. Trans-sphenoidal surgery may be effective in PDH-affected dogs that develop PTA, but careful attention should be paid to tissue adhesions secondary to hemorrhage that may occur after PTA.
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Surgery for Pituitary Tumor Apoplexy Is Associated with Rapid Headache and Cranial Nerve Improvement. Curr Oncol 2022; 29:4914-4922. [PMID: 35877250 PMCID: PMC9319222 DOI: 10.3390/curroncol29070390] [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: 05/20/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Pituitary tumor apoplexy (PTA) classically comprises sudden-onset headache, loss of vision, ophthalmoparesis, and decreased consciousness. It typically results from hemorrhage and/or infarction within a pituitary adenoma. Presentation is heterologous, and optimal management is debated. The time course of recovery of cranial nerve deficits (CNDs) and headaches is not well established. In this study, a retrospective series of consecutive patients with PTA managed at a single academic institution over a 22-year period is presented. Headaches at the time of surgery were more severe in the early and subacute surgical cohort and improved significantly within 72 h postoperatively (p < 0.01). At one year, 90% of CNDs affecting cranial nerves (CNs) 3, 4, and 6 had recovered, with no differences between early (<4 d), subacute (4−14 d), and delayed (>14 d) time-to-surgery cohorts. Remarkably, half recovered within three days. In total, 56% of CN2 deficits recovered, with the early surgery cohort including more severe deficits and recovering at a lower rate (p = 0.01). No correlation of time-to-surgery and rapidity of recovery of CNDs was observed (p = 0.65, 0.72). Surgery for PTA is associated with rapid recovery of CNDs in the early, subacute, and delayed time frames, and with rapid headache improvement in the early and subacute time frames in 50% or more of patients.
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Mallereau CH, Ribeiro M, Ardellier FD, Dannhoff G, Cebula H, Proust F, Chibbaro S, Todeschi J. Delayed cerebral ischemia after meningioma resection: Literature review and illustrative case. Neurochirurgie 2022; 68:e27-e33. [DOI: 10.1016/j.neuchi.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
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15
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Oertel J, Teping F. Editorial "pituitary apoplexy-are visual deficits the only indication for emergent surgical intervention?". Acta Neurochir (Wien) 2022; 164:1125-1126. [PMID: 35067785 PMCID: PMC8967756 DOI: 10.1007/s00701-022-05120-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 01/01/2023]
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16
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Suarez-Meade P, Marenco-Hillembrand L, Sherman WJ. Neuro-oncologic Emergencies. Curr Oncol Rep 2022; 24:975-984. [PMID: 35353348 DOI: 10.1007/s11912-022-01259-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Patients with brain and spine tumors are at high risk of presenting cancer-related complications at disease presentation or during active treatment and are usually related to the type and location of the lesion. Here, we discuss presentation and management of the most common emergencies affecting patients with central nervous system neoplastic lesions. RECENT FINDINGS Tumor-related emergencies encompass complications in patients with central nervous system neoplasms, as well as neurologic complications in patients with systemic malignancies. Brain tumor patients are at high risk of developing multiple complications such as intracranial hypertension, brain herniation, intracranial bleeding, spinal cord compression, and others. Neuro-oncologic emergencies require immediate attention and multi-disciplinary care. These emergent situations usually need rapid decision-making and management on an inpatient basis.
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Affiliation(s)
| | | | - Wendy J Sherman
- Department of Neurology and Neurosurgery, Mayo Clinic, Jacksonville, FL, USA.
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17
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Azuma M, Khant ZA, Kadota Y, Takeishi G, Watanabe T, Yokogami K, Takeshima H, Hirai T. Added Value of Contrast-enhanced 3D-FLAIR MR Imaging for Differentiating Cystic Pituitary Adenoma from Rathke's Cleft Cyst. Magn Reson Med Sci 2021; 20:404-409. [PMID: 33487606 PMCID: PMC8922349 DOI: 10.2463/mrms.mp.2020-0127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Half of the surgically proven Rathke's cleft cysts (RCCs) can be preoperatively misdiagnosed as cystic pituitary adenoma (CPA). We aimed to evaluate the usefulness of contrast-enhanced (CE) 3D T2 fluid-attenuated inversion-recovery (3D T2-FLAIR) imaging for differentiating between CPA and RCC. METHODS This retrospective study included six patients with RCC (all pathologically confirmed) and six patients with CPA (five pathologically confirmed, one clinically diagnosed). The 12 patients underwent pre- and post-contrast T1-weighted (T1W)- and 3D T2-FLAIR imaging at 3T. Based on the degree of enhancement of the lesion wall, two radiologists independently scored the images using a 3-point grading system. Interobserver agreement was calculated by using the κ coefficient. The statistical significance of grading differences was analyzed with the Mann-Whitney U-test. Another neuroradiologist first interpreted conventional MR images (1st session), and then the reader read images to which the 3D T2-FLAIR images had been added (2nd session). Sensitivity, specificity, and accuracy of the reader's interpretation were calculated. RESULTS Interobserver agreement for post-contrast T1W- and 3D T2-FLAIR images was excellent (κ = 1.000 and 0.885, respectively). Although the mean enhancement grade on post-contrast T1W images of RCCs and CPAs was not significantly different, on post-contrast 3D T2-FLAIR images it was significantly higher for RCCs and CPAs (P < 0.05). Three CPAs (50%) showed remarkable, donut-like enhancement along the inner margin of the cyst on CE-3D T2-FLAIR images; this was not the case on CE-T1W images. The sensitivity, specificity, and accuracy of the 2nd session were 1.00, 0.83, and 0.92, respectively, which were improved compared to the 1st session (1.00, 0.50, and 0.75, respectively). CONCLUSION CE-3D FLAIR imaging is useful for discriminating CPAs and RCCs.
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Affiliation(s)
- Minako Azuma
- Department of Radiology, Faculty of Medicine, University of Miyazaki
| | - Zaw Aung Khant
- Department of Radiology, Faculty of Medicine, University of Miyazaki
| | - Yoshihito Kadota
- Department of Radiology, Faculty of Medicine, University of Miyazaki
| | - Go Takeishi
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
| | - Takashi Watanabe
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
| | - Kiyotaka Yokogami
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
| | - Hideo Takeshima
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
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18
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Elarjani T, Alhuthayl MR, Dababo M, Kanaan IN. Rathke cleft cyst apoplexy: Hormonal and clinical presentation. Surg Neurol Int 2021; 12:504. [PMID: 34754554 PMCID: PMC8571240 DOI: 10.25259/sni_382_2021] [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: 04/18/2021] [Accepted: 07/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Rathke cleft cyst (RCC) apoplexy is an uncommon type of lesion that is challenging to diagnose without histopathological samples. Very few articles have been published describing the details of RCC apoplexy. We studied a good number of published articles to analyze its demographics, clinical and hormonal presentations, and outcomes. Methods: A literature review of English language publications about RCC apoplexy or pituitary apoplexy was conducted using Medline and EMBASE search engines. Thirty articles with histological diagnosis of RCC apoplexy were identified, the earliest of which was published in 1990 and the latest in 2019. We combined the findings of these articles with our own case report and then compared the demographics, clinical and hormonal presentations, and outcomes between RCC apoplexy and pituitary adenoma apoplexy. Results: Our data included 29 patients with RCC, with a mean age of 36.87 years (8–72) and a predominance of female patients (68%). The hemorrhagic type was most common, reported in 86%. Headache was the most common presenting symptom, being reported in 93% followed by hypogonadism (73%) and hormonal deficits (52%). All but three patients improved neurologically (90%); however, 45% of patients required long-term hormonal replacement, mostly thyroid hormone. No cases of worsening neurological or hormonal status were reported. Conclusion: RCC apoplexy presents with less severe neurological and hormonal abnormalities than pituitary adenoma apoplexy; it also has a better prognosis in endocrine functional recovery. We recommend applying current management guidelines of pituitary adenoma apoplexy to RCC apoplexy.
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Affiliation(s)
- Turki Elarjani
- Department of Neurological Surgery, University of Miami MILLER School of medicine Jackson Memorial Hospital, Miami, Florida, United States
| | - Meshari Rashed Alhuthayl
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Tachassoussi, Riyadh, Saudi Arabia
| | - Mahammad Dababo
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Tachassoussi, Riyadh, Saudi Arabia
| | - Imad N Kanaan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Tachassoussi, Riyadh, Saudi Arabia
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19
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Cabuk B, Kaya NS, Polat C, Geyik AM, Icli D, Anik I, Ceylan S. Outcome in pituitary apoplexy patients, stratified by delay between symptom appearance and surgery: A single center retrospective analysis. Clin Neurol Neurosurg 2021; 210:106991. [PMID: 34700278 DOI: 10.1016/j.clineuro.2021.106991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/17/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are surgical and conservative management strategies in pituitary apoplexy patients. The use of both methods may lead to delayed surgery in the treatment of pituitary apoplexy. The aim of this study was to evaluate the surgical indications and outcomes of a series of patients with pituitary apoplexy according to delay between surgery and symptom onset. METHODS A retrospective analysis was performed of 2711 cases with sellar pathologies treated with endoscopic transsphenoidal surgery in a single centre. Inclusion criteria were histopathological confirmation of haemorrhage or necrosis, acute onset and at least one of the following: symptoms of endocrine dysfunction; visual impairment; ophtalmoplegia; headache; or altered consciousness. Patients were divided into three groups based on the number of days from initial symptoms to surgery: early (1-7 day), delayed (8-21 days) and late (>21 day). The indication for and outcome of surgery was reviewed according to symptoms and timing of surgery. RESULTS Ninety-one patients with pituitary apoplexy underwent surgery. The median time from ictus until surgery was 16 days (1-120 days). Headache was the most common presenting symptom. Visual impairment and ophtalmoplegia were found in 26.4% and 23.1% of patients, respectively. Surgical intervention was successful in treatment of headache in 82 (97,6%) patients. In patients in the early or delayed groups a significant improvement was found between pre- and post-operative headache, ocular palsy, visual impairment, and hormone deficiencies. Patients in the late group also had a significant improvement in headache and visual symptoms after surgery. CONCLUSION Surgery was sufficient in headache, endocrine, and neuro-ophthalmic outcomes at first 21 days (early and delayed groups). Beyond 21 days (late group), surgery was not effective on recovery of pituitary function.
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Affiliation(s)
- Burak Cabuk
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Necdet Selim Kaya
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Caner Polat
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Abidin Murat Geyik
- Gaziantep University, School of Medicine, Department of Neurosurgery, Gaziantep, Turkey
| | - Dilek Icli
- KocaeliUniversity, School of Medicine, Department of Anesthesiology, Kocaeli, Turkey
| | - Ihsan Anik
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Savas Ceylan
- Kocaeli University, School of Medicine, Department of Neurosurgery, Kocaeli, Turkey; Kocaeli University, Pituitary Research Center, Kocaeli, Turkey.
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20
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Ohata H, Shinde B, Nakamura H, Teranishi Y, Morisako H, Ohata K, Goto T. Pituitary apoplexy in a puberal child: A case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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21
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Nakhleh A, Assaliya Naffa M, Sviri G, Shehadeh N, Hochberg I. Outcomes of pituitary apoplexy: a comparison of microadenomas and macroadenomas. Pituitary 2021; 24:492-498. [PMID: 33462744 DOI: 10.1007/s11102-020-01124-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE We aimed to assess clinical characteristics of apoplexy of pituitary microadenomas compared to macroadenomas. METHODS We retrieved clinical records of patients > 18 years old, hospitalized in Rambam hospital between January 2001 and October 2017, with pituitary apoplexy and follow-up of at least one year. We compared clinical course and outcomes of apoplexy between patients with microadenomas and macroadenomas, and between patients who received conservative or surgical treatment. Statistical analysis was done using Fisher's exact and Mann-Whitney tests. RESULTS Twenty-seven patients with pituitary apoplexy were included in the final analysis: mean age was 40.7 ± 12.5 years, 13(48%) were female, 7(26%) had microadenomas, and 21(78%) harbored clinically nonfunctioning pituitary adenomas. Upon admission, hyponatremia, random cortisol level of < 200 nmol/L, and secondary hypothyroidism, were evident in 6/20, 8/18, and 4/18 patients with macroadenoma and 1/5, 2/5, and 1/6 patients with microadenoma, respectively (P = 1.0). Hypogonadotropic hypogonadism was evident in 9/12 men with macroadenoma. In 12 macroadenoma patients, the tumor abutted the optic chiasm, of whom eight had visual field defects. Fifteen patients with macroadenoma and two with microadenoma underwent transsphenoidal surgery. Median follow-up was 3 years. At last follow-up visit, patients with microadenoma had lower rates of corticotropic deficiency or secondary hypothyroidism compared to macroadenoma patients (1/7 vs. 13/20 respectively, p = 0.033). Only two patients with macroadenomas had persistent visual field defects. Outcomes were comparable between conservative and surgical treatment groups. CONCLUSIONS Long term pituitary hormone deficiencies are more common in pituitary apoplexy patients with macroadenomas. Apoplexy of pituitary microadenoma carries a more favorable prognosis.
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Affiliation(s)
- Afif Nakhleh
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel.
| | - Mai Assaliya Naffa
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
| | - Gill Sviri
- Department of Neurosurgery, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Efron St, Haifa, Israel
| | - Naim Shehadeh
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Efron St, Haifa, Israel
| | - Irit Hochberg
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Efron St, Haifa, Israel
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22
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de Silva NL, Somasundaram N, Constantine R, Kularatna H. Apoplexy of Crooke cell tumour leading to the diagnosis of severe Cushing disease; a case report. BMC Endocr Disord 2021; 21:93. [PMID: 33933049 PMCID: PMC8088723 DOI: 10.1186/s12902-021-00761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/26/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Patients with Crooke cell tumours present with features of Cushing syndrome or mass effect. There are few reports of patients with Crooke cell tumours presenting due to apoplexy. All of them had silent tumours. Patients with Cushing syndrome caused by Crooke cell tumours have not been reported to present with apoplexy. CASE PRESENTATION A 35-year-old female presented with sudden onset headache and visual loss for 1 week. She had secondary amenorrhoea for 10 years. There were features of Cushing syndrome including central obesity, multiple monomorphic acne, dorso-cervical and supraclavicular fat pads, hypertension, proximal weakness, pigmentation and refractory hypokalaemia. She was found to have markedly elevated serum cortisol, central hypothyroidism and hypogonadotropic hypogonadism. There was a mass in the sellar region (4.7 cm × 1.9 cm × 5.3 cm) suggestive of a pituitary tumour extending to the suprasellar region. Imaging showed evidence of bleeding and compression of the optic chiasm. She underwent urgent trans-sphenoidal excision of the tumour. Histology was compatible with a pituitary neuroendocrine tumour. There was margination of ACTH reactivity to the cell periphery and ring like positivity in most of the cells in the cytokeratin stain. Features were in favour of a Crooke cell tumour. After surgery she improved gradually and became eucortisolaemic. CONCLUSIONS This is a unique presentation of an apoplexy of Crooke cell tumour causing Cushing syndrome. Delayed health seeking behaviour of this patient despite severe Cushing disease could have led to this presentation which has not been reported before.
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Affiliation(s)
| | - Noel Somasundaram
- Diabetes and Endocrine Unit, National Hospital of Sri Lanka, Colombo 10, Sri Lanka
| | - Roshana Constantine
- Department of Histopathology, National Hospital of Sri Lanka, Colombo 10, Sri Lanka
| | - Himashi Kularatna
- Neurosurgical Unit, National Hospital of Sri Lanka, Colombo 10, Sri Lanka
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23
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Fialho C, Barbosa MÁ, Lima CHA, Wildemberg LEA, Gadelha MR, Kasuki L. Apoplexy in sporadic pituitary adenomas: a single referral center experience and AIP mutation analysis. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:295-304. [PMID: 33909377 PMCID: PMC10065329 DOI: 10.20945/2359-3997000000358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations. Methods The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced. Results Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort. Conclusion Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.
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Affiliation(s)
- Christhiane Fialho
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Monique Álvares Barbosa
- Unidade de Radiologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Carlos Henrique Azeredo Lima
- Laboratório de Neuropatologia e Genética Molecular, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Luiz Eduardo Armondi Wildemberg
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Mônica R Gadelha
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.,Laboratório de Neuropatologia e Genética Molecular, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil
| | - Leandro Kasuki
- Centro de Pesquisas em Neuroendocrinologia/Seção de Endocrinologia, Faculdade de Medicina e Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil, .,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, RJ, Brasil.,Seção de Endocrinologia, Hospital Federal de Bonsucesso, Rio de Janeiro, RJ, Brasil
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Abstract
Neuro-ophthalmic emergencies include optic nerve, central visual pathway, and ocular motility disorders that, if not identified and treated promptly, may lead to permanent vision loss, other significant morbidity, or mortality. This article provides a framework for approaching patients with neuro-ophthalmic symptoms and reviews the presentation, evaluation, and treatment of select emergent conditions that can cause them. Emergent causes of blurry vision, transient vision loss, papilledema, and diplopia, including giant cell arteritis, cardioembolic disease, and aggressive infection, are discussed.
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25
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Evaluating thunderclap headache. Curr Opin Neurol 2021; 34:356-362. [PMID: 33661161 DOI: 10.1097/wco.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Thunderclap headache (TCH) is an abrupt-onset of severe headache that needs to be thoroughly investigated because the most common secondary cause is subarachnoid hemorrhage (SAH). There has been no consensus guideline regarding the diagnostic workup. This review aims to provide an update on the evaluation of TCH. RECENT FINDINGS The most important update in the 2019 American College of Emergency Physicians guideline for evaluation of acute headache in the emergency department is that negative noncontrast brain computed tomography (CT) findings within 6 h from ictus essentially excludes SAH. Additionally, the updated guideline recommends that after a negative brain CT, CT angiogram is a reasonable alternative to lumbar puncture if clinical suspicion of an intracranial source of SAH is high. An important update of reversible vasoconstriction syndrome (RCVS), the second most common etiology of TCH, is the RCVS2 score development based on clinical and radiological features, providing high specificity and sensitivity for distinguishing RCVS from other intracranial arteriopathies. SUMMARY Although the evaluation of TCH is exhaustive, the potentially catastrophic consequence of a missed diagnosis of sentinel headache justifies the efforts. Awareness of the clinical features and application of diagnostic tools specific for different pathological conditions can facilitate the diagnostic workup.
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Teramoto S, Tahara S, Kondo A, Morita A. Key Factors Related to Internal Carotid Artery Stenosis Associated with Pituitary Apoplexy. World Neurosurg 2021; 149:e447-e454. [PMID: 33567365 DOI: 10.1016/j.wneu.2021.02.005] [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: 01/15/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Internal carotid artery (ICA) stenosis rarely occurs in pituitary apoplexy. Little is known of the causes of this condition. The present study investigated the factors related to ICA stenosis associated with pituitary apoplexy. METHODS Forty-five patients with pituitary apoplexy were retrospectively examined and divided into the stenotic and normal ICA groups. The baseline characteristics of patient background, tumor properties, clinical findings, and treatment overview were compared between the groups. RESULTS Eight patients were assigned to the stenotic ICA group and 37 to the normal ICA group. Patient age in the stenotic ICA group was significantly lower than that in the normal ICA group (P = 0.001). Maximum tumor diameter (P = 0.001), tumor volume (P = 0.044), and Knosp grade (P < 0.001) were significantly greater in the stenotic ICA group than in the normal ICA group. The stenotic ICA group had a significantly greater incidence of sphenoid sinus mucosal thickening than the normal-ICA group (P = 0.039). Multivariate logistic regression analysis demonstrated that age (odds ratio 0.915, 95% confidence interval 0.846-0.991, P = 0.029) was a significant and independent predictor of ICA stenosis associated with pituitary apoplexy. Receiver operating characteristic curve analysis showed that the optimal cut-off point for age was 35.0 years (specificity 0.946, sensitivity 0.750). CONCLUSIONS Our study revealed that age, tumor size, and sphenoid sinus mucosal thickening were strongly related to the occurrence of ICA stenosis in pituitary apoplexy. Among these factors, age had the potential of being an independent predictor of the condition.
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Affiliation(s)
- Shinichiro Teramoto
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan; Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan.
| | | | - Akihide Kondo
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akio Morita
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan
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Fu J, Li Y, Wu L, Yang X, Quan T, Li X, Zeng J, Deng Y, Yu J. Pituitary hemorrhage in pituitary adenomas treated with gamma knife radiosurgery: incidence, risk factors and prognosis. J Cancer 2021; 12:1365-1372. [PMID: 33531981 PMCID: PMC7847656 DOI: 10.7150/jca.52349] [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: 08/24/2020] [Accepted: 12/04/2020] [Indexed: 11/05/2022] Open
Abstract
Objective: The aims of this study were to investigate the incidence, risk factors and prognosis of pituitary hemorrhage in pituitary adenomas treated with gamma knife radiosurgery (GKRS). Methods and materials: Between December 1993 and December 2016, 751 consecutive pituitary adenoma patients treated with GKRS were retrospectively reviewed in a single center. There were 271 male (36.1%) and 480 female (63.9%) patients with a median age of 38.5 (range, 7.2-84.0) years. The number of nonfunctioning pituitary adenomas (NFPAs) and functioning pituitary adenomas were 369 (49.1%) and 382 (50.9%) respectively. The median follow-up time was 61.1 (range, 12.1-304.4) months. Results: In this study, 88 patients (11.7%) were diagnosed with pituitary hemorrhage before GKRS, 55 patients (7.3%) developed new or worsened pituitary hemorrhage after GKRS (excluding 3 patients with new or worsened pituitary hemorrhage due to tumor regrowth). The median time to new or worsened pituitary hemorrhage after GKRS was 18.9 (range 3.1-70.7) months. Overall, 128 patients (17.0%) were diagnosed with pituitary hemorrhage in the entire series. After adjustment with logistic regression, nonfunctioning pituitary adenomas (NFPAs) (odds ratio [OR]=2.121, 95% confidence interval [CI]=1.195-3.763, p=0.010) and suprasellar extension (OR=2.470, 95% CI=1.361-4.482, p=0.003) were associated with pituitary hemorrhage before GKRS. NFPA (OR=3.271, 95% CI=1.278-8.373, p=0.013) was associated with new or worsened pituitary hemorrhage after GKRS. Five patients received surgical resection for new or worsened pituitary hemorrhage were considered as GKRS treatment failure. Two patients with new hypopituitarism were considered to be owed to new or worsened pituitary hemorrhage after GKRS. Conclusions: New or worsened pituitary hemorrhage after GKRS was not an uncommon phenomenon. NFPA was an independent risk factor of new or worsened pituitary hemorrhage after GKRS. New or worsened pituitary hemorrhage after GKRS could lead to GKRS treatment failure. GKRS might be a precipitating factor of pituitary hemorrhage.
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Affiliation(s)
- Junyi Fu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Lisha Wu
- Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China. 510120
| | - Xin Yang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Tingting Quan
- Department of Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China, 510060
| | - Xi Li
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Jiamin Zeng
- Department of Pathology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Yinhui Deng
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Jinxiu Yu
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
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Wang M, Jiang Y, Cai Y, Wu H, Peng Y. Subclinical hemorrhagic nonfunctionning pituitary adenoma: pituitary gland function status, endoscopic endonasal transsphenoidal surgery, and outcomes. Br J Neurosurg 2020:1-7. [PMID: 32896169 DOI: 10.1080/02688697.2020.1815651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE How do subclinical hemorrhages into nonfunctioning pituitary adenomas (NFPAs) influence the hormonal status and surgical outcomes remains unclear, our study aim at evaluating its definite effects on pituitary gland function and surgical outcomes. METHODS All 103 consecutive patients who underwent initial endoscopic endonasal approach (EEA) for NFPAs resection from June 2016 to June 2018 were retrospectively reviewed, depending on magnetic resonance imaging (MRI), operative and pathological findings, patients were divided into the non-hemorrhagic NFPAs group and the subclinical hemorrhagic NFPAs group. A comparative analysis was conducted between these two groups to investigate the effects of subclinical hemorrhages in NFPAs on pituitary endocrine function and surgical outcomes. RESULTS The incidence of subclinical hemorrhage on NFPAs was 22.3% (23/103), which was more frequently observed in larger adenomas (28.9 ± 9.6 mm vs 19.2 ± 9.2 mm, p = 0.001). The incidence of preoperative hypopituitarism was 69.6% (16/23) for subclinical hemorrhagic NFPAs group and 31% (25/80) for non-hemorrhagic NFPAs group (p = 0.001), a high incidence of hypopituitarism for subclinical hemorrhagic NFPAs finally was found to be owing to the large tumor rather than the intratumoral hemorrhage. All those NFPAs were resected via EEA with the technology of extra-pseduocapusual dissection in a standard elective fashion. Postoperatively, there were more than 75.6% of patients with preoperative hypopituitarism had at least one axis recovered, with hyperprolactinemia resolved in 91.7% of patients, 94.7% headaches and 90% visual symptoms resolved or improved after surgery, there was no significant difference between these two groups (p > 0.05), indicates there was no any surgical outcome difference between NFPAs with or without subclinical hemorrhage. A very low postoperative complication was achieved with new postoperative anterior pituitary failure occurred in 9.7% of patients and permanent diabetes insipidus (DI) occurred in 9.7% of patients, which advocated that EEA can be chosen as a safe surgical treatment for subclinical hemorrhagic NFPAs. Furthermore, with the technology of extra-pseduocapusual dissection, more than 87% subclinical hemorrhagic NFPAs had achieved gross total resection (GTR) with a low incidence of new postoperative hypopituitarism (14%). CONCLUSION Subclinical hemorrhage in NFPAs does not aggravate pituitary gland function. A surgical management strategy by EEA with the technology of extra-pseduocapusual dissection for the subclinical hemorrhagic NFPAs usually yields satisfactory endocrine and surgical outcomes, but it does not necessitate emergent tumor decompression.
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Affiliation(s)
- Ming Wang
- Department of Neurosurgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yugang Jiang
- Department of Neurosurgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yang Cai
- Department of Neurosurgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Huixuan Wu
- Department of Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yong Peng
- Department of Neurosurgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Assessing the association of tumor consistency and gland manipulation on hormonal outcomes and delayed hyponatremia in pituitary macroadenoma surgery. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2020. [DOI: 10.1016/j.inat.2019.100628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chu C, Perilli GA, Judge C, Sheng S, Yacoub HA. Pituitary apoplexy mimicking meningoencephalitis: case report and scoping study. Hosp Pract (1995) 2020; 48:29-34. [PMID: 31976773 DOI: 10.1080/21548331.2020.1717801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Pituitary apoplexy (PA) is a rare but potentially life-threatening condition that may require urgent surgical intervention.Case Presentation: We report a case of a patient who was initially diagnosed with meningoencephalitis (ME) based on clinical presentation and cerebrospinal fluid (CSF) analysis, but was eventually diagnosed with PA. We present a summary of other cases reported in the literature of PA mimicking ME and analyze their clinical features and CSF findings.Results: Among all 22 PA cases reviewed, headache was the most commonly reported symptom. Hypopituitarism was seen in 94.4% of the cases; of these, panhypopituitarism was noted in 38.9%. The sensitivity of magnetic resonance image (MRI) for detecting PA was 94.7%, much higher than that of computed tomography (CT), which was only 31.6%. Neutrophil predominant pleocytosis was present in all cases with a neutrophil percentage ranging from 73% to 98%. CSF leukocyte count was less than 1000/ul in 86% of the cases. CSF erythrocytosis was seen in 92.9% of the cases with a count ranging from 15 to 2030/ul. Elevated CSF protein was present in all cases with a range of 69.8 to 239 mg/dl. CSF glucose level varied with a range between 12 and 136 mg/dl; the level was greater than 40 mg/dl in 73% of the cases.Conclusion: PA tends to be misdiagnosed as ME due to the similarities of semiology and CSF findings. PA should be considered in refractory acute headache cases, especially those with visual and endocrine abnormalities. Early recognition and treatment may lead to significant reduction in morbidity and mortality.Abbreviations: ACTH: adrenocorticotropic hormone; CSF: cerebrospinal fluid; CT: computed tomography; GRE: gradient echo; HRT: hormone replacement therapy;HSV: Herpes Simplex Virus; IV: intravenous; ME: meningoencephalitis; MRI: magnetic resonance image; PA: pituitary apoplexy; RBC: red blood cell; WBC: white blood cell.
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Affiliation(s)
- Chun Chu
- Departments of Neurology, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Gretchen A Perilli
- Department of Endocrinology, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Casey Judge
- Departments of Neurology, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Sen Sheng
- Department of Neurology, University of Arkansas for Medical Sciences, Little, Rock, Arkansas
| | - Hussam A Yacoub
- Departments of Neurology, Lehigh Valley Health Network, Allentown, Pennsylvania
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Strange F, Remonda L, Schütz P, Fandino J, Berkmann S. 10 Years' Experience of Using Low-Field Intraoperative MRI in Transsphenoidal Surgery for Pituitary Adenoma: Results of the Swiss Pituitary Registry (SwissPit). World Neurosurg 2019; 136:e284-e293. [PMID: 31899402 DOI: 10.1016/j.wneu.2019.12.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 12/21/2019] [Accepted: 12/23/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND For 20 years, several studies have reported intraoperative magnetic resonance imaging (iMRI) utility to achieve gross total resections in transsphenoidal pituitary adenoma surgery. Although few studies on low-field iMRI included >100 patients, data on hormonally active tumors remain scarce and follow-up times are <3 years. This is not sufficient to judge the long-term efficiency of the use of low-field iMRI. The aim of this retrospective study is to report the detailed outcome of iMRI-controlled transsphenoidal surgery in >200 patients during a follow-up exceeding 5 years. METHODS Patients undergoing surgery for pituitary adenoma by iMRI-controlled, endoscopically assisted transsphenoidal surgery at the authors' institution between 2006 and 2016 were eligible for inclusion. Data were collected in the Swiss Pituitary Registry. A Polestar 0.15T-scanner was used. RESULTS A total of 231 patients had surgery for 160 nonfunctioning adenomas; 28 hGH-, 27 PRL-, 10 ACTH-secreting and 6 mixed adenomas and were followed for 62 months (9-178). Additional iMRI-guided resections were possible in 54% and increased the gross total resection rate by 4% (P = 0.004). Remission rates were as follows: nonfunctioning adenoma, 53%; acromegaly, 61%; prolactinoma, 50%; Cushing disease, 90%. Tumor regrowth and recurrence was detected at a mean time of 24 and 63 months, respectively. Recovery of deficient hormone axes was detected in 22% to 27%. The risk for new postoperative hormonal deficiencies was 15%. Postoperative relieve of visual field and visual acuity deficiencies was seen in 94 (86%) and 73 (81%) patients, respectively. CONCLUSION Judged by long-term follow-ups of >200 nonfunctioning/functioning pituitary adenomas, the use of low-field iMRI in transsphenoidal surgery increases resection rates and sustainably influences outcomes.
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Affiliation(s)
- Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schütz
- Division of Endocrinology, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Sven Berkmann
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
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Lubbe DE, Mankahla N, Carrara H, Semple P. Surgical intervention for binocular blindness in pituitary apoplexy. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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33
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Goshtasbi K, Abiri A, Sahyouni R, Mahboubi H, Raefsky S, Kuan EC, Hsu FPK, Cadena G. Visual and Endocrine Recovery Following Conservative and Surgical Treatment of Pituitary Apoplexy: A Meta-Analysis. World Neurosurg 2019; 132:33-40. [PMID: 31470146 DOI: 10.1016/j.wneu.2019.08.115] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/14/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pituitary apoplexy (PA) can manifest with visual and endocrine defects. The literature lacks strong support for either surgical or conservative management with respect to symptomatic improvement of these deficits. This meta-analysis compared visual and endocrine outcomes in conservative and surgical treatment of PA. METHODS A systematic literature search was performed in PubMed, Cochrane, and Ovid MEDLINE for articles published between 1988 and 2018. Recovery outcomes were binarized, such that complete and partial improvements were combined as "improvement." Primary outcome variables evaluated via a binary random-effects model were improvements in endocrine dysfunction, visual field and acuity deficits, and ophthalmoplegia or ocular nerve palsy. RESULTS Of 483 published articles, 14 studies comprising 457 cases (259 surgical treatments and 198 conservative treatments) were included. On initial examination, 58% of patients had endocrine dysfunction, 37% had visual acuity or field deficit, and 47% had ophthalmoplegia or ocular nerve palsy. Evaluation of outcomes for surgically and conservatively treated patients yielded odds ratios of 0.609 (95% confidence interval [CI], 0.199-1.859; P = 0.383), 0.763 (95% CI, 0.307-2.374; P = 0.763), 1.167 (95% CI, 0.433-3.146; P = 0.760), and 0.801 (95% CI, 0.305-2.105; P = 0.653) for improvements in endocrine dysfunction, visual acuity dysfunction, visual field dysfunction, and ophthalmoplegia or ocular nerve palsy. CONCLUSIONS Both surgical intervention and conservative management of PA can lead to visual and endocrine recovery, although the management decision may heavily rely on severity of initial deficits. Treatment of PA can be multifaceted and tailored to the individual case and clinical judgment. Further investigation into appropriate intervention based on longitudinal outcome data is warranted.
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Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Ronald Sahyouni
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Hossein Mahboubi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Sophia Raefsky
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Gilbert Cadena
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA.
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Abstract
Pituitary apoplexy is a clinical condition with acute-onset headaches, vision loss, and/or pituitary dysfunction associated with a hemorrhagic or infarcted pituitary tumor or cyst. Treatment varies based on clinical presentation, although often urgent or emergent surgical resection is indicated. Conservative treatment strategies tend to be applied for more mild conditions of apoplexy. Overall outcomes may be similar in this less severe cohort. Acute-onset vision loss with apoplexy should be treated with urgent or emergent surgical evacuation of hematoma and resection of tumor when possible.
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Affiliation(s)
- Garni Barkhoudarian
- John Wayne Cancer Institute, Santa Monica, CA, USA; Pacific Neuroscience Institute, 2125 Arizona Avenue, Santa Monica, CA 90404, USA.
| | - Daniel F Kelly
- John Wayne Cancer Institute, Santa Monica, CA, USA; Pacific Neuroscience Institute, 2125 Arizona Avenue, Santa Monica, CA 90404, USA
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35
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Vision Outcomes in Early versus Late Surgical Intervention of Pituitary Apoplexy: Meta-Analysis. World Neurosurg 2019; 127:52-57. [DOI: 10.1016/j.wneu.2019.03.133] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/26/2022]
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Kirigin Biloš LS, Kruljac I, Radošević JM, Ćaćić M, Škoro I, Čerina V, Pećina IH, Vrkljan M. Empty Sella in the Making. World Neurosurg 2019; 128:366-370. [PMID: 31128314 DOI: 10.1016/j.wneu.2019.05.119] [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: 03/13/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pituitary apoplexy may occur when a large tumor compresses or outgrows its nutrient supply, resulting in ischemic necrosis and hemorrhage. Although once deemed a neurosurgical emergency, increasing evidence suggests that conservative management of pituitary apoplexy leads to favorable neuro-ophthalmologic and endocrinologic outcomes as well. Spontaneous remission after pituitary apoplexy has been described in functioning pituitary adenomas, but it is a rare occurrence in nonfunctioning tumors. CASE DESCRIPTION We report a man that presented with pituitary apoplexy of a nonfunctioning pituitary macroadenoma that was managed conservatively and treated hormonally for hypopituitarism during a 2-year follow-up period, with serial neuroimaging demonstrating significant tumor volume reduction with almost complete resolution resulting in partial empty sella. In addition, a short literature review was performed pertaining to the management of pituitary apoplexy with emphasis on a more conservative approach. CONCLUSIONS A subset of patients with pituitary apoplexy without altered consciousness and nonprogressive or mild ophthalmologic deficits may be managed conservatively; however, lifelong periodic assessment, preferably by a specialized multidisciplinary pituitary team, is essential until clinical outcomes become clear.
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Affiliation(s)
- Lora Stanka Kirigin Biloš
- Department of Endocrinology, Diabetology and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia.
| | - Ivan Kruljac
- Department of Endocrinology, Diabetology and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Jelena Marinković Radošević
- Department of Endocrinology, Diabetology and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Miroslav Ćaćić
- Department of Endocrinology, Diabetology and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Ivan Škoro
- Department of Neurosurgery, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Vatroslav Čerina
- Department of Neurosurgery, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Ivan Hrvoje Pećina
- Department of Radiology, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Milan Vrkljan
- Department of Endocrinology, Diabetology and Metabolic Diseases "Mladen Sekso", University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
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Hosmann A, Micko A, Frischer JM, Roetzer T, Vila G, Wolfsberger S, Knosp E. Multiple Pituitary Apoplexy-Cavernous Sinus Invasion as Major Risk Factor for Recurrent Hemorrhage. World Neurosurg 2019; 126:e723-e730. [PMID: 30851467 DOI: 10.1016/j.wneu.2019.02.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pituitary apoplexy is a rare but potentially life-threatening disorder that occurs in up to 10% of adenomas. Whereas risk factors for the initial hemorrhagic event are well described, there is minor knowledge on clinical symptomatic recurrent pituitary apoplexies. METHODS At the Medical University of Vienna, 76 patients were surgically treated for clinical symptomatic pituitary apoplexy between 1990 and 2017. Four patients (5.3%) suffered multiple pituitary apoplexies after initial surgery. In this retrospective study, neuroradiologic images, clinical data, and intraoperative findings were reviewed for potential risk factors of multiple apoplexies in pituitary adenomas. RESULTS Patients with multiple apoplexies had significantly higher Knosp grading on preoperative imaging (median grade 4), and more frequently observed cavernous sinus invasion intraoperatively (P = 0.01). Consequently, all cases with multiple pituitary apoplexies remained with residual adenoma postoperatively. In cases of residual tumor within the cavernous sinus, recurrent apoplexy occurred in 23.5% of patients. A tumor recurrence/residual was resected significantly earlier in patients with single apoplexy (median 2.2 years) than in patients with multiple apoplexies (median 5.4 years; P = 0.05). Multiple pituitary apoplexies caused significantly greater rates of ophthalmoplegia (75% vs. 14.1%; P = 0.01) and long-term hormone-replacement therapy was necessary in all cases. CONCLUSIONS Cavernous sinus invasion and subtotal resection are high risk factors for multiple apoplexies in pituitary adenomas. Early treatment is recommended for residual tumor in the cavernous sinus to minimize the risk of recurrent apoplexy with subsequent worse clinical outcome.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Roetzer
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
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Solari D, Zenga F, Angileri FF, Barbanera A, Berlucchi S, Bernucci C, Carapella C, Catapano D, Catapano G, Cavallo LM, D'Arrigo C, de Angelis M, Denaro L, Desogus N, Ferroli P, Fontanella MM, Galzio RJ, Gianfreda CD, Iacoangeli M, Lauretti L, Locatelli D, Locatelli M, Luglietto D, Mazzatenta D, Menniti A, Milani D, Nasi MT, Romano A, Ruggeri AG, Saladino A, Santonocito O, Schwarz A, Skrap M, Stefini R, Volpin L, Wembagher GC, Zoia C, Zona G, Cappabianca P. A Survey on Pituitary Surgery in Italy. World Neurosurg 2019; 123:e440-e449. [DOI: 10.1016/j.wneu.2018.11.186] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022]
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Ćaćić M, Marinković J, Kruljac I, Perić B, Čerina V, Stipić D, Pažanin L, Pećina HI, Vrkljan M. ISCHEMIC PITUITARY APOPLEXY, HYPOPITUITARISM AND DIABETES INSIPIDUS: A TRIAD UNIQUE TO NECROTIZING HYPOPHYSITIS. Acta Clin Croat 2018; 57:768-771. [PMID: 31168215 PMCID: PMC6544104 DOI: 10.20471/acc.2018.57.04.20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
- A rare case of necrotizing hypophysitis (NH) in a 52-year-old man presenting with pituitary apoplexy and sterile meningitis is described. This case indicates that the diagnosis of NH could be made without biopsy, based on concomitant presence of diabetes insipidus, hypopituitarism and radiologic features of ischemic pituitary apoplexy. Conservative management of pituitary apoplexy should be advised in NH. Additionally, this is the first report of a case of sterile meningitis caused by ischemic pituitary apoplexy.
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Affiliation(s)
| | - Jelena Marinković
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivan Kruljac
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Božidar Perić
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Vatroslav Čerina
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Darko Stipić
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Leo Pažanin
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Hrvoje Ivan Pećina
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Milan Vrkljan
- 1Mladen Sekso Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 3Ljudevit Jurak Department of Pathology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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Fan Y, Bao X, Wang R. Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature. Clin Interv Aging 2018; 13:1981-1985. [PMID: 30349217 PMCID: PMC6188166 DOI: 10.2147/cia.s181109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA. Case description We describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient’s poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family’s wishes, we continued the conservative treatment and watched closely for any changes in the patient’s condition. After 6 months of conservative treatment, the patient’s symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient’s hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone. Conclusion In older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients’ condition closely and continue conservative treatment, which may yield good results.
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Affiliation(s)
- Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
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Abbara A, Clarke S, Eng PC, Milburn J, Joshi D, Comninos AN, Ramli R, Mehta A, Jones B, Wernig F, Nair R, Mendoza N, Sam AH, Hatfield E, Meeran K, Dhillo WS, Martin NM. Clinical and biochemical characteristics of patients presenting with pituitary apoplexy. Endocr Connect 2018; 7:EC-18-0255. [PMID: 30139818 PMCID: PMC6198188 DOI: 10.1530/ec-18-0255] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/16/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE To review the clinical and biochemical characteristics and clinical outcome of patients presenting with pituitary apoplexy to a tertiary centre. METHODS We retrospectively reviewed the clinical features, predisposing factors, biochemistry and clinical outcome of patients presenting with pituitary apoplexy to Imperial College Healthcare NHS Trust between 1991 to 2015. RESULTS We identified 64 patients with pituitary apoplexy (more complete clinical records were available in 52 patients). The median age at presentation was 46.7 years (IQR 31.5-57.0 years). Pituitary apoplexy was the first presentation of pituitary disease in 38/52 of patients and predisposing factors were identified in 28/52. Pituitary apoplexy predominantly occurred in patients with non-functioning pituitary adenomas (47/52). Headache was most commonly described as sudden-onset, severe, lateralising to the frontal or temporal regions. Symptoms of meningeal irritation were reported in 7/18 and visual abnormalities in 22/35. A pre-treatment serum cortisol <100nmol/l was recorded in 12/31 of patients. All patients with visual disturbance had some resolution of their visual symptoms whether managed surgically (14/14) or conservatively (5/5), although pituitary endocrine function did not fully recover in any patient. CONCLUSIONS In conclusion, these data describe the clinical features of pituitary apoplexy to aid the clinician in diagnosing this rare emergency presentation of pituitary disease. Prospective multicentre studies of the presentation of pituitary apoplexy are required to further characterise presentation and outcomes.
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Affiliation(s)
- Ali Abbara
- A Abbara, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Sophie Clarke
- S Clarke, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Pei Chia Eng
- P Eng, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - James Milburn
- J Milburn, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Devavrata Joshi
- D Joshi, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Alexander N Comninos
- A Comninos, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Rozana Ramli
- R Ramli, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Amrish Mehta
- A Mehta, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Brynmor Jones
- B Jones, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Florian Wernig
- F Wernig, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Ramesh Nair
- R Nair, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Nigel Mendoza
- N Mendoza, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Amir H Sam
- S Amir, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Emma Hatfield
- E Hatfield, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Karim Meeran
- K Meeran, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Waljit Singh Dhillo
- W Dhillo, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Niamh M Martin
- N Martin, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
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Seo Y, Kim YH, Dho YS, Kim JH, Kim JW, Park CK, Kim DG. The Outcomes of Pituitary Apoplexy with Conservative Treatment: Experiences at a Single Institution. World Neurosurg 2018; 115:e703-e710. [PMID: 29709755 DOI: 10.1016/j.wneu.2018.04.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Pituitary apoplexy is an unpredictable complication caused by hemorrhage or infarction in a pituitary adenoma. We retrospectively analyzed the radiologic and clinical outcomes of patients with conservatively managed pituitary apoplexy. METHODS A total of 32 patients who had undergone conservative treatment with high-dose corticosteroid replacement were enrolled in this study. This cohort study consisted of 20 male and 12 female patients. The median patient age was 60 years. Five patients had a previously diagnosed pituitary tumor, and one third of the patients had a history of hypertension. RESULTS The median follow-up duration was 50 months. The median tumor volumes at the initial and final assessments were 2.75 cm3 (range, 0.32-10.7 cm3) and 0.64 cm3 (range, 0-8.74 cm3), respectively. Complete radiographic regression occurred in 9 of the 32 patients, partial regression occurred in 14 patients, and no change in size or progression occurred in 9 patients. Eighteen of the 32 patients had visual disturbances at the initial presentation; in this subgroup, 17 patients showed improvement over the course of the study. One patient had newly developed diplopia related to tumor progression. Nineteen of the 32 patients had ≥1 hormonal deficiency at the initial assessment, 8 of whom recovered to normal endocrine status. Three patients developed a new hormonal deficiency during the follow-up, and 3 patients experienced tumor recurrence. CONCLUSIONS This study showed the regression of tumors related to pituitary apoplexy, with favorable ophthalmologic and endocrinologic recovery. Conservative management should be considered in patients without severe or progressive neuro-ophthalmic deficits.
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Affiliation(s)
- Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Yun-Sik Dho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Zaidi HA, Wang AJ, Cote DJ, Smith TR, Prevedello D, Solari D, Cappabianca P, Quiroga M, Laws ER. Preoperative Stratification of Transsphenoidal Pituitary Surgery Patients Based on Surgical Urgency. Neurosurgery 2018; 81:659-664. [PMID: 28520927 DOI: 10.1093/neuros/nyx073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/31/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Currently, there is no prioritization scale available to distinguish those patients with pituitary tumors who require urgent surgical intervention from those who are candidates for elective treatment. OBJECTIVE To develop a classification system that can help primary care physicians, endocrinologists, neurosurgeons, ancillary support staff, and hospital administrators identify high-priority surgical candidates. METHODS An expert international panel of clinicians consisting of endocrinologists and neurosurgeons who are involved in the diagnosis and management of sellar disease was convened. The panel retrospectively reviewed individual experiences, including a cohort of patients operated upon for pituitary related disease at the Brigham and Women's Hospital from January 2008 to November 2015. A risk stratification schema was developed to streamline patient care pathways. RESULTS We identified 4 groups of surgical candidates with varying levels of risk, and then assigned treatment timelines and different differential diagnoses to each. The 4 groups were as follows: group A: urgent-immediate; group B: prompt-initiate treatment within 1 to 2 weeks; group C: soon-initiate treatment within 3 months; group D: elective-as soon as indicated. Among 472 patients treated at Brigham and Women's Hospital for pituitary adenomas, each was assigned to 1 of the 4 predetermined subgroups: group A, 6.8%; group B, 30.1%; group C, 31.1%; group D, 32.0%. CONCLUSIONS We developed a risk stratification schema that may serve as a platform to streamline care to the patients at highest risk. The expert opinions presented provide a basis for future studies regarding the risk prioritization of patients.
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Affiliation(s)
- Hasan A Zaidi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy J Wang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Cote
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Prevedello
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | | | | | - Monica Quiroga
- Department of Neurosurgery, Hospital Mexico, PINECOS, University of Costa Rica, San Jose, Costa Rica
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Pituitary apoplexy is an uncommon event, occurring due to the infarction and/or haemorrhage usually of a previously unknown pituitary adenoma. It can occur in all adenoma subtypes but is more common in nonfunctioning pituitary adenomas. The physiopathology is not completely clear, and precipitating factors, such as major surgeries, anticoagulant use or pituitary dynamic tests, can be found in up to 40% of patients. The clinical presentation is characterized by a rapid onset with a headache as the main symptom, but visual disturbances can also be present as well as meningism and intracranial hypertension. The diagnosis is based on imaging evaluations, mainly using magnetic resonance imaging, which can show various patterns depending on the timeframe following the occurrence of the apoplectic event. Pituitary hormonal deficits are also common, and the evaluation of hormonal levels is mandatory. Pituitary apoplexy can be managed by surgery or conservative treatment, and a multidisciplinary team is essential for the decision-making process. The outcome is usually positive with both surgical and conservative approaches, but surveillance is needed due to the risk of re-bleeding or tumour recurrence.
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Affiliation(s)
- Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9F - Sala de Pesquisa em Neuroendocrinologia, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, 9° andar - Setor 9F - Sala de Pesquisa em Neuroendocrinologia, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil.
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
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Takasuna H, Sase T, Ito H, Ono H, Oshio K, Tanaka Y. Clinical significance of thickened sphenoid sinus mucosa in Rathke's cleft cyst. Surg Neurol Int 2017; 8:263. [PMID: 29184714 PMCID: PMC5682693 DOI: 10.4103/sni.sni_283_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/25/2017] [Indexed: 11/04/2022] Open
Abstract
Background: To determine the clinical significance of thickening of the sphenoid sinus mucosa (TSSM) in Rathke's cleft cyst (RCC). Methods: We retrospectively reviewed patients with pituitary lesions. A total of 99 patients, who underwent surgery of pituitary lesions between 2008 and 2015, were analyzed to evaluate the clinical significance of TSSM using magnetic resonance imaging. The patients with TSSM were evaluated for their characteristics. Results: Of the 99 operations, 15 patients with paranasal sinusitis, direct invasion to the sellar floor, and/or a history of transsphenoidal surgery were excluded. There were 51 pituitary adenomas (PAs), 18 RCCs, and 15 other tumors. TSSM was observed in 6 patients (7.1%). Pathologies included 3 RCCs (16.7%), 1 PA (2.0%), and 2 other lesions. Three RCCs were especially analyzed. The pituitary dysfunction was found in all 3 patients with TSSM, whereas that was noted in 2 of 15 patients (13.3%) without TSSM. The sensitivity was 60%, specificity was 86.7%, and the positive predictive value was 100%. There was no significant difference in the age, thickness of TSSM, symptoms, and squamous metaplasia between patients with and without TSSM. Conclusions: TSSM occurs more frequently in RCCs than in PAs. TSSM can potentially suggest hypopituitarism in RCCs. The surgical and/or endocrinological interventions are required for preventing further endocrine deterioration.
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Affiliation(s)
- Hiroshi Takasuna
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Taigen Sase
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidemichi Ito
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hajime Ono
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kotaro Oshio
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuichiro Tanaka
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
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46
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Hayashi Y, Sasagawa Y, Kita D, Fukui I, Oishi M, Tachibana O, Ueda F, Nakada M. Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage. Pituitary 2017; 20:531-538. [PMID: 28616673 DOI: 10.1007/s11102-017-0814-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Although hemorrhage within pituitary adenomas frequently exacerbates the symptoms, there are many grades of severity. Moreover, the contributing factors for symptom severity are still controversial. METHODS This retrospective study included 82 patients who underwent transsphenoidal surgery for pituitary adenomas with intratumoral hemorrhage. The grades of preoperative symptoms were classified into group A, asymptomatic or minor symptoms; group B, moderate symptoms sufficient for complain; and group C, severe symptoms disturbing daily life. RESULTS The hemorrhage volume within an adenoma was significantly higher in group C (92.6%) than in groups A (48.6%) and B (58.7%). Both headache and diplopia were dominant in group C, occurring in 72.2% and 27.8% of the patients, respectively. In group C, there was no significant difference in frequency between adenoma extensions into the sphenoid sinus (0%) and involvement of the cavernous sinus of Knosp grade 4 (0%), and extensions into the suprasellar region were not common (38.9%). The most distinctive feature was that "no extrasellar extension" was found only in group C (41.2%), and "multidirectional extension" was not detected in this group (0%). Multiple regression analysis revealed that the most powerful determining factors were the high frequencies of intratumoral hemorrhage and lack of extrasellar and multidirectional extensions. CONCLUSION Rapid volume expansion of a hematoma and lack of extension or unidirectional extension might lead to significant compression of the sellar and surrounding structures. Of note, the integrity of the sellar dura might contribute to the acute onset of symptom manifestations caused by hemorrhage in pituitary adenomas.
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Affiliation(s)
- Yasuhiko Hayashi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Yasuo Sasagawa
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Daisuke Kita
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Issei Fukui
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Masahiro Oishi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Osamu Tachibana
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Fumiaki Ueda
- Department of Radiology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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47
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Osman M, Wild A. Spindle Cell Oncocytoma of the Anterior Pituitary Presenting with an Acute Clinical Course Due To Intraventricular Hemorrhage. A Case Report and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:894-901. [PMID: 28814709 PMCID: PMC5570152 DOI: 10.12659/ajcr.903702] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patient: Male, 56 Final Diagnosis: Spindle cell oncocytoma of the adenohypophysis Symptoms: Disturbed conscious level • visual disturbances Medication: — Clinical Procedure: Urgent craniotomy Specialty: Neurosurgery
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Affiliation(s)
- Mostafa Osman
- Department of Neurosurgery, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Andrew Wild
- Department of Neurosurgery, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
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Xiao D, Wang S, Zhao L, Zhong Q, Huang Y, Ding C. Fluid-fluid level on magnetic resonance images may predict the occurrence of pituitary adenomas in cystic sellar-suprasellar masses. Exp Ther Med 2017; 13:3123-3129. [PMID: 28588668 DOI: 10.3892/etm.2017.4299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 12/23/2016] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to evaluate the value of identifying fluid-fluid level via preoperative magnetic resonance (MR) images in differentiating pituitary adenomas from craniopharyngioma, Rathke's cleft cyst (RCC), and other cystic sellar-suprasellar lesions. The data of 293 consecutive patients who underwent surgery for sellar-suprasellar lesions between July 2010 and December 2012 was retrospectively reviewed, and a total of 133 cystic cases were included in the present study. MR images and pathological features of all subjects were examined. Among the 133 cystic sellar-suprasellar masses, there were 78 cases of pituitary adenomas, 31 cases of craniopharyngioma, 21 cases of RCC, one case of epidermoid cyst and two cases of abscess. Fluid-fluid levels were identified n 43 cases (55.13%) of cystic pituitary adenomas, with a single fluid level in 23 cases, two fluid levels in 8 cases, and three levels or more in 12 cases. Two cases (6.45%) of craniopharyngioma, and one case (4.76%) of RCC presented single fluid level. No instances of fluid-fluid levels were observed in epidermoid cyst or abscess. Fluid-fluid levels were typically exhibited on axial T2-weighted images. The identification of fluid-fluid level in cysts provides useful diagnostic value in distinguishing pituitary adenoma from other sellar-suprasellar lesions. The findings of the present study suggest that a sellar-suprasellar mass with a fluid-fluid level inside the tumor is most likely a pituitary adenoma, particularly if multiple fluid levels are observed in the same tumor. The fluid-fluid level is typically clearly depicted on axial or sagittal MR images, suggesting subacute or chronic hemorrhage in pituitary adenomas.
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Affiliation(s)
- Deyong Xiao
- Department of Neurosurgery, Fuzong Clinical College, Fujian Medical University, Fuzhou, Fujian 350025, P.R. China
| | - Shousen Wang
- Department of Neurosurgery, Fuzong Clinical College, Fujian Medical University, Fuzhou, Fujian 350025, P.R. China
| | - Lin Zhao
- Department of Neurosurgery, Fuzong Clinical College, Fujian Medical University, Fuzhou, Fujian 350025, P.R. China
| | - Qun Zhong
- Department of Radiology, Fuzong Clinical College, Fujian Medical University, Fuzhou, Fujian 350025, P.R. China
| | - Yinxing Huang
- Department of Neurosurgery, Fuzong Clinical College, Fujian Medical University, Fuzhou, Fujian 350025, P.R. China
| | - Chenyu Ding
- Department of Neurosurgery, Fuzong Clinical College, Fujian Medical University, Fuzhou, Fujian 350025, P.R. China
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Balaparameswara Rao SJ, Savardekar AR, Nandeesh BN, Arivazhagan A. Management dilemmas in a rare case of pituitary apoplexy in the setting of dengue hemorrhagic fever. Surg Neurol Int 2017; 8:4. [PMID: 28217383 PMCID: PMC5288990 DOI: 10.4103/2152-7806.198731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 11/16/2016] [Indexed: 11/24/2022] Open
Abstract
Background: Pituitary apoplexy occurs due to infarction or hemorrhage, within a pituitary adenoma or a nontumorous pituitary gland and can have catastrophic consequences. Dengue hemorrhagic fever (DHF) is a severe manifestation of the spectrum of dengue virus infection and is characterized by high-grade fever, thrombocytopenia, hemorrhagic tendencies, and increased vascular permeability. Cases of incidentalomas complicated by DHF and presenting with apoplexy are extremely rare. Case Description: We describe the case of a 45-year-old gentleman who suffered an attack of pituitary apoplexy while being treated for DHF. The issues pertaining to the management of hydrocephalus, timing of surgical intervention, and treatment of electrolyte imbalances encountered in the dual setting of DHF and pituitary apoplexy are discussed with reference to the outcome in our case. Conclusion: Although patients suffering from DHF harbor multiple factors, which may be precipitants of pituitary apoplexy, the association between these two conditions is rare and only few case reports document their coexistence. We review the pertinent literature and discuss the management dilemmas faced by us while dealing with these dual pathological states.
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Affiliation(s)
| | | | - B N Nandeesh
- Department of Neuropathology, NIMHANS, Bengaluru, Karnataka, India
| | - A Arivazhagan
- Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
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50
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Surgical versus non-surgical treatment for pituitary apoplexy: A systematic review and meta-analysis. J Neurol Sci 2016; 370:258-262. [DOI: 10.1016/j.jns.2016.09.047] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/23/2022]
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