Clinical relevance of precipitating factors in pituitary apoplexy

Pituitary Apoplexy: An Updated Review

Pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland. It is clinically characterized by the sudden onset of headache. Depending on the severity, it may also be accompanied by nausea, vomiting, visual disturbances, varying degrees of adenohypophyseal hormone deficiency, and decreased level of consciousness. Corticotropic axis involvement may result in severe hypotension and contribute to impaired level of consciousness. Precipitating factors are present in up to 30% of cases. PA may occur at any age and sometimes develops during pregnancy or the immediate postpartum period. PA occurs more frequently in men aged 50-60, being rare in children and adolescents. It can develop in healthy pituitary glands or those affected by inflammation, infection, or tumor. The main cause of PA is usually spontaneous hemorrhage or infarction of a pituitary adenoma (pituitary neuroendocrine tumor, PitNET). It is a medical emergency requiring immediate attention and, in many cases, urgent surgical intervention and long-term follow-up. Although the majority of patients (70%) require surgery, about one-third can be treated conservatively, mainly by monitoring fluid and electrolyte levels and using intravenous glucocorticoids. There are scoring systems for PA with implications for management and therapeutic outcomes that can help guide therapeutic decisions. Management of PA requires proper evaluation and long-term follow-up by a multidisciplinary team with expertise in pituitary pathology. The aim of the review is to summarize and update the most relevant aspects of the epidemiology, etiopathogenesis, pathophysiology, clinical presentation and clinical forms, diagnosis, therapeutic strategies, and prognosis of PA.

A Prospective, Multicenter, Observational Study of Surgical vs Nonsurgical Management for Pituitary Apoplexy

CONTEXT

Pituitary apoplexy (PA) has been traditionally considered a neurosurgical emergency, yet retrospective single-institution studies suggest similar outcomes among patients managed medically.

OBJECTIVE

We established a multicenter, international prospective registry to compare presentation and outcomes in PA patients treated with surgery or medical management alone.

METHODS

A centralized database captured demographics, comorbidities, clinical presentation, visual findings, hormonal status, and imaging features at admission. Treatment was determined independently by each site. Key outcomes included visual, oculomotor, and hormonal recovery, complications, and hospital length of stay. Outcomes were also compared based on time from symptom onset to surgery, and from admission or transfer to the treating center. Statistical testing compared treatment groups based on 2-sided hypotheses and P less than .05.

RESULTS

A total of 100 consecutive PA patients from 12 hospitals were enrolled, and 97 (67 surgical and 30 medical) were evaluable. Demographics, clinical features, presenting symptoms, hormonal deficits, and imaging findings were similar between groups. Severe temporal visual field deficit was more common in surgical patients. At 3 and 6 months, hormonal, visual, and oculomotor outcomes were similar. Stratifying based on severity of visual fields demonstrated no difference in any outcome at 3 months. Timing of surgery did not affect outcomes.

CONCLUSION

We found that medical and surgical management of PA yield similar 3-month outcomes. Although patients undergoing surgery had more severe visual field deficits, we could not clearly demonstrate that surgery led to better outcomes. Even without surgery, apoplectic tumor volumes regress substantially within 2 to 3 months, indicating that surgery is not always needed to reduce mass effect.

Pituitary Apoplexy Following Elective Total Hip Replacement

Pituitary apoplexy is an endocrine-related emergency most commonly caused by hemorrhage into a preexisting pituitary adenoma. Known risk factors for such hemorrhage include major surgical procedures, head trauma, pregnancy, anticoagulation, and the administration of hormone therapies for the correction of primary hypothalamic deficiencies. Elective orthopedic surgery is an uncommon precipitator of pituitary apoplexy that is rarely described. We report the case of a patient with a previously unknown pituitary macroadenoma who developed apoplexy as a complication of elective right total hip arthroplasty.

Acromegaly complicated with fulminant pituitary apoplexy: clinical characteristic analysis and review of literature

PURPOSE

To retrospectively summarize the clinical features of acromegaly complicated with fulminant pituitary apoplexy and analyze the prognostic factors to guide early identification and timely treatment of such patients.

METHODS

A retrospective analysis was carried out to summarize the clinical manifestations, hormone changes, imaging, treatment and follow-up of ten patients with acromegaly complicated with fulminant pituitary apoplexy admitted to our hospital from February 2013 to September 2021.

RESULTS

The mean age of the ten patients (five males and five females) at the time of pituitary apoplexy was 37.1 ± 13.4 years old. There were nine cases with sudden severe headaches and five cases with visual impairment. All patients had pituitary macroadenomas, of which six cases with Knosp grade ≥3. The level of GH/IGF-1 hormone after pituitary apoplexy was lower compared with pre-apoplexy, and 1 patient reached biochemical remission spontaneously. Seven patients underwent transsphenoidal pituitary surgery after apoplexy and one patient was treated with long-acting somatostatin analog. The biochemical remission rate was 37.5% in eight patients immediately after treatment and 50% at the last follow-up. Patients with Knosp grade ≥3 were less likely to achieve biochemical remission than those with Knosp grade <3 (16.7% vs. 100%, p = 0.048), and patients who achieved biochemical remission had a smaller maximum tumor diameter [20.1 (20.1,28.0) mm vs. 44.0 (44.0,60) mm, p = 0.016].

CONCLUSION

Acromegaly complicated with fulminant pituitary apoplexy remains a diagnostic and therapeutic challenge.

Challenges of Pituitary Apoplexy in Pregnancy

Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012-December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal-fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample-case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal-fetal outcomes from multidisciplinary insights.

Determinants of visual and endocrinological outcome after early endoscopic endonasal surgery for pituitary apoplexy

Background:

Patients diagnosed with pituitary apoplexy and presenting with acute visual deterioration require urgent surgical resection. This is also commonly associated with pituitary hypopituitarism that requires hormonal replacement for correction. This study was undertaken to evaluate the clinical recovery of 45 patients diagnosed with symptomatic pituitary apoplexy who underwent early (within 72 h of symptom onset) endoscopic transsphenoidal surgical resection with an emphasis on visual, ocular craniopathy, and endocrinological outcome.

Methods:

This is a retrospective analysis of a consecutive series of patients diagnosed with pituitary apoplexy between 2011 and 2020 treated by early (within 72 h of symptom onset) endoscopic transsphenoidal surgical resection. All tumors were histologically proven as pituitary adenomas. Clinical and neuro-ophthalmological examinations, imaging studies, and endocrinological evaluation were retrospectively reviewed. Patients with a minimum of 6 months follow-up were included in the study. The influence of patients’ demographics, extent of visual and ocular motility impairment, preoperative endocrinological dysfunction, tumor size and extent, degree of resection, and surgical complications were analyzed as potential prognostic factors for recovery.

Results:

Forty-five patients were included in this retrospective study. Ages ranged from 27 to 57 years (mean: 42 years). All patients presented with headache and variable degrees of visual loss and visual field deficit. Ophthalmoplegia was present in 22 (48.9%) patients with 17 (37.8%) having bilateral ocular cranial nerve palsy. All patients had variable degrees of endocrinological deficiencies. All patients showed evidence of low cortisol, 14 (31.1%) showed hypothyroidism and 11 (24.4%) showed hypogonadism. There was evidence of hyperprolactinemia in 16 (35.6%) patients. All patients harbored a pituitary macroadenoma. Tumor resection was complete in 33 (73%) of patients, with residual tumor related to cavernous sinus or retrosellar extension. Operative complications were mainly related to short-term nasal complications occurring in 14 (31%) patients. Cerebrospinal fluid leak requiring revision surgery occurred in only one patient harboring a modified SIPAP Grade 3s tumor. Transient diabetes insipidus occurred in 9 (20%) patients, with 2 (4.4%) requiring long-term hormonal replacement. The mean follow-up was 25 months. Baseline visual improvement was achieved in 39 (86.7%) patients. Ocular cranial nerve palsy showed complete recovery in 17 (77.2%) patients. Endocrine follow-up showed that patients with panhypopituitarism (11 [24.4%]) failed to recover.

Conclusion:

The current surgical series showed safety in terms of low complication rate and efficacy in terms of clinical outcome. The significant prognostic factor related to visual recovery was the degree of preoperative visual deficit. Recovery of ocular cranial neuropathy showed a higher recovery rate when it was unilateral as opposed to bilateral. Pituitary hormonal recovery was less favorable with pituitary panhypopituitarism being a poor prognostic factor.

Pituitary Apoplexy: Risk Factors and Underlying Molecular Mechanisms

Pituitary apoplexy is a rare syndrome, graded from asymptomatic subclinical apoplexy to a life-threatening condition due to pituitary ischemia or haemorrhage of an enlarged pituitary gland. The risk factors and the molecular underlying mechanisms are yet to be elucidated. We provide an overview of the general concepts, the potential factors associated with pituitary adenoma susceptibility for apoplectic events and the molecular mechanisms that could be involved such as HIF-1α/VEGF pathways and metalloproteinases activation, among others. The knowledge of the molecular mechanisms that could participate in the pathogenesis of pituitary apoplexy is crucial to advancement in the identification of future diagnostic tools and therapeutic targets in this rare but sometimes fatal condition.

Pituitary Apoplexy Precipitated by Systemic Chemotherapy

Pituitary apoplexy often occurs in patients with previously undiagnosed pituitary adenomas and no predisposing factors. Among patients with precipitating events, there are very few cases of pituitary apoplexy occurring in the setting of systemic chemotherapy treatment. A 31-year-old man with newly diagnosed metastatic testicular cancer developed headaches, nausea, and a right-sided visual field deficit one week after initiation of bleomycin, etoposide, and cisplatin chemotherapy. Computed tomography and magnetic resonance imaging revealed hemorrhage within a pituitary macroadenoma consistent with pituitary apoplexy, and he underwent urgent transnasal resection. We also review the four prior cases of pituitary apoplexy temporally associated with the administration of systemic chemotherapy.

Chronic rhinosinusitis as a risk factor for intracranial and extracranial complications after endoscopic transsphenoidal surgery

PURPOSE

To elucidate whether chronic rhinosinusitis (CRS), usually an inflammatory-mediated rather than infectious process, is a risk factor for extracranial and intracranial complications after elective endoscopic transsphenoidal surgery (ETSS).

MATERIALS AND METHODS

A single-center retrospective cohort study of consecutive patients who underwent ETSS between January 2015 and July 2019 was performed, which included chart review and computed tomography assessment. CRS was defined by symptomatology and concurrent endoscopic or radiographic findings.

RESULTS

Of 292 subjects, 11% (n = 33) met criteria for CRS. Median difference in Lund-Mackay scores between the CRS and non-CRS groups was 3.0 (95% CI 2.0-4.0). Complications included acute rhinosinusitis requiring antibiotics (23%, 68/292), epistaxis (10%, 28/292), meningitis (1%, 3/292), cerebrospinal fluid (CSF) leak (7%, 20/292), revision sinonasal procedures (10%, 28/292), and frequent in-office debridement (13%, 39/292). CRS was strongly associated with postoperative acute rhinosinusitis (aRR 1.85, 95% CI 1.18-2.90) and frequent debridement (aRR 1.96, 95% CI 1.00-3.83). Conversely, CRS was not associated with epistaxis (aRR 1.52, 95% CI 0.62-3.72), postoperative CSF leak (aRR 0.91, 95% CI 0.24-3.44), or additional sinonasal procedures (aRR 0.70, 95% CI 0.21-2.29). The rate of meningitis was not significantly higher in the CRS cohort (difference 2.2%, 95% CI -1.0% to 14.5%).

CONCLUSIONS

CRS was a strong risk factor for acute rhinosinusitis and need for frequent in-office debridement after ETSS. It was not associated with other postoperative complications including epistaxis, CSF leak, or revision sinonasal procedures. CRS patients had a slightly higher rate of meningitis, which is likely not clinically meaningful.

Predictive Clinical and Surgical Factors Associated with Recurrent Apoplexy in Pituitary Adenomas

Introduction Pituitary apoplexy is an uncommon clinical condition that can require urgent surgical intervention, but the factors resulting in recurrent apoplexy remain unclear. The purpose of this study is to determine the risks of a recurrent apoplexy and better understand the goals of surgical treatment.

Methods A retrospective chart review was performed for all consecutive patients diagnosed and surgically treated for pituitary apoplexy from 2004 to 2021. Univariate analysis was performed to identify risk factors associated with recurrent apoplexy.

Results A total of 115 patients were diagnosed with pituitary apoplexy with 11 patients showing recurrent apoplexy. This occurred at a rate of 2.2 cases per 100 patient-years of follow-up. There were no major differences in demographic factors, such as hypertension or anticoagulation use. There were no differences in tumor locations, cavernous sinus invasion, or tumor volumes (6.84 ± 4.61 vs. 9.15 ± 8.45 cm, p = 0.5). Patients with recurrent apoplexy were less likely to present with headache (27.3%) or ophthalmoplegia (9.1%). Recurrent apoplexy was associated with prior radiation (0.0 vs. 27.3%, p = 0.0001) and prior subtotal resection (10.6 vs. 90.9%, p = 0.0001) compared with first time apoplexy. The mean time to recurrent apoplexy was 48.3 ± 76.9 months and no differences in overall follow-up were seen in this group.

Conclusion Recurrent pituitary apoplexy represents a rare event with limited understanding of pathophysiology. Prior STR and radiation treatment are associated with an increased risk. The relatively long time from the first apoplectic event to a recurrence suggests long-term patient follow-up is necessary.

Recurrent pituitary apoplexy in pregnancy

Pituitary apoplexy is caused by haemorrhage or infarction of the pituitary gland. Presenting signs and symptoms often include severe headache, visual disturbance, ophthalmoplegia, altered consciousness and impaired pituitary function. The management of pituitary apoplexy has very rarely been described during pregnancy and there is no existing data for further pregnancies of affected women. We present a case of a woman with a recurrent pituitary apoplexy due to haemorrhages in a pituitary adenoma in her third and fourth pregnancies. In both pregnancies, the pituitary apoplexy was managed conservatively, but due to therapy-resistant headaches, a preterm delivery was implemented.

Coronavirus disease 2019 infection and pituitary apoplexy: A causal relation or just a coincidence? A case report and review of the literature

Background:

Pituitary tumor apoplexy (PA) is an emergency condition caused by hemorrhage or infarction of the preexisting adenoma. Many factors are currently well-known to predispose to PA. However, during the period of coronavirus disease 2019 (COVID-19) pandemic, case reports of PA associated with COVID-19 infection have been sequentially published. To the best of our knowledge, four cases have been reported so far in the English literature. We herein report the fifth case of this association and review the pertinent literature.

Case Description:

A 55-year-old male patient with confirmed COVID-19 infection presented by progressive decrease in visual acuity and oculomotor nerve palsy. His medical history is notable for diabetes mellitus, hypertension, and pituitary macroadenoma resection 11 years ago. He was on hormonal replacement therapy for panhypopituitarism that complicated the surgery. Previous magnetic resonance (MR) imaging studies were consistent with enlarging residual pituitary adenoma. During the current hospitalization, computed tomography revealed hyperdensity of the sellar and suprasellar areas. MR imaging revealed PA in a recurrent large adenoma. Endoscopic endonasal transsphenoidal resection was uneventfully undertaken with near total excision of the adenoma and partial improvement of visual loss and oculomotor palsy. Histopathological examination demonstrated classic features of PA. However, his chest condition progressed and he had to be transferred to COVID-19 intensive care unit in the referring hospital where he was intubated and put on mechanical ventilation. One week later, the patient unfortunately passed away due to complications of severe COVID-19 pneumonia.

Conclusion:

We report the fifth case of PA associated with COVID-19 infection. Based on our patient’s clinical findings, review of the other reported cases, as well as the available literature, we put forth a multitude of pathophysiological mechanisms induced by COVID-19 that can possibly lead to the development of PA. In our opinion, the association between both conditions is not just a mere coincidence. Although the histopathological features of PA associated with COVID-19 are similar to PA induced by other etiologies, future research may disclose unique pathological fingerprints of COVID-19 virus that explains its capability of inducing PA.

SPONTANEOUS RESOLUTION OF A NONFUNCTIONING PITUITARY ADENOMA OVER ONE-MONTH PERIOD: A CASE REPORT

Spontaneous resolution of nonfunctioning pituitary adenoma after hemorrhagic apoplexy is a rare clinical entity of unknown etiology and is defined as disappearance of a tumor without any specific treatment. Here we present a 54-year-old male patient who presented with acute onset of severe headache, vomiting, photophobia, and sonophobia. He was referred to brain computed tomography, which showed a 16x12x16 mm tumor mass located in the sellar region with signs of hemorrhage. Endocrinologic evaluation was consistent with under-function of pituitary gonadotropic cells. Magnetic resonance imaging (MRI) performed ten days later was consistent with hemorrhagic apoplexy of the pituitary adenoma. The patient’s symptoms resolved after conservative treatment with dexamethasone, but he was scheduled for elective pituitary surgery. Preoperative MRI was performed one month after the first one and disclosed normal pituitary gland without any signs of adenoma. Our case is remarkable due to the fact that spontaneous remission of pituitary adenoma occurred within the first month, which is the shortest interval reported to date. Our case highlights the importance of conservative therapy as the first-line treatment for pituitary apoplexy in the absence of neurological impairment, since spontaneous remission may occur in a short time interval.

Pituitary hemorrhage in pituitary adenomas treated with gamma knife radiosurgery: incidence, risk factors and prognosis

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.

Acute Sterile Meningitis as a Primary Manifestation of Pituitary Apoplexy

Objective

We report a case of pituitary apoplexy (PA) with negative radiographic findings for PA and cerebrospinal fluid (CSF) analysis consistent with neutrophilic meningitis. PA is a rare endocrinopathy requiring prompt diagnosis and treatment. Presentation with acute neutrophilic meningitis is uncommon.

Methods

The diagnostic modalities included pituitary function tests (adrenocorticotropic hormone, thyroid-stimulating hormone, luteinizing hormone, prolactin), brain computed tomography and magnetic resonance imaging (MRI), and CSF analysis.

Results

A 67-year-old man presented with worsening headache, nausea, and retching. He was somnolent with an overall normal neurologic examination other than a peripheral vision defect in the left eye. MRI showed a pituitary mass bulging into the suprasellar cistern with optic chiasm elevation, consistent with pituitary macroadenoma. Laboratory evaluation revealed decreased levels of adrenocorticotropic hormone, random cortisol, thyroid-stimulating hormone, thyroxine, luteinizing hormone, and testosterone. He had worsening encephalopathy with left eye ptosis and decreased vision, prompting a repeat computed tomography and MRI, showing no interval change in the pituitary adenoma or evidence of bleeding. CSF analysis revealed a leukocyte count of 1106/mm³ (89% neutrophils), a total protein level of 138 mg/dL, red blood cell count of 2040/mm³ without xanthochromia, and glucose level of 130 mg/dL. The CSF culture result was negative. Transsphenoidal resection revealed a necrotic pituitary adenoma with apoplexy.

Conclusions

Including PA in the differential diagnosis of acute headache is important, particularly in patients with visual disturbances. PA can present with sterile meningitis, mimicking acute bacterial meningitis. While neuroimaging can help detect PA, the diagnosis of PA remains largely clinical.

Subclinical hemorrhagic nonfunctionning pituitary adenoma: pituitary gland function status, endoscopic endonasal transsphenoidal surgery, and outcomes

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.

Pituitary apoplexy: how to define safe boundaries of conservative management? Early and long-term outcomes from a single UK tertiary neurosurgical unit

OBJECTIVES

(1) Describe presentation, management and outcomes of a single-centre series of patients with pituitary apoplexy. (2) Compare early and long-term outcomes of conservative and surgical management. (3) Identify predictive factors for visual recovery.

METHODS

Retrospective analysis of patients acutely managed by Sheffield's Neurosurgery over a 9-years period. Outcome comparison was made between 2 groups ('conservative' versus 'emergency') at early FU and 3 groups ('conservative' versus 'elective' versus 'emergency') at long-term FU.

RESULTS

Data from 30 patients (M:F = 2.8:1; mean age: 54 years; median FU: 31.5 months) were collected. 86,7% patients presented with visual disturbances (70% acuity, 50% field, 50% diploplia). 10 (33%) patients underwent emergency surgery and further 8 underwent delayed elective surgery.At early FU, resolution rates of VA (33% versus 38%), VF (40% versus 50%) and CN deficits (71% versus 40%) were not significantly different between groups.At long-term FU, resolution of VA (80% versus 20% versus 75%) and CN deficits (67% versus 50% versus 80%) was not significantly different between groups. Most patients who underwent surgery presented with severe VA deficit (20% versus 40% versus 63%) but severity of initial deficit wasn't correlated with long-term resolution.VF recovery rates showed significant difference between groups (p = 0.027): 67% versus 0% versus 88%.Endocrine outcomes were generally poor, regardless of the management strategy.Regarding possible predictive factors, age and tumour size correlated with visual outcomes. Especially in patients treated conservatively in the acute phase, no cases of complete resolution of VA or VF deficit were recorded when tumour was higher than 35 mm.

CONCLUSIONS

Good results are possible with conservative management in selected cases. Emergency surgery provides better visual outcomes. Decision-making process should be tailored to every single patient. We believe that a tumour vertical diameter >35 mm should tip the balance in favour of surgical management in presence of visual deficit.

Contemporary Management of Clinically Non-functioning Pituitary Adenomas: A Clinical Review

Non-functioning pituitary adenomas (NFPAs) are benign pituitary tumours that constitute about one-third of all pituitary adenomas. They typically present with symptoms of mass effects resulting in hypopituitarism, visual symptoms, or headache. Most NFPAs are macroadenomas (>1 cm in diameter) at diagnosis that can occasionally grow quite large and invade the cavernous sinus causing acute nerve compression and some patients may develop acute haemorrhage due to pituitary apoplexy. The progression from benign to malignant pituitary tumours is not fully understood; however, genetic and epigenetic abnormalities may be involved. Non-functioning pituitary carcinoma is extremely rare accounting for only 0.1% to 0.5 % of all pituitary tumours and presents with cerebrospinal, meningeal, or distant metastasis along with the absence of features of hormonal hypersecretion. Pituitary surgery through trans-sphenoidal approach has been the treatment of choice for symptomatic NFPAs; however, total resection of large macroadenomas is not always possible. Recurrence of tumours is frequent and occurs in 51.5% during 10 years of follow-up and negatively affects the overall prognosis. Adjuvant radiotherapy can decrease and prevent tumour growth but at the cost of significant side effects. The presence of somatostatin receptor types 2 and 3 (SSTR3 and SSTR2) and D2-specific dopaminergic receptors (D2R) within NFPAs has opened a new perspective of medical treatment for such tumours. The effect of dopamine agonist from pooled results on patients with NFPAs has emerged as a very promising treatment modality as it has resulted in reduction of tumour size in 30% of patients and stabilization of the disease in about 58%. Despite the lack of long-term studies on the mortality, the available limited evidence indicates that patients with NFPA have higher standardized mortality ratios (SMR) than the general population, with women particularly having higher SMR than men. Older age at diagnosis and higher doses of glucocorticoid replacement therapy are the only known predictors for increased mortality.

Benign and malignant tumors of the central nervous system and pregnancy

Tumors of the central nervous system (CNS) are rare entities, typically affecting the very young or the very old, but span a spectrum of disease that may present in any age group. Women of reproductive age are more likely to be affected by benign tumors, including pituitary adenomas and meningiomas, and aggressive intracranial malignancies, such as brain metastases and glioblastoma, rarely present in pregnancy. Definitive management of CNS tumors may involve multimodal therapy, including surgery, radiation, and chemotherapy, and each of these treatments carries risk to the mother and developing fetus. CNS tumors often present with challenging and morbid symptoms such as headache and seizure, which need to be managed throughout a pregnancy. Decisions about timing treatment during pregnancy or delaying until after delivery, continuing or electively terminating a pregnancy, and future family planning and fertility are complex and require a multidisciplinary care team to evaluate the implications to both mother and baby. There are no guidelines or consensus recommendations regarding brain tumor management in pregnancy, and thus, individual treatment decisions are made by the care team based on experiential evidence, extrapolation of guidelines for nonpregnant patients, and patient values and preferences.

Empty Sella in the Making

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.

Cognition of Nurses in Neurology Department on Rehabilitation Nursing

Stroke has become a major disease seriously threating human health due to its high morbidity, mortality and disability. Rehabilitation nursing care for stroke patients has always been a key part of clinical care. The neurological nursing managers should pay high attention to the issue about how to more effectively improve the level of nurses’ rehabilitation nursing on stroke patients. Therefore, this paper investigates the current cognition of neurological nurses about stroke knowledge, attitude and behaviour, and then analyses the factors affecting the knowledge, attitude and behaviour of stroke in the nurses, in order to provide better nursing services for stroke patients, and improve their nursing quality. The findings show that the different cognitions of nurses about their role have different effects on the knowledge, attitudes and behavioural levels of the neurological nurses; the nurses with more types of roles have better knowledge and behavioural levels of stroke.

Pituitary apoplexy in nonfunctioning pituitary macroadenomas: a case-control study

OBJECTIVE

Pituitary apoplexy (PA) is an endocrinologic emergency characterized by headache, visual abnormalities, and hemodynamic instability in the context of hemorragic infarction of a pituitary adenoma. Our goal was to estimate the incidence, precipitating factors, clinical characteristics, and outcome of PA in a cohort of patients with nonfunctioning pituitary macroadenomas (NFPMAs).

METHODS

A retrospective, case-control study of 46 patients with PA and 47 controls matched for age, gender, and tumor invasiveness. Clinical, hormonal, and tumoral charactersitics, as well as the presence of potential precipitating factors and long-term outcome were evaluated using both bivariate and multivariate analysis.

RESULTS

The prevalence of PA was 8%. Cases and controls were similar in regards to the prevalence of diabetes, hypertension, use of antiplatelet agents, and the presence of headaches and visual field defects. Oculomotor paralysis was present in 18% of cases and in none of the controls (P = .001). Prior use of dopamine agonists was significantly more frequent among cases than in controls on both bivariate and multivariate analysis. Pituitary hormone deficiencies were more common among cases than in controls on bivariate but not on multivariate analysis. Early and late surgical treatment was carried out in 11 and 25 patients, respectively; 11 patients were managed conservatively. Visual and endocrine outcomes were similar among the 3 groups.

CONCLUSION

PA represents a life-threatening medical emergency. Prior use of dopamine agonists and the presence of oculomotor abnormalities clearly distinguished patients with NFPMA who developed PA from those who did not.

Pituitary Apoplexy Following Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Pituitary apoplexy is an uncommon neurosurgical emergency that may be the initial presentation of undiagnosed pituitary adenomas. Though the exact pathogenesis is unclear, there appears to be an association between pituitary apoplexy and medical interventions that disturb the blood supply and venous drainage of the abnormal sellar region. We present the first case of pituitary apoplexy occurring after an endoscopic retrograde cholangiopancreatography (ERCP).

CASE DESCRIPTION

A 43-year-old male who was several hours status post ERCP presented with a severe headache, bilateral ptosis, and multidirectional ophthalmoplegia. Computed tomography scan and magnetic resonance imaging of the brain revealed a hemorrhagic and necrotic sellar mass with suprasellar extension compressing the optic chiasm and bilateral extension displacing the cavernous carotid arteries laterally. The patient underwent emergent endoscopic endonasal transsphenoidal resection of the underlying pituitary tumor apoplexy with eventual resolution of his cranial nerve palsies.

CONCLUSIONS

Although pituitary apoplexy has been recognized as a sequela of surgical and laparoscopic procedures, it should also be considered in less invasive gastrointestinal procedures which may alter the intraabdominal pressures, such as ERCP. Early detection of this unusual complication allows for rapid diagnosis and timely surgical intervention in select cases to prevent debilitating cranial nerve palsies, preserve visual function, and retain normal pituitary function.

Clinical and biochemical characteristics of patients presenting with pituitary apoplexy

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.

Survivin as a potential therapeutic target of acetylsalicylic acid in pituitary adenomas

Acetylsalicylic acid (ASA) is known as a cancer preventing agent, but there is no data available regarding the effect of ASA on pituitary cells.

We investigated 66 nonfunctioning (NFPA) and growth hormone (GH)-producing adenomas and 15 normal pituitary samples. Functional assays (cell viability, proliferation, flow cytometry cell cycle analysis, caspase-3 activation and DNA degradation) were applied to explore the effect of ASA, YM155 (survivin inhibitor), survivin-targeting siRNA and TNF-related apoptosis-inducing ligand (TRAIL) in RC-4B/C and GH3 cells. Pituitary adenoma xenografts were generated in immunocompromised mice.

We found that survivin was overexpressed and TRAIL was downregulated in NFPAs compared to normal pituitary tissue. ASA decreased proliferation but did not induce apoptosis in pituitary cells. Additionally, ASA treatment decreased cells in S phase and increased cells in G2/M phase of the cell cycle. Inhibition of survivin using an inhibitor or siRNA-mediated silencing reversed the ASA-induced growth inhibition partially. In addition, we also found survivin-independent effects of ASA on the cell cycle that were mediated through inhibition of cyclin A, cyclin dependent kinase 2 (CDK2) and phospho-CDK2. We also aimed to test the effect of acetylsalicylic acid in an animal model using RC-4 B/C cells, but in contrast to GH3 cells, RC-4 B/C cells failed to adhere and grow a xenograft.

We concluded that ASA inhibited the growth of pituitary adenoma cells. Survivin inhibition is a key mechanism explaining its antineoplastic effects. Our results suggest that inhibition of survivin with small molecules or ASA could serve as potential therapeutic agents in NFPA.

Extensive Pituitary Apoplexy after Chemotherapy in a Patient with Metastatic Breast Cancer

Surgery, anticoagulation therapy, pregnancy, and hormone treatments, such as bromocriptine, are well-characterized precipitating factors for pituitary apoplexy. However, whether cytotoxic chemotherapy for systemic cancer could cause pituitary apoplexy has not been investigated. Here, we present a case of a 41-year-old woman who developed a severe headache with decreased visual acuity after intravenous cytotoxic chemotherapy to treat metastatic breast cancer. Preoperative neuroimaging revealed pituitary adenoma with necrosis. Operative findings and pathologic examination concluded extensive necrosis with a small intratumoral hemorrhage in a pre-existing pituitary adenoma. We reviewed two additional previously published cases of pituitary apoplexy after systemic chemotherapy and suggest that cytotoxic chemotherapy may induce pituitary apoplexy.

The Outcomes of Pituitary Apoplexy with Conservative Treatment: Experiences at a Single Institution

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.

Management of non-functioning pituitary adenomas: surgery

Non-functional pituitary adenomas (NFPAs) are benign tumors of the pituitary gland that do not over-secrete hormonal products, therefore, they are generally detected through symptoms of mass effect, including headache, vision loss, or hypopituitarism. There are multiple pathological subtypes of NFPAs, such as null cell adenomas, silent gonadotrophs, silent somatotrophs, silent corticotrophs, and silent subtype 3, all of which can be classified based on immunohistochemical studies and electron microscopy. Despite these numerous pathological subtypes, surgical resection remains the first-line treatment for NFPAs. Diagnosis is best made using high resolution MRI brain with and without gadolinium contrast, which is also helpful in determining the extent of invasion of the tumor and recognizing necessary sinonasal anatomy prior to surgery. Additional pre-operative work-up should include full laboratory endocrine evaluation with replacement of hormone deficiencies, and ideally, full neuro-ophthalmologic exam. Although transcranial surgical approaches to the pituitary gland can be performed, the most common approach used is the transnasal transsphenoidal approach with endoscopic or microscopic visualization. This approach avoids retraction of the brain and cranial nerves during tumor removal. Surgery for symptoms caused by mass effect, including headaches and visual loss, are successfully treated with surgical resection, resulting in improvement in pre-operative symptoms as high as 90% in some reports. Although the risk of complications is low, major and minor events, such as permanent hypopituitarism, persistent CSF leak, and carotid artery injury can occur at rates ranging from zero to about 9%.

Landscape of Molecular Events in Pituitary Apoplexy

Apoplectic pituitary adenomas cause significant morbidity and even mortality. The pituitary apoplexy denotes a pituitary adenoma presenting with hemorrhage and/or infarction, implementation in remedial effects of various of drugs in pituitary apoplexy is a promising pharmacogenomic field in the near future adenoma treatment. Indisputably, this is an important horizon for complicated pituitary adenomas. In a pituitary adenoma, the interplay between genetic, cytokine, and growth factors promotes the pathogenic transformation into an apoplectic formation. However, till date, little is known about how all these factors together lead to the pathogenesis of apoplectic pituitary. The vascular endothelial growth factor, tumor necrosis factor-α (TNF-α), pituitary tumor-transforming gene (PTTG), matrix metalloproteinase-2/9 (MMP-2/9), proliferating marker (Ki-67), as well as hypoxia-inducing factor are the major contributing factors involved in pituitary apoplexy. The molecular mechanism involved in pituitary apoplexy has never been described so far. In this review, we discuss the various proteins/cytokines/growth factors and signaling molecules which are involved in the pathogenesis of pituitary apoplexy and their potential role as biomarkers or as therapeutic targets.

Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage

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.

Surgical intervention for pituitary apoplexy: an analysis of functional outcomes

OBJECTIVE Pituitary apoplexy is a clinical syndrome consisting of neurological and endocrine abnormalities secondary to hemorrhage or ischemia of an underlying pituitary adenoma. The authors investigated whether there was a significant difference in neurological, endocrine, and nonneuroendocrine outcomes for patients with pituitary apoplexy, based on the time between symptom onset and surgical intervention. METHODS The authors retrospectively analyzed the medical records of 32 patients who had presented to their institution with acute pituitary apoplexy and subsequently undergone endonasal transsphenoidal resection in the period from 2003 to 2014. All patients had undergone preoperative MRI demonstrating evidence of apoplexy in the form of intratumoral hemorrhage, ischemia, and necrosis. Neurological deficits, partial or complete endocrinopathy, and nonneuroendocrine abnormalities were analyzed both pre- and postoperatively. RESULTS Preoperatively, neurological deficits including visual loss and cranial nerve palsies were found in 31 (97%) of the 32 patients, endocrinopathy in the form of partial or panhypopituitarism was seen in 28 patients (88%), and nonneuroendocrine signs and symptoms were seen in 32 patients (100%). Thirteen patients (41%) underwent surgery within 72 hours of symptom onset ("early"), whereas 19 patients (59%) underwent surgery more than 72 hours from symptom onset ("delayed"). Early versus delayed resection did not appear to significantly improve visual deficits, total visual loss, resolution of oculomotor palsy, recovery from hypopituitarism, or nonneuroendocrine signs and symptoms such as headache and encephalopathy. Overall, visual improvement was seen in 77% of patients, complete restoration of normal vision in 38% of patients, and resolution of preoperative oculomotor palsies in 81% of patients. Only 6 (21%) of 28 patients showed evidence of partial hormone recovery following preoperative hypopituitarism. An absence of benefit for early surgery held true even when considering time to surgery from symptom onset as a continuous variable. CONCLUSIONS Neurological deficits such as visual loss and cranial neuropathies show moderate improvement following surgical decompression, as does preoperative hypopituitarism. The timing of surgical intervention relative to the onset of symptoms does not appear to significantly affect the resolution of neurological or endocrinological deficits.

Clinically non-functioning pituitary adenomas: Pathogenic, diagnostic and therapeutic aspects

Clinically non-functioning pituitary adenomas (NFPAs) are among the most common tumors in the sellar region. These lesions do not cause a hormonal hypersecretion syndrome, and are therefore found incidentally (particularly microadenomas) or diagnosed based on compressive symptoms such as headache and visual field defects, as well as clinical signs of pituitary hormone deficiencies. Immunohistochemically, more than 45% of these adenomas stain for gonadotropins or their subunits and are therefore called gonadotropinomas, while 30% of them show no immunostaining for any hormone and are known as null cell adenomas. The diagnostic approach to NFPAs should include visual field examination, an assessment of the integrity of all anterior pituitary hormone systems, and magnetic resonance imaging of the sellar region to define tumor size and extension. The treatment of choice is transsphenoidal resection of the adenoma, which in many instances cannot be completely accomplished. The recurrence rate after surgery may be up to 30%. Persistent or recurrent adenomas are usually treated with radiation therapy. In a small proportion of these cases, drug treatment with dopamine agonists and, to a lesser extent, somatostatin analogs may achieve reduction or at least stabilization of the tumor.

Pituitary apoplexy presenting as a peripheral rim enhancing parasellar mass lesion with dural enhancement along the tentorium

Pituitary apoplexy is a potentially life-threatening clinical condition caused by rapid enlargement of a pituitary adenoma because of haemorrhage or infarction. The clinical features are typically acute in onset. We report an interesting case of 25-year-old man with complaints of sudden onset of headache and ophthalmoplegia in the right eye one month previously. He had ptosis and complete ophthalmoplegia in the right eye with visual acuity 6/24 and 6/12. Imaging showed a peripheral rim-enhancing mass lesion in the right parasellar and cavernous sinus with a dural tail. He underwent craniotomy and subtotal excision of the lesion. Histopathology was reported as pituitary apoplexy. Hormonal analysis was within normal limits. At two years of follow-up he had complete resolution of ophthalmoplegia and improvement in his vision. It is very uncommon to see pituitary apoplexy evolved in right parasellar region presenting as peripheral rim-enhancing mass lesion.

Time Course of Symptomatic Recovery After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma Apoplexy in the Modern Era

BACKGROUND

Pituitary tumor apoplexy can result from either hemorrhagic or infarctive expansion of pituitary adenomas, and the related mass effect can result in compression of critical neurovascular structures. The time course of recovery of visual field deficits, headaches, ophthalmoparesis, and pituitary dysfunction after endoscopic transsphenoidal surgery has not been well established.

METHODS

Medical records were retrospectively reviewed for all patients who underwent endoscopic transsphenoidal surgery for pituitary tumor apoplexy from April 2008 to November 2014.

RESULTS

Of 578 patients who underwent transsphenoidal surgery, pituitary tumor apoplexy was identified in 44 patients (7.6%). Two patients had prior surgery, leaving 42 patients for final analysis. These included infarction-related apoplexy in 7 (14.4%) patients, and hemorrhagic apoplexy in 35 (85.6%) patients. Hemorrhagic adenomas had a larger axial tumor diameter than patients with infarctive adenomas (4.4 ± 4.1 cm vs. 1.8 ± 0.8 cm; P < 0.01), but were otherwise equivalent. At an average last follow-up of 2.52 years (range, 0.1-6.7 years), resolution of ophthalmoparesis as a result of pituitary tumor apoplexy demonstrated the longest recovery course (range, 2.4 ± 2.2 months) compared with visual field deficits (range, 8.0 ± 9.9 days), headaches (range, 1.9 ± 3.0 days), or pituitary dysfunction (range, 2.0 ± 1.8 weeks; P < 0.01). All patients who presented with headaches (n = 37) and/or visual disturbances (n = 22) had complete resolution of symptoms at last follow-up, whereas 83.3% of patients who presented with ophthalmoplegia experienced resolution. Endocrinologic dysfunction remained relatively consistent after surgery.

CONCLUSIONS

Endoscopic transsphenoidal surgery can provide durable resolution of symptoms for patients presenting with pituitary tumor apoplexy. Recovery from headaches, visual, and pituitary dysfunction may be more rapid compared with ophthalmoparesis.

Pituitary apoplexy: considerations on a single center experience and review of the literature

PURPOSE

To present a single-center experience on pituitary tumor apoplexy and a review of literature focusing on predisposing and precipitating factors.

METHODS

Clinical presentation of our series of cases. Contemporary published literature is also reviewed.

RESULTS

The definition of this syndrome has not been consistent although now the majority of authors agree to definite it as an acute condition caused by hemorrhage or infarction of a pre-existing pituitary adenoma. Different predisposing and precipitating factors have been described in literature; among these antithrombotic and anticoagulant drugs, seem to play relevant roles. The clinical cases observed in our clinic confirm these data and suggest a probable association between elderly patients taking anticoagulant therapy and pituitary apoplexy adenoma.

CONCLUSION

Pituitary tumor apoplexy remains a challenging disease in relation to difficulties in correct diagnosis and thus in appropriate treatment. Antithrombotic/anticoagulant therapy may have an important role as precipitating factor. When a pituitary disorder is known, great care should be taken in the prescription of anticoagulant therapy.

Multidisciplinary Management of Pituitary Apoplexy

Pituitary apoplexy is a rare clinical syndrome due to ischemic or haemorrhagic necrosis of the pituitary gland which complicates 2-12% of pituitary tumours, especially nonfunctioning adenomas. In many cases, it results in severe neurological, ophthalmological, and endocrinological consequences and may require prompt surgical decompression. Pituitary apoplexy represents a rare medical emergency that necessitates a multidisciplinary approach. Modalities of treatment and times of intervention are still largely debated. Therefore, the management of patients with pituitary apoplexy is often empirically individualized and clinical outcome is inevitably related to the multidisciplinary team's skills and experience. This review aims to highlight the importance of a multidisciplinary approach in the management of pituitary apoplexy and to discuss modalities of presentation, treatment, and times of intervention.

Pituitary Apoplexy After Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitor: A Novel Complication

Pituitary adenomas are common in the general population. They can be complicated by intratumoral hemorrhage, otherwise known as apoplexy, which frequently presents with neurologic deficits that may necessitate urgent surgical decompression. Many risk factors for pituitary apoplexy have been suggested in the literature. We present a case of symptomatic apoplexy in a woman following the intravitreal administration of the vascular endothelial growth factor (VEGF) inhibitor ranibizumab. Ophthalmoplegia resolved and visual acuity significantly improved following gross total resection of the tumor via an endoscopic endonasal surgical approach. The association between intravitreal injection of a VEGF inhibitor and pituitary apoplexy has not been previously described, but physicians performing these procedures should be aware of this potential complication.

Pituitary Apoplexy

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

Incidence of Pituitary Apoplexy and Its Risk Factors in Chinese People: A Database Study of Patients with Pituitary Adenoma

Background

There are few studies of the incidence and clinical characteristics of pituitary apoplexy (PA) in pituitary adenoma patients, and the findings have been inconsistent.

Objective

The aim of the study was to retrospectively assess the incidence, clinical presentation, surgical management and postoperative complications of PA in pituitary adenoma patients.

Methods

A database was specifically designed to collect clinical, therapeutic, prognostic and histological information about pituitary adenoma patients. Using multivariate logistic regression, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to identify associated factors.

Results

A total of 2021 pituitary adenoma patients were recruited. 97 (4.8%) patients had PA. The incidence of PA was 10.11% in patients with pituitary macroadenoma, and 0.36% in patients with microadenoma. Variables for the logistic regression model independently associated with PA were sex (male vs. female, OR = 2.54, 95% CI: 1.59~4.07), tumor type (negative staining vs. positive staining, OR = 2.04, 95% CI: 1.29~3.23), and tumor size (macroadenoma vs. microadenoma, OR = 26.46, 95% CI = 9.66~72.46). Headache, visual deterioration, and vomiting were the most common symptoms in patients with pituitary adenoma. Patients with and without PA had similar frequency of visual deterioration, head trauma, acromegalic appearance, galactorrhoea, cold intolerance and Cushingoid appearance, but headache, vomiting, ptosis, diplopia, fever and blindness were significantly more common in patients with PA. Pearson Chi-Square tests revealed a significant difference in surgical approach between patients with and without PA (95.88% vs. 85.57%, P = 0.01).

Conclusion

Our findings suggest that PA is not a rare event. Male sex, non-functioning tumor, and macroadenoma are associated with an increased risk of PA. Compared with pituitary adenoma patients without PA, patients with PA have more severe symptoms.

Pediatric ischemic stroke from an apoplectic prolactinoma

INTRODUCTION

Pediatric pituitary neoplasms and associated pituitary apoplexy are uncommon. There are few reports in pediatric patients of pituitary apoplexy causing focal arterial compression or diffuse vasospasm resulting in cerebral infarction, and the acute, focal neurological deficits associated with stroke differ from the typical presentation of an apoplectic pituitary tumor. We report the first case of a teenage female with an apoplectic macroprolactinoma presenting with stuttering cerebral infarction secondary to compression of the internal carotid artery (ICA).

CASE

A 14-year-old female was transferred from an outside facility after presenting with right hand paresthesias and word-finding difficulty that eventually progressed to include right upper extremity weakness and mental status changes. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed an apoplectic macroprolactinemia and diffusion-weighted imaging showed acute stroke in the left anterior and middle cerebral artery distributions. Evaluation of the cerebral vasculature with MRA showed focal compression of the left supraclinoid ICA. Despite prompt surgical decompression, the patient developed right lower extremity weakness in addition to her other deficits though her deficits improved after inpatient rehabilitation.

CONCLUSIONS

In the pediatric population, there is only one other case of pituitary apoplexy presenting with stroke, which was secondary to vasospasm. We present the first case of pituitary apoplexy presenting with stroke secondary to ICA compression. Though rare, it is important to consider that pituitary apoplexy may present with non-classical symptoms such as ischemic stroke even in pediatric patients.

Apoplexy of pituitary adenomas: the perfect storm

OBJECT

Pituitary adenomas occasionally undergo infarction, apoplexy, which often destroys much of the tumor. It is well known that apoplexy can be precipitated by several acute factors, including cardiac surgery, other types of surgery, trauma, insulin infusion, and stimulation with administration of hypothalamic releasing factors.

METHODS

The prior focus on mechanisms underlying pituitary apoplexy has been on these acute events. Less attention has been given to the endogenous features of pituitary tumors that make them susceptible to spontaneous infarction, despite that most pituitary apoplexy occurs in the absence of a recognized precipitating event. The authors examine intrinsic features of pituitary adenomas that render them vulnerable to apoplexy-features such as high metabolic demand, paucity of angiogenesis, and sparse vascularity, qualities that have previously not been linked with apoplexy-and argue that it is these features of adenomas that underlie their susceptibility to spontaneous infarction. The sensitivity of freshly cultured pituitary adenomas to hypoglycemia is assessed.

RESULTS

Adenomas have high metabolic demand, limited angiogenesis, and reduced vessel density compared with the normal gland. Pituitary adenoma cells do not survive in the presence of reduced or absent concentrations of glucose.

CONCLUSIONS

The authors propose that the frequent ischemic infarction of pituitary adenomas is the product of intrinsic features of these tumors. These endogenous qualities create a tenuous balance between high metabolic demand and marginal tissue perfusion. Thus, the tumor is vulnerable to spontaneous infarction or to acute ischemia by any event that acutely alters the balance between tumor perfusion and tumor metabolism, events such as acute systemic hypotension, abruptly decreased supply of nutrients, hypoglycemia with insulin administration, or increase in the tumor's metabolic demand due to administration of hypothalamic releasing factors. It may be possible to take advantage of these intrinsic features of pituitary adenomas by using aspects of this vulnerability for development of new approaches for treatment.

A Case of Apoplexy of Rathke's Cleft Cyst Followed by Cerebral Infarction

Rathke's cleft cyst (RCC) apoplexy is a rare clinical entity. We report a case of apoplexy of an RCC followed by cerebral infarction. A 67-year-old woman was found lying on the street unconscious. She had fallen from her motorbike. On referral to our hospital she gradually regained consciousness and presented with no neurological deficits. CT showed a round and slightly hyperdense area in the suprasellar region. However, the attending physician did not find this abnormal finding on CT and the patient was discharged the same day. Thirteen days after the first emergency visit she developed left hemiparesis and dysarthria. CT showed a round hypodense area in the suprasellar region. The change of the density in the suprasellar region on CT suggested the pituitary apoplexy. CT also showed a low density area in the territory of the right middle cerebral artery, which indicated the cerebral infarction. MR angiography revealed poor visibility and stenotic changes of right middle cerebral arteries. Transsphenoidal surgery was performed. Histopathological findings confirmed a hemorrhagic RCC. Postoperative MR angiography showed that the visibility and stenosis of right middle cerebral arteries were recovered. This is the rare case of apoplexy of an RCC followed by cerebral infarction.

Pituitary tumor apoplexy

We review the etiology, investigations, management and outcomes of pituitary tumor apoplexy. Pituitary tumor apoplexy is a clinical syndrome which typically includes the acute onset of headache and/or visual disturbance, cranial nerve palsy and partial or complete endocrine dysfunction. It is associated with either infarction or hemorrhage of a pre-existing pituitary adenoma and is associated with significant morbidity and potential fatality. Not all patients will present with classic signs and symptoms, therefore it is pertinent to appreciate the clinical spectrum in which this condition can present.

Pituitary apoplexy

Pituitary apoplexy (PA) is a rare clinical syndrome caused by sudden hemorrhaging and/or infarction of the pituitary gland, generally within a pituitary adenoma. The main symptom is sudden-onset severe headache, associated with visual disorders or ocular palsy. Corticotropic deficiency may be life-threatening if left untreated. Computed tomography (CT) or MRI confirms the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. PA used to be considered a neurosurgical emergency but a conservative approach is increasingly used in selected patients, as it yields similar outcomes. Glucocorticoid treatment must always be started immediately after onset.