Unusual Complication of Pituitary Macroadenoma: A Case Report and Review

Bilateral antererior circulation stroke: A rare but threatening consequence of pituitary apoplexy. Case report and systematic literature review

BACKGROUND

Brain stroke is a rare, life-threatening condition associated with pituitary apoplexy (PA), resulting from direct arterial occlusion due to mechanical compression secondary to the sudden enlargement of the pituitary adenoma, or to vessel vasospasm, induced by tumor hemorrhage.

CASE REPORT

We report the case of a 64-year-old woman with PA complicated by bilateral anterior circulation stroke due to critical stenosis of both anterior cerebral arteries (ACA). Despite the quick surgical decompression and consequent blood flow restoration, the neurological conditions of the patient did not improve and she died 18 days later. Ten other cases of anterior circulation stroke due to PA were retrieved in a systematic review of literature. Clinical and neuroradiological features of these patients and treatment outcome were assessed to suggest the most proper management.

CONCLUSION

The onset of neurological symptoms suggestive for brain stroke in patients with PA requires performing an emergency Magnetic Resonance Imaging (MRI), including Diffusion-weighted and angiographic MR-sequences. The role of surgery in these cases is debated, however, transsphenoidal adenomectomy would permit us to decompress the ACA and restore blood flow in their territories. Although the prognosis of PA-induced anterior circulation stroke is generally poor, a timely diagnosis and treatment would be paramount for improving patient outcome.

Unusual bifrontal cerebral infarction related to pituitary apoplexy. An uncommon presentation and literature review

Background

Pituitary apoplexy (PA) is a syndromic condition described in 1950. The main symptoms are headache, visual impairment, ophthalmoplegia, and hypopituitarism. The relationship between stroke and PA is uncommon and two mechanisms are described: vascular compression and vasospasm.

Case Report

A 65-old-year man presented with severe headache, vomiting, ophthalmoplegia, and somnolence. Radiological examinations showed an expansive sellar and suprasellar lesion with a heterogeneous signal, besides Diffusion-weighted imaging (DWI) restriction in the bifrontal area was present. The findings were compatible with PA and stroke.

Conclusion

PA leading to cerebral infarction is a rare condition that presents high morbidity and mortality levels. There are two main mechanisms related: direct arterial compression and arterial vasospasm. The cases must be conducted as neuroendocrinological emergencies and surgical management is a key point to better the prognosis of patients.

Failed endovascular therapy for acute internal carotid artery occlusion from pituitary apoplexy: illustrative case

BACKGROUND

Large pituitary adenomas can rarely cause compression of the cavernous internal carotid artery (ICA) due to chronic tumor compression or invasion. Here, the authors present a case of pituitary apoplexy causing acute bilateral ICA occlusion with resultant stroke. Our middle-aged patient presented with sudden vision loss and experienced rapid deterioration requiring intubation. Computed tomography (CT) angiography revealed a large pituitary mass causing severe stenosis of the bilateral ICAs. CT perfusion revealed a significant perfusion delay in the anterior circulation. The patient was taken for cerebral angiography, and balloon angioplasty was attempted with no improvement in arterial flow. Resection of the tumor was then performed, with successful restoration of blood flow. Despite restoration of luminal patency, the patient experienced bilateral ICA infarcts.

OBSERVATIONS

Pituitary apoplexy can present as an acute stroke due to flow-limiting carotid compression. Balloon angioplasty is ineffective for the treatment of this type of compression. Surgical removal of the tumor restores the flow and luminal caliber of the ICA.

LESSONS

Pituitary apoplexy can be a rare presentation of acute stroke and should be managed with immediate surgical decompression rather than attempted angioplasty in order to restore blood flow and prevent the development of cerebral ischemia.

Pituitary Apoplexy Leading to Cerebral Infarction: A Systematic Review

Background: Cerebral infarction caused by pituitary apoplexy (PA) is rare. To characterize the clinical features of cerebral infarction caused by PA, we performed a systematic review. Summary: The clinical symptoms are mainly sudden headache, hemiplegia, visual impairment, disturbance of consciousness, and ophthalmalgia in patients with cerebral infarction caused by PA. Treatment for this type of infarction is different from treatment for general acute cerebral infarction. Compared to patients who underwent emergency surgery and conservative treatment, patients treated with delayed surgery showed a better prognosis and a lower mortality rate. Compared to patients who underwent craniotomy or conservative treatment, patients who underwent transsphenoidal surgery (TSS) not only improved well but also showed a lower mortality rate. Key Messages: PA rarely causes cerebral infarction, which is a critical condition with a poor prognosis and is more common in men. Delayed surgery and TSS appear to confer a better prognosis in patients with this condition.

Suprasellar ganglioglioma presenting as a middle cerebral artery infarction

BACKGROUND

Gangliogliomas are a relatively rare neoplasm with a major incidence in the pediatric population. As the temporal lobes are the most common site, patients usually present with seizures.

CASE REPORT

We report the case of a 9-year-old child with an extensive suprasellar ganglioglioma presenting with a cerebral infarction due to direct compression of the medium cerebral artery.

CONCLUSIONS

Suprasellar lesions can compress adjacent vascular structures, so an accurate diagnosis is necessary for an early treatment.

Pituitary Apoplexy Presenting as Ophthalmoplegia and Altered Level of Consciousness without Headache

Background. Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The typical clinical presentation of PA includes acute onset of severe headache, visual disturbance, cranial nerve palsy, and altered level of consciousness. Case Report. A 78-year-old man presented to the emergency department with one-day history of ptosis and diplopia and an acute-onset episode of altered level of consciousness which was resolving. He denied having headache, nausea, or vomiting. Physical examination revealed third-cranial nerve palsy and fourth-cranial nerve palsy both on the right side. Noncontrast computed tomography (CT) scan of the head was unremarkable. Brain magnetic resonance imaging (MRI) showed a pituitary mass with hemorrhage (apoplexy) and extension to the right cavernous sinus. The patient developed another episode of altered level of consciousness in the hospital. Transsphenoidal resection of the tumor was done which resulted in complete recovery of the ophthalmoplegia and mental status. Conclusion. Pituitary apoplexy can present with ophthalmoplegia and altered level of consciousness without having headache, nausea, or vomiting. A CT scan of the head could be negative for hemorrhage. A high index of suspicion is needed for early diagnosis and timely management of pituitary apoplexy.

Preoperative Computed Tomography (CT) Evaluation of Anatomical Abnormalities in Endonasal Transsphenoidal Approach in Pituitary Adenoma

BACKGROUND This study aimed to retrospectively analyze patient clinical data to investigate the effects of computed tomography (CT) reconstruction and the measurement of abnormal structures in the endonasal sphenoidal sinus approach on the operative effects in patients undergoing pituitary adenoma resection. MATERIAL AND METHODS The records of 53 patients who underwent pituitary adenoma resection via the endonasal transsphenoidal approach in the Neurosurgery Department of Tai'an City Central Hospital from December 2010 to June 2016 were analyzed retrospectively. All cases showed anatomical abnormalities in the endonasal transsphenoidal approach that were detected by conventional CT scans. The clinical data of the patients were reviewed. After review, 26 patients who underwent preoperative CT reconstruction and measurement of abnormal structures before surgery were included in the observation group (CT reconstruction group), and 27 patients who did not undergo CT reconstruction and measurement of abnormal structures were included in the control group. Data on intraoperative blood loss, surgical time, hospital stay, and postoperative complications were collected to assess the quality of the surgery. RESULTS Compared with the control group, the observation group showed less blood loss (p<0.001), a shorter operation time (p<0.001), fewer postoperative complications (p<0.001), and a shorter hospital stay (p<0.001). CONCLUSIONS Preoperative CT reconstruction and measurement of abnormal structures in patients undergoing pituitary adenoma resection by the endonasal transsphenoidal approach can improve operative quality and reduce complications.