Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature

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.

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.

Pilot Findings on SARS-CoV-2 Vaccine-Induced Pituitary Diseases: A Mini Review from Diagnosis to Pathophysiology

Since the emergence of the COVID-19 pandemic at the end of 2019, a massive vaccination campaign has been undertaken rapidly and worldwide. Like other vaccines, the COVID-19 vaccine is not devoid of side effects. Typically, the adverse side effects of vaccination include transient headache, fever, and myalgia. Endocrine organs are also affected by adverse effects. The major SARS-CoV-2 vaccine-associated endocrinopathies reported since the beginning of the vaccination campaign are thyroid and pancreas disorders. SARS-CoV-2 vaccine-induced pituitary diseases have become more frequently described in the literature. We searched PubMed/MEDLINE for commentaries, case reports, and case series articles reporting pituitary disorders following SARS-CoV-2 vaccination. The search was reiterated until September 2022, in which eight case reports were found. In all the cases, there were no personal or familial history of pituitary disease described. All the patients described had no previous SARS-CoV-2 infection prior to the vaccination episode. Regarding the type of vaccines administered, 50% of the patients received (BNT162b2; Pfizer-BioNTech) and 50% received (ChAdOx1 nCov-19; AstraZeneca). In five cases, the pituitary disorder developed after the first dose of the corresponding vaccine. Regarding the types of pituitary disorder, five were hypophysitis (variable clinical aspects ranging from pituitary lesion to pituitary stalk thickness) and three were pituitary apoplexy. The time period between vaccination and pituitary disorder ranged from one to seven days. Depending on each case's follow-up time, a complete remission was obtained in all the apoplexy cases but in only three patients with hypophysitis (persistence of the central diabetes insipidus). Both quantity and quality of the published data about pituitary inconveniences after COVID-19 vaccination are limited. Pituitary disorders, unlike thyroid disorders, occur very quickly after COVID-19 vaccination (less than seven days for pituitary disorders versus two months for thyroid disease). This is partially explained by the ease of reaching the pituitary, which is a small gland. Therefore, this gland is rapidly overspread, which explains the speed of onset of pituitary symptoms (especially ADH deficiency which is a rapid onset deficit with evocative symptoms). Accordingly, these pilot findings offer clinicians a future direction to be vigilant for possible pituitary adverse effects of vaccination. This will allow them to accurately orient patients for medical assistance when they present with remarkable symptoms, such as asthenia, polyuro-polydipsia, or severe headache, following a COVID-19 vaccination.

A Case of Nonapoplectic Pituitary Adenoma Presenting with Isolated Oculomotor Nerve Palsy

We report a rare case of nonapoplectic pituitary adenoma that did not invade the cavernous sinus and was associated with isolated oculomotor nerve palsy. A 61-year-old male was admitted to our hospital due to diplopia that had gradually worsened from 6 months to presentation. He was diagnosed with right oculomotor nerve palsy, and brain magnetic resonance imaging (MRI) showed a mass lesion within the sella. The tumor was homogeneously enhanced on contrast-enhanced MRI. However, no findings suggestive of pituitary apoplexy were found. Brain computed tomography revealed the tumor to have eroded the right side of the posterior clinoid process by gradual expansion. Endoscopic transsphenoidal surgery was used for complete resection of the tumor. Intraoperative findings showed that the tumor did not invade the cavernous sinus. The histological diagnosis was pituitary adenoma, and symptom improvement was observed from the early postoperative stage onward. Surgical treatment is essential because oculomotor nerve palsy caused by the enlargement of pituitary adenoma is not expected to resolve if treated conservatively, unlike that caused by pituitary apoplexy.

Rapid resolution of a third nerve palsy from pituitary apoplexy

A 49-year-old man presented with new onset headache and diplopia, with right ptosis and limitation of extraocular movements consistent with a third nerve palsy. He had a known diagnosis of a non-functioning pituitary adenoma, and his presentation and neuroimaging were consistent with ischaemic pituitary apoplexy. The patient was otherwise stable with no signs of optic neuropathy or endocrine abnormality. He was observed with close interval follow-up and reported resolution of symptoms within 4 days after onset. Pituitary apoplexy is a potentially life-threatening condition often managed with initial medical stabilisation followed by neurosurgical decompression. The guidelines regarding the utility of surgery in patients with isolated ocular motility disorders are unclear, and recent retrospective studies suggested that outcomes may be similar in patients managed conservatively. This case demonstrates that rapid resolution of an isolated third nerve palsy may occur in this setting, and that observation is a reasonable initial management strategy.

Diffusion Tensor Imaging Tractography Detecting Isolated Oculomotor Paralysis Caused by Pituitary Apoplexy

OBJECTIVES

Pituitary apoplexy (PA)-induced oculomotor palsy, although rare, can be caused by compression on the lateral wall of the cavernous sinus. This study aimed to visualize PA-induced oculomotor nerve damage using diffusion tensor imaging (DTI) tractography.

MATERIALS AND METHODS

We enrolled 5 patients with PA-induced isolated oculomotor palsy (patient group) and 10 healthy participants (control group); all underwent DTI tractography preoperatively. Fractional anisotropy (FA) and mean diffusion (MD) values of the cisternal portion of the bilateral oculomotor nerve were measured. DTI tractography was repeated after the recovery of oculomotor palsy.

RESULTS

While no statistical difference was observed in FA and MD values of the bilateral oculomotor nerve in the control group (P>0.05), the oculomotor nerve on the affected side was disrupted in the patient group, with a statistical difference in FA and MD values of the bilateral oculomotor nerve (P<0.01). After the recovery of oculomotor palsy, the FA value of the oculomotor nerve on the affected side increased, whereas the MD value decreased (P<0.01). Meanwhile, no significant difference was observed in FA and MD values of the bilateral oculomotor nerve (P>0.05). DTI tractography of the oculomotor nerve on the affected side revealed restoration of integrity. Furthermore, the symptoms of oculomotor palsy improved in all patients 7 days postoperatively.

CONCLUSION

DTI tractography could be a helpful adjunct to the standard clinical and paraclinical ophthalmoplegia examinations in patients with PA; thus, this study establishes the feasibility of DTI tractography in this specific clinical setting.

Pituitary Apoplexy Accompanying Temporal Lobe Seizure as a Complication

BACKGROUND

Pituitary apoplexy is an acute clinical syndrome caused by infarction and/or hemorrhage of pituitary adenoma, which typically presents with severe headache, visual deterioration, and endocrine abnormalities. However, temporal lobe seizure (and temporal lobe epilepsy) has not been viewed as a symptom of pituitary apoplexy in the literature.

CASE DESCRIPTION

To elucidate further such a rare complication of temporal lobe seizure, we describe here the rare clinical manifestations of a 55-year-old previously healthy man with pituitary apoplexy harboring headache, combined palsies involving cranial nerves III to VI, endocrinologic disturbances, and temporal lobe seizure. In addition, we discuss the temporal lobe seizure (and temporal lobe epilepsy) associated with pituitary adenoma based on the literature.

CONCLUSIONS

Although further accumulation of clinical data is needed, we would like to emphasize the importance of recognition of temporal lobe seizure caused by pituitary apoplexy, and to suggest that early surgery could be considered as an option in patients displaying such a rare complication.