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Saktiwarawat K, Tunthanathip T, Oearsakul T, Taweesomboonyat C. Comparing neuroendocrine recovery between surgical and conservative management in pituitary apoplexy patients: a propensity score-matched analysis. Neurosurg Rev 2024; 47:236. [PMID: 38802695 DOI: 10.1007/s10143-024-02461-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/08/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
Pituitary apoplexy is a rare and potentially life-threatening clinical syndrome. Patients may present with severeneuro-ophthalmologic or endocrine symptoms. Current evidence is unclear whether conservative or surgicalmanagement leads to the best neuroendocrine outcomes. This study aimed to compare neuroendocrine outcomesbetween surgical and conservative treatments in a single center. Cases of patients with pituitary apoplexy whoreceived transsphenoidal surgery or conservative management in Songklanagarind Hospital between January 1,2005 and December 31, 2022 were retrospectively reviewed. A propensity score matching method was used toadjust bias from treatment selection (surgery or conservative treatment). Differences in visual field, visual acuity,cranial nerve, and endocrine outcomes between the surgical and conservative treatment groups were analyzedusing logistic regression analysis. This study included 127 patients, with 98 and 29 patients in the surgical and theconservative treatment group, respectively. The optimal matching method was used for propensity score matching.Compared to the conservative group, the surgically treated patients had a significantly higher rate of visual fieldrecovery (odds ratio (OR): 12.89, P = 0.007). However, there were no statistical differences in the recovery rate ofpreoperative visual acuity, cranial nerve, and endocrine deficits between the groups. Transsphenoidal surgery wasassociated with a higher rate of visual field recovery when compared to the conservative treatment for pituitaryapoplexy patients. Careful selection of appropriate treatment based on the patient's presentation andneuroendocrine status will result in the best outcomes while avoiding unnecessary surgical intervention.
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Affiliation(s)
- Krittithee Saktiwarawat
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thakul Oearsakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chin Taweesomboonyat
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
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Moscona-Nissan A, Sidauy-Adissi J, Hermoso-Mier KX, Glick-Betech SS, Chávez-Vera LDJ, Martinez-Mendoza F, Delgado-Casillas OM, Taniguchi-Ponciano K, Marrero-Rodríguez D, Mercado M. Diagnosis and Treatment of Pituitary Apoplexy, A True Endocrine Emergency. Arch Med Res 2024; 55:103001. [PMID: 38703639 DOI: 10.1016/j.arcmed.2024.103001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024]
Abstract
Pituitary apoplexy (PA) is a clinical syndrome resulting from a hemorrhagic infarction of the pituitary gland. It is characterized by the sudden onset of visual disturbances, nausea, vomiting, headache and occasionally, signs of meningeal irritation and an altered mental status. The exact pathogenesis of PA remains to be elucidated, although tumor overgrowth of its blood supply remains the most popular theory. Main risk factors for the development of PA include systemic, iatrogenic, and external factors as well as the presence of an underlying pituitary tumor. The diagnostic approach of PA includes both neuroimaging and evaluation of pituitary secretory function. PA is a potentially life-threatening condition which should be managed with hemodynamic stabilization, correction of electrolyte abnormalities and replacement of hormonal deficiencies. PA treatment should be individualized based on the severity of the clinical picture which may vary widely. Treatment options include conservative management with periodic follow-up or neurosurgical intervention, which should be decided by a multidisciplinary team. We conducted a systematic review of the literature to unveil the frequency of PA predisposing factors, clinical and biochemical presentations, management strategies and outcomes.
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Affiliation(s)
- Alberto Moscona-Nissan
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Jessica Sidauy-Adissi
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Karla Ximena Hermoso-Mier
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Shimon Shlomo Glick-Betech
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Leonel de Jesús Chávez-Vera
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Florencia Martinez-Mendoza
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Oscar Mario Delgado-Casillas
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Keiko Taniguchi-Ponciano
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Daniel Marrero-Rodríguez
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Moisés Mercado
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
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Wu J, Zhang F, Huang Y, Wei L, Mei T, Wang S, Zeng Z, Wang W. Predictive value of cyst/tumor volume ratio of pituitary adenoma for tumor cell proliferation. BMC Med Imaging 2024; 24:69. [PMID: 38515047 PMCID: PMC10958862 DOI: 10.1186/s12880-024-01246-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND MRI has been widely used to predict the preoperative proliferative potential of pituitary adenoma (PA). However, the relationship between the cyst/tumor volume ratio (C/T ratio) and the proliferative potential of PA has not been reported. Herein, we determined the predictive value of the C/T ratio of PA for tumor cell proliferation. METHODS The clinical data of 72 patients with PA and cystic change on MRI were retrospectively analyzed. PA volume, cyst volume, and C/T ratio were calculated. The corresponding intraoperative specimens were collected. Immunohistochemistry and hematoxylin-eosin staining were performed to evaluate the Ki67 index and nuclear atypia. Patients were categorized according to the Ki67 index (< 3% and ≥ 3%) and nuclear atypia (absence and presence). Univariate and multivariate analyses were used to identify the significant predictors of the Ki67 index and nuclear atypia. The receiver operating characteristic curve assessed the prediction ability of the significant predictors. RESULTS Larger tumor volumes, smaller cyst volumes, and lower C/T ratios were found in patients with higher Ki67 indexes and those with nuclear atypia (P < 0.05). C/T ratio was an independent predictor of the Ki67 index (odds ratio = 0.010, 95% confidence interval = 0.000-0.462) and nuclear atypia (odds ratio = 0.010, 95% confidence interval = 0.000-0.250). The predictive value of the C/T ratio did not differ significantly from that of tumor volume (P > 0.05) but was better than that of cyst volume (P < 0.05). The area under the curve of the C/T ratio for predicting the Ki67 index and nuclear atypia was larger than that for predicting cyst volume and tumor volume. CONCLUSIONS C/T ratios can be used to predict PA tumor proliferation preoperatively. Our findings may facilitate the selection of surgery timing and the efficacy evaluation of surgery.
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Affiliation(s)
- Jianwu Wu
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, No. 156 Xi'erhuanbei Road, Fuzhou, 350025, P. R. China
| | - Fangfang Zhang
- Department of Endocrinology, the Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, 350009, P. R. China
| | - Yinxing Huang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, No. 156 Xi'erhuanbei Road, Fuzhou, 350025, P. R. China
| | - Liangfeng Wei
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, No. 156 Xi'erhuanbei Road, Fuzhou, 350025, P. R. China
| | - Tao Mei
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen, 518000, P. R. China
| | - Shousen Wang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, No. 156 Xi'erhuanbei Road, Fuzhou, 350025, P. R. China.
| | - Zihuan Zeng
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, No. 156 Xi'erhuanbei Road, Fuzhou, 350025, P. R. China.
| | - Wei Wang
- Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, No. 2, Fuxue Lane, Wuma Street, Lucheng District, Wenzhou, 325000, P. R. China.
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Mamelak AN, Little AS, Gardner PA, Almeida JP, Recinos P, Soni P, Kshettry VR, Jane JA, Barkhoudarian G, Kelly DF, Dodd R, Mukherjee D, Gersey ZC, Fukuhara N, Nishioka H, Kim EH, Litré CF, Sina E, Mazer MW, Cui Y, Bonert V. A Prospective, Multicenter, Observational Study of Surgical vs Nonsurgical Management for Pituitary Apoplexy. J Clin Endocrinol Metab 2024; 109:e711-e725. [PMID: 37698130 DOI: 10.1210/clinem/dgad541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/14/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
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.
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Affiliation(s)
- Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Medical Center, Phoenix, AZ 85013, USA
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | | | - Pablo Recinos
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Pranay Soni
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - John A Jane
- Departments of Neurosurgery, Virginia Tech Medical Center, Roanoke, VA 24014, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Robert Dodd
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Eui-Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | | | - Elliott Sina
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Mia W Mazer
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Yujie Cui
- Biostatistic Core, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Vivien Bonert
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Wu J, Li S, Huang Y, Zeng Z, Mei T, Wang S, Wang W, Zhang F. MRI features of pituitary adenoma apoplexy and their relationship with hypoxia, proliferation, and pathology. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023. [PMID: 37235536 DOI: 10.1002/jcu.23492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/20/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE We aim to study the MRI features of pituitary adenoma (PA) apoplexy and their relationship with hypoxia, proliferation, and pathology. METHODS Sixty-seven patients with MRI signs of PA apoplexy were selected. According to the MRI signs, they were divided into the parenchymal group and the cystic group. The parenchymal group had a low signal area on T2WI without cyst >2 mm and this area was not significantly enhanced on the corresponding TW1 enhancement. The cystic group had a cyst >2 mm on T2WI, and the cyst showed liquid stratification on T2WI or high signal on T1WI. The relative T1WI (rT1WI) enhancement value and relative T2WI (rT2WI) value of non-apoplexy areas were measured. Protein levels of hypoxia-inducible factor-1 (HIF-1α), pyruvate dehydrogenase kinase 1 (PDK1), and Ki67 were detected with immunohistochemistry and Western blot. Nuclear morphology was observed with HE staining. RESULTS The rT1WI enhancement average value, rT2WI average value, Ki67 protein expression level, and the number of abnormal nuclear morphology of non-apoplexy lesions in the parenchymal group were significantly lower than those in the cystic group. The protein expression levels of HIF-1α and PDK1 in the parenchymal group were significantly higher than those in the cystic group. HIF-1α protein was positively correlated with PDK1 but negatively correlated with Ki67. CONCLUSION When there is PA apoplexy, the ischemia and hypoxia of the cystic group are lesser than those of the parenchymal group, but the proliferation is stronger.
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Affiliation(s)
- Jianwu Wu
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Songyuan Li
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Yinxing Huang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Zihuan Zeng
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Tao Mei
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen, People's Republic of China
| | - Shousen Wang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Wei Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Fangfang Zhang
- Department of Endocrinology, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, People's Republic of China
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Impact of social reward on the evolution of cooperation in voluntary prisoner's dilemma. Biosystems 2023; 223:104821. [PMID: 36464161 DOI: 10.1016/j.biosystems.2022.104821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
The existence and sustainability of cooperation is a critical issue in nature and social systems. Reward is an essential mechanism to enhance cooperation. Meanwhile, some individuals loathe competition and then choose to escape and become a loner in competition. In this scenario, we propose a four-strategy networked evolutionary game model involving rewarders, loners, cooperators, and defectors. The classical square lattice and the Erdös-Rényi random network are adopted to describe the interaction between individuals. The four-strategy model is an extension of the classic prisoner's dilemma game model. The simulation results show that the introduction of new strategic choices can significantly improve cooperation in the population. The promotion level of cooperation is directly correlated with reward intensity and negatively correlated with reward cost. With regard to the evolution of altruistic behaviors, the fixed income from interactions with loners has an impact that is connected to the temptation to defect. Furthermore, by analyzing characteristic snapshots of four strategies, we further dissect the essence of the evolution of cooperation. As the temptation value increases, cooperators and rewarders first form compact clusters, then more and more loners join to resist the intrusion of defectors. Eventually, the three strategies coexist stably in a spatially structured population. Our research may shed some light on exploring the nature of cooperation and solving social dilemmas in the future.
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Biagetti B, Sarria-Estrada S, Cordero Asanza E, Chaachou-Charradi A, Ng-Wong YK, Cicuendez M, Hernandez I, Rojano-Toimil A, Costa P, Martinez-Saez E, Casteràs A, Simò R. Risk Factors, Radiological and Clinical Outcomes in Subclinical and Clinical Pituitary Apoplexy. J Clin Med 2022; 11:jcm11247288. [PMID: 36555904 PMCID: PMC9786023 DOI: 10.3390/jcm11247288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/25/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pituitary apoplexy (PA) can be symptomatic, namely acute apoplexy (APA), or asymptomatic or subclinical (SPA). OBJECTIVE To describe the clinical characteristics and evolution of the patients with APA compared to SPA Patients and methods: Retrospective, longitudinal database analysis. RESULTS We identified 58 patients with PA, and 37 accomplished the inclusion criteria (17 men, median age 47.7 years). A total of 29 (78.4%) had APA (17 underwent surgery, and 12 were conservatively managed), and 8 (21.6%) had SPA. The presence of non-functioning pituitary adenoma (NFPA) odds ratio (OR): 29.36 (95% confidence interval (CI): 1.86-462.36) and the largest size OR 1.10 (95% CI: 1.01-1.2) elevated the risk of having surgery. Hypopituitarism developed in 35.1% without significant differences between APA and SPA. In non-surgical patients, adenoma volume shrunk spontaneously at one year magnetic resonance imaging (MRI), without statistical differences between the conservatively treated and SPA group. CONCLUSIONS APA is more frequent in larger NFPAs, and this subset of patients has a higher risk of surgery. Hypopituitarism is quite frequent even in patients with SPA, and, therefore, long-term follow-up is mandatory. In the non-surgical group, the pituitary tumour shrinkage is clinically relevant after one year of PA. Consequently, surgery indication in NFPA should be delayed and reassessed if patients remain asymptomatic.
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Affiliation(s)
- Betina Biagetti
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
| | - Silvana Sarria-Estrada
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Esteban Cordero Asanza
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | | | - Yiken Karelys Ng-Wong
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Marta Cicuendez
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Irene Hernandez
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Alba Rojano-Toimil
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Pilar Costa
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Elena Martinez-Saez
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Anna Casteràs
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
| | - Rafael Simò
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
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Rai RS, Gelnick S, Pomeranz H, Verma R. Recovery of Complete Blindness and Internal Ophthalmoplegia After Transsphenoidal Decompression of Pituitary Apoplexy. Cureus 2022; 14:e28681. [PMID: 36199649 PMCID: PMC9526680 DOI: 10.7759/cureus.28681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 11/05/2022] Open
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Donegan D, Erickson D. Revisiting Pituitary Apoplexy. J Endocr Soc 2022; 6:bvac113. [PMID: 35928242 PMCID: PMC9342855 DOI: 10.1210/jendso/bvac113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Pituitary apoplexy (PA) is a rare clinical syndrome due to pituitary hemorrhage or infarction. It is characterized by the sudden onset of one or more of the following: severe headache, visual disturbance, nausea/vomiting, and or altered mental status. Most commonly, PA occurs in an underlying pituitary adenoma. The pathophysiology is not fully understood, but it is thought to involve elements of increased metabolic demand and/or compromise to the vasculature of the pituitary or pituitary tumor. Several risk factors have been described. Stabilization of the patient on presentation, replacement of hormonal deficiencies, and reversal of electrolyte abnormalities are the recommended initial steps in the management of patients with PA. Surgical decompression of the mass effect had been the recommended treatment for patients with PA; however, retrospective studies of patients with PA have demonstrated similar outcomes when a conservative approach is applied. This suggests that in highly selected clinical scenarios (mild visual deficit and improving symptoms), conservative management is possible. Further studies, however, are necessary to better stratify patients but are limited by the rarity of the condition and the acuity.
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Affiliation(s)
- Diane Donegan
- Division of Endocrinology, Diabetes and Metabolism, Indiana University , Indianapolis, Indiana 46220 , USA
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic Minnesota , Rochester, Minnesota 55905 , USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic Minnesota , Rochester, Minnesota 55905 , USA
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Pituitary Apoplexy: Risk Factors and Underlying Molecular Mechanisms. Int J Mol Sci 2022; 23:ijms23158721. [PMID: 35955859 PMCID: PMC9369054 DOI: 10.3390/ijms23158721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/31/2022] [Accepted: 08/04/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Abstract
PURPOSE OF REVIEW Pituitary adenoma resections comprise a large proportion of intracranial tumor surgeries. This patient population is medically and physiologically complex and requires careful perioperative planning and management on the part of the anesthesiologist. This review will summarize anesthetic considerations for pre, intra, and postoperative management of patients undergoing transsphenoidal pituitary surgery. RECENT FINDINGS An endoscopic approach is favored for patients undergoing transsphenoidal pituitary surgery. Hemodynamic monitoring is important to maintain cerebral perfusion and avoid risk of bleeding; however, 'controlled' hypotension may have adverse effects. Multimodal analgesia is effective for the management of postoperative pain and may reduce the risk of postoperative complications, including respiratory depression and postoperative nausea and vomiting. SUMMARY Transsphenoidal pituitary surgery is a preferred approach for the surgical management of nonfunctioning pituitary macroadenomas with symptoms of mass effect and functioning adenomas that cannot be otherwise managed medically. Understanding tumor pathologies and systemic effects are essential for preoperative planning and providing safe anesthetic care during the perioperative period.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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