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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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Salle H, Cane M, Rocher M, Auditeau E, Teissier MP, Raverot G, Salle L. Pituitary apoplexy score, toward standardized decision-making: a descriptive study. Pituitary 2024; 27:77-87. [PMID: 38150169 DOI: 10.1007/s11102-023-01372-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 12/28/2023]
Abstract
Pituitary apoplexy (PA), a rare and life-threatening complication of pituitary adenomas, prompts urgent glucocorticoid administration. The optimal surgical approach is debated, and the Pituitary Apoplexy Score (PAS) aids decision-making. Our retrospective study (2003-2022) assesses variables in PA patient groups (surgical vs. non-surgical), applying PAS to establish a significant threshold for surgical decisions. Additionally, we aim to compare the rates of ophthalmological and endocrine deficit between both groups and identify any associated variables. PAS discrepancies were observed, with averages of 1.7 ± 1.7 (p < 0.0001) for conservative and 3.9 ± 1.7 (p < 0.0001) for surgical groups, confirmed by multivariate analysis (p = 0.009). A PAS threshold of 5, showing over 80% positive predictive value, was established. Patients with low prolactin levels (< 5 ng/ml) had higher corticotropic deficiency prevalence at 3-month and 1-year follow-ups (p = 0.017 and 0.027). Our study supports PAS as a valuable PA management tool, suggesting potential variable adjustments. Multicenter studies are crucial due to PA's low incidence.
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Affiliation(s)
- Henri Salle
- Neurosurgery, CHU Limoges, Limoges, France.
- CAPTuR, Inserm, University of Limoges, CHU Limoges, Limoges, France.
| | | | | | - Emilie Auditeau
- Inserm U1094, IRD U270, EpiMaCT, University of Limoges, CHU Limoges, Limoges, France
| | | | - Gerald Raverot
- Endocrinology, Hospices Civils de Lyon and Lyon 1 University, Lyon, France
| | - Laurence Salle
- Endocrinology, CHU Limoges, Limoges, France
- Inserm U1094, IRD U270, EpiMaCT, University of Limoges, CHU Limoges, Limoges, France
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Surgery for Pituitary Tumor Apoplexy Is Associated with Rapid Headache and Cranial Nerve Improvement. Curr Oncol 2022; 29:4914-4922. [PMID: 35877250 PMCID: PMC9319222 DOI: 10.3390/curroncol29070390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Pituitary tumor apoplexy (PTA) classically comprises sudden-onset headache, loss of vision, ophthalmoparesis, and decreased consciousness. It typically results from hemorrhage and/or infarction within a pituitary adenoma. Presentation is heterologous, and optimal management is debated. The time course of recovery of cranial nerve deficits (CNDs) and headaches is not well established. In this study, a retrospective series of consecutive patients with PTA managed at a single academic institution over a 22-year period is presented. Headaches at the time of surgery were more severe in the early and subacute surgical cohort and improved significantly within 72 h postoperatively (p < 0.01). At one year, 90% of CNDs affecting cranial nerves (CNs) 3, 4, and 6 had recovered, with no differences between early (<4 d), subacute (4−14 d), and delayed (>14 d) time-to-surgery cohorts. Remarkably, half recovered within three days. In total, 56% of CN2 deficits recovered, with the early surgery cohort including more severe deficits and recovering at a lower rate (p = 0.01). No correlation of time-to-surgery and rapidity of recovery of CNDs was observed (p = 0.65, 0.72). Surgery for PTA is associated with rapid recovery of CNDs in the early, subacute, and delayed time frames, and with rapid headache improvement in the early and subacute time frames in 50% or more of patients.
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Suspected Pituitary Apoplexy: Clinical Presentation, Diagnostic Imaging Findings and Outcome in 19 Dogs. Vet Sci 2022; 9:vetsci9040191. [PMID: 35448689 PMCID: PMC9026492 DOI: 10.3390/vetsci9040191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 02/01/2023] Open
Abstract
In human medicine, pituitary apoplexy (PA) is a clinical syndrome characterised by the sudden onset of neurological signs because of haemorrhage or infarction occurring within a normal or tumoral pituitary gland. The diagnosis is usually performed combining neurological signs and imaging findings. The aim of the present study is to describe the abnormal neurological signs, the diagnostic imaging findings, based on Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI), and the outcome in a population of dogs with suspected PA. Clinical cases were retrospectively reviewed. Nineteen cases of suspected PA were included. The majority of dogs showed behavioural abnormalities (11/19). Neurological signs more frequently identified were obtundation (7/19), vestibular signs (7/19) and epileptic seizures (6/19). The onset of neurological signs was per-acute in 14 out of 19 cases. Data regarding CT and MRI were available in 18 and 9 cases, respectively. Neurological signs resolved in less than 24 h in seven patients. The short-term prognosis was defined as favourable in the majority of our study population. The median survival time was of 7 months from the time of PA diagnosis. This is the first description of neurological signs, imaging findings and outcome in a large group of dogs with PA.
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Zhu Q, Liang Y, Fan Z, Liu Y, Zhou C, Zhang H, Li T, Zhou Y, Yang J, Wang Y, Wang L. Ischemic Infarction of Pituitary Apoplexy: A Retrospective Study of 46 Cases From a Single Tertiary Center. Front Neurosci 2022; 15:808111. [PMID: 35140585 PMCID: PMC8818988 DOI: 10.3389/fnins.2021.808111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveIschemic infarction of pituitary apoplexy (PA) is a rare type of pituitary apoplexy. This study aims to characterize ischemic PA via clinical presentations, imaging data, histopathological manifestations, and focus on the management and prognosis of the disease.MethodsThis study retrospectively identified 46 patients with ischemic PA confirmed using histopathology at a single institution from January 2013 to December 2020. The clinical presentations, imaging data, laboratory examination, management, and outcomes were collected. We then summarized the clinical presentations, imaging features, intraoperative findings, and histopathological manifestations, and compared the outcomes based on the timing of surgical intervention.ResultsHeadache was the most common initial symptom (95.65%, 44/46), followed by visual disturbance (89.13%, 41/46), and nausea and vomiting (58.70%, 27/46). 91.3% of the patients had at least one pituitary dysfunction, with hypogonadism being the most common endocrine dysfunction (84.78%, 39/46). Cortisol dysfunction occurred in 24 (52.17%) patients and thyroid dysfunction occurred in 17 (36.96%). Typical rim enhancement and thickening of the sphenoid sinus on MRI were seen in 35 (85.37%) and 26 (56.52%) patients, respectively. Except for one patient with asymptomatic apoplexy, the remaining patients underwent early (≤ 1 week, 12 patients) and delayed (> 1 week, 33 patients) transsphenoidal surgery. Total tumor resection was achieved in 27 patients and subtotal tumor resection in 19 patients. At surgery, cottage cheese–like necrosis was observed in 50% (23/46) of the patients. At the last follow-up of 5.5 ± 2.7 years, 92.68% (38/41) of the patients had gained a significant improvement in visual disturbance regardless of surgical timing, and 65% of the patients were still receiving long-term hormone replacement therapy.ConclusionPatients with ischemic PA can be accurately diagnosed by typical imaging characteristics preoperatively. The timing of surgical intervention does not significantly affect the resolution of neurological and endocrinological dysfunctions. Preoperative endocrine dysfunctions are common and usually appear to be poor after surgical intervention.
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Spontaneous Remission of Acromegaly After Pituitary Apoplexy in a Middle-Aged Male. Ochsner J 2021; 21:194-199. [PMID: 34239382 PMCID: PMC8238097 DOI: 10.31486/toj.20.0002] [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] [Indexed: 11/29/2022] Open
Abstract
Background: Pituitary apoplexy results from hemorrhage, infarction, or hemorrhagic infarction within a pituitary tumor. Subclinical or clinical apoplexy is not uncommon in acromegaly, owing to the large size of the tumor at initial detection. Growth hormone excess in acromegaly often persists following surgery. However, in rare instances, pituitary apoplexy may present a spontaneous cure to growth hormone excess. Case Report: A 40-year-old male presented with holocranial headache for the past 16 years that had worsened in severity during the prior year. Two months before presentation, he experienced a severe headache that he described as the worst headache of his life. The patient had prominent acromegaloid features that he ignored, as they seemed to cause no harm. The patient had no signs of clinically active disease. Magnetic resonance imaging of the brain revealed a pituitary macroadenoma with evidence of hemorrhage. Serum insulin-like growth factor 1 and oral glucose–suppressed serum growth hormone levels were normal, suggestive of inactive or silent disease. Pituitary apoplexy causing spontaneous remission of acromegaly was diagnosed, and close follow-up was planned for the evolution of hypopituitarism. Conclusion: This case highlights a rare presentation of acromegaly in which an episode of symptomatic pituitary apoplexy revealed the diagnosis of pituitary adenoma and led to the cure of growth hormone hypersecretion.
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Comparative analysis of pituitary adenoma with and without apoplexy in pediatric and adolescent patients: a clinical series of 80 patients. Neurosurg Rev 2021; 45:491-498. [PMID: 33914243 DOI: 10.1007/s10143-021-01551-z] [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: 03/09/2021] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
Pituitary adenomas (PAs) have a low incidence in pediatric and adolescent patients, and their clinical characteristics remain unclear. As a severe complication of PA, apoplexy was investigated in young patients in the present study. Eighty patients younger than 20 years with PAs who underwent surgery were included and divided into an apoplexy group and non-apoplexy group. The clinical data of these two groups were statistically analyzed and compared. The study included 33 boys and 47 girls, with a mean age of 16.9 years. There were six (7.5%) adrenocorticotropic hormone-secreting, 13 (16.3%) growth hormone-secreting, 47 (58.7%) prolactin-secreting, and 14 (17.5%) non-functioning PAs. There were 34 (42.5%) patients in the apoplexy group and 46 (57.5%) patients in the non-apoplexy group. Pre-operatively, patients in the apoplexy group were more likely to have visual impairment (hazard ratio: 2.841, 95% confidence interval: 1.073-7.519; P = 0.033) and had poorer visual impairment scores than those in the non-apoplexy group (P = 0.027). Furthermore, a longer duration of symptoms before surgery was significantly correlated with a poorer visual outcome in the apoplexy group (R = - 1.204; P = 0.035). However, apoplexy was not associated with tumor type, tumor size, resection rate, or tumor recurrence. Tumor apoplexy is common in pediatric and adolescent patients with PAs and is associated with more severe preoperative visual deficits. Hence, the appropriate timing of surgical treatment may be important for rescuing visual function in young PA patients.
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8
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Iqbal F, Adams W, Dimitropoulos I, Muquit S, Flanagan D. Pituitary haemorrhage and infarction: the spectrum of disease. Endocr Connect 2021; 10:171-179. [PMID: 33434143 PMCID: PMC7983520 DOI: 10.1530/ec-20-0545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/06/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pituitary apoplexy is an acute syndrome of haemorrhage or infarction into the pituitary. The condition is relatively well-described. Less well-described is sub-acute presentation of the same condition. OBJECTIVE To compare the clinical presentation and natural history of subacute pituitary haemorrhage/infarction with pituitary apoplexy (acute). METHOD Retrospective analysis of a consecutive cohort of 55 patients (33 with pituitary apoplexy, 22 with subacute disease) presenting to University Hospital Plymouth between 1994 and 2019. Comparison of the clinical, endocrinological and radiological features at presentation. Comparison of clinical treatment and subsequent outcomes for the two groups. RESULTS There were no significant differences in predisposing factors for the two groups. Acute headache was more frequent in the acute group. Chronic headache was common in both groups prior to presentation. Low sodium was more common at presentation in the acute group (11/26 vs 2/19 P = 0.02) otherwise there were no differences in endocrine deficit at presentation. A significant proportion showed an improvement in endocrine function at follow up (acute 8/31, subacute 5/21 P = 1.0). MRI characteristics were variable at presentation and follow up in both groups. Ring enhancement with contrast was more frequent in acute (14/20 vs 3/11 P = 0.03). This appearance resolved at follow up in the majority. CONCLUSIONS Pituitary apoplexy has a characteristic and dramatic presentation. Subacute pituitary haemorrhage/infarction shows similar natural history and outcome. These conditions would appear to represent a spectrum of the same condition.
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Affiliation(s)
- Fizzah Iqbal
- Department of Endocrinology, University Hospital Plymouth, Plymouth, UK
| | - William Adams
- Department of Radiology, University Hospital Plymouth, Plymouth, UK
| | | | - Samiul Muquit
- Department of Neurosurgery, University Hospital Plymouth, Plymouth, UK
| | - Daniel Flanagan
- Department of Endocrinology, University Hospital Plymouth, Plymouth, UK
- Correspondence should be addressed to D Flanagan:
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Ghosh R, Roy D, Roy D, Mandal A, Dutta A, Naga D, Benito-León J. A Rare Case of SARS-CoV-2 Infection Associated With Pituitary Apoplexy Without Comorbidities. J Endocr Soc 2021; 5:bvaa203. [PMID: 33501401 PMCID: PMC7798947 DOI: 10.1210/jendso/bvaa203] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Indexed: 12/11/2022] Open
Abstract
Pituitary apoplexy is a medical and surgical emergency caused by hemorrhage or infarction of the hypophysis, which typically occurs within a pituitary adenoma. It is usually characterized by severe (often thunderclap) headache, visual disturbances, cranial nerve impairments, and hormonal deficiencies. We herein report a case of a previously healthy woman with severe acute respiratory syndrome coronavirus 2 infection associated with pituitary apoplexy. The plausible pathophysiological mechanisms of pituitary apoplexy in infectious coronavirus disease 2019 are discussed.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Dipayan Roy
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Devlina Roy
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Arpan Mandal
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Aloke Dutta
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Dinabandhu Naga
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre," Madrid, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
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Huang H, Jiang S, Yang C, Deng K, Wang R, Bao X. Surgical treatment of a 72-year-old patient with headache, hyponatremia and oculomotor nerve palsy: a case report and literature review. Gland Surg 2021; 10:364-370. [PMID: 33633993 DOI: 10.21037/gs-20-517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pituitary apoplexy is a life-threatening syndrome caused by acute infarction of the pituitary gland. The most common symptoms associated with pituitary apoplexy are headache, nausea, vomiting, visual symptoms, hypopituitarism, and altered mental status. Both oculomotor nerve palsy and hyponatremia are relatively rare complications of pituitary apoplexy. The treatment of pituitary apoplexy is controversial. We report a case of a 72-year-old man with severe headache, nausea, vomiting, confusion and left oculomotor nerve palsy, who was initially considered as posterior communicating artery aneurysm (PCOAA) based on the presenting symptoms. Initial biochemical evaluation showed severe hyponatremia, hormonal evaluation identified multiple pituitary hormone deficiency and enhanced magnetic resonance imaging showed a large pituitary adenoma with signs of hemorrhage. A diagnosis of pituitary apoplexy and secondary hypopituitarism was finally made. The patient was treated with intravenous hydrocortisone 100 mg twice daily and oral levothyroxine 100 mg once daily. Appropriate venous transfusion with sodium was also used concomitantly to correct hyponatremia. After seven days of treatment, the patient's serum electrolytes normalized and he gradually recovered alertness. Then, the patient underwent transsphenoidal surgery for tumor removal. Left ptosis and oculomotor nerve palsy completely recovered three months after surgery. Postoperatively, hormone replacement therapy was essential for the patient with 20 mg hydrocortisone and 50 mg levothyroxine once daily. During the last follow up 4 years later, the patient was still on hormonal replacement and in good condition. So, for patients with pituitary apoplexy, we have shown that a semi-elective surgery after conservative treatment when the patient becomes clinically stable and hypopituitarism has been corrected is a good approach.
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Affiliation(s)
- Hanchun Huang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shenzhong Jiang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Chengxian Yang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Marx C, Rabilloud M, Borson Chazot F, Tilikete C, Jouanneau E, Raverot G. A key role for conservative treatment in the management of pituitary apoplexy. Endocrine 2021; 71:168-177. [PMID: 32959228 DOI: 10.1007/s12020-020-02499-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The management of pituitary apoplexy, a rare emergency neuroendocrine condition, is controversial. The aim of the present study is to compare the outcomes of patients with pituitary apoplexy managed either by a conservative or surgical approach. METHODS A retrospective cohort study including patients diagnosed between 2007 and 2018 in a tertiary French university hospital. Pituitary Apoplexy Score (PAS) was retrospectively applied in the perspective of therapeutic decision support. RESULTS Forty-six patients were treated for pituitary apoplexy either with conservative management (n = 27) or surgery (n = 19). At initial evaluation, visual field defects (VFD) and visual acuity impairment were more frequent in patients from the surgery group. At 1 year there were no statistical differences in the rates of complete/near-complete resolution of VFD (100 vs. 91.7%), visual acuity impairment (100 vs. 87.5%), and cranial nerve palsies (83.3 vs. 100%), between conservative and surgical treatment groups. There were more endocrine deficits at 1 year in the surgical group (p = 0.029). PAS (n = 41) was 3.4 on average in the early surgery group and 1.3 in the conservative treatment/delayed surgery group. Among patients with a score < 4, 31.3% were operated at first line and did not present better outcomes than patients managed conservatively. In all, 88.9% of patients with a score ≥ 4 underwent surgery. CONCLUSIONS PAS may be a reliable parameter for defining therapeutic strategy. Patients with non-severe and nonprogressive neuro-ophthalmological deficits can be managed conservatively without negative impact on outcomes, thus surgery should be reserved only for those patients with a PAS ≥ 4.
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Affiliation(s)
- Claire Marx
- Hospices Civils de Lyon, Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO, 59 Pinel Boulevard, 69677, Bron, France.
- Lyon I University, F-69373, Lyon, France.
| | - Muriel Rabilloud
- Lyon I University, F-69373, Lyon, France
- I.f.c.s Hospices Civils de Lyon, 162 avenue Lacassagne, 75003, Lyon, France
| | - Françoise Borson Chazot
- Hospices Civils de Lyon, Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO, 59 Pinel Boulevard, 69677, Bron, France
- Lyon I University, F-69373, Lyon, France
| | - Caroline Tilikete
- Lyon I University, F-69373, Lyon, France
- "Groupement Hospitalier Est" Hospices Civils de Lyon, Neuro-ophthalmology and Neuro-cognitive Unit, 69677, Bron, France
- CRNL INSERM U1028 CNRS UMR5292, ImpAct Team, F-69676, Bron, France
| | - Emmanuel Jouanneau
- Lyon I University, F-69373, Lyon, France
- Neurosurgery Department, "Groupement Hospitalier Est" Hospices Civils de Lyon, 69677, Bron, France
- INSERM U1052, CNRS, UMR5286, Cancer Research Center of Lyon, 69372, Lyon, France
| | - Gerald Raverot
- Hospices Civils de Lyon, Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO, 59 Pinel Boulevard, 69677, Bron, France
- Lyon I University, F-69373, Lyon, France
- INSERM U1052, CNRS, UMR5286, Cancer Research Center of Lyon, 69372, Lyon, France
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AlMalki MH, Ahmad MM, Brema I, AlDahmani KM, Pervez N, Al-Dandan S, AlObaid A, Beshyah SA. Contemporary Management of Clinically Non-functioning Pituitary Adenomas: A Clinical Review. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2020; 13:1179551420932921. [PMID: 32636692 PMCID: PMC7318824 DOI: 10.1177/1179551420932921] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Mussa H AlMalki
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia.,Faculty of Medicine, King Saud Bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Imad Brema
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khaled M AlDahmani
- Department of Endocrinology, Tawam Hospital in Affiliation with Johns Hopkins Medicine, Al Ain, United Arab Emirates.,College of Medicine and Health Sciences (CMHS), UAE University, Al Ain, United Arab Emirates
| | - Nadeem Pervez
- Department of Radiation Oncology, Tawam Hospital in affiliation with Johns Hopkins Medicine, Al Ain, United Arab Emirates
| | - Sadeq Al-Dandan
- Department of Histopathology, Maternity and Children Hospital, Al-Hasa, Saudi Arabia
| | - Abdullah AlObaid
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates.,Department of Endocrinology, Mediclinic Airport, Abu Dhabi, United Arab Emirates
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Fan Y, Bao X, Wang R. Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature. Clin Interv Aging 2018; 13:1981-1985. [PMID: 30349217 PMCID: PMC6188166 DOI: 10.2147/cia.s181109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA. Case description We describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient’s poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family’s wishes, we continued the conservative treatment and watched closely for any changes in the patient’s condition. After 6 months of conservative treatment, the patient’s symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient’s hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone. Conclusion In older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients’ condition closely and continue conservative treatment, which may yield good results.
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Affiliation(s)
- Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, ;
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Abbara A, Clarke S, Eng PC, Milburn J, Joshi D, Comninos AN, Ramli R, Mehta A, Jones B, Wernig F, Nair R, Mendoza N, Sam AH, Hatfield E, Meeran K, Dhillo WS, Martin NM. Clinical and biochemical characteristics of patients presenting with pituitary apoplexy. Endocr Connect 2018; 7:EC-18-0255. [PMID: 30139818 PMCID: PMC6198188 DOI: 10.1530/ec-18-0255] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/16/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE To review the clinical and biochemical characteristics and clinical outcome of patients presenting with pituitary apoplexy to a tertiary centre. METHODS We retrospectively reviewed the clinical features, predisposing factors, biochemistry and clinical outcome of patients presenting with pituitary apoplexy to Imperial College Healthcare NHS Trust between 1991 to 2015. RESULTS We identified 64 patients with pituitary apoplexy (more complete clinical records were available in 52 patients). The median age at presentation was 46.7 years (IQR 31.5-57.0 years). Pituitary apoplexy was the first presentation of pituitary disease in 38/52 of patients and predisposing factors were identified in 28/52. Pituitary apoplexy predominantly occurred in patients with non-functioning pituitary adenomas (47/52). Headache was most commonly described as sudden-onset, severe, lateralising to the frontal or temporal regions. Symptoms of meningeal irritation were reported in 7/18 and visual abnormalities in 22/35. A pre-treatment serum cortisol <100nmol/l was recorded in 12/31 of patients. All patients with visual disturbance had some resolution of their visual symptoms whether managed surgically (14/14) or conservatively (5/5), although pituitary endocrine function did not fully recover in any patient. CONCLUSIONS In conclusion, these data describe the clinical features of pituitary apoplexy to aid the clinician in diagnosing this rare emergency presentation of pituitary disease. Prospective multicentre studies of the presentation of pituitary apoplexy are required to further characterise presentation and outcomes.
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Affiliation(s)
- Ali Abbara
- A Abbara, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Sophie Clarke
- S Clarke, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Pei Chia Eng
- P Eng, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - James Milburn
- J Milburn, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Devavrata Joshi
- D Joshi, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Alexander N Comninos
- A Comninos, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Rozana Ramli
- R Ramli, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Amrish Mehta
- A Mehta, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Brynmor Jones
- B Jones, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Florian Wernig
- F Wernig, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Ramesh Nair
- R Nair, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Nigel Mendoza
- N Mendoza, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Amir H Sam
- S Amir, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Emma Hatfield
- E Hatfield, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Karim Meeran
- K Meeran, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Waljit Singh Dhillo
- W Dhillo, Department of Investigative Medicine, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Niamh M Martin
- N Martin, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
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15
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Kasl RA, Kistka HM, Turner JH, Devin JK, Chambless LB. Pituitary Apoplexy After Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitor: A Novel Complication. J Neurol Surg Rep 2015; 76:e205-10. [PMID: 26623228 PMCID: PMC4648717 DOI: 10.1055/s-0035-1554909] [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: 09/05/2014] [Accepted: 04/09/2015] [Indexed: 10/26/2022] Open
Abstract
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.
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Affiliation(s)
- Rebecca A Kasl
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Heather M Kistka
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Jessica K Devin
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Division of Neurological Surgery, Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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