Pituitary apoplexy of a giant prolactinoma during pregnancy

AIMS AND METHODS

Prolactinomas are a common cause of sexual dysfunction and infertility. We aimed, through this case report, to illustrate the difficulties of management of women with giant prolactinoma, especially in cases of desire of pregnancy.

RESULTS

A 30-year-old woman was referred to our department for secondary amenorrhea. Investigations showed a prolactin level of 5168 ng/mL and giant pituitary adenoma of 4 cm in diameter. Cytoreductive surgery was performed after failure to normalize prolactin levels during three years with medical treatment by cabergoline. After seven months, menstrual cycles have resumed, and after 13 months, the patient became pregnant. At 22nd week of gestation, she was admitted in our hospital for pituitary apoplexy. Medical treatment with bromocriptine was chosen. The vaginal premature delivery at 28 weeks gave birth to twins weighing 1 Kg each who died on the 7th day of life.

CONCLUSION

This is a relevant clinical case that illustrates the efficacy of cytoreductive surgery in case of insufficient response to dopamine agonists to restore gonadal function. The possibility of a pregnancy should be considered in these patients since it can be associated with high maternal and fetal risks.

Pituitary apoplexy masquerading as functional decline in an older person

We report the case of an older lady who was admitted to a tertiary teaching hospital with sub-acute functional decline of two months' duration, which was initially attributed to a concomitant urinary tract infection. Further investigations, however, revealed the diagnosis of pituitary apoplexy with central hypocortisolism. Subsequent treatment with physiological doses of steroids improved patient's function and overall well-being. This report adds to the sparse literature on pituitary apoplexy in the older adults and emphasizes the non-specific presentation of this clinical syndrome.

[PITUITARY ADENOMA APOPLEXY]

We present 3 cases of pituitary adenoma apoplexy in young women (one microadenoma and two macroadenomas). The possible risk factors, clinical presentation and outcome of pituitary apoplexy are discussed. Diagnostic errors as regards pituitary adenoma apoplexy are analyzed.

Management of endocrine disease: pituitary tumour apoplexy

Pituitary tumour apoplexy (PA) is a rare clinical syndrome that occurs as a result of acute haemorrhage and/or infarction within a frequently undiagnosed pituitary tumour. The sudden enlargement of the pituitary mass undergoing PA is responsible for a wide range of acute symptoms/signs (severe headache, visual loss, diplopia, hypopituitarism, impaired consciousness) which, together with the radiological evidence of a pituitary lesion, establish the diagnosis. The optimal care of PA requires involvement of a multidisciplinary team including endocrinologist, neurosurgeon, neuroophthalmologist and the management strategy that depends on the clinical manifestations, as well as the presence of co-morbidities. Prompt surgical decompression is initially indicated in cases with severe or progressive impairment of the visual acuity or the visual fields or with altered mental state and leads to visual and neurological recovery in most of the patients. The patients with mild, stable clinical picture (including those with isolated ocular palsies) can be managed conservatively (support of fluid and electrolyte balance and stress doses of steroids in most cases) with favourable visual and neurological outcome. Frequent reassessment is mandatory because the clinical course can be unpredictable; if progression of symptoms occurs, later elective surgery is indicated and is beneficial, especially in terms of visual outcome. The endocrinological outcome is less favourable, irrespective of the treatment option, with many patients remaining on long-term replacement therapy. Despite the above guidelines, clear proof of optimal outcomes in the form of randomised controlled trials is lacking. Regrowth of the pituitary tumour years after a PA episode is possible and patients require long-term surveillance.

Cavernous sinus invasion might be a risk factor for apoplexy

The clinical features of pituitary hemorrhage vary from asymptomatic to catastrophic. We aimed to evaluate the frequency, symptoms, outcome and risk factors of clinical and subclinical pituitary apoplexy (PA) patients. In a retrospective analysis, charts of 547 pituitary adenoma patients from 2000 to December 2011 were reviewed. The patients were classified as clinical or subclinical PA. We compared the results with a control group without PA. Anterior pituitary hormones for endocrine dysfunction, histology, Ki-67 labeling index (LI), and p53 positivity of the tumor and pituitary imaging by magnetic resonance imaging were evaluated. Thirty-two patients (5.8%) were diagnosed as clinical and 81 patients (14.8%) as subclinical PA. Among PA patients, 85 patients (75.2%) had a macroadenoma, 8 patients (7.1%) had a microadenoma. The most frequent symptoms at presentation in PA patients were visual loss and headache. The patients with macroadenoma had a significantly increased risk for PA (p < 0.05). Hormone inactive tumors were significantly associated with the development of clinical PA (p = 0.05). Dopamine agonist use was significantly higher in subclinical PA patients (p = 0.001). Sex, Ki-67 LI, p53 positivity, diabetes mellitus, hypertension, somatostatin analogue and anticoagulant use did not predispose to PA whereas cavernous sinus invasion predisposed patients to PA (p < 0.01). The incidence of subclinical PA is higher than that of clinical PA. The development of PA is associated with macroadenomas. Clinically non-functioning tumors predispose to clinical PA. Cavernous sinus invasion of the tumor may be a sign of increased risk of bleeding.

Headache and pituitary disease: a systematic review

Headache is very common in pituitary disease and is reported to be present in more than a third of all patients with pituitary adenomas. Tumour size, cavernous sinus invasion, traction or displacement of intracranial pain-sensitive structures such as blood vessels, cranial nerves and dura mater, and hormonal hypersecretion are implicated causes. The present review attempts to systematically review the literature for any combination of headache and pituitary or hormone overproduction or deficiency. Most data available are retrospective and/or not based on the International Headache Society (IHS) classification. Whereas in pituitary apoplexy a mechanical component explains the almost universal association of the condition with headaches, this correlation is less clear in other forms of pituitary disease and a positive impact of surgery on headaches is not guaranteed. Similarly, invasion into the cavernous sinus or local inflammatory changes have been linked to headaches without convincing evidence. Some studies suggest that oversecretion of GH and prolactin may be important for the development of headaches, and treatment, particularly with somatostatin analogues, has been shown to improve symptoms in these patients. Otherwise, treatment rests on general treatment options for headaches based on an accurate clinical history and a precise classification which includes assessment of the patient's psychosocial risk factors.

Pituitary apoplexy due to thyroxine therapy in a patient with congenital hypothyroidism

A 24-year-old woman was admitted with general weakness, umbilical swelling, developmental delay, speech disorder, constipation, gait problem. Her findings were umbilical hernia, xerosis, dry hair, and short stature. After thyroxine treatment, she also had headache, vomiting, and palpitation, lack of appetite, and sleep disturbance. Pituitary magnetic resonance imaging revealed a heterogeneous mass at the central part of the gland on coronal section and it was interpreted as pituitary apoplexy. In the current case, the patient with congenital hypothyroidism (CH) developed pituitary apoplexy (PA) after thyroxine therapy. Therefore, it is suggested that the complaints were related to PA rather than adrenal insufficiency. Here we describe a case report evaluating PA in a patient with thyrotrophic pituitary adenoma due to CH. To the best of our knowledge, this is the first case in terms of PA associated with CH after thyroxine therapy in the literature.

Pituitary apoplexy in non-functioning pituitary adenomas: long term follow up is important because of significant numbers of tumour recurrences

OBJECTIVES

The frequency of pituitary tumour regrowth after an episode of classical pituitary apoplexy is unknown. It is thus unclear whether regrowth, if it occurs, does so less frequently than with non-apoplectic non-functioning pituitary macroadenomas that have undergone surgery without postoperative irradiation. This has important repercussions on follow up protocols for these patients.

DESIGN

Retrospective cohort study of patients diagnosed with classical pituitary apoplexy in Oxford in the last 24 years.

MEASUREMENTS

MRI/CT scans of the pituitary were performed post-operatively and in those patients who did not receive pituitary irradiation, this was repeated yearly for 5 years and 2 yearly thereafter.

RESULTS

Thirty-two patients with non-functioning pituitary adenomas who presented with classical pituitary apoplexy were studied. There were 23 men and the mean age was 56·6 years (range 29-85). The mean follow up period was 81 months (range 6-248). Five patients received adjuvant radiotherapy within 6 months of surgery and were excluded from further analysis. In this group, there were no recurrences during a mean follow up of 83 months (range 20-150). In the remaining 27 cases there were 3 recurrences, with a mean of 79 months follow up (range 6-248) occurring 12, 51 and 86 months after surgery. This gives a recurrence rate of 11·1% at a mean follow up of 6·6 years post surgery. All recurrences had residual tumour on the post operative scan.

CONCLUSIONS

Patients with classical pituitary apoplexy may show recurrent pituitary tumour growth and therefore these patients need continued post-operative surveillance if they have not had post-operative radiotherapy.

[Pituitary apoplexy. A review]

Pituitary apoplexy constitutes a syndrome that is characterized by the ischemic infarction or hemorrhage into a pituitary tumour. Clinically the patient develops sudden headache, meningismus, visual disturbances, even blindness, and occasionally decrease in level of consciousness. To diagnose it is basic to perform a cerebral MRI. Treatment consists in urgent sellar decompression by transsphenoidal surgery and substitute therapy with steroids.

[Pituitary adenoma apoplexy after spinal anaesthesia. Report of two cases and review of the literature]

Two cases of pituitary apoplexy occurring after spinal anaesthesia are described. Both presented with headache and III par palsy, one of them with additional visual disturbance and hyponatremia. A bibliographical review has been done, looking for early diagnostic keys. We propose the arterial hypotension as a possible pathogenetic mechanism of pituitary adenoma apoplexy.

Pituitary apoplexy: a neurological emergency case report

Pituitary Apoplexy (PA) is associated with the sudden onset of headache, visual symptoms, altered mental status, and hormonal dysfunction due to acute hemorrhage or infarction of the pituitary gland. PA is one of the most serious life threatening complications of pituitary adenoma. We report a 48-year-old male who woke lip with the worst headache of his life and was found to have an infarction of a pituitary macroadenoma. Rapid recognition, prompt management, and neurosurgical referral was lifesaving in this patient.

Pituitary Apoplexy and CABG: Should We Change Our Strategy?

Patients with pituitary adenoma that had coronary artery bypass grafting with cardiopulmonary bypass had pituitary apoplexy develop with neurologic deficits and even death. Four patients with pituitary adenoma underwent coronary artery bypass grafting operations (3 patients had coronary artery bypass grafting on bypass, 1 of them with known pituitary adenoma. All of them had pituitary apoplexy develop with neurologic deficits). One patient with known pituitary adenoma who had a coronary artery bypass grafting operation off pump was neurologically intact. Our recommendation is to consider operating on patients with pituitary adenoma who need coronary artery bypass grafting operation off pump, and to prevent pituitary apoplexy that cardiopulmonary bypass may cause.

An interesting case of a pituitary adenoma apoplexy mimicking an acute meningitis. Case report

Apoplexy of a pituitary adenoma is a rare and under-diagnosed clinical occurrence. It results from either infarction or haemorrhage into an adenoma of the pituitary gland. Its clinical presentation more often includes rapid development of impaired consciousness, severe headache, visual disturbance and variable association of oculomotor nerve palsy. Meningeal irritation signs are considered very rare and usually not reported as presenting symptoms. A 33-year-old male suffered a pituitary macroadenoma apoplexy, clinically indistinguishable from an infectious meningitis at presentation. Three days after surgery, the patient developed a left ophthalmoplegia due to 3(rd) nerve palsy, which fully resolved within 2 months. A right pterional craniotomy was performed during which complete tumour removal was achieved. In conclusion the authors believe that, despite many reports in the literature, encouraging conservative management in pituitary apoplexy by administering intravenous steroids, surgery should be undertaken in order to avoid eventual visual field defects, relieve pituitary gland compression and prevent a possible recurrent apoplectic episode or tumor re-growth.

Pituitary apoplexy associated with anterior communicating artery aneurysm and aberrant blood supply

Pituitary apoplexy is an uncommon condition typically caused by acute, hemorrhagic expansion of the pituitary gland in patients with an adenoma that undergoes infarction. Although various risk factors have been described, the vascular events leading to apoplexy are not well understood. Disruption of microvascular blood flow is a well-known cause of morbidity from hemorrhage of an intracranial aneurysm, but pituitary apoplexy is rarely associated with aneurysmal subarachnoid hemorrhage. We report here a 46-year-old woman with pituitary apoplexy who developed subarachnoid hemorrhage from rupture of an anterior communicating artery aneurysm. Intraoperatively, she was found to have an unusual, large recurrent artery originating at the junction of the aneurysm and the A2 segment of the anterior cerebral artery that traveled to the suprasellar cistern and along the pituitary stalk. This recurrent hypophyseal artery established a direct vascular relationship between an intracerebral aneurysm and the pituitary gland.

Frequent occurrence of pituitary apoplexy in patients with non-functioning pituitary adenoma

BACKGROUND AND OBJECTIVE

There is agreement in the literature that pituitary apoplexy is a rare disorder. As our experience differs from this view, we analysed the incidence in patients operated on for a nonfunctioning pituitary adenoma.

PATIENTS AND DESIGN

One hundred ninety-two consecutive patients with a suprasellar, clinically inactive adenoma operated on during the period 1985-1996 were retrospectively reviewed. A diagnosis of pituitary apoplexy was made from relevant neurological symptoms together with pertinent findings at operation.

RESULTS

Pituitary apoplexy occurred in 41 patients (21%), in 23 patients within 12 days prior to the operation. The male/female ratio was 1.9. Median follow-up time was 13.7 years (range 8.9-19.9). During this period, 12 patients had died, yielding a standard mortality ratio of 1.09 (95% CI 0.62-1.92), similar to that in the patients who had not sustained pituitary apoplexy. Postoperatively, 24% of the patients had normal pituitary function, 38% were panhypopituitary and partial pituitary insufficiency was present in 38%. Subnormal GH secretion was present in virtually all patients tested. Two patients died within 60 days of surgery and in two no or incomplete data were available, although they most likely were panhypopituitary.

CONCLUSION

Most of our findings add little to what is known about pituitary apoplexy. On one point, however, they are contrary to previously presented data. We found a much higher incidence of pituitary apoplexy despite rather rigorous criteria for the diagnosis. The outcome as regards survival and endocrine function was not different from that in patients with a nonfunctioning adenoma who did not suffer pituitary apoplexy.

Pituitary apoplexy after aortic abdominal aneurysm surgery: a case report

Pituitary apoplexy (PA) occurring after surgery is a rare but life-threatening acute clinical situation following extensive haemorrhage or necrosis within a pituitary adenoma. Pituitary apoplexy has been reported to occur spontaneously in the majority of cases or in association with various inducing factors. One of the pathophysiological mechanism that has been postulated is the fall of arterial blood pressure inducing ischaemia followed by infarction of the pituitary gland. We report a case of pituitary apoplexy following aortic abdominal surgery. To our knowledge, this has not been previously reported. A 73-year old man complained of headache and diplopia. At clinical examination, he presented a right oculomotor nerve palsy. Magnetic resonance imaging (MRI) showed a haemorrhagic sellar mass. In our case, intraoperative hypotension could have been the precipitating factor. Diagnostic and therapeutic measures are discussed.

Intraventricular haemorrhage from a renal cell carcinoma pituitary metastasis

Symptomatic pituitary metastasis and intraventricular haemorrhage from a cerebral metastasis are exceptional events in the natural history of a renal cell carcinoma. We report the first case of a metastatic renal cell carcinoma to the pituitary gland presenting with intraventricular haemorrhage. The origin of intraventricular haemorrhage and its association with renal cell carcinoma pituitary metastasis are discussed.

Apoplexie hypophysaire

Pituitary apoplexy is a life threatening condition caused by sudden hemorrhage or infarction of the pituitary gland. Most patients present with headaches and neuro-ophthalmologic symptoms and signs, often associated with altered mental status.

Visual outcome of blind eyes in pituitary apoplexy after transsphenoidal surgery: a series of 14 eyes

BACKGROUND

To study the visual outcome of patients who became blind after an episode of pituitary apoplexy and who subsequently underwent emergency transsphenoidal decompression of the optic apparatus, and to identify factors that may have a bearing on the visual outcome in such patients.

METHODS

Twenty-three patients underwent transsphenoidal surgery for pituitary apoplexy over a 5-year period at the All India Institute of Medical Sciences. Among them, 8 (35%) presented with visual deterioration to monocular (n = 2) or binocular (n = 6) blindness after the apoplectic episode. There were 7 males and 1 female with the average age of patients being 43 years. The mean delay between the apoplexy and neurosurgical consultation was 10 days, with a range of 4 to 30 days. The adenoma was classified as "giant" in 4 and multicompartmental in 2 patients. After surgery, all patients had a minimum follow-up of 3 months.

RESULTS

Four patients (50%) had improvement in vision to greater than 2/60 (Snellen's), including 2 patients whose vision improved to 6/6. All patients in whom there was improvement in vision had been operated on within a week of the apoplectic episode.

CONCLUSIONS

This study shows that even completely blind eyes may have remarkable improvement in vision if surgical decompression of the optic apparatus is undertaken early. Awareness regarding pituitary apoplexy and reversibility of vision loss needs to be increased among the medical community, especially ophthalmologists and physicians, so that timely neurosurgical intervention can occur.

Rare fatal vascular complication of transsphenoidal surgery

We report the case of a 61-year-old man, who underwent transsphenoidal surgery for a pituitary macroadenoma. The presence of tough fibrous septa dividing the tumour permitted only a partial resection. Progressive loss of consciousness soon after surgery occurred, an emergency CT scan showed no evidence of haemorrhage. Twenty hours later, MRI revealed compression of both internal carotid arteries with arrest of arterial flow resulting in stroke by an enlarged haemorrhagic mass consistent with a pituitary apoplexy. On the second postoperative day, the patient died as a result of this extensive stroke. The mechanisms of this rare complication after transsphenoidal surgery are theorized and the sensitivity of imaging methods is discussed.

Vanishing pituitary mass revealed by timely magnetic resonance imaging: examples of spontaneous resolution of nonfunctioning pituitary adenoma

Spontaneous necrosis of a pituitary adenoma is not rare but represents a very unlikely way of curing a nonfunctioning pituitary adenoma. We report two cases of nonfunctioning pituitary adenoma, one of them with a family history of pituitary adenoma, in whom spontaneous complete resolution occurred through the necrosis of previously well-delineated adenoma. Sequential magnetic resonance imaging (MRI) scans provided clear evidence of the event, resulting in an empty sella. In the present cases, the pituitary necrosis was entirely asymptomatic with the exception of an initial atypical headache in one case, and cured the patients as well as a surgical procedure would have done. This exceptional curative process, however, should certainly not be relied on and does not rule out the possibility of recurrence.

Spontaneous remission of functioning pituitary adenomas without hypopituitarism following infarctive apoplexy: two case reports

Functioning pituitary adenomas may exhibit spontaneous remission after pituitary apoplexy usually in association with hypopituitarism. We report two patients who presented with sudden headache and double vision, showed a ring-enhanced sellar tumor on MRI, underwent transsphenoidal surgery that revealed a coagulation necrotic adenoma without massive hemorrhage, and showed normal pituitary function after the surgery. Definitive diagnoses were made based on immunohistochemistry of the necrotic cells. The findings were consistent with the presence of selective infarct of a GH adenoma and a prolactinoma that had led to remission of acromegaly and menstrual disturbance, respectively, without pituitary insufficiency. In contrast to hemorrhagic apoplexy, infarctive apoplexy tends to affect only the tumor and thus presents with mild symptoms and lack pituitary deficiencies.

Management of pituitary apoplexy: clinical experience with 40 patients

BACKGROUND

Pituitary apoplexy is a rare major clinical event with neurological, neuro-ophthalmological, cardiovascular and hormonal consequences, resulting from an acute infarction of pituitary adenoma. We report our experience with a series of 40 patients presenting with pituitary apoplexy.

PATIENTS

Forty patients (27 males, 13 females; mean age, 51.2 yr) were admitted to our medical center between years 1985-2002 with acute presentation of pituitary apoplexy. Visual field defects occurred in 61% and ocular paresis in 40% of subjects. Sixty-three percent of adenomas were nonfunctional, and prolactinomas comprised 31%.

RESULTS

Thirty-four patients underwent transsphenoidal pituitary decompression. Visual fields and ophthalmoplegia improved in 81% and 71%, respectively. During follow-up (4.5+/-5.4 yr), 79% of patients developed hypogonadotrophic hypogonadism, central hypothyroidism appeared in 54% and hypocortisolism--in 40% of patients. Permanent diabetes insipidus was diagnosed in 8%. Serial sellar MRI showed disappearance of pituitary tumor in 63% of operated subjects. Six patients (3 with PRL-secreting and 3 nonfunctional adenomas) were treated medically (corticosteroids, dopamine agonists), two patients (out of three) with visual deficits improved, and tumor shrinkage was noted in four.

CONCLUSIONS

We present a large series of patients with pituitary apoplexy. Most subjects were operated, but six were treated conservatively. Almost all patients improved clinically, including those who were not operated, but hormonal deficiencies are very common.

Extreme elevation of intrasellar pressure in patients with pituitary tumor apoplexy: relation to pituitary function

The dominant mechanism for hypopituitarism and hyperprolactinemia commonly observed in patients with pituitary macroadenomas was postulated to be increased intrasellar pressure (ISP) caused by the slow and gradual expansion of adenomas within the sella turcica. Hemorrhagic infarction of adenomas (pituitary tumor apoplexy) is associated with a rapid, rather than gradual, increase in intrasellar contents. The impacts of the sudden increase in intrasellar contents on ISP and pituitary function are unknown. ISP and pituitary function were determined in 13 patients with pituitary tumor apoplexy who had surgical decompression within 1 wk of symptoms' onset. ISP measurements were remarkably high (median, 47 mm Hg), whereas serum prolactin (PRL) concentrations were generally low (median, 3.5 microg/liter). There was an inverse correlation (r = -0.76; P < 0.01) between ISP measurements and serum PRL concentrations. Postoperatively, partial recovery or maintenance of pituitary function was noted in seven of 13 patients. These seven patients had higher (P = 0.013) serum PRL levels (9.3 +/- 7.4 microg/liter) and lower (P < 0.001) ISP measurements (35.9 +/- 7.3 mm Hg) than the respective values in the remaining six with persistent postoperative hypopituitarism (1.6 +/- 0.6 microg/liter and 55.9 +/- 2.4 mm Hg, respectively). The low serum PRL levels in patients with tumor apoplexy suggested that ischemic necrosis of the anterior pituitary resulting from sudden and extreme elevation of ISP was commonly observed in this setting. A normal or elevated serum PRL level in patients with non-PRL-secreting macroadenomas indicates the presence of viable pituitary cells and the high likelihood of postoperative recovery of pituitary function.

Pituitary apoplexy masquerading as meningoencephalitis

BACKGROUND

Pituitary apoplexy, a rare but life-threatening disorder, is characterized by the abrupt destruction of pituitary tissue secondary to infarction or hemorrhage of the gland itself. Its clinical features include severe headache, stiff neck, fever, visual disturbances, and symptoms of hypoadrenalism.

OBJECTIVES

To assess how pituitary apoplexy may mimic the clinical findings of an infectious meningoencephalitis.

METHODS AND RESULTS

We describe 3 individuals whose clinical profile and paraclinical studies were consistent with a diagnosis of presumed infectious meningoencephalitis. With minimal improvement on antimicrobial therapy, however, an extensive clinical and radiographic reevaluation yielded pituitary apoplexy as the etiology of their acute neurologic event.

CONCLUSIONS

Pituitary apoplexy is often misdiagnosed as meningitis or subarachnoid hemorrhage due to the presence of leukocytes and erythrocytes in the cerebrospinal fluid. These cases serve to highlight the importance of maintaining a broad differential diagnosis when evaluating patients presenting with an acute headache.

Pituitary apoplexy induced by corticotrophin-releasing hormone in a patient with Cushing's disease

Pituitary apoplexy can occur spontaneously or following anterior pituitary stimulation tests. Apoplexy is a rare complication of Cushing's disease. We report a 19-year-old woman who was admitted to the National Institutes of Health for evaluation of possible Cushing's syndrome. Her symptoms and initial laboratory work were suggestive of Cushing's disease. Magnetic resonance imaging (MRI) revealed a macroadenoma of the pituitary gland. As part of her evaluation she received corticotrophin-releasing hormone (CRH). Two days later she developed severe headache, accompanied by nausea and vomiting, followed by meningismus, ptosis and diplopia. A diagnosis of pituitary apoplexy was made and she was treated conservatively with dexamethasone. Her neurological symptoms resolved shortly afterwards. By the time of discharge her anterior pituitary function was suppressed. All symptoms and signs of Cushing's syndrome resolved thereafter. This is the first case to demonstrate that CRH administration can induce pituitary apoplexy in a patient with Cushing's disease. Therapy with glucocorticoids was effective in our case, suggesting that conservative treatment can be successfully and safely applied in certain cases with pituitary apoplexy.

Abrupt-onset oculomotor paralysis: an endocrine emergency

Pituitary apoplexy is a severe and potentially life-threatening condition that may be highly variable in its clinical presentation. We report a 37-year-old man presenting to the emergency department with diplopia that abruptly developed while he was eating canned and bottled food prepared at home. A computed tomography scanning revealed an isodense mass within the sellar region and, subsequently, a magnetic resonance imaging showed a pituitary apoplexy causing a compression of the right III and VI oculomotor nerves. There was no improvement with hydrocortisone therapy and the patient underwent a transsphenoidal excision of the mass with an uneventful course. Pituitary apoplexy may raise in the appropriate setting the suspicion of botulism. The abrupt-onset paralysis of oculomotor nerves has been described as the chief presenting sign of pituitary apoplexy in only few cases including this. A pathophysiology, differential diagnosis with botulism and other causes of multiple cranial nerve paralysis, and treatment are described.

Spontaneous resolution of pituitary adenoma after apoplexy

A patient with typical pituitary apoplexy with documented intralesional hemorrhage and spontaneous resolution is presented. There was no evidence of a tumor at a 3-month follow-up.

[A case of pituitary apoplexy approving as severe headache and nausea]

The causes of pituitary apoplexy are unclear. We report a case of pituitary apoplexy presenting with headache and nausea. On June 17th, 1997 a 74-year-old woman had complained of retro-orbital headache, fever and vomiting. A cold was diagnosed for which she recurred medication. In addition to the previous symptoms she was getting to lose appetite. She was admitted to our hospital for further examination and treatment on June 21. On admission neurological examination showed left pupil mydriasis, the left eye had no light reflex and the right eye had only a slight response to the light. She could hardly move both eyeballs up. Laboratory data showed a normal white blood cell count and the CRP was 16.2 mg/dl. Lumbar puncture showed 97 mg/dl total protein and 82 cells per microliter, most of which were lymphocytes. We diagnosed viral infection based on the evidence of clinical symptoms and lumbar puncture data. The patient was treated with gamma-globulin and improved. From the 16th day of sickness we recognized symptoms of oculomotor paralysis and the syndrome of inappropriate antidiuretic hormone. On the 23rd day of sickness we strongly suspected pituitary apoplexy based on transaxial MR images. After absorption of intra-tumor hemorrhage, the oculomotor symptoms recurred. We finally reached a diagnosis of pituitary apoplexy based on pathological material, MR images, symptoms and laboratory data. We must think of pituitary apoplexy when we see an aged out-patient with severe headache, nausea, vomiting and oculomotor paralysis. It was difficult to diagnose this disease in the early time course of the disease.

Classical pituitary apoplexy: clinical features, management and outcome

OBJECTIVE

The term classical pituitary apoplexy describes a clinical syndrome characterized by sudden headache, vomiting, visual impairment and meningismus caused by the rapid enlargement of a pituitary adenoma usually due to haemorrhagic infarction of the tumour. Most published reports looking at the clinical features and management of pituitary apoplexy have not differentiated between patients with clinical and subclinical apoplexy, the latter diagnosed at surgery. Furthermore, little is reported on the clinical outcome, in particular visual and endocrinological, and the role of radiotherapy. The purpose of this study was to observe not only the clinical presentation but also the possible predisposing events, investigations, management, clinical outcome as well as the role of radiotherapy in patients presenting with classical pituitary apoplexy.

PATIENTS AND DESIGN

In a retrospective analysis 1985-96, the medical records of 21 male and 14 female patients (mean age 49.8 years, range 30-74) with classical pituitary apoplexy were reviewed. This represents all patients seen with this condition over the stated period.

MEASUREMENTS

In all patients, pre- and post- operative measurements were made of FT4, FT3, TSH, PRL, LH, FSH, cortisol (0900 h), GH, oestradiol (females) and testosterone (males). Pituitary imaging was by computerized tomography (CT) scan, magnetic resonance imaging (MRI) or both.

RESULTS

Patients were followed for up to 11 years (mean 6.3 years: range 0.5-11). Headache (97%) was the commonest presenting symptom, followed by nausea (80%) and a reduction of visual fields (71%). Hypertension, defined as a systolic > 160 mmHg and/or a diastolic > 90 mmHg, was seen in 26% of patients. MRI correctly identified pituitary haemorrhage in 88% (n = 7), but CT scanning identified haemorrhage in only 21% (n = 6). By immunostaining criteria, null-cell adenomas were the most common tumour type (61%). Transsphenoidal surgery resulted in improvement in visual acuity in 86%. Complete restoration of visual acuity occurred in all patients operated on within 8 days but only in 46% of patients operated on after this time (9-34 days). Long-term steroid or thyroid hormone replacement was necessary in 58% and 45% of patients, respectively. Of the male patients, 43% required testosterone replacement, and long-term desmopressin therapy was required in 6%. Only two patients (6%) with tumour recurrence after transsphenoidal surgery for the initial apoplectic event, subsequently required radiotherapy.

CONCLUSIONS

In classical pituitary apoplexy, headache is the commonest presenting symptom and hypertension may be an important predisposing factor. MRI is the imaging method of choice. Transsphenoidal surgery is safe and effective. It is indicated if there are associated abnormalities of visual acuity or visual fields because, when performed within 8 days, it resulted in significantly greater improvement in visual acuity and fields than if surgery was performed after this time. Radiotherapy is not indicated immediately as the risk of tumour recurrence is small, but careful follow-up initially with annual imaging is indicated in this group.

Pituitary apoplexy. Clinical course, endocrine evaluations and treatment analysis

BACKGROUND

The purpose was to analyze clinical manifestations, hormonal changes, diagnosis difficulties and treatment of pituitary apoplexy (PA).

EXPERIMENTAL DESIGN

A retrospective study of clinical records from patients with pituitary adenomas admitted from January 1980 to June 1996; the purpose was to identify the patients with clinical evidence compatible with PA.

SETTING

Neurosurgery unit of an institutional hospital.

PATIENTS

Sixteen (12.8%) of 125 patients with pituitary adenomas were analyzed because they had pituitary apoplexy.

INTERVENTIONS

Surgical treatment by the trans-sphenoidal or transcranial route or both routes; dexamethasone (DXM) treatment with 16 mg/day i.v.

MEASURES

Hormone assays were performed either by radioimmunoassay or by chemical luminescence.

RESULTS

Tumors were nonfunctioning in nine patients and functioning in seven. TSH and prolactin basal serum levels were impaired in 55.5% and 10%, respectively; after exogenous TRH 80% of the patients did not show stimulation of TSH and prolactin secretions. LH and FSH levels were low in 63.6% and 54.6% of the patients, respectively; gonadotrophin-releasing hormone (GnRH) testing was abnormal in 75% of the patients evaluated. Cortisol levels were low in 50% of the patients. After insulin-induced hypoglycemia, cortisol and GH failed to rise in 25% and 40% of cases, respectively. Ten patients were submitted to surgical treatment, but none during PA. The average time from the onset of apoplectic symptoms and surgery was 70+/-50 days. Only one patient died two months after surgery. Five patients were treated with dexamethasone (DXM) during the apoplectic symptoms: three patients died; one patient had good quality of life; the other patient was treated initially with DXM with improvement of vision, but after surgery he developed panhypopituirarism. Two other patients did not receive specific treatment for PA.

CONCLUSIONS

PA is not a rare pituitary adenoma complication and its prognosis may be poor; baseline hormone levels showed a wide range of abnormalities of pituitary function; surgical treatment was required in the majority of patients and the prognosis was relatively good; on the contrary, the treatment with DXM only had high levels of mortality.

[Pituitary apoplexy followed by endocrine remission. Report of two cases]

Pituitary apoplexy is rare and endocrine remission in patients with apopletic secreting pituitary adenomas is even rarer. This study reports on two patients with pituitary macroadenomas (one with Cushing's disease and the other with acromegaly) in whom endocrine remission occurred after apoplexy. The first patient had Cushing's disease and had an ictus of headache and vomiting after which she started a progressive remission of hypercortisolism. A post-apoplexy MRI disclosed persistence of a sellar and supra-sellar mass. She was submitted to transesphenoidal surgery. An hypertensive hemorrhagic cyst was found with no tumor. The second patient had acromegaly. While performing a LHRH-stimulation test he had an ictus of headache, vomiting, no visual loss and appearance of diabetes insipidus. A CT scan disclosed an intrasellar hematoma. Despite the size of the tumor and since there was no visual impairment, this patient was followed up without surgery. Imaging follow-up showed a progressive shrinkage and disappearance of the mass, which was corroborated by endocrine remission. A high rate of recurrence is reported in such patients in the literature. Both patients are being currently followed-up on a long-term basis.

[A case of pituitary apoplexy: remarkable improvement of visual acuity and field by surgical intervention at the subchronic stage]

A case is reported of a pituitary apoplexy which shows remarkable improvement of visual acuity and field by transsphenoidal surgery performed 33 days after hemorrhage. Possible factors contributing to this excellent surgical outcome are speculated about as follows; atrophic brain (wide suprasellar cistern), destruction of the sella floor by the tumor (infrasellar/extracranial decompression), no vasospasm (pure intracapsular hemorrhage), no hypopituitarism, less invasive operation (transsphenoidal surgery), and so on. Transsphenoidal surgery is thought to be worth performing for pituitary apoplexy, even if timing for the operation is later than the acute stage and even if initial visual impairment is severe.

Pituitary apoplexy into nonadenomatous tissue: case report and review

Pituitary apoplexy into nonadenomatous tissue is extremely rare. The authors describe a 20-year-old woman with symptomatic pituitary hemorrhage into an apparently intrasellar malignant teratoma, which caused headache, visual impairment, involvement of III, IV, VI, and 1st division of the V cranial nerves, and hypopituitarism. Diabetes insipidus had developed previously. Magnetic resonance scans had a high-intensity signal in the pituitary on T1- and T2-weighted images, and lack of the signal of the posterior pituitary. Transsphenoidal approach, radiotherapy, and chemotherapy management did not preclude a fatal outcome.

[Pituitary apoplexy after injection of pituitary-hormone releasing hormones]

Pituitary apoplexy often occurs spontaneously in adenomas. A few cases have been reported after testing anterior pituitary function by means of intravenous injections of a mixture of gonadotropin-releasing hormone and thyrotropin-releasing hormone, or gonadotropin-releasing hormone alone. In these cases the development of visual field defects has necessitated surgical intervention, which confirmed pituitary apoplexy. We describe a patient with a pituitary macroadenoma. He developed symptoms and signs of pituitary apoplexy immediately after intravenous injection of a mixture of hypothalamic releasing hormones. His visual fields remained normal, and he recovered spontaneously.

[MRI findings and endocrinological dysfunction in hemorrhagic pituitary adenoma]

Magnetic resonance image (MRI) findings, intraoperative macroscopic findings and endocrinological functions were reported in 13 cases of hemorrhagic pituitary adenoma (HPA) according to clinical severity. The cases were divided into 3 groups: (1) classical pituitary apoplexy (PA) (n = 2), (2) subacute PA (n = 4), (3) asymptomatic HPA (n = 7). Based on MRI intensity and intraoperative findings, there were 7 cases with hemorrhagic PA and 5 with necrotic cyst formation. MRI intensities predicted the cyst contents, either hemorrhagic or xanthochromic, more accurately than CT findings. In addition, two classical cases of the PA group disclosed niveau formation on MRI, but MRI intensity in the first case differed from that in the second case. Classical PA of the first case occurred during the pregnancy. MRI intensity in the case 7 months after the onset disclosed high intensity of the upper part and normointensity of the lower part. T1 weighted image and proton image showed homogeneous intensity. On the contrast, PA of the second case showed water-like intensity on the upper part and methemoglobin-like intensity on the lower part. These different MRI intensities suggest different etiologies of niveau formation. MRI findings in the first case may indicate the chronic stage of massive intratumoral hemorrhage but the mechanism may be the same in both cases. From MRI intensity and clinical course, the cause of niveau formation in the second case is similar to that found in the literature. That is, hemorrhage was thought to have occurred in the pre-existing cyst cavity.(ABSTRACT TRUNCATED AT 250 WORDS)

Pituitary apoplexy

Pituitary apoplexy is a clinical syndrome of headache, visual deficits, ophthalmoplegia, and alteration in mental status resulting from the sudden hemorrhage or infarction of a pituitary adenoma. Infarction of a normal gland also may occur in certain circumstances. Its manifestations are variable, ranging from a clinically benign event to a catastrophic presentation with permanent neurologic deficits or even death. It frequently mimics other intracranial processes and, without a high index of suspicion, may be difficult to diagnose. Radiographic studies, particularly CT and MR imaging, are helpful for diagnosis in both the acute and subacute settings. In its most fulminant presentation, prompt neurosurgical decompression is necessary to preserve sight and life. Corticosteroid replacement is also essential in the acute phase because of the high incidence of adrenal insufficiency. Fortunately, however, with proper management most patients may have good outcomes.

Recovery of vision after transcranial decompression of pituitary apoplexy characterized by third ventricular hemorrhage

The authors present a case of pituitary apoplexy characterized by massive third ventricular hemorrhage. This rare complication, which caused total blindness in the patient, a 67-year-old man, was treated with transcranial decompression of the pituitary tumor and removal of a blood clot from the third ventricle. After surgery, the patient totally recovered his vision. To the best of our knowledge, this is the first case of a patient with pituitary apoplexy that ruptured into the third ventricle (diagnosed by imaging studies) who was treated by emergency transcranial decompression.

Pressure and blood flow in pituitary adenomas measured during transsphenoidal surgery

In 48 patients undergoing transsphenoidal surgery for pituitary adenoma, the intrasellar pressure was recorded during surgery. In 14 patients, adenoma blood flow was measured with the technique of local injection of 133xenon. Median intrasellar pressure was 30 mmHg (range 8-62), n = 48, and median adenoma blood flow was 8 ml/100 g/min (range 0-37), n = 14. In two patients, blood flow in the anterior pituitary gland was measured, and values of 26 and 22 ml/100 g/min were obtained. The finding that intrasellar pressure is above central venous and intracranial pressure suggests the possibility that the adenoma and the anterior pituitary gland are supplied not only with venous blood, but receive an additional arterial supply at a less than normal arterial pressure. In three cases perfusion pressures that caused arrest of adenoma blood flow were found, and these observations are discussed with reference to pituitary apoplexy.