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Iglesias P. Pituitary Apoplexy: An Updated Review. J Clin Med 2024; 13:2508. [PMID: 38731037 PMCID: PMC11084238 DOI: 10.3390/jcm13092508] [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: 04/01/2024] [Revised: 04/21/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland. It is clinically characterized by the sudden onset of headache. Depending on the severity, it may also be accompanied by nausea, vomiting, visual disturbances, varying degrees of adenohypophyseal hormone deficiency, and decreased level of consciousness. Corticotropic axis involvement may result in severe hypotension and contribute to impaired level of consciousness. Precipitating factors are present in up to 30% of cases. PA may occur at any age and sometimes develops during pregnancy or the immediate postpartum period. PA occurs more frequently in men aged 50-60, being rare in children and adolescents. It can develop in healthy pituitary glands or those affected by inflammation, infection, or tumor. The main cause of PA is usually spontaneous hemorrhage or infarction of a pituitary adenoma (pituitary neuroendocrine tumor, PitNET). It is a medical emergency requiring immediate attention and, in many cases, urgent surgical intervention and long-term follow-up. Although the majority of patients (70%) require surgery, about one-third can be treated conservatively, mainly by monitoring fluid and electrolyte levels and using intravenous glucocorticoids. There are scoring systems for PA with implications for management and therapeutic outcomes that can help guide therapeutic decisions. Management of PA requires proper evaluation and long-term follow-up by a multidisciplinary team with expertise in pituitary pathology. The aim of the review is to summarize and update the most relevant aspects of the epidemiology, etiopathogenesis, pathophysiology, clinical presentation and clinical forms, diagnosis, therapeutic strategies, and prognosis of PA.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, 28222 Madrid, Spain
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Ciavarra B, McIntyre T, Kole MJ, Li W, Yao W, Guttenberg KB, Blackburn SL. Antiplatelet and anticoagulation therapy and the risk of pituitary apoplexy in pituitary adenoma patients. Pituitary 2023:10.1007/s11102-023-01316-5. [PMID: 37115294 DOI: 10.1007/s11102-023-01316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Pituitary apoplexy can be a life threatening and vision compromising event. Antiplatelet and anticoagulation use has been reported as a contributing factor in pituitary apoplexy (PA). Utilizing one of the largest cohorts in the literature, this study aims to determine the risk of PA in patients on antiplatelet/anticoagulation (AP/AC) therapy. METHODS A single center, retrospective study was conducted on 342 pituitary adenoma patients, of which 77 patients presented with PA (23%). Several potential risk factors for PA were assessed, including: patient demographics, tumor characteristics, pre-operative hormone replacement, neurologic deficits, coagulation studies, platelet count, and AP/AC therapy. RESULTS Comparing patients with and without apoplexy, there was no significant difference in the proportion of patients taking aspirin (45 no apoplexy vs. 10 apoplexy; p = 0.5), clopidogrel (10 no apoplexy vs. 4 apoplexy; p = 0.5), and anticoagulation (7 no apoplexy vs. 3 apoplexy; p = 0.7). However, male sex (p-value < 0.001) was a predictor for apoplexy while pre-operative hormone treatment was a protective factor from apoplexy (p-value < 0.001). A non-clinical difference in INR was also noted as a predictor for apoplexy (no apoplexy: 1.01 ± 0.09, apoplexy: 1.07 ± 0.15; p < 0.001). CONCLUSIONS Although pituitary tumors have a high risk for spontaneous hemorrhage, the use of aspirin is not a risk for hemorrhage. Our study did not find an increased risk of apoplexy with clopidogrel or anticoagulation, but further investigation is needed with a larger cohort. Confirming other reports, male sex is associated with an increased risk for PA.
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Affiliation(s)
- Bronson Ciavarra
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Timothy McIntyre
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Matthew J Kole
- The Vivian L Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Wen Li
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - William Yao
- Department of Otorhinolaryngology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Katie B Guttenberg
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Spiros L Blackburn
- The Vivian L Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA.
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Liu J, Huang P, Zhang X, Chen Y, Zheng X, Shen R, Tang X, Yang H, Li S. Differences in Clinical Characteristics and Surgical Outcomes of Patients with Ischemic and Hemorrhagic Pituitary Adenomas. J Korean Neurosurg Soc 2023; 66:72-81. [PMID: 36625014 PMCID: PMC9837490 DOI: 10.3340/jkns.2022.0071] [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: 04/06/2022] [Accepted: 07/19/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Ischemia and hemorrhage of pituitary adenomas (PA) caused important clinical syndrome. However, the differences on clinical characteristics and surgical outcomes between these two kinds apoplexy were less reported. METHODS A retrospective analysis was made of patients with pituitary apoplexy between January 2013 and June 2018. Baseline and clinical characteristics before surgery were reviewed. All patients underwent transsphenoidal surgery and were followed up at least 1 year. RESULTS Total 67 cases (5.8%) among 1147 pituitary tumor patients were enrolled, which consisted of 28 (~2.4%) ischemic PA and 39 (~3.4%) hemorrhagic PA. There were more male patients in the ischemic group compared with hemorrhagic group (78.6% vs 53.8%, p=0.043). However, the mean age, tumor size and functional tumor ratio were significant higher in the hemorrhagic group. Headache was more common in ischemic PA (82.1%) than that of hemorrhagic PA (51.3%, p=0.011). Magnetic resonance imaging findings found that mucosal thickening and enhancement of the sphenoid sinus was observed in 15 ischemic PA patients (n=27, 55.6%), but none in patients with hemorrhagic PA (n=38, p<0.0001). It was worth noting that the rate of pre-surgical hypopituitarism in ischemic PA patients were seemed higher than that in hemorrhagic PA patients, but not significant. The two groups got a total tumor resection rate at 94.1% and 92.9%, independently. No significant difference on the operative time, blood loss in operation and complications in perioperative period was observed in two groups. After operation, cranial nerve symptoms recovered to normal at 81.8% of ischemic PA patients and 82.6% of hemorrhagic PA patients. Importantly, the incidence of postoperative hypopituitarism partially decreased in both groups, among which the rate of hypothyroidism in ischemic PA patients significantly decreased from 46.4% to 18.5% (p=0.044). CONCLUSION Patients with ischemic PA presented different clinical characteristics to the hemorrhagic ones. Transsphenoidal surgery should be considered for the patients with neuro-ophthalmic deficits and might benefit for pituitary function recovery of the apoplectic adenoma patients, especially pituitary thyroid axis in ischemic PA patients.
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Affiliation(s)
- Jingpeng Liu
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Peng Huang
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Xiaoqing Zhang
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Yong Chen
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Xin Zheng
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China
| | - Rufei Shen
- Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Department of Endocrinology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xuefeng Tang
- Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Department of Pathology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hui Yang
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Address for correspondence : Hui Yang Department of Neurosurgery, Xinqiao Hospital, Army Medical University, 183th Xinqiao Main Street, Shapingba District, Chongqing 400037, China Tel : +86-02368763513, Fax : +86-02368763513, E-mail :
| | - Song Li
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China,Multidisciplinary Center for Pituitary Adenomas of Chongqing, Chongqing, China,Address for correspondence : Hui Yang Department of Neurosurgery, Xinqiao Hospital, Army Medical University, 183th Xinqiao Main Street, Shapingba District, Chongqing 400037, China Tel : +86-02368763513, Fax : +86-02368763513, E-mail :
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Sun, MD Z, Cai, MD X, Li, MD Y, Shao, MD D, Jiang, PhD Z. Endoscopic Endonasal Transsphenoidal Approach for the Surgical Treatment of Pituitary Apoplexy and Clinical Outcomes. Technol Cancer Res Treat 2021; 20:15330338211043032. [PMID: 34486456 PMCID: PMC8422825 DOI: 10.1177/15330338211043032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: This study investigated the clinical manifestations, surgical method, and treatment outcomes of patients with pituitary apoplexy and evaluated the safety and effectiveness of the endoscopic endonasal transsphenoidal approach in the treatment of pituitary adenomas. Patients and methods: In this retrospective study, were analyzed the data of patients with symptomatic pituitary apoplexy who received surgical treatment by endoscopic endonasal transsphenoidal approach from January 2017 to June 2020 at the Department of Neurosurgery of the First Affiliated Hospital of Bengbu Medical College. Patients were followed up through outpatient visits and telephone interviews. Results: Data for 24 patients including 13 males and 11 females with an average age of 46.46 years were analyzed. Headache (83.33%) and visual disturbances (75.00%) were the most common preoperative manifestations. In the 24 patients, 21 (87.50%) tumors were completely removed and 3 (12.50%) were partly removed. Intractable headache improved in all patients over a mean follow-up time of 25.16 months, and postoperative improvement in visual acuity was achieved in 17 of 18 patients (94.44%) with vision defects. Four patients (16.67%) experienced transient urinary collapse after the operation. No intracranial infection, carotid artery injury, or death occurred. Conclusion: The endoscopic endonasal transsphenoidal approach is a safe and effective method for the treatment of pituitary apoplexy.
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Affiliation(s)
- Zhixiang Sun, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Xintao Cai, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yu Li, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Dongqi Shao, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Zhiquan Jiang, PhD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Zhiquan Jiang, Department of Neurosurgery, First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Road, Bengbu, Anhui 233004, China.
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Martucci G, Bonicolini E, Parekh D, Thein OS, Scherkl M, Amrein K. Metabolic and Endocrine Challenges. Semin Respir Crit Care Med 2020; 42:78-97. [PMID: 32882734 DOI: 10.1055/s-0040-1713084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This review aims to provide an overview of metabolic and endocrine challenges in the setting of intensive care medicine. These are a group of heterogeneous clinical conditions with a high degree of overlap, as well as nonspecific signs and symptoms. Several diseases involve multiple organ systems, potentially causing catastrophic dysfunction and death. In the majority of cases, endocrine challenges accompany other organ failures or manifest as a complication of prolonged intensive care unit stay and malnutrition. However, when endocrine disorders present as an isolated syndrome, they are a rare and extreme manifestation. As they are uncommon, these can typically challenge both with diagnosis and management. Acute exacerbations may be elicited by triggers such as infections, trauma, surgery, and hemorrhage. In this complex scenario, early diagnosis and prompt treatment require knowledge of the specific endocrine syndrome. Here, we review diabetic coma, hyponatremia, hypercalcemia, thyroid emergencies, pituitary insufficiency, adrenal crisis, and vitamin D deficiency, highlighting diagnostic tools and tricks, and management pathways through defining common clinical presentations.
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Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Eleonora Bonicolini
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Dhruv Parekh
- Critical Care, Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Onn Shaun Thein
- Critical Care, Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Mario Scherkl
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Heparin-Induced Pituitary Apoplexy Presenting as Isolated Unilateral Oculomotor Nerve Palsy: A Case Report and Literature Review. Case Rep Endocrinol 2019; 2019:5043925. [PMID: 31687223 PMCID: PMC6803741 DOI: 10.1155/2019/5043925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/25/2019] [Accepted: 09/05/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Pituitary apoplexy (PA) is a rare and potentially life-threatening clinical syndrome resulting from pituitary gland hemorrhage and/or infarction. Anticoagulation is a risk factor for triggering PA. Isolated oculomotor nerve palsy is an atypical presentation of PA. Case Presentation A 65-year-old African American female with no past medical history of pituitary disease presented to the emergency department (ED) with nonspecific abdominal pain that was thought to be secondary to fecal stasis and subsequently improved with laxatives. She also reported atypical chest pain that was concerning for unstable angina. She was started on aspirin, clopidogrel, and intravenous (IV) heparin. Later, coronary catheterization showed no significant coronary artery disease (CAD). Twelve hours after the procedure, the patient developed acute complete left oculomotor nerve palsy with a severe headache. Magnetic resonance imaging (MRI) of the head showed a large pituitary mass. Pituitary apoplexy was suspected and the patient eventually underwent a successful trans-sphenoidal pituitary resection. Discussion We report a case of PA manifesting as isolated left oculomotor nerve palsy without visual field defects in the setting of using dual antiplatelet therapy (DAPT) and IV heparin for acute coronary syndrome. To the best of our knowledge, this unique combination has not been previously reported.
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