Pituitary apoplexy

Diagnosis and Treatment of Pituitary Apoplexy, A True Endocrine Emergency

Pituitary apoplexy (PA) is a clinical syndrome resulting from a hemorrhagic infarction of the pituitary gland. It is characterized by the sudden onset of visual disturbances, nausea, vomiting, headache and occasionally, signs of meningeal irritation and an altered mental status. The exact pathogenesis of PA remains to be elucidated, although tumor overgrowth of its blood supply remains the most popular theory. Main risk factors for the development of PA include systemic, iatrogenic, and external factors as well as the presence of an underlying pituitary tumor. The diagnostic approach of PA includes both neuroimaging and evaluation of pituitary secretory function. PA is a potentially life-threatening condition which should be managed with hemodynamic stabilization, correction of electrolyte abnormalities and replacement of hormonal deficiencies. PA treatment should be individualized based on the severity of the clinical picture which may vary widely. Treatment options include conservative management with periodic follow-up or neurosurgical intervention, which should be decided by a multidisciplinary team. We conducted a systematic review of the literature to unveil the frequency of PA predisposing factors, clinical and biochemical presentations, management strategies and outcomes.

Challenges of Pituitary Apoplexy in Pregnancy

Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012-December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal-fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample-case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal-fetal outcomes from multidisciplinary insights.

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

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

Pituitary Incidentalomas: Best Practices and Looking Ahead

Pituitary Incidentalomas (PI) are pituitary lesions serendipitously identified on imaging. PIs have become common in clinical practice because of increased use of imaging and radiologic advances. The most frequently incidentally detected lesions in adults are pituitary adenomas, followed by cystic lesions, and rarely other types of tumors and infiltrative and inflammatory disorders. Biochemical screening for hyperprolactinemia and acromegaly is needed in all patients with PI, whereas testing for hyposecretion is recommended for lesions larger than 6.0 mm. Most PIs are small nonfunctioning adenomas or cysts, which can be conservatively managed. For larger lesions, a multidisciplinary approach including endocrinology, neurosurgery, and neuro-ophthalmology is required. For incidentally detected lactotroph, somatotroph, and corticotroph adenomas, disease-specific management guidelines apply. Prospective studies are needed to enhance our understanding of the long-term course and response to treatment.

Adrenocorticotropic hormone-producing pituitary adenoma with pituitary apoplexy treated by surgical decompression: a case report

Background

Pituitary-dependent hypercortisolism (PDH) is one of the most common endocrine disorders in veterinary medicine. However, there are few reports on pituitary tumor apoplexy (PTA) in dogs and no reports on its surgical intervention in veterinary medicine. Accordingly, the appropriate treatment is unknown. Herein, a case of PDH and PTA in a dog treated surgically is described.

Case presentation

A mongrel female dog (spayed; age, 8 years and 8 months; weight, 6.1 kg) with persistently elevated alkaline phosphatase underwent adrenocorticotropic hormone (ACTH) stimulation testing (post-stimulation cortisol: 20.5 μg/dL), abdominal ultrasonography (adrenal gland thickness: left, 5.7 mm; right, 8.1 mm), and brain magnetic resonance imaging (MRI) (pituitary-to-brain ratio [PBR], 0.61) at the referral hospital, resulting in a diagnosis of PDH (day 0). On day 9, the dog visited XXXX for the preparation of pituitary surgery to treat PDH. However, on days 10–15, the dog developed a loss of energy and appetite, bloody diarrhea, vomiting, and a decreased level of consciousness. However, on day 16, the dog’s condition recovered. A preoperative MRI scan performed on day 52 (the day of surgery) showed apoplexy in the dorsal pituitary region (PBR, 0.68). Based on the PTA findings, the risks of surgery were described to the owner, and approval was obtained. At the time of trans-sphenoidal surgery, a partial pituitary resection was performed with preservation of the PTA area due to adhesions between the PTA area of the right side of the pituitary and surrounding tissues. The resected pituitary tissue was diagnosed as an ACTH-producing adenoma, with necrotic and hemorrhagic findings. As of day 290, endogenous ACTH and cortisol levels did not exceed the reference range.

Conclusions

The acute signs that occurred on days 10–15 were most likely caused by PTA. Therefore, when signs similar to those detected in acute hypoadrenocorticism are observed in dogs with PDH, it is necessary to include PTA as a differential diagnosis. Trans-sphenoidal surgery may be effective in PDH-affected dogs that develop PTA, but careful attention should be paid to tissue adhesions secondary to hemorrhage that may occur after PTA.

Determinants of visual and endocrinological outcome after early endoscopic endonasal surgery for pituitary apoplexy

Background:

Patients diagnosed with pituitary apoplexy and presenting with acute visual deterioration require urgent surgical resection. This is also commonly associated with pituitary hypopituitarism that requires hormonal replacement for correction. This study was undertaken to evaluate the clinical recovery of 45 patients diagnosed with symptomatic pituitary apoplexy who underwent early (within 72 h of symptom onset) endoscopic transsphenoidal surgical resection with an emphasis on visual, ocular craniopathy, and endocrinological outcome.

Methods:

This is a retrospective analysis of a consecutive series of patients diagnosed with pituitary apoplexy between 2011 and 2020 treated by early (within 72 h of symptom onset) endoscopic transsphenoidal surgical resection. All tumors were histologically proven as pituitary adenomas. Clinical and neuro-ophthalmological examinations, imaging studies, and endocrinological evaluation were retrospectively reviewed. Patients with a minimum of 6 months follow-up were included in the study. The influence of patients’ demographics, extent of visual and ocular motility impairment, preoperative endocrinological dysfunction, tumor size and extent, degree of resection, and surgical complications were analyzed as potential prognostic factors for recovery.

Results:

Forty-five patients were included in this retrospective study. Ages ranged from 27 to 57 years (mean: 42 years). All patients presented with headache and variable degrees of visual loss and visual field deficit. Ophthalmoplegia was present in 22 (48.9%) patients with 17 (37.8%) having bilateral ocular cranial nerve palsy. All patients had variable degrees of endocrinological deficiencies. All patients showed evidence of low cortisol, 14 (31.1%) showed hypothyroidism and 11 (24.4%) showed hypogonadism. There was evidence of hyperprolactinemia in 16 (35.6%) patients. All patients harbored a pituitary macroadenoma. Tumor resection was complete in 33 (73%) of patients, with residual tumor related to cavernous sinus or retrosellar extension. Operative complications were mainly related to short-term nasal complications occurring in 14 (31%) patients. Cerebrospinal fluid leak requiring revision surgery occurred in only one patient harboring a modified SIPAP Grade 3s tumor. Transient diabetes insipidus occurred in 9 (20%) patients, with 2 (4.4%) requiring long-term hormonal replacement. The mean follow-up was 25 months. Baseline visual improvement was achieved in 39 (86.7%) patients. Ocular cranial nerve palsy showed complete recovery in 17 (77.2%) patients. Endocrine follow-up showed that patients with panhypopituitarism (11 [24.4%]) failed to recover.

Conclusion:

The current surgical series showed safety in terms of low complication rate and efficacy in terms of clinical outcome. The significant prognostic factor related to visual recovery was the degree of preoperative visual deficit. Recovery of ocular cranial neuropathy showed a higher recovery rate when it was unilateral as opposed to bilateral. Pituitary hormonal recovery was less favorable with pituitary panhypopituitarism being a poor prognostic factor.

Surgery for Pituitary Tumor Apoplexy Is Associated with Rapid Headache and Cranial Nerve Improvement

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.

Neurological Presentation of Giant Pituitary Tumour Apoplexy: Case Report and Literature Review of a Rare but Life-Threatening Condition

Background: Giant pituitary adenomas are benign intracranial tumours with a diameter ≥4 cm. Even if hormonally non-functional, they may still cause local extension, leading to symptoms that include mostly gland dysfunction, mass effects, and, much less frequently, apoplexy due to haemorrhage or infarction. Neurological presentation of giant pituitary tumour apoplexy is even more rare and has not been systematically reviewed. Case Presentation: An 81-year-old woman was admitted to the Emergency Department because of acute onset headache, bilateral visual deficit, and altered consciousness. Computed tomography showed a giant mass lesion (>5.5 cm diameter) expanding upward to the suprasellar cistern, optic chiasm, and third ventricle, over-running the sphenoid sinus, and with lateral invasion of the cavernous sinus. Laboratory investigations revealed central adrenal and hypothyroidism insufficiency, while magnetic resonance imaging confirmed a voluminous suprasellar tumour (~6 cm diameter), with signs of pituitary tumour apoplexy. Neurological manifestations and gland-related deficits improved after hormonal replacement therapy with a high dose of intravenous hydrocortisone, followed by oral hydrocortisone and levo-thyroxine. The patient declined surgical treatment and follow-up visit. Conclusions: Giant pituitary tumour apoplexy is a rare but potentially life-threatening condition. Prompt diagnosis and multidisciplinary management may allow a remarkable clinical improvement, as seen in this case.

Rathke cleft cyst apoplexy: Hormonal and clinical presentation

Background:

Rathke cleft cyst (RCC) apoplexy is an uncommon type of lesion that is challenging to diagnose without histopathological samples. Very few articles have been published describing the details of RCC apoplexy. We studied a good number of published articles to analyze its demographics, clinical and hormonal presentations, and outcomes.

Methods:

A literature review of English language publications about RCC apoplexy or pituitary apoplexy was conducted using Medline and EMBASE search engines. Thirty articles with histological diagnosis of RCC apoplexy were identified, the earliest of which was published in 1990 and the latest in 2019. We combined the findings of these articles with our own case report and then compared the demographics, clinical and hormonal presentations, and outcomes between RCC apoplexy and pituitary adenoma apoplexy.

Results:

Our data included 29 patients with RCC, with a mean age of 36.87 years (8–72) and a predominance of female patients (68%). The hemorrhagic type was most common, reported in 86%. Headache was the most common presenting symptom, being reported in 93% followed by hypogonadism (73%) and hormonal deficits (52%). All but three patients improved neurologically (90%); however, 45% of patients required long-term hormonal replacement, mostly thyroid hormone. No cases of worsening neurological or hormonal status were reported.

Conclusion:

RCC apoplexy presents with less severe neurological and hormonal abnormalities than pituitary adenoma apoplexy; it also has a better prognosis in endocrine functional recovery. We recommend applying current management guidelines of pituitary adenoma apoplexy to RCC apoplexy.

Outcome in pituitary apoplexy patients, stratified by delay between symptom appearance and surgery: A single center retrospective analysis

BACKGROUND

There are surgical and conservative management strategies in pituitary apoplexy patients. The use of both methods may lead to delayed surgery in the treatment of pituitary apoplexy. The aim of this study was to evaluate the surgical indications and outcomes of a series of patients with pituitary apoplexy according to delay between surgery and symptom onset.

METHODS

A retrospective analysis was performed of 2711 cases with sellar pathologies treated with endoscopic transsphenoidal surgery in a single centre. Inclusion criteria were histopathological confirmation of haemorrhage or necrosis, acute onset and at least one of the following: symptoms of endocrine dysfunction; visual impairment; ophtalmoplegia; headache; or altered consciousness. Patients were divided into three groups based on the number of days from initial symptoms to surgery: early (1-7 day), delayed (8-21 days) and late (>21 day). The indication for and outcome of surgery was reviewed according to symptoms and timing of surgery.

RESULTS

Ninety-one patients with pituitary apoplexy underwent surgery. The median time from ictus until surgery was 16 days (1-120 days). Headache was the most common presenting symptom. Visual impairment and ophtalmoplegia were found in 26.4% and 23.1% of patients, respectively. Surgical intervention was successful in treatment of headache in 82 (97,6%) patients. In patients in the early or delayed groups a significant improvement was found between pre- and post-operative headache, ocular palsy, visual impairment, and hormone deficiencies. Patients in the late group also had a significant improvement in headache and visual symptoms after surgery.

CONCLUSION

Surgery was sufficient in headache, endocrine, and neuro-ophthalmic outcomes at first 21 days (early and delayed groups). Beyond 21 days (late group), surgery was not effective on recovery of pituitary function.

GnRH agonist-associated pituitary apoplexy: a case series and review of the literature

PURPOSE

To examine the clinical presentation and longitudinal outcome of Pituitary Apoplexy (PA) after gonadotropin-releasing hormone agonist (GnRHa) in a series of patients and compare to prior reports.

METHODS

A retrospective chart review was performed on seven patients receiving GnRHa who developed PA. Prior reported cases were analyzed.

RESULTS

Six men (median age 72 years) with prostate cancer and one woman (aged 22 years) undergoing oocyte donation presented with PA between 1990 and 2020. Most presented with within 24 h of the first dose, but two developed PA 1 to 5 months after GnRHa initiation. The main clinical manifestations were headache (100%), nausea and vomiting (86%). While no patients had a previously known pituitary tumor, all had imaging demonstrating sellar mass and/or hemorrhage at presentation. Among those surgically treated (5/7), 80% (4/5) of patients had pathologic specimens that stained positive for gonadotropins; the remaining patient's pathologic specimen was necrotic. At the time of PA, the most common pituitary dysfunction was hypocortisolism. Central adrenal insufficiency and central hypothyroidism were reversible in a subset. Pituitary imaging remained stable.

CONCLUSIONS

This is the first report of a case series with PA after GnRHa administration with longitudinal follow-up. Although infrequent, PA can be life-threatening and should be suspected among patients receiving GnRHa, with or without a known pituitary adenoma, who develop acute headache, nausea and/or vomiting. Since hypopituitarism was reversible in a subset, ongoing pituitary function testing may be indicated.

Predictive Clinical and Surgical Factors Associated with Recurrent Apoplexy in Pituitary Adenomas

Introduction Pituitary apoplexy is an uncommon clinical condition that can require urgent surgical intervention, but the factors resulting in recurrent apoplexy remain unclear. The purpose of this study is to determine the risks of a recurrent apoplexy and better understand the goals of surgical treatment.

Methods A retrospective chart review was performed for all consecutive patients diagnosed and surgically treated for pituitary apoplexy from 2004 to 2021. Univariate analysis was performed to identify risk factors associated with recurrent apoplexy.

Results A total of 115 patients were diagnosed with pituitary apoplexy with 11 patients showing recurrent apoplexy. This occurred at a rate of 2.2 cases per 100 patient-years of follow-up. There were no major differences in demographic factors, such as hypertension or anticoagulation use. There were no differences in tumor locations, cavernous sinus invasion, or tumor volumes (6.84 ± 4.61 vs. 9.15 ± 8.45 cm, p = 0.5). Patients with recurrent apoplexy were less likely to present with headache (27.3%) or ophthalmoplegia (9.1%). Recurrent apoplexy was associated with prior radiation (0.0 vs. 27.3%, p = 0.0001) and prior subtotal resection (10.6 vs. 90.9%, p = 0.0001) compared with first time apoplexy. The mean time to recurrent apoplexy was 48.3 ± 76.9 months and no differences in overall follow-up were seen in this group.

Conclusion Recurrent pituitary apoplexy represents a rare event with limited understanding of pathophysiology. Prior STR and radiation treatment are associated with an increased risk. The relatively long time from the first apoplectic event to a recurrence suggests long-term patient follow-up is necessary.

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.

Intracerebral and subarachnoid hemorrhage in pregnancy

Maternal stroke occurs in around 34 out of every 100,000 deliveries and is responsible for around 5%-12% of all maternal deaths. It is most commonly hemorrhagic, and women are at highest risk for developing pregnancy-related hemorrhage during the early postpartum period through 6 weeks following the delivery. The most common causes of hemorrhagic stroke in pregnant patients are arteriovenous malformations and cerebral aneurysms. Management is similar to that for acute hemorrhagic stroke in the nonpregnant population with standard use of computed tomography and judicious utilization of intracranial vessel imaging and contrast. The optimal delivery method is evaluated on a case-by-case basis, and cesarean delivery is not always required. As most current studies are limited by retrospective design, relatively small sample sizes, and heterogeneous study term definitions, strong and comprehensive evidence-based guidelines on the management of acute hemorrhagic stroke in pregnant patients are still lacking. In the future, multicenter registries and prospective studies with uniform definitions will help improve management strategies in this complex patient population.

Coronavirus disease 2019 infection and pituitary apoplexy: A causal relation or just a coincidence? A case report and review of the literature

Background:

Pituitary tumor apoplexy (PA) is an emergency condition caused by hemorrhage or infarction of the preexisting adenoma. Many factors are currently well-known to predispose to PA. However, during the period of coronavirus disease 2019 (COVID-19) pandemic, case reports of PA associated with COVID-19 infection have been sequentially published. To the best of our knowledge, four cases have been reported so far in the English literature. We herein report the fifth case of this association and review the pertinent literature.

Case Description:

A 55-year-old male patient with confirmed COVID-19 infection presented by progressive decrease in visual acuity and oculomotor nerve palsy. His medical history is notable for diabetes mellitus, hypertension, and pituitary macroadenoma resection 11 years ago. He was on hormonal replacement therapy for panhypopituitarism that complicated the surgery. Previous magnetic resonance (MR) imaging studies were consistent with enlarging residual pituitary adenoma. During the current hospitalization, computed tomography revealed hyperdensity of the sellar and suprasellar areas. MR imaging revealed PA in a recurrent large adenoma. Endoscopic endonasal transsphenoidal resection was uneventfully undertaken with near total excision of the adenoma and partial improvement of visual loss and oculomotor palsy. Histopathological examination demonstrated classic features of PA. However, his chest condition progressed and he had to be transferred to COVID-19 intensive care unit in the referring hospital where he was intubated and put on mechanical ventilation. One week later, the patient unfortunately passed away due to complications of severe COVID-19 pneumonia.

Conclusion:

We report the fifth case of PA associated with COVID-19 infection. Based on our patient’s clinical findings, review of the other reported cases, as well as the available literature, we put forth a multitude of pathophysiological mechanisms induced by COVID-19 that can possibly lead to the development of PA. In our opinion, the association between both conditions is not just a mere coincidence. Although the histopathological features of PA associated with COVID-19 are similar to PA induced by other etiologies, future research may disclose unique pathological fingerprints of COVID-19 virus that explains its capability of inducing PA.

Emergency endoscopic surgery for pituitary apoplexy presenting as cerebral infarction in a limited resources condition: A case report

Introduction and importance

Pituitary apoplexy is defined as a sudden onset of neurologic deficit due to infarction or hemorrhage of the pituitary tumor. We report a case of emergency endoscopic surgery for pituitary apoplexy presenting as cerebral infarction due to ICA compression in a limited resources condition.

Case presentation

A 38-year-old female presented with acute onset of severe headache, decreased level of consciousness, decreased visual acuity bilaterally, aphasia, and right hemiparesis. Computed tomography angiography showed a hyperdense sellar mass with stenosis of the left ICA. The patient underwent emergent endoscopic transsphenoidal surgery for sellar decompression.

Clinical discussion

The epidermiology, presentation and diagnosis and strategy of treatments as well as their outcomes were discussed.

Conclusion

Pituitary apoplexy should be taken into consideration in a patient with increasing headache and neuro-ophthalmic symptoms. Pituitary apoplexy presenting as cerebral infarction is rare. The aim of surgery in emergency setting was sellar decompression. Endoscopic transsphenoidal surgery was an effective treatment.

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Pituitary apoplexy should be taken into consideration in a patient with increasing headache and neuro-ophthalmic symptoms.

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Pituitary apoplexy presenting as cerebral infarction is rare.

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The aim of surgery in emergency setting was sellar decompression.

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Endoscopic transsphenoidal surgery was an effective treatment.

Radiological and clinical outcomes of pituitary apoplexy: comparison of conservative management versus early surgical intervention

OBJECTIVE

Early surgical intervention for patients with pituitary apoplexy (PA) is thought to improve visual outcomes and decrease mortality. However, some patients may have good clinical outcomes without surgery. The authors sought to compare the radiological and clinical outcomes of patients with PA who were managed conservatively versus those who underwent early surgery.

METHODS

Patients with symptomatic PA were identified. Radiological, endocrinological, and ophthalmological data were reviewed. Patients with progressive visual deterioration or ophthalmoplegia were candidates for early surgery (within 7 days). Patients without visual symptoms or whose symptoms improved on high-dose steroids were treated conservatively. Log-rank and univariate analysis compared clinical and radiological outcomes between those receiving early surgery and those who underwent intended conservative management.

RESULTS

Sixty-four patients with PA were identified: 47 (73.4%) underwent intended conservative management, while 17 (26.6%) had early surgery. Patients receiving early surgery had increased rates of impaired visual acuity (VA; 64.7% vs 27.7%, p = 0.009); visual field (VF) deficits (64.7% vs 19.2%, p = 0.002); and cranial neuropathies (58.8% vs 29.8%, p < 0.05) at presentation. Tumor volumes were greater in the early surgical cohort (15.1 ± 14.8 cm3 vs 4.5 ± 10.3 cm3, p < 0.001). The median clinical and radiological follow-up visits were longer in the early surgical cohort (70.0 and 64.4 months vs 26.0 and 24.7 months, respectively; p < 0.001). Among those with VA/VF deficits, visual outcomes were similar between both groups (p > 0.9). The median time to VA improvement (2.0 vs 3.0 months, p = 0.9; HR 0.9, 95% CI 0.3-3.5) and the median time to VF improvement (2.0 vs 1.5 months; HR 0.8, 95% CI 0.3-2.6, p = 0.8) were similar across both cohorts. Cranial neuropathy improvement was more common in conservatively managed patients (HR 4.8, 95% CI 1.5-15.4, p < 0.01). Conservative management failed in 7 patients (14.9%) and required surgery. PA volumes spontaneously regressed in 95.0% of patients (38/40) with successful conservative management, with a 6-month regression rate of 66.2%. Twenty-seven patients (19 in the conservative and 8 in the early surgical cohorts) responded to a prospectively administered Visual Function Questionnaire-25 (VFQ-25). VFQ-25 scores were similar across both cohorts (conservative 95.5 ± 3.8, surgery 93.2 ± 5.1, p = 0.3). Younger age, female sex, and patients with VF deficits or chiasmal compression were more likely to experience unsuccessful conservative management. Surgical outcomes were similar for patients receiving early versus delayed surgery.

CONCLUSIONS

These data suggest that a majority of patients with PA can be successfully managed without surgical intervention assuming close neurosurgical, radiological, and ophthalmological follow-up is available.

Pituitary tumor apoplexy associated with extrapontine myelinolysis during pregnancy: A case report

RATIONALE

Pituitary tumor apoplexy (PTA) is a rare clinical syndrome which requires urgent diagnosis and treatment due to its life-threatening consequences. Management of undiagnosed pituitary tumor before pregnancy is a problem during pregnancy.

PATIENT CONCERNS

We reported a case with PTA which was not diagnosed before pregnancy presenting with vomiting associated with hyponatremia during the third trimester. After supplying the sodium the patient presented with dysarthria and hemiplegia.

DIAGNOSES

MRI examination showed PTA accompanied with extrapontine myelinolysis (EPM).

INTERVENTIONS

The patient was given hydrocortisone according to the symptoms gradually to taper off dose, at the same times oral levothyroxine therapy (25μg/day) was given.

OUTCOMES

The patient delivered a healthy baby via cesarean section at hospital at 38 + 1 week of gestation. We performed MRI examination regularly and the tumor regressed significantly 8 months postpartum.

LESSONS

We reported a case as PTA associated with EPM. Headache during pregnancy is often nonspecific, so careful medical history inquiry is very important.

Pituitary Apoplexy: A Retrospective Study of 33 Cases From a Single Center

PURPOSE

Acute symptomatic pituitary apoplexy is a rare and potentially life-threatening condition. However, pituitary apoplexy can also present with milder symptoms and stable hemodynamics. Due to the rarity of this inhomogeneous condition, clinical studies are important to increase the knowledge.

METHODS

We retrospectively reviewed all consecutive cases of pituitary apoplexy being admitted between January 1^st, 2005 and December 31^st, 2019 at the Karolinska University Hospital, Stockholm, Sweden, for symptoms, results of magnetic resonance (MRI), biochemistry, management and mortality.

RESULTS

Thirty-three patients were identified with pituitary apoplexy, 18 were men (55%) and mean age was 46.5 (17.2) years. The incidence of symptomatic pituitary apoplexy was 1.6 patients/year (0.76 patients/1,000,000 inhabitants/year). The majority presented with headache (n=27, 82%) and hormonal deficiencies (n=18, 55%), which were most frequent in men. ACTH deficiency was present in nine patients (27% but 50% of those with hormonal deficiencies). All had the characteristic findings on MRI. Only three patients (9%) required acute pituitary surgery, while eight were operated after more than one week. Seven (21%) were on antithrombotic therapy. None of the patients died in the acute course. During follow-up (7.6 ± 4.3 years) none of the hormonal deficiencies regressed and 3 patients died from non-related causes.

CONCLUSION

Our study confirmed the rarity and the symptoms of this condition. Surprisingly, only 3 patients needed acute neurosurgical intervention, perhaps due to milder cases and a general intensified treatment of precipitating factors. An early awareness and in severe cases decision on pituitary surgery is of utmost importance to avoid severe complications.

Pituitary apoplexy associated with acute COVID-19 infection and pregnancy

PURPOSE

We report a case of a pregnant female presenting with pituitary apoplexy and simultaneous SARS-CoV-2 infection with a focus on management decisions.

CLINICAL HISTORY

A 28-year-old G5P1 38w1d female presented with 4 days of blurry vision, left dilated pupil, and headache. She tested positive for SARS-CoV-2 on routine nasal swab testing but denied cough or fever. Endocrine testing demonstrated an elevated serum prolactin level, and central hypothyroidism. MRI showed a cystic-solid lesion with a fluid level in the pituitary fossa and expansion of the sella consistent with pituitary apoplexy. Her visual symptoms improved with corticosteroid administration and surgery was delayed to two weeks after her initial COVID-19 infection and to allow for safe delivery of the child. A vaginal delivery under epidural anesthetic occurred at 39 weeks. Two days later, transsphenoidal resection of the mass was performed under strict COVID-19 precautions including use of Powered Air Purifying Respirators (PAPRs) and limited OR personnel given high risk of infection during endonasal procedures. Pathology demonstrated a liquefied hemorrhagic mass suggestive of pituitary apoplexy. She made a full recovery and was discharged home two days after surgery.

CONCLUSION

Here we demonstrate the first known case of successful elective induction of vaginal delivery and transsphenoidal intervention in a near full term gravid patient presenting with pituitary apoplexy and acute SARS-CoV-2 infection. Further reports may help determine if there is a causal relationship or if these events are unrelated. Close adherence to guidelines for caregivers can greatly reduce risk of infection.

Pituitary apoplexy: how to define safe boundaries of conservative management? Early and long-term outcomes from a single UK tertiary neurosurgical unit

OBJECTIVES

(1) Describe presentation, management and outcomes of a single-centre series of patients with pituitary apoplexy. (2) Compare early and long-term outcomes of conservative and surgical management. (3) Identify predictive factors for visual recovery.

METHODS

Retrospective analysis of patients acutely managed by Sheffield's Neurosurgery over a 9-years period. Outcome comparison was made between 2 groups ('conservative' versus 'emergency') at early FU and 3 groups ('conservative' versus 'elective' versus 'emergency') at long-term FU.

RESULTS

Data from 30 patients (M:F = 2.8:1; mean age: 54 years; median FU: 31.5 months) were collected. 86,7% patients presented with visual disturbances (70% acuity, 50% field, 50% diploplia). 10 (33%) patients underwent emergency surgery and further 8 underwent delayed elective surgery.At early FU, resolution rates of VA (33% versus 38%), VF (40% versus 50%) and CN deficits (71% versus 40%) were not significantly different between groups.At long-term FU, resolution of VA (80% versus 20% versus 75%) and CN deficits (67% versus 50% versus 80%) was not significantly different between groups. Most patients who underwent surgery presented with severe VA deficit (20% versus 40% versus 63%) but severity of initial deficit wasn't correlated with long-term resolution.VF recovery rates showed significant difference between groups (p = 0.027): 67% versus 0% versus 88%.Endocrine outcomes were generally poor, regardless of the management strategy.Regarding possible predictive factors, age and tumour size correlated with visual outcomes. Especially in patients treated conservatively in the acute phase, no cases of complete resolution of VA or VF deficit were recorded when tumour was higher than 35 mm.

CONCLUSIONS

Good results are possible with conservative management in selected cases. Emergency surgery provides better visual outcomes. Decision-making process should be tailored to every single patient. We believe that a tumour vertical diameter >35 mm should tip the balance in favour of surgical management in presence of visual deficit.

Risk factors for the incidence of apoplexy in pituitary adenoma: a single-center study from southwestern China

Background

Although the incidence and clinical manifestations of pituitary apoplexy were reported by a few researches, the results are not consistent. This study aimed to explore the risk factors associated with an incidence of apoplexy in pituitary adenomas.

Methods

The clinical information of 843 patients with pituitary adenoma from the Department of Neurological Surgery, 1st Affiliated Hospital of Kunming Medical University, was reviewed. The incidence, clinical manifestation, and potential risk factors for pituitary apoplexy were analyzed by a case-control study.

Results

In total, 121 patients (14.4%) with macroadenoma were suffered from pituitary apoplexy. Headache, vomiting, and visual impairment are the top 3 symptoms for the pituitary apoplexy.Logistic regression results showed that the hypertension(hypertension vs non-hypertension OR = 2.765, 95%CI:1.41~5.416), tumor type (negative staining vs. positive staining, OR = 1.501, 95%CI:1.248~5.235), and tumor size (diameter > 2 cm vs. diameter ≤ 2 cm, OR = 3.952, 95%CI:2.211~7.053) are independent factors associated with pituitary apoplexy.

Conclusion

Our results indicate that the risk factors for the incidence of pituitary apoplexy depend mainly on properties of the tumor itself (tumor size and pathologic type) and the blood pressure of patients.

55-year-old Woman with Headache, Vomiting, and Visual Disturbance

Case Presentation

A 55-year-old woman with a past medical history of hypertension, hyperlipidemia, and iron deficiency anemia presented to the emergency department with three days of headache, nausea, vomiting, and visual changes. Her vital signs were within normal limits. She was noted to have a left cranial nerve six palsy on exam.

Results

Her laboratory testing revealed leukocytosis, hyponatremia, and hypokalemia. A non-contrast computed tomography scan of the head revealed an enlarged sella turcica and pituitary gland with hemorrhage and deviation of the optic chiasm.

Conclusion

Her symptoms improved and she was discharged from the hospital in stable condition.

Rathke Cleft Cysts with Apoplexy-Like Symptoms: Clinicoradiologic Comparisons with Pituitary Adenomas with Apoplexy

BACKGROUND

Rathke cleft cyst (RCC) can cause acute symptoms mimicking pituitary adenoma (PA) apoplexy. We evaluated the clinicoradiologic features for distinguishing RCC from PA apoplexy.

METHODS

We retrospectively evaluated 22 patients with RCC and 24 patients with PA with apoplexy-like symptoms who underwent surgery via a transsphenoidal approach between November 1999 and December 2016. We compared the clinical data and magnetic resonance (MR) images between the 2 groups.

RESULTS

The RCC group was younger and had smaller tumors compared with the PA group (P = 0.02 and 0.001, respectively). The incidences of visual deficits and cranial nerve palsy were lower in the RCCs than in the PAs (P ≤ 0.02 for all). MR images showed more frequent intracystic nodules in the RCCs (P < 0.001), whereas nodular enhancement and lateral deviation of the pituitary stalk were more commonly seen in the PAs (P ≤ 0.003 for both). However, the presence of endocrine dysfunction or decreased consciousness, and the recurrence ratio, were not significantly different between the groups (P ≥ 0.48 for all). In the multivariable logistic regression analysis, patients without nodular enhancement had a 15.84-fold greater risk of RCC than did those with nodular enhancement (P = 0.031). The probability of RCC decreased 0.59-fold with each 1-cm³ increase in tumor volume.

CONCLUSIONS

RCC with apoplexy-like symptoms has different clinicoradiologic features compared with PA apoplexy. Patients with RCC present with milder ocular symptoms and smaller tumor volumes compared with those with PA apoplexy. The absence of nodular enhancement on MR images could suggest RCC.

A case of atypical macroprolactinoma presenting with pituitary apoplexy during pregnancy and review of the literature

Pituitary apoplexy (PA) during pregnancy is a rare acute clinical situation which could have life-threatening consequences. Here we reported a case of 26-year-old nulliparous woman presenting with PA at the second trimester of her pregnancy. We also have reviewed reported cases of PA during pregnancy and conducted a detailed discussion on presenting symptoms, underlying pituitary pathology, management of apoplexy during pregnancy and outcomes.

Imaging of Altered Mental Status

Neuroimaging is an invaluable diagnostic tool for sorting through the vast array of etiologies that underlie altered mental status (AMS). Head computed tomography (CT) without contrast is the primary modality for evaluation of AMS and should be complemented by MR imaging in cases of negative CT but high clinical concern. Studies to maximize brain imaging efficiency and improve the yield of positive scans through the utilization of clinical and laboratory pre-scan diagnostics are ongoing. However, imaging remains the gold standard due to its rapidity with which certain diagnoses can be made or excluded.

Visual and Endocrine Recovery Following Conservative and Surgical Treatment of Pituitary Apoplexy: A Meta-Analysis

BACKGROUND

Pituitary apoplexy (PA) can manifest with visual and endocrine defects. The literature lacks strong support for either surgical or conservative management with respect to symptomatic improvement of these deficits. This meta-analysis compared visual and endocrine outcomes in conservative and surgical treatment of PA.

METHODS

A systematic literature search was performed in PubMed, Cochrane, and Ovid MEDLINE for articles published between 1988 and 2018. Recovery outcomes were binarized, such that complete and partial improvements were combined as "improvement." Primary outcome variables evaluated via a binary random-effects model were improvements in endocrine dysfunction, visual field and acuity deficits, and ophthalmoplegia or ocular nerve palsy.

RESULTS

Of 483 published articles, 14 studies comprising 457 cases (259 surgical treatments and 198 conservative treatments) were included. On initial examination, 58% of patients had endocrine dysfunction, 37% had visual acuity or field deficit, and 47% had ophthalmoplegia or ocular nerve palsy. Evaluation of outcomes for surgically and conservatively treated patients yielded odds ratios of 0.609 (95% confidence interval [CI], 0.199-1.859; P = 0.383), 0.763 (95% CI, 0.307-2.374; P = 0.763), 1.167 (95% CI, 0.433-3.146; P = 0.760), and 0.801 (95% CI, 0.305-2.105; P = 0.653) for improvements in endocrine dysfunction, visual acuity dysfunction, visual field dysfunction, and ophthalmoplegia or ocular nerve palsy.

CONCLUSIONS

Both surgical intervention and conservative management of PA can lead to visual and endocrine recovery, although the management decision may heavily rely on severity of initial deficits. Treatment of PA can be multifaceted and tailored to the individual case and clinical judgment. Further investigation into appropriate intervention based on longitudinal outcome data is warranted.

Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature

OBJECTIVE

Pituitary apoplexy is associated with visual, cranial nerve, and endocrine dysfunction. In this article, the results of surgical and conservative management of pituitary apoplexy in a single center are evaluated and a review of the literature is presented.

METHODS

A retrospective analysis was made of patients with pituitary apoplexy who underwent surgery or conservative management at our center between January 2007 and June 2017. Surgery was typically selected for patients who presented with acute deterioration of visual status and/or level of consciousness. Patients with no visual field deficit and those who had medical contraindications to undergo a surgical procedure because of previous comorbidities typically had conservative treatment. Baseline characteristics and clinical and radiologic outcomes were reviewed. A review of the literature (1990-2018) was performed according to PRISMA guidelines. Studies comparing the results of conservative and surgical management were identified. Visual, cranial nerve, and endocrine outcomes and tumor recurrence were analyzed.

RESULTS

Forty-nine patients (73.1%) were managed surgically and 18 (26.9%) conservatively. After careful case selection, patients underwent surgical or conservative treatment. Patients who underwent conservative treatment had fewer visual deficits. At diagnosis, visual deficit (38.8% vs. 75.5%; P = 0.008) and cranial nerve palsy (27.7% vs. 51%; P = 0.058) were less common in the conservative group. Conservative and surgical treatments had similar visual and cranial nerve improvement rates (75% vs. 58.3%, P = 0.63 and 75% vs. 69.2%, P = 1.0, respectively). In the conservative group, tumor shrinkage was observed in 76.4% of cases. The systematic review retrieved 11 studies. No significant difference between conservative and surgical treatment for clinical outcomes (visual field recovery, odds ratio [OR], 1.45; 95% confidence interval [CI], 0.72-2.92; cranial nerve recovery, OR, 2.30; 95% CI, 0.93-5.65; and hypopituitarism, OR, 1.05; 95% CI, 0.64-1.74) or tumor recurrence (OR, 0.68; 95% CI, 0.20-2.34) was observed.

CONCLUSIONS

A tailored approach to pituitary apoplexy, one that does not include an absolute need for surgery, is appropriate. Conservative management is appropriate in selected patients presenting without visual deficits.

The aetiologies of the unilateral oculomotor nerve palsy: a review of the literature

Oculomotor nerve palsy (ONP) is an important and common clinical diagnosis. Its main features are diplopia and ptosis. Its aetiologies are various and complex. A number of different conditions have been reported to cause ONP, such as diabetes mellitus, aneurysm, tumours, painful ophthalmoplegia, pituitary lesions, cavernous sinus lesions, central nervous system infections, and subarachnoid haemorrhage. A patients needs to undergo several tests in order to establish the correct underlying pathology. In this review, we have summarized the aetiologies of the unilateral ONP, and discussed their relative clinical features, pathogenesis, diagnostic criteria, treatment options, and prognosis. We searched PubMed for papers related to ONP and its aetiologies, and selected the publications, which seemed appropriate.

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

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.

Hypophysitis Due to Paranasal Sinusitis: Neurosurgical Perspective from Developing World

BACKGROUND

Sinusitis is a common clinical condition, but sphenoid sinusitis is a less common form and even rarer is hypophysitis as a complication of the latter. Clinically, hypophysitis may mimic a pituitary neoplasm in presenting with mass effect and pituitary hormone dysfunction.

CASE DESCRIPTION

We present 5 cases of sinusitis-related hypophysitis treated at the Royal Care International Hospital in Khartoum, Sudan. Clinical symptoms at presentation included headache, fever, ptosis, ophthalmoplegia, and history of sinusitis with running nose (nasal discharge). None of the patients were immunocompromised or showed signs of meningitis. Laboratory tests indicated neutrophilia and elevated inflammatory indices, namely C-reactive protein and erythrocyte sedimentation rate. There was also a disturbance of the hypothalamic-pituitary hormone axis, particularly impaired cortisol level. Magnetic resonance imaging scans on all patients revealed swollen masses in the pituitary fossa and enhancement of the sellar region and paranasal sinuses, especially the sphenoid sinus. All cases were empirically treated with hydrocortisone and amoxicillin-clavulanate, resulting in reversal of symptoms.

CONCLUSIONS

Sinusitis is common in tropical regions where the climate is usually warm and often hot and dry. Here, the condition is considered a common incidental finding in magnetic resonance imaging examinations done for various indications. Hence it is not considered to be a serious health problem. Though our cohort of cases is small, we emphasize the importance of keeping a high index of suspicion for the diagnosis of hypophysitis in relevant case settings. This would help make an early diagnosis and ensure appropriate medical, perhaps nonsurgical, management.

Management of non-functioning pituitary adenomas: surgery

Non-functional pituitary adenomas (NFPAs) are benign tumors of the pituitary gland that do not over-secrete hormonal products, therefore, they are generally detected through symptoms of mass effect, including headache, vision loss, or hypopituitarism. There are multiple pathological subtypes of NFPAs, such as null cell adenomas, silent gonadotrophs, silent somatotrophs, silent corticotrophs, and silent subtype 3, all of which can be classified based on immunohistochemical studies and electron microscopy. Despite these numerous pathological subtypes, surgical resection remains the first-line treatment for NFPAs. Diagnosis is best made using high resolution MRI brain with and without gadolinium contrast, which is also helpful in determining the extent of invasion of the tumor and recognizing necessary sinonasal anatomy prior to surgery. Additional pre-operative work-up should include full laboratory endocrine evaluation with replacement of hormone deficiencies, and ideally, full neuro-ophthalmologic exam. Although transcranial surgical approaches to the pituitary gland can be performed, the most common approach used is the transnasal transsphenoidal approach with endoscopic or microscopic visualization. This approach avoids retraction of the brain and cranial nerves during tumor removal. Surgery for symptoms caused by mass effect, including headaches and visual loss, are successfully treated with surgical resection, resulting in improvement in pre-operative symptoms as high as 90% in some reports. Although the risk of complications is low, major and minor events, such as permanent hypopituitarism, persistent CSF leak, and carotid artery injury can occur at rates ranging from zero to about 9%.

Apoplexy in nonfunctioning pituitary adenomas

Pituitary apoplexy is an uncommon event, occurring due to the infarction and/or haemorrhage usually of a previously unknown pituitary adenoma. It can occur in all adenoma subtypes but is more common in nonfunctioning pituitary adenomas. The physiopathology is not completely clear, and precipitating factors, such as major surgeries, anticoagulant use or pituitary dynamic tests, can be found in up to 40% of patients. The clinical presentation is characterized by a rapid onset with a headache as the main symptom, but visual disturbances can also be present as well as meningism and intracranial hypertension. The diagnosis is based on imaging evaluations, mainly using magnetic resonance imaging, which can show various patterns depending on the timeframe following the occurrence of the apoplectic event. Pituitary hormonal deficits are also common, and the evaluation of hormonal levels is mandatory. Pituitary apoplexy can be managed by surgery or conservative treatment, and a multidisciplinary team is essential for the decision-making process. The outcome is usually positive with both surgical and conservative approaches, but surveillance is needed due to the risk of re-bleeding or tumour recurrence.

Delayed Onset of Isolated Unilateral Oculomotor Nerve Palsy Caused by Post-Traumatic Pituitary Apoplexy: A Case Report

Post-traumatic pituitary apoplexy is uncommon, most of which present with a sudden onset of severe headache and visual impairments associated with a dumbbell-shaped pituitary tumor. We experienced an unusual case of post-traumatic pituitary apoplexy with atypical clinical features. A 66-year-old man presented with mild cerebral contusion and an incidentally diagnosed intrasellar tumor after a fall accident with no loss of consciousness. The patients denied any symptoms before the accident. After 4 days, the left oculomotor nerve palsy developed and deteriorated associated with no severe headache. Repeated neuroimages suggested that pituitary apoplexy had occurred at admission and showed that the tumor compressed the left cavernous sinus. The patient underwent endonasal transsphenoidal surgery at 6 days after head injury, and the mass reduction improved the oculomotor nerve palsy completely within the following 14 days. The pathologic diagnosis was nonfunctioning pituitary adenoma with hemorrhage and necrosis.

Endoscopic Endonasal Surgery for Treatment of Pituitary Apoplexy: 16 Years of Experience in a Specialized Pituitary Center

OBJECTIVE

Symptomatic pituitary apoplexy is a rare but life-threatening condition caused by sudden hemorrhage or infarction of a pituitary adenoma. In the current study, we aim to evaluate the clinical presentation, management, and clinical outcomes in a cohort of patients who were treated for this condition in our center in the last 16 years.

METHODS

We performed a retrospective analysis of all patients who underwent endoscopic endonasal surgery for treatment of symptomatic pituitary apoplexy between 2001 and 2016 in our center.

RESULTS

A total of 39 patients were included in the study, mean age of 54.9 years (range, 18-70 years) and mean follow-up 5.1 years (range, 0.6-16 years). Most of the patients had nonfunctioning adenomas (32 patients). Headache (89%), visual impairment (79%), and hypopituitarism (86%) were the most common preoperative findings. Surgical treatment led to gross total resection in 31 patients (79.4%). During follow-up, visual fields and oculomotor improvement was observed in 23 (74.1%) and 21 (67.7%) of the patients, respectively. Intractable headache also improved in all patients. Hypopituitarism was present in 77% of patients after surgery. In this series, no cerebrospinal fluid leak, vascular injury, or infection was observed. There was no postoperative mortality.

CONCLUSIONS

The endoscopic endonasal transsphenoidal approach is an effective modality to treat pituitary apoplexy with a high rate of success and minimal risk in selected cases. Although reversion of preoperative visual deficits is often observed, hormonal deficits tend to persist, and require long-term hormonal therapy, even after successful endoscopic endonasal surgical resection.

Unusual Complication of Pituitary Macroadenoma: A Case Report and Review

Patient: Male, 48

Final Diagnosis: Pituitary apoplexy complicated by cerebral infarction

Symptoms: Disturbed conscious level • loss of vision

Medication: —

Clinical Procedure: —

Specialty: Radiology

Time Course of Symptomatic Recovery After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma Apoplexy in the Modern Era

BACKGROUND

Pituitary tumor apoplexy can result from either hemorrhagic or infarctive expansion of pituitary adenomas, and the related mass effect can result in compression of critical neurovascular structures. The time course of recovery of visual field deficits, headaches, ophthalmoparesis, and pituitary dysfunction after endoscopic transsphenoidal surgery has not been well established.

METHODS

Medical records were retrospectively reviewed for all patients who underwent endoscopic transsphenoidal surgery for pituitary tumor apoplexy from April 2008 to November 2014.

RESULTS

Of 578 patients who underwent transsphenoidal surgery, pituitary tumor apoplexy was identified in 44 patients (7.6%). Two patients had prior surgery, leaving 42 patients for final analysis. These included infarction-related apoplexy in 7 (14.4%) patients, and hemorrhagic apoplexy in 35 (85.6%) patients. Hemorrhagic adenomas had a larger axial tumor diameter than patients with infarctive adenomas (4.4 ± 4.1 cm vs. 1.8 ± 0.8 cm; P < 0.01), but were otherwise equivalent. At an average last follow-up of 2.52 years (range, 0.1-6.7 years), resolution of ophthalmoparesis as a result of pituitary tumor apoplexy demonstrated the longest recovery course (range, 2.4 ± 2.2 months) compared with visual field deficits (range, 8.0 ± 9.9 days), headaches (range, 1.9 ± 3.0 days), or pituitary dysfunction (range, 2.0 ± 1.8 weeks; P < 0.01). All patients who presented with headaches (n = 37) and/or visual disturbances (n = 22) had complete resolution of symptoms at last follow-up, whereas 83.3% of patients who presented with ophthalmoplegia experienced resolution. Endocrinologic dysfunction remained relatively consistent after surgery.

CONCLUSIONS

Endoscopic transsphenoidal surgery can provide durable resolution of symptoms for patients presenting with pituitary tumor apoplexy. Recovery from headaches, visual, and pituitary dysfunction may be more rapid compared with ophthalmoparesis.

Pituitary apoplexy: pathophysiology, diagnosis and management

Pituitary apoplexy is characterized by sudden increase in pituitary gland volume secondary to ischemia and/or necrosis, usually in a pituitary adenoma. Most cases occur during the 5th decade of life, predominantly in males and in previously unknown clinically non-functioning pituitary adenomas. There are some predisposing factors as arterial hypertension, anticoagulant therapy and major surgery. Clinical picture comprises headache, visual impairment, cranial nerve palsies and hypopituitarism. Most cases improve with both surgical and expectant management and the best approach in the acute phase is still controversial. Surgery, usually by transsphenoidal route, is indicated if consciousness and/or vision are impaired, despite glucocorticoid replacement and electrolyte support. Pituitary function is impaired in most patients before apoplexy and ACTH deficiency is common, which makes glucocorticoid replacement needed in most cases. Pituitary deficiencies, once established, usually do not recover, regardless the treatment. Sellar imaging and endocrinological function must be periodic reevaluated.

Spontaneous pituitary apoplexy during the second trimester of pregnancy, with sensory loss

A 32-year-old Hispanic woman at 23 weeks gestation presented with right-sided headache, associated with photophobia and right-sided numbness. She denied visual problems, menstrual irregularities and galactorrhoea. Examination revealed visual acuity 20/40 bilaterally with some blurriness on the left side, decreased right V1-V2 facial sensation and preserved 5/5 power, but decreased sensation over the entire right upper extremity (RUE) and right lower extremity (RLE) to touch and pinprick. Laboratories suggested normal pituitary function, but MRI of the brain revealed enlargement of the pituitary (1.7 cm), with layering haemorrhage posteriorly and mild compression of the optic nerve. The patient underwent emergent evacuation of a pituitary haematoma, and histology revealed minute fragments of adenohypophysis with haemorrhage and fibrosis.

Neuroendocrine disorders: pituitary imaging

Significant advances in pituitary imaging have taken place in the past several decades, including the introduction of magnetic resonance imaging (MRI). This imaging modality has vastly improved our ability to detect and characterize sellar masses and more accurately characterize the extent and spread of lesions in and around the sella. Intraoperative MRI may help improve the completeness of resection of sellar masses. Other imaging modalities, including magnetic resonance angiography, computed tomography (CT), and CT angiography, have an important role in specific cases. Interventional methods, including bilateral inferior petrosal sinus sampling, may establish the pituitary origin of corticotropin (ACTH) excess in patients with ACTH-dependent Cushing's syndrome. Pituitary imaging should be obtained in patients with pituitary hormone excess, hypopituitarism, or mass effect in the sella. Despite rapid advances in pituitary imaging, there are several diagnostic challenges remaining. Future research may help improve the radiographic detection of small sellar lesions, such as ACTH-secreting adenomas causing Cushing's disease, accurately characterize the type and extent of sellar pathologies, and provide prognostic information regarding their growth potential.