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Wu J, Li S, Huang Y, Zeng Z, Mei T, Wang S, Wang W, Zhang F. MRI features of pituitary adenoma apoplexy and their relationship with hypoxia, proliferation, and pathology. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023. [PMID: 37235536 DOI: 10.1002/jcu.23492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/20/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE We aim to study the MRI features of pituitary adenoma (PA) apoplexy and their relationship with hypoxia, proliferation, and pathology. METHODS Sixty-seven patients with MRI signs of PA apoplexy were selected. According to the MRI signs, they were divided into the parenchymal group and the cystic group. The parenchymal group had a low signal area on T2WI without cyst >2 mm and this area was not significantly enhanced on the corresponding TW1 enhancement. The cystic group had a cyst >2 mm on T2WI, and the cyst showed liquid stratification on T2WI or high signal on T1WI. The relative T1WI (rT1WI) enhancement value and relative T2WI (rT2WI) value of non-apoplexy areas were measured. Protein levels of hypoxia-inducible factor-1 (HIF-1α), pyruvate dehydrogenase kinase 1 (PDK1), and Ki67 were detected with immunohistochemistry and Western blot. Nuclear morphology was observed with HE staining. RESULTS The rT1WI enhancement average value, rT2WI average value, Ki67 protein expression level, and the number of abnormal nuclear morphology of non-apoplexy lesions in the parenchymal group were significantly lower than those in the cystic group. The protein expression levels of HIF-1α and PDK1 in the parenchymal group were significantly higher than those in the cystic group. HIF-1α protein was positively correlated with PDK1 but negatively correlated with Ki67. CONCLUSION When there is PA apoplexy, the ischemia and hypoxia of the cystic group are lesser than those of the parenchymal group, but the proliferation is stronger.
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Affiliation(s)
- Jianwu Wu
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Songyuan Li
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Yinxing Huang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Zihuan Zeng
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Tao Mei
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen, People's Republic of China
| | - Shousen Wang
- Department of Neurosurgery, 900 Hospital of the Joint Logistics Team, Fuzhou, People's Republic of China
| | - Wei Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Fangfang Zhang
- Department of Endocrinology, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, People's Republic of China
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Gheorghe AM, Trandafir AI, Ionovici N, Carsote M, Nistor C, Popa FL, Stanciu M. Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET). Biomedicines 2023; 11:biomedicines11030680. [PMID: 36979658 PMCID: PMC10044830 DOI: 10.3390/biomedicines11030680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
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.
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Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra Ioana Trandafir
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Nina Ionovici
- Department of Occupational Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy & “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy & Thoracic Surgery Department, “Carol Davila” Central Emergency University Military Hospital, 013058 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania
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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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Sedai H, Shrestha S, Poddar E, Sharma P, Dahal D, Khatiwada P, Pradhanang A. Delayed identification of massive pituitary apoplexy in pregnancy: A case report. Int J Surg Case Rep 2022; 99:107706. [PMID: 36261935 PMCID: PMC9568870 DOI: 10.1016/j.ijscr.2022.107706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/16/2022] [Accepted: 09/24/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction and importance Pituitary apoplexy is a very rare cause of sudden and severe headache with a neuro-ophthalmic deficit during pregnancy due to hemorrhage or infarction in the pituitary gland. Delayed identification can be life-threatening to both mother and baby. Case presentation A 40-year-old nulliparous female without any prior comorbidities in her 21 weeks of gestation presented with complaints of severe headache, vomiting, decreased vision, and altered sensorium for five days. On a low index of suspicion of pituitary apoplexy, she was managed in the line of impending eclampsia at a local center. On presentation to our center; the neurological deficit had progressed. CT head showed massive pituitary apoplexy with sellar and suprasellar extension. She underwent emergency right pterional craniotomy and resection of the tumor with hematoma evacuation but lost her life on her 2nd postoperative day. Discussion In the context of pregnancy, the diagnosis of pituitary apoplexy can get tricky and overlap with other common conditions such as preeclampsia or eclampsia. Magnetic resonance imaging (MRI) is the most sensitive investigation to confirm the diagnosis. Corticotropic deficiency with adrenal insufficiency is a potentially life-threatening disorder for both mother and the fetus if left untreated. The choice between conservative management and surgical approach depends on the neuro-ophthalmic signs, MRI findings, and gestational week. Conclusion Pituitary apoplexy should be a differential diagnosis of acute severe headache in pregnancy which when suspected should be investigated promptly. Early identification and multi-disciplinary team management are imperative for better outcomes. Pituitary apoplexy is a very rare condition in pregnancy. It presents with a sudden and severe headache with neuro-ophthalmic deficits due to hemorrhage in the pituitary gland. Delayed identification can have a grave outcome to both mother and baby.
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Affiliation(s)
- Hari Sedai
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.
| | - Suraj Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Elisha Poddar
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Pratima Sharma
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Dipendra Dahal
- Nepal Medical College Teaching Hospital, Jorpati, Kathmandu, Nepal
| | - Prajwal Khatiwada
- Department of Neurosurgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Amit Pradhanang
- Department of Neurosurgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Zhu Q, Liang Y, Fan Z, Liu Y, Zhou C, Zhang H, Li T, Zhou Y, Yang J, Wang Y, Wang L. Ischemic Infarction of Pituitary Apoplexy: A Retrospective Study of 46 Cases From a Single Tertiary Center. Front Neurosci 2022; 15:808111. [PMID: 35140585 PMCID: PMC8818988 DOI: 10.3389/fnins.2021.808111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveIschemic infarction of pituitary apoplexy (PA) is a rare type of pituitary apoplexy. This study aims to characterize ischemic PA via clinical presentations, imaging data, histopathological manifestations, and focus on the management and prognosis of the disease.MethodsThis study retrospectively identified 46 patients with ischemic PA confirmed using histopathology at a single institution from January 2013 to December 2020. The clinical presentations, imaging data, laboratory examination, management, and outcomes were collected. We then summarized the clinical presentations, imaging features, intraoperative findings, and histopathological manifestations, and compared the outcomes based on the timing of surgical intervention.ResultsHeadache was the most common initial symptom (95.65%, 44/46), followed by visual disturbance (89.13%, 41/46), and nausea and vomiting (58.70%, 27/46). 91.3% of the patients had at least one pituitary dysfunction, with hypogonadism being the most common endocrine dysfunction (84.78%, 39/46). Cortisol dysfunction occurred in 24 (52.17%) patients and thyroid dysfunction occurred in 17 (36.96%). Typical rim enhancement and thickening of the sphenoid sinus on MRI were seen in 35 (85.37%) and 26 (56.52%) patients, respectively. Except for one patient with asymptomatic apoplexy, the remaining patients underwent early (≤ 1 week, 12 patients) and delayed (> 1 week, 33 patients) transsphenoidal surgery. Total tumor resection was achieved in 27 patients and subtotal tumor resection in 19 patients. At surgery, cottage cheese–like necrosis was observed in 50% (23/46) of the patients. At the last follow-up of 5.5 ± 2.7 years, 92.68% (38/41) of the patients had gained a significant improvement in visual disturbance regardless of surgical timing, and 65% of the patients were still receiving long-term hormone replacement therapy.ConclusionPatients with ischemic PA can be accurately diagnosed by typical imaging characteristics preoperatively. The timing of surgical intervention does not significantly affect the resolution of neurological and endocrinological dysfunctions. Preoperative endocrine dysfunctions are common and usually appear to be poor after surgical intervention.
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Andriuskeviciute A, Cossu G, Ameti A, Papadakis G, Daniel RT, Dunet V, Messerer M. Potential Association Between Anabolic Androgenic Steroid Abuse and Pituitary Apoplexy: A Case Report. Front Endocrinol (Lausanne) 2022; 13:890853. [PMID: 35937816 PMCID: PMC9354695 DOI: 10.3389/fendo.2022.890853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Pituitary apoplexy (PA) is a rare, and potentially life-threatening condition, caused by hemorrhage or infarction into the pituitary gland with a rapid expansion of the contents of the sella turcica, associated with sudden intense headache, neurological and endocrinological deterioration. The identification of risk factors is crucial for prevention and optimal management. Herein we report a case of PA occurring 1 month after the initiation of anabolic androgenic steroid abuse for bodybuilding. CASE REPORT A 40-year-old male patient presents with abrupt onset headache associated with left partial third cranial nerve palsy. The MRI shows a sellar lesion involving left cavernous sinus with a heterogenous anterior aspect of the lesion with hemorrhagic zones in favor of PA. Endocrine work-up shows high testosterone level in patient who was using exogenous testosterone without a medical prescription for a month. CONCLUSION We report a case of PA of a pituitary neuroendocrine tumor occurring shortly after AAS. The association between PA and AAS should be considered as a potential risk.
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Affiliation(s)
- Agne Andriuskeviciute
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Adelina Ameti
- Department of Endocrinology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Georgios Papadakis
- Department of Endocrinology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Vincent Dunet
- Department of Radiology, Neuroradiology division, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
- *Correspondence: Mahmoud Messerer,
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Kato Y, Ogawa Y, Tominaga T. Treatment and therapeutic strategies for pituitary apoplexy in pregnancy: a case series. J Med Case Rep 2021; 15:289. [PMID: 34039424 PMCID: PMC8157460 DOI: 10.1186/s13256-021-02892-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/03/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pregnancy is a known risk factor for pituitary apoplexy, which is life threatening for both mother and child. However, very few clinical interventions have been proposed for managing pituitary apoplexy in pregnancy. CASE PRESENTATION We describe the management of three cases of pituitary apoplexy during pregnancy and review available literature. Presenting symptoms in our case series were headache and/or visual disturbances, and the etiology in all cases was hemorrhage. Conservative therapy was followed until 34 weeks of gestation, after which babies were delivered by cesarean section with prophylactic bolus hydrocortisone supplementation. Tumor removal was only electively performed after delivery using the transsphenoidal approach. All three patients and their babies had a good clinical course, and postoperative pathological evaluation revealed that all tumors were functional and that they secreted prolactin. CONCLUSIONS Although the mechanism of pituitary apoplexy occurrence remains unknown, the most important treatment strategy for pituitary apoplexy in pregnancy remains adequate hydrocortisone supplementation and frequent hormonal investigation. Radiological follow-up should be performed only if clinical symptoms deteriorate, and optimal timing for surgical resection should be discussed by a multidisciplinary team that includes obstetricians and neonatologists.
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Affiliation(s)
- Yuya Kato
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi, 982-8523, Japan
| | - Yoshikazu Ogawa
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan.
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi, 982-8523, Japan
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Pangal DJ, Chesney K, Memel Z, Bonney PA, Strickland BA, Carmichael J, Shiroishi M, Jason Liu CS, Zada G. Pituitary Apoplexy Case Series: Outcomes After Endoscopic Endonasal Transsphenoidal Surgery at a Single Tertiary Center. World Neurosurg 2020; 137:e366-e372. [PMID: 32032792 DOI: 10.1016/j.wneu.2020.01.204] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management of pituitary apoplexy, caused by acute hemorrhage and/or infarction of a pituitary adenoma, is debated. OBJECTIVE To analyze clinical characteristics of patients undergoing endoscopic endonasal approaches (EEAs) for pituitary apoplexy. METHODS A retrospective review of patients at our institution from 2012 to 2018 undergoing EEA for pituitary apoplexy diagnosed clinically and with imaging/pathologic findings. Analysis included demographics, symptoms, neuroendocrine deficits, neuroimaging, complications, symptom resolution, and follow-up details. RESULTS Fifty patients (mean age, 53 years) were included. Preoperative symptoms included headache (86%), vision loss (62%), and cranial nerve paresis (40%). Mean tumor diameter was 2.7 cm and extrasellar extension was observed in 96% of tumors. Twenty-eight tumors were hemorrhagic (76%), 24 were necrotic (65%), and 13 (35%) had both features. Magnetic resonance imaging showed gross total resection in 58% of patients. Headache and vision loss improved in 87% and 86% of presenting patients. Cranial nerve paresis resolved in 72% of patients, partially improved in 11%, and remained unchanged in 17%. There were no deaths or carotid artery injuries. Surgical complications included postoperative cerebrospinal fluid leak (n = 4, 8%), epistaxis (n = 2, 4%), postoperative abscess (n = 1, 2%), and transient postoperative vision loss requiring reoperation (n = 1, 4%). Endocrinopathies improved in 21% of patients and panhypopituitarism persisted in 48% and developed in 6% of patients. Mean follow-up time was 26 months; 2 patients experienced recurrence. CONCLUSIONS EEA for pituitary apoplexy is effective in rapidly improving headache and visual symptoms. Although neuro-ophthalmic deficits often improve over time, panhypopituitarism persists in most patients after surgical resection.
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Affiliation(s)
- Dhiraj J Pangal
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Kelsi Chesney
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Zoe Memel
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - John Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Mark Shiroishi
- Department of Radiology, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Chia-Shang Jason Liu
- Department of Radiology, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
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Chen J, Li S. Clinical Study of Neurology Nursing on Cerebral Apoplexy Rehabilitation. Transl Neurosci 2019; 10:164-167. [PMID: 31410298 PMCID: PMC6689212 DOI: 10.1515/tnsci-2019-0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 04/09/2019] [Indexed: 11/15/2022] Open
Abstract
The incidence of cerebral apoplexy has been on the rise in recent years, and research on the treatment and care of this disease has also received much attention. Therefore, a clinical study of neurological care for cerebral apoplexy rehabilitation care was conducted. Firstly, the Diffie-Hellman key exchange algorithm is introduced, and then the Diffie-Hellman prediction model is established. The patient is taken as an example to carry out simulation test, and the prediction model is compared with the real data. The data of the network model training set, the verification set and the test set are obtained. Patients were divided into observation group and control group by random number table method. The evaluation indicators included the treatment efficiency and the quality of life of the two groups. The results showed that the effective rate of the observation group was higher than that of the control group, and the difference between the two groups was statistically significant (P < 0.05). The experiment proves that the clinical effect of neurological nursing on cerebral apoplexy rehabilitation nursing is positive, which can improve the limb movement and self-living ability of patients, improve the quality of life of patients and improve patient satisfaction. Clinical study of neurology nursing on cerebral apoplexy rehabilitation nursing is discussed in this paper, and the rehabilitation nursing method and formal standardized nursing process of this disease are standardized.
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Affiliation(s)
- Jie Chen
- The first hospital of Lanzhou University, Lanzhou City, China
| | - Shuangxi Li
- The first hospital of Lanzhou University, Lanzhou City, China
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Wang Z, Gao L, Wang W, Guo X, Feng C, Lian W, Li Y, Xing B. Coagulative necrotic pituitary adenoma apoplexy: A retrospective study of 21 cases from a large pituitary center in China. Pituitary 2019; 22:13-28. [PMID: 30390276 DOI: 10.1007/s11102-018-0922-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE Coagulative necrotic pituitary apoplexy (CNPA) is a clinical entity with unique intraoperative and histopathological manifestations. We aimed to improve the knowledge of this rare disease through the largest case series published to date. METHODS A retrospective review of 21 CNPA patients was performed from among 5095 patients who underwent surgery for pituitary adenomas at a single institution between January 2009 and June 2017. The demographic, clinical, endocrine, neuroimaging, intraoperative, and histopathological findings, management and prognosis were summarized. RESULTS Headache was the most common symptom that was observed in 21 patients, followed by visual disturbances (17/21, 81.0%), nausea and vomiting (16/21, 76.2%), electrolyte disturbance (13/21, 61.9%), and oculomotor palsies (10/21, 47.6%). Hypopituitarism with at least one anterior pituitary deficiency, especially panhypopituitarism (10/21, 47.6%), was present in 81.0% of patients. Most patients (81.0%) showed typical MRI appearances. All 21 patients underwent transsphenoidal surgery (TSS), and 16 patients had total tumor resection demonstrated by postoperative MRI. Cottage cheese-like necrosis was observed in 16 patients (76.2%) intraoperatively. Histopathology showed large areas of pink, acellular, coagulative necrotic areas in the central zone, and a pseudocapsule in the border zone. After follow-up for 4.3 ± 2.3 years, only 28.6% of patients still suffered from corticotropic deficiency, and 9.5% of patients had gonadotropic deficiency. These patients were administered the appropriate corresponding hormones for life. CONCLUSIONS CNPA can be correctly diagnosed preoperatively by typical clinical and MRI characteristics. Early surgery combined with hyperbaric oxygen therapy early postoperatively usually yields satisfactory endocrine and neuro-ophthalmic outcomes.
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Affiliation(s)
- Zihao Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lu Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wenze Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Chenzhe Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wei Lian
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Yongning Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
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Mid-term prognosis of non-functioning pituitary adenomas with high proliferative potential: really an aggressive variant? J Neurooncol 2018; 137:543-549. [DOI: 10.1007/s11060-017-2740-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/29/2017] [Indexed: 10/18/2022]
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Hayashi Y, Sasagawa Y, Kita D, Fukui I, Oishi M, Tachibana O, Ueda F, Nakada M. Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage. Pituitary 2017; 20:531-538. [PMID: 28616673 DOI: 10.1007/s11102-017-0814-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Although hemorrhage within pituitary adenomas frequently exacerbates the symptoms, there are many grades of severity. Moreover, the contributing factors for symptom severity are still controversial. METHODS This retrospective study included 82 patients who underwent transsphenoidal surgery for pituitary adenomas with intratumoral hemorrhage. The grades of preoperative symptoms were classified into group A, asymptomatic or minor symptoms; group B, moderate symptoms sufficient for complain; and group C, severe symptoms disturbing daily life. RESULTS The hemorrhage volume within an adenoma was significantly higher in group C (92.6%) than in groups A (48.6%) and B (58.7%). Both headache and diplopia were dominant in group C, occurring in 72.2% and 27.8% of the patients, respectively. In group C, there was no significant difference in frequency between adenoma extensions into the sphenoid sinus (0%) and involvement of the cavernous sinus of Knosp grade 4 (0%), and extensions into the suprasellar region were not common (38.9%). The most distinctive feature was that "no extrasellar extension" was found only in group C (41.2%), and "multidirectional extension" was not detected in this group (0%). Multiple regression analysis revealed that the most powerful determining factors were the high frequencies of intratumoral hemorrhage and lack of extrasellar and multidirectional extensions. CONCLUSION Rapid volume expansion of a hematoma and lack of extension or unidirectional extension might lead to significant compression of the sellar and surrounding structures. Of note, the integrity of the sellar dura might contribute to the acute onset of symptom manifestations caused by hemorrhage in pituitary adenomas.
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Affiliation(s)
- Yasuhiko Hayashi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Yasuo Sasagawa
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Daisuke Kita
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Issei Fukui
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Masahiro Oishi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Osamu Tachibana
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Fumiaki Ueda
- Department of Radiology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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Endoscopic Endonasal Surgery for Pituitary Apoplexy: Evidence On a 75-Case Series From a Tertiary Care Center. World Neurosurg 2017; 106:331-338. [PMID: 28669873 DOI: 10.1016/j.wneu.2017.06.117] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/17/2017] [Accepted: 06/19/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal management of pituitary apoplexy (PA) remains debated. The aim of this study was to assess the outcome of the transsphenoidal approach for PA in a large surgical experience. MATERIALS Each consecutive case of PA consecutively operated by endoscopic endonasal approach from our tertiary care center, from 1998 to 2015, was included in this series. RESULTS Seventy-five patients (47 male; mean age 52.4 ± 16.2 years) were included. Mean follow-up was 69.3 ± 46.7 months. On admission, all patients presented with abrupt severe headache (100%), associated with anterior hypopituitarism in 51 patients (68%), visual disturbances in 55 (73.4%), ophthalmoplegia in 38 (50.7%), and a remarkable reduction of consciousness in 2 (2.6%). Apoplexy proved to be ischemic in 35 patients (46.7%) and hemorrhagic in 40 (53.3%). Patients with hemorrhagic necrosis presented more often with major suprasellar expansion (P = 0.012) Radical removal was achieved in 60 cases (80%). Surgical morbidity consisted in one case of postoperative cerebrospinal fluid leak (1.3%). Anterior hypopituitarism worsened in 15 cases (20%), and diabetes insipidus occurred in 4 cases (5.3%). Ophthalmoplegia improved/normalized in 71% and visual symptoms in 85.5% of the patients, with better results achieved in ischemic forms (P = 0.043). The 2 comatose patients regained normal consciousness. CONCLUSIONS The endoscopic endonasal approach represents a valid, effective, and safe technique in the management of PA. Favorable outcomes can be achieved by referring patients to dedicated pituitary centers with a multidisciplinary team. Further studies are still needed to define criteria for surgical indication and to identify outcome predictors.
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Omodaka S, Ogawa Y, Sato K, Matsumoto Y, Tominaga T. Preoperative embolization and immediate removal of a giant pituitary adenoma: a case report. BMC Res Notes 2017; 10:63. [PMID: 28126010 PMCID: PMC5270227 DOI: 10.1186/s13104-017-2383-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 01/10/2017] [Indexed: 11/11/2022] Open
Abstract
Background Giant pituitary adenomas, with maximum diameter of at least 40 mm, continue to involve high surgical risks despite recent advances in microsurgical and/or endoscopic surgery. We treated a case of giant pituitary adenoma with preoperative endovascular embolization in an attempt to reduce blood loss. Case presentation A 48-year-old Japanese Woman presented with severe right visual disturbance. Magnetic resonance imaging revealed a giant pituitary adenoma with maximum diameter of 82 mm. Angiography revealed significant tumor stain, with blood supply mainly from the branches of the right meningohypophyseal trunk. These feeding arteries were endovascularly embolized with n-butyl cyanoacrylate. Subsequently, the tumor was safely removed by transsphenoidal surgery in two stages. The patient showed significant improvement of visual disturbance postoperatively, and was discharged without other neurological deficit. The surgical policy was explained preoperatively to the patients and written informed consents were obtained. Conclusions Preoperative embolization of a giant pituitary adenoma is a useful procedure that can potentially decrease the morbidity and mortality of this devastating tumor.
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Affiliation(s)
- Shunsuke Omodaka
- Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi, 982-8523, Japan
| | - Yoshikazu Ogawa
- Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi, 982-8523, Japan.
| | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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