1
|
Pagoada-Torres JD, Villalobos-Díaz R, Pineda-Centeno LM, Pesci-Eguia L, Gomez-Villegas T, Rivera-Montes H, Portocarrero-Ortiz LA. Bilateral Sixth Nerve Palsy: A Rare Presentation of Primary Hypophysitis. Cureus 2024; 16:e58850. [PMID: 38784347 PMCID: PMC11115475 DOI: 10.7759/cureus.58850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Cranial nerve palsy is common in pituitary disease and depends on the extension of the lesion into the cavernous sinuses. Bilateral cranial nerve palsy was described in pituitary adenomas with apoplexy and in only one case in hypophysitis. We present a case of a 32-year-old female manifesting with headache, diplopia, bilateral sixth nerve palsy, and hypopituitarism. Magnetic resonance imaging (MRI) revealed symmetric expansion of the pituitary gland, with bilateral cavernous sinus invasion and thickening of the pituitary stalk. Hypophysitis was suspected, and after treatment with IV methylprednisolone boluses, a decrease in the pituitary lesion was observed, with complete remission of sixth nerve palsy in the right eye and partial improvement in the left eye. In this case, we report an infrequent form of presentation of hypophysitis, and highlight that steroids are the first line of treatment.
Collapse
Affiliation(s)
- Josue D Pagoada-Torres
- Endocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Rodolfo Villalobos-Díaz
- Neurosurgery, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Luz M Pineda-Centeno
- Neurology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Luis Pesci-Eguia
- Ophthalmology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Thamar Gomez-Villegas
- Ophthalmology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Hector Rivera-Montes
- Endocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Lesly A Portocarrero-Ortiz
- Neuroendocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Yokoyama K, Ikeda N, Sugie A, Yamada M, Tanaka H, Ito Y, Kawanishi M. A Case of Nonapoplectic Pituitary Adenoma Presenting with Isolated Oculomotor Nerve Palsy. Asian J Neurosurg 2021; 16:391-393. [PMID: 34268172 PMCID: PMC8244716 DOI: 10.4103/ajns.ajns_397_20] [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: 08/14/2020] [Revised: 11/25/2020] [Accepted: 03/28/2021] [Indexed: 12/03/2022] Open
Abstract
We report a rare case of nonapoplectic pituitary adenoma that did not invade the cavernous sinus and was associated with isolated oculomotor nerve palsy. A 61-year-old male was admitted to our hospital due to diplopia that had gradually worsened from 6 months to presentation. He was diagnosed with right oculomotor nerve palsy, and brain magnetic resonance imaging (MRI) showed a mass lesion within the sella. The tumor was homogeneously enhanced on contrast-enhanced MRI. However, no findings suggestive of pituitary apoplexy were found. Brain computed tomography revealed the tumor to have eroded the right side of the posterior clinoid process by gradual expansion. Endoscopic transsphenoidal surgery was used for complete resection of the tumor. Intraoperative findings showed that the tumor did not invade the cavernous sinus. The histological diagnosis was pituitary adenoma, and symptom improvement was observed from the early postoperative stage onward. Surgical treatment is essential because oculomotor nerve palsy caused by the enlargement of pituitary adenoma is not expected to resolve if treated conservatively, unlike that caused by pituitary apoplexy.
Collapse
Affiliation(s)
- Kunio Yokoyama
- Department of Neurosurgery, Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Naokado Ikeda
- Department of Neurosurgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Akira Sugie
- Department of Neurosurgery, Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Makoto Yamada
- Department of Neurosurgery, Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Hidekazu Tanaka
- Department of Neurosurgery, Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Yutaka Ito
- Department of Neurosurgery, Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Masahiro Kawanishi
- Department of Neurosurgery, Takeda General Hospital, Fushimi, Kyoto, Japan
| |
Collapse
|
4
|
Comparative analysis of pituitary adenoma with and without apoplexy in pediatric and adolescent patients: a clinical series of 80 patients. Neurosurg Rev 2021; 45:491-498. [PMID: 33914243 DOI: 10.1007/s10143-021-01551-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
Pituitary adenomas (PAs) have a low incidence in pediatric and adolescent patients, and their clinical characteristics remain unclear. As a severe complication of PA, apoplexy was investigated in young patients in the present study. Eighty patients younger than 20 years with PAs who underwent surgery were included and divided into an apoplexy group and non-apoplexy group. The clinical data of these two groups were statistically analyzed and compared. The study included 33 boys and 47 girls, with a mean age of 16.9 years. There were six (7.5%) adrenocorticotropic hormone-secreting, 13 (16.3%) growth hormone-secreting, 47 (58.7%) prolactin-secreting, and 14 (17.5%) non-functioning PAs. There were 34 (42.5%) patients in the apoplexy group and 46 (57.5%) patients in the non-apoplexy group. Pre-operatively, patients in the apoplexy group were more likely to have visual impairment (hazard ratio: 2.841, 95% confidence interval: 1.073-7.519; P = 0.033) and had poorer visual impairment scores than those in the non-apoplexy group (P = 0.027). Furthermore, a longer duration of symptoms before surgery was significantly correlated with a poorer visual outcome in the apoplexy group (R = - 1.204; P = 0.035). However, apoplexy was not associated with tumor type, tumor size, resection rate, or tumor recurrence. Tumor apoplexy is common in pediatric and adolescent patients with PAs and is associated with more severe preoperative visual deficits. Hence, the appropriate timing of surgical treatment may be important for rescuing visual function in young PA patients.
Collapse
|
5
|
Munawar K, Nayak G, Fatterpekar GM, Sen C, Zagzag D, Zan E, Hagiwara M. Cavernous sinus lesions. Clin Imaging 2020; 68:71-89. [PMID: 32574933 DOI: 10.1016/j.clinimag.2020.06.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 11/16/2022]
Abstract
The cavernous sinus is a complex structure susceptible to a wide variety of vascular, neoplastic and inflammatory pathologies. Vascular pathologies include ICA aneurysms, carotid-cavernous fistulas, cavernous sinus thrombosis, and cavernous hemangioma. Neoplasms that involve the cavernous sinus include pituitary adenoma, meningioma, schwannoma, lymphoma, perineural tumor spread, metastases, and direct tumor invasion. Infectious and inflammatory diseases include Tolosa-Hunt syndrome, sarcoidosis, granulomatosis with polyangiitis, IgG-4 related disease and invasive fungal infections. In this article, we review the clinical and imaging findings of a number of pathologies involving the cavernous sinus, focusing on key features that can narrow the differential diagnosis and, in some cases, support a particular diagnosis.
Collapse
Affiliation(s)
- Kamran Munawar
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Gopi Nayak
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Girish M Fatterpekar
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Chandra Sen
- NYU Langone Health, Department of Neurosurgery, New York, NY, United States of America
| | - David Zagzag
- NYU Langone Health, Department of Pathology, New York, NY, United States of America
| | - Elcin Zan
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Mari Hagiwara
- NYU Langone Health, Department of Radiology, New York, NY, United States of America.
| |
Collapse
|
6
|
Cho H, Song YJ, Ryu WY. Pituitary Apoplexy Presenting as Isolated Bilateral Oculomotor Nerve Palsy. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.10.1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Heejung Cho
- Department of Ophthalmology, Dong-A University College of Medicine, Busan, Korea
| | - Young Jin Song
- Department of Neurosurgery, Dong-A University College of Medicine, Busan, Korea
| | - Won Yeol Ryu
- Department of Ophthalmology, Dong-A University College of Medicine, Busan, Korea
| |
Collapse
|
7
|
Salehi N, Firek A, Munir I. Pituitary Apoplexy Presenting as Ophthalmoplegia and Altered Level of Consciousness without Headache. Case Rep Endocrinol 2018; 2018:7124364. [PMID: 29854489 PMCID: PMC5966706 DOI: 10.1155/2018/7124364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 03/28/2018] [Indexed: 11/18/2022] Open
Abstract
Background. Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The typical clinical presentation of PA includes acute onset of severe headache, visual disturbance, cranial nerve palsy, and altered level of consciousness. Case Report. A 78-year-old man presented to the emergency department with one-day history of ptosis and diplopia and an acute-onset episode of altered level of consciousness which was resolving. He denied having headache, nausea, or vomiting. Physical examination revealed third-cranial nerve palsy and fourth-cranial nerve palsy both on the right side. Noncontrast computed tomography (CT) scan of the head was unremarkable. Brain magnetic resonance imaging (MRI) showed a pituitary mass with hemorrhage (apoplexy) and extension to the right cavernous sinus. The patient developed another episode of altered level of consciousness in the hospital. Transsphenoidal resection of the tumor was done which resulted in complete recovery of the ophthalmoplegia and mental status. Conclusion. Pituitary apoplexy can present with ophthalmoplegia and altered level of consciousness without having headache, nausea, or vomiting. A CT scan of the head could be negative for hemorrhage. A high index of suspicion is needed for early diagnosis and timely management of pituitary apoplexy.
Collapse
Affiliation(s)
- Nooshin Salehi
- Department of Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Anthony Firek
- Division of Endocrinology, Department of Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Iqbal Munir
- Division of Endocrinology, Department of Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| |
Collapse
|
8
|
Wright HE, Brodsky MC, Chacko JG, Ramakrishnaiah RH, Phillips PH. Diplopia is better than no plopia! Surv Ophthalmol 2017; 62:875-881. [DOI: 10.1016/j.survophthal.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022]
|
9
|
Teasdale S, Hashem F, Olson S, Ong B, Inder WJ. Recurrent pituitary apoplexy due to two successive neoplasms presenting with ocular paresis and epistaxis. Endocrinol Diabetes Metab Case Rep 2015; 2015:140088. [PMID: 25755879 PMCID: PMC4322370 DOI: 10.1530/edm-14-0088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 01/19/2015] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED A case of recurrent pituitary apoplexy is described in a 72-year-old man who initially presented with haemorrhage in a non-functioning pituitary adenoma. Five years later, he re-presented with a severe pituitary haemorrhage in an enlarging sellar mass invading both cavernous sinuses causing epistaxis and bilateral ocular paresis. Subsequent histology was consistent with a sellar malignant spindle and round cell neoplasm. Multiple pituitary tumours have previously been reported to coexist in the same individual, but to our knowledge this is the only case where two pathologically distinct pituitary neoplasms have sequentially arisen in a single patient. This case is also notable with respect to the progressive ocular paresis, including bilateral abducens nerve palsies, and the presentation with epistaxis. LEARNING POINTS Ocular paresis in pituitary apoplexy can result from tumour infiltration of nerves, or by indirect compression via increased intrasellar pressure.Epistaxis is a very rare presentation of a pituitary lesion.Epistaxis more commonly occurs following trans-sphenoidal surgery, and can be delayed.
Collapse
Affiliation(s)
- Stephanie Teasdale
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital , Brisbane, Queensland , Australia
| | - Fahid Hashem
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital , Brisbane, Queensland , Australia
| | - Sarah Olson
- Department of Neurosurgery, Princess Alexandra Hospital , Brisbane, Queensland , Australia
| | - Benjamin Ong
- Department of Radiology, Princess Alexandra Hospital , Brisbane, Queensland , Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital , Brisbane, Queensland , Australia ; School of Medicine, The University of Queensland Brisbane, Queensland , Australia
| |
Collapse
|
10
|
Berkenstock M, Szeles A, Ackert J. Encephalopathy, Chiasmal Compression, Ophthalmoplegia, and Diabetes Insipidus in Pituitary Apoplexy. Neuroophthalmology 2014; 38:286-289. [PMID: 27928316 DOI: 10.3109/01658107.2014.944315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/03/2014] [Accepted: 07/03/2014] [Indexed: 11/13/2022] Open
Abstract
Pituitary apoplexy with haemorrhage is a potentially life-threatening condition, and a rare cause of third nerve palsies. The range of vision loss and ophthalmoplegia seen in cases of apoplexy reflects the variability of cranial structures compressed by mass effect. The pathophysiology of extraocular muscle limitation and facial paraesthesia occurs with compression of the cavernous sinus, which contains cranial nerves III, IV, VI, and the ophthalmic branch of V. Blood supply to adjacent structures may be also compromised, causing additional loss of function. This case report of a patient with diabetes insipidus and a third nerve palsy illustrates the anatomic basis of the presenting signs of pituitary apoplexy, and the necessity for prompt neuroimaging if it is suspected.
Collapse
Affiliation(s)
- Meghan Berkenstock
- Department of Ophthalmology, Drexel University College of Medicine Philadelphia, Pennsylvania USA
| | - Alexander Szeles
- Department of Ophthalmology, Drexel University College of Medicine Philadelphia, Pennsylvania USA
| | - Jessica Ackert
- Department of Ophthalmology, Drexel University College of Medicine Philadelphia, Pennsylvania USA
| |
Collapse
|
11
|
Adam MK, Krespan K, Moster ML, Sergott RC. Simultaneous, Bilateral Ophthalmoplegia as the Presenting Sign of Paediatric Multiple Sclerosis: Case Report and Discussion of the Differential Diagnosis. Neuroophthalmology 2014; 38:230-237. [DOI: 10.3109/01658107.2014.902972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 12/18/2022] Open
|
12
|
Ní Chróinín D, Lambert J. Sudden headache, third nerve palsy and visual deficit: thinking outside the subarachnoid haemorrhage box. Age Ageing 2013; 42:810-2. [PMID: 23913476 DOI: 10.1093/ageing/aft088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 75-year-old lady presented with sudden severe headache and vomiting. Examination was normal, and CT and lumbar puncture not convincing for subarachnoid haemorrhage. Shortly thereafter, she developed painless diplopia. Examination confirmed right third cranial nerve palsy plus homonymous left inferior quadrantanopia. Urgent cerebral MRI with angiography was requested to assess for a possible posterior communicating artery aneurysm, but revealed an unsuspected pituitary mass. Pituitary adenoma with pituitary apoplexy was diagnosed. Pituitary apopolexy is a syndrome comprising sudden headache, meningism, visual and/or oculomotor deficits, with an intrasellar mass. It is commonly due to haemorrhage or infarction within a pituitary adenoma. Treatment includes prompt steroid administration, and potentially surgical decompression. While subarachnoid haemorrhage is an important, well-recognised cause of sudden severe headache, other aetiologies, including pituitary apoplexy, should be considered and sought.
Collapse
|