1
|
Brás-Cruz R, Cruz I, Camões S. Pituitary apoplexy and cerebral infarction. BMJ Case Rep 2023; 16:e254507. [PMID: 37185246 PMCID: PMC10151939 DOI: 10.1136/bcr-2022-254507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Pituitary apoplexy (PA) is a possible complication of pituitary adenoma but is rarely followed by cerebral infarction. The mechanism by which this occurs is not totally understood but is believed to have multiple aetiologies such as arterial compression due to mass effect, vasospasm induced by the presence of blood or by vasoactive agents. In this report, we present a man in his 80s with known pituitary adenoma with a sudden onset of left central facial palsy, left hemiparesis, paresis of the VI left pair and previously unrecognised atrial fibrillation in the ECG. At first, the signs of haemorrhage on imaging were unnoticed, which led to a diagnosis of ischaemic stroke that was submitted to thrombolysis. Due to complications during hospitalisation, the team suspected of PA with panhypopituitarism, confirmed by brain MRI and blood tests. The patient underwent conservative management with glucocorticoids with resolution of the acute adrenal insufficiency related symptoms.
Collapse
Affiliation(s)
- Rute Brás-Cruz
- Department of Medicine - Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Isabel Cruz
- Internal Medicine, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Sara Camões
- Department of Medicine - Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| |
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
|
Pituitary Apoplexy Causing Bilateral Internal Carotid Artery Ischemia. Neurol Sci 2023; 50:147-148. [PMID: 34904555 DOI: 10.1017/cjn.2021.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
4
|
Holanda TSF, Pimentel IMF, Araujo PVFG, da Silva Damasceno Gomes JÍ, de Morais Moreira VC, Soares TBS, de Albuquerque LAF. Unusual bifrontal cerebral infarction related to pituitary apoplexy. An uncommon presentation and literature review. Surg Neurol Int 2022; 13:577. [PMID: 36600731 PMCID: PMC9805633 DOI: 10.25259/sni_979_2022] [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: 10/25/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
Background Pituitary apoplexy (PA) is a syndromic condition described in 1950. The main symptoms are headache, visual impairment, ophthalmoplegia, and hypopituitarism. The relationship between stroke and PA is uncommon and two mechanisms are described: vascular compression and vasospasm. Case Report A 65-old-year man presented with severe headache, vomiting, ophthalmoplegia, and somnolence. Radiological examinations showed an expansive sellar and suprasellar lesion with a heterogeneous signal, besides Diffusion-weighted imaging (DWI) restriction in the bifrontal area was present. The findings were compatible with PA and stroke. Conclusion PA leading to cerebral infarction is a rare condition that presents high morbidity and mortality levels. There are two main mechanisms related: direct arterial compression and arterial vasospasm. The cases must be conducted as neuroendocrinological emergencies and surgical management is a key point to better the prognosis of patients.
Collapse
Affiliation(s)
- Tiago S. F. Holanda
- Department of Neurosurgery, General Hospital of Fortaleza, Fortaleza, Brazil.,Corresponding author: Tiago S. F. Holanda, Department of Neurosurgery, General Hospital of Fortaleza, Fortaleza, Brazil.
| | | | | | | | | | | | | |
Collapse
|
5
|
Osorio RC, Oh JY, Choudhary N, Lad M, Savastano L, Aghi MK. Pituitary adenomas and cerebrovascular disease: A review on pathophysiology, prevalence, and treatment. Front Endocrinol (Lausanne) 2022; 13:1064216. [PMID: 36578965 PMCID: PMC9791098 DOI: 10.3389/fendo.2022.1064216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Pituitary adenomas (PAs) have been shown to cause excess cardiovascular disease comorbidity and mortality. Cerebrovascular disease (CeVD) is a small subset of cardiovascular disease with high morbidity, and its risk in patients with pituitary adenomas has been sparingly explored. In this review, we examine what is known about the prevalence of cerebrovascular disease in patients with PAs, from its initial discovery in 1970 to present. An abundance of literature describes increased cerebrovascular mortality in patients with acromegaly, while research on other PA subtypes is less frequent but shows a similarly elevated CeVD mortality relative to healthy populations. We also review how cerebrovascular risk changes after PAs are treated, with PA treatment appearing to prevent further accumulation of cerebrovascular risk without reversing prior elevations. While acromegaly-associated CeVD appears to be caused by elevated growth hormone (GH) levels and Cushing disease's elevated glucocorticoids similarly cause durable alterations in cerebrovascular structure and function, less is known about the mechanisms behind CeVD in other PA subpopulations. Proposed pathophysiologies include growth hormone deficiency inducing vessel wall damage or other hormone deficits causing increased atherosclerotic disease. Early diagnosis and treatment of PAs may be the key to minimizing lifetime CeVD risk elevations. More research is needed to better understand the mechanisms behind the increased CeVD seen in patients with PAs. Physicians caring for PA patients must remain vigilant for signs and symptoms of cerebrovascular disease in this patient population.
Collapse
|
6
|
Teramoto S, Tahara S, Kondo A, Morita A. Key Factors Related to Internal Carotid Artery Stenosis Associated with Pituitary Apoplexy. World Neurosurg 2021; 149:e447-e454. [PMID: 33567365 DOI: 10.1016/j.wneu.2021.02.005] [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: 01/15/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Internal carotid artery (ICA) stenosis rarely occurs in pituitary apoplexy. Little is known of the causes of this condition. The present study investigated the factors related to ICA stenosis associated with pituitary apoplexy. METHODS Forty-five patients with pituitary apoplexy were retrospectively examined and divided into the stenotic and normal ICA groups. The baseline characteristics of patient background, tumor properties, clinical findings, and treatment overview were compared between the groups. RESULTS Eight patients were assigned to the stenotic ICA group and 37 to the normal ICA group. Patient age in the stenotic ICA group was significantly lower than that in the normal ICA group (P = 0.001). Maximum tumor diameter (P = 0.001), tumor volume (P = 0.044), and Knosp grade (P < 0.001) were significantly greater in the stenotic ICA group than in the normal ICA group. The stenotic ICA group had a significantly greater incidence of sphenoid sinus mucosal thickening than the normal-ICA group (P = 0.039). Multivariate logistic regression analysis demonstrated that age (odds ratio 0.915, 95% confidence interval 0.846-0.991, P = 0.029) was a significant and independent predictor of ICA stenosis associated with pituitary apoplexy. Receiver operating characteristic curve analysis showed that the optimal cut-off point for age was 35.0 years (specificity 0.946, sensitivity 0.750). CONCLUSIONS Our study revealed that age, tumor size, and sphenoid sinus mucosal thickening were strongly related to the occurrence of ICA stenosis in pituitary apoplexy. Among these factors, age had the potential of being an independent predictor of the condition.
Collapse
Affiliation(s)
- Shinichiro Teramoto
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan; Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan.
| | | | - Akihide Kondo
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akio Morita
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
7
|
Oh JS, Kim HJ, Hann HJ, Kang TU, Kim DS, Kang MJ, Lee JY, Shim JJ, Lee MR, Ahn HS. Incidence, mortality, and cardiovascular diseases in pituitary adenoma in Korea: a nationwide population-based study. Pituitary 2021; 24:38-47. [PMID: 32949324 DOI: 10.1007/s11102-020-01084-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Few nationally representative studies have evaluated the epidemiology of PA (pituitary adenoma). This South Korean study evaluated the incidence of different PA subtypes, cardiovascular disease (CVD), and related mortality. METHODS This population-based study evaluated 31,898 patients with PA during 2005-2015. The incidence of PA, mortality, and CVD occurrence in PA cases were evaluated during a median follow-up of 5.3 years (range: 0-10 years). Cox regression analysis was used to evaluate the associations between CVD and mortality. RESULTS The annual incidences (per 100,000 population) were 3.5 for non-functioning pituitary adenoma (NFPA), 1.6 for prolactinoma (PRL), 0.5 for growth hormone-secreting pituitary adenoma (GH), and 0.2 for adrenocorticotropic or thyroid-stimulating hormone-secreting pituitary adenoma (ACTH + TSH). The standardized mortality ratios were 1.9 for ACTH + TSH, 1.7 for NFPA with hypopituitarism, 1.4 for NFPA without hypopituitarism, 1.3 for GH, and 1.1 for PRL. During 2005-2015, the overall incidence of CVD among PA patients was 6.6% (2106 cases), and the standardized incidence ratios were 4.1 for hemorrhagic stroke, 3.0 for ischemic stroke, and 1.7 for acute myocardial infarction. The standardized incidence ratios for stroke were significantly higher in the ACTH + TSH and NFPA groups, which also had higher risks of CVD-related mortality, relative to the PRL and GH groups. CONCLUSION South Korea had a relatively high incidence of NFPA. The incidence of stroke was highest for ACTH + TSH and NFPA, which was directly related to mortality during long-term follow-up. Patients with these types of PA should receive stroke prevention measures to reduce their risk of mortality.
Collapse
Affiliation(s)
- Jae Sang Oh
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Asan, Republic of Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, College of Medicine, Korea University, 126-1, 5-ga, Anam-dong, Sungbuk-gu, Seoul, 136-705, Republic of Korea
| | - Hoo Jae Hann
- Medical Research Institute, Ewha Womans University, Seoul, Republic of Korea
| | - Tae Uk Kang
- Department of Public Health, Graduate School, Korea University, Seoul, Republic of Korea
| | - Dong Sook Kim
- Department of Research, Health Insurance Review & Assessment Service, Wonju, Republic of Korea
| | - Min Ji Kang
- Department of Public Health, Graduate School, Korea University, Seoul, Republic of Korea
| | - Ji Young Lee
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Asan, Republic of Korea
| | - Jai Joon Shim
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Asan, Republic of Korea
| | - Man Ryul Lee
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Cheonan Hospital, Republic of Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, 126-1, 5-ga, Anam-dong, Sungbuk-gu, Seoul, 136-705, Republic of Korea.
| |
Collapse
|