Pituitary tumor apoplexy: characteristics, treatment, and outcomes

Subarachnoid hemorrhage due to pituitary adenoma apoplexy-case report and review of the literature

Pituitary apoplexy (PA) may be complicated by development of subarachnoid hemorrhage (SAH). We conducted a literature review to evaluate the rate of PA-associated tumor rupture and SAH. We conducted a systematic literature search (PubMed, Web of Science, Medline) for patients with PA-associated SAH and report a case SAH following PA. Suitable articles, case series, and case reports were selected based on predefined criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). We reviewed included publications for clinical, radiological, surgical, and histopathological parameters.We present the case of a patient with PA developing extensive SAH whilst on the MRI who underwent delayed transsphenoidal resection. According to our literature review, we found 55 patients with a median age of 46 years; 18 (32.7%) were female. Factors associated with PA-related SAH were hypertension, diabetes mellitus, prior trauma, anticoagulant, and/or antiplatelet therapy. The most common presenting symptoms included severe headache, nausea and/or vomiting, impaired consciousness, and meningeal irritation. Acute onset was described in almost all patients. Twenty-two of the included patients underwent resection. In patients with available outcome, 45.1% had a favorable outcome, 10 (19.6%) had persisting focal neurological deficits, 7 developed cerebral vasospasms (12.7%), and 18 (35.3%) died. Mortality greatly differed between surgically (9.1%) and non-surgically (44.8%) treated patients. PA-associated SAH is a rare condition developing predominantly in males with previously unknown macroadenomas. Timely surgery often prevents aggravation or development of severe neuro-ophthalmological defects and improves clinical outcome.

Non-colloid-cyst primary brain tumors: A systematic review of unexpected fatality

OBJECTIVE

Primary brain tumors have the potential to present a substantial health hazard, ultimately resulting in unforeseen fatalities. Despite the enhanced comprehension of many diseases, the precise prediction of disease progression continues to pose a significant challenge. The objective of this study is to investigate cases of unexpected mortality resulting from primary brain tumors and analyze the variables that contribute to such occurrences.

METHODS

This systematic review explores research on individuals diagnosed with primary brain tumors who experienced unexpected deaths. It uses PRISMA standards and searches PubMed, Google Scholar, and Scopus. Variables considered include age, gender, symptoms, tumor type, WHO grade, postmortem findings, time of death - time taken from first medical presentation or hospital admission to death, comorbidity, and risk factors.

RESULTS

This study examined 46 studies to analyze patient-level data from 76 individuals with unexpected deaths attributed to intracranial lesions, deliberately excluding colloid cysts. The cohort's age distribution showed an average age of 37 years, with no significant gender preference. Headache was the most common initial symptom. Astrocytomas, meningiomas, and glioblastoma were the most common lesions, while the frontal lobe, temporal lobe, and cerebellum were common locations. Meningiomas and astrocytomas showed faster deaths within the first hour of hospital admission.

CONCLUSION

The etiology of unforeseen fatalities resulting from cerebral tumors elucidates an intricate and varied phenomenon. Although unexpected deaths account for a very tiny proportion of total fatalities, it is probable that their actual occurrence is underestimated as a result of underreporting and misdiagnosis.

Secondary headaches in pregnancy and the puerperium

Headache during pregnancy can be due to primary causes such as migraine but can also be a presenting symptom of secondary causes including life threatening conditions. This is a minireview of secondary causes of headache during pregnancy and the puerperium. Unique alterations in physiological and vascular functions as well as in the coagulation pathway which occur during pregnancy increase the risk of most of these secondary conditions which include preeclampsia, eclampsia, hemorrhagic stroke, cerebral venous, sinus thrombosis, reversible cerebral vascular syndrome, and posterior reversible encephalopathy. Marked increase in progesterone level in pregnancy is also associated with the growth of tumors such as meningiomas, as 70% of these tumors are positive for progesterone receptors and increase in size can lead to headache along with other neurological symptoms. Hemodynamic changes can lead to the growth of meningiomas as well. Although hormone producing pituitary tumors are usually not conducing to pregnancy, women with known pituitary tumors who do get pregnant may become symptomatic during pregnancy and develop secondary headache. Another rare cause of secondary headache during pregnancy is pituitary apoplexy. Although its occurrence is uncommon, it needs to be properly recognized and treated to avoid endocrine and visual complications. Other rare entities with increased incidence during the puerperium such postdural puncture headache will be also discussed. In summary, new onset headache during pregnancy deserves special attention because in the absence of proper recognition and treatment, secondary headache disorders can endanger the life of the mother and the fetus.

Immune Thrombocytopenic Purpura Presenting with Pituitary Apoplexy: A Case Report and Literature Review

Background  Pituitary apoplexy is a rare condition that usually occurs in the setting of a pituitary adenoma. It can present with symptoms of visual disturbances, vertigo, headache, and neurological impairments. Computed tomography (CT) scans can aid in identifying pituitary apoplexy and ruling out other diseases. We present a unique case of pituitary apoplexy in the setting of immune thrombocytopenic purpura (ITP). Case Description  A 61-year-old man with a past medical history significant for myocardial infarction presented to the emergency department with symptoms of diplopia and headache 36 hours after onset. The patient was found to have severe thrombocytopenia with a platelet count below 20,000. A CT of the head revealed a possible pituitary adenoma with compression of the optic chiasm. The patient's platelet count continued to decrease throughout his admission and dropped below 7,000 on day 2 of admission. The patient was given platelet transfusion along with intravenous immunoglobulins. The patient underwent endoscopic transsphenoidal resection of the pituitary mass. Pathology of the mass revealed immature platelets characteristic of immune ITP in the setting of pituitary apoplexy. Conclusion  While ITP in the setting of pituitary apoplexy is a rare entity, we believe that clinicians should have pituitary apoplexy on their differential diagnosis in patients with ITP.

Clinical evaluations of pituitary apoplexy in incidental nonfunctional pituitary adenomas

Pituitary apoplexy is an uncommon syndrome that often results in spontaneous hemorrhage or infarction of pituitary tumors or glands. We previously reported pituitary apoplexy occurred most frequently in nonfunctional pituitary adenomas among all types of pituitary incidentalomas. In the present study, we aimed to investigate the characteristics of pituitary apoplexy in patients with incidental nonfunctional pituitary adenomas. 65 patients with pituitary incidentaloma were enrolled. All patients underwent clinical/endocrinological/pathological investigations. As a result, 33 patients were diagnosed with nonfunctional pituitary adenomas. Of these, 12.1% of patients had pituitary apoplexy. There was no difference in tumor diameter, age, or sex between the apoplexy and the non-apoplexy groups. However, the liver enzymes aspartate transaminase and alanine aminotransferase were significantly higher, and plasma sodium and chloride levels were significantly lower in the apoplexy group than in the non-apoplexy group (each P < .05). In addition, low-density lipoprotein-cholesterol was significantly higher in the apoplexy group than in the non-apoplexy group (P < .05). Besides, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, and prolactin deficiencies were significantly more frequent in the apoplexy group than in the non-apoplexy group (each P < .05), and growth hormone and adrenocorticotropic hormone deficiencies were more frequent in the apoplexy group than in the non-apoplexy group (P = .09 and.08, respectively). Furthermore, tumor diameter was not associated with pituitary apoplexy, whereas thyroid-stimulating hormone, luteinizing hormone, and follicle-stimulating hormone deficiencies were significantly associated with the apoplexy group (each P < .05). Hence, the present study indicated that pituitary apoplexy could not be related to tumor diameter. Moreover, hormonal deficiencies, hepatic dysfunction, hyponatremia or hypochloremia, and dyslipidemia might be indicators of pituitary apoplexy. There could be the possibility the treatment for dyslipidemia prevents pituitary apoplexy.

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.

Preventing Poor Outcomes for Neurosurgical Patients

Ensuring that patients with neurosurgical conditions have the best possible outcome requires early diagnosis, monitoring, and interventions to prevent complications and optimize care. Here, we review several neurosurgical conditions and the measures taken to prevent complications and optimize outcomes. We hope that the practical tips provided herein prove helpful in caring for neurosurgical patients.

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.

Pituitary apoplexy presenting as isolated third cranial nerve palsy: case series

Pituitary apoplexy (PA) is caused by a sudden increase in pressure in the pituitary region due to acute hemorrhage, infarction or necrosis. PA can also be caused by restricting blood supply to the nerve due to compression of the internal carotid artery. Acute third cranial nerve palsy (third CN) secondary to PA is a rare medical emergency caused by bleeding within a growing mass within the sella turcica. We presented two cases of PA with isolated third CN palsy treated with transsphenoidal pituitary decompression. PA is therefore an important differential diagnosis to consider in patients with isolated third nerve palsy. The prognosis for isolated third nerve palsy in PA appeared successful, with variable recovery from medical and surgical intervention.

Apoplexy in sellar metastasis from papillary thyroid cancer: A case report and literature review

Background:

Pituitary metastasis from papillary thyroid cancer (PTC) is rare and only a few cases have been reported.

Case Description:

We report the case of a patient who presented with visual dysfunction and panhypopituitarism. Magnetic resonance imaging revealed a pituitary tumor and hydrocephalus. Transsphenoidal surgery had been indicated, but his surgery had been postponed due to COVID-19 pandemic. During that waiting period, he showed pituitary apoplexy with consciousness disturbance, resulting in acute adrenal insufficiency and diabetes insipidus. He was urgently hospitalized and underwent transsphenoidal surgery. Rapid and permanent pathological examinations have confirmed metastasis of PTC to the pituitary. The patient also underwent serial thyroidectomy. He was also suspected to have secondary hydrocephalus and underwent lumboperitoneal shunting after excluding cerebrospinal fluid metastasis. Thereafter, his cognitive dysfunction and performance status improved dramatically.

Conclusion:

To the best of our knowledge, this is the first patient with PTC who developed pituitary apoplexy secondary to metastasis.

Suspected Pituitary Apoplexy: Clinical Presentation, Diagnostic Imaging Findings and Outcome in 19 Dogs

In human medicine, pituitary apoplexy (PA) is a clinical syndrome characterised by the sudden onset of neurological signs because of haemorrhage or infarction occurring within a normal or tumoral pituitary gland. The diagnosis is usually performed combining neurological signs and imaging findings. The aim of the present study is to describe the abnormal neurological signs, the diagnostic imaging findings, based on Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI), and the outcome in a population of dogs with suspected PA. Clinical cases were retrospectively reviewed. Nineteen cases of suspected PA were included. The majority of dogs showed behavioural abnormalities (11/19). Neurological signs more frequently identified were obtundation (7/19), vestibular signs (7/19) and epileptic seizures (6/19). The onset of neurological signs was per-acute in 14 out of 19 cases. Data regarding CT and MRI were available in 18 and 9 cases, respectively. Neurological signs resolved in less than 24 h in seven patients. The short-term prognosis was defined as favourable in the majority of our study population. The median survival time was of 7 months from the time of PA diagnosis. This is the first description of neurological signs, imaging findings and outcome in a large group of dogs with PA.

Neuro-oncologic Emergencies

PURPOSE OF REVIEW

Patients with brain and spine tumors are at high risk of presenting cancer-related complications at disease presentation or during active treatment and are usually related to the type and location of the lesion. Here, we discuss presentation and management of the most common emergencies affecting patients with central nervous system neoplastic lesions.

RECENT FINDINGS

Tumor-related emergencies encompass complications in patients with central nervous system neoplasms, as well as neurologic complications in patients with systemic malignancies. Brain tumor patients are at high risk of developing multiple complications such as intracranial hypertension, brain herniation, intracranial bleeding, spinal cord compression, and others. Neuro-oncologic emergencies require immediate attention and multi-disciplinary care. These emergent situations usually need rapid decision-making and management on an inpatient basis.

Ischemic Infarction of Pituitary Apoplexy: A Retrospective Study of 46 Cases From a Single Tertiary Center

Objective

Ischemic 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.

Methods

This 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.

Results

Headache 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 (&gt; 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.

Conclusion

Patients 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.

Pituitary Apoplexy in Geriatric Patients: A Report of Four Cases

Pituitary apoplexy (PA) is a rare clinical syndrome related to abrupt hemorrhage and/or infarction of the pituitary gland, usually occurring in patients with preexisting pituitary disease. It is an endocrine emergency requiring rapid diagnosis and appropriate management.

This is a literature review and a retrospective study reporting the observation of four patients that have suffered from pituitary macroadenomas.

These observations illustrate the particularities of this pathology in the elderly. The symptoms may be truncated and lead to a late diagnosis with its repercussions on management, without forgetting the particularity of the fragile and multisystemic terrain, which may contraindicate the usual surgical treatment. A rapid diagnosis and appropriate management can limit the occurrence of irreversible complications.

Growth hormone storm following infarction of a residual growth hormone secreting pituitary macroadenoma

BACKGROUND

Thyrotroph pituitary adenomas have been reported to be a rare cause of 'thyroid storms', causing myriad metabolic and autonomic disturbances. In this case, we describe the second reported case in literature of a 'GH storm' in an infarcted somatotroph adenoma.Case description: We describe a residual invasive somatotroph macroadenoma that underwent infarction, producing a dramatic elevation in serum GH levels. While infarction of adenomas may in some cases lead to remission, the patient went on to require re-surgery and re-radiation due to growth of the residual viable tumour.Conclusions- 'GH storms' are rare but interesting events that may occur in somatotroph adenomas. Infarction or apoplexy must be considered when managing residual adenomas.

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.

Recurrent pituitary apoplexy in pregnancy

Pituitary apoplexy is caused by haemorrhage or infarction of the pituitary gland. Presenting signs and symptoms often include severe headache, visual disturbance, ophthalmoplegia, altered consciousness and impaired pituitary function. The management of pituitary apoplexy has very rarely been described during pregnancy and there is no existing data for further pregnancies of affected women. We present a case of a woman with a recurrent pituitary apoplexy due to haemorrhages in a pituitary adenoma in her third and fourth pregnancies. In both pregnancies, the pituitary apoplexy was managed conservatively, but due to therapy-resistant headaches, a preterm delivery was implemented.

Isolated Third Cranial Nerve Palsy in Pituitary Apoplexy: Case Report and Systematic Review

OBJECTIVES

To report a case of isolated third nerve palsy from pituitary apoplexy and perform a systematic literature review.

MATERIALS AND METHODS

MEDLINE/EMBASE databases were searched up to September 2020.

INCLUSION CRITERIA

Age≥18, isolated third nerve palsy from pituitary apoplexy.

EXCLUSION CRITERIA

Age<18, presence of other neurological findings, no hemorrhage or infarction of pituitary.

RESULTS

Case report: A 76-year-old woman presented with headache and right-sided ptosis. Right-eye exam revealed complete ptosis, absent pupillary constriction and accommodation, depressed and abducted eye on primary gaze, and -1 impaired depression, adduction, elevation, without other neurological findings. Brain MRI was suggestive of pituitary apoplexy. Pathology after transsphenoidal resection revealed an infarcted pituitary adenoma. Third nerve palsy resolved completely in 21 days. Systematic review: Twenty-three studies reporting 35 patients were selected from 182 abstracts. Twenty-nine (83%) had complete isolated third nerve palsy. Headache was reported in 31 (97%). Thirty-one had hemorrhage and 1 had infarction of pituitary. Cavernous sinus invasion occurred in 14 (50%). Twenty-eight were managed surgically (80%) and 7 medically (20%). Nerve palsy resolved completely in 27 (82%) and partially in 4 (11%).

CONCLUSIONS

Pituitary apoplexy is an important differential diagnosis in patients with isolated third nerve palsy. Isolated third nerve palsy in apoplexy appears to have favorable prognosis.

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.

Apoplexy in sporadic pituitary adenomas: a single referral center experience and AIP mutation analysis

Objective

To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations.

Methods

The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced.

Results

Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort.

Conclusion

Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.

Key Factors Related to Internal Carotid Artery Stenosis Associated with Pituitary Apoplexy

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.

Rare Case of a Disappearing Pituitary Adenoma During the Coronavirus Disease 2019 (COVID-19) Pandemic

We present a case of a 28-year-old woman with a history of severe headaches and pituitary insufficiency. She was found to have a large, enhancing, sellar mass consistent with a pituitary adenoma. The patient's surgical care was delayed due to the coronavirus disease 2019 (COVID-19) pandemic, and follow-up imaging revealed spontaneous involution of the sellar mass. Spontaneous involution of pituitary masses has been described but not often encountered in clinical practice. This case highlights that follow-up imaging is necessary when scheduling elective surgeries during the COVID-19 pandemic.

Cavernous sinus lesions

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.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Nonfunctioning pituitary adenomas in pediatric and adolescent patients: a clinical analysis of a series of 14 patients

PURPOSE

Nonfunctional pituitary adenomas (NFPAs) in pediatric and adolescent age are extremely rare. This study aimed to report a series of 14 pediatric and adolescent NFPAs to assist in its clinical management.

METHODS

A total of 14 consecutive patients pathologically diagnosed with NFPAs (age ≤ 20 years) were retrospectively examined, and the clinical data were analyzed.

RESULTS

NFPA is uncommon in pediatric and adolescent patients (0.4%). The most common clinical symptoms were a headache (6/14, 42.9%) and visual loss (4/14, 28.6%). Ten patients (71.4%) had preoperative hypopituitarism. All patients were diagnosed with macroadenoma including 8 (57.1%) invasive tumors, and the average tumor diameter was 2.8 cm. All patients underwent transsphenoidal surgery, and a near-total resection was achieved in nine (64.3%) patients. Postoperative visual acuity improved in three patients (75%). The results of immunohistochemistry showed 6 silent plurihormonal adenomas (42.9%), 3 null cell adenomas (21.4%), 3 silent lactotroph adenomas (21.4%), 1 silent gonadotroph adenoma (7.1%) and 1 silent corticotroph adenoma (7.1%). The mean follow-up was 54.8 months, and five patients had tumor recurrence. Tumors with Ki-67 ≧ 2% (28.6%) showed higher recurrence rate than those with lower index (P = 0.001). Two patients received secondary surgery and radiation for recurrent tumors suffered from panhypopituitarism.

CONCLUSION

Pediatric and adolescent NFPA is clinically rare, and shows potential invasiveness. The silent plurihormonal adenoma is the most frequent phenotype. Transsphenoidal surgery is as safe and effective as in adults. However, individualized care and teamwork of neurosurgeons, pediatricians, endocrinologists, and radiation oncologists are important, especially for recurrent diseases.

Fertility and Pregnancy in Women With Hypopituitarism: A Systematic Literature Review

CONTEXT

Human reproduction is mainly governed from the hypothalamic-adrenal-gonadal (HPG) axis, which controls both ovarian morphology and function. Disturbances in the secretion of other anterior pituitary hormones (and their respective endocrine axes) interfere with HPG activity and have been linked to fertility problems. In normal pregnancy, maintenance of homeostasis is associated with continuous changes in pituitary morphology and function, which need to be considered during hormone replacement in patients with hypopituitarism.

DESIGN

We conducted a systematic PubMed literature review from 1969 to 2019, with the following keywords: fertility and hypopituitarism, pregnancy and hypopituitarism, and ovulation induction and hypopituitarism. Case reports or single-case series of up to 2 patients/4 pregnancies were excluded.

RESULTS

Eleven publications described data on fertility (n = 6) and/or pregnancy (n = 7) in women with hypopituitarism. Women with hypopituitarism often need assisted reproductive treatment, with pregnancy rates ranging from 47% to 100%. In patients achieving pregnancy, live birth rate ranged from 61% to 100%. While glucocorticoids, levothyroxine, and desmopressin are safely prescribed during pregnancy, growth hormone treatment regimens vary significantly between countries, and several publications support a positive effect in women seeking fertility.

CONCLUSIONS

In this first systematic review on fertility, ovulation induction, and pregnancy in patients with hypopituitarism, we show that while literature is scarce, birth rates are high in patients achieving pregnancy. However, prospective studies are needed for evaluating outcomes in relationship to treatment patterns. Replacement therapy in hypopituitarism should always mimic normal physiology, and this becomes challenging with changing demands during pregnancy evolution.

Pituitary apoplexy mimicking meningoencephalitis: case report and scoping study

Background: Pituitary apoplexy (PA) is a rare but potentially life-threatening condition that may require urgent surgical intervention.Case Presentation: We report a case of a patient who was initially diagnosed with meningoencephalitis (ME) based on clinical presentation and cerebrospinal fluid (CSF) analysis, but was eventually diagnosed with PA. We present a summary of other cases reported in the literature of PA mimicking ME and analyze their clinical features and CSF findings.Results: Among all 22 PA cases reviewed, headache was the most commonly reported symptom. Hypopituitarism was seen in 94.4% of the cases; of these, panhypopituitarism was noted in 38.9%. The sensitivity of magnetic resonance image (MRI) for detecting PA was 94.7%, much higher than that of computed tomography (CT), which was only 31.6%. Neutrophil predominant pleocytosis was present in all cases with a neutrophil percentage ranging from 73% to 98%. CSF leukocyte count was less than 1000/ul in 86% of the cases. CSF erythrocytosis was seen in 92.9% of the cases with a count ranging from 15 to 2030/ul. Elevated CSF protein was present in all cases with a range of 69.8 to 239 mg/dl. CSF glucose level varied with a range between 12 and 136 mg/dl; the level was greater than 40 mg/dl in 73% of the cases.Conclusion: PA tends to be misdiagnosed as ME due to the similarities of semiology and CSF findings. PA should be considered in refractory acute headache cases, especially those with visual and endocrine abnormalities. Early recognition and treatment may lead to significant reduction in morbidity and mortality.Abbreviations: ACTH: adrenocorticotropic hormone; CSF: cerebrospinal fluid; CT: computed tomography; GRE: gradient echo; HRT: hormone replacement therapy;HSV: Herpes Simplex Virus; IV: intravenous; ME: meningoencephalitis; MRI: magnetic resonance image; PA: pituitary apoplexy; RBC: red blood cell; WBC: white blood cell.

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature

Introduction  For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes. Methods  A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time. Results  A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation ( p  = 0.047) . Conclusion  Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.

Spontaneous "pneumo-apoplexy" as a presentation of pituitary adenoma

Cases of spontaneous CSF leak associated with pituitary tumor apoplexy are uncommon in the literature with pneumocephalus or pneumosella being rare, especially spontaneous occurrence of pneumocephalus being extremely rare. We present a case of pituitary macroadenoma apoplexy resulting in spontaneous CSF leak and a large volume of intra-tumoral gas. A 65-year-old female presented with severe headache, profuse rhinorrhea and acute vision loss and was found to have a large sellar and suprasellar lesion with air and hemorrhage with mild peripheral enhancement. The patient underwent trans-sphenoidal tumor resection and repair of skull base for CSF leak with nasoseptal flap placement. Pathology demonstrated a pituitary adenoma exhibiting immunoreactivity for ACTH. To our best knowledge, our case is the first report of features of pituitary tumor apoplexy with hemorrhage and pneumosella, which could be summarized by the term "pneumo-apoplexy".

Acromegaly remission, SIADH and pituitary function recovery after macroadenoma apoplexy

Summary

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterised by ischaemic infarction or haemorrhage into a pituitary tumour that can lead to spontaneous remission of hormonal hypersecretion. We report the case of a 50-year-old man who attended the emergency department for sudden onset of headache. A computed tomography (CT) scan at admission revealed pituitary haemorrhage and the blood test confirmed the clinical suspicion of acromegaly and an associated hypopituitarism. The T1-weighted magnetic resonance imaging (MRI) showed the classic pituitary ring sign on the right side of the pituitary. Following admission, he developed acute-onset hyponatraemia that required hypertonic saline administration, improving progressively. Surprisingly, during the follow-up, IGF1 levels became normal and he progressively recovered pituitary function.

Learning Points

Patients with pituitary apoplexy may have spontaneous remission of hormonal hypersecretion. If it is not an emergency, we should delay a decision to undertake surgery following apoplexy and re-evaluate hormone secretion. Hyponatraemia is an acute sign of hypocortisolism in pituitary apoplexy. However, SIADH although uncommon, could appear later as a consequence of direct hypothalamic insult and requires active and individualised treatment. For this reason, closely monitoring sodium at the beginning of the episode and throughout the first week is advisable to guard against SIADH. Despite being less frequent, if pituitary apoplexy is limited to the tumour, the patient can recover pituitary function previously damaged by the undiagnosed macroadenoma.

Pituitary adenoma apoplexy associated with vardenafil intake

Vardenafil is a potent phosphodiesterase-5 (PDE-5) inhibitor used in the treatment of erectile dysfunction. Several cases of stroke related to the use of PDE-5 inhibitors have been reported. Here, we describe the case of a 51-year-old man with headache and right ophthalmoplegia subsequent to vardenafil consumption. Computed tomography and magnetic resonance imaging showed a suprasellar mass with hemorrhage suggesting pituitary apoplexy. He underwent transsphenoidal resection of the pituitary mass. Histopathology confirmed the diagnosis of a necrotic pituitary adenoma with hemorrhage. This report suggests a possible association between pituitary apoplexy and vardenafil use. In patients with preexisting pituitary adenoma, vardenafil may enhance the risk of pituitary apoplexy. Although headache is the most commonly reported side effect of vardenafil, pituitary apoplexy should be considered in the differential diagnosis of a patient with headache and ophthalmoplegia subsequent to vardenafil intake.

The dangers of the "Head Down" position in patients with untreated pituitary macroadenomas: case series and review of literature

PURPOSE

Cavernous sinus syndrome is a rare phenomenon, characterized by simultaneous neuropathies of cranial nerves III-VI. Various pathological processes have been reported as precipitating etiologies, including infection, inflammation, vascular lesions, and neoplasms.

PURPOSE

We report a unique case series of cavernous sinus syndrome attributable to prolonged Trendelenburg or prone positioning during non-cranial procedures and review the pertinent literature to enlighten on this rare but catastrophic phenomenon.

METHODS

Retrospective case series.

RESULTS

In the past year we encountered two patients who presented with acute cavernous sinus syndrome upon awakening from non-cranial operations. One patient underwent an extensive urologic resection of a bladder malignancy positioned in Trendelenburg for approximately 4 h. The second patient underwent a lumbar laminectomy and discectomy in prone position. Both patients were discovered to have infarcted large pituitary macroadenomas as the etiology of their acute ophthalmoplegias, and transnasal, transsphenoidal resection was performed acutely to decompress the cavernous sinus contents. Pathologic analysis of the resected specimens in each case confirmed necrotic, infarcted pituitary adenoma. Both patients made a complete recovery with no evidence of residual or recurrent tumor in short term follow-up.

CONCLUSION

We report a brief case series of acute cavernous sinus syndrome resulting from dependent positioning during non-cranial operations in patients with pituitary macroadenoma. Although rare, this highlights a potential danger of "head down" positioning in patients with intracranial pathology-particularly in or around the sella and cavernous sinus. Despite multiple cranial neuropathies upon presentation, both patients made complete recovery following surgical decompression of the cavernous sinuses.

Isolated Unilateral Abducens Cranial Nerve Palsy: A Rare Presentation of Pituitary Apoplexy

Purpose

To describe a rare presentation of pituitary apoplexy as unilateral abducens nerve palsy demonstrating the various presentations of the condition.

Methods

Case report.

Results

A 48-year-old man presented with isolated right abducens nerve palsy. Magnetic resonance imaging showed a large pituitary macroadenoma with evidence of recent bleed into the right cavernous sinus and surrounding the right internal carotid artery.

Conclusions

Pituitary apoplexy may present subtly with an isolated sixth nerve palsy but the condition is critical and high index of suspicion needs to be governed.

Pituitary Apoplexy Producing Internal Carotid and Basilar Artery Compression: A Rare Case Report

Pituitary apoplexy is a rare disease followed by ischemic or hemorrhagic process within the pituitary adenoma. Here, we report two cases of pituitary apoplexy with a history of sudden onset of headache, vomiting, and diminished vision. Our aim is to share our experience and discuss these cases as follows: the first one to know the compression of basilar artery along with the compression of basilar part of pons and in both the cases with compression of an internal carotid artery leading to cerebral infarcts.

Pituitary Apoplexy: Should Endoscopic Surgery Be the Gold Standard?

BACKGROUND

Pituitary apoplexy is an uncommon, potentially fatal condition due to spontaneous ischemia or hemorrhage in a pituitary adenoma. The treatment of this disorder has long been a matter of debate.

METHODS

Retrospective cohort study including all patients admitted with pituitary apoplexy in our department between 2005 and 2015 was undertaken. Clinical symptoms and signs on admission, treatment (conservative vs. surgical), neurologic deficit on discharge and at 6 months' follow-up, and endocrinologic evaluation at 6 months' follow-up were analyzed. The statistical analysis was performed with STATA 13.0. Endocrinologic and visual outcomes at 6 months in the different groups according to treatment were compared by applying an independent multinomial probit regression test. Outcomes between the conservative and the surgical (endoscopic and microscopic considered together) groups also were compared and the differences between surgical treated groups were analyzed with logistic regression analysis. P values <0.05 were considered significant.

RESULTS

Twenty-three patients were included in this study; 60.9% (n = 14) were treated surgically (5 microsurgically; 9 endoscopically) and 39.1% (n = 9) conservatively. Statistical analysis revealed no significant differences in the visual function between the 3 treatment groups in both univariate and multivariate analysis (P > 0.05). The endocrinologic outcome was better in the surgical group (P = 0.017; adjusted P = 0.027), with a significant difference between the conservative group and the endoscopic group (P = 0.004; adjusted P = 0.005). When we compared both surgical groups, the endoscopic group has a better endocrinologic outcome (P = 0.020; adjusted P = 0.012).

CONCLUSIONS

Our results support endoscopic intranasal transsphenoidal surgery as a treatment of pituitary apoplexy patients, as it probably decreases the need for long-term hormonal replacement.

A retrospective review of 34 cases of pediatric pituitary adenoma

PURPOSE

The purpose of this paper is to study invasiveness, tumor features and clinical symptoms of pediatric pituitary adenoma, and to discuss some inconclusive results in prior studies.

METHODS

We retrospectively reviewed 34 cases of children (<20 year-old) who were pathologically diagnosed with pituitary adenoma and surgically treated from 2010 to 2017. Data of general information, clinical symptoms, invasive behaviors, surgery approaches, and tumor features were collected and analyzed.

RESULTS

Sixteen boys and 18 girls aged from 12 to 19 years old were included. Prolactinoma was most suffered, followed by GH-, none- and ACTH-secreting pituitary adenoma. Invasive behaviors were observed frequently and suprasellar extensions were most found. Macroadenoma account 70% of all cases. Meanwhile, unlike prior studies, a significant raise of incidence on invasive tumor and pituitary adenoma apoplexy were observed. Craniotomy and transsphenoidal surgery were both applied with zero mortality. Nine cases occurred with transient hypopituitarism and diabetes insipidus. Three cases of tumor recurrence received secondary surgery or radiotherapy.

CONCLUSIONS

Invasive behaviors were more frequent than previous prediction. Craniotomy is worth considering for total tumor removal. Pituitary adenoma apoplexy needs further studies since its different features between children and adults in present study. Specialized care and teamwork of neurosurgeons, pediatricians, and endocrinologists are important.

Surgical intervention for pituitary apoplexy: an analysis of functional outcomes

OBJECTIVE Pituitary apoplexy is a clinical syndrome consisting of neurological and endocrine abnormalities secondary to hemorrhage or ischemia of an underlying pituitary adenoma. The authors investigated whether there was a significant difference in neurological, endocrine, and nonneuroendocrine outcomes for patients with pituitary apoplexy, based on the time between symptom onset and surgical intervention. METHODS The authors retrospectively analyzed the medical records of 32 patients who had presented to their institution with acute pituitary apoplexy and subsequently undergone endonasal transsphenoidal resection in the period from 2003 to 2014. All patients had undergone preoperative MRI demonstrating evidence of apoplexy in the form of intratumoral hemorrhage, ischemia, and necrosis. Neurological deficits, partial or complete endocrinopathy, and nonneuroendocrine abnormalities were analyzed both pre- and postoperatively. RESULTS Preoperatively, neurological deficits including visual loss and cranial nerve palsies were found in 31 (97%) of the 32 patients, endocrinopathy in the form of partial or panhypopituitarism was seen in 28 patients (88%), and nonneuroendocrine signs and symptoms were seen in 32 patients (100%). Thirteen patients (41%) underwent surgery within 72 hours of symptom onset ("early"), whereas 19 patients (59%) underwent surgery more than 72 hours from symptom onset ("delayed"). Early versus delayed resection did not appear to significantly improve visual deficits, total visual loss, resolution of oculomotor palsy, recovery from hypopituitarism, or nonneuroendocrine signs and symptoms such as headache and encephalopathy. Overall, visual improvement was seen in 77% of patients, complete restoration of normal vision in 38% of patients, and resolution of preoperative oculomotor palsies in 81% of patients. Only 6 (21%) of 28 patients showed evidence of partial hormone recovery following preoperative hypopituitarism. An absence of benefit for early surgery held true even when considering time to surgery from symptom onset as a continuous variable. CONCLUSIONS Neurological deficits such as visual loss and cranial neuropathies show moderate improvement following surgical decompression, as does preoperative hypopituitarism. The timing of surgical intervention relative to the onset of symptoms does not appear to significantly affect the resolution of neurological or endocrinological deficits.

Sphenoid sinus mucosal thickening in the acute phase of pituitary apoplexy

PURPOSE

In pituitary apoplexy (PA), there are preliminary reports on the appearance of sphenoid sinus mucosal thickening (SSMT). SSMT is otherwise uncommon with an incidence of up to 7% in asymptomatic individuals. The aim of this study was to evaluate the incidence and clinical significance of SSMT in patients with PA and a control group of surgically treated non-functioning pituitary adenomas (NFPAs).

METHODS

Retrospective review of clinical and imaging variables in PA and NFPA patients. Sphenoid sinus mucosal thickness was measured on the presenting MRI scan by a blinded neuroradiologist. Pathological SSMT was defined as >1 mm adjacent to the pituitary fossa. Forward stepwise logistic regression was used to identify factors associated with SSMT.

RESULTS

There were 50 NFPA and 47 PA patients. PA patients were managed conservatively (N = 11) or surgically (N = 36). The median sphenoid sinus mucosal thickness was greater in the PA than NFPA groups (2.0 vs. 0.5 mm; p < 0.001). In multivariate analysis of both the PA and NFPA groups, the presence of PA was the only factor associated with SSMT (OR 0.043, 95% CI 0.012-0.16; p < 0.001). In multivariate analysis of the PA group alone, a shorter time from symptom onset to presenting MRI scan (OR 0.12, 95% CI 0.026-0.54; p = 0.006) and a more severe grade of apoplexy (OR 7.29, 95% CI 1.10-48.40; p = 0.04), were associated with SSMT.

CONCLUSION

The incidence of SSMT is higher in patients with PA, especially during the acute phase of PA. The aetiology of SSMT in PA is unclear and may reflect inflammatory and/or infective changes.

Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To formulate clinical practice guidelines for hormonal replacement in hypopituitarism in adults.

PARTICIPANTS

The participants include an Endocrine Society-appointed Task Force of six experts, a methodologist, and a medical writer. The American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology co-sponsored this guideline.

EVIDENCE

The Task Force developed this evidence-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines.

CONCLUSIONS

Using an evidence-based approach, this guideline addresses important clinical issues regarding the evaluation and management of hypopituitarism in adults, including appropriate biochemical assessments, specific therapeutic decisions to decrease the risk of co-morbidities due to hormonal over-replacement or under-replacement, and managing hypopituitarism during pregnancy, pituitary surgery, and other types of surgeries.

Sellar Lesions/Pathology

The sellar region is a tiny anatomic compartment in which many lesions and developmental diseases can be found. If pituitary adenomas represent most of the sellar mass, it is important to recognize other pathologic conditions before any surgical procedure, because the optimal treatment may differ considerably from one lesion to another. A careful clinical evaluation followed by neuroimaging studies and an endocrinologic and ophtalmologic workup will lead, in most cases, to a diagnosis with near certainty. This article provides an overview of sellar diseases with emphasis on their most useful characteristics for clinical practice.

Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy

BACKGROUND

Pituitary apoplexy (PA) often presents with acute headache and neuro-ophthalmic manifestations, including ocular motility dysfunction (OMD) from cranial nerve palsies (CNPs). Our goal was to describe the epidemiology and outcomes of OMD in a large, single-center series of patients with PA.

METHODS

We conducted a retrospective chart review of all patients with PA seen in our pituitary center between January 1995 and December 2012. Presenting neuro-ophthalmic, endocrine, and radiologic data, as well as neuro-ophthalmology follow-up data, were collected.

RESULTS

We identified 235 patients with PA, 59 of whom (25%) had OMD. Twenty-seven of those 59 patients underwent neuro-ophthalmic evaluation. Preoperatively, 23 of these 27 patients had unilateral OMD, 18 (78%) with a single CNP and 5 (22%) with multiple CNPs. Bilateral OMD was present in 4 of the 27 patients. Postoperatively, 24 of the 27 patients with OMD had follow-up (median duration, 7 months; interquartile range [IQR], 3-17 months). At the last postoperative follow-up, 7 of these 24 patients (29%) had OMD (5 unilateral, 2 bilateral). OMD resolved in 3 of the 24 patients (12%) within 1 month, in 13 of 21 patients (62%) within 6 months (3 lost to follow-up), and in 17 of 19 patients (89%) within 1 year (2 lost to follow-up). Surgery was performed at ≤14 days after presentation in 16 of 18 (89%) resolved cases and in 4 of 6 (67%) unresolved cases. Patients with OMD were more likely than those without OMD to have larger tumors (2.6 vs. 2.0 cm; P < 0.001), panhypopituitarism (31% vs. 14%; P = 0.005), and necrosis (58% vs. 37%; P = 0.03).

CONCLUSIONS

OMD from CNPs is common in PA, occurring in one-quarter of patients, and is frequently associated with certain radiologic, endocrinologic, and pathological features. The prognosis is excellent, with 90% of cases of OMD resolving by 1 year after early pituitary surgery.

Ischemic pituitary adenoma apoplexy-Clinical appearance and prognosis after surgical intervention

BACKGROUND

Several retrospective investigations have recommended more passive surgical indications for intratumoral hemorrhage of pituitary adenomas due to probable spontaneous resolution. However, no definitive analyses have compared pituitary adenomas with hemorrhagic apoplexy and intratumoral hemorrhage without evident apoplectic symptoms or pituitary adenoma infarction.

METHODS

This study retrospectively identified 43 patients with symptomatic pituitary apoplexy among 1067 patients with pituitary adenomas initially treated by surgery at a single institute between April 2005 and May 2015, with 27 cases of hemorrhagic (2.53%) and 16 cases of ischemic apoplexy (1.50%). The inclusion criteria involved evident and sudden onset of symptoms and simultaneous histological confirmation as hemorrhagic or ischemic pituitary apoplexy. Diagnostic differentiation with magnetic resonance (MR) imaging was performed to examine the agreement between MR imaging and histological findings, and the clinical appearance and mid-term prognosis were compared for ischemic pituitary apoplexy and hemorrhagic apoplexy.

RESULTS

Diagnostic matching with MR imaging could be performed in 41 of 43 patients (25 with hemorrhagic and 16 with ischemic apoplexy). Agreement with the histological finding was found in 32 of 41 patients overall (78%), 23 of 25 patients with hemorrhagic apoplexy (92%), and 9 of 16 patients with ischemic apoplexy (56%). The main reason for diagnostic discrepancy was thought to be the difficulty in identifying ischemic lesion. All patients in the ischemic group suffered progression of symptoms from initial onset including various cranial nerve palsies, aseptic meningitis, and decreased level of consciousness, whereas the hemorrhagic group suffered progression in 4 of 27 patients. Ischemic group showed a statistically stronger tendency to disease progression than the hemorrhagic group (P<0.001). Endocrinological examinations showed 4 patients required no hormone supplement therapies but the other 11 patients had persistent hypopituitarism and required hormone supplementation in the ischemic group, whereas 2 of 25 patients required hormone supplementation in the hemorrhagic group. Endocrinological recovery showed a significant difference between the ischemic group and hemorrhagic group (P<0.01).

CONCLUSIONS

Ischemic pituitary adenoma apoplexy has a more severe clinical course than hemorrhagic apoplexy. Development of preoperative diagnostic technology to differentiate ischemic from hemorrhagic apoplexy is required to improve the low rate of agreement between the histological and MR imaging findings in patients with ischemic apoplexy.

Pituitary apoplexy: considerations on a single center experience and review of the literature

PURPOSE

To present a single-center experience on pituitary tumor apoplexy and a review of literature focusing on predisposing and precipitating factors.

METHODS

Clinical presentation of our series of cases. Contemporary published literature is also reviewed.

RESULTS

The definition of this syndrome has not been consistent although now the majority of authors agree to definite it as an acute condition caused by hemorrhage or infarction of a pre-existing pituitary adenoma. Different predisposing and precipitating factors have been described in literature; among these antithrombotic and anticoagulant drugs, seem to play relevant roles. The clinical cases observed in our clinic confirm these data and suggest a probable association between elderly patients taking anticoagulant therapy and pituitary apoplexy adenoma.

CONCLUSION

Pituitary tumor apoplexy remains a challenging disease in relation to difficulties in correct diagnosis and thus in appropriate treatment. Antithrombotic/anticoagulant therapy may have an important role as precipitating factor. When a pituitary disorder is known, great care should be taken in the prescription of anticoagulant therapy.

Multidisciplinary Management of Pituitary Apoplexy

Pituitary apoplexy is a rare clinical syndrome due to ischemic or haemorrhagic necrosis of the pituitary gland which complicates 2-12% of pituitary tumours, especially nonfunctioning adenomas. In many cases, it results in severe neurological, ophthalmological, and endocrinological consequences and may require prompt surgical decompression. Pituitary apoplexy represents a rare medical emergency that necessitates a multidisciplinary approach. Modalities of treatment and times of intervention are still largely debated. Therefore, the management of patients with pituitary apoplexy is often empirically individualized and clinical outcome is inevitably related to the multidisciplinary team's skills and experience. This review aims to highlight the importance of a multidisciplinary approach in the management of pituitary apoplexy and to discuss modalities of presentation, treatment, and times of intervention.