A rare fatal course of disease in a patient with spontaneous pituitary apoplexy. Case report and literature review

Pituitary apoplexy: clinical features, management and outcome. Clinical study and review of the literature

Background: Pituitary apoplexy is a clinical syndrome secondary to rapid expansion of the content of the sella and extension to suprasellar region, cavernous sinus, sphenoid sinus secondary to a bleeding, ischemic or mixed episode taking place in a pituitary adenoma. This episode will determine a significant compression of the optic nerves, optic chiasm, cavernous sinus and hypothalamus, which translates clinically most often by headache, visual disturbances, deceased level of consciousness and ophthalmoplegia. Material and methods: This paper presents a retrospective study over a period of five years, from January 2009 to December 2013 and includes 98 patients diagnosed with pituitary apoplexy and treated in the Third Department of Neurosurgery, Emergency Clinical Hospital Bagdasar-Arseni. Of the 98 patients, 62 were females (63.3 %) and 36 were males (36.7 %) with a ratio of female to male of 1.7:1. The patients were aged between 17 and 75 years old, average age being approximately 50 years. Follow-up period ranged from 2 months to 5 years. The main symptomsat presentation was sudden, intense headache, this symptom was encountered in 90 patients (91.83%), vomiting showed by 76 patients (77.55%), decreased visual acuity observed in 57 patients (58.16%), visual field deficits in 74 patients (75.51%), cranial nerves palsy (III, IV, VI) observed in 14 patients (14.28 %). Conclusions: Pituitary apoplexy is a disease that can endanger patients' lives. The clinical presentation may vary from minor symptoms to major neurological deficits and even death so early diagnosis and treatment are vital.

Classical pituitary tumour apoplexy: clinical features, management and outcomes in a series of 24 patients

We retrospectively analysed the incidence, clinical presentation, endocrinological and radiological findings, medical and surgical management of pituitary apoplexy in our department (single-centre study), having a large experience in pituitary surgery. Among 1540 pituitary lesions, 24 patients presented with pituitary apoplexy. Their charts were retrospectively reviewed. The symptoms included headache (92%), nausea and vomiting (54%), visual deficit (50%), oculomotor paresis (54%) and/or an altered mental state (42%). Skull X-rays (n = 14) demonstrated an enlarged sella turcica in all cases; CT-scan and/or MRI always revealed a sellar and suprasellar expanding lesion. Panhypopituitarism was present on admission in 70% of the patients. Urgent therapeutic management included high-dose cortisone treatment in all but one patients and CSF drainage in three. Three patients were treated conservatively. Nine patients were operated on rapidly, within hours or a few days because of severe visual deficit and/or altered level of consciousness. Nineteen patients were operated by the trans-sphenoidal approach; one of them required a second operation by craniotomy. There were two deaths related to the illness and one to an ill-defined reason at 4 months. Among the other patients 95% made a good recovery. All but two patients required a substitutive treatment with adrenal (83%), thyroid (68%), gonadal (42%) and/or growth (16%) hormones. The preoperative visual deficits recovered in all but one patients (92%) whereas the oculomotor pareses improved in all but two patients (85%). In conclusion, pituitary tumour apoplexy is a rare event, complicating in our series 1.6% of 1540 pituitary adenomas. Even in severe cases, complete recovery is possible if the diagnosis is rapidly obtained and adequate management is initiated in time. Surgical results after trans-sphenoidal approach are in the majority of cases very satisfactory.

Late recurrent bleeding after surgical treatment for pituitary apoplexy

Pituitary apoplexy is an uncommon syndrome characterised by sudden onset of headache, meningeal signs, visual disturbances, ophthalmoplegia and confusion. Documented recurrent apoplexy or treated apoplexy is even rarer with only few reports in the literature. Between 1994 and 2001, 18 patients were treated for pituitary apoplexy at Bayindir Medical Centre through transsphenoidal route. In all, topical bromocriptine was applied after tumour resection as described by Ozgen. We hereby present the cases of two patients with recurrent apoplexy 3 and 7 years after the initial surgical treatment for pituitary adenoma with apoplexy. The patients were treated non-surgically with success. Additional treatment in the form of radiosurgery was found necessary for the first patient. Surgical excision of the pituitary tumours with apoplexy reduces the risk of recurrent bleedings but eradication is not a rule. These patients need to be followed closely in the postoperative period for possible recurrence of bleeding.

Pituitary tumor apoplexy: characteristics, treatment, and outcomes

Pituitary tumor apoplexy is an uncommon event heralded by abrupt onset of severe headache, restriction of visual fields, deterioration of visual acuity, and weakness of ocular motility frequently coupled with clinical indications of decreased endocrine function. Hemorrhage into or necrosis of a preexisting sellar mass, usually a pituitary macroadenoma, produces an expansion of sellar contents. Compression of adjacent structures elicits the variable expression of symptoms referable to displacement of the optic nerves and chiasm and impingement of the third, fourth, and sixth cranial nerves. Damage to or destruction of the anterior pituitary leads to multiple acute and/or chronic hormone deficiencies in many patients. Medical management may be used in rare cases in which the signs and symptoms are mild and restricted to meningismus or ophthalmoplegia deemed to be stable. In patients with visual or oculomotor lability or an altered level of consciousness, expeditious surgical decompression, accomplished most commonly through a transsphenoidal approach, should be performed to save life and vision and to optimize the chance of regaining or maintaining pituitary function.

Sudden death due to pituitary apoplexy

A case of sudden, unexpected death due to hemorrhage into a large, previously undiagnosed pituitary adenoma (pituitary apoplexy) in a 41-year-old man is presented. Pituitary adenomas are frequent intracranial tumors with usually benign prognosis. Acute hemorrhage into the tumor is a severe and potentially fatal complication, if not diagnosed and treated early, and occurs in up to 10% of cases. Sudden tumor enlargement due to the hemorrhage with compression of vessels and neural tissue at the skull base may result in coma and death without preceding symptoms leading to forensic investigations as demonstrated by this case report.