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Anton N, Bogdănici CM, Branișteanu DC, Armeanu T, Ilie OD, Doroftei B. A Narrative Review on Neuro-Ophthalmological Manifestations That May Occur during Pregnancy. Life (Basel) 2024; 14:431. [PMID: 38672703 PMCID: PMC11051142 DOI: 10.3390/life14040431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
AIM As a medical condition, pregnancy mandates the simultaneous treatment of both the mother and the fetus, making it a distinctive aspect of clinical medicine. MATERIAL AND METHOD We analyze the physiological changes occurring in the eyes and brain during pregnancy, as well as the neuro-ophthalmological manifestations that can occur during pregnancy. Studies published in both English and other languages, case reports, and reviews from 2011 to 2023 onwards were included. All surveys were acquired by exploring the databases. RESULTS We found a total of 2135 articles that showcase neuro-ophthalmic changes related to pregnancy: review and research articles (Science Direct 804, Web of Science 923, Scopus 345, and 63 Pub Med). In total, 86 studies were examined after applying the inclusion and exclusion criteria. Bilateral papilledema can be a warning sign for intracranial hypertension or cerebral venous sinus thrombosis. Additionally, when unilateral, it is important to differentially diagnose anterior ischemic optic neuropathy secondary to a hypercoagulant, compressive or inflammatory optic neuropathy, optic neuritis, or even orbital pseudotumor state. Severe eclampsia and preeclampsia can manifest as choroidal infarction, serous retinal detachment, and even cortical blindness. There can also be implications at the level of cranial nerves or transient Horner syndrome. CONCLUSIONS Evaluating and treating a pregnant woman with neuro-ophthalmological manifestations is challenging. The obstetrician closely follows and has a medical relationship with the pregnant woman; hence he/she might be the first to be informed about the general condition of the pregnant woman or might request an ophthalmologic examination tailored to each specific case.
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Affiliation(s)
- Nicoleta Anton
- Ophthalmology Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania;
- Ophthalmology Clinic, Sf. Spiridon Emergency Clinical Hospital of Iaşi, 700111 Iași, Romania
| | - Camelia Margareta Bogdănici
- Ophthalmology Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania;
- Ophthalmology Clinic, Sf. Spiridon Emergency Clinical Hospital of Iaşi, 700111 Iași, Romania
| | - Daniel Constantin Branișteanu
- Ophthalmology Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania;
| | - Theodora Armeanu
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania; (T.A.); (O.-D.I.); (B.D.)
- Origyn Fertility Center, Palace Street, No. 3C, 700032 Iasi, Romania
| | - Ovidiu-Dumitru Ilie
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania; (T.A.); (O.-D.I.); (B.D.)
- Origyn Fertility Center, Palace Street, No. 3C, 700032 Iasi, Romania
| | - Bogdan Doroftei
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania; (T.A.); (O.-D.I.); (B.D.)
- Origyn Fertility Center, Palace Street, No. 3C, 700032 Iasi, Romania
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Mamelak AN. Response to Letter to the Editor from Salle et al.: "A prospective multi-center observational study of surgical versus non-surgical management for pituitary apoplexy". J Clin Endocrinol Metab 2024:dgae091. [PMID: 38381088 DOI: 10.1210/clinem/dgae091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Affiliation(s)
- Adam N Mamelak
- Professor of Neurosurgery, Co-Director, Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
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Mamelak AN, Little AS, Gardner PA, Almeida JP, Recinos P, Soni P, Kshettry VR, Jane JA, Barkhoudarian G, Kelly DF, Dodd R, Mukherjee D, Gersey ZC, Fukuhara N, Nishioka H, Kim EH, Litré CF, Sina E, Mazer MW, Cui Y, Bonert V. A Prospective, Multicenter, Observational Study of Surgical vs Nonsurgical Management for Pituitary Apoplexy. J Clin Endocrinol Metab 2024; 109:e711-e725. [PMID: 37698130 DOI: 10.1210/clinem/dgad541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/14/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
CONTEXT Pituitary apoplexy (PA) has been traditionally considered a neurosurgical emergency, yet retrospective single-institution studies suggest similar outcomes among patients managed medically. OBJECTIVE We established a multicenter, international prospective registry to compare presentation and outcomes in PA patients treated with surgery or medical management alone. METHODS A centralized database captured demographics, comorbidities, clinical presentation, visual findings, hormonal status, and imaging features at admission. Treatment was determined independently by each site. Key outcomes included visual, oculomotor, and hormonal recovery, complications, and hospital length of stay. Outcomes were also compared based on time from symptom onset to surgery, and from admission or transfer to the treating center. Statistical testing compared treatment groups based on 2-sided hypotheses and P less than .05. RESULTS A total of 100 consecutive PA patients from 12 hospitals were enrolled, and 97 (67 surgical and 30 medical) were evaluable. Demographics, clinical features, presenting symptoms, hormonal deficits, and imaging findings were similar between groups. Severe temporal visual field deficit was more common in surgical patients. At 3 and 6 months, hormonal, visual, and oculomotor outcomes were similar. Stratifying based on severity of visual fields demonstrated no difference in any outcome at 3 months. Timing of surgery did not affect outcomes. CONCLUSION We found that medical and surgical management of PA yield similar 3-month outcomes. Although patients undergoing surgery had more severe visual field deficits, we could not clearly demonstrate that surgery led to better outcomes. Even without surgery, apoplectic tumor volumes regress substantially within 2 to 3 months, indicating that surgery is not always needed to reduce mass effect.
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Affiliation(s)
- Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Medical Center, Phoenix, AZ 85013, USA
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | | | - Pablo Recinos
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Pranay Soni
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - John A Jane
- Departments of Neurosurgery, Virginia Tech Medical Center, Roanoke, VA 24014, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Robert Dodd
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Eui-Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | | | - Elliott Sina
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Mia W Mazer
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Yujie Cui
- Biostatistic Core, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Vivien Bonert
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Krishnan G, Mohd Makhatar NH, Ching TH, Khoo S. Primary pituitary tuberculoma with a pituitary apoplexy-like presentation. Endocrinol Diabetes Metab Case Rep 2024; 2024:23-0092. [PMID: 38290212 PMCID: PMC10895304 DOI: 10.1530/edm-23-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024] Open
Abstract
Summary Pituitary tuberculoma is extremely rare and may pose as a diagnostic challenge especially when encountered as an isolated lesion without other systemic manifestation of tuberculosis. A 21-year-old female was admitted for diabetic ketoacidosis. On the third day of admission following the resolution of diabetic ketoacidosis she developed a sudden onset of headache and blurring of vision suggestive of pituitary apoplexy. An urgent MRI brain revealed a large sellar mass with erosion into the sphenoid sinus and intracranial vasculitis. Transphenoidal surgery was done for tumour debulking which allowed histopathological examination of the sellar mass. Immunohistochemical examination of the sellar mass was positive for Gene Xpert MTB/Rif suggesting a tuberculoma. Anti-tuberculous therapy was commenced with full recovery of pituitary hormonal profile seen 7 months post-treatment. In regions with a high incidence of tuberculosis, a tuberculoma should be a considered in a diagnostic evaluation of a sellar lesion. Learning points In an endemic area of tuberculosis, tuberculoma should be considered as a differential diagnosis when evaluating sellar lesions. Pituitary tuberculoma can present with pituitary apoplexy-like symptoms. Prompt diagnosis and treatment may lead to recovery of pituitary function.
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Affiliation(s)
- Gaayathri Krishnan
- Endocrinology Unit, Department of Internal Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Nur Hidayah Mohd Makhatar
- Endocrinology Unit, Department of Internal Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Tee Hwee Ching
- Endocrinology Unit, Department of Internal Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Serena Khoo
- Endocrinology Unit, Department of Internal Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
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Dzialach L, Sobolewska J, Respondek W, Wojciechowska-Luzniak A, Witek P. Pituitary apoplexy as the first manifestation of non‑functioning pituitary neuroendocrine tumour. Endokrynol Pol 2024; 75:111-112. [PMID: 38497398 DOI: 10.5603/ep.96305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 03/19/2024]
Abstract
Not required for a Clinical Vignette.
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Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland.
| | - Joanna Sobolewska
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Wioleta Respondek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Brodnowski Hospital, Warsaw, Poland
| | | | - Przemyslaw Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
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Alshahrani AM, Al Bshabshe A, Al Shahrani MB. Pituitary Apoplexy After a Major Abdominal Surgery: A Case Report. Cureus 2024; 16:e52966. [PMID: 38406091 PMCID: PMC10894319 DOI: 10.7759/cureus.52966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Pituitary apoplexy is a major complication of pituitary adenoma, and the diagnosis might be challenging if the patient presents with signs of meningeal irritation or electrolyte imbalance. It can be fatal if not diagnosed and treated appropriately. Apoplexy is the first clinical presentation in the majority of pituitary adenoma cases. The pathophysiology of pituitary apoplexy involves bleeding and/or ischemia of pituitary enlargement. In this case report, we present a case of pituitary apoplexy that developed after a major abdominal surgery. The patient presented with headache, hypertension, and visual loss. After confirming the diagnosis through a CT scan, the patient underwent a transsphenoidal surgical decompression.
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Affiliation(s)
| | - Ali Al Bshabshe
- Intensive Care Unit, Aseer Central Hospital, Abha, SAU
- Medicine, King Khalid University, Abha, SAU
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Aramaki K, Aihara M, Kanazawa Y, Kawashima T, Yamaguchi R, Matsumoto M, Tosaka M, Yoshimoto Y. Radiological features of internal carotid artery occlusion caused by pituitary apoplexy: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23484. [PMID: 38048571 DOI: 10.3171/case23484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/10/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Pituitary apoplexy rarely causes internal carotid artery (ICA) occlusion and acute ischemic stroke. Some cases have been reported, but the neuroimaging findings, including cerebral angiography, have not been discussed. OBSERVATIONS A 55-year-old male suffered the sudden onset of right cervical pain and left mild hemiparesis. Computed tomography indicated a pituitary mass, and magnetic resonance angiography showed a right ICA occlusion. The initial diagnosis was ICA occlusion caused by ICA dissection. His symptoms worsened and the region of cerebral infarction expanded, so the patient was transferred to our hospital. Magnetic resonance imaging and cerebral angiography showed the sudden stoppage of right ICA blood flow caused by local compression of the tumor near the distal dural ring. The diagnosis was acute ischemic stroke resulting from ICA pseudo-occlusion caused by pituitary apoplexy, and emergent endoscopic transsphenoidal resection was performed. Postoperatively, the right ICA was completely patent, and hemiparesis was improved with rehabilitation. LESSONS ICA occlusion caused by pituitary apoplexy is very rare, but emergent treatment is necessary. However, the pathology is difficult to diagnose quickly. Neuroimaging findings showing that the ICA is easily stenosed or occluded if rapidly compressed by the tumor near the distal dural ring may be useful to rapidly diagnose and treat.
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Affiliation(s)
- Keigo Aramaki
- 1Department of Neurosurgery, Hokushin General Hospital Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Nakano, Nagano, Japan
| | - Masanori Aihara
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
| | - Yu Kanazawa
- 3Department of Neurosurgery, Tatebayashi Kosei General Hospital, Tatebayashi, Gunma, Japan
| | - Takahiro Kawashima
- 3Department of Neurosurgery, Tatebayashi Kosei General Hospital, Tatebayashi, Gunma, Japan
| | - Rei Yamaguchi
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
| | - Masahiro Matsumoto
- 3Department of Neurosurgery, Tatebayashi Kosei General Hospital, Tatebayashi, Gunma, Japan
| | - Masahiko Tosaka
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
| | - Yuhei Yoshimoto
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
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Meira Goncalves J, Polónia P, Pereira J, Silva PA. Primary Central Nervous System Lymphoma Mimicking the Presentation of Pituitary Apoplexy: A Case Report. Cureus 2023; 15:e50912. [PMID: 38249173 PMCID: PMC10799692 DOI: 10.7759/cureus.50912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Pituitary lymphoma is one of the rare variants of primary central nervous system lymphoma (PCNSL), mostly arising due to the metastatic spread of systemic lymphoma. We report the case of a 69-year-old woman who initially presented to her family physician with a headache but without any other symptoms. The MRI scan revealed a sellar mass consistent with a pituitary macroadenoma. When the patient was referred to our hospital, two weeks later, the symptoms had progressed, comprising complete right-sided ophthalmoplegia and ptosis, with left-sided amaurosis. A repeat MRI revealed an increased size of the sellar mass, consistent with pituitary apoplexy. A right pterional craniotomy with partial resection of the mass was performed and an intraoperative frozen section biopsy was carried out. The final pathology revealed diffuse large B-cell lymphoma. A systemic follow-up including a whole-body CT, bone marrow aspiration, and cerebrospinal fluid studies ruled out any systemic manifestation, and the patient was HIV-negative. The patient underwent treatment with methotrexate, cytarabine, thiotepa, and rituximab for PCNSL. Although rare, PCNSL can mimic pituitary apoplexy, which needs to be considered if conservative therapy or surgery is to be offered to a patient with a radiological and clinical diagnosis of pituitary apoplexy.
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Affiliation(s)
- Joao Meira Goncalves
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
| | - Patricia Polónia
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
| | - Josué Pereira
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
- Neurosciences Centre, Hospital CUF, Porto, PRT
| | - Pedro Alberto Silva
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
- Neurosciences Centre, Hospital CUF, Porto, PRT
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Zoli M, Guaraldi F, Rustici A, Cirillo L, Asioli S, Mazzatenta D. Bilateral antererior circulation stroke: A rare but threatening consequence of pituitary apoplexy. Case report and systematic literature review. Neuroradiol J 2023; 36:746-751. [PMID: 35343284 PMCID: PMC10649528 DOI: 10.1177/19714009221083146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Brain stroke is a rare, life-threatening condition associated with pituitary apoplexy (PA), resulting from direct arterial occlusion due to mechanical compression secondary to the sudden enlargement of the pituitary adenoma, or to vessel vasospasm, induced by tumor hemorrhage. CASE REPORT We report the case of a 64-year-old woman with PA complicated by bilateral anterior circulation stroke due to critical stenosis of both anterior cerebral arteries (ACA). Despite the quick surgical decompression and consequent blood flow restoration, the neurological conditions of the patient did not improve and she died 18 days later. Ten other cases of anterior circulation stroke due to PA were retrieved in a systematic review of literature. Clinical and neuroradiological features of these patients and treatment outcome were assessed to suggest the most proper management. CONCLUSION The onset of neurological symptoms suggestive for brain stroke in patients with PA requires performing an emergency Magnetic Resonance Imaging (MRI), including Diffusion-weighted and angiographic MR-sequences. The role of surgery in these cases is debated, however, transsphenoidal adenomectomy would permit us to decompress the ACA and restore blood flow in their territories. Although the prognosis of PA-induced anterior circulation stroke is generally poor, a timely diagnosis and treatment would be paramount for improving patient outcome.
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Affiliation(s)
- Matteo Zoli
- Programma Neurochirurgia Ipofisi- Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
| | - Federica Guaraldi
- Programma Neurochirurgia Ipofisi- Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy
| | - Arianna Rustici
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Italy
| | - Luigi Cirillo
- Programma Neurochirurgia Ipofisi- Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
| | - Sofia Asioli
- Programma Neurochirurgia Ipofisi- Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
| | - Diego Mazzatenta
- Programma Neurochirurgia Ipofisi- Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Italy
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Li B, Kim MG, Dominguez JF, Feldstein E, Kleinman G, Al-Mufti F, Kim M, Hanft S. Intrasellar hemorrhagic chordoma masquerading as pituitary apoplexy: case report and review of the literature. Br J Neurosurg 2023; 37:1685-1688. [PMID: 34148480 DOI: 10.1080/02688697.2021.1941761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND IMPORTANCE Chordomas are centrally located, expansile soft tissue neoplasms that arise from the remnants of the embryological notochord. Hemorrhagic presentation is exceedingly rare and can resemble pituitary apoplexy. Moreover, a purely intrasellar location of a chordoma is extremely uncommon. We report a case of a hemorrhagic intrasellar chordoma in an adult male, which presented similarly to pituitary apoplexy and was resolved with surgical resection. CLINICAL PRESENTATION A 69-year-old male presented with a 4 week history of acute onset headache and concurrent diplopia, with significantly reduced testosterone and slightly reduced cortisol. His left eye demonstrated a sixth cranial nerve palsy. Magnetic resonance imaging of the brain showed a large hemorrhagic mass in the pituitary region with significant compression of the left cavernous sinus and superior displacement of the pituitary gland. The patient underwent an endoscopic endonasal transsphenoidal approach for the resection of the lesion. Near total resection was achieved. Final pathology revealed chordoma with evidence of intratumoral hemorrhage, further confirmed by immunopositive stain for brachyury. Post-operatively, the patient had improved diplopia and was discharged home on low dose hydrocortisone. At 3-month follow-up, his diplopia was resolved and new MRI showed stable small residual disease. CONCLUSIONS Apoplectic chordomas are uncommon given chordoma's characteristic lack of intralesional vascularity and represent a diagnostic challenge in the sellar region. Our unique case demonstrates that despite our initial impression of pituitary apoplexy, this was ultimately a case of apoplectic chordoma that responded well to endoscopic endonasal surgery.
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Affiliation(s)
- Boyi Li
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Michael G Kim
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Eric Feldstein
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - George Kleinman
- Department of Pathology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Matthew Kim
- Department of Otolaryngology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Kharel M, Hossain MF. Pituitary apoplexy associated with bacterial meningitis: Diagnostic dilemma. Clin Case Rep 2023; 11:e7887. [PMID: 37670816 PMCID: PMC10475759 DOI: 10.1002/ccr3.7887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/07/2023] Open
Abstract
Pituitary apoplexy is a rare entity, which is characterized by severe neurological, ophthalmological, and endocrinological complications, with acute adrenal crisis being a major concern. The diagnosis of pituitary apoplexy is challenging, particularly in cases where it coexists with bacterial meningitis, leading to a diagnostic dilemma and delay in treatment. We report a case of a 23-year-old female diagnosed with pituitary apoplexy with concurrent bacterial meningitis.
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Mattogno PP, Zoli M, D’Alessandris QG, Bongetta D, Caccavella VM, Rigante M, Della Pepa GM, Mazzatenta D, Lauretti L, Olivi A, Spena G, Zoia C. Ultra-Early Treatment of Neurosurgical Emergencies with Endoscopic Endonasal Approach: Experience from Three Italian Referral Centers. J Clin Med 2023; 12:5471. [PMID: 37685541 PMCID: PMC10487769 DOI: 10.3390/jcm12175471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE the aim of this multicenter study is to preliminarily assess the role of the Endoscopic Endonasal Approach (EEA) in ultra-early (i.e., within 12 h) management of selected neurosurgical emergencies in terms of clinical and radiological outcomes. METHODS 26 patients affected by sellar/parasellar pathologies with rapid progression of symptoms were managed with EEA within 12 h from diagnosis in three Italian tertiary referral Centers from January 2016 to December 2019. Both clinical and radiological data have been collected preoperatively as well as post-operatively in order to perform retrospective analysis. RESULTS The average time from admission to the operating room was 5.5 h (±2.3). The extent of resection was gross-total in 20 (76.9%), subtotal in 6 (23.1%) patients. One patient experienced re-bleeding after a subtotal removal of a hemorrhagic lesion. Patients with a longer time from admission (>4 h) to the operatory room (OR) experienced stable impairment of the visual acuity (p = 0.033) and visual field (p = 0.029) in the post-operative setting. CONCLUSIONS The Endoscopic Endonasal Approach represents a safe, effective technique that can be efficiently used with good results in the management of selected neurosurgical emergencies in centers with adequate experience.
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Affiliation(s)
- Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Matteo Zoli
- Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Institute of Neurological Sciences of Bologna, 40121 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40121 Bologna, Italy
| | | | - Daniele Bongetta
- Department of Neurosurgery, ASST Fatebenefratelli Sacco, 20100 Milan, Italy
| | - Valerio Maria Caccavella
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Mario Rigante
- Department of Otolaryngology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Diego Mazzatenta
- Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Institute of Neurological Sciences of Bologna, 40121 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40121 Bologna, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Giannantonio Spena
- Neurosurgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cesare Zoia
- Neurosurgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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13
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Hussain H, Janaka K, Muthukuda DT, Perera SG. Pituitary Apoplexy as a Complication of COVID-19 Infection. Cureus 2023; 15:e43524. [PMID: 37719628 PMCID: PMC10500954 DOI: 10.7759/cureus.43524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
Pituitary apoplexy (PA) is a complication occurring due to hemorrhage and/or infarction in a pituitary adenoma due to various pathophysiological mechanisms. Herein, we report a case of a 47-year-old previously healthy male who presented with fever and reduced level of consciousness for one day. During the hospital stay, he was diagnosed with PA in a background of pituitary macroadenoma along with positive nasopharyngeal swabs for SARS-CoV-2 infection. Even though the PA was successfully managed, the patient succumbed four days after admission due to respiratory failure caused by severe COVID-19 pneumonia.
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Affiliation(s)
- Hassan Hussain
- General Medicine, Sri Jayewardenepura General Hospital, Colombo, LKA
| | - Kvc Janaka
- Internal Medicine, Sri Jayewardenepura General Hospital, Colombo, LKA
| | - D T Muthukuda
- Endocrinology, Sri Jayewardenepura General Hospital, Colombo, LKA
| | - S G Perera
- Pulmonology, Sri Jayewardenepura General Hospital, Colombo, LKA
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14
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Tanaka H, Nishimura F, Nakase K, Yokoyama S, Nakagawa I, Yamada S, Tamura K, Matsuda R, Takeshima Y, Kotsugi M, Park YS, Nakase H. Case report: Giant pituitary neuroendocrine tumor presented along with acute visual loss due to pituitary apoplexy after receiving COVID-19 vaccination. Front Surg 2023; 10:1220098. [PMID: 37576925 PMCID: PMC10413133 DOI: 10.3389/fsurg.2023.1220098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 08/15/2023] Open
Abstract
Objective A case of giant pituitary neuroendocrine tumor presented along with acute visual loss due to pituitary apoplexy after receiving a COVID-19 vaccination is reported. Case presentation A 45-year-old man was referred for a giant pituitary tumor with bitemporal hemianopsia. A surgical procedure was planned and then delayed due to the COVID-19 outbreak in Japan, with a Pfizer/BioNTech vaccine administered while awaiting surgery. Three days after the second COVID-19 vaccination the patient noted a progressively worsening headache that caused pituitary apoplexy and then a decrease in vision. Emergency surgery was thus performed. Conclusion Pituitary apoplexy is a rare and life-threatening complication that may occur after undergoing a COVID-19 vaccination.
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15
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Funari A, Jeong SS, Pecorari IL, Flaquer I, Anderson CL, Agarwal V. Infarctive Apoplexy of Previously Healthy Pituitary Glands: A Small Case Series and Literature Review. J Neurol Surg Rep 2023; 84:e71-e79. [PMID: 37492614 PMCID: PMC10365896 DOI: 10.1055/s-0043-1770788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/26/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction We present two cases of suspected pituitary apoplexy found instead to be infarcted pituitary glands without histopathologic evidence of neoplastic cells, likely resulting from spontaneous infarction of previously healthy pituitary glands. Case Presentations The first case is a 55-year-old man who presented with a pulsating headache, nausea, and several months of decreased libido, polyuria, and polydipsia. Magnetic resonance imaging (MRI) revealed a rim-enhancing sellar/suprasellar mass with evidence of recent hemorrhage on the right. Testosterone, follicle-stimulating hormone, and luteinizing hormone levels were suppressed. Analysis of the resected specimen showed fibrocollagenous tissue with evidence of old hemorrhage and microscopic focus of necrotic tissue. The second case is a 56-year-old man who presented with a throbbing headache, associated nausea, and 6 weeks of polyuria and polydipsia. Testosterone levels were found to be low, and 8-hour water deprivation test showed evidence for partial diabetes insipidus. MRI revealed a mass on the right side of the pituitary gland, with evidence of likely hemorrhage on the left. Analysis of the resected specimen showed necrotic tissue without neoplastic cells. Conclusion When evaluating small pituitary lesions in patients presenting with indolent onset of pituitary insufficiency, there should be a high degree of suspicion for an infarcted pituitary gland.
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Affiliation(s)
- Abigail Funari
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Seth S. Jeong
- Department of Otolaryngology—Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Isabella L. Pecorari
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Isabella Flaquer
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Cassidy L. Anderson
- Department of Otolaryngology—Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Vijay Agarwal
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Otolaryngology—Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
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16
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Hazzi C, Villemure-Poliquin N, Nadeau S, Champagne PO. SARS-CoV-2 Infection, A Risk Factor for Pituitary Apoplexy? A Case Series and Literature Review. Ear Nose Throat J 2023:1455613231179714. [PMID: 37291861 PMCID: PMC10261951 DOI: 10.1177/01455613231179714] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 05/03/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023] Open
Abstract
Introduction: Pituitary apoplexy (PA) is a rare phenomenon, characterized by a hemorrhagic or ischemic event of the pituitary gland, most often in association with a pituitary lesion. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the strain of virus responsible for the internationally recognized global pandemic COVID-19. Multiple clinical manifestations associated with this virus have been described, ranging from asymptomatic, mild flu symptoms to acute respiratory distress syndrome, end-organ failure leading to death. Cases of patients with concomitant COVID-19 infections and PA are being further recognized in the literature, but the causal association between the 2 entities remains speculative. Objectives: The objectives of this case series are 3-fold: to describe additional cases of patients with concomitant COVID-19 infection and PA (1), to review the current evidence regarding this potential complication associated with a COVID-19 infection (2), and to discuss physiopathological hypotheses, treatments, and prognoses of this newly recognized association (3). Method: We conducted an electronic chart review of patients treated for PA with concomitant COVID-19 infection from March 2020 to December 2021. A literature review was performed using MEDLINE, Web of Science, and Embase databases to identify other cases of COVID-19-associated PA. Results: From March 2020 to December 2021, 3 patients presented to our center with PA following a symptomatic COVID-19 infection. Two of these patients developed PA symptoms days following the viral infection, whereas the third patient developed PA after a 2-month period. The 2 first patients were managed surgically because of persistent visual symptoms. Results from our literature review yielded 12 other cases of COVID-19-associated PAs. Conclusions: The association between COVID-19 infection and PA has been increasingly reported in the literature. With the addition of the 3 cases described in our article, a total of 15 cases have been published. Many contributing mechanisms may lead to PA following COVID-19 infection. Coagulopathy is probable major contributing cause responsible for hemorrhage or infarction of the pituitary gland. Our case series provides further arguments that PA may be a direct manifestation of a COVID-19 infection.
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Affiliation(s)
- Christina Hazzi
- Department of Ophthalmology and Otolaryngology—Head and Neck Surgery, CHU de Québec, Quebec, QC, Canada
| | - Noémie Villemure-Poliquin
- Department of Ophthalmology and Otolaryngology—Head and Neck Surgery, CHU de Québec, Quebec, QC, Canada
| | - Sylvie Nadeau
- Department of Ophthalmology and Otolaryngology—Head and Neck Surgery, CHU de Québec, Quebec, QC, Canada
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17
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Waqar F, Arif A, Muazzam A, Khan A. Pituitary Adenoma With Apoplexy Presenting As Unilateral Third Nerve Palsy. Cureus 2023; 15:e40555. [PMID: 37465780 PMCID: PMC10351210 DOI: 10.7759/cureus.40555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Pituitary adenomas are one of the most common intracranial tumors. Non-functioning macroadenomas are usually diagnosed when they cause symptoms due to the mass effect on surrounding structures. We present the case of a 48-year-old man who presented with a headache associated with ptosis of the right eye and right-sided blurry vision for three days. Initial computerized tomography (CT) scan of the head did not report a mass, acute infarct, or hemorrhage. He was given 325mg of aspirin for concern of a stroke while waiting for magnetic resonance imaging (MRI) of the brain, which was done the next day and revealed a pituitary macroadenoma with hemorrhage, mass effect, and compression of the optic chiasm consistent with pituitary apoplexy. He ultimately underwent trans-sphenoidal resection of the tumor; however, his surgery was delayed for five days as he had received a high dose of aspirin in the Emergency Room. His adrenocorticotropic hormone (ACTH), cortisol, and testosterone levels were found to be quite low. He was administered stress dose steroids peri-operatively and ultimately discharged on indefinite hydrocortisone therapy and endocrinology follow-up. Our case highlights a serious complication of pituitary adenomas that can occur called pituitary apoplexy which is caused by acute ischemic infarction or hemorrhage in the pituitary. It needs prompt identification and management. Our case also emphasizes the importance of recognizing pituitary apoplexy as one of the causes of sudden onset cranial nerve deficits, as it is a rare presentation of pituitary adenomas that can be taken for a stroke in the Emergency Department.
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Affiliation(s)
- Fatima Waqar
- Internal Medicine, Abington Memorial Hospital, Abington, USA
| | - Ansharah Arif
- Internal Medicine, Abington Memorial Hospital, Abington, USA
| | - Asmaa Muazzam
- Internal Medicine/Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Areej Khan
- Internal Medicine, Berkshire Medical Center, Pittsfield, USA
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18
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Fadul A, Demir G, Safieh M, Lebbe A, Falamrz F, Alhassan AT, Abdalla ELM, Fadul MH, Elawad M, Akbar RA. Isolated Sixth Cranial Nerve Palsy as Initial Presentation of Pituitary Apoplexy: A Case Report. Cureus 2023; 15:e41154. [PMID: 37525778 PMCID: PMC10386906 DOI: 10.7759/cureus.41154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/02/2023] Open
Abstract
Pituitary apoplexy is a serious condition, which if left untreated, might lead to irreversible life-long complications. Hence, pituitary apoplexy should always be included in the differential diagnoses of a patient with an isolated sixth cranial nerve (CN) palsy. This report highlights the case of a patient presenting with isolated CN palsy associated with pituitary apoplexy. Although pituitary adenomas are common, they seldom present with isolated abducent nerve palsy without any other CN involvement. The 47-year-old female patient presented with acute right eye pain, diplopia, and a squint. Examination revealed an isolated unilateral sixth CN palsy. Brain MRI showed a sellar and suprasellar mass suggestive of hemorrhagic pituitary apoplexy. The patient was transferred to neurosurgery and underwent transsphenoidal resection of a pituitary macroadenoma. Postoperative follow-up showed clinical improvement. It is, thus, imperative for physicians to have the knowledge to recognize an isolated sixth cranial nerve palsy and its associated causes.
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Affiliation(s)
- Abdalla Fadul
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Gokhan Demir
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | | | | | | | | | | | | | | | - Raza A Akbar
- Internal Medicine, Hamad General Hospital, Doha, QAT
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19
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Makadia AA, Jenkins W, Azad F, Bebawee R. Pituitary Apoplexy Following Elective Total Hip Replacement. Cureus 2023; 15:e40600. [PMID: 37337556 PMCID: PMC10277164 DOI: 10.7759/cureus.40600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 06/21/2023] Open
Abstract
Pituitary apoplexy is an endocrine-related emergency most commonly caused by hemorrhage into a preexisting pituitary adenoma. Known risk factors for such hemorrhage include major surgical procedures, head trauma, pregnancy, anticoagulation, and the administration of hormone therapies for the correction of primary hypothalamic deficiencies. Elective orthopedic surgery is an uncommon precipitator of pituitary apoplexy that is rarely described. We report the case of a patient with a previously unknown pituitary macroadenoma who developed apoplexy as a complication of elective right total hip arthroplasty.
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Affiliation(s)
| | | | - Farhan Azad
- Internal Medicine, University at Buffalo, Buffalo, USA
| | - Remon Bebawee
- Internal Medicine, University at Buffalo, Buffalo, USA
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20
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Gheorghe AM, Trandafir AI, Stanciu M, Popa FL, Nistor C, Carsote M. Challenges of Pituitary Apoplexy in Pregnancy. J Clin Med 2023; 12:jcm12103416. [PMID: 37240522 DOI: 10.3390/jcm12103416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012-December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal-fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample-case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal-fetal outcomes from multidisciplinary insights.
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Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra-Ioana Trandafir
- Department of Endocrinology, Doctoral School of "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 50169 Sibiu, Romania
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy & Thoracic Surgery Department, "Dr. Carol Davila" Central Emergency University Military Hospital, 013058 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, "Carol Davila" University of Medicine and Pharmacy & "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
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21
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Baldia M, Rajshekhar V. Preventing Postoperative Apoplexy in Giant Pituitary Adenomas using Combined Trans-Sphenoidal and Cranial Surgery. Neurol India 2023; 71:439-446. [PMID: 37322737 DOI: 10.4103/0028-3886.378658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Background Combined surgery consisting of endoscopic trans-sphenoidal surgery (ETSS) and transcranial (TC) surgery for giant pituitary adenomas (GPAs) has been recommended to prevent lethal postoperative apoplexy. Based on our experience, we attempt to rationalize the indications for such surgery. Materials and Methods We report the magnetic resonance (MR) characteristics of the tumor and the outcomes in patients with GPAs who underwent ETSS only and combined surgery. Total tumor volume (TTV), tumor extension volume (TEV), and suprasellar extension of tumor (SET) were calculated based on the lines drawn on MR images and compared between those who underwent ETSS only and those who underwent combined surgery. Results Of 80 patients with GPAs, eight (10%) underwent combined surgery (seven in the same sitting and one had staged surgery). All eight patients (100%) who underwent combined surgery had tumors with multilobulations, extensions, and encasement of the vessels in the circle of Willis (COW). Of 72 patients who underwent ETSS alone, 21 (29.1%) had a multilobulated tumor, 26 (36.2%) tumors had anterior/lateral extensions, and 12 (16.6%) had encasement of the COW. The mean TTV, TEV, and SET for the combined surgery group were significantly higher than those in the ETSS group. None of the patients who underwent combined surgery suffered postoperative residual tumor apoplexy. Conclusion Patients with GPAs in whom there are significant lateral intradural or subfrontal tumor extensions should be considered for combined surgery at the same sitting to avoid devastating postoperative apoplexy in the residual tumor, which can occur when ETSS alone is performed.
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Affiliation(s)
- Manish Baldia
- Department of Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
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22
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Gamito MAPDO, Amaral NYB, Rodrigues CF, Ribeiro JM, Guerra S. Pituitary Apoplexy in Pregnancy: What do We Know? Rev Bras Ginecol Obstet 2023; 45:273-280. [PMID: 37339647 PMCID: PMC10442903 DOI: 10.1055/s-0043-1770128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/21/2023] [Indexed: 06/22/2023] Open
Abstract
Pituitary apoplexy refers to a rare clinical syndrome consisting of signs and symptoms that occur due to rapid expansion of the contents of the sella turcica. It can occur spontaneously or associated with pituitary tumors. It can have a broad clinical spectrum, but usually presents with severe headache, visual impairment and hypopituitarism. Sudden onset of symptoms associated to imagiologic confirmation makes the diagnosis. Surgical treatment is advised when there is important compression of the optic tract. We present a case report and a review of the literature on pituitary apoplexy in pregnancy. The cases were reviewed to obtain information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities and maternal and fetal outcomes. Our review found 36 cases of pituitary apoplexy in pregnancy. Most of the cases occurred in the second trimester of pregnancy and headache was the most frequent symptom at presentation. Surgical therapy was required in more than half of the patients. In what respect maternal and fetal outcomes, there were 3 cases of preterm delivery and one case of maternal death. Our clinical case and literature review reinforces the importance of an early diagnosis to avoid potential adverse consequences.
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23
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Mastandrea K, Voica M, Tetlay M, Hasan F. Pituitary Apoplexy Secondary to Gonadotropin-Releasing Hormone Agonist for Breast Cancer. JCEM Case Rep 2023; 1:luad069. [PMID: 37908581 PMCID: PMC10580572 DOI: 10.1210/jcemcr/luad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Indexed: 11/02/2023]
Abstract
Pituitary apoplexy is a potentially fatal clinical condition that results from pituitary infarction due to ischemia or hemorrhage. We present a case of a 53-year-old female patient with a history of recurrent pituitary macroadenoma who presented with headache, blurry vision, nausea, vomiting, and photophobia after receiving a gonadotropin-releasing hormone (GnRH) agonist, leuprolide, as part of adjuvant endocrine therapy for breast cancer. Magnetic resonance imaging (MRI) confirmed the presence of pituitary apoplexy, and endocrine workup showed anterior hypopituitarism. The patient was managed conservatively and required glucocorticoid replacement. A repeat MRI after 3 months showed a partially empty sella. A review of the literature revealed that this case adds to the growing number of patients who present with headache, visual symptoms, and symptoms related to meningeal irritation after administration of GnRH agonists, with varying latency from treatment to symptom onset. Although there are other cases involving female patients or patients with known pituitary macroadenomas, to our knowledge, this is the first reported case of pituitary apoplexy in a patient receiving a GnRH agonist as an adjuvant for breast cancer. Physicians should be aware of this rare complication of GnRH agonist therapy in patients with a pituitary macroadenoma.
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Affiliation(s)
- Katherine Mastandrea
- Division of Endocrinology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15090, USA
| | - Mihail Voica
- Division of Endocrinology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15090, USA
| | - Maryam Tetlay
- Division of Endocrinology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15090, USA
| | - Farhad Hasan
- Division of Endocrinology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA 15090, USA
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24
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Nabulsi O, Abouelleil M, Lyons L, Walsh M, Singer J. Immune Thrombocytopenic Purpura Presenting with Pituitary Apoplexy: A Case Report and Literature Review. J Neurol Surg Rep 2023; 84:e61-e64. [PMID: 37213415 PMCID: PMC10195162 DOI: 10.1055/a-2072-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 01/26/2023] [Indexed: 05/23/2023] Open
Abstract
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.
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Affiliation(s)
- Omar Nabulsi
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
- Address for correspondence Omar Nabulsi, BA Department of NeurosurgerySpectrum Health, 25 Michigan St. NE, Grand Rapids, MI 49503-2560United States
| | - Mohamed Abouelleil
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
| | - Leah Lyons
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
| | - Meggen Walsh
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
| | - Justin Singer
- Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, United States
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25
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Takagi F, Yagi R, Kanemitsu T, Tsuji Y, Ikeda N, Nonoguchi N, Furuse M, Kawabata S, Takami T, Wanibuchi M. Chronic expanding pituitary hematoma with calcification resulting from pituitary adenoma: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE2315. [PMID: 36880516 PMCID: PMC10550663 DOI: 10.3171/case2315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Pituitary apoplexy (PA) is characterized by sudden headache, vomiting, visual dysfunction, anterior lobe dysfunction, and endocrine disorder due to bleeding or infarction from a pituitary adenoma. PA occurs in approximately 0.6-10% of pituitary adenomas, more commonly in men aged 50-60 years, and more frequently in nonfunctioning and prolactin-producing pituitary adenomas. Further, asymptomatic hemorrhagic infarction is found in approximately 25% of PA. OBSERVATIONS A pituitary tumor with asymptomatic hemorrhage was detected on head magnetic resonance imaging (MRI). Thereafter, the patient underwent head MRI every 6 months. After 2 years, the tumor was enlarged and visual dysfunction was noticed. The patient underwent endoscopic transnasal pituitary tumor resection and was diagnosed with a chronic expanding pituitary hematoma with calcification. The histopathological findings were very similar to those of chronic encapsulated expanding hematoma (CEEH). LESSONS CEEH associated with pituitary adenomas gradually increases in size, causing visual dysfunction and pituitary dysfunction. In case of calcification, total removal is difficult due to adhesions. In this case, calcification developed within 2 years. A pituitary CEEH, even when showing calcification, should be operated on, as visual function can be fully recovered.
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Affiliation(s)
- Fugen Takagi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Ryokichi Yagi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Takuya Kanemitsu
- Department of Neurosurgery, Midorigaoka Hospital, Takatsuki City, Osaka, Japan
| | - Yuichiro Tsuji
- Department of Neurosurgery, Kano Genral Hospital, Osaka City, Osaka, Japan; and
| | - Naokado Ikeda
- Department of Neurosurgery, Takeda Hospital, Kyoto City, Kyoto, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Motomasa Furuse
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki City, Osaka, Japan
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Ruella M, Caffaratti G, Katz D, Marengo R, Cervio A. [ Pituitary apoplexy and SARS-CoV-2 (COVID-19) infection]. Medicina (B Aires) 2023; 83:133-137. [PMID: 36774609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
Coronavirus disease (SARS-CoV-2/COVID-19) is responsible for a wide variety of extrapulmonary manifestations, among which direct or indirect neurological compromise stands out. Pituitary apoplexy is a clinical and neurosurgical entity of variable severity, usually associated with a pituitary adenoma. Literature is scarce regarding the association between these diseases. This paper reports a case of pituitary apoplexy, manifested concomitantly to the diagnosis of COVID 19 in a patient with unknown pituitary macroadenoma, and its therapeutic management, reviewing the mechanisms potentially underlying the link between both entities.
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Affiliation(s)
- Mauro Ruella
- Departamento de Neurocirugía, FLENI, Buenos Aires, Argentina. E-mail:
| | | | - Débora Katz
- Servicio de Neuro-Endocrinología, FLENI, Buenos Aires, Argentina
| | - Ricardo Marengo
- Servicio de Otorrinolaringología, FLENI, Buenos Aires, Argentina
| | - Andrés Cervio
- Departamento de Neurocirugía, FLENI, Buenos Aires, Argentina
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27
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Pailler JI, Villalonga JF, Ries-Centeno T, Saenz A, Baldoncini M, Pipolo DO, Cárdenas Ruiz-Valdepeñas E, Kaen A, Hirtler L, Roytowski D, Solari D, Cervio A, Campero A. Clinical Applicability of the Sellar Barrier Concept in Patients with Pituitary Apoplexy: Is It Possible? Life (Basel) 2023; 13:life13010158. [PMID: 36676107 PMCID: PMC9861876 DOI: 10.3390/life13010158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.
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Affiliation(s)
- José Ignacio Pailler
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Juan Francisco Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
- Correspondence:
| | | | - Amparo Saenz
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Matías Baldoncini
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Derek Orlando Pipolo
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | | | - Ariel Kaen
- Hospital Virgen del Rocío, 41013 Sevilla, Spain
| | - Lena Hirtler
- Endoscopic Laboratory of Anatomy Center, Medical University of Vienna, 1090 Vienna, Austria
| | - David Roytowski
- Department of Neurosurgery, University of Cape Town, Cape Town 7701, South Africa
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Andrés Cervio
- Departamento de Neurocirugía, FLENI, Buenos Aires 1625, Argentina
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
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Muacevic A, Adler JR, Khan E, Palawat SS. A Case of Sheehan Syndrome Six Years Postpartum Presented With Adrenal Crisis and Complicated by Hypothyroidism and Massive Pericardial Effusion. Cureus 2023; 15:e33972. [PMID: 36824567 PMCID: PMC9941025 DOI: 10.7759/cureus.33972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/21/2023] Open
Abstract
Sheehan syndrome is often a sequela of massive postpartum hemorrhage in resource-poor healthcare settings where blood loss during delivery is often neglected. The diagnosis of this rare but fatal disease is often delayed because the symptoms are vague and the pituitary dysfunction is insidious in nature. We report the case of a 35-year-old multiparous female with anhedonia and raised serum transaminases. She presented with constitutional symptoms. Her last vaginal delivery, six years back, was the last obstetric event that yielded a stillbirth child. She had had amenorrhea since then. Upon further evaluation, she was found to have a massive pericardial effusion, hypopituitarism, and a partially empty sella. This case report highlights the uncharacteristic symptoms that a patient presents with which ultimately lead to delayed diagnosis. Early diagnosis can go miles in improving the quality of life of the patient besides saving the patient from an adrenal crisis.
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Affiliation(s)
- Alexander Muacevic
- Department of Internal Medicine, Ganesh Shankar Vidyarthi Memorial Medical College, Kanpur, IND
| | - John R Adler
- Department of Internal Medicine, Ganesh Shankar Vidyarthi Memorial Medical College, Kanpur, IND
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Racca G, D’Agnano S, Fasano N, Gianotti L. Pituitary Apoplexy With Transition to Acute Hypophysitis in a Patient With Sars-CoV-2 Pneumonia. JCEM Case Rep 2023; 1:luac010. [PMID: 37908272 PMCID: PMC10578393 DOI: 10.1210/jcemcr/luac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Indexed: 11/02/2023]
Abstract
COVID-19 is a systemic disease associated with respiratory insufficiency, systemic inflammation, as well as coagulation, neurological, and endocrine disorders. Among them pituitary apoplexy (PA) as well as, more rarely, acute hypophysitis (AH) have been reported. In the present report, we described a case of PA in an 84-year-old man with SARS-CoV-2 pneumonia, with a previous unknown pituitary adenoma and a possible but not confirmed overlap with transitory AH. After reviewing the available literature, we discuss the potential clinical and pathophysiological relationship between PA and AH. Furthermore, we focus on the neuroradiological features of pituitary lesions in the presence of SARS-CoV-2 infection.
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Affiliation(s)
- Giulia Racca
- Division of Internal Medicine, Department of Medicine, Hospital S. Croce & Carle Cuneo, Cuneo, Italy
| | - Salvatore D’Agnano
- Division of Internal Medicine, Department of Medicine, Hospital S. Croce & Carle Cuneo, Cuneo, Italy
| | - Nicoletta Fasano
- Division of Neuroradiology, Department of Radiology, Hospital S. Croce & Carle Cuneo, Cuneo, Italy
| | - Laura Gianotti
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, S. Croce & Carle Hospital Cuneo, Cuneo, Italy
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Takeshita K, Abe I, Kameda W, Ishii K, Fujita Y, Nagata M, Ochi K, Senda Y, Koga M, Kudo T, Hada Y, Takase K, Morinaga Y, Ito M, Abe M, Ishizawa K, Kobayashi K. Clinical evaluations of pituitary apoplexy in incidental nonfunctional pituitary adenomas. Medicine (Baltimore) 2022; 101:e32026. [PMID: 36550872 PMCID: PMC9771219 DOI: 10.1097/md.0000000000032026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Kaori Takeshita
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Ichiro Abe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
- * Correspondence: Ichiro Abe, Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, 1-1-1, Zokumyoin, Chikushino, Fukuoka 818-8502, Japan (e-mail: )
| | - Wataru Kameda
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kota Ishii
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yuya Fujita
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Mai Nagata
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Kentaro Ochi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yuki Senda
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Midori Koga
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Tadachika Kudo
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yurika Hada
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kaoru Takase
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yusuke Morinaga
- Department of Neurosurgery, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Miiko Ito
- Department of Neurosurgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Makiko Abe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kenichi Ishizawa
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kunihisa Kobayashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Japan
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Biagetti B, Sarria-Estrada S, Cordero Asanza E, Chaachou-Charradi A, Ng-Wong YK, Cicuendez M, Hernandez I, Rojano-Toimil A, Costa P, Martinez-Saez E, Casteràs A, Simò R. Risk Factors, Radiological and Clinical Outcomes in Subclinical and Clinical Pituitary Apoplexy. J Clin Med 2022; 11:jcm11247288. [PMID: 36555904 PMCID: PMC9786023 DOI: 10.3390/jcm11247288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/25/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pituitary apoplexy (PA) can be symptomatic, namely acute apoplexy (APA), or asymptomatic or subclinical (SPA). OBJECTIVE To describe the clinical characteristics and evolution of the patients with APA compared to SPA Patients and methods: Retrospective, longitudinal database analysis. RESULTS We identified 58 patients with PA, and 37 accomplished the inclusion criteria (17 men, median age 47.7 years). A total of 29 (78.4%) had APA (17 underwent surgery, and 12 were conservatively managed), and 8 (21.6%) had SPA. The presence of non-functioning pituitary adenoma (NFPA) odds ratio (OR): 29.36 (95% confidence interval (CI): 1.86-462.36) and the largest size OR 1.10 (95% CI: 1.01-1.2) elevated the risk of having surgery. Hypopituitarism developed in 35.1% without significant differences between APA and SPA. In non-surgical patients, adenoma volume shrunk spontaneously at one year magnetic resonance imaging (MRI), without statistical differences between the conservatively treated and SPA group. CONCLUSIONS APA is more frequent in larger NFPAs, and this subset of patients has a higher risk of surgery. Hypopituitarism is quite frequent even in patients with SPA, and, therefore, long-term follow-up is mandatory. In the non-surgical group, the pituitary tumour shrinkage is clinically relevant after one year of PA. Consequently, surgery indication in NFPA should be delayed and reassessed if patients remain asymptomatic.
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Affiliation(s)
- Betina Biagetti
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
| | - Silvana Sarria-Estrada
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Esteban Cordero Asanza
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | | | - Yiken Karelys Ng-Wong
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Marta Cicuendez
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Irene Hernandez
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Alba Rojano-Toimil
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Pilar Costa
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Elena Martinez-Saez
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Anna Casteràs
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
| | - Rafael Simò
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
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32
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Muacevic A, Adler JR, Almousa AS, Khawaji EA, Almousa AM, Albaqshi MA, Alharbi AS. Pituitary Apoplexy With Pituitary Macroadenoma in a Patient With Asymptomatic COVID-19: A Case Report. Cureus 2022; 14:e32810. [PMID: 36694516 PMCID: PMC9860463 DOI: 10.7759/cureus.32810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Pituitary apoplexy is a rare and potentially life-threatening condition that usually occurs in the setting of a pre-existing pituitary tumor, which may be undiagnosed. There are a growing number of reports describing the pituitary apoplexy associated with coronavirus disease 2019 (COVID-19). We present the case of a 41-year-old man who presented with a gradually worsening headache for four days. It was a bilateral frontal headache of sharp quality with no radiation. He scored the headache as 9 out of 10 on the 10-point severity scale. He had no previous episodes of similar headaches. Fundoscopic examination revealed bilateral optic disc blurring suggestive of papilledema and cranial nerves examination revealed bilateral hemianopia. The patient was admitted for further investigation and management. As part of the admission protocol, the patent underwent a nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which yielded positive results. Computed tomography demonstrated a large solid intrasellar mass with areas of high density suggesting hemorrhage along with a small amount of subarachnoid hemorrhage space in the left parietal lobe. The findings were consistent with pituitary apoplexy in the setting of pituitary macroadenoma. Intravenous hydrocortisone was administered. The patient underwent transsphenoidal surgical resection of the pituitary tumor, which resulted in significant improvement in the patient's symptoms. Pituitary apoplexy is a rare condition. The case suggests that COVID-19 may predispose to the development of pituitary apoplexy.
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Ageely GA, Alsulami SS, Alkenani AA, Albeshri EEMS. Cardiac myxoma presenting with multisystem involvement. Saudi Med J 2022; 43:1057-1061. [PMID: 36104063 PMCID: PMC9987664 DOI: 10.15537/smj.2022.43.9.20220346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
A cardiac myxoma is a rare tumor that could be incidental or present with common symptoms due to embolization. A minority of cases are attributed to carney complex, a rare inherited disease. A 73-year-old Asian male presented with acute left-side weakness, slurred speech, gait imbalance, and subacute constitutional symptoms. Left atrial myxoma was discovered by computed tomography and confirmed by echocardiography. Brain imaging revealed pituitary macroadenoma with subarachnoid and intraventricular hemorrages. The hormonal profile confirmed pituitary apoplexy, for which hormone replacement was initiated. Workup also revealed multiple endocrine tumors and excluded infection and malignancy. Myxoma resection could not be carried out, due to the patient's rapid clinical deterioration and death.Furthermore, the presence of cardiac myxoma, non-functioning pituitary macroadenomas, and pituitary apoplexy is extremely rare and rarely documented in the literature. Therefore, we emphasize clinical awareness of rare conditions with atypical presentations to improve outcomes.
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Affiliation(s)
- Ghofran A. Ageely
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Salhah S. Alsulami
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Ahad A. Alkenani
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Ebtihal EMS. Albeshri
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
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Cross KA, Desai R, Vellimana A, Liu Y, Rich K, Zipfel G, Dacey R, Chicoine M, Klatt-Cromwell C, McJunkin J, Pipkorn P, Schneider JS, Silverstein J, Kim AH. Surgery for Pituitary Tumor Apoplexy Is Associated with Rapid Headache and Cranial Nerve Improvement. Curr Oncol 2022; 29:4914-22. [PMID: 35877250 DOI: 10.3390/curroncol29070390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Pituitary tumor apoplexy (PTA) classically comprises sudden-onset headache, loss of vision, ophthalmoparesis, and decreased consciousness. It typically results from hemorrhage and/or infarction within a pituitary adenoma. Presentation is heterologous, and optimal management is debated. The time course of recovery of cranial nerve deficits (CNDs) and headaches is not well established. In this study, a retrospective series of consecutive patients with PTA managed at a single academic institution over a 22-year period is presented. Headaches at the time of surgery were more severe in the early and subacute surgical cohort and improved significantly within 72 h postoperatively (p < 0.01). At one year, 90% of CNDs affecting cranial nerves (CNs) 3, 4, and 6 had recovered, with no differences between early (<4 d), subacute (4−14 d), and delayed (>14 d) time-to-surgery cohorts. Remarkably, half recovered within three days. In total, 56% of CN2 deficits recovered, with the early surgery cohort including more severe deficits and recovering at a lower rate (p = 0.01). No correlation of time-to-surgery and rapidity of recovery of CNDs was observed (p = 0.65, 0.72). Surgery for PTA is associated with rapid recovery of CNDs in the early, subacute, and delayed time frames, and with rapid headache improvement in the early and subacute time frames in 50% or more of patients.
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35
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Hsu CC, Lin HD, Huang CY, Chiang YL. Unusual manifestations of adrenal insufficiency: A case report of hypopituitarism and Well's syndrome after apoplexy of a silent pituitary gonadotropic adenoma. Medicine (Baltimore) 2022; 101:e29274. [PMID: 35665730 PMCID: PMC9276179 DOI: 10.1097/md.0000000000029274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/25/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Pituitary apoplexy occurs in about 8% of those with nonfunctioning pituitary adenoma. Subsequent hormone deficiency, especially corticotropic deficiency, is the most common finding. We describe the unusual manifestations of adrenal insufficiency that are usually overlooked in such cases, with the aim of raising awareness of this disease. PATIENT CONCERNS A 53-year-old male with a history of hyponatremia came to our hospital with intermittent fever and generalized pruritic skin rash. He also reported general weakness, abdominal pain, poor appetite, and severe retroorbital headache. DIAGNOSES Laboratory data revealed hypereosinophilia, hypotonic hyponatremia, and hypopituitarism, including secondary adrenal insufficiency. Sellar magnetic resonance imaging revealed a pituitary macroadenoma, 2 cm in height, with mild displacement of the optic chiasm. Pathologic report and immunohistochemical stains of surgical specimen showed pituitary gonadotropic adenoma with apoplexy. INTERVENTIONS Transsphenoidal removal of the pituitary adenoma was performed. The patient received intravenous hydrocortisone then oral form cortisone acetate regularly. OUTCOMES His symptoms and laboratory data recovered after the operation and medical treatment. LESSONS This case highlights that eosinophilia, pruritic skin rash and fever can be manifestations of adrenal insufficiency, and that they may initially be regarded as cellulitis.
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Affiliation(s)
- Chia-Chen Hsu
- Division of Endocrinology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Hong-Da Lin
- Department of Medicine, Taipei-Veterans General Hospital, Taipei, Taiwan
| | - Chung-Yen Huang
- Division of Endocrinology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yi-Lun Chiang
- Division of Endocrinology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Galli G, Bertolini G, Dalla Serra G, Menchetti M. Suspected Pituitary Apoplexy: Clinical Presentation, Diagnostic Imaging Findings and Outcome in 19 Dogs. Vet Sci 2022; 9:191. [PMID: 35448689 DOI: 10.3390/vetsci9040191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 02/01/2023] Open
Abstract
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.
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Geyik AM, Durmaz MO, Dogan A, Ugur BK, Geyik S, Erkutlu İ, Yasar S, Kırık A, Kose G, Nehir A. Pituitary apoplexy: An emergent and potential life-threatening complication of pituitary adenomas. ULUS TRAVMA ACIL CER 2022; 28:483-489. [PMID: 35485523 PMCID: PMC10443134 DOI: 10.14744/tjtes.2021.93539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pituitary apoplexy is an emergent and potential life-threatening complication of pituitary adenomas if not managed properly. The aim of our study is to present our series of pituitary adenomas and to focus on the clinical, radiological, and surgical characteristics of this rare complication. METHODS In this study, a total of 143 patients with pituitary adenoma underwent surgical treatment between 2016 and 2018. All patients were operated using endoscopic endonasal transsphenoidal (EET) technique. The data of pituitary apoplexy cases were recorded. Resection rates, hormonal results, and visual outcomes of patients with pituitary apoplexy were evaluated. RESULTS Of the 143 patients, 8 (5.59%) were presented with the symptoms and radiological findings of pituitary apoplexy. The mean age was 26.75 years, and 4 (50%) of them were male and 4 were female. Pre-operative mean Knosp grading score was 2.1 All of eight patients underwent emergent surgical intervention and total resection was achieved in 75% of patients with apoplexy. Hormone levels were significantly decreased after surgery (p<0.05), except prolactin (p>0.05). Cerebrospinal fluid leakage occurred in one pa-tient. None of the patient with pituitary apoplexy died in our series. CONCLUSION Pituitary apoplexy is an important complication of pituitary adenomas. Early diagnosis and surgical intervention provide excellent ophthalmological and hormonal outcomes. Emergent EET approach is crucial for patients with ophthalmological findings and macroadenomas.
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Affiliation(s)
- Abidin Murat Geyik
- Department of Neurosurgery, Gaziantep University Faculty of Medicine, Gaziantep-Turkey
| | - Mehmet Ozan Durmaz
- Department of Neurosurgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara-Turkey
| | - Adem Dogan
- Department of Neurosurgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara-Turkey
| | - Berna Kaya Ugur
- Department of Anesthesiology, Gaziantep University Faculty of Medicine, Gaziantep-Turkey
| | - Sırma Geyik
- Department of Neurology, Gaziantep University Faculty of Medicine, Gaziantep-Turkey
| | - İbrahim Erkutlu
- Department of Neurosurgery, Gaziantep University Faculty of Medicine, Gaziantep-Turkey
| | - Soner Yasar
- Department of Neurosurgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara-Turkey
| | - Alparslan Kırık
- Department of Neurosurgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara-Turkey
| | - Gulsah Kose
- Department of Nursing, Muğla Sıtkı Koçman University, Faculty of Health Sciences, Muğla-Turkey
| | - Ali Nehir
- Department of Neurosurgery, Gaziantep University Faculty of Medicine, Gaziantep-Turkey
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Puglisi V, Morini E, Biasini F, Vinciguerra L, Lanza G, Bramanti P. Neurological Presentation of Giant Pituitary Tumour Apoplexy: Case Report and Literature Review of a Rare but Life-Threatening Condition. J Clin Med 2022; 11:jcm11061581. [PMID: 35329907 PMCID: PMC8953299 DOI: 10.3390/jcm11061581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/11/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Giant pituitary adenomas are benign intracranial tumours with a diameter ≥4 cm. Even if hormonally non-functional, they may still cause local extension, leading to symptoms that include mostly gland dysfunction, mass effects, and, much less frequently, apoplexy due to haemorrhage or infarction. Neurological presentation of giant pituitary tumour apoplexy is even more rare and has not been systematically reviewed. Case Presentation: An 81-year-old woman was admitted to the Emergency Department because of acute onset headache, bilateral visual deficit, and altered consciousness. Computed tomography showed a giant mass lesion (>5.5 cm diameter) expanding upward to the suprasellar cistern, optic chiasm, and third ventricle, over-running the sphenoid sinus, and with lateral invasion of the cavernous sinus. Laboratory investigations revealed central adrenal and hypothyroidism insufficiency, while magnetic resonance imaging confirmed a voluminous suprasellar tumour (~6 cm diameter), with signs of pituitary tumour apoplexy. Neurological manifestations and gland-related deficits improved after hormonal replacement therapy with a high dose of intravenous hydrocortisone, followed by oral hydrocortisone and levo-thyroxine. The patient declined surgical treatment and follow-up visit. Conclusions: Giant pituitary tumour apoplexy is a rare but potentially life-threatening condition. Prompt diagnosis and multidisciplinary management may allow a remarkable clinical improvement, as seen in this case.
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Affiliation(s)
- Valentina Puglisi
- Department of Neurology and Stroke Unit, Istituti Ospitalieri, ASST Cremona, Viale Concordia 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Elisabetta Morini
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (E.M.); (P.B.)
| | - Fiammetta Biasini
- Unit of Neurology and Neuromuscular Diseases, Policlinico University Hospital “G. Martino”, Via Consolare Valeria 1-2, 98124 Messina, Italy;
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, Istituti Ospitalieri, ASST Cremona, Viale Concordia 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018 Troina, Italy
- Correspondence: ; Tel.: +39-095-3782448
| | - Placido Bramanti
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (E.M.); (P.B.)
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Pop LG, Ilian A, Georgescu T, Bacalbasa N, Balescu I, Toader OD. Pituitary adenoma apoplexy in pregnancy: Case report and literature review. Exp Ther Med 2022; 23:218. [PMID: 35126721 DOI: 10.3892/etm.2022.11143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/26/2021] [Indexed: 11/06/2022] Open
Abstract
Gestational pituitary apoplexy is an extremely rare condition. It is characterised by an unexpected headache, vomiting, nausea, and visual disturbances. Pituitary apoplexy in pregnancy and postpartum is a challenging diagnosis with symptoms overlapping multiple conditions. There is a limited number of articles presenting cases or case series of gestational pituitary apoplexy. This is a potentially life-threatening emergency which requires a high index of suspicion for its diagnosis. This article presents a case of postpartum pituitary apoplexy and outlines the current stage of clinical, imagistic diagnosis and management options. A 26-year-old primipara was submitted to a Caesarean section, with no perioperative incidents. Forty-eight hours later she reported the apparition of frontal and temporal throbbing headaches, nausea, photophobia, and she was diagnosed with a pituitary tumor measuring 33x10.5x15.5 mm. Although initially conservative treatment was proposed, the clinical outcome was not favourable, thus the patient was submitted to endoscopic transsphenoidal resection. The histopathological studies demonstrated the presence of a pituitary macroadenoma. At the 2-year follow-up, the patient is free of disease. Although it represents an extremely rare condition, gestational pituitary apoplexy should be suspected whenever headache and neurological disorders such as nausea and photophobia are reported during the postpartum period.
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Affiliation(s)
- Lucian Gheorghe Pop
- Department of Obstetrics and Gynecology, National Institute of Mother and Child Care, 400012 Bucharest, Romania
| | - Aurora Ilian
- Department of Obstetrics and Gynecology, 'Victor Babes' University of Medicine and Pharmacy, 300014 Timisoara, Romania
| | - Tiberiu Georgescu
- Department of Obstetrics and Gynecology, National Institute of Mother and Child Care, 400012 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Nicolae Bacalbasa
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Visceral Surgery, 'Dan Setlacec' Center of Gastrointestinal Diseases and Liver Transplantation, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, 'Ponderas' Academic Hospital, 021188 Bucharest, Romania
| | - Oana Daniela Toader
- Department of Obstetrics and Gynecology, National Institute of Mother and Child Care, 400012 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Jazdarehee A, Huget-Penner S, Pawlowska M. Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0100. [PMID: 35212265 PMCID: PMC8897593 DOI: 10.1530/edm-21-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022] Open
Abstract
SUMMARY Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting. LEARNING POINTS Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.
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Key Words
- adolescent/young adult
- adult
- geriatric
- neonatal
- paediatric
- pregnant adult
- female
- male
- american indian or alaska native
- asian - bangladeshi
- asian - chinese
- asian - filipino
- asian - indian
- asian - japanese
- asian - korean
- asian - pakistani
- asian - vietnamese
- asian - other
- black - african
- black - caribbean
- black - other
- hispanic or latino - central american or south american
- hispanic or latino - cuban
- hispanic or latino - dominican
- hispanic or latino - mexican, mexican american, chicano
- hispanic or latino - puerto rican
- hispanic or latino - other
- native hawaiian/other pacific islander
- white
- other
- afghanistan
- aland islands
- albania
- algeria
- american samoa
- andorra
- angola
- anguilla
- antarctica
- antigua and barbuda
- argentina
- armenia
- aruba
- australia
- austria
- azerbaijan
- bahamas
- bahrain
- bangladesh
- barbados
- belarus
- belgium
- belize
- benin
- bermuda
- bhutan
- bolivia
- bosnia and herzegovina
- botswana
- bouvet island
- brazil
- british indian ocean territory
- brunei darussalam
- bulgaria
- burkina faso
- burundi
- cambodia
- cameroon
- canada
- cape verde
- cayman islands
- central african republic
- chad
- chile
- china
- christmas island
- cocos (keeling) islands
- colombia
- comoros
- congo
- congo, the democratic republic of the
- cook islands
- costa rica
- côte d'ivoire
- croatia
- cuba
- cyprus
- czech republic
- denmark
- djibouti
- dominica
- dominican republic
- ecuador
- egypt
- el salvador
- equatorial guinea
- eritrea
- estonia
- ethiopia
- falkland islands (malvinas)
- faroe islands
- fiji
- finland
- france
- french guiana
- french polynesia
- french southern territories
- gabon
- gambia
- georgia
- germany
- ghana
- gibraltar
- greece
- greenland
- grenada
- guadeloupe
- guam
- guatemala
- guernsey
- guinea
- guinea-bissau
- guyana
- haiti
- heard island and mcdonald islands
- holy see (vatican city state)
- honduras
- hong kong
- hungary
- iceland
- india
- indonesia
- iran, islamic republic of
- iraq
- ireland
- isle of man
- israel
- italy
- jamaica
- japan
- jersey
- jordan
- kazakhstan
- kenya
- kiribati
- korea, democratic people's republic of
- korea, republic of
- kuwait
- kyrgyzstan
- lao people's democratic republic
- latvia
- lebanon
- lesotho
- liberia
- libyan arab jamahiriya
- liechtenstein
- lithuania
- luxembourg
- macao
- macedonia, the former yugoslav republic of
- madagascar
- malawi
- malaysia
- maldives
- mali
- malta
- marshall islands
- martinique
- mauritania
- mauritius
- mayotte
- mexico
- micronesia, federated states of
- moldova, republic of
- monaco
- mongolia
- montenegro
- montserrat
- morocco
- mozambique
- myanmar
- namibia
- nauru
- nepal
- netherlands
- netherlands antilles
- new caledonia
- new zealand
- nicaragua
- niger
- nigeria
- niue
- norfolk island
- northern mariana islands
- norway
- oman
- pakistan
- palau
- palestinian territory, occupied
- panama
- papua new guinea
- paraguay
- peru
- philippines
- pitcairn
- poland
- portugal
- puerto rico
- qatar
- réunion
- romania
- russian federation
- rwanda
- saint barthélemy
- saint helena
- saint kitts and nevis
- saint lucia
- saint martin
- saint pierre and miquelon
- saint vincent and the grenadines
- samoa
- san marino
- sao tome and principe
- saudi arabia
- senegal
- serbia
- seychelles
- sierra leone
- singapore
- slovakia
- slovenia
- solomon islands
- somalia
- south africa
- south georgia and the south sandwich islands
- spain
- sri lanka
- sudan
- suriname
- svalbard and jan mayen
- swaziland
- sweden
- switzerland
- syrian arab republic
- taiwan, province of china
- tajikistan
- tanzania, united republic of
- thailand
- timor-leste
- togo
- tokelau
- tonga
- trinidad and tobago
- tunisia
- turkey
- turkmenistan
- turks and caicos islands
- tuvalu
- uganda
- ukraine
- united arab emirates
- united kingdom
- united states
- united states minor outlying islands
- uruguay
- uzbekistan
- vanuatu
- vatican city state
- venezuela
- viet nam
- virgin islands, british
- virgin islands, u.s.
- wallis and futuna
- western sahara
- yemen
- zambia
- zimbabwe
- maylaysia
- adipose tissue
- adrenal
- bone
- duodenum
- heart
- hypothalamus
- kidney
- liver
- ovaries
- pancreas
- parathyroid
- pineal
- pituitary
- placenta
- skin
- stomach
- testes
- thymus
- thyroid
- andrology
- autoimmunity
- cardiovascular endocrinology
- developmental endocrinology
- diabetes
- emergency
- endocrine disruptors
- endocrine-related cancer
- epigenetics
- genetics and mutation
- growth factors
- gynaecological endocrinology
- immunology
- infectious diseases
- late effects of cancer therapy
- mineral
- neuroendocrinology
- obesity
- ophthalmology
- paediatric endocrinology
- puberty
- tumours and neoplasia
- vitamin d
- 17ohp
- acth
- adiponectin
- adrenaline
- aldosterone
- amh
- androgens
- androstenedione
- androsterone
- angiotensin
- antidiuretic hormone
- atrial natriuretic hormone
- avp
- beta-endorphin
- big igf2
- brain natriuretic peptide
- calcitonin
- calcitriol
- cck
- corticosterone
- corticotrophin
- cortisol
- cortisone
- crh
- dehydroepiandrostenedione
- deoxycorticosterone
- deoxycortisol
- dhea
- dihydrotestosterone
- dopamine
- endothelin
- enkephalin
- epitestosterone
- epo
- fgf23
- fsh
- gastrin
- gh
- ghrelin
- ghrh
- gip
- glp1
- glp2
- glucagon
- glucocorticoids
- gnrh
- gonadotropins
- hcg
- hepcidin
- histamine
- human placental lactogen
- hydroxypregnenolone
- igf1
- igf2
- inhibin
- insulin
- kisspeptin
- leptin
- lh
- melanocyte-stimulating hormone
- melatonin
- metanephrines
- mineralocorticoids
- motilin
- nandrolone
- neuropeptide y
- noradrenaline
- normetanephrine
- oestetrol (e4)
- oestradiol (e2)
- oestriol (e3)
- oestrogens
- oestrone (e1)
- osteocalcin
- oxyntomodulin
- oxytocin
- pancreatic polypeptide
- peptide yy
- pregnenolone
- procalcitonin
- progesterone
- prolactin
- prostaglandins
- pth
- relaxin
- renin
- resistin
- secretin
- somatostatin
- testosterone
- thpo
- thymosin
- thymulin
- thyroxine (t4)
- trh
- triiodothyronine (t3)
- tsh
- vip
- 17-alpha hydroxylase/17,20 lyase deficiency
- 17-beta-hydroxysteroid dehydrogenase type 3 deficiency
- 3-m syndrome
- 22q11 deletion syndrome
- 49xxxxy syndrome
- abscess
- acanthosis nigricans
- acromegaly
- acute adrenocortical insufficiency
- addisonian crisis
- addison's disease
- adenocarcinoma
- aip gene mutation
- adrenal insufficiency
- adrenal salt-wasting crisis
- adrenarche
- adrenocortical adenoma
- adrenocortical carcinoma
- adrenoleukodystrophy
- aip gene variant
- amenorrhoea (primary)
- amenorrhoea (secondary)
- amyloid goitre
- amyloidosis
- anaplastic thyroid cancer
- anaemia
- aneuploidy
- androgen insensitivity syndrome
- anti-phospholipid antibody syndrome
- asthma
- autoimmune disorders
- autoimmune polyendocrine syndrome 1
- autoimmune polyendocrine syndrome 2
- autoimmune polyglandular syndrome
- autoimmune hypophysitis
- autosomal dominant hypophosphataemic rickets
- autosomal dominant osteopetrosis
- bardet-biedl syndrome
- bartter syndrome
- bilateral adrenal hyperplasia
- biliary calculi
- breast cancer
- brenner tumour
- brown tumour
- burkitt's lymphoma
- casr gene mutation
- catecholamine secreting carotid body paraganglionoma
- cancer-prone syndrome
- carcinoid syndrome
- carcinoid tumour
- carney complex
- carotid body paraganglioma
- c-cell hyperplasia
- cerebrospinal fluid leakage
- chronic fatigue syndrome
- circadian rhythm sleep disorders
- congenital adrenal hyperplasia
- congenital hypothyroidism
- congenital hyperinsulinism
- conn's syndrome
- corticotrophic adenoma
- craniopharyngioma
- cretinism
- crohn's disease
- cryptorchidism
- cushing's disease
- cushing's syndrome
- cystolithiasis
- de quervain's thyroiditis
- denys-drash syndrome
- desynchronosis
- developmental abnormalities
- diabetes - lipoatrophic
- diabetes - mitochondrial
- diabetes - steroid-induced
- diabetes insipidus - dipsogenic
- diabetes insipidus - gestational
- diabetes insipidus - nephrogenic
- diabetes insipidus - neurogenic/central
- diabetes mellitus type 1
- diabetes mellitus type 2
- diabetic foot syndrome
- diabetic hypoglycaemia
- diabetic ketoacidosis
- diabetic muscle infarction
- diabetic nephropathy
- diverticular disease
- donohue syndrome
- down syndrome
- eating disorders
- ectopic acth syndrome
- ectopic cushing's syndrome
- ectopic parathyroid adenoma
- empty sella syndrome
- endometrial cancer
- endometriosis
- eosinophilic myositis
- euthyroid sick syndrome
- familial hypocalciuric hypercalcaemia
- familial dysalbuminaemic hyperthyroxinaemia
- familial euthyroid hyperthyroxinaemia
- fat necrosis
- female athlete triad syndrome
- fetal demise
- fetal macrosomia
- follicular thyroid cancer
- fractures
- frasier syndrome
- friedreich's ataxia
- functional parathyroid cyst
- galactorrhoea
- gastrinoma
- gastritis
- gastrointestinal perforation
- gastrointestinal stromal tumour
- gck mutation
- gender identity disorder
- gestational diabetes mellitus
- giant ovarian cysts
- gigantism
- gitelman syndrome
- glucagonoma
- glucocorticoid remediable aldosteronism
- glycogen storage disease
- goitre
- goitre (multinodular)
- gonadal dysgenesis
- gonadoblastoma
- gonadotrophic adenoma
- gorham's disease
- granuloma
- granulosa cell tumour
- graves' disease
- graves' ophthalmopathy
- growth hormone deficiency (adult)
- growth hormone deficiency (childhood onset)
- gynaecomastia
- hamman's syndrome
- haemorrhage
- hajdu-cheney syndrome
- hashimoto's disease
- hemihypertrophy
- hepatitis c
- hereditary multiple osteochondroma
- hirsutism
- histiocytosis
- huntington's disease
- hürthle cell adenoma
- hyperaldosteronism
- hyperandrogenism
- hypercalcaemia
- hypercalcaemic crisis
- hyperglucogonaemia
- hyperglycaemia
- hypergonadotropic hypogonadism
- hypergonadotropism
- hyperinsulinaemia
- hyperinsulinaemic hypoglycaemia
- hyperkalaemia
- hyperlipidaemia
- hypernatraemia
- hyperosmolar hyperglycaemic state
- hyperparathyroidism (primary)
- hyperparathyroidism (secondary)
- hyperparathyroidism (tertiary)
- hyperpituitarism
- hyperprolactinaemia
- hypersexuality
- hypertension
- hyperthyroidism
- hypoaldosteronism
- hypocalcaemia
- hypoestrogenism
- hypoglycaemia
- hypoglycaemic coma
- hypogonadism
- hypogonadotrophic hypogonadism
- hypoinsulinaemia
- hypokalaemia
- hyponatraemia
- hypoparathyroidism
- hypophosphataemia
- hypophosphatasia
- hypophysitis
- hypopituitarism
- hypothyroidism
- iatrogenic disorder
- idiopathic bilateral adrenal hyperplasia
- idiopathic pituitary hyperplasia
- igg4-related systemic disease
- inappropriate tsh secretion
- incidentaloma
- infertility
- insulin autoimmune syndrome
- insulin resistance
- insulinoma
- intracranial vasospasm
- intrauterine growth retardation
- iodine allergy
- ischaemic heart disease
- kallmann syndrome
- ketoacidosis
- klinefelter syndrome
- kwashiorkor
- kwashiorkor (marasmic)
- leg ulcer
- laron syndrome
- latent autoimmune diabetes of adults (lada)
- laurence-moon syndrome
- left ventricular hypertrophy
- leukocytoclastic vasculitis
- leydig cell tumour
- lipodystrophy
- lipomatosis
- liver failure
- lung metastases
- luteoma
- lymphadenopathy
- macronodular adrenal hyperplasia
- macronodular hyperplasia
- macroprolactinoma
- marasmus
- maturity onset diabetes of young (mody)
- mccune-albright syndrome
- mckittrick-wheelock syndrome
- medullary thyroid cancer
- meigs syndrome
- membranous nephropathy
- men1
- men2a
- men2b
- men4
- menarche
- meningitis
- menopause
- metabolic acidosis
- metabolic syndrome
- metastatic carcinoma
- metastatic chromaffin cell tumour
- metastatic gastrinoma
- metastatic melanoma
- metastatic tumour
- microadenoma
- microprolactinoma
- motor neurone disease
- myasthenia gravis
- myelolipoma
- myocardial infarction
- myositis
- myotonic dystrophy type 1
- myotonic dystrophy type 2
- myxoedema
- myxoedema coma
- nelson's syndrome
- neonatal diabetes
- nephrolithiasis
- neuroblastoma
- neuroendocrine tumour
- neurofibromatosis
- nodular hyperplasia
- non-functioning pituitary adenoma
- non-hodgkin lymphoma
- non-islet-cell tumour hypoglycaemia
- noonan syndrome
- oculocerebrorenal syndrome
- osteogenesis imperfecta
- osteomalacia
- osteomyelitis
- osteoporosis
- osteoporosis (pregnancy/lactation-associated)
- osteosclerosis
- ovarian cancer
- ovarian dysgenesis
- ovarian hyperstimulation syndrome
- ovarian tumour
- paget's disease
- paget's disease (juvenille)
- pancreatic neuroendocrine tumour
- pancreatitis
- panhypopituitarism
- papillary thyroid cancer
- paraganglioma
- paranasal sinus lesion
- paraneoplastic syndromes
- parasitic thyroid nodules
- parathyroid adenoma
- parathyroid adenoma (ectopic)
- parathyroid carcinoma
- parathyroid cyst
- parathroid hyperplasia
- pcos
- periodontal disease
- phaeochromocytoma
- phaeochromocytoma crisis
- pickardt syndrome
- pituitary abscess
- pituitary adenoma
- pituitary apoplexy
- pituitary carcinoma
- pituitary cyst
- pituitary haemorrhage
- pituitary hyperplasia
- pituitary hypoplasia
- pituitary tumour (malignant)
- plurihormonal pituitary adenoma
- poems syndrome
- polycythaemia
- porphyria
- pneumonia
- posterior reversible encephalopathy syndrome
- post-prandial hypoglycaemia
- prader-willi syndrome
- prediabetes
- pre-eclampsia
- pregnancy
- premature ovarian failure
- premenstrual dysphoric disorder
- premenstrual syndrome
- primary hypertrophic osteoarthropathy
- prolactinoma
- prostate cancer
- pseudohypoaldosteronism type 1
- pseudohypoaldosteronism type 2
- pseudohypoparathyroidism
- psychosocial short stature
- puberty (delayed or absent)
- puberty (precocious)
- pulmonary oedema
- quadrantanopia
- rabson-mendenhall syndrome
- rhabdomyolysis
- rheumatoid arthritis
- rickets
- schwannoma
- sellar reossification
- sertoli cell tumour
- sertoli-leydig cell tumour
- sexual development disorders
- sheehan's syndrome
- short stature
- siadh
- small-cell carcinoma
- small intestine neuroendocrine tumour
- solitary fibrous tumour
- solitary sellar plasmacytoma
- somatostatinoma
- somatotrophic adenoma
- squamous cell thyroid carcinoma
- stiff person syndrome
- struma ovarii
- subcutaneous insulin resistance
- systemic lupus erythematosus
- takotsubo cardiomyopathy
- tarts
- testicular cancer
- thecoma
- thyroid adenoma
- thyroid carcinoma
- thyroid cyst
- thyroid dysgenesis
- thyroid fibromatosis
- thyroid hormone resistance syndrome
- thyroid lymphoma
- thyroid nodule
- thyroid storm
- thyroiditis
- thyrotoxicosis
- thyrotrophic adenoma
- traumatic brain injury
- tuberculosis
- tuberous sclerosis complex
- tumour-induced osteomalacia
- turner syndrome
- unilateral adrenal hyperplasia
- ureterolithiasis
- urolithiasis
- von hippel-lindau disease
- wagr syndrome
- waterhouse-friderichsen syndrome
- williams syndrome
- wolcott-rallison syndrome
- wolfram syndrome
- xanthogranulomatous hypophysitis
- xlaad/ipex
- zollinger-ellison syndrome
- abdominal adiposity
- abdominal distension
- abdominal cramp
- abdominal discomfort
- abdominal guarding
- abdominal lump
- abdominal pain
- abdominal tenderness
- abnormal posture
- abdominal wall defects
- abrasion
- acalculia
- accelerated growth
- acne
- acrochorda
- acroosteolysis
- acute stress reaction
- adverse breast development
- aggression
- agitation
- agnosia
- akathisia
- akinesia
- albuminuria
- alcohol intolerance
- alexia
- alopecia
- altered level of consciousness
- amaurosis
- amaurosis fugax
- ambiguous genitalia
- amblyopia
- amenorrhoea
- ameurosis
- amnesia
- amusia
- anasarca
- angiomyxoma
- anhedonia
- anisocoria
- ankle swelling
- anorchia
- anorectal malformations
- anorexia
- anosmia
- anosognosia
- anovulation
- antepartum haemorrhage
- anuria
- anxiety
- apathy
- aphasia
- aphonia
- apnoea
- appendicitis
- appetite increase
- appetite reduction/loss
- apraxia
- aqueductal stenosis
- arteriosclerosis
- arthralgia
- articulation impairment
- ascites
- asperger syndrome
- asphyxia
- asthenia
- astigmatism
- asymptomatic
- ataxia
- atrial fibrillation
- atrial myxoma
- atrophy
- adhd
- autism
- autonomic neuropathy
- avulsion
- babinski's sign
- back pain
- bacteraemia
- behavioural problems
- belching
- bifid scrotum
- biliary colic
- bitemporal hemianopsia
- blindness
- blistering
- bloating
- bloody show
- boil(s)
- bone cyst
- bone fracture(s)
- bone lesions
- bone pain
- bony metastases
- borborygmus
- bowel movements - bleeding
- bowel movements - increased frequency
- bowel movements - pain
- bowel obstruction
- bowel perforation
- brachycephaly
- brachydactyly
- bradycardia
- bradykinesia
- bradyphrenia
- bradypnea
- breast contour change
- breast enlargement
- breast lump
- breast reduction
- breast tenderness
- breastfeeding difficulties
- breathing difficulties
- bronchospasms
- brushfield spots
- bruxism
- buffalo hump
- cachexia
- calcification
- cardiac fibrosis
- cardiac malformations
- cardiac tamponade
- cardiogenic shock
- cardiomegaly
- cardiomyopathy
- cardiopulmonary arrest
- carpal tunnel syndrome
- caruncle - inflammation
- cataplexy
- cataract(s)
- catathrenia
- central obesity
- cerebrospinal fluid rhinorrhoea
- cervical pain
- cheeks - full
- cheiloschisis
- chemosis
- chest pain
- chest pain (pleuritic)
- chest pain (precordial)
- cheyne-stokes respiration
- chills
- cholecystitis
- cholestasis
- chondrocalcinosis
- chordee
- chorea
- choroidal atrophy
- chronic pain
- circulatory collapse
- cirrhosis
- citraturia
- claudication
- clitoromegaly
- cloacal exstrophy
- clonus
- club foot
- clumsiness
- coagulopathy
- coarctation
- coeliac disease
- cognitive problems
- cold intolerance
- collapse
- colour blindness
- coma
- concentration difficulties
- confusion
- congenital heart defect
- conjunctivitis
- constipation
- convulsions
- coordination difficulties
- coughing
- crackles
- cramps
- craniofacial abnormalities
- craniotabes
- cutaneous ischaemia
- cutaneous myxoma
- cutaneous pigmentation
- cyanosis
- dalrymple's sign
- deafness
- deep vein thrombosis
- dehydration
- delayed puberty
- delirium
- dementia
- dental abscess(es)
- dental problems
- depression
- diabetes insipidus
- diabetic neuropathy
- diabetic foot infection
- diabetic foot neuropathy
- diabetic foot ulceration
- diarrhoea
- diplopia
- dizziness
- duodenal atresia
- duplex kidney(s)
- dysarthria
- dysdiadochokinesia
- dysgraphia
- dyslexia
- dyslipidaemia
- dysmenorrhoea
- dyspareunia
- dyspepsia
- dysphagia
- dysphonia
- dysphoria
- dyspnoea
- dystonia
- dysuria
- ear, nose and/or throat infection
- early menarche
- ears - low set
- ears - pinna abnormalities
- ears - small
- ecchymoses
- ectopic ureter
- emotional immaturity
- encopresis
- endometrial hyperplasia
- enlarged bladder
- enlarged prostate
- eosinophilia
- epicanthic fold
- epilepsy
- epistaxis
- erectile dysfunction
- erythema
- euphoria
- eyebrows - bushy
- eyelid retraction
- eyelid swelling
- eyelids - redness
- eyes - almond-shaped
- eyes - dry
- eyes - feeling of grittiness
- eyes - inflammation
- eyes - irritation
- eyes - itching
- eyes - pain (gazing down)
- eyes - pain (gazing up)
- eyes - redness
- eyes - watering
- face - change in appearance
- face - coarse features
- face - numbness
- facial fullness
- facial palsy
- facial plethora
- facial weakness
- facies - abnormal
- facies - hippocratic
- facies - moon
- faecal incontinence
- failure to thrive
- fallopian tube hyperplasia
- fasciculation
- fatigue
- fatigue (post-exertional)
- feet - cold
- feet - increased size
- feet - large
- feet - pain
- feet - small
- fingers - thick
- flaccid paralysis
- flatulence
- flushing
- fontanelles - enlarged
- frontal bossing
- fungating lesion
- fungating mass
- funny turns
- gait abnormality
- gait unsteadiness
- gallbladder calculi
- gallstones
- gangrene
- gastro-oesophageal reflux
- genital oedema
- genu valgum
- genu varum
- gestational diabetes
- glaucoma
- glucose intolerance
- glucosuria
- growth hormone deficiency
- growth retardation
- haematemesis
- haematochezia
- haematoma
- haematuria
- haemoglobinuria
- haemoptysis
- hair - coarse
- hair - dry
- hair - temporal balding
- hairline - low
- hallucination
- hands - enlargement
- hands - large
- hands - single palmar crease
- hands - small
- head - large
- headache
- hearing loss
- heart failure
- heart murmur
- heat intolerance
- height loss
- hemiballismus
- hemianopia
- hemiparesis
- hemispatial neglect
- hepatic cysts
- hepatic metastases
- hepatomegaly
- hidradenitis suppurativa
- high-arched palate
- hip dislocation
- hippocampal dysgenesis
- hirschsprung's disease
- hot flushes
- hydronephrosis
- hypolipidaemia
- hyperactivity
- hyperacusis
- hyperandrogenaemia
- hypercalciuria
- hypercapnea
- hypercholesterolaemia
- hypercortisolaemia
- hyperflexibility
- hyperglucagonaemia
- hyperhidrosis
- hyperhomocysteinaemia
- hypernasal speech
- hyperopia
- hyperoxaluria
- hyperpigmentation
- hyperplasia
- hyperpnoea
- hypersalivation
- hyperseborrhea
- hypersomnia
- hyperthermia
- hypertrichosis
- hypertrophy
- hyperuricaemia
- hyperventilation
- hypoadrenalism
- hypoalbuminaemia
- hypocalciuria
- hypocitraturia
- hypomagnesaemia
- hypopigmentation
- hypoplastic scrotum
- hypopotassaemia
- hypoprolactinaemia
- hyporeflexia
- hyposmia
- hypospadias
- hypotension
- hypothermia
- hypotonia
- hypoventilation
- hypovitaminosis d
- hypovolaemia
- hypovolaemic shock
- hypoxia
- immunodeficiency
- impulsivity
- inattention
- infections
- inflexibility
- insomnia
- instability
- intussusception
- irritability
- ischaemia
- ischuria
- itching
- jaundice
- keratoconus
- ketonuria
- ketotic odour
- kidney dysplasia
- kidney stones
- kyphoscoliosis
- kyphosis
- labioscrotal fold abnormalities
- laceration
- late dentition
- learning difficulties
- leg pain
- legs - increased length
- leukaemia
- leukocytosis
- libido increase
- libido reduction/loss
- lichen sclerosus
- lips - dry
- lips - thin
- little finger - in-curved
- little finger - short
- liver masses
- lordosis
- lordosis (loss of)
- lymphadenectomy
- lymphadenitis
- lymphocytosis
- lymphoedema
- macroglossia
- malaise
- malaise (post-exertional)
- malodorous perspiration
- mania
- marcus gunn pupil
- mastalgia
- meckel's diverticulum
- melena
- menorrhagia
- menstrual disorder
- mesenteric ischaemia
- metabolic alkalosis
- microalbuminuria
- microcephaly
- micrognathia
- micropenis
- milk-alkali syndrome
- miscarriage
- mood changes/swings
- mouth - down-turned
- mouth - small
- movement - limited range of
- mucosal pigmentation
- muscle atrophy
- muscle freezing
- muscle hypertrophy
- muscle rigidity
- myalgia
- myasthaenia
- mydriasis
- myelodysplasia
- myeloma
- myoclonus
- myodesopsia
- myokymia
- myopathy
- myopia
- myosis
- nail clubbing
- nail dystrophy
- nasal obstruction
- nausea
- neck - loose skin (nape)
- neck - short
- neck mass
- neck pain/discomfort
- necrolytic migratory erythema
- necrosis
- nephrocalcinosis
- nephropathy
- neurofibromas
- night terrors
- nipple change
- nipple discharge
- nipple inversion
- nipple retraction
- nipples widely spaced
- nocturia
- normochromic normocytic anaemia
- nose - depressed bridge
- nose - flat bridge
- nose - thickening
- nystagmus
- obsessive-compulsive disorder
- obstetrical haemorrhage
- obstructive sleep apnoea
- odynophagia
- oedema
- oesophageal atresia
- oesophagitis
- oligomenorrhoea
- oliguria
- onychauxis
- oophoritis
- ophthalmoplegia
- optic atrophy
- orbital fat prolapse
- orbital hypertelorism
- orthostatic hypotension
- osteoarthritis
- osteopenia
- otitis media
- ovarian cysts
- ovarian hyperplasia
- palatoschisis
- pallor
- palmar erythema
- palpebral fissure (downslanted)
- palpebral fissure (extended)
- palpebral fissure (reduced)
- palpebral fissure (upslanted)
- palpitations
- pancreatic fibrosis
- pancytopaenia
- panic attacks
- papilloedema
- paraesthesia
- paralysis
- paranoia
- patellar dislocation
- patellar subluxation
- pedal ulceration
- pellagra
- pelvic mass
- pelvic pain
- penile agenesis
- peptic ulcer
- pericardial effusion
- periodontitis
- periosteal bone reactions
- peripheral oedema
- personality change
- pes cavus
- petechiae
- peyronie's disease
- pharyngitis
- philtrum - long
- philtrum - short
- phosphaturia
- photophobia
- photosensitivity
- pleurisy
- poikiloderma
- polydactyly
- polydipsia
- polyphagia
- polyuria
- poor wound healing
- postmenopausal bleeding
- post-nasal drip
- postprandial fullness
- postural instability
- prehypertension
- premature birth
- premature labour
- prenatal growth retardation
- presbyopia
- pretibial myxoedema
- proctalgia fugax
- prognathism
- proptosis
- prosopagnosia
- proteinuria
- pruritus
- pruritus scroti
- pruritus vulvae
- pseudarthrosis
- psoriatic arthritis
- psychiatric problems
- psychomotor retardation
- psychosis
- pterygium colli
- ptosis
- puberty (delayed/absent)
- puberty (early/precocious)
- puffiness
- pulmonary embolism
- purpura
- pyelonephritis
- pyloric stenosis
- pyrexia
- pyrosis
- pyuria
- rash
- rectal pain
- rectorrhagia
- refractory anemia
- reluctance to weight-bear
- renal agenesis
- renal clubbing
- renal colic
- renal cyst
- renal failure
- renal insufficiency
- renal phosphate wasting (isolated)
- renal tubular acidosis
- respiratory failure
- reticulocytosis
- retinitis pigmentosa
- retinopathy
- retrobulbar pain
- retrograde ejaculation
- retroperitoneal fibrosis
- salivary gland swelling
- salpingitis
- salt craving
- salt wasting
- sarcoidosis
- schizophrenia
- scoliosis
- scotoma
- seborrhoeic dermatitis
- seizures
- sensory loss
- sepsis
- septic arthritis
- septic shock
- shivering
- singultus
- sinusitis
- sixth nerve palsy
- skeletal deformity
- skeletal dysplasia
- skin - texture change
- skin infections
- skin necrosis
- skin pigmentation - spotty
- skin thickening
- skin thinning
- sleep apnoea
- sleep difficulties
- sleep disturbance
- sleep hyperhidrosis
- slow growth
- slurred speech
- social difficulties
- soft tissue swelling
- somnambulism
- somniloquy
- somnolence
- sore throat
- spasms
- spastic paraplegia
- spasticity
- speech delay
- spider naevi
- splenomegaly
- sputum production
- steatorrhoea
- stomatitis
- strabismus
- strangury
- striae
- stridor
- stroke
- subfertility
- suicidal ideation
- supraclavicular fat pads
- supranuclear gaze palsy
- sweating
- syncope
- syndactyly
- tachycardia
- tachypnoea
- teeth gapping
- telangiectasias
- telecanthus
- tetraparesis
- t-reflex (absent)
- t-reflex (depressed)
- tetany
- thermodysregulation
- thrombocytopenia
- thrombocytosis
- thrombophilia
- thrush
- tics
- tinnitus
- toe clubbing
- toe deformities
- toes - thick
- toes - widely spaced
- tongue - protruding
- tracheo-oesophageal compression
- tracheo-oesophageal fistula
- tremulousness
- tricuspid insufficiency
- umbilical hernia
- uraemia
- ureter duplex
- uricaemia
- urinary frequency
- urinary incontinence
- urogenital sinus
- urticaria
- uterine hyperplasia
- uterus duplex
- vagina duplex
- vaginal bleeding
- vaginal discharge
- vaginal dryness
- vaginal pain/tenderness
- vaginism
- ventricular fibrillation
- ventricular hypertrophy
- vertigo
- viraemia
- virilisation (abnormal)
- vision - acuity reduction
- vision - blurred
- visual disturbance
- visual field defect
- visual impairment
- visual loss
- vitiligo
- vocal cord paresis
- vomiting
- von graefe's sign
- weight gain
- weight loss
- wheezing
- widened joint space(s)
- xeroderma
- xerostomia
- 3-methoxy 4-hydroxy mandelic acid
- 17-hydroxypregnenolone (urine)
- 17-ketosteroids
- 25-hydroxyvitamin-d3
- 5hiaa
- aberrant adrenal receptors
- acid-base balance
- acth stimulation
- activated partial thromboplastin time
- acyl-ghrelin
- adrenal antibodies
- adrenal function
- adrenal scintigraphy
- adrenal venous sampling
- afp tumour marker
- alanine aminotransferase
- albumin
- albumin to creatinine ratio
- aldosterone (24-hour urine)
- aldosterone (blood)
- aldosterone (plasma)
- aldosterone (serum)
- aldosterone to renin ratio
- alkaline phosphatase
- alkaline phosphatase (bone-specific)
- alpha-fetoprotein
- ammonia
- amniocentesis
- amylase
- angiography
- anion gap
- anti-acetylcholine antibodies
- anticardiolipin antibody
- anti-insulin antibodies
- anti-islet cell antibody
- anti-gh antibodies
- antinuclear antibody
- anti-tyrosine phosphatase antibodies
- asvs
- barium studies
- basal insulin
- base excess
- apolipoprotein h
- beta-hydroxybutyrate
- bicarbonate
- bilirubin
- biopsy
- blood film
- blood pressure
- bmi
- body fat mass
- bone age
- bone biopsy
- bone mineral content
- bone mineral density
- bone mineral density test
- bone scintigraphy
- bone sialoprotein
- bound insulin
- brca1/brca2
- c1np
- c3 complement
- c4 complement
- ca125
- calcifediol
- calcium (serum)
- calcium (urine)
- calcium to creatinine clearance ratio
- carcinoembryonic antigen
- cardiac index
- catecholamines (24-hour urine)
- catecholamines (plasma)
- cd-56
- chemokines
- chest auscultation
- chloride
- chorionic villus sampling
- chromatography
- chromogranin a
- chromosomal analysis
- clomid challenge
- clonidine suppression
- collagen
- colonoscopy
- colposcopy
- continuous glucose monitoring
- core needle biopsy
- corticotropin-releasing hormone stimulation test
- cortisol (9am)
- cortisol (plasma)
- cortisol (midnight)
- cortisol (salivary)
- cortisol (serum)
- cortisol day curve
- cortisol, free (24-hour urine)
- c-peptide (24-hour urine)
- c-peptide (blood)
- c-reactive protein
- creatinine
- creatine kinase
- creatinine (24-hour urine)
- creatinine (serum)
- creatinine clearance
- crh stimulation
- ctpa scan
- ct scan
- c-telopeptide
- cytokines
- deoxypyridinoline
- dexa scan
- dexamethasone suppression
- dexamethasone suppression (high dose)
- dexamethasone suppression (low dose)
- dhea sulphate
- discectomy
- dldl cholesterol
- dmsa scan
- dna sequencing
- domperidone
- down syndrome screening
- ductal lavage
- echocardiogram
- eeg
- electrocardiogram
- electrolytes
- electromyography
- endoscopic ultrasound
- endoscopy
- endosonography
- enzyme immunoassay
- epinephrine (plasma)
- epinephrine (urine)
- erythrocyte sedimentation rate
- estimated glomerular filtration rate
- ethanol ablation
- ewing and clarke autonomic function
- exercise tolerance
- fbc
- ferritin
- fine needle aspiration biopsy
- flow cytometry
- fludrocortisone suppression
- fluticasone-propionate-17-beta carboxylic acid
- fmri
- folate
- ft3
- ft4
- gada
- gallium nitrate
- gallium scan
- gastric biopsy
- genetic analysis
- genitography
- gh day curve
- gh stimulation
- gh suppression
- glp-1
- glp-2
- glucose suppression test
- glucose (blood)
- glucose (blood, fasting)
- glucose (blood, postprandial)
- glucose (urine)
- glucose tolerance
- glucose tolerance (intravenous)
- glucose tolerance (oral)
- glucose tolerance (prolonged)
- gluten sensitivity
- gnrh stimulation
- gonadotrophins
- growth hormone-releasing peptide-2 test
- gut hormones (fasting)
- haematoxylin and eosin staining
- haemoglobin
- haemoglobin a1c
- hcg (serum)
- hcg (urine)
- hcg stimulation
- hdl cholesterol
- hearing test
- heart rate
- hepatic venous sampling with arterial stimulation
- high-sensitivity c-reactive protein
- histopathology
- hla genotyping
- holter monitoring
- homa
- homocysteine
- hyaluronic acid
- hydrocortisone day curve
- hydroxyproline
- hydroxyprogesterone
- hysteroscopy
- igfbp2
- igfbp3
- igg4/igg ratio
- immunocytochemistry
- immunohistochemistry
- immunoglobulins
- immunoglobulin g2
- immunoglobulin g4
- immunoglobulin a
- immunoglobulin m
- immunostaining
- inferior petrosal sinus sampling
- inhibin b
- insulin (fasting)
- insulin suppression
- insulin tissue resistance tests
- insulin tolerance
- intracranial pressure
- irm imaging
- ketones (plasma)
- ketones (urine)
- kidney function
- lactate
- lactate dehydrogenase
- laparoscopy
- laparoscopy and dye
- laparotomy
- ldl cholesterol
- leuprolide acetate stimulation
- leukocyte esterase (urine)
- levothyroxine absorption
- lipase (serum)
- lipid profile
- liquid-based cytology
- liquid chromatography-mass spectrometry
- liver biopsy
- liver function
- lumbar puncture
- lung function testing
- luteinising hormone releasing hormone test
- macroprolactin
- magnesium
- mag3 scan
- mammogram
- mantoux test
- metanephrines (plasma)
- metanephrines (urinary)
- methoxytyramine
- metoclopramide
- metyrapone cortisol day curve
- metyrapone suppression
- metyrapone test dose
- mibg scan
- microarray analysis
- molecular genetic analysis
- mri
- myocardial biopsy
- nerve conduction study
- neuroendocrine markers
- neuron-specific enolase
- norepinephrine
- ntx
- oct
- octreotide scan
- octreotide suppression test
- osmolality
- ovarian venous sampling
- p1np
- palpation
- pap test
- parathyroid scintigraphy
- pentagastrin
- perchlorate discharge
- percutaneous umbilical blood sampling
- peripheral blood film
- pet scan
- ph (blood)
- phosphate (serum)
- phosphate (urine)
- pituitary function
- plasma osmolality
- plasma viscosity
- platelet count
- pneumococcal antigen
- pneumococcal pcr
- polymerase chain reaction
- polysomnography
- porter-silber chromogens
- potassium
- pregnancy test
- proinsulin
- prostate-specific antigen
- protein electrophoresis
- protein fingerprinting
- protein folding analysis
- psychiatric assessment
- psychometric assessment
- pulse oximetry
- pyelography
- pyridinium crosslinks
- quicki
- plasma renin activity
- radioimmunoassay
- radionuclide imaging
- raiu test
- red blood cell count
- renal biopsy
- renin (24-hour urine)
- respiratory status
- renin (blood)
- renin plasma activity
- rheumatoid factor
- salt loading
- sdldl cholesterol
- secretin stimulation
- selective parathyroid venous sampling
- selective transhepatic portal venous sampling
- semen analysis
- serotonin
- serum osmolality
- serum free insulin
- sestamibi scan
- sex hormone binding globulin
- shbg
- skeletal muscle mass
- skin biopsy
- sleep diary
- sodium
- spect scan
- supervised 72-hour fast
- surgical biopsy
- sweat test
- synaptophysin
- systemic vascular resistance index
- tanner scale
- thoracocentesis
- thyroid transcription factor-1
- thyroglobulin
- thyroid antibodies
- thyroid function
- thyroid scintigraphy
- thyroid ultrasonography
- total cholesterol
- total ghrelin
- total t3
- total t4
- trabecular thickness
- transaminase
- transvaginal ultrasound
- trap 5b
- trh stimulation
- triglycerides
- triiodothyronine (t3) suppression
- troponin
- tsh receptor antibodies
- type 3 precollagen
- type 4 collagen
- ultrasound-guided biopsy
- ultrasound scan
- urea and electrolytes
- uric acid (blood)
- uric acid (urine)
- urinalysis
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- vanillylmandelic acid (24-hour urine)
- visual field assessment
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- pancreatectomy
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- pericardiotomy
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- pituitary adenomectomy
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- radionuclide therapy
- radiotherapy
- reconstruction of genitalia
- resection of tumour
- right-sided hemicolectomy
- salpingo-oophorectomy
- small bowel resection
- speech and language therapy
- spinal surgery
- splenectomy
- stereotactic radiosurgery
- termination of pregnancy
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- thyroidectomy
- tracheostomy
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- transsphenoidal surgery
- transtentorial surgery
- vaginoplasty
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- phosphate binders
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- plicamycin
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- prednisolone
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- protease inhibitors
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- somatostatin analogues
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- warfarin
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- z-drugs
- zoledronic acid
- zolpidem
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- cardiology
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- general practice
- genetics
- geriatrics
- gynaecology
- nephrology
- neurology
- nursing
- obstetrics
- oncology
- otolaryngology
- paediatrics
- pathology
- podiatry
- psychology/psychiatry
- radiology/rheumatology
- rehabilitation
- surgery
- urology
- insight into disease pathogenesis or mechanism of therapy
- novel diagnostic procedure
- novel treatment
- unique/unexpected symptoms or presentations of a disease
- new disease or syndrome: presentations/diagnosis/management
- unusual effects of medical treatment
- error in diagnosis/pitfalls and caveats
- february
- 2022
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Affiliation(s)
- Aria Jazdarehee
- Department of Medicine and Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Sawyer Huget-Penner
- Division of Endocrinology and Metabolism, Fraser Health Authority, British Columbia, Canada
| | - Monika Pawlowska
- Division of Endocrinology and Metabolism, University of British Columbia, British Columbia, Canada
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Taneja C, Fazeli PK, Gardner PA, Wang EW, Snyderman CH, Mahmud H. Rapidly Progressive Pituitary Apoplexy in a Patient with COVID-19 Disease Treated with Endoscopic Endonasal Surgery. J Neurol Surg Rep 2022; 83:e8-e12. [PMID: 35028278 PMCID: PMC8747894 DOI: 10.1055/s-0041-1742104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 09/20/2021] [Indexed: 01/06/2023] Open
Abstract
This report describes a case of pituitary apoplexy with rapidly evolving hemorrhage in a 74-year-old female with coronavirus disease 2019 (COVID-19) disease. The patient presented with severe headache and mild respiratory symptoms, with laboratories concerning for pituitary hypofunction. Brain imaging demonstrated a sellar mass concerning for a pituitary adenoma with ischemic apoplexy. She subsequently developed visual deficits within 24 hours of presentation, and repeat imaging demonstrated evolving hemorrhage and new mass effect on the optic chiasm. She was successfully managed with urgent endoscopic endonasal surgery despite her COVID-19 positive status by taking special intraoperative precautions to mitigate SARS-CoV2 transmission risk. Only a handful of cases of pituitary apoplexy have been reported in association with COVID-19 disease, and even fewer reports exist of endonasal procedures in such cases. We discuss the potential implication of COVID-19 in the occurrence of pituitary apoplexy, in addition to the safety and success of endonasal surgery in this population.
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Affiliation(s)
- Charit Taneja
- Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Pouneh K Fazeli
- Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Andriuskeviciute A, Cossu G, Ameti A, Papadakis G, Daniel RT, Dunet V, Messerer M. Potential Association Between Anabolic Androgenic Steroid Abuse and Pituitary Apoplexy: A Case Report. Front Endocrinol (Lausanne) 2022; 13:890853. [PMID: 35937816 PMCID: PMC9354695 DOI: 10.3389/fendo.2022.890853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Pituitary apoplexy (PA) is a rare, and potentially life-threatening condition, caused by hemorrhage or infarction into the pituitary gland with a rapid expansion of the contents of the sella turcica, associated with sudden intense headache, neurological and endocrinological deterioration. The identification of risk factors is crucial for prevention and optimal management. Herein we report a case of PA occurring 1 month after the initiation of anabolic androgenic steroid abuse for bodybuilding. CASE REPORT A 40-year-old male patient presents with abrupt onset headache associated with left partial third cranial nerve palsy. The MRI shows a sellar lesion involving left cavernous sinus with a heterogenous anterior aspect of the lesion with hemorrhagic zones in favor of PA. Endocrine work-up shows high testosterone level in patient who was using exogenous testosterone without a medical prescription for a month. CONCLUSION We report a case of PA of a pituitary neuroendocrine tumor occurring shortly after AAS. The association between PA and AAS should be considered as a potential risk.
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Affiliation(s)
- Agne Andriuskeviciute
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Adelina Ameti
- Department of Endocrinology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Georgios Papadakis
- Department of Endocrinology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Vincent Dunet
- Department of Radiology, Neuroradiology division, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
- *Correspondence: Mahmoud Messerer,
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Aliberti L, Gagliardi I, Rizzo R, Bortolotti D, Schiuma G, Franceschetti P, Gafà R, Borgatti L, Cavallo MA, Zatelli MC, Ambrosio MR. Pituitary apoplexy and COVID-19 vaccination: a case report and literature review. Front Endocrinol (Lausanne) 2022; 13:1035482. [PMID: 36465651 PMCID: PMC9712198 DOI: 10.3389/fendo.2022.1035482] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
A 50-year-old man was admitted to our hospital for vomit, nausea, diplopia, and headache resistant to analgesic drugs. Symptoms started the day after his third COVID-19 mRNA vaccine (Moderna) whereas SARS-CoV-2 nasal swab was negative. Pituitary MRI showed recent bleeding in macroadenoma, consistent with pituitary apoplexy. Adverse Drug Reaction was reported to AIFA (Italian Medicines Agency).A stress dexamethasone dose was administered due to the risk of adrenal insufficiency and to reduce oedema. Biochemistry showed secondary hypogonadism; inflammatory markers were elevated as well as white blood cells count, fibrinogen and D-dimer. Pituitary tumour transsphenoidal resection was performed and pathology report was consistent with pituitary adenoma with focal haemorrhage and necrosis; we found immunohistochemical evidence for SARS-CoV-2 proteins next to pituitary capillaries, in the presence of an evident lymphocyte infiltrate.Few cases of pituitary apoplexy after COVID-19 vaccination and infection have been reported. Several hypotheses have been suggested to explain this clinical picture, including cross-reactivity between SARS-CoV-2 and pituitary proteins, COVID-19-associated coagulopathy, infection-driven acutely increased pituitary blood demand, anti-Platelet Factor 4/heparin antibodies development after vaccine administration. Ours is the first case of SARS-CoV-2 evidence in pituitary tissue, suggesting that endothelial infection of pituitary capillaries could be present before vaccination, possibly due to a previous asymptomatic SARS-CoV-2 infection. Our case underlines that SARS-CoV-2 can associate with apoplexy by penetrating the central nervous system, even in cases of negative nasal swab. Patients with pituitary tumours may develop pituitary apoplexy after exposure to SARS-CoV-2, therefore clinicians should be aware of this risk.
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Affiliation(s)
- Ludovica Aliberti
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
| | - Irene Gagliardi
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
| | - Roberta Rizzo
- Department of Chemical, Pharmaceutical and Agricultural Sciences, University of Ferrara, Ferrara, Italy
| | - Daria Bortolotti
- Department of Chemical, Pharmaceutical and Agricultural Sciences, University of Ferrara, Ferrara, Italy
| | - Giovanna Schiuma
- Department of Chemical, Pharmaceutical and Agricultural Sciences, University of Ferrara, Ferrara, Italy
| | - Paola Franceschetti
- Unit of Endocrinology and Metabolic Diseases – Oncology and Specialty Medicines Department, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Roberta Gafà
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Luca Borgatti
- Neuroradiology Unit, Department of Neuroscience and Rehabilitation, Azienda Ospedaliera Universitaria, Arcispedale S. Anna, Ferrara, Italy
| | - Michele A. Cavallo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy
| | - Maria C. Zatelli
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
- Unit of Endocrinology and Metabolic Diseases – Oncology and Specialty Medicines Department, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Maria R. Ambrosio
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
- Unit of Endocrinology and Metabolic Diseases – Oncology and Specialty Medicines Department, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
- *Correspondence: Maria R. Ambrosio,
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Thomas K, Ocran C, Monterastelli A, Sadun AA, Cockerham KP. Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners. Clin Pract 2021; 11:919-32. [PMID: 34940005 DOI: 10.3390/clinpract11040106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/28/2021] [Accepted: 11/19/2021] [Indexed: 01/13/2023] Open
Abstract
Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.
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Konar S, Nishanth S, Devi BI. Rare Consequence of Pituitary Apoplexy Surgery: Artery of Percheron Infarction. Asian J Neurosurg 2021; 16:595-597. [PMID: 34660376 PMCID: PMC8477806 DOI: 10.4103/ajns.ajns_491_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 05/02/2021] [Accepted: 05/30/2021] [Indexed: 11/26/2022] Open
Abstract
Management of pituitary apoplexy is multimodal. The surgical intervention followed by endocrinological management is the standard of care. Various vascular complications have been described in the literature after pituitary adenoma surgery. Artery of Percheron (AOP) infract is a rare finding. Few cases were reported in the English literature after the endoscopic approach for pituitary adenoma. We present a 55-year-old lady presented with sudden-onset headache followed by vision loss. She was evaluated with imaging and diagnosed pituitary adenoma with apoplexy. She underwent an endoscopic transnasal approach and decompression of the tumor. In the postoperative period, she developed bilateral ptosis with altered sensorium. Imaging showed infarction of bilateral paramedian thalamus and rostral midbrain, suggestive of AOP infarct. Gradually, the patient improved, and at 3 months of follow-up, she was conscious and obeying with partial improvement of ptosis.
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Affiliation(s)
- Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sadashiva Nishanth
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - B Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Abstract
Összefoglaló. Az agyalapimirigy-apoplexia ritka klinikai kórkép, mely hirtelen kialakult bevérzés vagy infarktus következményeként jelenik meg. A hypophysisadenomás betegek 2-12%-ában fordul elő, a leggyakrabban funkcionálisan inaktív daganatokban, de jelentkezhet gyógyszeresen kezelt adenomákban is. Klinikai képe hirtelen kialakuló heves fejfájás, mely látászavarral vagy kettős látással társulhat, de meningealis izgalmi jel, a tudati szint romlása is előfordulhat. A bevérzés miatt kialakult kortikotropinhiány kezelés nélkül mellékvese-elégtelenséghez vezet. A mágneses rezonancia a komputertomográfhoz képest jobban kimutatja az adenoma bevérzését vagy akár infarktusát. Retrospektív tanulmányok a korábbi, azonnali idegsebészeti beavatkozás helyett a konzervatív kezelés létjogosultságát emelik ki. Orv Hetil. 2021; 162(38): 1520-1525. Summary. Pituitary apoplexy is a rare clinical syndrome secondary to haemorrhage or infarction of pituitary adenoma. The prevalence is 2-12% of pituitary adenoma patients especially in nonfunctioning tumours but may be found in medically treated adenomas as well. Its clinical picture is sudden onset of headache with visual disturbances and/or ocular palsy. Meningeal signs and altered consciousness can occur. Corticotropin deficiency if untreated can lead to adrenal insufficiency. Compared to computed tomography, magnetic resonance imaging better demonstrates the haemorrhage or even infarction of pituitary adenoma. Retrospective studies emphasize the wait-and-see management instead of the formerly considered urgent neurosurgical intervention. Orv Hetil. 2021; 162(38): 1520-1525.
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Affiliation(s)
- László Sipos
- 1 Országos Mentális, Ideggyógyászati és Idegsebészeti Intézet, Budapest, Amerikai út 57., 1145.,2 Semmelweis Egyetem, Általános Orvostudományi Kar, Idegsebészeti Tanszék, Budapest
| | - Nikolette Szücs
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest
| | - Péter Várallyay
- 1 Országos Mentális, Ideggyógyászati és Idegsebészeti Intézet, Budapest, Amerikai út 57., 1145
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Sun, MD Z, Cai, MD X, Li, MD Y, Shao, MD D, Jiang, PhD Z. Endoscopic Endonasal Transsphenoidal Approach for the Surgical Treatment of Pituitary Apoplexy and Clinical Outcomes. Technol Cancer Res Treat 2021; 20:15330338211043032. [PMID: 34486456 PMCID: PMC8422825 DOI: 10.1177/15330338211043032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: This study investigated the clinical manifestations, surgical method, and treatment outcomes of patients with pituitary apoplexy and evaluated the safety and effectiveness of the endoscopic endonasal transsphenoidal approach in the treatment of pituitary adenomas. Patients and methods: In this retrospective study, were analyzed the data of patients with symptomatic pituitary apoplexy who received surgical treatment by endoscopic endonasal transsphenoidal approach from January 2017 to June 2020 at the Department of Neurosurgery of the First Affiliated Hospital of Bengbu Medical College. Patients were followed up through outpatient visits and telephone interviews. Results: Data for 24 patients including 13 males and 11 females with an average age of 46.46 years were analyzed. Headache (83.33%) and visual disturbances (75.00%) were the most common preoperative manifestations. In the 24 patients, 21 (87.50%) tumors were completely removed and 3 (12.50%) were partly removed. Intractable headache improved in all patients over a mean follow-up time of 25.16 months, and postoperative improvement in visual acuity was achieved in 17 of 18 patients (94.44%) with vision defects. Four patients (16.67%) experienced transient urinary collapse after the operation. No intracranial infection, carotid artery injury, or death occurred. Conclusion: The endoscopic endonasal transsphenoidal approach is a safe and effective method for the treatment of pituitary apoplexy.
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Affiliation(s)
- Zhixiang Sun, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Xintao Cai, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yu Li, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Dongqi Shao, MD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Zhiquan Jiang, PhD
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Zhiquan Jiang, Department of Neurosurgery, First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Road, Bengbu, Anhui 233004, China.
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Khaldi S, Saad G, Elfekih H, Ben Abdelkrim A, Ach T, Kacem M, Chaieb M, Maaroufi A, Hasni Y, Ach K. Pituitary apoplexy of a giant prolactinoma during pregnancy. Gynecol Endocrinol 2021; 37:863-866. [PMID: 34124989 DOI: 10.1080/09513590.2021.1938527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AIMS AND METHODS Prolactinomas are a common cause of sexual dysfunction and infertility. We aimed, through this case report, to illustrate the difficulties of management of women with giant prolactinoma, especially in cases of desire of pregnancy. RESULTS A 30-year-old woman was referred to our department for secondary amenorrhea. Investigations showed a prolactin level of 5168 ng/mL and giant pituitary adenoma of 4 cm in diameter. Cytoreductive surgery was performed after failure to normalize prolactin levels during three years with medical treatment by cabergoline. After seven months, menstrual cycles have resumed, and after 13 months, the patient became pregnant. At 22nd week of gestation, she was admitted in our hospital for pituitary apoplexy. Medical treatment with bromocriptine was chosen. The vaginal premature delivery at 28 weeks gave birth to twins weighing 1 Kg each who died on the 7th day of life. CONCLUSION This is a relevant clinical case that illustrates the efficacy of cytoreductive surgery in case of insufficient response to dopamine agonists to restore gonadal function. The possibility of a pregnancy should be considered in these patients since it can be associated with high maternal and fetal risks.
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Affiliation(s)
- Safa Khaldi
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Ghada Saad
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Hamza Elfekih
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Asma Ben Abdelkrim
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Taieb Ach
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Maha Kacem
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Molka Chaieb
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Amel Maaroufi
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Yosra Hasni
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
| | - Koussay Ach
- Endocrinology and Diabetes Department, Farhat Hached University Hospital of Sousse, Sousse, Tunisia
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Kynčl M, Kasl Z, Rusňák Š, Sobotová M, Krčma M, Tintěra J, Fůs M, Lešták J. Pituitary apoplexy without chiasm compression: A case report. Mol Clin Oncol 2021; 15:176. [PMID: 34276995 PMCID: PMC8278391 DOI: 10.3892/mco.2021.2338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/28/2021] [Indexed: 11/18/2022] Open
Abstract
The present report presents a rare case in which a patient with pituitary apoplexy (PA) without compression of the optic chiasm experienced diagnosable visual impairment in the ensuing months. Endocrinologically, the condition was a prolactinoma followed by bleeding into the pituitary gland. Due to the unexplained functional changes in the patient, an electrophysiological examination (pattern electroretinogram and pattern visual evoked potentials) was performed, which verified a bilateral non-inflammatory neurogenic lesion. This finding was confirmed by functional magnetic resonance imaging (fMRI) examination. Structural MRI did not reveal chiasm compression in the time sequence or alteration of the optic nerves (the diameter of the optic nerve at different distances from the eye and the diameter of the optic nerve sheath at different distances from the eye). Similarly, neither the retinal nerve fiber layer (RNFL) nor the vessel density was altered. The present report suggests that changes in visual fields may be due to ischemia in the area of the chiasm and optic nerves, similar to PA.
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Affiliation(s)
- Martin Kynčl
- Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic
| | - Zdeněk Kasl
- Department of Ophthalmology, University Hospital in Pilsen, 301 00 Pilsen, Czech Republic
| | - Štěpán Rusňák
- Department of Ophthalmology, University Hospital in Pilsen, 301 00 Pilsen, Czech Republic
| | - Marketa Sobotová
- Department of Ophthalmology, University Hospital in Pilsen, 301 00 Pilsen, Czech Republic
| | - Michal Krčma
- First Clinic of Internal Medicine, Department of Endocrinology, University Hospital in Pilsen, 301 00 Pilsen, Czech Republic
| | - Jaroslav Tintěra
- Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic
| | - Martin Fůs
- Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic
| | - Jan Lešták
- Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic
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Abstract
Pituitary apoplexy is a life-threatening complication that may result from hemorrhage or infarction of a pituitary adenoma. Neuroimaging may reveal a snowman-like or 'figure of 8' configuration as a result of bilateral indentation of the tumor by the sellar diaphragm.
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Affiliation(s)
- Khulood Bukhari
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, Maryland, USA
| | - Vandhna Sharma
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Sonia Gupta
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Abbas Motazedi
- Center of Diabetes, Thyroid, and Endocrinology, Washington, DC, USA
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