Pituitary Apoplexy Presenting with Isolated Third Nerve Palsy: A Rare Case Report

A 46-year-old female came to neurosurgery outpatient department with sudden onset of drooping of RE upper eyelid and restriction of movements in adduction, depression and elevation in right eye. Patient was a known case of diabetes mellitus whose blood sugar levels were deranged. On examination, patient was diagnosed pituitary macroadenoma. Patient was treated for her uncontrolled diabetes mellitus following which she had underwent transsphenoidal pituitary macroadenoma removal. On treatment, patient's ptosis had subsided and restriction of movement has resolved.

Optochiasmatic Cavernomas: Updated systematic review and proposal of a novel classification with surgical approaches

Cavernomas are histologically benign vascular malformations found at different sites in the brain. A rare site for such cavernomas, however, is the anterior optic pathway, comprising the optic nerve, chiasma, and optic tract-called optochiasmatic cavernomas (OCC). These lesions usually present with sudden onset or progressive vision loss, headache, and features mimicking pituitary apoplexy. In this paper, we describe a case of OCC operated at our center. We carry out an updated review of literature depicting cases of OCC, their clinical presentation, management, and postoperative complications. We also propose a novel classification system based on lesion location and further analyze these cavernoma types with respect to the surgical approach used and visual outcome. A 30-year-old lady had presented with a 3-week history of progressive bilateral vision loss and headache. Based on imaging, she was suspected to have a cavernous angioma of the chiasma and left optic tract. Due to progressive vision deterioration, the lesion was surgically excised using pterional craniotomy. Postoperatively, her visual symptoms improved, but she developed diabetes insipidus. Clinical and radiological follow-up has been done for 18 months after surgery. A total of 81 cases have been described in the literature, including the present case. Chiasmal apoplexy is the most common presentation. Surgical excision is the standard of care. Our analysis based on lesion location shows the most appropriate surgical approach to be used for each cavernoma type. Visual outcome correlates with the preoperative visual status. Visual outcome is good in patients presenting with acute chiasmal apoplexy, and when complete surgical excision is performed. The endonasal endoscopic approach was found to provide the best visual outcome. In addition to preoperative visual status, complete surgical excision predicts favorable visual outcomes in OCC. Our proposed classification system guides the appropriate surgical approach required for a particular location of the cavernoma.

An algorithm for the treatment of concurrent pituitary adenoma and cavernous sinus aneurysm: A systematic review & case report

BACKGROUND

Rarely, Pituitary adenomas (PA) can co-occur with intrasellar or intracavernous aneurysms. There is currently no clear guidance for the management of this dual pathology. We attempt to provide an algorithm to help guide clinical decision making for treatment of PAs co-occurring with adjacent cerebral aneurysms.

METHODS

A comprehensive literature search was conducted following PRISMA guidelines using various databases. Search terms included "(Pituitary Adenoma OR Prolactinoma OR Macroadenoma OR Adenoma) AND (ICA OR Internal Carotid Artery OR paracliniod OR clinoid) Aneurysm AND (Intra-cavernous OR intracavernous OR intrasellar OR Cavernous)."

RESULTS

A total of 24 studies with 24 patients were included. Twelve (50%) patients experienced visual symptoms. Ten patients (42%) had an aneurysm embedded within the adenoma. Fourteen patients (58%) had an aneurysm adjacent to the adenoma. Embedded aneurysms were significantly associated with rupture events.

CONCLUSION

Vision loss is the most pressing determinant of treatment. In the absence of visual symptoms, the aneurysm should be treated first by coil embolization. If not amenable to coiling, place flow diverting stent followed by six months of anticoagulation and antiplatelet therapy. If visual loss is apparent, the adenoma-aneurysm spatial relationship becomes critical. In cases of an adjacent aneurysm, the adenoma should be removed transsphenoidally with extreme care and aneurysm rupture protocols in place. If the aneurysm is embedded within the adenoma, then a BTO is favored with permanent ICA occlusion followed by transsphenoidal resection if adequate collateral supply is demonstrated. If there is inadequate collateral supply, then an open-approach for amenable aneurysms with transcranial adenoma debulking should be performed.

Pituitary Adenoma "Pneumo-Apoplexy"

Tension pneumosella has been recognized as a very rare complication of pituitary transsphenoidal surgery. To the best of our knowledge, we report the second case of a pituitary adenoma "pneumo-apoplexy", which is characterized by findings consistent with tension pneumosella in the context of apoplexy of a pituitary adenoma; although it is an extremely rare diagnosis, it should be considered in patients with compatible clinical and radiological findings, particularly with a previous history of transsphenoidal pituitary surgery.

Ferulic acid is a putative surrender signal to stimulate programmed cell death in grapevines after infection with Neofusicoccum parvum

An apoplectic breakdown from grapevine trunk diseases (GTDs) has become a serious challenge to viticulture as a consequence of drought stress. We hypothesize that fungal aggressiveness is controlled by a chemical communication between the host and colonizing fungus. We introduce the new concept of a 'plant surrender signal' accumulating in host plants under stress and facilitating the aggressive behaviour of the strain Neofusicoccum parvum (Bt-67) causing Botryosphaeriaceae-related dieback in grapevines. Using a cell-based experimental system (Vitis cells) and bioactivity-guided fractionation, we identify trans-ferulic acid, a monolignol precursor, as a 'surrender signal'. We show that this signal specifically activates the secretion of the fungal phytotoxin fusicoccin A aglycone. We show further that this phytotoxin, mediated by 14-3-3 proteins, activates programmed cell death in Vitis cells. We arrive at a model showing a chemical communication facilitating fusicoccin A secretion that drives necrotrophic behaviour during Botryosphaeriaceae-Vitis interaction through trans-ferulic acid. We thus hypothesize that channelling the phenylpropanoid pathway from this lignin precursor to the trans-resveratrol phytoalexin could be a target for future therapy.

The natural history of non-functioning pituitary adenomas: A meta-analysis of conservatively managed tumors

BACKGROUND

Non-functioning pituitary adenomas (NFPA) are often discovered incidentally. The natural history of NFPA is not well understood, obfuscating evidence-based management decisions. Meta-data of radiographically followed NFPA may help guide conservative versus operative treatment of these tumors.

METHODS

We searched PubMed, Medline, Embase, and Ovid for studies with NFPA managed nonoperatively with radiographic follow-up. Studies on postoperative outcomes after NFPA resection and studies that did not delineate NFPA data from functional pituitary lesions were excluded. NFPA were divided into micro- and macroadenomas based on size at presentation. We performed a meta-analysis of aggregate data for length of follow-up, change in tumor size, rate of apoplexy, and need for resection during follow-up.

RESULTS

Our database search yielded 1787 articles, of which 19 were included for final analysis. The studies included 1057 patients with NFPA followed radiographically. Macroadenomas were significantly more likely to undergo growth (34% vs. 12%; p < 0.01) or apoplexy (5% vs. < 1%; p = 0.01) compared to microadenomas. Resection was performed in 11% of all NFPA patients during follow-up regardless of size at presentation. Meta-regression showed that surgery during follow-up was associated with macroadenomas and negatively associated with microadenomas that decreased in size.

CONCLUSION

Low-quality evidence suggests that NFPA classified as macroadenomas have an increased rate of growth and apoplexy during follow-up compared to microadenomas. A significant minority of all NFPA patients ultimately underwent surgery. In select patients, nonoperative management may be the appropriate strategy for NFPA. Macroadenomas may require closer follow-up.

Rathke cleft cyst apoplexy: Hormonal and clinical presentation

Background:

Rathke cleft cyst (RCC) apoplexy is an uncommon type of lesion that is challenging to diagnose without histopathological samples. Very few articles have been published describing the details of RCC apoplexy. We studied a good number of published articles to analyze its demographics, clinical and hormonal presentations, and outcomes.

Methods:

A literature review of English language publications about RCC apoplexy or pituitary apoplexy was conducted using Medline and EMBASE search engines. Thirty articles with histological diagnosis of RCC apoplexy were identified, the earliest of which was published in 1990 and the latest in 2019. We combined the findings of these articles with our own case report and then compared the demographics, clinical and hormonal presentations, and outcomes between RCC apoplexy and pituitary adenoma apoplexy.

Results:

Our data included 29 patients with RCC, with a mean age of 36.87 years (8–72) and a predominance of female patients (68%). The hemorrhagic type was most common, reported in 86%. Headache was the most common presenting symptom, being reported in 93% followed by hypogonadism (73%) and hormonal deficits (52%). All but three patients improved neurologically (90%); however, 45% of patients required long-term hormonal replacement, mostly thyroid hormone. No cases of worsening neurological or hormonal status were reported.

Conclusion:

RCC apoplexy presents with less severe neurological and hormonal abnormalities than pituitary adenoma apoplexy; it also has a better prognosis in endocrine functional recovery. We recommend applying current management guidelines of pituitary adenoma apoplexy to RCC apoplexy.

Apoplexy of Crooke cell tumour leading to the diagnosis of severe Cushing disease; a case report

BACKGROUND

Patients with Crooke cell tumours present with features of Cushing syndrome or mass effect. There are few reports of patients with Crooke cell tumours presenting due to apoplexy. All of them had silent tumours. Patients with Cushing syndrome caused by Crooke cell tumours have not been reported to present with apoplexy.

CASE PRESENTATION

A 35-year-old female presented with sudden onset headache and visual loss for 1 week. She had secondary amenorrhoea for 10 years. There were features of Cushing syndrome including central obesity, multiple monomorphic acne, dorso-cervical and supraclavicular fat pads, hypertension, proximal weakness, pigmentation and refractory hypokalaemia. She was found to have markedly elevated serum cortisol, central hypothyroidism and hypogonadotropic hypogonadism. There was a mass in the sellar region (4.7 cm × 1.9 cm × 5.3 cm) suggestive of a pituitary tumour extending to the suprasellar region. Imaging showed evidence of bleeding and compression of the optic chiasm. She underwent urgent trans-sphenoidal excision of the tumour. Histology was compatible with a pituitary neuroendocrine tumour. There was margination of ACTH reactivity to the cell periphery and ring like positivity in most of the cells in the cytokeratin stain. Features were in favour of a Crooke cell tumour. After surgery she improved gradually and became eucortisolaemic.

CONCLUSIONS

This is a unique presentation of an apoplexy of Crooke cell tumour causing Cushing syndrome. Delayed health seeking behaviour of this patient despite severe Cushing disease could have led to this presentation which has not been reported before.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Johann Jakob Wepfer (1620-1695): A review of his contributions to neuropsychology on the quadricentennial of his birth

The effects of brain damage on behavior have been reported by authors from the Greek, Roman, Medieval, Renaissance, and seventeenth-century medical traditions. However, few of the reported cases discussed mind-brain relationships, even fewer reported data that offered a description of cognitive functions, and none described a clear association of a functional mechanism of cognitive impairment with identifiable focal brain damage. An exception is found in the case studies by Johann Jakob Wepfer (1620-1695). After reviewing the pre-seventeenth-century background and Wepfer's milieu, we analyze his texts on neuroanatomy, apoplexy, and brain vascularization (Observationes anatomicae ex cadaveribus eorum, quos sustulit apoplexia cum exercitatione de ejus loco affecto) and his remarkable collection of 222 neurological cases (Observationes medico-practicae de affectibus capitis internis & externis), posthumously published in 1727. We focus on his reports concerning on the presence of aphasia, memory disorders, and unilateral neglect, correlated with focal brain damage, with particular emphasis on his examination of language impairments.

From Cerebellar Apoplexy in 1849 to Cerebellar Stroke in the 2020s: Robert Dunn's Contribution

Stroke of the cerebellum represents about 10% of strokes of the brain. Both infarction and hemorrhage manifest with symptoms related to the location and extent of the lesion(s). Bilateral cerebellar infarcts constitute up to one third of all cerebellar infarctions. The leading cause of cerebellar infarcts is emboli of cardiac origin or from intra-arterial sources. Potential complications include brainstem compression and hydrocephalus. Malignant cerebellar edema is a life-threatening complication of ischemic posterior circulation stroke requiring urgent management. The advent of MRI has revolutionized the early diagnosis in vivo, showing small and large territorial infarcts, hemorrhages, and venous infarcts. Endovascular procedures are growingly applied and are impacting on the prognosis of stroke, although cerebellar stroke from occlusion of small cerebellar arteries is currently not accessible to thrombectomy. Surgical procedures of space-occupying stroke include external ventricular drainage, suboccipital craniotomy, or combined procedures. In 1849, Robert Dunn (1799-1877), an English surgeon, reported the details of a case of apoplexy of the cerebellum in a 52-year-old man, pointing to the importance of post-mortem studies of patients followed meticulously during lifetime. Dunn discussed inflammation surrounding hemorrhage as a source of cerebral degeneration, linking for the first time cerebellar stroke, neuroinflammation, and atherosclerosis.

A key role for conservative treatment in the management of pituitary apoplexy

PURPOSE

The management of pituitary apoplexy, a rare emergency neuroendocrine condition, is controversial. The aim of the present study is to compare the outcomes of patients with pituitary apoplexy managed either by a conservative or surgical approach.

METHODS

A retrospective cohort study including patients diagnosed between 2007 and 2018 in a tertiary French university hospital. Pituitary Apoplexy Score (PAS) was retrospectively applied in the perspective of therapeutic decision support.

RESULTS

Forty-six patients were treated for pituitary apoplexy either with conservative management (n = 27) or surgery (n = 19). At initial evaluation, visual field defects (VFD) and visual acuity impairment were more frequent in patients from the surgery group. At 1 year there were no statistical differences in the rates of complete/near-complete resolution of VFD (100 vs. 91.7%), visual acuity impairment (100 vs. 87.5%), and cranial nerve palsies (83.3 vs. 100%), between conservative and surgical treatment groups. There were more endocrine deficits at 1 year in the surgical group (p = 0.029). PAS (n = 41) was 3.4 on average in the early surgery group and 1.3 in the conservative treatment/delayed surgery group. Among patients with a score < 4, 31.3% were operated at first line and did not present better outcomes than patients managed conservatively. In all, 88.9% of patients with a score ≥ 4 underwent surgery.

CONCLUSIONS

PAS may be a reliable parameter for defining therapeutic strategy. Patients with non-severe and nonprogressive neuro-ophthalmological deficits can be managed conservatively without negative impact on outcomes, thus surgery should be reserved only for those patients with a PAS ≥ 4.

Neuroimaging of the Pituitary Gland: Practical Anatomy and Pathology

The pituitary gland is a small endocrine organ located within the sella turcica. Various pathologic conditions affect the pituitary gland and produce endocrinologic and neurologic abnormalities. The most common lesion of the pituitary gland is the adenoma, a benign neoplasm. Dedicated MR imaging of the pituitary is radiologic study of choice for evaluating pituitary gland and central skull region. Computed tomography is complimentary and allows for identification of calcification and adjacent abnormalities of the osseous skull base. This review emphasizes basic anatomy, current imaging techniques, and highlights the spectrum of pathologic conditions that affect the pituitary gland and sellar region.

Characterization of the TNF and IL-1 systems in human brain and blood after ischemic stroke

Preclinical and clinical proof-of-concept studies have suggested the effectiveness of pharmacological modulation of inflammatory cytokines in ischemic stroke. Experimental evidence shows that targeting tumor necrosis factor (TNF) and interleukin (IL)-1 holds promise, and these cytokines are considered prime targets in the development of new stroke therapies. So far, however, information on the cellular expression of TNF and IL-1 in the human ischemic brain is sparse.We studied 14 cases of human post-mortem ischemic stroke, representing 21 specimens of infarcts aged 1 to > 8 days. We characterized glial and leukocyte reactions in the infarct/peri-infarct (I/PI) and normal-appearing tissue (NAT) and the cellular location of TNF, TNF receptor (TNFR)1 and TNFR2, IL-1α, IL-1β, and IL-1 receptor antagonist (IL-1Ra). The immunohistochemically stained tissue sections received a score reflecting the number of immunoreactive cells and the intensity of the immunoreactivity (IR) in individual cells where 0 = no immunoreactive cells, 1 = many intermediately to strongly immunoreactive cells, and 2 = numerous and intensively immunoreactive cells. Additionally, we measured blood TNF, TNFR, and IL-1 levels in surviving ischemic stroke patients within the first 8 h and again at 72 h after symptom onset and compared levels to healthy controls.We observed IL-1α and IL-1β IR in neurons, glia, and macrophages in all specimens. IL-1Ra IR was found in glia, in addition to macrophages. TNF IR was initially found in neurons located in I/PI and NAT but increased in glia in older infarcts. TNF IR increased in macrophages in all specimens. TNFR1 IR was found in neurons and glia and macrophages, while TNFR2 was expressed only by glia in I/PI and NAT, and by macrophages in I/PI. Our results suggest that TNF and IL-1 are expressed by subsets of cells and that TNFR2 is expressed in areas with increased astrocytic reactivity. In ischemic stroke patients, we demonstrate that plasma TNFR1 and TNFR2 levels increased in the acute phase after symptom onset compared to healthy controls, whereas TNF, IL-1α, IL-1β, and IL-1Ra did not change.Our findings of increased brain cytokines and plasma TNFR1 and TNFR2 support the hypothesis that targeting post-stroke inflammation could be a promising add-on therapy in ischemic stroke patients.

Hemorrhagic Presentation of Rathke Cleft Cysts: A Surgical Case Series

BACKGROUND

Rathke cleft cysts (RCCs) are benign sellar and suprasellar lesions commonly presenting as asymptomatic incidental findings. Rarely, RCCs hemorrhage and mimic pituitary apoplexy on presentation.

OBJECTIVE

To review a series of hemorrhagic RCCs for physicians encountering this rare presentation.

METHODS

A database review of >1700 transsphenoidal pituitary operations was performed at the USC Pituitary Center to identify patients with pathologically confirmed RCCs presenting with acute symptoms and evidence of hemorrhage at the time of surgery. Surgical treatment involved transsphenoidal RCC fenestration and drainage. Clinical, endocrine, and imaging outcomes were reviewed.

RESULTS

A total of 119 RCCs were identified, and 6 (5.0%) presented with hemorrhage mimicking pituitary apoplexy. Presenting symptoms included acute onset headaches (5/6), vision loss (2/6), and oculomotor nerve palsy (n = 1). Endocrine disturbances at presentation included pre-existing amenorrhea in all female patients (3/3), hypothyroidism (n = 2), panhypopituitarism (n = 2), and one with profound hyponatremia (Na 116 meq/L). All patients underwent endonasal transsphenoidal fenestration and drainage with no major complications. Over mean follow-up of 38.4 mo, 2/2 patients with vision loss reported improvement, and 2/5 patients with headaches reported improvement. Although all women resumed menses, patients with preoperative hypopituitarism did not experience pituitary axis improvement. Follow-up magnetic resonance imaging showed no instances of RCC recurrence with a mean imaging follow-up of 38.6 mo.

CONCLUSION

RCCs occasionally present with hemorrhage and clinical symptoms that may be confused with apoplexy. Outcomes following hemorrhagic RCC treatment are excellent when treated at tertiary pituitary centers. Although hyperprolactinemia often improves following surgery, other pituitary axis deficits typically do not.

Pituitary Apoplexy Case Series: Outcomes After Endoscopic Endonasal Transsphenoidal Surgery at a Single Tertiary Center

BACKGROUND

The management of pituitary apoplexy, caused by acute hemorrhage and/or infarction of a pituitary adenoma, is debated.

OBJECTIVE

To analyze clinical characteristics of patients undergoing endoscopic endonasal approaches (EEAs) for pituitary apoplexy.

METHODS

A retrospective review of patients at our institution from 2012 to 2018 undergoing EEA for pituitary apoplexy diagnosed clinically and with imaging/pathologic findings. Analysis included demographics, symptoms, neuroendocrine deficits, neuroimaging, complications, symptom resolution, and follow-up details.

RESULTS

Fifty patients (mean age, 53 years) were included. Preoperative symptoms included headache (86%), vision loss (62%), and cranial nerve paresis (40%). Mean tumor diameter was 2.7 cm and extrasellar extension was observed in 96% of tumors. Twenty-eight tumors were hemorrhagic (76%), 24 were necrotic (65%), and 13 (35%) had both features. Magnetic resonance imaging showed gross total resection in 58% of patients. Headache and vision loss improved in 87% and 86% of presenting patients. Cranial nerve paresis resolved in 72% of patients, partially improved in 11%, and remained unchanged in 17%. There were no deaths or carotid artery injuries. Surgical complications included postoperative cerebrospinal fluid leak (n = 4, 8%), epistaxis (n = 2, 4%), postoperative abscess (n = 1, 2%), and transient postoperative vision loss requiring reoperation (n = 1, 4%). Endocrinopathies improved in 21% of patients and panhypopituitarism persisted in 48% and developed in 6% of patients. Mean follow-up time was 26 months; 2 patients experienced recurrence.

CONCLUSIONS

EEA for pituitary apoplexy is effective in rapidly improving headache and visual symptoms. Although neuro-ophthalmic deficits often improve over time, panhypopituitarism persists in most patients after surgical resection.

Pineal Cyst Apoplexy: A Rare Complication of Common Entity

Pineal cysts (PCs) are often encountered as incidental findings in intracranial images. The vast majority of cysts are normally asymptomatic and clinically benign. Bleeding into the cysts, which leads to neurological symptoms and signs, is considered to be quite rare. The authors illustrate a newly identified complication of PC in a 56-year-old woman who characterized by headache of sudden onset and vomiting. MRI disclosed a small hemorrhagic PC without narrowing of the cerebral aqueduct. The patient was managed conservatively without any surgical interventions, and she remained symptom-free over a period of 15-year follow-up. The description of this case adds to the limited literature on the series in which nonsurgical treatments had a role in the care for patients with PC complicated by intracystic hemorrhage.

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

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

Endoscopic endonasal resection of nonfunctioning pituitary adenoma with radiological calcification

OBJECTIVE

Radiological calcification in nonfunctioning pituitary adenoma is scarcely rare, which appears in various formations and raises special diagnostic and therapeutic challenges. Here we present our experience about the clinical aspects and treatment of calcified nonfunctioning pituitary adenoma.

METHODS

A total of 145 patients who underwent surgical resection of nonfunctioning pituitary adenomas via endoscopic endonasal approach from February 2008 to December 2018 were reviewed. Among these patients, cases with radiological calcifications on preoperative imaging were included in this study. We analyzed these patients' records, radiological neuroimaging, endocrine evaluation, operative notes as well as intraoperative videos.

RESULTS

Calcification on preoperative neuroimaging was observed in only 7 patients with nonfunctioning pituitary adenomas. The study population consisted of these seven patients with intra-tumor calcification (n = 2), thin and egg shelf-like capsular calcification (n = 3), hard and armor-like capsular calcification (n = 2). In 85.7% of cases (n = 6), nonfunctioning pituitary adenomas with calcification were characterized by soft tumor texture. Evidences demonstrated apoplexy occurred in 71.4% of cases with calcified pituitary adenomas (n = 5). Patients with intra-tumor calcification as well as with thin and egg shelf-like capsular calcification underwent resection of both tumor and calcification through extra-pseduocapusual dissection via endoscopic endonasal approach. Besides, in the remaining 2 cases (28.6%), hard and armor-like capsular calcification was found surrounding a soft tumor component; however, it did not interfere with adequate removal of the soft part via endoscopic endonasal approach with the hard calcification untouched. Postoperative course of all patients was uneventful. Long term follow-up (median interval of 49 months, range 8-70 months) showed that no recurrence occurred.

CONCLUSIONS

Although relatively rare, calcified nonfunctioning pituitary adenoma should be kept in mind to avoid making a wrong preoperative diagnosis. Given various calcification types, multiple surgical tactics is required accordingly. Extra-pseudocapusual resection via endoscopic endonasal approach is helpful for the resection of both adenoma and calcification.

Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature

OBJECTIVE

Pituitary apoplexy is associated with visual, cranial nerve, and endocrine dysfunction. In this article, the results of surgical and conservative management of pituitary apoplexy in a single center are evaluated and a review of the literature is presented.

METHODS

A retrospective analysis was made of patients with pituitary apoplexy who underwent surgery or conservative management at our center between January 2007 and June 2017. Surgery was typically selected for patients who presented with acute deterioration of visual status and/or level of consciousness. Patients with no visual field deficit and those who had medical contraindications to undergo a surgical procedure because of previous comorbidities typically had conservative treatment. Baseline characteristics and clinical and radiologic outcomes were reviewed. A review of the literature (1990-2018) was performed according to PRISMA guidelines. Studies comparing the results of conservative and surgical management were identified. Visual, cranial nerve, and endocrine outcomes and tumor recurrence were analyzed.

RESULTS

Forty-nine patients (73.1%) were managed surgically and 18 (26.9%) conservatively. After careful case selection, patients underwent surgical or conservative treatment. Patients who underwent conservative treatment had fewer visual deficits. At diagnosis, visual deficit (38.8% vs. 75.5%; P = 0.008) and cranial nerve palsy (27.7% vs. 51%; P = 0.058) were less common in the conservative group. Conservative and surgical treatments had similar visual and cranial nerve improvement rates (75% vs. 58.3%, P = 0.63 and 75% vs. 69.2%, P = 1.0, respectively). In the conservative group, tumor shrinkage was observed in 76.4% of cases. The systematic review retrieved 11 studies. No significant difference between conservative and surgical treatment for clinical outcomes (visual field recovery, odds ratio [OR], 1.45; 95% confidence interval [CI], 0.72-2.92; cranial nerve recovery, OR, 2.30; 95% CI, 0.93-5.65; and hypopituitarism, OR, 1.05; 95% CI, 0.64-1.74) or tumor recurrence (OR, 0.68; 95% CI, 0.20-2.34) was observed.

CONCLUSIONS

A tailored approach to pituitary apoplexy, one that does not include an absolute need for surgery, is appropriate. Conservative management is appropriate in selected patients presenting without visual deficits.

[Pituitary apoplexy secondary to pituitary macroadenoma, a diagnostic challenge]

BACKGROUND

Pituitary apoplexy is a clinical syndrome reflecting a rapid expansion of sellar content, typically secondary to a stroke in a previous pituitary adenoma. This pathology is a rare complication, and, therefore, underdiagnosed. The consequences of a delay in the diagnosis are translated into serious functional and even deadly complications for the patient.

CASE REPORT

We present the case of a 42-year-old male patient, who began his condition with a diffuse clinical setting, characterized by headache, amblyopia, and alterations of consciousness. The diagnosis was pituitary apoplexy, and secondary hypopituitarism, and it was treated in a conservative way, with steroid anti-inflammatories and hormonal substitution. The patient presented a psychotic episode induced by steroids, due to the supraphysiological doses used, necessary to reverse the existing neurological damage; however, it ended in a restitutio ad integrum 15 days after medical treatment, without requiring neuro-surgical intervention.

CONCLUSIONS

The clinical case presented and its resolution are clear evidence of the importance of a timely and adequate diagnosis, given that being detected in early stages, and treated early according to the evolution of the pathology, will not always require surgical intervention, allowing a total neurological restitution.

Empty Sella in the Making

BACKGROUND

Pituitary apoplexy may occur when a large tumor compresses or outgrows its nutrient supply, resulting in ischemic necrosis and hemorrhage. Although once deemed a neurosurgical emergency, increasing evidence suggests that conservative management of pituitary apoplexy leads to favorable neuro-ophthalmologic and endocrinologic outcomes as well. Spontaneous remission after pituitary apoplexy has been described in functioning pituitary adenomas, but it is a rare occurrence in nonfunctioning tumors.

CASE DESCRIPTION

We report a man that presented with pituitary apoplexy of a nonfunctioning pituitary macroadenoma that was managed conservatively and treated hormonally for hypopituitarism during a 2-year follow-up period, with serial neuroimaging demonstrating significant tumor volume reduction with almost complete resolution resulting in partial empty sella. In addition, a short literature review was performed pertaining to the management of pituitary apoplexy with emphasis on a more conservative approach.

CONCLUSIONS

A subset of patients with pituitary apoplexy without altered consciousness and nonprogressive or mild ophthalmologic deficits may be managed conservatively; however, lifelong periodic assessment, preferably by a specialized multidisciplinary pituitary team, is essential until clinical outcomes become clear.

Apoplectic Silent Crooke Cell Adenoma with Adjacent Pseudoaneurysms: Causation or Bystander?

BACKGROUND

Crooke cell adenomas (CCAs) are rare and potentially aggressive pituitary tumors that often invade the cavernous sinuses. Although clinical presentations of pituitary tumors may include the development of accompanying intracranial aneurysms, there are no documented cases of coexistent intracranial aneurysms and CCAs to date. Herein we describe an apoplectic silent CCA that presented with adjacent cavernous internal carotid artery (ICA) aneurysms.

CASE DESCRIPTION

A 45-year old male patient presented for evaluation of headaches and diplopia. Subsequent imaging series revealed a hemorrhagic pituitary macroadenoma that had invaded the left cavernous sinus and circumferentially involved the ICA. Two pseudoaneurysms were visualized along regions of the ICA directly attached to the tumor. A transnasal transsphenoidal endoscopic approach was used for resection of the tumor, which was identified histologically as a CCA. Endocrine evaluations characterized the tumor as nonfunctional. The patient experienced an excellent recovery with resolution of related symptoms. A pseudoaneurysm was treated with a Pipeline embolization device; however, it persisted at last follow-up.

CONCLUSIONS

CCAs are a poorly characterized and rare pituitary tumor type. In this case, an apoplectic silent CCA invaded the left cavernous sinus and presented with pseudoaneurysms along its involvement of the ICA. Accordingly, the authors speculated that the invasive qualities of this silent corticotroph adenoma may have directly contributed to the development of these aneurysms.

Hemorrhagic Atypical Planum Sphenoidale Meningioma with Intermittent Vision Loss-Rare Presentation of Apoplexy

BACKGROUND

Symptoms that mimic pituitary apoplexy may be encountered with other neoplastic or infectious lesions.

CASE DESCRIPTION

This 38-year-old man presented with severe sudden-onset headache and relapsing and remitting vision loss. Radiographic imaging studies demonstrated radiographic features of a hyperdense, hemorrhagic mass in the sellar region. Magnetic resonance imaging (MRI) revealed a 4-cm mass abutting the optic chiasm and compressing the pituitary. After 4-week follow-up, surveillance MRI demonstrated near-complete resolution of the previously identified planum sphenoidale and suprasellar mass. The patient re-presented 13 months later with recurrent symptoms. MRI demonstrated recurrence of the mass. Given the broad differential diagnosis, an endoscopic endonasal biopsy was obtained; the findings were suggestive of a high-grade meningioma. The patient underwent elective resection of the extraaxial lesion via a frontotemporal approach. The lesion was identified as a hemorrhagic suprasellar atypical planum sphenoidale meningioma. Postoperatively, the patient's headaches improved significantly and his right-sided visual changes resolved. After adjuvant radiotherapy (5400 cGy in 30 fractions) to the surgical cavity 3 months later, at last follow-up 5 months postoperatively, the patient was at his neurologic baseline and denied any headaches or visual sequelae.

CONCLUSIONS

As the most common benign intracranial tumors, meningiomas should remain in the differential for patients presenting with apoplectiform symptoms.

Pituitary tumour apoplexy within prolactinomas in children: a more aggressive condition?

OBJECTIVES

To evaluate clinical presentations, diagnosis and management of paediatric patients presenting with pituitary apoplexy.

METHODS

A retrospective case series describing a cohort of paediatric patients presenting with this condition from 2010-2016 to a tertiary referral children's hospital in the United Kingdom.

RESULTS

Pituitary apoplexy is a rare condition that seems to have a higher relative incidence in children than adults. Our series suggests that pituitary apoplexy in paediatric patients with adenomas appears more common than previously described. All our patients required surgery, either as an acute or delayed procedure, for visual compromise. Two patients had commenced growth hormone (GH) for GH deficiency two weeks prior to the onset of pituitary apoplexy.

CONCLUSIONS

With only a limited number of published case reports surrounding this topic our case series contributes to help further understand and manage this condition.

Management of cystic prolactinomas: a review

INTRODUCTION

Cystic prolactinoma is a variant of prolactin-secreting pituitary adenoma. The strategies for the management of cystic prolactinoma have not been addressed thoroughly in clinical guidelines.

METHODS

A literature search was performed using Pubmed to review the current approaches to the treatment of cystic prolactinoma.

RESULTS

Transsphenoidal resection is an effective and relatively safe approach for the treatment of cystic prolactinoma, however, morbidity of surgery is dependent on the skill of the surgeon. Emerging studies allude to the efficacy and safety of dopamine agonists in the management of cystic prolactinoma. Dopamine agonists are associated with considerable rates of clinical improvement and tumor shrinkage, hence reducing the need for surgical intervention.

CONCLUSIONS

Recent studies suggest that dopamine agonist therapy may be an effective and safe treatment option in a considerable portion of patients with cystic prolactinomas. We suggest that dopamine agonists should be considered as a first-line therapy for cystic prolactinoma in the absence of indications for early surgical intervention.

Apoplexy in nonfunctioning pituitary adenomas

Pituitary apoplexy is an uncommon event, occurring due to the infarction and/or haemorrhage usually of a previously unknown pituitary adenoma. It can occur in all adenoma subtypes but is more common in nonfunctioning pituitary adenomas. The physiopathology is not completely clear, and precipitating factors, such as major surgeries, anticoagulant use or pituitary dynamic tests, can be found in up to 40% of patients. The clinical presentation is characterized by a rapid onset with a headache as the main symptom, but visual disturbances can also be present as well as meningism and intracranial hypertension. The diagnosis is based on imaging evaluations, mainly using magnetic resonance imaging, which can show various patterns depending on the timeframe following the occurrence of the apoplectic event. Pituitary hormonal deficits are also common, and the evaluation of hormonal levels is mandatory. Pituitary apoplexy can be managed by surgery or conservative treatment, and a multidisciplinary team is essential for the decision-making process. The outcome is usually positive with both surgical and conservative approaches, but surveillance is needed due to the risk of re-bleeding or tumour recurrence.

Rathke's Cleft Cyst or Pituitary Apoplexy: A Case Report and Literature Review

BACKGROUND:

During the examination of the sellar region by magnetic resonance imaging, hyperintensity in T1 weighted is a common finding. This signal intensity has different sources, and its significance depends on the clinical context. Pathologic variations in T1 signal hyperintensity may be related to clotting of blood (pituitary apoplexy) or the presence of a high concentration of protein (Rathke cleft cyst). The purpose of this study is to describe the significance of intracystic nodule, a diagnostic characteristic found in Rathke’s cleft cyst, on MRI.

CASE REPORT:

We will present the case of a 20–year-old girl which referral to our hospital for head examination with magnetic resonance imaging because she has a post-traumatic headache. Pathological findings presented in T1-weighted hyperintensity intrasellar which persist even in T1 weighted-Fat suppression. These changes signal the presence of methemoglobin imposes. The patient is a referral to laboratory tests which result in rate except for slight value increase of prolactin. Recommended controller examination after a month but finding the same results which exclude the presence of methemoglobin.

CONCLUSION:

Morphological characteristics and signal intensity can impose the presence of high concentration of protein (Rathke cleft cyst).

Evaluation of Clinical and Magnetic Resonance Imaging Profile of Pituitary Macroadenoma: A Prospective Study

Background

Pituitary macroadenoma is a common tumor of middle-aged people. Magnetic resonance imaging (MRI) is the investigation of choice for its evaluation. Various parameters regarding the extent, consistency, and contrast uptake can be studied and a noninvasive diagnosis is possible.

Aims and Objectives

To study the MRI features and extent of pituitary macroadenomas.

Materials and Methods

We studied clinical and MRI features of 33 patients of all age groups and both sexes with pituitary macroadenomas who presented to Dayanand Medical College and Hospital, Ludhiana from January 2014 to June 2015. MRI was carried out on MAGNETOM Avanto 18 Channel 1.5 Tesla Machine by Seimens India Ltd. The dedicated sellar protocol consisted of sagittal and coronal T1-weighted image (TI-WI) and T2-WI without intravenous contrast using thin slices (3 mm) and a field of view of <200 mm.

Results

On analysis of the 33 cases, we observed that patients of pituitary macroadenoma showed an almost equal sex incidence and average age group of 50-60 years. The common presenting complaints were headache and decreased vision. Superior and inferior extent of the lesion was beyond the defined boundaries of sella in most cases, but the lateral extent was limited, resulting in characteristic "snowman-like" appearance. The imaging characteristics showed solid to predominantly solid consistency, appearing mostly heterogeneously hyperintense on T2-WI, and hypo to isointense on T1-WI with intense postcontrast enhancement. Hemorrhage is less common. Pituitary apoplexy is rare and can result in spontaneous resolution.

Conclusions

We conclude that the knowledge of clinical and imaging profile of pituitary macroadenoma can help the radiologists to diagnose these sellar lesions, and hence their therapeutic approach can be defined timely.

Pituitary Apoplexy: Should Endoscopic Surgery Be the Gold Standard?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Concomitant Primary CNS Lymphoma and FSH-Pituitary Adenoma Arising Within the Sella. Entirely Coincidental?

BACKGROUND AND IMPORTANCE: Collision tumors are the simultaneous occurrence of more than one type of neoplasm within an anatomic space. In the pituitary sella, collision tumors are exceedingly rare, and not much is known about their etiology and prognosis.

CLINICAL PRESENTATION: A 74-year-old man presented with a concomitant primary pituitary lymphoma (diffuse large B-cell non-Hodgkin's lymphoma; DLBCL) and follicle-stimulating hormone (FSH)-adenoma diagnosed histologically after clinical features of apoplexy prompted urgent surgical decompression and resection. Strong immunoreactivity for FSH by the lymphoma was evident. Full-body workup demonstrated no other source for the lymphoma. He subsequently underwent 4 cycles of chemotherapy and has been in remission for over 32 months. His ophthalmoplegia at presentation persisted with no further deficits.

CONCLUSIONS: Four cases of collision tumors of primary pituitary lymphoma and adenoma have previously been reported. This case represents the first combination of an FSH-adenoma and a DLBCL in the literature. Prompt involvement of the hematology-oncology team contributed to the good outcome seen in this case. The putative role played by pituitary hormones in tumorigenesis is reviewed in this case report. The association is either a chance occurrence or due to the induction of lymphoma cell proliferation by the binding of FSH produced by the adenoma to the FSH receptors on the lymphoma cells.

Apoplexy of a collision tumour composed of subependymoma and cavernous-like malformation in the lateral ventricle: a case report

Subependymomas are rare benign tumours arising from subependymal glial precursors that usually remain asymptomatic or may present due to obstruction of cerebrospinal fluid pathways. We describe the first report of intraventricular haemorrhage from subependymoma and cavernous-like malformation collision tumour in a 74-year-old male presented with an impaired level of consciousness.

Endoscopic Endonasal Surgery for Treatment of Pituitary Apoplexy: 16 Years of Experience in a Specialized Pituitary Center

OBJECTIVE

Symptomatic pituitary apoplexy is a rare but life-threatening condition caused by sudden hemorrhage or infarction of a pituitary adenoma. In the current study, we aim to evaluate the clinical presentation, management, and clinical outcomes in a cohort of patients who were treated for this condition in our center in the last 16 years.

METHODS

We performed a retrospective analysis of all patients who underwent endoscopic endonasal surgery for treatment of symptomatic pituitary apoplexy between 2001 and 2016 in our center.

RESULTS

A total of 39 patients were included in the study, mean age of 54.9 years (range, 18-70 years) and mean follow-up 5.1 years (range, 0.6-16 years). Most of the patients had nonfunctioning adenomas (32 patients). Headache (89%), visual impairment (79%), and hypopituitarism (86%) were the most common preoperative findings. Surgical treatment led to gross total resection in 31 patients (79.4%). During follow-up, visual fields and oculomotor improvement was observed in 23 (74.1%) and 21 (67.7%) of the patients, respectively. Intractable headache also improved in all patients. Hypopituitarism was present in 77% of patients after surgery. In this series, no cerebrospinal fluid leak, vascular injury, or infection was observed. There was no postoperative mortality.

CONCLUSIONS

The endoscopic endonasal transsphenoidal approach is an effective modality to treat pituitary apoplexy with a high rate of success and minimal risk in selected cases. Although reversion of preoperative visual deficits is often observed, hormonal deficits tend to persist, and require long-term hormonal therapy, even after successful endoscopic endonasal surgical resection.

Descriptions of Apoplexy by Joseph Frank in the Beginning of the Nineteenth Century in Vilnius

In the beginning of the 19th century, apoplexy was understood to be a disease of the cerebral blood vessels, manifesting with a sudden weakening or extinction of sensation and the patient's inability to move. In this study, we examined the situation of neurology in the beginning of the 19th century in Vilnius through the perspective of a nervous system disease - apoplexy. Case reports and descriptions of apoplexy in the textbook and memoirs by Joseph Frank (1771-1842), descriptions of patients with apoplexy from the proceedings of Vilnius University Clinic were analysed. It was identified that the main cause of apoplexy was not an imbalance of the four humours but the pathology of cerebral blood vessels. However, following ancient tradition, the principles of recreation and moderation were thought to be important for the prevention of apoplexy, and bloodletting and diet were believed to be essential for the treatment.

Jean-André Rochoux (1787-1852), a physician philosopher at the dawn of vascular neurology

Jean-André Rochoux (1787-1852) can be considered the author, in 1812, of the first clinical and neuropathological description of cerebral hemorrhage and ischemia, based on concepts that underlie current vascular neurology. His biography reveals how his thinking was shaped by materialist philosophy, which was also the basis of his rigorous scientific reasoning. Due to his intransigent defence of his philosophical ideas and his outspoken anticlericalism, he was often contradicted and had many opponents who were not inclined to perpetuate his memory after his death, despite the high quality of his medical research. Our biography traces the career of this iconoclastic thinker and physician ahead of his time.

Rathke Cleft Cyst with Evidence of Rupture into Subarachnoid Space

BACKGROUND

A Rathke cleft cyst (RCC) with nonhemorrhagic rupture mimicking pituitary apoplexy has been reported rarely.

CASE DESCRIPTION

A 52-year-old woman, previously diagnosed with asymptomatic RCC, came to us with a severe headache, along with visual dysfunction and symptoms of pituitary insufficiency. Fluid-attenuated inversion recovery magnetic resonance imaging demonstrated diffuse hyperintensity in the cerebral cisterns, whereas watery clear cerebrospinal fluid was obtained by lumbar puncture. Surgery performed 1 month after onset revealed a nonhemorrhagic lesion, with a final diagnosis of nonhemorrhagic RCC rupture.

CONCLUSIONS

We conclude that nonhemorrhagic RCC rupture and subsequent leakage of the contents into subarachnoid space were the underlying pathogenesis in the present case of RCC resembling apoplexy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Apoplexy in an intradural clival chordoma causing intraventricular bleed

Background:

A few cases depicting apoplexy in a chordoma have been reported. Rarely, this intratumoral bleed may spillover into intracerebral or intraventricular regions.

Case Description:

The authors report an intradural variety of clival chordoma presenting with apoplexy and spillover of blood into lateral ventricle. Clinical presentation, radiological scans, and relevant literature is also described.

Conclusions:

In a stable case of clival chordoma, intratumoral bleed or apoplexy may cause rapid neurological worsening and warranting urgent surgical intervention.

Pituitary tumor apoplexy

We review the etiology, investigations, management and outcomes of pituitary tumor apoplexy. Pituitary tumor apoplexy is a clinical syndrome which typically includes the acute onset of headache and/or visual disturbance, cranial nerve palsy and partial or complete endocrine dysfunction. It is associated with either infarction or hemorrhage of a pre-existing pituitary adenoma and is associated with significant morbidity and potential fatality. Not all patients will present with classic signs and symptoms, therefore it is pertinent to appreciate the clinical spectrum in which this condition can present.

Pituitary tumor apoplexy in adolescents

OBJECTIVE

The aim of this study was to determine whether there are differences in pituitary apoplexy and subclinical apoplexy secondary to adenoma hemorrhage in the adolescent population with regard to symptomatology, neuroimaging features, pathology, and outcomes compared with adults.

METHODS

A retrospective series of 9 consecutive patients with a diagnosis of pituitary hemorrhage who were surgically treated at Rady's Children's Hospital San Diego, between 2008 and 2013 were evaluated for clinical, endocrine, neuroradiographic, and pathologic features in association with clinical outcomes.

RESULTS

Nine patients (6 girls, age 14-21 years) presented to our institution with headache (9/9), nausea (3/9), dizziness (4/9), and visual disturbances (6/9) in the setting of a sellar hemorrhagic tumor on magnetic resonance imaging (MRI). Three patients presented with apoplexy and 6 with subclinical apoplexy. Duration of symptoms ranged from 3 days to 1 year. MRI revealed hemorrhage (9/9), rim enhancement (6/9), sphenoid sinus mucosal thickening (2/9), mass effect on the optic chiasm (8/9), and sellar remodeling (9/9). The percentage of hemorrhage preoperatively observed on MRI ranged from 50% to greater than 95%. On presentation, hyperprolactinemia was recorded in 7 patients, 6 of whom had galactorrhea and/or amenorrhea. Open transsphenoidal decompression was performed in 8/9 patients; 7 of 9 were diagnosed with prolactinoma. Biopsy specimens revealed 10%-90% hemorrhage and no infarction in any of the cases. All patients treated showed improvement of symptoms after surgery (average follow-up, 28.2 months). Postoperative complications included transient diabetes insipidus (n = 5), persistent cerebrospinal fluid rhinorrhea (n = 3), and meningitis (n = 1). Five patients had long-term endocrine sequelae of hyperprolactinemia requiring ongoing medical treatment.

CONCLUSIONS

Pituitary hemorrhage resulting in apoplexy or subclinical apoplexy in adolescents may represent a distinct entity with a more indolent symptomatology and more favorable neurologic and endocrine outcome compared with adults that is worthy of further validation in a multi-institutional cohort.

Spontaneous pineal apoplexy in a pineal parenchymal tumor of intermediate differentiation

Pineal apoplexy is a rare clinical presentation of pineal parenchymal tumors. We report the curative treatment of a case of pineal parenchymal tumor of intermediate differentiation with spontaneous apoplectic hemorrhage. This case is shown through computed tomography and magnetic resonance imaging of the brain, and is confirmed via histopathological studies. Recurrent upward gaze paresis was observed after the stereotactic biopsy. The paresis required an expeditious tumor resection. The mechanism of the pineal apoplectic hemorrhage remains unclear although it has been observed in different pineal region lesions. Clinical and radiological evidence of the cure 5 years post-surgery is available.

Posterior communicating artery aneurysm rupture mimicking apoplexy

Background:

Cerebral aneurysm rupture can lead to devastating neurological complications and present a complex problem to treat. We report a unique case of a ruptured posterior communicating artery (PCoA) aneurysm presenting with sudden and complete vision loss.

Case Description:

A 39-year-old man presented with the acute onset of severe headache and complete bilateral vision loss. The patient described headaches for several months prior to presentation. However, prior to the day of presentation, he had no visual disturbance. A CT angiogram (CTA) and magnetic resonance imaging (MRI) of the brain revealed a 1.6-cm, non-contrast enhancing suprasellar mass, eccentric to the left side, consistent with hemorrhagic mass. There was no obvious aneurysm or vascular malformation. The sella tursica was normal in appearance. The patient was taken for an immediate endoscopic endonasal transtuberculum approach for optic nerve decompression. Hematoma without an associated tumor was encountered and partially evacuated before aborting with resultant partial improvement in vision. A subsequent cerebral angiogram revealed an irregularly shaped, postero-laterally pointing, 2.5-mm left PCoA aneurysm. The patient was then taken for open clipping of the ruptured aneurysm. A large, fibrinous capsule was found over the superolateral aspect of the aneurysm. The ruptured aneurysm was secured with clips and the surrounding hematoma was evacuated.

Conclusion:

In the immediate postoperative period, the patient regained vision in the nasal field of his right eye. This case illustrates a unique presentation of a ruptured PCoA aneurysm, and thus must be considered in the differential diagnosis of a suprasellar hemorrhage resulting in visual loss in absence of a recognizable associated tumor.

Pituitary apoplexy

Pituitary apoplexy is rare endocrine emergency which can occur due to infarction or haemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. There is conflicting data regarding which type of pituitary adenoma is prone for apoplexy. Some studies showed predominance of non-functional adenomas while some other studies showed a higher prevalence in functioning adenomas amongst which prolactinoma have the highest risk. Although pituitary apoplexy can occur without any precipitating factor in most cases, there are some well recognizable risk factors such as hypertension, medications, major surgeries, coagulopathies either primary or following medications or infection, head injury, radiation or dynamic testing of the pituitary. Patients usually present with headache, vomiting, altered sensorium, visual defect and/or endocrine dysfunction. Hemodynamic instability may be result from adrenocorticotrophic hormone deficiency. Imaging with either CT scan or MRI should be performed in suspected cases. Intravenous fluid and hydrocortisone should be administered after collection of sample for baseline hormonal evaluation. Earlier studies used to advocate urgent decompression of the lesion but more recent studies favor conservative approach for most cases with surgery reserved for those with deteriorating level of consciousness or increasing visual defect. The visual and endocrine outcomes are almost similar with either surgery or conservative management. Once the acute phase is over, patient should be re-evaluated for hormonal deficiencies.

Cavernous malformation of the optic chiasm : case report

Cavernous malformations (CMs) arising from the optic nerve and chiasm are extremely rare. The authors present a case of 39-year-old woman with CMs of the optic chiasm. She was referred due to sudden onset of bitemporal hemianopsia and headache, the so-called 'chiasmal apoplexy'. MRI findings suggested a diagnosis of hemorrhage and vascular malformation of the optic chiasm. Pterional craniotomy revealed an intrachiasmatic cavernous malformation with hemorrhage. The malformation was totally excised, but field deficits remained unchanged after surgery.