Pituitary Adenoma with Apoplexy with Arteriovenous Malformation

Background This is a rare association of pituitary adenoma with apoplexy with arteriovenous malformation as only single case was reported prior to this case as per our knowledge. Case Description A 25-year-old man presented with chief complaints of headache of sudden onset, severe in intensity with sudden loss of vision. Imaging shows pituitary adenoma with apoplexy with right parietal arteriovenous malformation. The patient was managed with embolization for parietal arteriovenous malformation and medically for pituitary adenoma with apoplexy. Conclusion Pituitary apoplexy can be treated conservatively if no features of mass effect present. Follow-up of the patient must be done regularly to look for the size of pituitary adenoma and recurrence of arteriovenous malformation.

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Rapid Pituitary Apoplexy Regression: What Is the Time Course of Clot Resolution?

Case Reports in Radiology ◽

10.1155/2015/268974 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 2

Author(s):

Devon L. Jackson ◽

Jamie J. Van Gompel

Keyword(s):

Time Course ◽

Spontaneous Regression ◽

Pituitary Apoplexy ◽

Mass Effect ◽

Sudden Onset ◽

Pituitary Mass ◽

Initial Event ◽

Original Size ◽

Visual Complaints

A 29-year-old male patient with a functioning pituitary macroadenoma is discussed. The pituitary mass was detected by MRI after the patient presented with sudden onset of headache, suggestive of an apoplectic event. The headache resolved with analgesic medications. Within a follow-up period of one week, the pituitary mass had spontaneously regressed to nearly half its original size without any therapy. The patient never reported any visual complaints and displayed no signs of hypopituitarism. Elevated prolactin levels were present. Seven weeks after the initial event, the pituitary mass showed continued regression on MRI. Prolactin levels remained elevated. This case provides a unique look at the rapid spontaneous regression of mass effect that may occur following apoplexy of a pituitary adenoma.

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Pituitary apoplexy causing acute ischemic stroke: Which treatment should be given priority

Surgical Neurology International ◽

10.25259/sni_82_2020 ◽

2020 ◽

Vol 11 ◽

pp. 113 ◽

Cited By ~ 1

Author(s):

Jae-Min Ahn ◽

Hyuk-Jin Oh ◽

Jae-Sang Oh ◽

Seok-Mann Yoon

Keyword(s):

Pituitary Adenoma ◽

Cerebral Ischemia ◽

Pituitary Apoplexy ◽

Rare Complication ◽

Sudden Onset ◽

Pituitary Macroadenoma ◽

Conventional Angiography ◽

Pituitary Dysfunction ◽

Acute Cerebral Ischemia

Background: Pituitary apoplexy is syndrome of sudden onset of headache, visual loss, pituitary dysfunction, and altered consciousness. Pituitary apoplexy followed by acute cerebral ischemia is extremely rare. Here, we introduced the case of successful surgical resection of pituitary adenoma which induced acute cerebral ischemia. Case Description: A 78-year-old man with a known pituitary macroadenoma presented with decreased consciousness and left hemiparesis. Magnetic resonance image (MRI) and computed tomography (CT) showed large pituitary macroadenoma with hemorrhage and diffusion-perfusion mismatch of right internal carotid artery (ICA) territory. Conventional angiography was done and severe stenosis of bilateral ICA and prominent flow delay of left ICA were noted at paraclinoid segment. Microscopic tumor mass removal with transsphenoidal approach was performed. Final pathological diagnosis was pituitary adenoma with apoplexy. Immediately after surgery, his symptoms were disappeared. Follow-up image studies revealed much improved perfusion in right ICA territory and patency of bilateral ICAs. Conclusion: Direct compression of ICA is rare complication of pituitary apoplexy, which caused cerebral ischemia. Conventional angiography should be necessary for accurate diagnosis and prompt surgical decompression should be the treatment of choice.

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Pituitary apoplexy following endoscopic nasal surgery: A case report

SAGE Open Medical Case Reports ◽

10.1177/2050313x19855867 ◽

2019 ◽

Vol 7 ◽

pp. 2050313X1985586

Author(s):

Teemu Harju ◽

Juha Alanko ◽

Jura Numminen

Keyword(s):

Pituitary Adenoma ◽

Pituitary Apoplexy ◽

Sudden Onset ◽

Pituitary Macroadenoma ◽

Nasal Surgery ◽

Resonance Imaging ◽

Acute Haemorrhage ◽

Endoscopic Nasal Surgery ◽

Precipitating Factor ◽

Field Defects

Pituitary apoplexy develops as a consequence of acute haemorrhage and/or infarction in a pre-existing pituitary adenoma. Typical symptoms include sudden onset headache, visual acuity/field defects, and ocular palsies. We report a male patient with a known pituitary macroadenoma who underwent a right-sided endoscopic nasal surgery. Preoperatively, thickening of sphenoid mucosa was seen in computed tomography and magnetic resonance imaging. The patient developed pituitary apoplexy postoperatively. The presented report indicates that in patients with a pituitary adenoma, nasal surgery – like any other kind of surgery – is a possible precipitating factor for pituitary apoplexy. Isolated thickening of sphenoid mucosa is associated with pituitary apoplexy. It may also precede an apoplectic event.

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Pituitary Apoplexy: A Rare Cause of Cerebral Infarction

The Neuroradiology Journal ◽

10.1177/197140090802100509 ◽

2008 ◽

Vol 21 (5) ◽

pp. 661-665 ◽

Cited By ~ 6

Author(s):

A. Ben-Nakhi ◽

T.J.E. Muttikkal ◽

V.N.K. Chavan ◽

A. Yt Al-Turkomani ◽

R. Gupta

Keyword(s):

Pituitary Adenoma ◽

Cerebral Ischemia ◽

Sudden Death ◽

Cerebral Infarction ◽

Pituitary Apoplexy ◽

Clinical Presentation ◽

Mass Effect ◽

Mechanical Obstruction ◽

Hemorrhagic Infarction

Pituitary apoplexy is usually the result of hemorrhagic infarction in pituitary adenoma. The clinical presentation of pituitary apoplexy varies widely and includes asymptomatic hemorrhage, classical pituitary apoplexy and even sudden death. Few cases of cerebral infarction associated with pituitary apoplexy have been reported in the literature. Pituitary apoplexy can cause narrowing of intracranial vessels by mechanical obstruction due to mass effect or by vasospasm resulting in cerebral ischemia. We report a case of pituitary apoplexy associated with cerebral infarction and the putative mechanisms.

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Clinical versus Subclinical Pituitary Apoplexy: Presentation, Surgical Management, and Outcome in 21 Patients

Neurosurgery ◽

10.1227/00006123-199006000-00010 ◽

1990 ◽

Vol 26 (6) ◽

pp. 980-986 ◽

Cited By ~ 116

Author(s):

Stephen T. Onesti ◽

Thomas Wisniewski ◽

Kalmon D. Post

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Pituitary Apoplexy ◽

Clinical Signs ◽

Sudden Onset ◽

Resonance Imaging ◽

Duration Of Symptoms ◽

Computed Tomographic ◽

Sellar Tumor

Abstract A retrospective review of 16 consecutive patients with pituitary apoplexy treated over a 10-year period is reported. Eight men and 8 women (mean age, 48 years) underwent transsphenoidal decompression after an average duration of symptoms of 19 days. The diagnosis of pituitary apoplexy was made by the sudden onset of headache (88%), nausea (56%), or meningismus (13%), with or without visual disturbances (75%), in the setting of a sellar tumor on computed tomographic or magnetic resonance imaging scans. Thirteen of 16 patients showed significant improvement of symptoms after surgery (average follow-up, 2.5 years). In addition, 5 patients with clinically silent yet extensive pituitary hemorrhage were treated. Although extensive pituitary hemorrhage often produced fulminant apoplexy, it also presented insidiously over many days with few, if any, clinical signs. Rapid diagnosis, endocrine replacement, and transsphenoidal decompression constituted effective therapy. Magnetic resonance imaging (after at least 12 hours of symptoms) was superior to computed tomography in detecting hemorrhage.

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Pituitary Apoplexy in the Setting of Oral Anticoagulation Therapy With Apixaban

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1220 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A598-A599

Author(s):

Yadiel Rivera-Nieves ◽

Janet Marie Colon Castellano ◽

Nicolle Canales ◽

Alberto Javier Grana Santini ◽

Nicole Hernández Cordero ◽

...

Keyword(s):

Pituitary Adenoma ◽

Pituitary Gland ◽

Pituitary Apoplexy ◽

Case Reports ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Factor Xa ◽

High Dose ◽

Increased Risk

Abstract Background: Several medical conditions require chronic anticoagulation, but there are potential long-term complications, including intracranial hemorrhages. Pituitary apoplexy (PA), caused by infarction or bleeding into the pituitary gland, is a rare condition that commonly occurs in the setting of a pituitary adenoma. However, several reports have shown an increased risk of PA associated with anticoagulation therapy. Recent case reports have shown that even the newer oral anticoagulants may increase the risk of PA. Typically patients present with an acute headache, visual disturbances and pituitary hormonal deficiencies. Management is controversial and includes either a conservative medical treatment versus a more aggressive surgical approach. We present a case of a PA induced by Apixaban, an orally active factor Xa inhibitor. Clinical Case: This is the case of a 45 years-old male patient with prior medical history of hyperthyroidism treated with radioiodine ablation, systolic heart failure and atrial fibrillation, receiving Apixaban for stroke risk reduction. The patient presented initially to the ER after developing an acute, pulsatile frontal headache, associated with nausea and vomiting. He was treated for a suspected acute gastroenteritis and was discharged home. Two days later the patient returned to the ER, with persistent headaches unresponsive to oral analgesics. This time, the patient also complained of decreased energy, difficulty concentrating, and memory problems. He denied visual changes, galactorrhea, decreased libido or polyuria. Vital signs were unremarkable and there was no orthostatic hypotension. Physical examination showed a male in mild distress due to pain. There were no visual field defects on confrontation, no neurological deficits, and an intact mental status. Brain imaging showed hemorrhage within the pituitary gland with associated edema, compatible with PA. There was no obvious evidence of a pre-existing pituitary adenoma. Laboratory workup did not reveal any hormonal deficiencies. The patient was managed conservatively with close neurological follow up and empiric high dose dexamethasone. Headaches improved significantly after treatment and eventually resolved. After clinical improvement, the patient was discharged home on physiologic replacement of glucocorticoids with outpatient follow up and plans for re-evaluation of hormonal axis. Conclusion: Oral anticoagulants can increase the risk of PA, even in the absence of a pre-existing pituitary adenoma, as other case reports have shown. Management is controversial, and although there are agents for reversal of Apixaban effects (recombinant factor Xa), their use in PA has not been described. This case was managed conservatively with excellent results. Although we cannot exclude a pre-existing pituitary adenoma in this patient, this case shows that Apixaban increases the risk of PA.

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Management and outcomes of pituitary apoplexy

Journal of Neurosurgery ◽

10.3171/2014.10.jns141204 ◽

2015 ◽

Vol 122 (6) ◽

pp. 1450-1457 ◽

Cited By ~ 31

Author(s):

Tarun D. Singh ◽

Navid Valizadeh ◽

Fredric B. Meyer ◽

John L. D. Atkinson ◽

Dana Erickson ◽

...

Keyword(s):

Pituitary Adenoma ◽

Functional Outcomes ◽

Pituitary Apoplexy ◽

Histopathological Examination ◽

Visual Fields ◽

Visual Field Defects ◽

Ocular Motility ◽

Cranial Nerve Palsies

OBJECT This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes. METHODS The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale). RESULTS Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15–91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3–10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups. CONCLUSIONS The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.

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Lenticulostriate Artery Aneurysm Associated with Cerebral Arteriovenous Malformation: Report of Rare Association and Its Endovascular Management

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0037-1601450 ◽

2017 ◽

Vol 01 (02) ◽

pp. 114-116

Author(s):

Santhosh Kannath ◽

Jayadevan Rajan

Keyword(s):

Arteriovenous Malformation ◽

Single Case ◽

Case Reports ◽

Case Series ◽

Artery Aneurysm ◽

Endovascular Embolization ◽

Endovascular Management ◽

Rare Association ◽

Lenticulostriate Artery ◽

Targeted Approach

AbstractAneurysms involving the lenticulostriate arteries are rare and are described in the literature in small case series or single-case reports. In this report, we discuss a case of a young woman who presented with acute lateral ventricular bleed and was found to have an arteriovenous malformation within the corona radiata and an aneurysm involving the distal lenticulostriate artery. The aneurysm was treated successfully by endovascular embolization. In deep-seated arteriovenous malformations (AVMs) that are conventionally treated by stereotactic radiosurgery, a targeted approach for treatment of an associated aneurysm could be considered to reduce the risk of rebleed until the AVM is obliterated.

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Agyalapimirigy-apoplexia.

Orvosi Hetilap ◽

10.1556/650.2021.32209 ◽

2021 ◽

Vol 162 (38) ◽

pp. 1520-1525

Author(s):

László Sipos ◽

Nikolette Szücs ◽

Péter Várallyay

Keyword(s):

Pituitary Adenoma ◽

Retrospective Studies ◽

Pituitary Apoplexy ◽

Sudden Onset ◽

Clinical Syndrome ◽

Resonance Imaging ◽

Altered Consciousness ◽

Wait And See ◽

Neurosurgical Intervention ◽

Visual Disturbances

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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Ten-Year Follow-Up of Collision Tumors Composed of Craniopharyngioma and Pituitary Adenoma: A Case Report and Literature Review

Case Reports in Medicine ◽

10.1155/2019/8080163 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Takeshi Miyazaki ◽

Kentaro Kowari ◽

Hirotake Eda ◽

Mizuki Kambara ◽

Riruke Maruyama ◽

...

Keyword(s):

Pituitary Adenoma ◽

Gamma Knife ◽

Residual Tumor ◽

Mass Effect ◽

Gamma Knife Surgery ◽

Biological Behavior ◽

Suprasellar Cyst ◽

Collision Tumors ◽

Consciousness Disturbance

Although craniopharyngioma (CP) and pituitary adenoma (PA) are common tumors of the parasellar lesions, the coexistence of CP and PA is very rare. A 48-year-old male visited our hospital because of consciousness disturbance. The neuroimaging revealed a sellar tumor contact with a massive suprasellar cyst including calcification. Preoperative diagnosis was CP, and the patient underwent craniotomy to resolve the suprasellar mass effect. The histological examination disclosed adamantinomatous CP, and subsequently a transsphenoidal approach was chosen for the residual intrasellar tumor. Against expectations, the histological diagnosis was not CP but PA. The patient underwent gamma knife surgery for the residual tumor, and the postoperative course was good. After a 10-year follow-up, both lesions were still completely controlled. If we had suspected and diagnosed the tumor involved as not only CP but also PA at the first operation, the second operation could have been avoided because we would have chosen gamma knife surgery for the residual tumor. We should draw attention to this rare situation for differential diagnosis of parasellar tumor to avoid unnecessary surgery and to decide the best strategy for treatment. In addition, the biological behavior of collision tumors composed of CP and PA is probably the same as solitary CP or PA based on a long-term follow-up of our case.

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