Presenting Symptoms of Pituitary Apoplexy

2017 ◽  
Vol 79 (01) ◽  
pp. 052-059 ◽  
Author(s):  
Ioannis Mavridis ◽  
Maria Meliou ◽  
Efstratios-Stylianos Pyrgelis
Keyword(s):  
Pituitary Apoplexy ◽  
Sella Turcica ◽  
Abrupt Onset ◽  
Sudden Onset ◽  
Clinical Syndrome ◽  
Medical Emergency ◽  
Sudden Expansion ◽  
Visual Field Defects ◽  
Imaging Method ◽  
Presenting Symptoms

AbstractThe classical term “pituitary apoplexy” (PA) describes a clinical syndrome usually characterized by abrupt onset of headache accompanied by neurologic and/or endocrinologic deterioration due to sudden expansion of a mass within the sella turcica as a result of hemorrhage or infarction within a pituitary tumor and adjacent pituitary gland. PA is a medical emergency and a difficult diagnosis to establish. Thus this article reviews the presenting symptoms of PA patients to help clinicians recognize or at least suspect this critical condition early on. PA commonly occurs in the setting of a preexisting adenoma, and several patients are unaware of its existence prior to the onset of apoplexy symptoms, which are mainly of a neurologic, ophthalmologic, and endocrinologic nature. Neurologic symptoms include sudden-onset severe headache and other symptoms of subarachnoid hemorrhage, symptoms from compression of the cavernous sinus contents, nausea/vomiting, impaired consciousness, and symptoms of meningeal irritation. Ophthalmologic symptoms include visual field defects, visual loss, diplopia, and ophthalmoplegia. Endocrinologic disturbances include pituitary adenoma symptoms, cortisol deficiency, panhypopituitarism, diabetes insipidus, and syndrome of inappropriate secretion of antidiuretic hormone. Magnetic resonance imaging is the imaging method of choice to aid the PA diagnosis. Its differential diagnoses include cerebrovascular accidents, infectious diseases, and other causes of endocrinologic imbalance. Transsphenoidal surgery is the treatment of choice, especially if there are associated visual abnormalities and ophthalmoplegia. Clinicians should be aware of the presenting symptoms because early diagnosis may reduce the morbidity and mortality of this neurosurgical emergency.

scholarly journals Postpartum pituitary apoplexy with isolated oculomotor nerve palsy: A rare medical emergency

2015 ◽  
Vol 06 (04) ◽  
pp. 598-600
Author(s):  
Sujeet Raina ◽  
Vaneet Jearth ◽  
Ashish Sharma ◽  
Rajesh Sharma ◽  
Kewal Mistry
Keyword(s):  
Nerve Palsy ◽  
Pituitary Apoplexy ◽  
Sella Turcica ◽  
Altered Mental Status ◽  
Sudden Onset ◽  
Clinical Syndrome ◽  
Medical Emergency ◽  
Oculomotor Nerve Palsy ◽  
Hormonal Dysfunction ◽  
Third Cranial Nerve Palsy

ABSTRACTPituitary apoplexy is a clinical syndrome characterized by sudden onset headache, visual deficits, ophthalmoplegia, altered mental status, and hormonal dysfunction due to an expanding mass within the sella turcica resulting from hemorrhage or infarction of pituitary gland. We report a case of pituitary apoplexy that developed in postpartum period following postpartum hemorrhage and presented with isolated third cranial nerve palsy.

scholarly journals Heparin-Induced Pituitary Apoplexy Presenting as Isolated Unilateral Oculomotor Nerve Palsy: A Case Report and Literature Review

2019 ◽  
Vol 2019 ◽  
pp. 1-5 ◽  
Author(s):  
Bakr Swaid ◽  
Frank Kalaba ◽  
Ghassan Bachuwa ◽  
Stephen E. Sullivan
Keyword(s):  
Nerve Palsy ◽  
Pituitary Apoplexy ◽  
Significant Coronary Artery Disease ◽  
Clinical Syndrome ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy ◽  
Visual Field Defects ◽  
Pituitary Mass ◽  
Atypical Chest Pain ◽  
Coronary Syndrome

Introduction. Pituitary apoplexy (PA) is a rare and potentially life-threatening clinical syndrome resulting from pituitary gland hemorrhage and/or infarction. Anticoagulation is a risk factor for triggering PA. Isolated oculomotor nerve palsy is an atypical presentation of PA. Case Presentation. A 65-year-old African American female with no past medical history of pituitary disease presented to the emergency department (ED) with nonspecific abdominal pain that was thought to be secondary to fecal stasis and subsequently improved with laxatives. She also reported atypical chest pain that was concerning for unstable angina. She was started on aspirin, clopidogrel, and intravenous (IV) heparin. Later, coronary catheterization showed no significant coronary artery disease (CAD). Twelve hours after the procedure, the patient developed acute complete left oculomotor nerve palsy with a severe headache. Magnetic resonance imaging (MRI) of the head showed a large pituitary mass. Pituitary apoplexy was suspected and the patient eventually underwent a successful trans-sphenoidal pituitary resection. Discussion. We report a case of PA manifesting as isolated left oculomotor nerve palsy without visual field defects in the setting of using dual antiplatelet therapy (DAPT) and IV heparin for acute coronary syndrome. To the best of our knowledge, this unique combination has not been previously reported.

scholarly journals Multidisciplinary Management of Pituitary Apoplexy

2016 ◽  
Vol 2016 ◽  
pp. 1-11 ◽  
Author(s):  
Adriana Albani ◽  
Francesco Ferraù ◽  
Filippo Flavio Angileri ◽  
Felice Esposito ◽  
Francesca Granata ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Pituitary Gland ◽  
Multidisciplinary Approach ◽  
Pituitary Apoplexy ◽  
Clinical Syndrome ◽  
Surgical Decompression ◽  
Medical Emergency ◽  
Multidisciplinary Management ◽  
Pituitary Tumours ◽  
Haemorrhagic Necrosis

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

Pituitary Tumor Apoplexy: Pathophysiology, Clinical Manifestations, and Management

1997 ◽  
Vol 12 (3) ◽  
pp. 123-134 ◽  
Author(s):  
Baha M. Arafah ◽  
Juan Ybarra ◽  
Robert W. Tarr ◽  
Zuhayr T. Madhun ◽  
Warren R. Selman
Keyword(s):  
Pituitary Tumor ◽  
Clinical Manifestations ◽  
Residual Tumor ◽  
Symptomatic Patient ◽  
Sudden Onset ◽  
Clinical Syndrome ◽  
Endocrine Function ◽  
Visual Field Defects ◽  
Pituitary Hormone ◽  
Pituitary Tumor Apoplexy

Pituitary tumor apoplexy represents a rare clinical syndrome caused by hemorrhagic infarction of an existing, often previously unrecognized, large adenoma. We present our approach and experience in the field, and we provide a summary of pertinent published literature addressing diagnosis, management, and pathophysiology of the clinical manifestations of pituitary tumor apoplexy. Although many precipitating factors are known, most episodes occur spontaneously and present clinically with relatively sudden onset of severe headache, visual field defects, and ophthalmoplegia. Either computed tomography (nonenhanced and enhanced) or magnetic resonance imaging in a symptomatic patient can define pertinent anatomical changes and aid in establishing diagnosis. Immediate treatment with corticosteroids is necessary. Patients with the mild form of the syndrome respond quickly to steroids and can be managed conservatively with continued glucocorticoid therapy. Most patients with persistent neural deficits require urgent transsphenoidal decompression. Unless surgery is delayed, results of transsphenoidal decompression are usually very good, and improvements in neurological symptoms and endocrine function are noted within hours to days of the procedure. Patients need to be closely followed up after the episode because a large number continue to have residual tumor requiring additional therapy, or they have pituitary hormone abnormalities that need treatment. Close interaction between neurosurgeons and endocrinologists in the management of patients with pituitary tumor apoplexy is essential for optimal outcome.

scholarly journals Hyponatremia as the Initial Presentation of Evolving Pituitary Apoplexy

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A586-A586
Author(s):  
Jovan Milosavljevic ◽  
Asha Mary Thomas
Keyword(s):  
Mental Status ◽  
Pituitary Apoplexy ◽  
Pituitary Tumors ◽  
Altered Mental Status ◽  
Clinical Syndrome ◽  
Medical Emergency ◽  
Fluid Restriction ◽  
Free T4 ◽  
Acute Hemorrhage ◽  
Initial Testing

Abstract Pituitary apoplexy (PA) is a known, often under-recognized medical emergency and is characterized by ischemic or hemorrhagic necrosis of the pituitary gland. It is a rare clinical syndrome that occurs in 2-12% of pituitary tumors. Hyponatremia can occur secondary to hypocortisolism (12-40%) or, rarely, to the syndrome inappropriate antidiuretic hormone (ADH) secretion. We present the case of a 69-year-old man who presented with altered mental status on post-operative day 3 from total knee replacement surgery. Initial testing revealed hyponatremia of 124 mmol/L, low serum osmolality of 266 mOsm/kg, and high urine osmolality of 664 mOsm/kg with urine sodium of 179 mmol/L. Head computerized tomography revealed a sellar mass of 1.8 x 2.4 cm. Initial testing revealed low prolactin (0.7 ng/mL), normal TSH (0.458 mcIU/mL) with borderline low free T4 of 0.72 ng/dL. Morning cortisol was 12.7 mcg/dL with ACTH of 8.5 pg/mL. Cosyntropin stimulation test was done revealing baseline cortisol of 5.8 mcg/dL (at midnight), increasing to 25.8 mcg/dL after 30 minutes and to 30.9 mcg/dL 60 minutes after cosyntropin administration. His sodium and mental status initially improved with fluid restriction and salt tablets, for the assumed syndrome of inappropriate ADH secretion. The patient remained hemodynamically stable. On the fourth day, however, his mental status deteriorated. Magnetic resonance imaging revealed expansion of sella with hyperintense mass 2.2 x 2.0 x 2.8 cm with compression of the optic chiasm. He was given stress dose hydrocortisone and levothyroxine and underwent emergency transsphenoidal resection. Biopsy revealed acute hemorrhage within infarcted adenoma. Postoperatively, both the patient’s sodium and mental status improved significantly and he was discharged to home on hydrocortisone and levothyroxine. The main clinical concern in the management of PA remains under-diagnosis at presentation. Prognosis is dependent on management during the acute phase. PA can present as hyponatremia even in the absence of overt hypocortisolism, presumably due to inappropriate ADH secretion. Therefore, PA should be considered as one of the differential diagnoses in hemodynamically stable patients with altered mental status and hyponatremia.

Pituitary Apoplexy with raised intracranial pressure

2020 ◽  
Vol 17 (1) ◽  
pp. 41-43
Author(s):  
Bibesh Pokhrel ◽  
Amit Thapa
Keyword(s):  
Pituitary Apoplexy ◽  
Histopathological Examination ◽  
Sudden Onset ◽  
Visual Field Defects ◽  
Good Recovery ◽  
Acute Hemorrhage ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Tumor Specimen ◽  
Adenomatous Tissue ◽  
Sellar Floor

Pituitary apoplexy in pre-existing pituitary adenomas occurs as a consequence of acute hemorrhage or infarction. Patients with pituitary apoplexy present with sudden onset headache, vomiting, clouding of consciousness and visual field defects or total oculomotor palsies without any prior diagnosis of pituitary tumor. In this case report, we report a case of 52 years female who presented to the emergency department with headache throughout her head and periorbital area with vomiting. Investigations revealed sellar cystic lesion suggestive of pituitary apoplexy with normal hormonal profile. She underwent endoscopic trans-nasal trans-sphenoidal surgery with complete resection of pituitary adenoma. Histopathological examination of tumor specimen showed large areas of necrosis with blood surrounded by the adenomatous tissue. Post-operatively she had cerebrospinal fluid rhinorrhea with persistent papilledema and hydrocephalus. Sellar floor repair along with theco-peritoneal shunt lead to good recovery.  

scholarly journals Spontaneous retroclival hematoma in pituitary apoplexy: case series

2015 ◽  
Vol 123 (3) ◽  
pp. 808-812 ◽  
Author(s):  
Avetis Azizyan ◽  
Joseph M. Miller ◽  
Ramzi I. Azzam ◽  
Marcel M. Maya ◽  
Pouyan Famini ◽  
...  
Keyword(s):  
Pituitary Apoplexy ◽  
Clinical Symptoms ◽  
Case Reports ◽  
Brain Mri ◽  
Cranial Nerves ◽  
Case Series ◽  
Visual Disturbance ◽  
Sudden Onset ◽  
Laboratory Findings ◽  
Presenting Symptoms

OBJECT Pituitary apoplexy is a rare and potentially life-threatening disorder that is most commonly characterized by a combination of sudden headache, visual disturbance, and hypothalamic/hormonal dysfunction. In many cases, there is hemorrhagic infarction of an underlying pituitary adenoma. The resulting clinical symptoms are due to compression of the remaining pituitary, cavernous sinuses, or cranial nerves. However, there are only 2 case reports in the literature describing spontaneous retroclival expansion of hemorrhage secondary to pituitary apoplexy. Ten cases of this entity with a review of the literature are presented here. METHODS This is a single-institution retrospective review of 2598 patients with sellar and parasellar masses during the 10-year period between 1999 and 2009. The pituitary and brain MRI and MRI studies were reviewed by 2 neuroradiologists for evidence of apoplexy, with particular attention given to retroclival extension. RESULTS Eighteen patients (13 men and 5 women; mean age 54 years) were identified with presenting symptoms of sudden onset of headache and ophthalmoplegia, and laboratory findings consistent with pituitary apoplexy. Ten of these patients (8 men and 2 women; mean age 55 years) had imaging findings consistent with retroclival hematoma. CONCLUSIONS Retroclival hemorrhage was seen in the majority of cases of pituitary apoplexy (56%), suggesting that it is more common than previously thought.

scholarly journals Acromegaly remission, SIADH and pituitary function recovery after macroadenoma apoplexy

2019 ◽  
Vol 2019 ◽  
Author(s):  
E Sanz-Sapera ◽  
S Sarria-Estrada ◽  
F Arikan ◽  
B Biagetti
Keyword(s):  
Pituitary Apoplexy ◽  
Hormone Secretion ◽  
Spontaneous Remission ◽  
Pituitary Tumour ◽  
Sudden Onset ◽  
Acute Onset ◽  
Clinical Syndrome ◽  
Pituitary Function ◽  
List Type ◽  
The Right

Summary Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterised by ischaemic infarction or haemorrhage into a pituitary tumour that can lead to spontaneous remission of hormonal hypersecretion. We report the case of a 50-year-old man who attended the emergency department for sudden onset of headache. A computed tomography (CT) scan at admission revealed pituitary haemorrhage and the blood test confirmed the clinical suspicion of acromegaly and an associated hypopituitarism. The T1-weighted magnetic resonance imaging (MRI) showed the classic pituitary ring sign on the right side of the pituitary. Following admission, he developed acute-onset hyponatraemia that required hypertonic saline administration, improving progressively. Surprisingly, during the follow-up, IGF1 levels became normal and he progressively recovered pituitary function. Learning points: Patients with pituitary apoplexy may have spontaneous remission of hormonal hypersecretion. If it is not an emergency, we should delay a decision to undertake surgery following apoplexy and re-evaluate hormone secretion. Hyponatraemia is an acute sign of hypocortisolism in pituitary apoplexy. However, SIADH although uncommon, could appear later as a consequence of direct hypothalamic insult and requires active and individualised treatment. For this reason, closely monitoring sodium at the beginning of the episode and throughout the first week is advisable to guard against SIADH. Despite being less frequent, if pituitary apoplexy is limited to the tumour, the patient can recover pituitary function previously damaged by the undiagnosed macroadenoma.

scholarly journals Agyalapimirigy-apoplexia.

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.

A case of pituitary apoplexy. a acute medical emergency and restitutio ad integrum

2017 ◽  
Author(s):  
Pilar Rodriguez ◽  
Maria Lainez ◽  
Maria Jose Lopez ◽  
Eloisa Roldan ◽  
Isabel Rebollo
Keyword(s):  
Pituitary Apoplexy ◽  
Medical Emergency ◽  
Restitutio Ad Integrum
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