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

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.

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Hyponatremia as the Initial Presentation of Evolving Pituitary Apoplexy

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1195 ◽

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.

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Presenting Symptoms of Pituitary Apoplexy

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0037-1599051 ◽

2017 ◽

Vol 79 (01) ◽

pp. 052-059 ◽

Cited By ~ 7

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.

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Hyponatremia with Rhabdomyolysis - Unusual Presentation of Pituitary Apoplexy

Journal of Medicine ◽

10.3329/jom.v20i1.38823 ◽

2019 ◽

Vol 20 (1) ◽

pp. 49-51

Author(s):

Peter George ◽

Neema Montadka Lingappa Gowda

Keyword(s):

Creatine Phosphokinase ◽

Pituitary Apoplexy ◽

Urine Osmolality ◽

Clinical History ◽

Blood Chemistry ◽

Cystic Mass ◽

Medical Emergency ◽

Severe Hyponatremia ◽

Sodium Correction ◽

Calf Pain

Hyponatremia is increasingly being identified among hospitalized patients. It significantly alters outcome either by itself or by inappropriate correction. We report a 29-year-old man, who presented to the out-patient services with headache of 1 week and projectile vomiting of 2 days. He also had cramps in calf since a day. Had no fever and had received intramuscular injection for calf pain. Clinical examination including fundoscopy were normal except for irritability and calf tenderness. Blood chemistry and haematology were normal, except for hyponatremia (110 m Eq/L) and elevated CPK (creatine phosphokinase). SIADH was considered as he was euvolemic with low serum osmolality and high urine osmolality. Further evaluation showed hypoadrenalism and hypothyroidism suggestive of hypopituitarism. Subsequent MRI of sella revealed a 1 cm3 cystic mass with features of haemorrhage. Pituitary apoplexy with hypopituitarism was definitive, considering the acute presentation. Supplementation of steroids and thyroxine along with sodium correction improved him symptomatically. Trans-sphenoidal resection of the sellar cystic lesion was performed. Often a good clinical history, assessment and judicious investigations can identify the cause for hyponatremia. Rhabdomyolysis is known to occur in severe hyponatremia and adrenal insufficiency as with the present case. In literature, there are reports of pituitary apoplexy presenting with rhabdomyolysis and hyponatremia. Pituitary apoplexy is a medical emergency which requires early identification, hormonal supplementation and supportive care for better outcome. J MEDICINE JUL 2019; 20 (1) : 49-51

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

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.165348 ◽

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.

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