scholarly journals Apoplexy of pituitary adenomas: the perfect storm

2015 ◽  
Vol 122 (6) ◽  
pp. 1444-1449 ◽  
Author(s):  
Edward H. Oldfield ◽  
Marsha J. Merrill
Keyword(s):  
Pituitary Adenomas ◽  
Insulin Infusion ◽  
Pituitary Apoplexy ◽  
Pituitary Tumors ◽  
Tissue Perfusion ◽  
Acute Ischemia ◽  
Metabolic Demand ◽  
Releasing Factors ◽  
Perfect Storm ◽  
High Metabolic Demand

OBJECT Pituitary adenomas occasionally undergo infarction, apoplexy, which often destroys much of the tumor. It is well known that apoplexy can be precipitated by several acute factors, including cardiac surgery, other types of surgery, trauma, insulin infusion, and stimulation with administration of hypothalamic releasing factors. METHODS The prior focus on mechanisms underlying pituitary apoplexy has been on these acute events. Less attention has been given to the endogenous features of pituitary tumors that make them susceptible to spontaneous infarction, despite that most pituitary apoplexy occurs in the absence of a recognized precipitating event. The authors examine intrinsic features of pituitary adenomas that render them vulnerable to apoplexy—features such as high metabolic demand, paucity of angiogenesis, and sparse vascularity, qualities that have previously not been linked with apoplexy—and argue that it is these features of adenomas that underlie their susceptibility to spontaneous infarction. The sensitivity of freshly cultured pituitary adenomas to hypoglycemia is assessed. RESULTS Adenomas have high metabolic demand, limited angiogenesis, and reduced vessel density compared with the normal gland. Pituitary adenoma cells do not survive in the presence of reduced or absent concentrations of glucose. CONCLUSIONS The authors propose that the frequent ischemic infarction of pituitary adenomas is the product of intrinsic features of these tumors. These endogenous qualities create a tenuous balance between high metabolic demand and marginal tissue perfusion. Thus, the tumor is vulnerable to spontaneous infarction or to acute ischemia by any event that acutely alters the balance between tumor perfusion and tumor metabolism, events such as acute systemic hypotension, abruptly decreased supply of nutrients, hypoglycemia with insulin administration, or increase in the tumor's metabolic demand due to administration of hypothalamic releasing factors. It may be possible to take advantage of these intrinsic features of pituitary adenomas by using aspects of this vulnerability for development of new approaches for treatment.

Complex effects of apoplexy secondary to pituitary adenoma

2017 ◽  
Vol 28 (1) ◽  
pp. 59-64 ◽  
Author(s):  
Rui-Cheng Zhang ◽  
Ying-Feng Mu ◽  
Jing Dong ◽  
Xiao-Qian Lin ◽  
De-Qin Geng
Keyword(s):  
Pituitary Adenoma ◽  
Case Reports ◽  
Spontaneous Remission ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Sudden Onset ◽  
Clinical Syndrome ◽  
Metabolic Demand ◽  
Releasing Factors ◽  
High Metabolic Demand

AbstractPituitary adenoma apoplexy is a well-known clinical syndrome induced by insulin infusion, cardiac surgery, trauma, and hypothalamic releasing factors. Pituitary apoplexy can cause secondary cerebral infarct and internal carotid artery occlusion. With blockade of tumor perfusion, apoplexy triggers a sudden onset of headache, visual impairment, cranial nerve palsy, disturbances of consciousness, eyelid ptosis, and hemiparesis. However, pituitary adenoma cells with high metabolic demand cannot survive with deficient blood supply and glucose concentrations. Moreover, a number of case reports have shown that spontaneous remission of syndromes, such as acromegaly, may be caused by pituitary adenoma after apoplexy. Therefore, understanding mechanism that underlies the balance between pituitary adenoma apoplexy and subsequent spontaneous remission of syndromes may suggest new approaches for treatment of pituitary adenoma apoplexy.

Ultrastructural Immunocytochemistry of Five Rat Pituitary Adenomas

1980 ◽  
Vol 38 ◽  
pp. 724-725
Author(s):  
D. J. McComb ◽  
N. Ryan ◽  
E. Horvath ◽  
K. Kovacs ◽  
E. Nagy ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Tumors ◽  
Electron Microscopic ◽  
Electron Microscopic Immunocytochemistry ◽  
Transmission Electron ◽  
Rat Pituitary ◽  
Radiation Induced ◽  
Group 5 ◽  
Group 2 ◽  
Microscopic Techniques

Conventional light and electron microscopic techniques failed to clarify the cellular composition and derivation of spontaneous and induced, intrasellar and transplanted pituitary adenomas in rats (1). In the present work, electron microscopic immunocytochemistry was applied to evaluate five adenohypo-physial tumors using a technique described by Moriarty and Garner (2). Spontaneously occurring pituitary adenomas (group 1) were harvested from aging female Long-Evans rats. R-Amsterdam rats were treated with 2 x 1.0 mg estrone acetate (HogivaI) s.c. weekly for 6 months. Pituitary adenomas in excess of 30 mg were removed from these animals to make up the tumors of group 2. Groups 3 and 4 consisted of estrogen-induced autonomous transplan¬ted pituitary tumors MtT.WlO and MtT.F4. Group 5 was a radiation-induced transplanted autonomous pituitary tumor MtT.W5. The tumors of groups 3,4 and 5 were allowed to proliferate in host rats 6-8 weeks prior to removal for processing. Tissue was processed for transmission electron microscopy (glutaraldehyde fixation, OsO4 postfixation and epoxy resin embedding), and electron microscopic immunocytochemistry (3% paraformaldehyde fixation and Araldite embedding).

Pituitary apoplexy in clinically nonfunctioning pituitary adenomas: experience of a single center

2013 ◽  
Author(s):  
Apostolos Karagiannis ◽  
Dimitrios Boufas ◽  
Konstantinos Tzioras ◽  
Andreas Seretis ◽  
Andromachi Vryonidou
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Apoplexy ◽  
Single Center ◽  
Nonfunctioning Pituitary Adenomas

Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

2021 ◽  
Author(s):  
John T. Butterfield ◽  
Takako Araki ◽  
Daniel Guillaume ◽  
Ramachandra Tummala ◽  
Emiro Caicedo-Granados ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Apoplexy ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Morbidity And Mortality ◽  
Surgical Approaches ◽  
Subtotal Resection ◽  
Advantages And Disadvantages ◽  
Cranial Nerve Palsies ◽  
Giant Pituitary Adenomas

Abstract Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined. Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy. Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared. Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions. Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

scholarly journals MR Detection of Cortical Spreading Depression Immediately after Focal Ischemia in the Rat

1996 ◽  
Vol 16 (2) ◽  
pp. 214-220 ◽  
Author(s):  
Joachim Röther ◽  
Alexander J. de Crespigny ◽  
Helen D'Arceuil ◽  
Michael E. Moseley
Keyword(s):  
Cortical Spreading Depression ◽  
Spreading Depression ◽  
Tissue Perfusion ◽  
Artery Occlusion ◽  
Acute Ischemia ◽  
Planar Imaging ◽  
Mr Perfusion Imaging ◽  
Before And After ◽  
Apparent Diffusion ◽  
Cortical Regions

The suture model for middle cerebral artery occlusion (MCAO) was used to induce acute ischemia in rats remotely within a magnetic resonance (MRI) scanner. Serial MR diffusion weighted imaging (DWI) was performed during remote MCAO using an echo planar imaging technique. MR perfusion imaging was performed before and after occlusion using the bolus tracking technique. Transient apparent diffusion coefficient (ADC) changes were detected in six of seven rats as early as 2.7 ± 1.5 min post MCAO. ADC values declined transiently to 70.1 ± 6.0% of control and recovered to 95.5 ± 6.8% of control within 3.3 ± 2.9 min. These ADC changes propagated bidirectionally away from the ischemic core with a speed of 3.0 ± 1.1 mm/min. Transient ADC decreases only occurred in ischemic areas characterized by moderately decreased tissue perfusion. Propagation toward cortical regions with severe tissue perfusion deficits was not detected. DWI can detect the earliest dynamic, reversible ADC changes in the ischemic tissue. The speed of propagation of the decreasing ADC wave, the waveform characteristics, and the occurrence in moderately perturbated tissue are compatible with cortical spreading depression.

MICROSURGICAL ANATOMY OF THE DIAPHRAGMA SELLAE AND ITS ROLE IN DIRECTING THE PATTERN OF GROWTH OF PITUITARY ADENOMAS

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 717-723 ◽  
Author(s):  
Alvaro Campero ◽  
Carolina Martins ◽  
Alexandre Yasuda ◽  
Albert L. Rhoton
Keyword(s):  
Pituitary Adenoma ◽  
Cavernous Sinus ◽  
Dura Mater ◽  
Pituitary Adenomas ◽  
Potential Role ◽  
Pituitary Tumors ◽  
Microsurgical Anatomy ◽  
Suprasellar Region ◽  
Lateral Distance ◽  
Diaphragma Sellae

Abstract OBJECTIVE To evaluate the anatomic aspects of the diaphragma sellae and its potential role in directing the growth of a pituitary adenoma. METHODS Twenty cadaveric heads were dissected and measurements were taken at the level of the diaphragma sellae. RESULTS The diaphragma sellae is composed of two layers of dura mater. There is a remarkable variation in the morphology of the diaphragm opening. The average anteroposterior distance of the opening was 7.26 mm (range, 3.4–10.7 mm) and the average lateral-to-lateral distance was 7.33 mm (range, 2.8–14.1 mm). CONCLUSION The variability in the diameter of the opening of the diaphragma sellae could explain the growth of pituitary tumors toward the cavernous sinus or toward the suprasellar region.

Hemorrhagic and nonhemorrhagic Rathke cleft cysts mimicking pituitary apoplexy

2008 ◽  
Vol 108 (1) ◽  
pp. 3-8 ◽  
Author(s):  
Mandy J. Binning ◽  
James K. Liu ◽  
John Gannon ◽  
Anne G. Osborn ◽  
William T. Couldwell
Keyword(s):  
Mr Imaging ◽  
Pituitary Tumor ◽  
Pituitary Apoplexy ◽  
Pituitary Tumors ◽  
Imaging Features ◽  
Mr Images ◽  
Acute Hemorrhage ◽  
Consistent Finding ◽  
Imaging Characteristics ◽  
Intracystic Hemorrhage

Object Rathke cleft cysts (RCCs) are infrequently symptomatic, and apoplexy is one of the most unusual presentations. Only a few cases of apoplexy associated with RCCs have been reported, and their clinical, imaging, surgical, and pathological features are poorly understood. In the cases that have been reported, intracystic hemorrhage has been a consistent finding. The authors report 6 cases of RCCs in which the presenting clinical and imaging features indicated pituitary apoplexy, both with and without intracystic hemorrhage. Methods The authors retrospectively reviewed charts and magnetic resonance (MR) imaging studies obtained in patients who underwent transsphenoidal surgery for RCC. Six patients were identified who presented with symptoms and MR imaging characteristics consistent with pituitary apoplexy but were found intraoperatively to have an RCC. All 6 patients presented with a sudden headache, 2 with visual loss, and 1 with diplopia. Review of the preoperative MR images demonstrated mixed signal intensities in the sellar masses suggestive of a hemorrhagic pituitary tumor. In all patients there was a presumed clinical diagnosis of pituitary tumor apoplexy and an imaging-documented diagnosis of hemorrhagic pituitary tumor. Results All 6 patients underwent transsphenoidal resection to treat the suspected pituitary apoplexy. Intraoperative and histopathological findings were consistent with the diagnosis of an RCC in all cases. Only 2 cases showed evidence of hemorrhage intraoperatively. In all cases, an intracystic nodule was found within the RCC at surgery, and this intracystic nodule was present on the initial MR imaging when retrospectively reviewed. The imaging characteristics of the intracystic nodules were similar to those of acute hemorrhage seen in cases of pituitary apoplexy. Conclusions The clinical and imaging features of RCCs appear similar to those of hemorrhagic pituitary tumors, making them often indistinguishable from pituitary apoplexy.

Protocol for the Examination of Specimens From Patients With Primary Pituitary Tumors

2011 ◽  
Vol 135 (5) ◽  
pp. 640-646 ◽  
Author(s):  
Vania Nosé ◽  
Shereen Ezzat ◽  
Eva Horvath ◽  
Kalman Kovacs ◽  
Edward R. Laws ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Tumors ◽  
Diagnosis And Classification ◽  
Pathology Reporting ◽  
Synoptic Approach ◽  
Clear Information

Abstract In an effort to improve the diagnosis of pituitary tumors, we propose a synoptic approach to pituitary pathology reporting that will provide clear information to endocrinologists, neurosurgeons, neuropathologists, and surgical pathologists to advance the diagnosis and classification of pituitary adenomas.

scholarly journals Endoscopic endonasal transsphenoidal approach for pituitary adenomas: technical aspects and report of casuistic

2010 ◽  
Vol 68 (4) ◽  
pp. 608-612 ◽  
Author(s):  
Américo Rubens Leite dos Santos ◽  
Roberto Monteiro Fonseca Neto ◽  
José Carlos Esteves Veiga ◽  
José Viana Jr ◽  
Nilza Maria Scaliassi ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Tumors ◽  
Hormonal Control ◽  
Subtotal Resection ◽  
Endoscopic Endonasal ◽  
Technical Aspects ◽  
Transphenoidal Approach ◽  
Acth Secreting ◽  
Csf Leaks

OBJECTIVE: Analyse technical aspects, effectiveness and morbidity of the endoscopic endonasal transphenoidal approach for pituitary adenomas. METHOD: From January 2005 to September 2008, 30 consecutive patients underwent endoscopic endonasal resection of pituitary adenomas with a follow up from 3 to 36 months. Their medical charts were retrospectively analysed. RESULTS: There were 18 women and 12 men, mean age 44 years (range 17-65 yr). Among the 30 patients, 23 had macroadenomas and 7 microadenomas. Twelve patients had non-functioning tumors, 9 had ACTH-secreting tumors, 8 had GH-secreting tumors and 1 prolactinoma. Complete resection and hormonal control was achieved in all microadenomas. Macroadenomas were completely removed in 6 patients, subtotal resection in 6 and partial resection in 11. Three patients had diabetes insipidus and 5 had CSF leaks treated with lumbar drainage. CONCLUSION: The endonasal endoscopic approach for pituitary tumors is effective and has low morbidity.

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