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

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

Case Reports in Endocrinology ◽

10.1155/2019/5043925 ◽

2019 ◽

Vol 2019 ◽

pp. 1-5 ◽

Cited By ~ 1

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.

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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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Delayed Onset of Isolated Unilateral Oculomotor Nerve Palsy Caused by Post-Traumatic Pituitary Apoplexy: A Case Report

Clinical Medicine Insights Case Reports ◽

10.1177/1179547617731299 ◽

2017 ◽

Vol 10 ◽

pp. 117954761773129 ◽

Cited By ~ 1

Author(s):

Tomoki Ishigaki ◽

Yotaro Kitano ◽

Hirofumi Nishikawa ◽

Genshin Mouri ◽

Shigetoshi Shimizu ◽

...

Keyword(s):

Nerve Palsy ◽

Unusual Case ◽

Pituitary Apoplexy ◽

Sudden Onset ◽

Severe Headache ◽

Oculomotor Nerve ◽

Oculomotor Nerve Palsy ◽

Mass Reduction ◽

Cerebral Contusion ◽

Post Traumatic

Post-traumatic pituitary apoplexy is uncommon, most of which present with a sudden onset of severe headache and visual impairments associated with a dumbbell-shaped pituitary tumor. We experienced an unusual case of post-traumatic pituitary apoplexy with atypical clinical features. A 66-year-old man presented with mild cerebral contusion and an incidentally diagnosed intrasellar tumor after a fall accident with no loss of consciousness. The patients denied any symptoms before the accident. After 4 days, the left oculomotor nerve palsy developed and deteriorated associated with no severe headache. Repeated neuroimages suggested that pituitary apoplexy had occurred at admission and showed that the tumor compressed the left cavernous sinus. The patient underwent endonasal transsphenoidal surgery at 6 days after head injury, and the mass reduction improved the oculomotor nerve palsy completely within the following 14 days. The pathologic diagnosis was nonfunctioning pituitary adenoma with hemorrhage and necrosis.

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Pituitary Apoplexy Presenting as Isolated Oculomotor Nerve Palsy

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2007.41.4.246 ◽

2007 ◽

Vol 41 (4) ◽

pp. 246

Author(s):

Moon Seok Yang ◽

Won Ho Cho ◽

Seung Heon Cha

Keyword(s):

Nerve Palsy ◽

Pituitary Apoplexy ◽

Oculomotor Nerve ◽

Oculomotor Nerve Palsy

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T cell acute lymphoblastic leukaemia presenting with sudden onset right oculomotor nerve palsy with normal neuroradiography and cerebrospinal fluid studies

BMJ Case Reports ◽

10.1136/bcr.01.2012.5685 ◽

2012 ◽

Vol 2012 (mar26 1) ◽

pp. bcr0120125685-bcr0120125685

Author(s):

V. R. Bhatt ◽

M. Naqi ◽

R. Bartaula ◽

S. Murukutla ◽

S. Misra ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

T Cell ◽

Acute Lymphoblastic Leukaemia ◽

Lymphoblastic Leukaemia ◽

Nerve Palsy ◽

Sudden Onset ◽

Oculomotor Nerve ◽

Oculomotor Nerve Palsy

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Pituitary Apoplexy Causing Compression of Third Cranial Nerve—Management

Indian Journal of Neurosurgery ◽

10.1055/s-0039-1694849 ◽

2019 ◽

Vol 08 (02) ◽

pp. 119-122

Author(s):

Václav Masopust

Keyword(s):

Cavernous Sinus ◽

Nerve Palsy ◽

Clinical Symptoms ◽

Rapid Development ◽

Sella Turcica ◽

Oculomotor Nerve ◽

Oculomotor Nerve Palsy ◽

Future Research ◽

Third Nerve Palsy ◽

Increased Pressure

AbstractLesions of the oculomotor nerve as the first sign of pituitary adenoma are rare. The cause of such lesions without other clinical symptoms is discussed in this study. A small cohort of 4 patients (3.1%) with oculomotor nerve palsy (third nerve palsy) as the only neurologic deficit, from 129 patients who got operated upon for pituitary adenomas, is presented. In this group (mean age: 55 years, range: 36–65 years), all patients (two women and two men) underwent surgery. In two cases, there was arrested pneumatization and thickened bone. In the remaining two cases, a macroscopically visible, very solid opaque diaphragm was present, after the removal of the tumor and thickened bone. Complete adjustment was observed in all patients within 1 week after the surgery. Two factors that seem to increase the high risk for the development of oculomotor nerve palsy are that the cavernous sinus may be the only weak structure surrounding the sella turcica when the diaphragm and bone are thickened; and the rapid development of increased pressure in this region. The increased pressure on the cavernous sinus during the anatomical variations is the primary cause for lesions on the oculomotor nerve. However, this conjecture cannot be statistically demonstrated because of the small number of cases. Future research should be conducted on larger samples to increase statistical inference and generalizability.

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