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We report a patient with pituitary apoplexy in whom cerebral infarction developed, possibly secondary to vasospasm. Pituitary apoplexy is a clinical syndrome caused by acute hemorrhage or infarction of the pituitary gland. Our patient's clinical symptoms and radiographic findings greatly improved after surgical resection of the apoplectic pituitary...
Contexts in source publication
Context 1
... 35 patients with cerebral infarction associated with PA were identified. The main clinical features of the 36 patients, including the present study, are summarized in Supplementary Table 1. The average age was 45.2 years (range: 6-81). ...
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... symptoms included amenorrhea, sterility, photophobia, ptosis, change in appearance, mental confusion, and memory deficit. The precipitating factors for PA were identified in eight patients and included angiography, head trauma, pituitary surgery, endocrine stimulation tests, high fever, and anticoagulant therapy (22%; Table 1). ...
Context 3
... most common symptoms of PA were decreased conscious- ness (97%), signs of intracranial hypertension such as acute severe headache or vomiting (86%), motor deficit (75%), visual disturbance such as decreased visual acuity and visual field defect (72%), oph- thalmoplegia due to palsy of III, IV, or VI cranial nerves (44%), and meningismus (44%; Table 1). ...
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... infarction was confirmed by CT scans and/or MRI in 26 of 36 patients (72%), by DSA in eight (22%), and by autopsy in two (6%; Supp. Table 1). Intracranial vessel compression was visualized in 20 patients (56%), cerebral vasospasm in eight (22%), and subarachnoid hemorrhage (SAH) in five (14%). ...
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... computed tomography angiography (CTA), MRA, angiography, or autopsy, ICA compromise was demonstrated in 20 patients (56%), ACA involvement in 14 (39%), and MCA involve- ment in 11 (31%; Supp. Table 1). ...
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... patients (11%) had severe neurological deficits and 11 (30%) died (Supp. Table 1). Eleven patients (31%) were treated conservatively while the remaining 25 (69%) under- went pituitary surgery during the disease course. ...
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... infarction following PA is rare, with only 36 patients reported in the English language literature to date (Supp. Table 1). Only a few patients (8%) had a known history of pituitary adenoma. ...
Context 8
... a few patients (8%) had a known history of pituitary adenoma. Some precipitating factors such as angiography, head trauma, and pituitary surgery were identified in 22% of patients (Table 1). ...
Context 9
... most common symptoms of PA-related stroke were altered consciousness (97%), signs of intracranial hypertension, (86%), motor weakness (75%), and visual disturbance (72%; Table 1). The most common clinical manifestations of PA, unrelated to cere- bral infarct, are sudden severe headaches accompanied by nausea and vomiting (up to 100%), putatively caused by an increase in intrasellar pressure secondary to the rapidly expanding pituitary tumor. ...
Context 10
... cavernous or supra-clinoid portion of the ICA is usually affected, whereas, com- pression of the MCA and ACA are less common (Supp. Table 1). In most patients, only unilateral intracranial vessels are compressed, however, bilateral ICA compromise was documented in five [3,4,12,17,19]. ...
Context 11
... review showed that 89% (8/9) of the patients with visual field defects and 63% (10/16) with multiple cranial nerve palsies, 69% (22/32) with decreased consciousness on presentation, 70% (7/10) who were comatose, and 83% (10/12) who had deteriorating levels of con- sciousness after presentation underwent surgery (Supp. Table 1). These findings indicated that the management of patients with PA related to cerebral infarct was in accordance with the UK guidelines [1]. ...
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Citations
... Other common symptoms include nausea and vomiting, either with a neurological or endocrine component (acute secondary adrenal insufficiency) [25,29,30,33,174,176,217]. As mentioned, altered consciousness of various degrees up to coma was identified in 24 papers [56,64,70,79,93,97,100,103,111,112,114,122,123,141,151,169,174,177,189,209,210,215,216,218]. Weakness as a distinct clinical element was specified in five clinical cases (as a neurologic or endocrine consequence) [73,147,188,202,217]. ...
... PA-associated visual disturbances include decreased visual acuity in most cases [11,25,[31][32][33]37,57,70,75,80,93,[96][97][98]101,102,105,110,113,120,121,128,135,146,168,177,187,190,196]. Complete blindness was reported in two papers [199,212]. ...
... In terms of the PitNET stain profile (regardless clinical expression) non-functional type was followed by somatotroph PitNETs [32,38,42,46,53,56,66,76,78,86,92,93,98,100,108,109,121,128,136,141,148,152,156,166,168,169,171,175,192,217], lactotroph PitNETs [66,75,77,90,98,100,113,121,126,128,141,166,168,169,174,175,183,202,206], gonadotroph PitNETs [71,72,77,88,91,98,99,101,105,113,114,128,179,185,187,203,221], corticotroph PitNET [31,33,92,98,100,103,118,121,128,137,144,154,155,168,174,184,186,208,220], lactosomatotroph [32,100,109], and thyrotroph PitNETs [61,92,100,105]. Other pathologic features of pituitary masses complicated with PA include: Crooke cell adenoma [130,161], tumor with switching phenotypes [143], malignant spindle and round-cell tumor [91], Rathke's cyst [70,194], primitive neuroectodermal tumor [70], craniopharyngioma [70], and pituitary metastasis from squamous cell carcinoma [35], melanoma [55], lung and bronchogenic carcinoma [70,73], respectively, and breast carcinoma [62,187]. ...
Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.
... e incidence varies from 2% to 10% of all pituitary adenomas/pituitary neuroendocrinological tumor (PITNET). [3,12,17,19] e main risk factors are large adenomas, hypertension, high intracranial pressure, head injury, cavernous sinus invasion, dopamine agonists, use of an anticoagulant drug, radiotherapy, and hormonal stimulation. [8] Despite the better conditions of diagnosis and treatment, the morbidity and mortality keep with high indices like 15.3%. ...
... Neurosurgical treatment is necessary and emergencies. [1,2,8,15,16,19] Ischemic infarction related to PA is uncommon in the literature. Few cases were reported, the first manuscript was published in 1952 with a 62-year-old man who presented the left hemiparesis because of the direct compression of the right middle cerebral artery (MCA). ...
Background
Pituitary apoplexy (PA) is a syndromic condition described in 1950. The main symptoms are headache, visual impairment, ophthalmoplegia, and hypopituitarism. The relationship between stroke and PA is uncommon and two mechanisms are described: vascular compression and vasospasm.
Case Report
A 65-old-year man presented with severe headache, vomiting, ophthalmoplegia, and somnolence. Radiological examinations showed an expansive sellar and suprasellar lesion with a heterogeneous signal, besides Diffusion-weighted imaging (DWI) restriction in the bifrontal area was present. The findings were compatible with PA and stroke.
Conclusion
PA leading to cerebral infarction is a rare condition that presents high morbidity and mortality levels. There are two main mechanisms related: direct arterial compression and arterial vasospasm. The cases must be conducted as neuroendocrinological emergencies and surgical management is a key point to better the prognosis of patients.
... Pituitary apoplexy is an uncommon clinical syndrome in patients with pituitary adenomas. It has a quoted incidence of 0.6-9% in the existing literature [1,2]. Its aetiology is either haemorrhage or infarction within the adenoma. ...
... Its aetiology is either haemorrhage or infarction within the adenoma. Patients can present with varying signs and symptoms, most commonly including headaches, nausea, diminished visual acuity, temporal visual field cut, ophthalmoparesis and impaired mental status [1][2][3][4][5]. Risk factors for PA includes bromocriptine withdrawl or initiation, head trauma, intracranial hypertension, hormone stimulation of the gland (for example during pregnancy), large tumor, cavernous sinus invasion and anticoagulation [4,5]. ...
... Pituitary apoplexy is a neurological emergency caused by hemorrhage and/or infarction of the pituitary gland usually occurring in the pre-existing adenoma. 1 Pituitary apoplexy is rare, incidence being two to seven percent; pituitary apoplexy causing cerebral infarction is even rarer with high morbidity and mortality. [2][3][4] Only a few cases of pituitary apoplexy complicated with cerebral infarction are reported. 2 We report a patient with undiagnosed pituitary adenoma who presented with pituitary apoplexy complicated with cerebral infarction. ...
... [2][3][4] Only a few cases of pituitary apoplexy complicated with cerebral infarction are reported. 2 We report a patient with undiagnosed pituitary adenoma who presented with pituitary apoplexy complicated with cerebral infarction. Emergency transcranial excision of the tumor led to marked neurological improvement. ...
... 4,5,10 Cerebral infarction is thought to be caused by mechanical compression of the intracranial vessels, or cerebral vasospasm, or both, with studies showing vessel compression to be the more common mechanism. 2,11,12 Vasospasm may be induced by subarachnoid hemorrhage, the release of vasoactive substances from the adenoma, or the release of spasmogenic factors from hypothalamic damage. 11 In patients with pituitary apoplexy, the rapid expansion of intrasellar contents can markedly raise intrasellar pressure. ...
Cerebral infarction is a rare complication of pituitary apoplexy, which can result in significant morbidity if not treated on time. Pituitary apoplexy mostly occurs in pre-existing adenoma, which can remain undiagnosed until symptoms arise. Here, we present a case of a 26-year-old man with undiagnosed acromegaly who presented with left retro-orbital pain, diminished vision of the left eye, and right hemiparesis. Neuroimaging revealed large hemorrhagic sellar mass and ischemic infarction in the left middle cerebral artery territory. Emergency transcranial tumor excision was done, which resulted in significant neurological recovery.
... While cases also complicated by secondary cerebral ischaemia have been reported, such events remain highly uncommon, hence with our current scientific understanding accumulated from a few case reports [3,4]. In these infrequent situations, surgical decompression has been advocated in patients with severe visual field deficits or a declining level of consciousness [3]; however, ideal management and timing of treatment remain controversial [5][6][7]. Notably, in cases with mechanical compression of cerebral arteries, the potentially treacherous role of sustained perfusion via primary collaterals have scarcely been commented upon in the literature. We herein present the unique case of a 57-year-old female who suffered haemorrhage from a pituitary macroadenoma, with subsequent occlusion of the right cavernous internal carotid artery and delayed ischaemia due to temporarily preserved cerebral perfusion via Willisian collaterals. ...
Pituitary apoplexy complicated by internal carotid artery occlusion was encountered in a patient with surprisingly moderate symptoms at presentation. For a short period of watchful waiting, primary collaterals obscured the emergent need for decompressive surgery, which after the sudden onset of neurological deterioration fortunately salvaged imminent cerebral infarction. Although a few similar cases have been described previously, the importance of collateral circulation has been left virtually without comment, while contrasting treatment strategies and high mortality rates suggest further case reports are warranted. Notably, a symptoms-based management seems likely to be insufficient in these rare situations, while our experience indicate early surgery could be judicious to consider. Keywords: Pituitary apoplexy; Internal carotid artery occlusion; Collateral circulation.
... Pituitary apoplexy (PA) manifests as acute pituitary infarction or haemorrhage, and the main symptoms are acute headache, impaired vision, and reduced level of consciousness [1,2]. PA was first reported by Bailey in 1989, and the current incidence is approximately 0.6-22% [1,3]. ...
... PA leading to cerebral infarction is uncommon. Fortysix patients were included in this study [2,. A history of pituitary tumour was reported in 8.7% of patients, which is a very small proportion. ...
... There are 2 main pathophysiological mechanisms of the disease: one is the compression of intracranial blood vessels by a tumour and the other is blood vessel spasm caused by tumour bleeding [2]. In 25 patients with cerebral infarction caused by PA, infarction was due to direct intracranial vascular compression [4-6, 10, 14, 19, 21, 23-26, 29, 30, 33-35, 37-39, 41-44]. ...
Background:
Cerebral infarction caused by pituitary apoplexy (PA) is rare. To characterize the clinical features of cerebral infarction caused by PA, we performed a systematic review.
Summary:
The clinical symptoms are mainly sudden headache, hemiplegia, visual impairment, disturbance of consciousness, and ophthalmalgia in patients with cerebral infarction caused by PA. Treatment for this type of infarction is different from treatment for general acute cerebral infarction. Compared to patients who underwent emergency surgery and conservative treatment, patients treated with delayed surgery showed a better prognosis and a lower mortality rate. Compared to patients who underwent craniotomy or conservative treatment, patients who underwent transsphenoidal surgery (TSS) not only improved well but also showed a lower mortality rate. Key Messages: PA rarely causes cerebral infarction, which is a critical condition with a poor prognosis and is more common in men. Delayed surgery and TSS appear to confer a better prognosis in patients with this condition.
... Based on our literature review, reports of cerebral infarction owing to compression are more common than vasospasm. 6,7 The supraclinoid and cavernous segments of the ICA are most commonly affected in apoplexy-related vessel compression, with unilateral compression more frequent than bilateral compression (59% and 41%, respectively). 7 Furthermore, acute ischemic stroke owing to compression from apoplexy trended toward higher rates of mortality than apoplexy-associated vasospasm, although this difference was not significant (35% vs. 11%, P ¼ 0.186). ...
... 7 Furthermore, acute ischemic stroke owing to compression from apoplexy trended toward higher rates of mortality than apoplexy-associated vasospasm, although this difference was not significant (35% vs. 11%, P ¼ 0.186). Consistent with our study, Banerjee et al. 7 and Zou et al. 6 also found a higher mortality in the compression group compared with the vasospasm group (47% vs. 14%). ...
Introduction
Pituitary apoplexy is defined as a sudden neurologic deficit as a result of infarction or hemorrhage within the pituitary gland. In this study, we report a rare case of apoplexy presenting with cerebral infarction due to direct compression of the internal carotid artery (ICA) and review the literature.
Case Report
A 31-year-old male presented with sudden-onset headache, right hemiparesis, decreased left monocular visual acuity, and a nasal visual field deficit of the left eye. On computed tomography angiography (CTA) there was evidence of a hyperdense sellar/suprasellar mass with stenosis of the cavernous and supraclinoid segments of the ICAs bilaterally. However, on magnetic resonance imaging angiography (MRI/MRA) the following day there was a complete occlusion of the left cervical ICA as well as cystic changes of the sellar and suprasellar mass suggestive of pituitary hemorrhage. The patient underwent urgent endoscopic endonasal decompression of the mass and post-operative DSA demonstrated restored flow within the left cervical ICA.
Conclusion
Twenty-nine cases of cerebral infarction due to pituitary apoplexy have been previously documented with the majority of cases related to direct ICA compression. Vascular compression is associated with a high rate of mortality (24%) and should be treated urgently by surgical decompression in cases of severe or progressive neurological symptoms.
Ischemic stroke associated with pituitary apoplexy is an extremely rare but devastating complication. Arterial stenosis or occlusion due to direct compression secondary to acute expansion of the hemorrhagic pituitary adenoma may induce ischemic stroke. In case of presentation of diffusion-perfusion or diffusion-clinical mismatch, urgent tumor resection to decompress the involved arteries should be performed to salvage ischemic penumbra. If emergent surgery is not possible, other therapeutic options are needed to prevent the progression of cerebral ischemia. Herein, we report the case of successful revascularization achieved in a patient with ischemic stroke who underwent balloon angioplasty and stent placement for the non-atherosclerotic steno-occlusion of intracranial internal carotid artery due to pituitary apoplexy.
Background
Several recent studies have shown a relationship between the degree of awareness of emergency eye diseases according to a set of variables. Research objective to study the degree of awareness about emergency eye diseases among students of medical colleges at the Syrian Private University and to find out the differences about the degree of their knowledge of emergency eye diseases according to the variables (sex - specialization - academic year).
Methods
A cross-sectional, descriptive and analytical study was conducted on (516) students from medical colleges at the Syrian Private University. A questionnaire prepared by the researcher consisting of (18) items was distributed, in addition to some personal information (gender / specialization / academic year). Informed consent was taken from all participants, and the answers of the sample members were compared after dividing them according to the variables. The data was analyzed using the statistical analysis program (SPSS) version No. (24) and considering the variable as statistically significant when the value of the significance level (P-Value) is smaller than (0.05).
Results
The degree of awareness about emergency eye diseases among students of medical colleges at the Syrian Private University was medium, and the disease (glaucoma, which is one of the emergency eye diseases) came in the first place with a high degree, followed by the disease (closed-angle artery occlusion) in the second place and with a moderate degree, then came Disease (retinal detachment) in third place. There are no statistically significant differences in the degree of awareness about emergency eye diseases among medical college students at the Syrian Private University due to the gender variable (male / female). There are statistically significant differences between the estimates of the study sample in the degree of medical students' knowledge of separation disease, according to the variable of specialization, in favor of the students of the Faculty of Human Medicine, followed by pharmacy, and finally dentistry. There are statistically significant differences at the level (05.0 ≤ α) between the estimates of the study sample in the degree of awareness about emergency eye diseases among students of medical colleges at the Syrian Private University due to the variable of the academic year, in favor of both the sixth and fifth years.
Background:
Brain stroke is a rare, life-threatening condition associated with pituitary apoplexy (PA), resulting from direct arterial occlusion due to mechanical compression secondary to the sudden enlargement of the pituitary adenoma, or to vessel vasospasm, induced by tumor hemorrhage.
Case report:
We report the case of a 64-year-old woman with PA complicated by bilateral anterior circulation stroke due to critical stenosis of both anterior cerebral arteries (ACA). Despite the quick surgical decompression and consequent blood flow restoration, the neurological conditions of the patient did not improve and she died 18 days later. Ten other cases of anterior circulation stroke due to PA were retrieved in a systematic review of literature. Clinical and neuroradiological features of these patients and treatment outcome were assessed to suggest the most proper management.
Conclusion:
The onset of neurological symptoms suggestive for brain stroke in patients with PA requires performing an emergency Magnetic Resonance Imaging (MRI), including Diffusion-weighted and angiographic MR-sequences. The role of surgery in these cases is debated, however, transsphenoidal adenomectomy would permit us to decompress the ACA and restore blood flow in their territories. Although the prognosis of PA-induced anterior circulation stroke is generally poor, a timely diagnosis and treatment would be paramount for improving patient outcome.
