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Non-visualization of the right internal carotid artery on MRA (A) and linear high signal intensity in the right fronto-parietal region on a diffusion-weighted image (B).
Source publication
We report a case of pituitary apoplexy resulting in right internal carotid artery occlusion accompanied by hemiplegia and lethargy. A 43-yr-old man presented with a sudden onset of severe headache, visual disturbance and left hemiplegia. Investigations revealed a nodular mass, located in the sella and suprasellar portion and accompanied by compress...
Citations
... ere have been a few similar reports in the past. [1,3,4,7,9,10] e mechanism of ICO could be related to ISP, which is similar to the normal intracranial pressure of 7-15 mmHg. [8] Hemorrhage or infarction due to PA increases anterior pituitary cell volume, leading to a rapid increase in ISP, which, in turn, can lead to ICA or ICA compression or vasospasm, increasing the risk of ischemic stroke. ...
Background
Pituitary apoplexy (PA) is a rare clinical condition presenting with acute headache, visual disturbance, and disorientation. PA can cause strokes due to acute internal cervical artery occlusion (ICO), which is an extremely rare condition. Arterial spin labeling (ASL) on magnetic resonance imaging (MRI) is a popular technique, which is a quantitative perfusion imaging useful for the diagnosis of ischemia. We report a treatment with acute pseudo-ICO in which ASL on MRI was useful for the decision of surgery timing.
Case Description
A 50-year-old male presented with a sudden headache and nausea. MRI and magnetic resonance angiography revealed a large pituitary tumor and left ICO. However, the left middle cerebral and anterior cerebral arteries were depicted due to a cross-flow through the anterior communicating artery. ASL on MRI showed decreased perfusion of the left hemisphere, suggesting acute ICO. As he had no neurological deficit, we treated him conservatively, following the guidelines. Two days after admission, he presented with sensory aphasia and incomplete right paralysis. Emergency head computed tomography revealed a low-density area in his left temporal lobe. We decided on emergency tumor decompression surgery to prevent ischemic progression. We performed endonasal transsphenoidal surgery. Postoperative MRI showed recanalization of the left internal carotid artery (ICA). His incomplete right paralysis improved immediately after surgery but remains mild sensory aphasia.
Conclusion
ICO-related PA is a very rare occasion but there are few similar reports. Some cases of successful ICO treatment due to PA have been reported, but the question of whether emergency or elective surgery is better remains unanswered. Our case may have been no neurological deficit if we had decided to have surgery on admission. Hypoperfusion of the ICA area due to PA may be an adaptation of emergency surgery. Perfusion images like ASL could be a useful technique to decide on surgery or conservative treatment.
... It also had been reported another possible mechanism of cerebral ischemia, vasospasm. [1,6] In general, in the case of a stroke with suspected acute large vessel occlusion, the hemodynamic stroke due to stenosis or embolic infarction should be considered first. erefore, patients who have large pituitary adenoma cannot give priority always to tumor surgery when an acute ischemic stroke symptom occurs. ...
Background
Pituitary apoplexy is syndrome of sudden onset of headache, visual loss, pituitary dysfunction, and altered consciousness. Pituitary apoplexy followed by acute cerebral ischemia is extremely rare. Here, we introduced the case of successful surgical resection of pituitary adenoma which induced acute cerebral ischemia.
Case Description
A 78-year-old man with a known pituitary macroadenoma presented with decreased consciousness and left hemiparesis. Magnetic resonance image (MRI) and computed tomography (CT) showed large pituitary macroadenoma with hemorrhage and diffusion-perfusion mismatch of right internal carotid artery (ICA) territory. Conventional angiography was done and severe stenosis of bilateral ICA and prominent flow delay of left ICA were noted at paraclinoid segment. Microscopic tumor mass removal with transsphenoidal approach was performed. Final pathological diagnosis was pituitary adenoma with apoplexy. Immediately after surgery, his symptoms were disappeared. Follow-up image studies revealed much improved perfusion in right ICA territory and patency of bilateral ICAs.
Conclusion
Direct compression of ICA is rare complication of pituitary apoplexy, which caused cerebral ischemia. Conventional angiography should be necessary for accurate diagnosis and prompt surgical decompression should be the treatment of choice.
... Pituitary adenoma was reported as the cause of ICA compression in twelve cases [15][16][17][18][19][20][21][22][23][24]. Invasion of the cavernous sinus (CS) is a typical feature in pituitary adenomas, but they rarely precipitate narrowing of the ICA within the CS [14]. ...
Introduction
Compression of the internal carotid artery (ICA) in the cavernous sinus area is a rare event and is mostly associated with pituitary adenomas and meningiomas. Other causes of ICA compression are less well known. We present a rare case of granulomatous hypophysitis causing compression of the ICA, which was treated successfully with immune-suppressive agents.
Methods
The electronic database MEDLINE (PubMed) was searched systematically and other cases with ICA compression were identified and analyzed.
Results
A female patient with a history of two previous transsphenoidal operations for suspected pituitary adenoma and post-operative complete pituitary insufficiency presented with severe headaches, nausea, fatigue, and diplopia. Pituitary MRI scan suggested relapse of the pituitary lesion with atypical bilateral infiltration of cavernous sinuses and compression of ICAs. After histological reevaluation of her previous pituitary operations, granulomatous hypophysitis was diagnosed. Treatment was started with high doses of prednisolone. With decreasing doses of prednisolone, symptoms recurred, and azathioprine was started, followed by administration of rituximab resulting in clinical recovery and regression of ICA compression. Literature analysis disclosed 36 case reports with ICA compression in the cavernous sinus region (12 pituitary adenoma, 6 meningioma, 7 hypophysitis, 5 other tumors, and 4 other etiologies). Two cases of hypophysitis recovered completely; five cases improved only partly.
Conclusion
In the case of ICA compression, clinical signs, onset of symptoms, radiological findings and pituitary insufficiencies should be thoroughly evaluated, and hypophysitis should be considered as a possible cause. In our patient, treatment with azathioprine and, finally, rituximab was successful.
... Pituitary apoplexy is a rare clinical syndrome characterized by sudden onset of headache, signs of meningeal irritation, visual impairment, ophthalmoplegia, and alteration in consciousness. [1][2][3][4] Pituitary apoplexy is a rare event characterized by the rapid expansion of a pituitary adenoma after a hemorrhagic event or schema and occurs in about 14%-22% of patients; age ranging from 38 to 85 with a mean age of 58.7 years. [5,6] However, the exact incidence of stroke in pituitary apoplexy is not described in the literature and is rare. ...
... The probable two most important mechanisms of cerebral ischemic in patients with pituitary apoplexy are mechanical obstruction of the circle of Willis by the enlarging mass and cerebral arterial vasospasm. [1,4,16] The internal carotid artery was occluded in the cavernous sinus or the supraclinoid portion by the enlarged tumor in most of the cases. [17] The pathophysiology of the vasospasm could be the release of vasoactive substances from the necrotic tumor itself. ...
Pituitary apoplexy is a rare disease followed by ischemic or hemorrhagic process within the pituitary adenoma. Here, we report two cases of pituitary apoplexy with a history of sudden onset of headache, vomiting, and diminished vision. Our aim is to share our experience and discuss these cases as follows: the first one to know the compression of basilar artery along with the compression of basilar part of pons and in both the cases with compression of an internal carotid artery leading to cerebral infarcts.
... Compromised cerebral blood flow following pituitary apoplexy is a rare occurrence. In this scenario, cerebral infarction can occur secondary to vasospasm or mechanical compression of the cavernous ICA [2][3][4][5][6][7][8][9][10][11][12]. Mechanical compression of the ICA would require intrasellar pressure (ISP) to surpass the mean arterial pressure (MAP). ...
We report the case of a 63 year-old man who presented with sudden-onset, severe headache. Work-up revealed a hemorrhagic pituitary macroadenoma. He then suffered sudden-onset aphasia and right hemiparesis. Further evaluation revealed left ICA occlusion. Emergent transsphenoidal resection of the tumor produced recanalization of the occluded ICA, but his neurological symptoms persisted. ICA occlusion following pituitary tumor apoplexy is a rare event that must be recognized early for optimal patient outcomes. We report the first case with demonstration of carotid recanalization after tumor resection, review the incidence of ICA occlusion due to pituitary tumors, describe the possible mechanisms, and recommend optimal treatment strategies.
... The probable two most important mechanisms of cerebral ischaemic in patients with PA are mechanical obstruction of the circle of willis by the enlarging mass [7] and cerebral arterial vasospasm [8]. The ICA was occluded in the cavernous sinus or supraclinoid portion by the enlarged tumour in most cases [9]. The pathophysiology of vasospasm could be the release of vasoactive substances from the necrotic haemorrhagic tumour itself [8,10], hypothalamic dysfunction, intra-operative manipulation, direct arterial wall injury and the subarachnoid blood [11]. ...
... There are only a few cases reporting mechanical compression of circle of willis as the chief event of cerebral ischaemic as illustrated by Rosenbaum TJ et al., Lath R and Rajshekar V et al., [12,13], and few other studies [7,9,14], while a few reporting cerebral vasospasm as the primary event [10,11,[15][16][17][18]. Following [Table/ 3a 3b 3c [ Fig-4]: Reviews the published studies on association of acute ischaemic stroke following pituitary apoplexy. ...
Pituitary Apoplexy (PA) is defined as a clinical syndrome comprising headache, visual deficits and altered sensorium, which can
result from haemorrhage or infarction of the pituitary gland. Acute ischaemic stroke following PA is very rare. We are presenting a
35-year-old young otherwise healthy lady who presented with neuro ophthalmological and vascular symptoms on a background
of PA. Imaging revealed a pituitary macro adenoma with parasellar extension with internal bleed. Cerebral angiography revealed
that the mass compressed the bilateral cavernous sinuses (left more than right), resulting in obliteration of the cavernous portion of
the left Internal Carotid Artery (ICA). She was treated with steroids and surgical debulking of the tumour through trans-sphenoidal
approach and postoperative imaging showed recanalization of the ICA with reduction of the tumour size. The histopathological
diagnosis was consistent with pituitary macro adenoma. Patient improved in level of sensorium, eye movement and the patient
showed almost full recovery after the operation. PA resulting in ICA occlusion is very rare. Early intervention is required for reducing
mortality and morbidity and to improve quality of life.
... Approximately 40 percent of all pituitary adenomas were macroadenomas which their growth might invade suprasellar area, cavernous sinus and sphenoid sinus. Internal carotid occlusion in cavernous sinus region has numerously reported in the setting of pituitary apoplexy (13,14). In addition, several studies have indicated that pituitary adenoma is an important precursor of pituitary apoplexy (15)(16)(17)(18). ...
Introduction: Pituitary adenoma producing symptomatic carotid compression of the internal carotid artery without any apoplexy sign would be extremely rare and there was only one report regarding to this condition. Case Presentation: In this case report we have described a 57-year-old woman with a nonfunctional pituitary macro adenoma which has resulted to symptomatic internal carotid occlusion. Magnetic resonance imaging (MRI) revealed a large pituitary adenoma caused tight stenosis of right internal carotid. The patient has also experienced the transient ischemic attack which has confirmed to be the cause of internal carotid artery occlusion by this macro adenoma tumor. There was not any sign of apoplexy at the time of admission and the patient has not shown a history of pituitary adenoma. The patient then has undergone an endonasal transsphenoidal resection because of this nonfunctional pituitary adenoma. Conclusions: Pituitary macro adenoma producing symptomatic internal carotid occlusion might develop to several serious conditions including transient ischemic attack. Urgent surgical procedure might be the best approach to prevent further severe complications in such patients.
... Approximately 40 percent of all pituitary adenomas were macroadenomas which their growth might invade suprasellar area, cavernous sinus and sphenoid sinus. Internal carotid occlusion in cavernous sinus region has numerously reported in the setting of pituitary apoplexy (13,14). In addition, several studies have indicated that pituitary adenoma is an important precursor of pituitary apoplexy (15)(16)(17)(18). ...
... Из 5 больных с ПА, которым проводилось хирургическое лечение в острой стадии развития, неблагоприятный исход отмечался у 2, у остальных 3 больных исход был благоприятным. Основной причиной летальных исходов, несмотря на проведение ранней хирургической декомпрессии, послужило нарастание ишемического поражения и прогрессирование отека головного мозга [16]. ...
Pituitary apoplexy is a clinical syndrome that is manifested by headache, visual disturbances, ophthalmoplegia or impaired consciousness. It can develop as a result of necrosis or hemorrhage in the pituitary gland or in cases of pituitary tumors. A favorable prognosis is possible if early diagnosis and timely surgical treatment. Pituitary apoplexy complicated by the disorder of the cerebral circulation occurs relatively rare. We observed the female patient aged of 51 year with pituitary adenoma, clinical signs of which were sudden depression of consciousness, right hemiparesis and left-sided ptosis. Signs of pituitary apoplexy were revealed after performed examinations. The sharp increase in the size of the tumor resulted in a compression of supraclinoid portion of the left internal carotid artery, which was the cause of ischemic brain damage in the pool left middle cerebral artery. After 2 weeks of conservative treatment, the patient was undergone to the surgery via transsphenoidal access. Histological examination confirmed the hemorrhage and necrosis of the pituitary adenoma. Complication developed 3 months after surgery partially regressed. Taking into account the relatively rare occurrence of pituitary apoplexy complicated with cerebrovascular ischemic type, clinicians should be alert to this complication. The method of choice is transsphenoidal delayed adenomectomy with conservative therapy.
... The association of internal carotid artery (ICA) occlusion and pituitary tumors is a very rare occurrence that has been described in only a handful of case reports [1,2]. Typically, the ICA occlusion has been attributed to the extrinsic compression exerted by the tumor on the artery that lies in the confined parasellar space. ...
... This is an alternative to the usual approach of directly removing the pituitary tumor. A MEDLINE and a manual search of the literature revealed only 14 case reports of pituitary adenoma and ICA occlusion [1][2][3][4][5][6][7][8][9][10][11][12][13][14] (Table 1) and in no case had the authors adopted a policy of performing a bypass as a bridge to stabilize the patient and reduce the risk of perioperative stroke or stroke evolution. According to the literature, 11 out of the 14 patients were symptomatic for cerebral ischemia (78.5%), while the ICA occlusion was an incidental finding in 2 cases. ...
Occlusion of the intracranial internal carotid artery (ICA) by a pituitary adenoma with resulting cerebral ischemia is a very rare but devastating occurrence. The authors present a case in which a condition of symptomatic ICA occlusion due to a giant pituitary adenoma was successfully treated using a preliminary extraintracranial bypass as a "bridge" to the tumor removal. A 52-year-old patient presented with a minor stroke followed by pressure-dependent transient ischemic attacks consistent with a condition of hypoperfusion. MR imaging and a digital subtraction angiography revealed a pituitary adenoma occluding the ICA on the right side. He underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with the aim of revascularizing the ischemic hemisphere and reducing the risk of perioperative stroke or stroke evolution. The patient was subsequently operated on to remove the adenoma through a transsphenoidal approach. The postoperative course was uneventful and the patient has suffered no further ischemic events. When there are no emergency indications to decompress the optical pathways but the patient is at risk of impending stroke because of ICA occlusion, a two-step strategy consisting of a bypass and subsequent removal of the pituitary adenoma may be a valuable option.
