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![a) A scheme of the vascularization of the pituitary gland [Adopted from Fig. 4 in Ref. 1 with slight modification] b) Vascular supply of the arteries feeding the pituitary gland c) Vascular supply of the artery-portal system feeding the pituitary gland AL, anterior lobe of the pituitary gland; PL, posterior lobe of the pituitary gland; ST, stalk; ME, median eminence SHA, superior hypophyseal artery; IHA, inferior hypophyseal artery; LPV, long portal vein; SPV, short portal vein; TA, trabecular artery; AFC, artery of fibrous core; CA, capsular artery. Pituitary stalk is supplied blood by SHA, TA, and IHA.](profile/Naoki-Matsuoka/publication/258102974/figure/fig1/AS:392562075553803@1470605500885/a-A-scheme-of-the-vascularization-of-the-pituitary-gland-Adopted-from-Fig-4-in-Ref-1.png)
a) A scheme of the vascularization of the pituitary gland [Adopted from Fig. 4 in Ref. 1 with slight modification] b) Vascular supply of the arteries feeding the pituitary gland c) Vascular supply of the artery-portal system feeding the pituitary gland AL, anterior lobe of the pituitary gland; PL, posterior lobe of the pituitary gland; ST, stalk; ME, median eminence SHA, superior hypophyseal artery; IHA, inferior hypophyseal artery; LPV, long portal vein; SPV, short portal vein; TA, trabecular artery; AFC, artery of fibrous core; CA, capsular artery. Pituitary stalk is supplied blood by SHA, TA, and IHA.
Source publication
We report characteristic magnetic resonance (MR) image findings in a case of Sheehan's syndrome. A 37-year-old woman experienced complications of retained placenta and massive bleeding (3600 g) during delivery of a full-term baby. A pituitary function test demonstrated panhypopituitarism. MR image of the pituitary gland on postpartum day 10 reveale...
Context in source publication
Context 1
... The novel hook-shaped enhancement on sagittal T1WI, to our knowledge, has not been reported so far. Only ring enhancement of the anterior lobe has been reported in the acute phase of Sheehan's syndrome [6][7][8]. We speculate that the char- acteristic hook-shaped enhancement reflects the com- plex vasculature of the pituitary gland and the stalk (Fig. 1) [1][2][3][4][5]. The anterior lobe of the pituitary gland receives blood from the four vessels: (1) the long portal vein, (2) the short portal vein, (3) the capsular artery, and (4) the trabecular artery. The pituitary stalk is sup- plied blood by the superior/inferior hypophyseal and the trabecular arteries which anastomose each ...
Citations
... Sheehan's syndrome early MRI fndings include a nonhemorrhagic enlargement of the pituitary gland with a thin rim of peripheral enhancement after gadolinium, an intrasellar mass with suprasellar extension, and a lack of enhancement of the pituitary gland [13,15,19,21,24,25,29,30]. However, in some cases, normal scans were reported in the acute period [1,22,23,26,27,33,34]. ...
... However, in some cases, normal scans were reported in the acute period [1,22,23,26,27,33,34]. After subsequent involution with pituitary shrinkage, atrophic glands and an empty sella are reported in late scans [1,7,13,19,[23][24][25]29]. Te pituitary gland during pregnancy increases in size and can reach a maximum size of 10 mm during the last trimester and 12 mm in the immediate postpartum period, with an upward symmetric convexity. ...
Background:
Acute Sheehan's syndrome is rare, as well as hyponatremia as its initial manifestation. In addition, spontaneous pregnancy in patients after Sheehan's syndrome is unusual. To our knowledge, no cases of spontaneous pregnancy after acute Sheehan's syndrome have been reported. We describe a case of Sheehan's syndrome that presented with acute hyponatremia and a spontaneous pregnancy.
Case:
A 34-year-old female developed blood loss during delivery, which required a blood transfusion. On day seven postpartum, she presented with headaches, lethargy, and difficulty in breastfeeding. The workup showed hyponatremia (118 mEq/l), secondary hypothyroidism, and low prolactin levels. Magnetic resonance imaging showed pituitary necrosis. She was treated with NaCl, hydrocortisone (cortisol results were not available), and levothyroxine. Laboratory tests six weeks after discharge showed low IGF-1 and 8 AM cortisol and normal FT4, LH, FSH, and PRL levels. She was able to partially breastfeed until 4 months postpartum. Regular menstrual cycles started three months later. She became spontaneously pregnant one year later.
Conclusion:
Acute Sheehan's syndrome should be considered in the evaluation of postpartum patients with suggestive symptoms. Physicians should be aware that hyponatremia could be an initial manifestation of Sheehan's syndrome, which requires a high index of suspicion for diagnosis. Spontaneous pregnancy can occur after acute Sheehan's syndrome.
... Deux études ont rapporté que les examens IRM étaient normaux au jour 6 du post-partum (13,14,18). Sept études rapportent des découvertes précoces à l'IRM (9,10,11,12,15,16,17). ...
The intensive care unit remains a paradigm of rare pathologies culminating in often unusual syndromes.Sheehan's syndrome (SS) is a potentially serious postpartum complication which corresponds to ischemic necrosis of the anterior pituitary related to postpartum hemorrhage. It remains topical despite the improvement in gynecological and obstetrics management. The diagnosis, which is usually made only several years after the obstetrical event, by the presence of signs of anterior pituitary insufficiency, can however be early in the immediate postpartum and borrow serious acute forms which are real metabolic and endocrine emergencies. (1).Sheehan's syndrome is usually diagnosed several years after childbirth; therefore, it was recognized as a chronic disease. However, in some cases, Sheehan syndrome presents with acute symptoms and this variant can be life-threatening (2). We report a particular and complex revelation of Sheehan syndrome in a 36-year-old woman, who arrived in emergency in a coma with breathing difficulties and oxygen saturation at 60%. His coma is deep and the biological cause is urgently revealed to be hypoglycemia. She was taken care urgently and her extensive work-up revealed an anterior pituitary insufficiency with mainly corticotroph, lactotrope and somatotrope damage. Her obstetrical history is obvious revealing abundant peripartum hemorrhage following a retroplacental hematoma resulting in a maternal salvage caesarean section 10 years ago. His CT scan is normal.
... Twenty cases of acute Sheehan's syndrome were published in international peer-reviewed literature. The 21 cases are summarized in Table 2 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. We selected the topics, which are distinct features of acute Sheehan's syndrome for further discussion. ...
... VBAC: Vaginal birth after cesarean section *Severe hypotension episode at the beginning of the epidural anesthesia with loss of consciousness was observed Abbreviations: CT computed tomography, Hb hemoglobin, MRI magnetic resonance imaging obtained on day 19 [20,21,24]. Seven studies reported their early MRI findings [11,13,17,19,22,23,26]. Lavallee [18,22,23,26]. ...
... Seven studies reported their early MRI findings [11,13,17,19,22,23,26]. Lavallee [18,22,23,26]. Specific findings included a non-enhancing, minimally hypointense lesion in the pituitary gland on day 26 postpartum [22] and a hypointense area with a flattened pituitary gland on day 32 postpartum [21]. ...
Background
Sheehan’s syndrome occurs because of severe postpartum hemorrhage causing ischemic pituitary necrosis. Sheehan’s syndrome is a well-known condition that is generally diagnosed several years postpartum. However, acute Sheehan’s syndrome is rare, and clinicians have little exposure to it. It can be life-threatening. There have been no reviews of acute Sheehan’s syndrome and no reports of successful pregnancies after acute Sheehan’s syndrome. We present such a case, and to understand this rare condition, we have reviewed and discussed the literature pertaining to it. An electronic search for acute Sheehan’s syndrome in the literature from January 1990 and May 2014 was performed.
Case presentation
A 27-year-old woman had massive postpartum hemorrhage (approximately 5000 mL) at her first delivery due to atonic bleeding. She was transfused and treated with uterine embolization, which successfully stopped the bleeding. The postpartum period was uncomplicated through day 7 following the hemorrhage. However, on day 8, the patient had sudden onset of seizures and subsequently became comatose. Laboratory results revealed hypothyroidism, hypoglycemia, hypoprolactinemia, and adrenal insufficiency. Thus, the patient was diagnosed with acute Sheehan’s syndrome. Following treatment with thyroxine and hydrocortisone, her condition improved, and she was discharged on day 24.
Her next pregnancy was established 2 years after her first delivery. She required induction of ovulation for the next conception. The pregnancy, delivery, and postpartum period were uneventful. An electronic search of the literature yielded 21 cases of acute Sheehan’s syndrome. Presenting signs varied, including adrenal insufficiency (12 cases), diabetes insipidus (4 cases), hypothyroidism (2 cases), and panhypopituitarism (3 cases), with a median time of presentation after delivery for each of those conditions being 7.9, 4, 18, and 9 days, respectively. Serial changes in magnetic resonance imaging were reported in some cases of acute Sheehan’s syndrome.
Conclusion
Clinicians should be aware of the risk of acute Sheehan’s syndrome after a massive postpartum hemorrhage in order to diagnose it accurately and treat it promptly.
... MRI findings vary with the stage of the disease. Although evidence is limited, some studies describe the acute structural changes as an enlarged non haemorrhagic pituitary gland with central infarc tion 30,38,67,93,94 (FIG. 5a,b). ...
Sheehan syndrome or postpartum hypopituitarism is a condition characterized by hypopituitarism due to necrosis of the pituitary gland. The initial insult is caused by massive postpartum haemorrhage (PPH), leading to impaired blood supply to the pituitary gland, which has become enlarged during pregnancy. Small sella turcica size, vasospasms (caused by PPH) and/or thrombosis (associated with pregnancy or coagulation disorders) are predisposing factors; autoimmunity might be involved in the progressive worsening of pituitary functions. Symptoms are caused by a decrease or absence of one or more of the pituitary hormones, and vary, among others, from failure to lactate and nonspecific symptoms (such as fatigue) to severe adrenal crisis. In accordance with the location of hormone-secreting cells relative to the vasculature, the secretion of growth hormone and prolactin is most commonly affected, followed by follicle-stimulating hormone and luteinizing hormone; severe necrosis of the pituitary gland also affects the secretion of thyroid-stimulating hormone and adrenocorticotropic hormone. Symptoms usually become evident years after delivery, but can, in rare cases, develop acutely. The incidence of Sheehan syndrome depends, to a large extent, on the occurrence and management of PPH. Sheehan syndrome is an important cause of hypopituitarism in developing countries, but has become rare in developed countries. Diagnosis is based on clinical manifestations combined with a history of severe PPH; hormone levels and/or stimulation tests can confirm clinical suspicion. Hormone replacement therapy is the only available management option so far.
... These findings on MRI characterize SS and provide early confirmation of the clinical diagnosis. [26][27][28] In our patient, we found a widened sella turcica with a flattened pituitary gland consistent with an empty sella. ...
Sheehan’s syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. The onset in most cases is several months or even years after the inciting delivery, so it is often unrecognized and not adequately treated. Because SS often evolves slowly, it is usually diagnosed late. We report a 47-year old woman with loss of consciousness. Fourteen years ago, she had postpartum hemorrhage with subsequent amenorrhea and failure to lactate. Laboratory investigation showed low blood sugar and serum sodium levels, amid normal cortisol and thyroid function tests. Magnetic resonance imaging (MRI) of the pituitary revealed an empty sella consistent with SS. The presentation of hypoglycemia and hyponatremia are less known complications of Sheehan’s syndrome with only a few documented in case reports.
... The pituitary gland was enhanced by the NBI. The anterior lobe of the pituitary gland has a rich blood supply [13] that is mainly supplied by the superior hypophyseal artery, a branch of the internal carotid artery. This rich blood supply network on the pituitary gland had a characteristic arabesque pattern on NBI. ...
Background:
Narrow band imaging (NBI) is an endoscopic technology that enhances the visualization of the superficial and submucosal vasculature. The aim of the present study was to evaluate the feasibility of NBI in visualizing the normal pituitary gland during the endoscopic endonasal removal of pituitary adenoma.
Methods:
A total of 25 patients with pituitary adenoma underwent endoscopic endonasal transsphenoidal surgery using a rigid endoscope with conventional imaging. The NBI of the surgical field was conducted under air and/or continuous irrigation of artificial cerebrospinal fluid using a flexible videoscope before and/or after the gross removal of the tumor.
Results:
The capillaries of the normal pituitary gland had a characteristic appearance that could be confirmed in 16 cases. In contrast, the adenomas exhibited no characteristic vascular enhancement under NBI. The reasons why NBI failed to visualize the pituitary gland included the presence of a blood clot or a certain amount of tumor obscuring the normal pituitary gland and difficulty in steering the videoscope within the sella to approach the assumed site of the residual pituitary gland.
Conclusions:
NBI observation during the endoscopic endonasal removal of pituitary adenoma may be useful for visualizing the normal pituitary gland after the gross removal of the tumor. The absence of a typical vascular pattern suggests the presence of a residual tumor, which may justify further exploration in cases where gross total removal is considered necessary.
Sheehan's syndrome or necrosis of pituitary gland is a rare complication of severe postpartum hemorrhage, initially described in 1937. It may cause hypopituitarism immediately or several years later, depending on the degree of tissue destruction. Sheehan's syndrome though rare is still one of the commonest causes of hypopituitarism in developing countries like ours. We present a case of young lady with this syndrome who presented on 7th day postpartum after normal vaginal delivery with resistant acute severe symptomatic hyponatremia which was complicated by postpartum hemorrhage. She was diagnosed as Sheehan's syndrome by clinical manifestations, laboratory tests, and magnetic resonance imaging.
Sheehan's syndrome or necrosis of pituitary gland is a rare complication of severe postpartum hemorrhage, initially described in 1937. It may cause hypopituitarism immediately or several years later, depending on the degree of tissue destruction. Sheehan's syndrome though rare is still one of the commonest causes of hypopituitarism in developing countries like ours. We present a case of young lady with this syndrome who presented on 7th day postpartum after normal vaginal delivery with resistant acute severe symptomatic hyponatremia which was complicated by postpartum hemorrhage. She was diagnosed as Sheehan's syndrome by clinical manifestations, laboratory tests, and magnetic resonance imaging.
