Pituitary Apoplexy in Pregnancy: What do We Know? / Apoplexia hipofisária na gravidez: o que sabemos?

Abstract Pituitary apoplexy refers to a rare clinical syndrome consisting of signs and symptoms that occur due to rapid expansion of the contents of the sella turcica. It can occur spontaneously or associated with pituitary tumors. It can have a broad clinical spectrum, but usually presents with severe headache, visual impairment and hypopituitarism. Sudden onset of symptoms associated to imagiologic confirmation makes the diagnosis. Surgical treatment is advised when there is important compression of the optic tract. We present a case report and a review of the literature on pituitary apoplexy in pregnancy. The cases were reviewed to obtain information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities and maternal and fetal outcomes. Our review found 36 cases of pituitary apoplexy in pregnancy. Most of the cases occurred in the second trimester of pregnancy and headache was the most frequent symptom at presentation. Surgical therapy was required in more than half of the patients. In what respect maternal and fetal outcomes, there were 3 cases of preterm delivery and one case of maternal death. Our clinical case and literature review reinforces the importance of an early diagnosis to avoid potential adverse consequences.

Pituitary Apoplexy, Meningitis and Cerebral Infarction - A Perplexing Trifecta

Pituitary apoplexy (PA) is a clinical diagnosis comprising a sudden onset of headache, neurological deficits, endocrine disturbances, altered consciousness, visual loss, or ophthalmoplegia. However, clinically, the presentation of PA is extremely variable and occasionally fatal. While meningitis and cerebral infarcts are themselves serious diseases, they are rarely seen as manifestations of PA and are exceedingly rare when present together. We present the case of a 20-year-old male with a rapid progression of symptoms of meningitis, PA and stroke. The present article seeks to emphasize a rare manifestation of PA with an attempt to understand the intricacies of its evaluation and management.

Apoplexy in sporadic pituitary adenomas: a single referral center experience and AIP mutation analysis

ABSTRACT Objective: To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations. Subjects and methods: The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced. Results: Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort. Conclusion: Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.

Remisión espontánea de acromegalia y enfermedad de Cushing en adultos mayores: casos clínicos / Spontaneous remission of acromegaly and Cushing's disease in older patients: report of two cases

Pituitary diseases such as acromegaly and Cushing's disease require surgical or medical therapy. In some functioning pituitary tumors, a spontaneous remission of hormonal hypersecretion is observed, mainly associated to apoplexy or pituitary infarction. We report the evolution of two female patients older than 70 years at the time of diagnosis, with multiple comorbidities. In case 1, acromegaly was diagnosed at 74 years of age. Sellar CT scan showed a 10-mm adenoma. During her follow-up, IGF1 levels remained normal. Nine years later, a magnetic resonance (MR) showed a 7-mm adenoma. In case 2, clinical and biochemical diagnosis of Cushing's disease was done being 71 years old. Sellar MR showed a 6-mm adenoma. Three years later, urinary cortisol normalized with no changes in adenoma at MR. Seven years later, she remains without clinical or biochemical signs of hypercortisolism. In both cases, no signs of hemorrhage were observed at MR.

Apoplejía hipofisaria en posoperatorio inmediato de cirugía cardiaca: a propósito de un caso / Postoperative pituitary apoplexy: case report after a cardiac surgery

Pituitary apoplexy is caused by ischemia or hemorrhage and is considered a medical emergency. A percentage of undiagnosed pituitary adenomas may be diagnosed in the postoperative period of cardiac surgery. The clinical picture is a consequence of the increase in pressure which causes compression on cerebral structures (optic chiasm, cranial nerves) and hormonal deficit. We present a clinical case of a 69-year-old Caucasian male, who debuted with a clinical syndrome of the left cavernous sinus in the immediate postoperative period of cardiac surgery. Clinical and imaging studies (MRI) confirmed the diagnosis of pituitary apoplexy. The condition was solved satisfactorily with replacement therapy. She underwent urgery sixth days later due to persistence of visual symptoms.

La apoplejía hipofisaria se produce por un infarto o una hemorragia en dicha glándula y se considera una emergencia médica. Un porcentaje de adenomas hipofisarios no diagnosticados debutan clínicamente así, pudiéndose producir en el postoperatorio de cirugía cardiaca. El cuadro clínico es consecuencia del aumento de presión y volumen en el interior de la silla turca, lo que origina compresión de las estructuras cerebrales colindantes (quiasma óptico, silla turca, nervios craneales, etc.) y déficit hormonal. Presentamos un caso clínico de un varón de raza caucásica de 69 años, el cual debuta con un síndrome clínico de seno cavernoso izquierdo en el posoperatorio inmediato de una cirugía cardiaca. La clínica y los estudios de imagen (RMN) confirmaron el diagnóstico de apoplejía hipofisaria. El cuadro se resolvió satisfactoriamente con tratamiento esteroideo sustitutivo y cirugía al sexto día del inicio de los síntomas por persistencia de los síntomas visuales.

Apoplejía hipofisaria, presentación de dos casos clínicos y revisión del tema / Pituitary apoplexy, presentation of two clinical cases and review of the subject

Antecedentes: la apoplejía hipofisaria es un síndrome clínico agudo, potencialmente fatal, que acontece como complicación de un adenoma hipofisario; presenta una complejidad diagnóstica, y puede imitar numerosos procesos intracraneales. Objetivo: realizar la revisión bibliográfica del tema, y describir dos casos clínicos, dada la poca frecuencia de presentación de la enfermedad y su complejidad diagnóstica. Desarrollo: caso 1, paciente masculino, de 52 años con antecedentes patológicos de hipertensión arterial y macroadenoma hipofisario no funcionante. Durante su seguimiento por Neurocirugía se detectó hiperprolactinemia, por lo que se inició tratamiento con bromocriptina a dosis progresiva, lo cual desencadenó cuadro agudo no definido. Tres meses después presentó nuevo cuadro agudo, que se diagnosticó como apoplejía hipofisaria; caso 2, paciente masculino, de 49 años, con antecedente de hipertensión arterial con tratamiento irregular. Fue ingresado en servicio de terapia intermedia con diagnóstico presuntivo de meningoencefalitis, y por estudios complementarios se llega al diagnóstico de apoplejía hipofisaria. Ambos casos llevaron tratamiento quirúrgico, con evolución favorable. Conclusiones: la apoplejía hipofisaria es una enfermedad que se presenta con poca frecuencia, por lo tanto, es importante la sospecha diagnóstica para una temprana identificación y tratamiento de la enfermedad(AU)

Background: pituitary apoplexy is an acute clinical syndrome, potentially fatal, that occurs as a complication of a pituitary adenoma. It presents a diagnostic complexity, and it can mimic numerous intracranial processes. Objective: to carry out the bibliographic review of the subject, and to describe two clinical cases given the infrequency of presentation of the disease and its diagnostic complexity. Development: case 1, male patient, 52 years old with pathological history of arterial hypertension and non-functioning pituitary macroadenoma. During follow-up by Neurosurgery, hyperprolactinemia was detected, so treatment with bromocriptine was started with a progressive dose, which triggered undefined acute symptoms. Three months later he presented new acute symptoms, which was diagnosed as pituitary apoplexy. Case 2, male patient, 49 years old, with a history of arterial hypertension under irregular treatment. He was admitted in the intermediate therapy service with a presumptive diagnosis of meningoencephalitis, and by complementary studies the diagnosis of pituitary apoplexy was reached. Both cases led to surgical treatment, with favorable evolution. Conclusions: pituitary apoplexy is a disease that occurs infrequently, therefore, diagnostic suspicion is important for early identification and treatment of the disease(AU)

Metastasis of a Dorsal Melanoma to a Pituitary Adenoma Mimicking Pituitary Apoplexy

Metastases to pituitary adenomas are very rare. From the 20 cases found in the literature, none originated from a cutaneous melanoma. We present the case of a 67-year-old man with a history of transcranial approach to treat a pituitary macroadenoma followed by adjuvant radiotherapy. Fifteen years later, he presented a dorsal nodular melanoma, and three years after that, he developed symptoms of pituitary apoplexy. He was submitted to transsphenoidal surgery, and the histology result revealed metastasis of the melanoma into a pituitary adenoma. The similarity in the clinical presentation of the two entities­pituitary apoplexy and metastasis of the melanoma into a pituitary adenoma­and the rarity of this type of metastization alert to challenges in the differential diagnosis that may confound the neurosurgeon's decision.

As metástases em adenomas pituitários são muito raras. Dos 20 casos descritos na literatura, nenhum foi originado por um melanoma cutâneo. Apresentamos um caso de um homem de 67 anos de idade, com história de abordagem transcraniana para tratar um macroadenoma pituitário, seguido de radioterapia adjuvante. Quinze anos depois, o paciente apresentou um melanoma nodular dorsal e 3 anos mais tarde desenvolveu sintomas de apoplexia pituitária. Ele foi então submetido a uma cirurgia transfenoidal, e o resultado histológico revelou tratar-se de uma metástase do melanoma em um adenoma hipofisário. A semelhança na apresentação clínica entre as duas entidades­apoplexia pituitária e metástase do melanoma em um adenoma hipofisário ­ e a raridade deste tipo de metastização alertam para desafios no diagnóstico diferencial que podem confundir a decisão do neurocirurgião.

Síndrome meningeo como manifestación de apoplejia hipofisiaria, análisis prospectivo de siete casos / Meningeal syndrome as manifestation of pituitary apoplexy, prospective analysis of seven cases

Introducción: la apoplejía hipofisiaria es una grave pero poco frecuente emergencia médico -neuroquirúrgica, con una incidencia global reportada del 1 por ciento a 2 por ciento Es causado por una hemorragia o infarto en relación a la glándula pituitaria, pudiendo existir extravasación de contenido necrótico o hemorrágico al espacio subaracnoideo, manifestándose como un síndrome meníngeo aséptico o hemorrágico. Sin embargo, su frecuencia no está estudiada. Material y Métodos: Se realizó un registro prospectivo entre enero de 2013 y agosto de 2014, para el estudio de líquido céfalo raquídeo, en pacientes con diagnóstico clínico- imagenológico de apoplejía hipofisiaria. Además un registró detallado de las manifestaciones clínicas y de laboratorio. Resultados: En este período se reclutaron 8 casos con apoplejía hipofisiaria clínica, de los cuales 7 fueron incluidos, siendo excluido un paciente por rechazar su participación en el estudio. De los 7 pacientes restantes, se evidenciaron signos meníngeos clínicos en el 86 por ciento (6/7), confirmando alteraciones del estudio cito-químico en todos ellos. En cada caso se descartó patología infecciosa o vascular como etiología. Conclusión: Si bien el debut de una apoplejía hipofisiaria como un síndrome meníngeo aséptico o hemorragia subaracnoidea, se encuentra documentado como casos anecdóticos, nuestros resultados apuntan a que sería una manifestación frecuente e importante a considerar para un adecuado diagnóstico diferencial y monitoreo de complicaciones infrecuentes.

Introduction: pituitary apoplexy is a serious but rare neurosurgical emergency, with an overall reported incidence of 1 percent to 2 percent. It is caused by bleeding or infarction related to the pituitary gland, there may be necrotic or hemorrhagic extravasation content to the subarachnoid space, manifesting as an aseptic o hemorrhagic meningeal syndrome. However, their frequency is not studied. Material and Methods: A prospective registry between January 2013 and August 2014, for the study of cerebro spinal fluid in patients with clinical and imaging diagnosis of pituitary apoplexy was performed. In addition, a detailed analysis of the clinical sintoms and laboratory was recorded. Results: In this period, 8 cases with clinical pituitary apoplexy were recluted, of which 7 were included, being excluded from a patient who refuses to participate in the study. Of the remaining 7 patients,clinical meningeal signs were evident in 86 percent (6/7), confirming alterations cyto-chemical study all of them. In each case infectious or vascular pathology was ruled out as a cause. Conclusion: While the debut of a pituitary apoplexy as an aseptic meningeal syndrome or subarachnoid hemorrhage, is documented as anecdotal cases, our results would suggest that is a common and important manifestation, to consider an appropriate differential diagnosis and monitoring of rare complications.

Apoplejía tumoral pituitaria / Pituitary tumor apoplexy

La apoplejía tumoral pituitaria es un síndrome infrecuente que resulta del infarto y/o hemorragia espontánea de un adenoma pituitario preexistente. Ya que el evento primario involucra el adenoma, este síndrome debe ser nombrado como apoplejía tumoral pituitaria y no como apoplejía pituitaria. El aumento súbito en la presión de los contenidos de la silla turca da como resultado una cefalea de inicio agudo (puede ser incluso una "cefalea en trueno") de intensidad severa, alteraciones visuales y compromiso en la función pituitaria. El diagnóstico se basa en una alta sospecha clínica, imagen por resonancia magnética y medición de hormonas hipofisiarias en sangre. El tratamiento se basa en medidas de soporte (líquidos intravenosos y corticoides) y en casos sin buena respuesta o con deterioro neurológico, descompresión de silla turca. A continuación presentamos el caso de un adenoma previamente no diagnosticado que debutó como apolejía tumoral pituitaria. (Acta Med Colomb 2015; 40: 249-253).

Pituitary tumor apoplexy is an infrequent condition resulting from infarction and/or spontaneous bleeding from a pre-existing pituitary adenoma. This entity requires the prior existence of an adenoma in order to be named as pituitary tumor apoplexy, otherwise, it should be named pituitary apoplexy. The sudden increase in pressure of the sella turcica's contents results in a clinical syndrome characterized by headache (which can be "thunderclap headache"), visual disturbances and hypopituitarism. Diagnosis is not always straight forward and requires high clinical suspicion in addition to magnetic resonance imaging and measurement of serum pituitary hormones. Treatment is mainly based on supportive measures (intravenous fluids and steroids) and surgical decompression in those cases with no response to medical treatment and progressive neurological impairment. We report the case of a patient with a previously unknown pituitary adenoma presenting as a tumor apoplexy. (Acta Med Colomb 2015; 40: 249-253).

Bilateral acute visual loss from Rathke's cleft cyst apoplexy in a patient with dengue fever / Perda visual aguda secundária a apoplexia de cisto de Rathke em paciente com dengue

Hemorrhagic complications of optic pathway diseases are extremely rare causes of acute visual loss associated with dengue fever. In this paper we report a patient presenting with dengue fever and bilateral acute visual loss caused by chiasmal compression due to Rathke's cleft cyst apoplexy. Considering the importance of early diagnosis and treatment to visual recovery, apoplexy of sellar and suprasellar tumors should be considered in the differential diagnosis of patients with acute visual loss and dengue fever.

Complicações hemorrágicas de doenças da via óptica são causas extremamente raras de perda aguda de visão em pacientes com dengue. Nesse trabalho, documentamos um caso de paciente com dengue apresentando perda de visão bilateral aguda secundária a compressão quiasmática por quadro hemorrágico em cisto de Rathke. Considerando a importância do diagnóstico e tratamento precoces para um bom prognóstico visual, a apoplexia de tumores da região selar e suprasselar deve ser incluída como um raro, porém importante, diagnóstico diferencial de perda visual aguda nesses pacientes.

Spontaneous remission of acromegaly: apoplexy mimicking meningitis or meningitis as a cause of apoplexy? / Remissão espontânea da acromegalia: meningite simulando apoplexia ou meningite como causa da apoplexia?

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterized by ischemic infarction or hemorrhage into a pituitary tumor. The diagnosis of pituitary tumor apoplexy is frequently complicated because of the nonspecific nature of its signs and symptoms, which can mimic different neurological processes, including meningitis. Several factors have been associated with apoplexy, such as dopamine agonists, radiotherapy, or head trauma, but meningitis is a rarely reported cause. We describe the case of a 51-year-old woman with acromegaly due to a pituitary macroadenoma. Before surgical treatment, she arrived at Emergency with fever, nausea, vomiting and meningismus. Symptoms and laboratory tests suggested bacterial meningitis, and antibiotic therapy was initiated, with quick improvement. A computerized tomography (CT) scan at admission did not reveal any change in pituitary adenoma, but a few weeks later, magnetic resonance imaging (MRI) showed data of pituitary apoplexy with complete disappearance of the adenoma. Currently, her acromegaly is cured, but she developed hypopituitarism and diabetes insipidus following apoplexy. We question whether she really experienced meningitis leading to apoplexy or whether apoplexy was misinterpreted as meningitis. In conclusion, the relationship between meningitis and pituitary apoplexy may be bidirectional. Apoplexy can mimic viral or bacterial meningitis, but meningitis might cause apoplexy, as well. This fact highlights the importance of differential diagnosis when evaluating patients with pituitary adenomas and acute neurological symptoms.

A apoplexia é uma síndrome clínica rara, mas potencialmente fatal, caracterizada por infarto isquêmico ou hemorragia em um tumor pituitário. O diagnóstico de apoplexia de tumor pituitário é frequentemente complicado pela natureza inespecífica dos seus sinais e sintomas, que podem simular diferentes processos neurológicos, incluindo a meningite. Vários fatores estão associados com a apoplexia, como o uso de agonistas dopaminérgicos, radioterapia ou trauma da cabeça, mas a meningite foi raramente relatada. Descrevemos o caso de uma mulher de 51 anos de idade com acromegalia por um macroadenoma pituitário. Antes do tratamento cirúrgico, ela foi trazida ao pronto-socorro com febre, náusea, vômitos e meningismo. Os sintomas e análises laboratoriais sugeriram meningite bacteriana e o tratamento com antibióticos foi iniciado, com melhora rápida dos sintomas. Uma tomografia computadorizada (CT) na admissão ao hospital não revelou nenhuma alteração no adenoma pituitário, mas algumas semanas depois uma ressonância magnética (MRI) mostrou informações de apoplexia pituitária, com desaparecimento completo do adenoma. Atualmente, a acromegalia está curada, mas ela desenvolveu hipopituitarismo e diabetes insipidus depois da apoplexia. Questionamo-nos se a paciente realmente apresentou meningite que levou à apoplexia ou se a apoplexia foi mal interpretada como sendo meningite. A relação entre a meningite e a apoplexia pode ser bidirecional. A apoplexia pode simular a meningite viral ou bacteriana, mas a meningite também pode causar apoplexia. Esse fato enfatiza a importância do diagnóstico diferencial ao se avaliar pacientes com adenomas pituitários e sintomas neurológicos.

Spontaneous remission of hypercortisolism presumed due to asymptomatic tumor apoplexy in ACTH-producing pituitary macroadenoma / Remissão espontânea do hipercortisolismo devido a provável apoplexia tumoral assintomática em paciente com macroadenoma produtor de ACTH

Cushing's disease (CD) is usually caused by secretion of ACTH by a pituitary corticotroph microadenoma. Nevertheless, 7%-20% of patients present with ACTH-secreting macroadenomas. Our aim is to report a 36-year-old female patient with CD due to solid-cystic ACTH-macroadenoma followed up during 34 months. The patient presented spontaneous remission due to presumed asymptomatic tumor apoplexy. She showed typical signs and symptoms of Cushing's syndrome (CS). Initial tests were consistent with ACTH-dependent CS: elevated urinary free cortisol, abnormal serum cortisol after low dose dexamethasone suppression test, and elevated midnight salivary cortisol, associated with high plasma ACTH levels. Pituitary magnetic resonance imaging (MRI) showed a sellar mass of 1.2 x 0.8 x 0.8 cm of diameter with supra-sellar extension leading to slight chiasmatic impingement, and showing hyperintensity on T2-weighted imaging, suggesting a cystic component. She had no visual impairment. After two months, while waiting for pituitary surgery, she presented spontaneous resolution of CS. Tests were consistent with remission of hypercortisolism: normal 24-h total urinary cortisol and normal midnight salivary cortisol. Pituitary MRI showed shrinkage of the tumor with disappearance of the chiasmatic compression. She has been free from the disease for 28 months (without hypercortisolism or hypopituitarism). The hormonal and imaging data suggested that silent apoplexy of pituitary tumor led to spontaneous remission of CS. However, recurrence of CS was described in cases following pituitary apoplexy. Therefore, careful long-term follow-up is required.

A doença de Cushing (DC) é usualmente causada por um microadenoma produtor de ACTH. Entretanto, 7%-20% dos pacientes apresentam um macroadenoma. O objetivo deste trabalho é reportar uma paciente de 36 anos, feminina, com diagnóstico de DC devido a macroadenoma hipofisário sólido-cístico com seguimento de 34 meses que apresentou remissão espontânea presumidamente em decorrência de uma apoplexia tumoral assintomática. Inicialmente, ela apresentava sinais e sintomas típicos da síndrome de Cushing (SC). Na admissão, os testes foram consistentes com o diagnóstico de SC ACTH-dependente: cortisol urinário livre de 24h elevado, não supressão do cortisol sérico após dose baixa de dexametasona e cortisol salivar noturno elevado, associado a concentrações elevadas do ACTH plasmático. Ressonância magnética (RM) de hipófise revelou uma massa selar de 1.2 x 0.8 x 0.8 cm com extensão suprasselar levando a uma discreta compressão do quiasma óptico e mostrando região de hipersinal na imagem ponderada em T2 sugerindo um componente cístico. A paciente não apresentava queixas visuais. Após dois meses, enquanto aguardava o tratamento cirúrgico, a paciente apresentou remissão espontânea da SC. A repetição dos exames indicou remissão do hipercortisolismo: normalização do cortisol urinário livre de 24h e normalização do cortisol salivar noturno. Nova RM de hipófise revelou redução do volume tumoral com desaparecimento da compressão quiasmática. A paciente permanece livre da doença por 28 meses (sem hipercortisolismo ou hipopituitarismo). Os dados hormonais e de imagem sugerem que tenha ocorrido uma apoplexia tumoral assintomática, levando à remissão espontânea da SC. Entretanto, como há relatos de recorrência após apoplexia hipofisária, cuidadoso seguimento a longo prazo faz-se necessário.

Apoplejía pituitaria con parálisis del III par craneal: reporte de caso / Pituitary apoplexy presenting as isolated third cranial nerve palsy: a case report

Se describe el caso de un varón de 65 años de edad, sin antecedentes patológicos de importancia, que acudió a emergencia del Hospital Nacional Cayetano Heredia por presentar cefalea intensa y ptosis palpebral izquierda. El examen físico mostró parálisis aislada del III par craneal izquierdo. Los análisis de laboratorio mostraron hiponatremia e hipopituitarismo y la resonancia magnética nuclear un adenoma pituitario con áreas de hemorragia e invasión de los senos cavernosos. El tratamiento incluyó glucocorticoides y descompresión quirúrgica transesfenoidal. La anatomía patológica confirmó el diagnóstico de infarto hemorrágico de un adenoma pituitario. El paciente fue dado de alta con terapia sustitutiva de levotiroxina y prednisona. La ptosis palpebral izquierda se recuperó en forma parcial. La apoplejía pituitaria es un síndrome clínico producido por un proceso expansivo dentro de la silla turca, secundario a hemorragia o infarto de un adenoma pituitario, que se caracteriza por cefalea, déficit visual, oftalmoplejía y alteración del nivel de conciencia. Este proceso expansivo puede comprimir los pares craneales en los senos cavernosos, produciendo diferentes grados de parálisis de los músculos oculomotores. La parálisis aislada del III par craneal es rara.

A 65-year-old man came to Hospital Nacional Cayetano Heredia with severe headache and isolated left-sided ptosis. Physical examination showed isolated third cranial nerve palsy. Laboratory tests showed mild hyponatremia and hypopituitarism. Further work-up included a pituitary magnetic resonance imaging that demonstrated a mass in the pituitary fossa with signs of hemorrhage and invasion of left cavernous sinus. Treatment was started with glucocorticoid replacement and neurosurgical decompression via a transsphenoidal approach. Patient was discharged from hospital with replacement therapy of levothyroxine and prednisone. Left-sided ptosis was partially recovered. Pituitary apoplexy is a clinical syndrome characterized by abrupt onset headache, visual deficit, ophthalmoplegia and altered mental status caused by rapid enlargement of a pituitary adenoma, usually due to hemorrhagic infarctionof the tumor. This expansive process can extends laterally into the cavernous sinus and compress the cranial nerves. Isolated third cranial nerve palsy is very rare. In most cases, improvement of cranial neuropathy is possible with rapid diagnosis and adequate and timely management.

Apoplejía postoperatoria de un macroadenoma hipofisiario residual e infarto de la arteria cerebral media / Post-operative apoplexy of a residual pituitary macro-adenoma and middle cerebral artery infarction

La apoplejía postoperatoria de los adenomas hipofisiarios es una complicación rara vez reportada. La presión ejercida por el tumor residular edematoso puede comprometer estructuras nerviosas y vasculares adyacentes a la región selar. Describios el caso de un hombre de 69 años de edad con un tumor selar gigante a quien le fue realizada una resección incompleta a través de un acceso pterional. La cirugía fue detenida por inestabilidad hemodinámica. Cuarenta y ocho horas más tarde, desarrolla oftalmparesias y disminución bilateral de la agudeza visual, deterioro del estado de consciencia, poliuria y hemiparesia izquierda. Una tomografía cerebral simple de emergencia demostró incremento del volumen tumoral con hemorragia y un infarto en el territorio de la arteria cerebral media derecha. El paciente falleció siete días más tarde. Este caso ejemplifica esta rara y catastrófica complicación con alta morbilidad y mortalidad. En la revisión de la literatura, solo fueron encontrados dos casos de ictus isquémico debido a la compresión de arterias intracraneales mayores por apoplejía postoperatoria de macroadenomas residuales.

Postoperative apoplexy of residual pituitary adenomas is a rarely reported complication. Pressure from edematous residual tumor may affect vascular and nervous structures adjacent to sellar region. We described a 69 years old man with a giant sellar tumor who underwent to incomplete resection through pterional approach. Surgery was stopped by hemodynamic instability. Forty-eight hours later, he developed bilateral decreased of visual acuity, bilateral ophthalmoparesis, drowsiness, polyuria and left hemiparesis. An emergency computed tomography scan showed increase in tumor volume with hemorrhage and an infarct of right middle cerebral artery. The patient died seven days later. This case exemplifies this rare and catastrophic complication with high morbidity and mortality. On literature review, only two cases of ischemic strokes due to compression major intracranial arteries by postoperative tumor apoplexy were found.

Pituitary tumor apoplexy / Apoplexia em tumor hipofisário

Pituitary tumor apoplexy is a medical emergency due to acute infarction or hemorrhage in the pituitary gland. In this review, the authors discuss the sellar anatomy, the pituitary gland and adenomas' vascularization and the general aspects of the syndrome such as its ethiopatogenesis, predisposing factors, clinical features, treatment and prognosis.

A apoplexia em tumor hipofisário é uma emergência médica decorrente do infarto agudo ou hemorrágico na glândula hipófise. Nesta revisão os autores discutem a anatomia da região selar, a vascularização da hipófise e adenomas hipofisários, e demais aspectos da síndrome como etiopatogenia, fatores predisponentes, quadro clínico, tratamento e prognóstico.

Apoplejía pituitaria: reporte de dos casos / Pituitary apoplexy: two cases report

Se presentan dos pacientes del Hospital Nacional Cayetano Heredia, el primero con un adenoma pituitario no funcionante sin diagnóstico previo, el segundo con acromegalia; inicialmente tuvieron los diagnósticos de hemorragia subaracnoidea y meningitis aguda respectivamente, y durante la evolución fueron diagnosticados de apoplejía pituitaria. Se describe la evolución clínica de ambos casos, y se hace una revisión bibliográfica del tema. Se plantea la necesidad de considerar el cuadro de apoplejía pituitaria dentro del diagnóstico diferencial cuando existe cefalea, oftalmoplejía y compromiso visual.