Comparing neuroendocrine recovery between surgical and conservative management in pituitary apoplexy patients: a propensity score-matched analysis.

Pituitary apoplexy is a rare and potentially life-threatening clinical syndrome. Patients may present with severeneuro-ophthalmologic or endocrine symptoms. Current evidence is unclear whether conservative or surgicalmanagement leads to the best neuroendocrine outcomes. This study aimed to compare neuroendocrine outcomesbetween surgical and conservative treatments in a single center. Cases of patients with pituitary apoplexy whoreceived transsphenoidal surgery or conservative management in Songklanagarind Hospital between January 1,2005 and December 31, 2022 were retrospectively reviewed. A propensity score matching method was used toadjust bias from treatment selection (surgery or conservative treatment). Differences in visual field, visual acuity,cranial nerve, and endocrine outcomes between the surgical and conservative treatment groups were analyzedusing logistic regression analysis. This study included 127 patients, with 98 and 29 patients in the surgical and theconservative treatment group, respectively. The optimal matching method was used for propensity score matching.Compared to the conservative group, the surgically treated patients had a significantly higher rate of visual fieldrecovery (odds ratio (OR): 12.89, P = 0.007). However, there were no statistical differences in the recovery rate ofpreoperative visual acuity, cranial nerve, and endocrine deficits between the groups. Transsphenoidal surgery wasassociated with a higher rate of visual field recovery when compared to the conservative treatment for pituitaryapoplexy patients. Careful selection of appropriate treatment based on the patient's presentation andneuroendocrine status will result in the best outcomes while avoiding unnecessary surgical intervention.

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.

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)

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)

Apoplejía pituitaria. Revisión del tema / Pituitary apoplexy. A review

La apoplejía pituitaria es un síndrome caracterizadopor una necrosis o hemorragia en el seno deun tumor hipofisario. Clínicamente cursa con cefalearepentina, signos de irritación meníngea, alteracionesen la agudeza visual, incluso ceguera y en ocasiones disminucióndel nivel de conciencia. Para el diagnósticoes fundamental la realización de pruebas radiológicas,siendo la de elección la resonancia magnética. El tratamientoconsiste en la descompresión quirúrgica sellartransesfenoidal urgente y terapia sustitutiva con altasdosis de corticoides (AU)

Pituitary apoplexy constitutes a syndrome that ischaracterized by the ischemic infarction or hemorrhageinto a pituitary tumour. Clinically the patient developssudden headache, meningismus, visual disturbances,even blindness, and occasionally decrease in level ofconsciousness. To diagnose it is basic to perform a cerebralMRI. Treatment consists in urgent sellar decompressionby transsphenoidal surgery and substitutetherapy with steroids (AU)

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.

Apoplexia subclínica em tumores pituitários / Subclinical apoplexy in pituitary tumors

Apoplexia pituitária aguda é fenômeno relativamente raro, mesmo em macroadenomas. No entanto, a presença de áreas necro-hemorrágicas intratumorais nestes tumores que nao se relacionam a qualquer sintomatologia aguda parece ser bem mais frequente do que se imaginava na era da tomografia. Com o advento da ressonância magnética estas áreas podem ser facilmente diagnosticadas pré-operatoriamente. Dentre os 40 últimos macroadenomas operados e examinados com RMN, 10 possuíam áreas apopléticas subclínicas em seu interior. Sete destes tumores eram nao secretores, 2 secretores de Gh e um de prolactina. O quadro clínico incluiu, além daqueles correspondentes à aventual secreçao endócrina, perda visual progressiva (sem história de piora abrupta ou rápida) (n=8) e cefaléia (n=3). Após a remoçao cirúrgica destes tumores e descompressao do aparato óptico, obtivemos melhora visual em 6 pacientes e em 2 a visao permaneceu inalterada. A cefaléia desapareceu em 2 casos. A presença de áreas apopléticas nestes macrotumores bem como sua ausência em séries de microtumores relatadas na literatura sugere que se relacionam mais ao tamanho do tumor do que ao seu caráter secretor ou nao, o que é compatível com a provável natureza (insuficiência vascular) da apoplexia subclínica nesses casos.

Apoplejía en metástasis hipofisiaria de carcinoma de células renales: caso clínico con 7 años de seguimiento / Pituitary apoplexy secondary to a metastatic renal cell carcinoma: report of a case followed for 7 years

We report a man in whom a 15 cm. renal tumor was excised at the age of 49. The pathological examination showed a clear cell carcinoma. Five years later, he presented with headache, vomiting and unilateral palpebral ptosis. Imaging studies showed a sellar tumor with pituitary apoplexy. The tumor was excised and the pathological study disclosed a clear cell tumor, positive for vimentin, cytokeratins AE1 and AE3 and immunohistochemically negative for LH, TSH, ACTH and GH. Considering the similar histopathological features, it was considered as a metastasis of the renal tumor. The patient was supplemented with thyroid, adrenal and gonadal hormones. Seven years later, he presented a new tumor in the remaining kidney, that corresponded to a cystic papillary renal cell carcinoma. Afterwards, he presented a transitional urinary bladder tumor. Mortality associated to renal cell tumors is 90 percent at 5 years, and pituitary metastases are extraordinarily uncommon

Apoplejia hipofisiaria / Pituitary apoplexy

Se hace la presentación de un caso clínico portador de apoplejía hipofisiaria con cuadro agregado de hidrocefalia aguda, manejada en una forma inmediata tanto médica como quirúrgica, utilizando todo el arsenal con que se contaba en ese momento y observando los frutos, en una recuperación y pronóstico excelente a través de un seguimiento de más de 36 meses. Hemos realizado una revisión de la literatura al respecto y creemos que estamos en condiciones adecuadas para el diagnóstico, manejo y tratamiento de futuros casos, gracias a la ayuda de un equipo interdisciplinario.

Apoplexia hipofisária intradenomatosa / Intra-adenomatous pituitary apoplexy

Os autores analisam a literatura sobre apoplexia hipofisária intradenomatosa, enfocando a fisiopatologia, o diagnóstico e a conduta terapêutica. Estudam 5 casos, de uma série de 86 pacientes com tumores hipofisários que desenvolveram esta síndrome e que foram diagnosticados e acompanhados pelos serviços de Neurocirurgia e Endocrinologia do Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro. Todos os casos, a partir da suspeita clínica, tiveram o diagnóstico confirmado por estudo de tomografia computadorizada de crânio e/ou ressonância magnética de crânio. O tratamento de escolha foi cirúrgico. As conclusöes apontam para as dificuldades diagnósticas desta situaçao clínica e da urgência na instituiçäo da terapia.

Adenoma pituitário: hemorragia intratumoral e sua associaçäo com apoplexia pituitária / Pituitary adenomas: intratumoral hemorrhage and pituitary apoplexy

Nove pacientes operados portadores de macroadenomas hipofisários que apresentaram hemorragia intratumoral foram revisados. O diagnóstico baseou-se nos sinais e sintomas clínicos, tomografia computadorizada (TC), ressonância nuclear magnética (RNM) e estudo histológico. Todos os tumores apresentavam expansäo supra-selar. Cinco pacientes tiveram sintomas agudos como cefaléia, vômitos, meningismo, diplopia e déficit da acuidade e do campo visual, enquanto 4 tiveram hemorragia "assintomática". Os pacientes foram operados pela via transesfenoidal e, à cirurgia, 6 apresentavam coleçäo sangüínea e 3, enfarte hemorrágico. O tempo médio entre a admissäo e a cirurgia foi de 18 días. Näo houve mortalidade operatória. A cirurgia proporcionou a melhora dos sintomas visuais e oculomotores na grande maioria dos pacientes, porém näo trouxe melhora da funçäo endócrina.

Aplopejia pituitaria: comunicacion de un caso / Pituitary apoplexy: case report

OBJETIVO: Describir un nuevo caso de aplopejia pituitaria. DESCRIPCION: paciente de sexo masculino y 65 años de edad que en forma repjetina comienza con cefaleas, diplopia y rigidez de nuca. La resonancia magnetica mostro una lesion expansiva selar de 30 x 30 mm. INTERVENCION: Se opero por via subfrontal, evacuando un hematoma y resecando el tumor. La evolucion postoperatoria a los 3 meses mostro ausencia del tumor y desaparicion de los sintomas. CONCLUSION: la apoplejia pituitaria es poco frecuente. El diagnostico con resonancia magnetica es sencillo. La cirugia precoz es el tratamiento de eleccion (AU)