Pituitary apoplexy: Surgical or conservative management? / Agyalapimirigy-apoplexia: Sebészi vagy konzervatív kezelés?

Összefoglaló. Az agyalapimirigy-apoplexia ritka klinikai kórkép, mely hirtelen kialakult bevérzés vagy infarktus következményeként jelenik meg. A hypophysisadenomás betegek 2-12%-ában fordul elo, a leggyakrabban funkcionálisan inaktív daganatokban, de jelentkezhet gyógyszeresen kezelt adenomákban is. Klinikai képe hirtelen kialakuló heves fejfájás, mely látászavarral vagy kettos látással társulhat, de meningealis izgalmi jel, a tudati szint romlása is elofordulhat. A bevérzés miatt kialakult kortikotropinhiány kezelés nélkül mellékvese-elégtelenséghez vezet. A mágneses rezonancia a komputertomográfhoz képest jobban kimutatja az adenoma bevérzését vagy akár infarktusát. Retrospektív tanulmányok a korábbi, azonnali idegsebészeti beavatkozás helyett a konzervatív kezelés létjogosultságát emelik ki. Orv Hetil. 2021; 162(38): 1520-1525. Summary. Pituitary apoplexy is a rare clinical syndrome secondary to haemorrhage or infarction of pituitary adenoma. The prevalence is 2-12% of pituitary adenoma patients especially in nonfunctioning tumours but may be found in medically treated adenomas as well. Its clinical picture is sudden onset of headache with visual disturbances and/or ocular palsy. Meningeal signs and altered consciousness can occur. Corticotropin deficiency if untreated can lead to adrenal insufficiency. Compared to computed tomography, magnetic resonance imaging better demonstrates the haemorrhage or even infarction of pituitary adenoma. Retrospective studies emphasize the wait-and-see management instead of the formerly considered urgent neurosurgical intervention. Orv Hetil. 2021; 162(38): 1520-1525.

Armand Trousseau (1801-1867), a neurologist before neurology.

Armand Trousseau is the emblematic figure of the prominent mid-19th century clinician, owing to the quality of his teaching and the influence of French medicine, which during his time brought students from around the world to Paris. A student of Pierre Bretonneau (1778-1862), the famous physician from the western French city of Tours, Trousseau carried forward Bretonneau's clinical description of infectious diseases, developing the notion of their contagion and paving the way toward the discovery of their microbial aetiology by Louis Pasteur (1822-1895) at the end of the century. His teachings, Les Leçons cliniques de l'Hôtel-Dieu, transcribed by his students, played a role in training young physicians for half a century. In this work, Trousseau covered several neurological diseases such as apoplexy, epilepsy, chorea, Parkinson's disease, and amyotrophic lateral sclerosis. The rich, Balzac-like detail of his clinical pictures would be unthinkable today. While he cannot be credited with any seminal descriptions in particular, some of his observations contain significant nuggets, such as a case of Gilles de la Tourette syndrome, twenty years before the seminal publication. After a biographical account, we will present the main lessons given by Trousseau on neurological subjects. One of Trousseau's little-known contributions is to have invited Guillaume Duchenne de Boulogne (1806-1875) to his department at the Hôtel-Dieu hospital, setting Duchenne on the path to becoming a pioneer of Parisian neurology.

Apoplexy, cerebrovascular disease, and stroke: Historical evolution of terms and definitions / Apoplexia, doença cerebrovascular e acidente vascular cerebral: evolução histórica dos termos e definições

ABSTRACT. The long-standing concept of "apoplexy' can be followed from Antiquity, passing through the Middle Ages and Renaissance, and reaching the Modern era and the present day, with the new designation of "stroke". The definition of "apoplexy" can be divided, by the history of autopsy, into a period predating this practice, which spanned from Antiquity until the Renaissance, with a relatively stable clinically-based umbrella concept, and an autopsy period of the Modern era, when the condition was subdivided into several subtypes. Thus, it took about 2,500 years assembling the numerous pieces of information to achieve a fairly well-defined picture. The "stroke" concept inherited the information developed for "apoplexy", incorporating all historical acquisitions to form the current state of this knowledge.

RESUMO. O conceito de "apoplexia", conhecido há muito tempo, pode ser seguida desde a Antiguidade, passando pela Idade Média e a Renascença e alcançando a era Moderna e os dias presentes, com uma nova designação, "acidente vascular cerebral". A definição de "apoplexia" pode ser dividida, pela história da autópsia, em um período precedendo essa prática, que durou da Antiguidade até a Renascença, com um conceito guarda-chuva relativamente estável baseado na clínica, e em um período de autópsia da era Moderna, quando foi alcançada a separação dessa condição em diversos subtipos. Assim, levou cerca de 2.500 anos reunindo os numerosos fragmentos de informação para chegar a um quadro satisfatoriamente bem definido. O conceito de "acidente vascular cerebral" herdou tal informação desenvolvida para a "apoplexia", incorporando todas as aquisições históricas, para formar o presente estado de conhecimento.

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.

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.

Apoplexia uteri: a rarely described post-mortem finding.

We present a case of apoplexia uteri, a rarely described condition of haemorrhagic necrosis in an atrophic endometrium and myometrium associated with terminal stress. This entity is well recognised in older literature but few recent publications have addressed this condition. It is thought to occur in association with hypoperfusion with passive hyperaemia and reperfusion injury. This case serves to highlight this rarely encountered entity as a possible cause of haemorrhage in an atrophic endometrium in the 'perimortem' period. Incidental findings are occasionally observed in the course of forensic autopsy practice and knowledge of rarely encountered entities, such as that described in this case, is essential to prevent diagnostic uncertainty and misdiagnosis.

Effectiveness of programmes as part of primary prevention demonstrated on the example of cardiovascular diseases and the metabolic syndrome.

BACKGROUND: The HTA-report (HTA = Health Technology Assessment) deals with the primary prevention of cardiovascular diseases and diabetes mellitus type 2. In 2009 approximately 356,000 people died in Germany due to cardiovascular diseases. According to estimations about 6.3 million people are suffering from diabetes mellitus type 2. The interventions that are subsidized by the public health insurance are mainly focused on sufficient physical activities, healthy nutrition, stress management and the reduction of the consumption of addictive drugs and luxury food. OBJECTIVES: Which lifestyle-related measures and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are effective? To what extent will the health status be improved by these offers? To what extent will existing health resources and skills be strengthened by these offers? Are there any differences regarding the effectiveness among the interventions with respect to different settings or subgroups? Which lifestyle-related interventions and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are sustainable and cost-effective? Which outcome parameters are in the view of the contributors decisive for the evaluation of the effectiveness? In the view of the contributor are there different values between the outcome parameters? In the view of the payers and other actors are there different values between the outcome parameters? Which ethical and juridical factors have to be considered? Which social and/or socio-economic parameters influence the use of the services and effectiveness? METHODS: A systematic literature research is done in 35 databases. For the period 2005 to 2010, reviews, epidemiological and clinical studies as well as economical evaluations which deal with primary prevention programmes regarding cardiovascular diseases or the metabolic syndrome are included. RESULTS: 44 publications meet the inclusion criteria. These studies confirm the effectiveness of the primary prevention programmes. Physical activity programs seem to have a stronger effect than nutrition programmes. Psychological programmes prove as well effectiveness, if they include cognitive behaviour therapy. The identified economical studies indicate that programmes for cardiovascular prevention can be conducted cost-effectively. Interventions that focus on the general population turn out to be particularly cost-effective and sustainable. DISCUSSION: There is a wide range of primary preventive effective lifestyle-related interventions with high evidence. The outcomes and results are consistent with the recommendations of the two identified evidence-based guidelines regarding the recommendations on lifestyle and healthy nutrition. Furthermore, the cost-effectiveness of primary prevention services is proven. With regard to the economical studies it is however worth noting that this result is based on very few publications. The transferability has to be critically assessed as the studies mainly originate from the American health system. CONCLUSION: On the whole a comprehensive setting approach with educative, somatic, psychosocial and activity therapeutic components is recommended. The sustainability of a prevention intervention must be ensured from programme to programme. Long-term studies are necessary to make valid statements regarding the sustainable effectiveness: There is an essential deficit in the current practiced evaluation of the use of primary prevention services provided by the health insurance - mainly regarding the comprehensive setting approach - regarding the evidence-based evaluation of the prescribed preventive interventions. With regard to the ethical, social and economical evaluation the research situation is deficient. The situation has to be particularly analyzed for the socially deprived and one has to respond to their specific needs for prevention.

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.

Discussion on Functions of Naomaitai Capsule from Basic Pathogenesis of Apoplexy / 国际中医中药杂志

TCM believes that apoplexia is a disease of deficiency in origin and asthenia in superficiality. The deficiency is mainly the Qi deficiency and the superficiality is turbid phlegm retention and blood stasis due to Qi deficiency. Therefore, the therapeutic method should treat the origin of apoplexy as well as its superficiality. Based on the pathogenesis of apoplexy of Qi deficiency and phlegm-blood stasis, Naomaitai Capsule was formulated with the functions of supplying Qi to consolidate the origin, activating blood flow, dissipating phlegm, dredging collaterals, and stopping endogenous wind.

Abscesso hipofisário simulando apoplexia / Pituitary abscess simulating apoplexy / Pituitary abscess simulating apoplexy

O abscesso hipofisário representa uma patologia rara, que, contudo, deve ser considerada na avaliação das massas selares, uma vez que o seu prognóstico depende da drenagem cirúrgica e do uso de antibióticos específicos. A principal manifestação clínica é cefaléia crônica e nem sempre está associada à identificação de um foco infeccioso, o que diminui a probabilidade da sua inclusão nas hipóteses diagnósticas. Apresenta-se o caso de um paciente com abscesso de hipófise e história pregressa de adenoma operado, cefaléia de início recente e hipopituitarismo adquirido, cujo diagnóstico inicial foi de apoplexia pituitária.

A pituitary abscess is a rare pathology, but it must be considered when evaluating sellar masses, since its prognosis depends on surgical drainage and on the use of specific antibiotics. The main clinical manifestation is chronic headache, and it is not always associated with the identification of a site of infection, which diminishes the probability of including it in diagnostic hypotheses. The case is presented of a patient with a pituitary abscess and a previous history of adenoma that had been operated on, recent onset headache and acquired hypopituitarism whose initial diagnosis was pituitary apoplexy.

Nosocomial Fungal Infection in Cerebral Apoplectic Patients: A Clinical Analysis / 中华医院感染学杂志

OBJECTIVE To investigate and control the risk factors about nosocomial fungal infection in cerebral apoplectic patients. METHODS To study retrospectively 3027 hospitalized patients with cerebral apoplexia in our hospital from Sep 2002 to Sep 2005. RESULTS The incidence of nosocomial fungal infection was 3.24% in all(3 027 cases).Nosocomial fungal infection occurred mainly in lower respiratory tract(67.2%) and oral cavity(21.1%),the main pathogens of nosocomial fungal infection were Candida spp(96.7%).Developments of nosocomial fungal infections were closely related with aging,time of antibiotics therapy,coma,bed-days,diabetes mellitus,difficulties in swallowing,and hypoalbuminemia. CONCLUSIONS The rate of nosocomial fungal infections is higher in cerebral apoplectic patients with aging coma,long bed-days,diabetes mellitus,difficulties in swallowing,hypoalbuminemia,and receiving broad-spectrum antimicrobial agents therapy.Candida spp are the main pathogens of nosocomial fungal infections.We must take some measures to control the risk factors mentioned above and prevent nosocomial fungal infections.