Subarachnoid hemorrhage due to pituitary adenoma apoplexy-case report and review of the literature.

Pituitary apoplexy (PA) may be complicated by development of subarachnoid hemorrhage (SAH). We conducted a literature review to evaluate the rate of PA-associated tumor rupture and SAH. We conducted a systematic literature search (PubMed, Web of Science, Medline) for patients with PA-associated SAH and report a case SAH following PA. Suitable articles, case series, and case reports were selected based on predefined criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). We reviewed included publications for clinical, radiological, surgical, and histopathological parameters.We present the case of a patient with PA developing extensive SAH whilst on the MRI who underwent delayed transsphenoidal resection. According to our literature review, we found 55 patients with a median age of 46 years; 18 (32.7%) were female. Factors associated with PA-related SAH were hypertension, diabetes mellitus, prior trauma, anticoagulant, and/or antiplatelet therapy. The most common presenting symptoms included severe headache, nausea and/or vomiting, impaired consciousness, and meningeal irritation. Acute onset was described in almost all patients. Twenty-two of the included patients underwent resection. In patients with available outcome, 45.1% had a favorable outcome, 10 (19.6%) had persisting focal neurological deficits, 7 developed cerebral vasospasms (12.7%), and 18 (35.3%) died. Mortality greatly differed between surgically (9.1%) and non-surgically (44.8%) treated patients. PA-associated SAH is a rare condition developing predominantly in males with previously unknown macroadenomas. Timely surgery often prevents aggravation or development of severe neuro-ophthalmological defects and improves clinical outcome.

Natural history of pituitary apoplexy: a long-term follow-up study.

BACKGROUND AND AIMS: Pituitary apoplexy (PA) is a rare neurosurgical emergency, associated with deficiency of one or more pituitary hormones. Few studies have explored the relative outcomes associated with conservative and neurosurgical intervention. METHODS: A retrospective evaluation of all patients with PA reviewed at Morriston Hospital was undertaken and diagnosis was obtained from Morriston database (Leicester Clinical Workstation database) between 1998 and 2019 from clinic letters and discharge summaries. RESULTS: Thirty-nine patients with PA were identified with a mean age of 74.5 years and 20 (51.3%) patients were women. Patients were followed up for a mean±SD 68.1±61.7 months. Twenty-three (59.0%) patients had a known pituitary adenoma. Commoner clinical presentations of PA were ophthalmoplegia or visual field loss. Following PA, 34 (87.2%) patients were noted to have a non-functioning pituitary adenoma (either pre-existing or new), while 5 (12.8%) patients had a pre-existing functional macroadenoma. Neurosurgical intervention was taken in 15 (38.5%) patients of which 3 (20.0%) patients also received radiotherapy, 2 (13.3%) patients had radiotherapy alone and the remainder managed conservatively. External ophthalmoplegia recovered in all cases. Visual loss remained in all cases. One (2.6%) patient with chromophobe adenoma had a significant second episode of PA requiring repeat surgery. CONCLUSION: PA often occurs in patients with undiagnosed adenoma. Hypopituitarism commonly occurred following conservative or surgical treatment. External ophthalmoplegia resolved in all cases, however, visual loss did not recover. Pituitary tumour recurrence and further PA episodes are rare.

Double jeopardy - pituitary apoplexy complicated by ruptured aneurysm of the internal carotid artery within an adenoma: a case report.

BACKGROUND: Sudden onset of severe headache is the most common presentation of a ruptured intracranial aneurysm. Similar symptoms can be caused by pituitary apoplexy, and radiological examination is needed to distinguish between the two. Development of infarction and/or haemorrhage of the hypophysis with concomitant unruptured cerebral aneurysm has been described. However, intratumoural aneurysm within a pituitary adenoma presenting with the ictus of both pathologies is extremely rare. CASE PRESENTATION: A 64-year-old man presented with classic symptoms of pituitary apoplexy. His symptoms improved after a few days, and he was discharged. However, he subsequently developed further episodes of sudden and severe headache together with visual decline and ophthalmoplegia. Radiographs demonstrated an enlarging sellar mass with suspicion of a ruptured internal carotid artery aneurysm, within the apoplectic pituitary macroadenoma. Although an endovascular procedure was planned, the patient developed massive subarachnoid haemorrhage resulting in brain death. CONCLUSION: This case report describes an intratumoural aneurysm of the cavernous internal carotid artery as a potential cause or result of pituitary apoplexy. Despite its rarity, this possible life-threatening complication of pituitary apoplexy should be recognised for prompt diagnosis and early management.

Pituitary apoplexy secondary to metastatic breast carcinoma into a gonadotroph cell adenoma of the pituitary.

A 65 year-old lady with metastatic breast cancer presented with pituitary apoplexy. Following surgery, histopathology confirmed metastatic breast carcinoma into a gonadotroph cell adenoma of the pituitary. Tumours that metastasise to a normal pituitary gland are unusual. More so, such neoplasm-to-neoplasm metastasis is extremely rare. This is, as far as we are aware, the first description of a metastasis into a gonadotroph cell pituitary adenoma presenting as apoplexy.

Pituitary Apoplexy: Risk Factors and Underlying Molecular Mechanisms.

Pituitary apoplexy is a rare syndrome, graded from asymptomatic subclinical apoplexy to a life-threatening condition due to pituitary ischemia or haemorrhage of an enlarged pituitary gland. The risk factors and the molecular underlying mechanisms are yet to be elucidated. We provide an overview of the general concepts, the potential factors associated with pituitary adenoma susceptibility for apoplectic events and the molecular mechanisms that could be involved such as HIF-1α/VEGF pathways and metalloproteinases activation, among others. The knowledge of the molecular mechanisms that could participate in the pathogenesis of pituitary apoplexy is crucial to advancement in the identification of future diagnostic tools and therapeutic targets in this rare but sometimes fatal condition.

Domino effect of pituitary growth hormone tumor complicated by diabetic ketoacidosis and pituitary apoplexy: a case report.

BACKGROUND: Patients with growth hormone (GH)-secreting adenoma usually develop glucose intolerance. GH increases metabolic rate and, when secreted aberrantly, may result in metabolic syndrome. Herein, we examine the associations of pituitary tumor-induced secretion of hormone with insulin resistance and metabolic syndrome, and determine the relation of pituitary tumor apoplexy-induced diabetic ketoacidosis (DKA) and acute pancreatitis. CASE PRESENTATION: A 44-year-old male with a history of hypertension presented to the emergency department of our hospital on February 14, 2019 with symptoms of headache, dizziness, and vomiting. Computed tomography of the head revealed pituitary tumor with bleeding. An ultrasound scan of the abdomen revealed fatty liver and acute pancreatitis. Further examination revealed the presence of DKA, hypertriglyceridemia, cortical hypofunction crisis and acute kidney injury. Surgical endoscopic resection of the pituitary tumor resection via the transsphenoidal approach was performed. The patient's postoperative recovery was remarkable. CONCLUSIONS: Long-term growth hormone abnormality may trigger insulin resistance, leading to metabolic syndrome and impaired glucose and lipid metabolism. The pituitary adenoma apoplexy may also directly induce DKA, creating a domino effect, which further deteriorate the aberrant metabolism of glucose and lipids.

Pituitary apoplexy of a giant prolactinoma during pregnancy.

AIMS AND METHODS: Prolactinomas are a common cause of sexual dysfunction and infertility. We aimed, through this case report, to illustrate the difficulties of management of women with giant prolactinoma, especially in cases of desire of pregnancy. RESULTS: A 30-year-old woman was referred to our department for secondary amenorrhea. Investigations showed a prolactin level of 5168 ng/mL and giant pituitary adenoma of 4 cm in diameter. Cytoreductive surgery was performed after failure to normalize prolactin levels during three years with medical treatment by cabergoline. After seven months, menstrual cycles have resumed, and after 13 months, the patient became pregnant. At 22nd week of gestation, she was admitted in our hospital for pituitary apoplexy. Medical treatment with bromocriptine was chosen. The vaginal premature delivery at 28 weeks gave birth to twins weighing 1 Kg each who died on the 7th day of life. CONCLUSION: This is a relevant clinical case that illustrates the efficacy of cytoreductive surgery in case of insufficient response to dopamine agonists to restore gonadal function. The possibility of a pregnancy should be considered in these patients since it can be associated with high maternal and fetal risks.

Case Report: Polyneuropathy Pituitary Apoplexy with Normal Perimetry and Initially Normal Neuroimaging.

SIGNIFICANCE: Pituitary apoplexy is a syndrome with a varied appearance, which carries a significant risk of morbidity and mortality. It is important to recognize the potential numerous symptoms and clinical findings, urgently investigate with the proper neuroimaging tests, and coordinate care with the appropriate specialists without delay. PURPOSE: This study aimed to describe a patient with worsening headache and ophthalmoparesis attributable to pituitary apoplexy who initially had reportedly a normal neuroimaging result and were diagnosed with migraine. CASE REPORT: A 39-year-old Hispanic man with a history of migraine developed a new and worsening headache. He presented to a hospital emergency department where he underwent a non-contrast-enhanced computed tomography and MRI, whose results were subsequently interpreted as normal. His headache was attributed to migraine, and he was medicated as such and discharged. Three days later, he developed horizontal and vertical diplopia and sought a second opinion. His visual acuity and visual fields were normal. He manifested a right pupil-sparing, external partial cranial nerve III palsy and concurrent right sixth nerve palsy. He also complained of worsening headache and lethargy. He was immediately referred for contrast-enhanced MRI and magnetic resonance angiography with suspicion of pituitary apoplexy. Subsequent imaging revealed a hemorrhagic pituitary macroadenoma consistent with pituitary apoplexy that was expanding laterally into the right cavernous sinus. He underwent immediate neurosurgical surgical repair. CONCLUSIONS: New or worsening headache with signs and symptoms of hypopituitarism should immediately be investigated for pituitary apoplexy. Other possible findings include involvement of cranial nerves III through VI because of cavernous sinus involvement and visual deficits if the optic chiasm or intracranial portion of the optic nerve is involved. However, growth may be lateral, and no visual deficits may be found, as in this case. Multiple concurrent cranial neuropathies should increase suspicion for cavernous sinus involvement.

Takotsubo cardiomyopathy and pituitary apoplexy: a case report.

BACKGROUND: Takotsubo cardiomyopathy (TTC) has been widely recognized in recent decades and is triggered by either physical or psychological stressors. CASE PRESENTATION: A 70-year-old woman presented to the Emergency Department due to confusion, hypotension, fever, chills, and cough. She had a one-year history of diabetes insipidus. Pituitary function examination at admission revealed decreased thyroid, sex and adrenal hormones. Pituitary MRI displayed findings suggestive of nonhemorrhagic pituitary apoplexy. Electrocardiogram (ECG) revealed T-wave inversion and extended QT interval. Transthoracic echocardiogram (TTE) showed left ventricular apical dysplasia and ballooning, accompanied by reduced left ventricular ejection fraction. Coronary angiography (CAG) revealed no obvious coronary arterial stenosis. The left ventriculogram demonstrated an octopus clathrate appearance. Most ECG and TTE changes recovered 10 days later. CONCLUSIONS: To the best of our knowledge, this is the first report of newly diagnosed TTC associated with pituitary apoplexy.

Pituitary Apoplexy Leading to Cerebral Infarction: A Systematic Review.

BACKGROUND: Cerebral infarction caused by pituitary apoplexy (PA) is rare. To characterize the clinical features of cerebral infarction caused by PA, we performed a systematic review. SUMMARY: The clinical symptoms are mainly sudden headache, hemiplegia, visual impairment, disturbance of consciousness, and ophthalmalgia in patients with cerebral infarction caused by PA. Treatment for this type of infarction is different from treatment for general acute cerebral infarction. Compared to patients who underwent emergency surgery and conservative treatment, patients treated with delayed surgery showed a better prognosis and a lower mortality rate. Compared to patients who underwent craniotomy or conservative treatment, patients who underwent transsphenoidal surgery (TSS) not only improved well but also showed a lower mortality rate. Key Messages: PA rarely causes cerebral infarction, which is a critical condition with a poor prognosis and is more common in men. Delayed surgery and TSS appear to confer a better prognosis in patients with this condition.

Presentation and Management of Headache in Pituitary Apoplexy.

PURPOSE OF REVIEW: Pituitary apoplexy (PA) occurs in the setting of an infarction and/or hemorrhage of a pre-existing adenoma. The most common presenting symptom is a severe, sudden onset headache. However, the characteristics of headache in the setting of PA are varied and can sometimes mimic primary headache disorders. The purpose of this article is to review the various presentations of headache in PA. We also outline treatment options for persistent headaches following PA. RECENT FINDINGS: A recent retrospective review of patients undergoing transsphenoidal resection of sellar lesions, including PA, found that gross total resection and short duration of preoperative headache were predictors of improvement in headaches postoperatively. This strengthens the importance of timely recognition of PA as potential etiology of headache. The most common presentation of PA is thunderclap headache; however, several other primary HA disorders have been described including status migraine, SUNCT, and paroxysmal hemicrania.

Pituitary apoplexy masquerading as functional decline in an older person.

We report the case of an older lady who was admitted to a tertiary teaching hospital with sub-acute functional decline of two months' duration, which was initially attributed to a concomitant urinary tract infection. Further investigations, however, revealed the diagnosis of pituitary apoplexy with central hypocortisolism. Subsequent treatment with physiological doses of steroids improved patient's function and overall well-being. This report adds to the sparse literature on pituitary apoplexy in the older adults and emphasizes the non-specific presentation of this clinical syndrome.

Ventriculitis from a pituitary prolactinoma: bacterial or chemical?

We report the case of a 70-year-old man presenting with pituitary apoplexy from a macroprolactinoma and ventriculitis. It was not possible to distinguish a bacterial or chemical origin, on the basis of his clinical presentation, laboratory studies and imaging, highlighting the importance of prompt imaging and attainment of CSF cultures, in making the diagnosis.

Prolactinoma and pregnancy - a series of cases including pituitary apoplexy.

The objective of this article is to evaluate the impact of pregnancy in women with prolactinoma, the possible consequences of therapy maintenance/discontinuation during pregnancy and to assess the type of delivery and maternal-foetal obstetrical outcome. A retrospective study of all pregnant women with prolactinoma in our Centre between 2006 and 2014 was made. We had 35 cases of pregnant women with prolactinoma, two of which had an episode of pituitary apoplexy during the second trimester. At the time of conception, most women were being treated with 5 mg bromocriptine. The majority of women had suspended medication in the 8th week of gestation. Caesarean rate was 48.6%. The maternal foetal outcome was favourable in all cases.

Pituitary apoplexy - bespoke patient management allows good clinical outcome.

OBJECTIVE: To describe the clinical presentation, management and outcome of pituitary apoplexy from a single centre and retrospectively apply the Pituitary Apoplexy Score (PAS). DESIGN: Retrospective review of patients presenting with classical pituitary apoplexy to a single neurosurgical centre in the Greater Manchester region. RESULTS: A total of 31 cases with classical pituitary apoplexy were identified between 2005 and 2014. The mean age at presentation was 55 years, and there were 19 men. In only one patient was there prior knowledge of a pituitary adenoma. Eleven (35%) patients were managed conservatively and 20 (65%) patients managed surgically. Emergency surgery was carried out in 11 patients. At presentation, visual symptoms were present in a higher proportion of patients in the surgical group (90%) compared to the conservatively managed group (64%). At final follow-up, visual recovery was apparent in most patients in both the surgical (100%) and conservatively (86%) managed groups. The proportion of patients with hypopituitarism was high in both the surgical (86%) and conservative (73%) groups at presentation, and this failed to improve at final follow-up (90% vs 73%, respectively). The median PAS scores were higher in the surgical (PAS 2), compared to the conservatively managed group (PAS 0). CONCLUSION: In pituitary apoplexy patients managed conservatively or surgically, there is good recovery of visual symptoms but not endocrine function. Patients should be managed on a case-by-case basis based on the severity of symptoms at presentation, progression of disease and surgical expertise available. Further prospective studies using the PAS are required to determine its usefulness in clinical practice.