A case of pituitary apoplexy masquerading as subarachnoid hemorrhage

Choudhury, M.; Eligar, Vinay; DeLloyd, Anna; Davies, John Stephen

doi:10.1002/ccr3.488

Cited by 7 publications

(3 citation statements)

References 12 publications

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“…Extravasation of haemorrhagic components from the pituitary into the subarachnoid space produces the typical clinical characteristics of SAH. Initial investigations can be non-discriminatory as imaging with CT or MRI usually demonstrates blood in the subarachnoid space and CSF analysis may reveal erythrocytes and/or xanthochromia ( 8 ). The MRI appearances of the adenoma may suggest fresh haemorrhage (hyperintense intratumoral lesion with gadolinium on T1-weighted image), and angiographic studies are required to exclude a ruptured intracranial aneurysm and to initiate urgent surgical decompression of the pituitary mass.…”

Section: Discussionmentioning

confidence: 99%

Aneurysmal subarachnoid haemorrhage in the pituitary fossa of a patient with acromegaly – a rare phenomenon

Fookeerah

McLean

2023

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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Summary The anatomy of the pituitary fossa is complex. The wall of the fossa can vary, resulting in inconsistencies in the nature and integrity of the sella barrier. Cerebrospinal fluid is generally confined to the subarachnoid space and does not circulate freely in the pituitary fossa. Spontaneous haemorrhage in the fossa typically occurs in the context of pre-existing intrasellar pathology such as a pituitary adenoma. Extravasation of blood into the subarachnoid space can rarely be observed following pituitary apoplexy. We describe the unique occurrence of subarachnoid haemorrhage in a largely empty pituitary fossa after the rupture of a cerebral aneurysm. Learning points Pituitary apoplexy and subarachnoid haemorrhage (SAH) are both high in the differential diagnosis of sudden onset severe headaches. Haemorrhagic pituitary apoplexy may result in extravasation into the subarachnoid space, resulting in typical SAH symptoms and signs. This is the first reported case of primary SAH resulting in blood pooling in an empty sella arising from previous surgical resection of a large macroadenoma.

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Section: Discussionmentioning

confidence: 99%

Aneurysmal subarachnoid haemorrhage in the pituitary fossa of a patient with acromegaly – a rare phenomenon

Fookeerah

McLean

2023

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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“…Anticoagulation [ 25 , 64 , 66 , 70 , 128 , 135 , 138 , 160 , 166 , 173 , 195 , 198 ] and antiplatelet therapy [ 90 , 94 , 97 , 113 , 141 , 160 , 166 , 169 ] are the most important iatrogenic elements. For instance, we mention rivaroxaban, enoxaparin, dabigatran etexilate, warfarin, heparin, apixaban, and aspirin.…”

Section: Pitnet Complicated With Pamentioning

confidence: 99%

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

et al. 2023

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Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.

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“…Notably, pituitary apoplexy can be the first presentation of a previously undiagnosed macroadenoma (6). Early recognition and management of PA by monitoring fluid and electrolyte levels, administering glucocorticoids awaiting hormonal work-up results, and correcting pituitary hormone deficiencies is a key to achieve a favorable outcome and complete symptoms resolution (7,8).…”

Section: Introductionmentioning

confidence: 99%

Potential Association Between Anabolic Androgenic Steroid Abuse and Pituitary Apoplexy: A Case Report

et al. 2022

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IntroductionPituitary apoplexy (PA) is a rare, and potentially life-threatening condition, caused by hemorrhage or infarction into the pituitary gland with a rapid expansion of the contents of the sella turcica, associated with sudden intense headache, neurological and endocrinological deterioration. The identification of risk factors is crucial for prevention and optimal management. Herein we report a case of PA occurring 1 month after the initiation of anabolic androgenic steroid abuse for bodybuilding.Case ReportA 40-year-old male patient presents with abrupt onset headache associated with left partial third cranial nerve palsy. The MRI shows a sellar lesion involving left cavernous sinus with a heterogenous anterior aspect of the lesion with hemorrhagic zones in favor of PA. Endocrine work-up shows high testosterone level in patient who was using exogenous testosterone without a medical prescription for a month.ConclusionWe report a case of PA of a pituitary neuroendocrine tumor occurring shortly after AAS. The association between PA and AAS should be considered as a potential risk.

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A case of pituitary apoplexy masquerading as subarachnoid hemorrhage

Abstract: Key Clinical MessagePituitary apoplexy may cause xanthochromia and mimic the clinical presentation of subarachnoid hemorrhage.

Cited by 7 publications

References 12 publications

Aneurysmal subarachnoid haemorrhage in the pituitary fossa of a patient with acromegaly – a rare phenomenon

Aneurysmal subarachnoid haemorrhage in the pituitary fossa of a patient with acromegaly – a rare phenomenon

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

Potential Association Between Anabolic Androgenic Steroid Abuse and Pituitary Apoplexy: A Case Report

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