Classical pituitary tumour apoplexy: Clinical features, management and outcomes in a series of 24 patients

Dubuisson, Annie; Beckers, Albert; Stevenaert, Achille

doi:10.1016/j.clineuro.2006.01.006

Cited by 175 publications

(168 citation statements)

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“…When apoplexy arises in functioning adenomas, it may result in spontaneous remission of symptoms and sometimes may lead to hypopituitarism. Similar to the present case, spontaneous remission of acromegaly after PA has been reported previously [1,2]. Although the patient had previous diagnosis and typical clinical features of acromegaly, basal hormone levels clearly showed deficiency of GH besides other pituitary hormones ( Table 1).…”

Section: Discussionsupporting

confidence: 68%

“…This clinical syndrome which is characterized by acute onset of headache, nausea, vomiting may be accompanied by loss of vision or ocular move- [1,2]. In addition to the visual and ocular problems, PA may lead to numerous endocrinopathies which can be transient or permanent.…”

Section: Discussionmentioning

confidence: 99%

“…PA is a rare event and its incidence in the large series of pituitary adenomas has been reported as 1.6% [1]. Recently, three clinical series including the largest groups in the literature from different centers have been published [1][2][3].…”

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confidence: 99%

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Complete Surgical Resolution of Bilateral Total Opthalmoplegia without Visual Field Defect in an Acromegalic Patient Presented with Pituitary Apoplexy

et al. 2007

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Abstract. Pituitary apoplexy (PA), which is one of the most serious life-threatening complications of pituitary adenoma, is characterized by abrupt onset of headache, nausea, vomiting, visual disturbances and oculomotor paresis. Combination of oculomotor cranial nerve paralysis with normal visual fields is very rare in PA. We report a 60-year-old acromegalic man presented with panhypopituitarism and bilateral total opthalmoplegia without a visual field defect. At initial evaluation his clinical findings were compatible with adrenal crisis and eye examination revealed total opthalmoplegia, bilateral ptosis and normal vision. MRI showed a large heterogeneous mass in the pituitary fossa. Although clinical findings due to adrenal crisis improved after glucocorticoid therapy there was no improvement in opthalmoplegia and ptosis. The patient underwent transsphenoidal excision of the pituitary mass. Histological examination revealed an adenoma with large areas of hemorrhagic infarction and most of the cells were positive for GH in immunohistochemical analysis. Although opthalmoplegia was severe at presentation, total recovery was achieved 3 months after transsphenoidal surgery. Therefore the presented case clearly demonstrates that opthalmoplegia without a visual field defect due to PA has a good prognosis and early diagnosis and treatment including surgical decompression are crucially important.

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Section: Discussionsupporting

confidence: 68%

Section: Discussionmentioning

confidence: 99%

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Complete Surgical Resolution of Bilateral Total Opthalmoplegia without Visual Field Defect in an Acromegalic Patient Presented with Pituitary Apoplexy

et al. 2007

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“…Traditionally, most patients with apoplexy were treated surgically after this initial stabilization. 3,8,13,16,31 However, more recent series have repeatedly reported good outcomes in selected patients treated conservatively with medical therapy only. 5,9,13,17,21,23,25,31 In our study, 70% of the patients were treated with early resection, but the rest were treated with a delayed, planned surgical intervention (9%) or solely with medical treatment (21%).…”

Section: Discussionmentioning

confidence: 99%

Management and outcomes of pituitary apoplexy

Singh¹,

Valizadeh²,

Meyer³

et al. 2015

JNS

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OBJECT This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes. METHODS The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale). RESULTS Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15–91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3–10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups. CONCLUSIONS The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.

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“…The typical clinical entity was described relatively late, in 1950, by Brougham et al 12 Since then pituitary apoplexy has been the subject of many reports describing the clinical presentation, patient management, imaging features, and outcome, as well as reports of acute circumstances predisposing to its occurrence. 9,10,14,15,17,[22][23][24][25]29,32,36,37,39,45 We propose here that infarction of these tumors is the product of a combination of intrinsic features of these tumors and that it is the tenuous imbalance between their high rate of demand for nutrients combined with their limited intrinsic blood supply that makes them vulnerable to infarction, with or without precipitating events, and suggest that this circumstance may permit new approaches to treatment based on this peculiar vulnerability. …”

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confidence: 99%

Apoplexy of pituitary adenomas: the perfect storm

Oldfield

Merrill

2015

JNS

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Pituitary tumors spontaneously infarct at a relatively high rate, higher than any other CNS tumor. This occurs with or without hemorrhage. The typical clinical entity was described relatively late, in 1950, by Brougham et al. 12 Since then pituitary apoplexy has been the subject of many reports describing the clinical presentation, patient management, imaging features, and outcome, as well as reports of acute circumstances predisposing to its occurrence. 9,10,14,15,17,[22][23][24][25]29,32,36,37,39,45 We propose here that infarction of these tumors is the product of a combination of intrinsic features of these tumors and that it is the tenuous imbalance between their high rate of demand for nutrients combined with their limited intrinsic blood supply that makes them vulnerable to infarction, with or without precipitating events, and suggest that this circumstance may permit new approaches to treatment based on this peculiar vulnerability. case of Pituitary apoplexyA 57-year-old male had the sudden onset of headache followed by excessive thirst, polydipsia, loss of energy, and abbreviatioNs FDG = fluorodeoxyglucose; PET = positron emission tomography; VEGF = vascular endothelial growth factor. submitted July 25, 2014. accePted October 8, 2014. iNclude wheN citiNg Published online April 10, 2015; DOI: 10.3171/2014.10.JNS141720. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. obJect Pituitary adenomas occasionally undergo infarction, apoplexy, which often destroys much of the tumor. It is well known that apoplexy can be precipitated by several acute factors, including cardiac surgery, other types of surgery, trauma, insulin infusion, and stimulation with administration of hypothalamic releasing factors. methods The prior focus on mechanisms underlying pituitary apoplexy has been on these acute events. Less attention has been given to the endogenous features of pituitary tumors that make them susceptible to spontaneous infarction, despite that most pituitary apoplexy occurs in the absence of a recognized precipitating event. The authors examine intrinsic features of pituitary adenomas that render them vulnerable to apoplexy-features such as high metabolic demand, paucity of angiogenesis, and sparse vascularity, qualities that have previously not been linked with apoplexy-and argue that it is these features of adenomas that underlie their susceptibility to spontaneous infarction. The sensitivity of freshly cultured pituitary adenomas to hypoglycemia is assessed. results Adenomas have high metabolic demand, limited angiogenesis, and reduced vessel density compared with the normal gland. Pituitary adenoma cells do not survive in the presence of reduced or absent concentrations of glucose. coNclusioNs The authors propose that the frequent ischemic infarction of pituitary adenomas is the product of intrinsic features of these tumors. These endogenous qualities create a tenuous balance between high metabolic demand and ...

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Classical pituitary tumour apoplexy: Clinical features, management and outcomes in a series of 24 patients

Cited by 175 publications

References 57 publications

Complete Surgical Resolution of Bilateral Total Opthalmoplegia without Visual Field Defect in an Acromegalic Patient Presented with Pituitary Apoplexy

Complete Surgical Resolution of Bilateral Total Opthalmoplegia without Visual Field Defect in an Acromegalic Patient Presented with Pituitary Apoplexy

Management and outcomes of pituitary apoplexy

Apoplexy of pituitary adenomas: the perfect storm

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