Clinical features and surgical outcome of clinical and subclinical pituitary apoplexy

Liu, Zhuo-Hao; Chang, Chih-Ching; Pai, Ping‐Ching; Wei, Kuo-Chen; Jung, Shih Ming; Chen, Nan-Yu; Chuang, Chi‐Cheng

doi:10.1016/j.jocn.2009.11.012

Cited by 79 publications

(70 citation statements)

References 26 publications

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“…Bleeding also typically occurs in pituitary adenomas. Repeated bleeding may occur on the basis of ischemic necrosis or hemorrhagic necrosis (11)(12)(13). Various previous studies have suggested that fluid-fluid level within a fluid cavity is induced by the sedimentation of blood products at the subacute or chronic stage, as well as the separation of unclotted blood as opposed to serous (interstitial) fluid (6,(10)(11)(12)14,15).…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, hemorrhage within pituitary adenomas is common in patients with non-functioning adenomas and prolactinomas (9,(16)(17)(18)(19)(20)(21); although an earlier study suggests that GH-and ACTH-secreting pituitary adenomas are more likely to present apoplexy than others (22). This immunological variation may be due to the lack of specific clinical markers for non-functioning and FSH/LH tumors, which may remain undetected for many years until they become large enough to induce tumor ischemia (13,21). In PRL and multi-functional pituitary adenomas, hemorrhage and cystic degeneration may occur due to high metabolism and relative ischemia (19).…”

Section: Discussionmentioning

confidence: 99%

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Fluid-fluid level on magnetic resonance images may predict the occurrence of pituitary adenomas in cystic sellar-suprasellar masses

Xiao

Wang

Zhang

et al. 2017

Experimental and Therapeutic Medicine

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Abstract. The aim of the present study was to evaluate the value of identifying fluid-fluid level via preoperative magnetic resonance (MR) images in differentiating pituitary adenomas from craniopharyngioma, Rathke's cleft cyst (RCC), and other cystic sellar-suprasellar lesions. The data of 293 consecutive patients who underwent surgery for sellar-suprasellar lesions between July 2010 and December 2012 was retrospectively reviewed, and a total of 133 cystic cases were included in the present study. MR images and pathological features of all subjects were examined. Among the 133 cystic sellar-suprasellar masses, there were 78 cases of pituitary adenomas, 31 cases of craniopharyngioma, 21 cases of RCC, one case of epidermoid cyst and two cases of abscess. Fluid-fluid levels were identified n 43 cases (55.13%) of cystic pituitary adenomas, with a single fluid level in 23 cases, two fluid levels in 8 cases, and three levels or more in 12 cases. Two cases (6.45%) of craniopharyngioma, and one case (4.76%) of RCC presented single fluid level. No instances of fluid-fluid levels were observed in epidermoid cyst or abscess. Fluid-fluid levels were typically exhibited on axial T2-weighted images. The identification of fluid-fluid level in cysts provides useful diagnostic value in distinguishing pituitary adenoma from other sellar-suprasellar lesions. The findings of the present study suggest that a sellar-suprasellar mass with a fluid-fluid level inside the tumor is most likely a pituitary adenoma, particularly if multiple fluid levels are observed in the same tumor. The fluid-fluid level is typically clearly depicted on axial or sagittal MR images, suggesting subacute or chronic hemorrhage in pituitary adenomas.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Fluid-fluid level on magnetic resonance images may predict the occurrence of pituitary adenomas in cystic sellar-suprasellar masses

Xiao

Wang

Zhang

et al. 2017

Experimental and Therapeutic Medicine

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“…Since apoplectic pituitary adenomas display higher proliferation than non-apoplectic ones and HIF-1α is expressed in all types of pituitary adenomas (12,13), it is anticipated that fast growing tumor cells are prone to outstrip their blood supply and suffer sublethal local hypoxia, which itself stimulates HIF-1α activity and then promotes hemorrhagic transformation in pituitary adenomas. Thus, in this study, we investigated cell proliferation and HIF-1α signaling in apoplectic and non-apoplectic pituitary adenomas and evaluated their relation with pituitary apoplexy.…”

Section: Introductionmentioning

confidence: 99%

Hypoxia induces hemorrhagic transformation in pituitary adenomas via the HIF-1α signaling pathway

Zhang

Liu²,

Zhao³

et al. 2011

Oncol Rep

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Abstract. The hypoxia inducible factor 1 α (HIF-1α) activity has been associated with various hemorrhagic events. The biological role of HIF-1α in the hemorrhagic transformation of pituitary adenomas remains unknown. We hypothesized that fast growing tumor cells tend to predispose themselves to sublethal hypoxia and activate the HIF-1α signaling pathway, leading to hemorrhagic transformation in pituitary adenomas. Here, we used apoplectic and non-apoplectic pituitary adenomas to determine the involvement of HIF-1α signaling in intratumoral hemorrhage. We employed HIF-1α overexpression/knockdown strategies to examine the association between HIF-1α signaling and hemorrhagic presentation in vitro and in vivo. In support of our hypothesis, compared with nonhemorrhagic pituitary adenomas, higher cellular proliferation was observed in hemorrhagic ones and it correlated with increased HIF-1α signaling. HIF-1α overexpression activated its downstream genes, vascular endothelial growth factor and the proapoptotic BNIP3, in MMQ pituitary adenoma cells and this up-regulation was attenuated by HIF-1 siRNA. In vivo studies using MMQ cell xenografts in nude mice showed that HIF-1α overexpression significantly promoted hemorrhagic transformation. Our study indicates that tumor hypoxia, following rapid tumor growth, may promote hemorrhagic transformation in pituitary adenomas via the HIF-1α signaling pathway.

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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: 87%

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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Clinical features and surgical outcome of clinical and subclinical pituitary apoplexy

Cited by 79 publications

References 26 publications

Fluid-fluid level on magnetic resonance images may predict the occurrence of pituitary adenomas in cystic sellar-suprasellar masses

Fluid-fluid level on magnetic resonance images may predict the occurrence of pituitary adenomas in cystic sellar-suprasellar masses

Hypoxia induces hemorrhagic transformation in pituitary adenomas via the HIF-1α signaling pathway

Apoplexy of pituitary adenomas: the perfect storm

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