Clinical versus Subclinical Pituitary Apoplexy: Presentation, Surgical Management, and Outcome in 21 Patients

Abstract

A retrospective review of 16 consecutive patients with pituitary apoplexy treated over a 10-year period is reported. Eight men and 8 women (mean age, 48 years) underwent transsphenoidal decompression after an average duration of symptoms of 19 days. The diagnosis of pituitary apoplexy was made by the sudden onset of headache (88%), nausea (56%), or meningismus (13%), with or without visual disturbances (75%), in the setting of a sellar tumor on computed tomographic or magnetic resonance imaging scans. Thirteen of 16 patients showed significant improvement of symptoms after surgery (average follow-up, 2.5 years). In addition, 5 patients with clinically silent yet extensive pituitary hemorrhage were treated. Although extensive pituitary hemorrhage often produced fulminant apoplexy, it also presented insidiously over many days with few, if any, clinical signs. Rapid diagnosis, endocrine replacement, and transsphenoidal decompression constituted effective therapy. Magnetic resonance imaging (after at least 12 hours of symptoms) was superior to computed tomography in detecting hemorrhage.

Pituitary Apoplexy Caused by Ruptured Internal Carotid Artery Aneurysm

“…1,7 In the present case, in retrospect, we should have suspected that the presence of an unusual flow-void protrusion suggested a vascular component from the ICA. If a pituitary adenoma is present, the possibility of a coincidental aneurysm should always be considered.…”

“…1,2 However, the exact mechanism of pituitary apoplexy is not always clear. 1,2 Recently, Provenzale et al 3 reported a case in which pituitary apoplexy occurred probably secondary to internal carotid artery (ICA) dissection. We present a case of pituitary apoplexy caused by an unsuspected aneurysmal bleeding into a pituitary adenoma.…”

Apoplexia subclínica em tumores pituitários

“…Isto está em concordância com outras publicações, em que as hemorragias intra-adenomatosas em sua maioria são silenciosas 2,11 . Setenta e cinco por cento dos tumores hipofisários, em nossa casuística, eram não funcionantes.…”

“…Dos 3 pacientes com cefaléia 2 melhoraram após o procedimento cirúrgico. Esses resultados estão em concordância com os resultados de Onesti e col. 2 , em que 13 de 16 pacientes (81.2%) apresentaram melhora neurológica após tratamento neurocirúrgico. O grau de melhora visual parece relacionar-se mais ao grau de acometimento campimétrico pré-operatório e ao grau de palidez papilar, do que ao grau de acometimento visual isoladamente 2 , como ocorre nos casos de apoplexia aguda (observação pessoal).…”

“…A apoplexia pituitária aguda pode caracterizar-se clinicamente por diminuição súbita da visão, paralisias oculomotoras, cefaléia severa, diminuição do nível de consciência, hipopituitarismo e sinais de irritação meníngea [1][2][3] . Isto geralmente ocorre em decorrência da expansão abrupta do conteúdo selar como resultado de hemorragia ou infarto de um adenoma pituitário ou, mais raramente, em tumores não adenomatosos e em glândulas normais 4 .…”