Hyperprolactinemia due to spontaneous intracranial hypotension

Abstract

SpontaneouS intracranial hypotension is an important cause of new, daily, persistent headaches that usually afflicts young to middle-aged adults, with a female predominance and a peak incidence in the 5th decade of life. 16 The headache is typically orthostatic and is often accompanied by nausea, neck pain, and hearing abnormalities. Spontaneous intracranial hypotension is uncommon, with an estimated incidence of approximately 5 per 100,000 per year. The cause of spontaneous intracranial hypotension is almost always a spontaneous spinal CSF leak, and a systemic connective tissue disorder affecting the spinal dura mater is often suspected.14 In spontaneous intracranial hypotension, pituitary enlargement is one of the 5 main imaging features that can be found on brain MRI (Sagging of the brain, Enhancement of the pachymeninges, Engorgement of venous structures, Pituitary enlargement, and Subdural fluid collections [SEEPS]). 16Pituitary enlargement in spontaneous intracranial hypotension has now been well documented and can resemble a pituitary tumor. 2,9,11,13,18 Moreover, sagging of the brain often is associated with distortion of the pituitary stalk. However, a systematic evaluation of pituitary function has not been reported in patients with spontaneous intracranial hypotension. Therefore, we investigated pituitary hormones in patients with this disorder. OBJect Spontaneous intracranial hypotension is an increasingly recognized cause of headaches. Pituitary enlargement and brain sagging are common findings on MRI in patients with this disorder. The authors therefore investigated pituitary function in patients with spontaneous intracranial hypotension. MethODS Pituitary hormones were measured in a group of 42 consecutive patients with spontaneous intracranial hypotension. For patients with hyperprolactinemia, prolactin levels also were measured following treatment. Magnetic resonance imaging was performed prior to and following treatment. reSultS The study group consisted of 27 women and 15 men with a mean age at onset of symptoms of 52.2 ± 10.7 years (mean ± SD; range 17-72 years). Hyperprolactinemia was detected in 10 patients (24%), ranging from 16 ng/ml to 96.6 ng/ml in men (normal range 3-14.7 ng/ml) and from 31.3 ng/ml to 102.5 ng/ml in women (normal range 3.8-23.2 ng/ml). In a multivariate analysis, only brain sagging on MRI was associated with hyperprolactinemia. Brain sagging was present in 60% of patients with hyperprolactinemia and in 19% of patients with normal prolactin levels (p = 0.02). Following successful treatment of the spontaneous intracranial hypotension, hyperprolactinemia resolved, along with normalization of brain MRI findings in all 10 patients. cONcluSiONS Spontaneous intracranial hypotension is a previously undescribed cause of hyperprolactinemia. Brain sagging causing distortion of the pituitary stalk (stalk effect) may be responsible for the hyperprolactinemia. Methods

A case of normoprolactinemic galactorrhea following aneurysmal subarachnoid hemorrhage

“…These two findings were reported in patients with normal prolactin levels. [8] Low cerebrospinal fluid pressure that may be seen after head trauma or cranial surgery can also cause pituitary stalk compression that was associated with galactorrhea in a patient with normal basal prolactin level. [9] In our patient, the development of normoprolactinemic galactorrhea after surgical intervention for aneurysmal brain hemorrhage could be possibly from the hemorrhage or decompression after surgical intervention leading to intracranial hypotension or low cerebrospinal fluid pressure.…”

“…[7] Spontaneous intracranial hypotension can also lead to both hyperprolactinemic and normoprolactinemic galactorrhea. [8] It is thought that intracranial hypotension causes brain sagging which can distort the pituitary stalk or cause pituitary enlargement. These two findings were reported in patients with normal prolactin levels.…”

“…Pregnancy, postpartum period, lactation, stress, nipple/ breast manipulation [8] , empty sella [10] , pituitary TSH secreting tumor [11] , Cushing's disease [12]…”

Diagnostic Imaging and Clinical Features of Intracranial Hypotension – Review of Literature

“…Following effective treatment of IH (improvements in clinical and MRI findings), hyperprolactinemia resolved in all patients. According to Schievink et al, hyperprolactinemia in patients with IH is not associated with pituitary enlargement, which occurred in only 29% of patients with elevated prolactin levels (in other studies 8–100%), but it is related to the presence of sagging of the brain [ 3 , 9 ].…”

“…Intracranial hypotension (IH), first described in 1938 by Schaltenbrand [ 1 ], is an important condition with characteristic clinical and magnetic resonance imaging (MRI) findings. It is an uncommon disease, with an estimated incidence of 5 per 100,000 per year [ 2 ], and it usually affects young to middle-aged adults, with a female predominance [ 3 ].…”