Pituitary apoplexy: an overview of 186 cases published during the last century

Abstract

Based on an overview of 186 cases of apoplectic pituitary adenoma presenting with monocular or binocular blindness, we highlight the importance of correct diagnosis and an early, but not necessarily emergency, surgery within the first week of admission to optimize visual outcome of such patients. The illustrative case further exemplifies the value of close interaction between members of the management team for optimal outcome.

Apoplexy of pituitary adenomas: the perfect storm

“…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. …”

“…2,10,15,25,35,38 Traumatic injury associated with shock, aortic dissection, and other types of surgery have also been linked with the onset of pituitary apoplexy. 10,35,37,39,45 Events that alter the balance between glucose supply and metabolic demand, such as hypoglycemia associated with insulin tolerance testing, or increasing metabolic demand by stimulation testing with hypothalamic releasing factors, have been reported to precipitate apoplexy of pituitary tumors. 8,10,31,44,46 experiments to assess vulnerability of…”

A case of pituitary apoplexy following posterior lumbar fusion surgery

“…The most important differential diagnosis to be considered is intracranial aneurysm, which may have devastating results if not approached cautiously. 13 Sometimes subarachnoid hemorrhage presents with PA, which makes the differential diagnosis even more complicated. If CT or MRI is not sufficient in such a case, MR angiography or conventional angiography should be used to make the final diagnosis.…”

“…5 Pituitary apoplexy (PA) is a rare complication (0.6%-21%) of pituitary adenomas, occurring as the result of sudden tumor growth 8,9,12,13 and having a male preponderance. It is most commonly observed in nonfunctional pituitary macroadenomas, secondly in prolactinomas.…”

“…7 Computed tomography is an emergency-setting tool for immediately evaluating the brain. Hemorrhage can be detected on CT 3 days after the onset of PA. 10,13 Magnetic resonance imaging is the best evaluation tool after the diagnosis of PA on CT. Tumor, hemorrhage, and infarction can be better differentiated on MRI. The most important differential diagnosis to be considered is intracranial aneurysm, which may have devastating results if not approached cautiously.…”