Pituitary Apoplexy due to Pituitary Adenoma Infarction

Abstract

Pituitary apoplexy is a life-threatening clinical syndrome which is caused by the fulminant expansion of pituitary mass due to hemorrhage, hemorrhagic infarction or infarction of pituitary adenoma or the adjacent tissues of pituitary gland. Since first introduced by Bailey in 1898, the incidence of pituitary apoplexy varies from 0.6% to 22.8% 7,11,12,17) . However, pituitary apoplexy due to tumor infarction is very rare. We report two cases of pituitary apoplexies, caused by pituitary tumor infarction after surgery by transsphenoidal approach (TSA) for pituitary macroadenomas. These cases showed pathologic findings of tumor infarction without any signs of related hemorrhage or hemorrhagic infarction. CASE REPORT Case 1A 44-year-old male patient was admitted via emergency room due to sudden onset of severe headache, nausea, vomiting and visual disturbance. These symptoms were developed 5 days prior to admission. He had no specific previous medical history. Subarachnoid hemorrhage (SAH) was ruled out on brain computed tomography (CT), however sella magnetic resonance imaging (MRI) showed a mass lesion in the sella and suprasellar area which was measured about 3.1×2.3×2.2 cm. On T1 weighted images, there was hyperintense peripheral portion and an isointense central portion. With gadolinium (Gd) enhancement, the mass showed peripheral rim enhancement but there was no enhancement in the hypointense central portion (Fig. 1). Diffusion MR images were not obtained due to emergency operation. The optic chiasm was compressed by the mass which resulted in bitemporal hemianopsia and the worsening of the visual acuity of the right eye to 0.4 and maintaining that of the left, 1.1. There was a decrease in the levels of free T4 (4 µg/dl), TSH (0.28 µU) and cortisol (2 µg/dl). Steroid was administered before the operation. The mass was totally resected by TSA and there was no evidence of remaining enhancing tumor or hemorrhage seen in the postoperative first day follow-up sella MRI (Fig. 2). Microscopic examination of the resected mass showed total infarction without viable tumor cells (Fig. 2). The cells showed pale appearance and maintained cellular architecture. These findings led to the diagnosis of pituitary apoplexy due to total tumor infarction of a nonfunctioning pituitary macroadenoma. Clinical symptoms and

Pituitary Apoplexy Presenting as Isolated Third Cranial Nerve Palsy with Ptosis : Two Case Reports

“…Isolated third cranial nerve palsy as the presenting sign of pituitary tumors and Sheehan's syndrome is very rare. Only a few cases of isolated third cranial nerve palsies in patients with pituitary tumors have been previously reported in the literature 4,5,7,14,15) . Previous reports have proposed several mechanisms to explain the occurrence of isolated third cranial nerve palsy in pituitary apoplexy.…”

Pituitary Apoplexy Causing Internal Carotid Artery Occlusion -Case Report-

“…Pituitary apoplexy may occur first leading to internal carotid artery occlusion. 5,14) Vasospasm may be caused by extravasation of blood from the pituitary tumor into the subarachnoid space or the vasoactive agent released from the pituitary tumor into the hypophyseal area. 10) We speculate that if the vasoactive agent is the main factor to cause acute internal carotid artery occlusion, the bilateral internal carotid arteries should be occluded.…”

Symptomatic Occlusion of Internal Carotid Artery Caused by Pituitary Macro Adenoma Among the Patients Without Apoplectic Signs; Case Report and Review of the Literature

“…This result has shown that pituitary adenoma producing internal carotid artery occlusion was extremely rare. In literature review we have found five case reports describing pituitary tumors producing carotid artery occlusion without the presence of apoplectic events (10,(21)(22)(23)(24). Table 1 has summarized the details of these reports.…”