Revisiting Pituitary Apoplexy

Abstract

Pituitary apoplexy (PA) is a rare clinical syndrome due to pituitary hemorrhage or infarction. It is characterized by the sudden onset of one or more of the following: severe headache, visual disturbance, nausea/vomiting and or altered mental status. Most commonly, PA occurs in an underlying pituitary adenoma. The pathophysiology is not fully understood, but it is thought to involve elements of increased metabolic demand and or compromise to the vasculature of the pituitary or pituitary tumor. Several risk factors have been described. Stabilization of patient on presentation, replacement of hormonal deficiencies and reversal of electrolyte abnormalities are the recommended initial steps in the management of patients with PA. Surgical decompression of the mass effect had been the recommended treatment for patients with PA, however retrospective studies of patients with PA have demonstrated similar outcomes when a conservative approach is applied. This suggests that in highly selected clinical scenarios (mild visual deficit and improving symptoms), conservative management is possible. Further studies however are necessary to better stratify patients but are limited by the rarity of the condition and the acuity.

Pituitary Apoplexy in Macroadenoma After Minor Surgery: An Unusual Case and Literature Review

“…In the absence of randomized prospective trials, the optimal management of PA remains unclear. There are several studies and meta-analyses with variable results according to the type of intervention, conservative management versus surgery, outcome, and timing of surgery [ 3 , 7 , 20 ]. Patients selected for conservative management mostly had milder neuro-ophthalmic deficits or improving symptoms, whereas surgically managed patients had a more severe clinical presentation [ 3 ].…”

“…Patients selected for conservative management mostly had milder neuro-ophthalmic deficits or improving symptoms, whereas surgically managed patients had a more severe clinical presentation [ 3 ]. Whether there is a difference in outcomes between these treatment groups remains inconclusive in most of the analyzed studies [ 3 , 7 ]. Several studies have reported improvement in visual deficits and cranial nerve palsies, and less improvement in pituitary function, regardless of the timing of surgery [ 3 ].…”

“…PA may present with one or more of the following clinical signs and symptoms: ocular palsy, visual loss, severe headache, nausea, vomiting, electrolyte imbalance, and endocrine abnormalities [4][5][6]. The pathogenesis of PA is not fully understood [7] and associated risk factors include large tumor size [8], dynamic pituitary testing and hormonal treatment [9], head trauma, and surgery [3]. Several cases of PA have been reported after endovascular treatment, laparoscopic surgery [3,10], cardiac surgery [11], and orthopedic surgery [3,12].…”

Neurologic Complications of Endocrine Disorders

“…Eighty percent to 90% of patients with pituitary apoplexy present with frontal or retro-orbital thunderclap headache alongside other clinical features, including ophthalmoparesis (40% to 50%), reduced visual acuity (20%), bitemporal hemianopsia (30% to 70%), adrenal crisis, or coma. 2 More to the point of this article are the effects of pituitary hormonal dysregulation on the nervous system. The pituitary gland releases eight hormones: six of these (growth hormone, thyroid-stimulating hormone [TSH], adrenocorticotropic hormone [ACTH], prolactin, luteinizing hormone, and follicle-stimulating hormone) are produced by glandular cells in the anterior pituitary or adenohypophysis, and the other two (antidiuretic hormone [ADH] and oxytocin) are produced in the hypothalamus and released by the posterior pituitary or neurohypophysis.…”

“…Pituitary apoplexy should be considered in the differential diagnosis of thunderclap headache 1 and is the result of pituitary hemorrhage or infarction often in the setting of a pituitary adenoma. Eighty percent to 90% of patients with pituitary apoplexy present with frontal or retro-orbital thunderclap headache alongside other clinical features, including ophthalmoparesis (40% to 50%), reduced visual acuity (20%), bitemporal hemianopsia (30% to 70%), adrenal crisis, or coma 2 …”