Sequential Pituitary MR Imaging in Sheehan Syndrome: Report of 2 Cases

Abstract

SUMMARY:We present the evolution of pituitary changes in the cases of 2 patients with Sheehan syndrome as assessed by MR imaging. Both patients had severe postpartum hemorrhage, symptoms of pituitary gland apoplexy, and hypopituitarism. Sequential MR imaging demonstrated evidence of ischemic infarct in the pituitary gland with enlargement followed by gradual shrinkage during several months, to pituitary atrophy. Clinical recognition of Sheehan syndrome (hypopituitarism resulting from postpartum pituitary gland infarction after severe hypotension secondary to massive bleeding 1 ) is often insidious, with the diagnosis being delayed for years. 2Pituitary imaging studies late in the course have revealed atrophy of the gland, resulting in a small empty sella. 3,4 Rarely, patients present with pituitary apoplexy.2 MR imaging studies have been reported in only a few cases. 5,6 We report the cases of 2 patients with Sheehan syndrome with acute presentations, in which the progression of pituitary gland changes was assessed by sequential MR imaging. Case Reports Case 1A 29-year-old woman delivered a full-term baby. The delivery was complicated by retained placenta and profuse bleeding, requiring emergent embolization of the uterine artery. Her hemoglobin level fell to 3.8 g/dL. Several hours later, the patient developed a severe headache and nausea. A routine CT study of her head showed no abnormality. Her symptoms resolved, and she was discharged from the hospital without additional work-up. She returned on day 17 postpartum with fatigue, fever, mild headache, failure to lactate, and postural syncope. Her temperature was 101.2°F, pulse 122, and a supine blood pressure of 90/48 mm Hg. Examination showed skin pallor, a cardiac flow murmur, clear lungs, and a soft abdomen. Laboratory evaluation revealed anemia, mild hyponatremia (sodium, 134 mEq/L), and abnormal pituitary function test results (Table) consistent with panhypopituitarism.MR imaging on postpartum day 26 (Fig 1) revealed a nonenhancing, minimally hypointense lesion in the pituitary gland. MR imaging 6 months postpartum (Fig 2) showed shrinkage of the pituitary gland with CSF signal intensity in the sella ("empty sella"). The pituitary infundibulum and hypothalamus appeared normal. Case 2A 21-year-old woman delivered a full-term healthy baby after labor was induced following premature rupture of membranes. During delivery, she sustained a fourth-degree perineal laceration with severe bleeding and hypotension (blood pressure, 60/30 mm Hg). Her he-

Delayed diagnosis of Sheehan's syndrome in a developed country: a retrospective cohort study

“…Some cases of women with an early SS diagnosis during the postpartum period have been reported in the literature. We can observe that these women often presented with hyponatremia, reflecting a severe corticotroph deficiency, and/or had severe headaches after delivery, corresponding to the acute pituitary apoplexy (17,18). In our study, 25% of the patients (nZ7/28) had headaches during the postpartum period.…”

A novel hook-shaped enhancement on contrast-enhanced sagittal magnetic resonance image in acute Sheehan’s syndrome: a case report

“…The novel hook-shaped enhancement on sagittal T1WI, to our knowledge, has not been reported so far. Only ring enhancement of the anterior lobe has been reported in the acute phase of Sheehan's syndrome [6][7][8]. We speculate that the characteristic hook-shaped enhancement reflects the complex vasculature of the pituitary gland and the stalk (Fig.…”

“…Difference between hook-shaped enhancement and ring enhancement is whether infarction of trabecular artery has occurred or not. Furthermore, in some rare cases, MR image at acute phase shows a heterogeneous enhancement in the anterior lobe [8]. The heterogeneous enhancement might reflect uneven blood supply from the …”

“…Thus, the anterior lobe primarily receives blood, through a long series of vessels, from the internal carotid artery and is vulnerable to hypovolemia resulting from massive hemorrhage in this complicated delivery system. In the acute phase of Sheehan's syndrome, a ring enhancement of the anterior lobe on gadolinium (Gd)-enhanced magnetic resonance (MR) image has been reported in some cases [6][7][8]. This reflects a situation wherein blood supply to the marginal zone occurs via the other three vessels, the short portal vein, the capsular artery, and the trabecular artery, but not the long portal vein.…”

A Duodecennial Era without Diagnosis: A Case Report On Sheehan Syndrome

“…[10, 13,14] The treatment of Sheehan syndrome is by replacement of deficient hormones. ACTH and TSH deficiency should be replaced with with glucocorticoids and levothyroxine.…”