The snowman sign in a patient with pituitary tumor apoplexy

Bukhari, Khulood; Sharma, Vandhna R.; Gupta, Sonia; Motazedi, Abbas

doi:10.1080/20009666.2021.1898086

Cited by 3 publications

(4 citation statements)

References 4 publications

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“…Essentially, the subjects were managed surgically (80%) or conservatively. Although the majority are TSSs, five papers introduced patients undergoing craniotomies [ 36 , 60 , 127 , 159 , 217 ]. Craniotomies were necessary for intracranial hemorrhage [ 36 ], subarachnoid hemorrhage [ 60 ], previous nasal surgery [ 127 ], and technical challenges such as cavernous sinus invasion with encasement of the internal carotid artery [ 159 ], respectively, encasing of both carotid arteries [ 217 ].…”

Section: Pitnet Complicated With Pamentioning

confidence: 99%

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

et al. 2023

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Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.

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Section: Pitnet Complicated With Pamentioning

confidence: 99%

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

et al. 2023

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“…11 ) may cross the sellar floor and invade the skull base, especially into sphenoid and cavernous sinuses, clivus, orbits, dura mater, and subarachnoid, extradural, and nasopharyngeal spaces [ 64 ]. With their growth, they can show the typical “snowman sign” or “figure of 8”, given by the bilateral indentation of the macroadenoma by the diaphragma sellae [ 65 ]. Rarely, pituitary adenomas are entirely contained in the sphenoid body with the sellar floor intact since they originate from Rathke’s pouch ectopic remnants, trapped in the sphenoid ossification centres.…”

Section: Benign Tumours (Table 2 )mentioning

confidence: 99%

“…Differential diagnoses : chordoma shows a higher T2 and DWI b1000 SI and higher ADC values than invasive macroadenoma, due to difference in histopathologic features (chordoma has an abundant myxoid stroma containing physaliferous cells with large cytoplasm, invasive macroadenoma shows highly crammed cells with large nuclei) [ 67 ]. Pituitary fossa meningioma could resemble a pituitary macroadenoma; nevertheless, two main aspects allow to distinguish these different conditions since meningioma reveals a more avid and homogeneous CE than adenoma [ 66 ], and in case of meningioma, the normal pituitary gland can still be recognised [ 65 ]. Moreover, meningioma does not show the “snowman sign” [ 65 ].…”

Section: Benign Tumours (Table 2 )mentioning

confidence: 99%

“…Pituitary fossa meningioma could resemble a pituitary macroadenoma; nevertheless, two main aspects allow to distinguish these different conditions since meningioma reveals a more avid and homogeneous CE than adenoma [ 66 ], and in case of meningioma, the normal pituitary gland can still be recognised [ 65 ]. Moreover, meningioma does not show the “snowman sign” [ 65 ]. On the other hand, invasive macroadenoma may displace the cavernous segment of the internal carotid artery laterally, a non-detected pattern in meningiomas [ 68 ].…”

Section: Benign Tumours (Table 2 )mentioning

confidence: 99%

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A practical overview of CT and MRI features of developmental, inflammatory, and neoplastic lesions of the sphenoid body and clivus

et al. 2022

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The sphenoid bone is an unpaired bone that contributes to the formation of the skull base. Despite the enormous progress in transnasal endoscopic visualisation, imaging techniques remain the cornerstones to characterise any pathological condition arising in this area. In the present review, we offer a bird’s-eye view of the developmental, inflammatory, and neoplastic alterations affecting the sphenoid body and clivus, with the aim to propose a practical diagnostic aid for radiologists based on clinico-epidemiological, computed tomography, and magnetic resonance imaging features.

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