Pituitary Apoplexy

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Pituitary Apoplexy

• Kyla Lokitz
• Morning Report
• 7/18/05

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Pituitary Apoplexy

• A clinical syndrome resulting from acute
  hemorrhage or infarction of the pituitary gland
  characterized by the onset of
• Headache
• Vomiting
• Visual Disturbances
• Opthalmoplegia CN III most common
• Meningismus
• Fever
• Decreased Consciousness
• Death

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Epidemiology

• Incidence found to be 0.6-9.0 in series of
  surgically treated adenomas in patients with
  pituitary apoplexy (Semple et al. 2005).
• Pituitary hemorrhage observed in 25 of
  surgically removed adenomas however, these
  patients were without clinical symptoms
  (Subclinical Pituitary Apoplexy) (Sibal et al.
  2005).
• Hemorrhage and infarction with similar clinical
  presentation described in nontumerous pituitary
  glands. Also seen in other pituitary tumors such
  as craniopharyngiomas and lymphocytic
  hypophysitis.
• Cases reported in patients in first through ninth
  decade although pediatric cases rare.
• Series suggest apoplexy occurs more frequently in
  males (Lubina et al. 2005).

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Predisposing Factors

• Arterial hypertension
• Sudden head trauma
• Cardiac surgery
• Transient elevation of intracranial pressure
• Diabetes
• Acromegaly
• Cushings Syndrome

• Estrogens
• Anticoagulation
• Bromocriptine
• Dynamic pituitary function tests
• GnRH analogues
• Radiotherapy

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Pathophysiology

• With rapid growth, tumor outgrows blood supply
• Compression of the infundibular and superior
  hypophyseal vessels against the diaphragma sellae
• Ischemia of the normal pituitary gland
• Intrinsic vasculopathy of pituitary tumors

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Diagnosis

• Laboratory Data
• Prolactin, TSH, FT4, FT3, Cortisol, LH, FSH,
  Testosterone, Estrogen, GH, IGF1
• Electrolytes, CBC (patients often present with
  hyponatremia and leukocytosis)
• CSF-rbcs, xanthachromia, pleocytosis, increased
  protein
• Imaging
• X-ray may demonstrate enlarged sella
• CT will demonstrate pituitary mass but not
  sensitive in demonstrating hemorrhage or
  infarction (i.e. CT diagnostic in only 28 of
  cases, defined sellar mass in 72 of cases)
  (Sibal et al. 04)
• MRI is the radiologic mode of choice (i.e.
  confirmed diagnosis in gt90 of cases) (Sibal et
  al. 04)

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Treatment

• Careful monitoring of fluid and electrolyte
  balance
• Replacement of deficient hormone, especially
  corticosteriods
• Pituitary surgery
• Long term monitoring for hypopituitarism and
  recurrence of pituitary adenomas

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Surgical Treatment Indicated with

• Diminished level of consciousness
• Hypothalmic disturbances
• Visual impairment
• Some disagreement in literature about timing of
  surgery question of improved outcome (in visual
  field and visual acuity) if operation occurs
  within 8 days of onset of symptoms (Randeva et
  al. 1999) other studies demonstrate satisfactory
  recovery of vision with late surgery (Ayuck et
  al. 2004, Sibal et al. 2005).

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Conservative Therapy

• Favored in patients without or with mild
  neuro-opthalmic signs.
• Retrospective studies have shown spontaneous
  improvement in neuro-opthalmic symptoms with
  conservative management (Sibal et al. 2005)

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References

• Ayuck, J. et al. Acute management of pituitary
  apoplexy surgery or conservative management?
  Clinical Endocrinology 2004, 61 747-752.
• Levy, A. et al. Pituitary Disease Presentation,
  Diagnosis, and Management. J Neurol Neurosur
  Psychiatry 2004, 751147-1152.
• Lubina A. et al. Management of pituitary
  apoplexy clinical experience with 40 patients.
  Acta Neurochirugica 2005, 147151-157.
• Ma, R. et al. Fever, headache, and a stiff neck.
  The Lancet 2004, 363 1868.
• Randeva, H. et al. Classical pituitary apoplexy
  clinical features, management, and outcome.
  Clinical Endocrinology 1999, 51181-188.
• Semple, P. et al. Pituitary apoplexy.
  Neurosurgery 2005, 56 65-73.