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Pituitary Apoplexy
Kyla Lokitz
Morning Report
7/18/05
Pituitary Apoplexy
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A clinical syndrome resulting from acute hemorrhage
or infarction of the pituitary gland characterized by the
onset of:
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Headache
Vomiting
Visual Disturbances
Opthalmoplegia – CN III most common
Meningismus
Fever
Decreased Consciousness
Death
Epidemiology
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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).
Predisposing Factors:
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Arterial hypertension
Sudden head trauma
Cardiac surgery
Transient elevation of
intracranial pressure
Diabetes
Acromegaly
Cushing’s Syndrome
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Estrogens
Anticoagulation
Bromocriptine
Dynamic pituitary
function tests
GnRH analogues
Radiotherapy
Pathophysiology
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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
Diagnosis
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Laboratory Data:
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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
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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 >90%
of cases) (Sibal et al. 04)
Treatment
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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
Surgical Treatment Indicated with:
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Diminished level of consciousness
Hypothalmic disturbances
Visual impairment
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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).
Conservative Therapy
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Favored in patients without or with mild neuroopthalmic signs.
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Retrospective studies have shown spontaneous
improvement in neuro-opthalmic symptoms with
conservative management (Sibal et al. 2005)
References
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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, 75:1147-1152.
Lubina A. et al. Management of pituitary apoplexy: clinical experience with 40
patients. Acta Neurochirugica 2005, 147:151-157.
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, 51:181-188.
Semple, P. et al. Pituitary apoplexy. Neurosurgery 2005, 56: 65-73.