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Precipitating Factors in Pituitary Apoplexy

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Precipitating Factors in Pituitary Apoplexy J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.71.4.542 on 1 October 2001. Downloaded from 542 J Neurol Neurosurg Psychiatry 2001;71:542–545 SHORT REPORT Precipitating factors in pituitary apoplexy V Biousse, N J Newman, N M Oyesiku Abstract management of patients with acute pituitary Pituitary apoplexy is a rare but life apoplexy remains to be elucidated. The aim of threatening condition caused by sudden our study was to identify associated conditions haemorrhage or infarction of the pituitary with the occurrence of acute, symptomatic gland. Potential precipitating factors in pituitary apoplexy, and to compare the charac- the occurrence of acute pituitary apoplexy teristics and outcome of patients with and in 30 consecutive patients were identified without identified associated diseases. and compared with the clinical character- istics and outcome of patients with and without associated factors. Six patients Methods had a previously known pituitary ad- We used the databases from the neuro- enoma. All patients complained of severe ophthalmology unit and the department of headaches, associated with neuro- neurological surgery to select patients with ophthalmological symptoms and signs in acute pituitary apoplexy seen at Emory Univer- 83% and altered mental status in 30%. sity School of Medicine between 1989 and Potential risk factors were identified in 2000. Pituitary apoplexy was defined as the nine patients (30%). When there was an acute onset of clinical symptoms associated associated factor, the clinical presentation with haemorrhage or infarction within a wasnodiVerent than in patients without normal pituitary gland or previously known such factors although altered mental sta- pituitary adenoma. All patients were initially tus may be more frequent in patients with evaluated by two of us (NJN and NMO), and associated diseases. In these patients, the were asked standardised questions, which were visual prognosis was worse and the diag- recorded in their chart. They underwent thor- nosis was more diYcult to establish. Acute ough neurological, neuro-ophthalmological, pituitary apoplexy is unpredictable and and endocrinological evaluations. Clinical should be considered in any patient with characteristics, neuro-ophthalmic examination (including visual field testing), neuroimaging, abrupt neuro-ophthalmological deterio- http://jnnp.bmj.com/ ration associated with headache. Patients and endocrinological status of the patients with pituitary apoplexy often have an were reviewed, as well as the existence of possi- associated disease that confounds recog- ble precipitating factors for pituitary apoplexy. Any new event occurring within the month Department of nition and treatment despite a typical before the occurrence of pituitary apoplexy was Ophthalmology, presentation. considered as a possible precipitating factor. Emory University (J Neurol Neurosurg Psychiatry 2001;71:542–545) School of Medicine, Patients were divided into two groups depend- Atlanta, GA, USA ing on the presence or the absence of possible Keywords: pituitary apoplexy; visual loss; diplopia on September 26, 2021 by guest. Protected copyright. V Biousse precipitating factors. Both groups were com- N J Newman pared using ÷2 and Student’s t tests. Department of Pituitary apoplexy is a rare but life threatening Neurology condition characterised by headache, visual V Biousse loss, ophthalmoplegia, and altered mental Results N M Oyesiku status caused by sudden haemorrhage or Thirty consecutive patients with acute pituitary infarction of the pituitary gland.12It remains a apoplexy were retrospectively included (14 Department of misunderstood and often misdiagnosed women, 16 men; age 21 to 90 years old, mean Neurological Surgery 1 3–13 N J Newman condition. Over the past 20 years, numer- 51 years). A pituitary adenoma was previously N M Oyesiku ous case reports and small series have empha- known in six patients (20%) (prolactinoma in sised the association of pituitary apoplexy with three and non-secreting adenoma in three) Correspondence To: Dr N J a wide variety of medications, procedures, and Associated conditions were identified in nine Newman, Neuro-ophthalmology Unit, pathological states such as anticoagulation, patients (30%): three patients had been antico- Emory Eye Center, 1365-B endocrinological testing, head trauma, or agulated recently (one for cardiac arrythmia Clifton Road, NE Atlanta, recent surgery.1 3–10 In most reports, these asso- and two for myocardial infarction); one addi- GA 30322, USA [email protected] ciated conditions have been qualified as tional patient had received thrombolysis and “precipitating factors”. However, the fre- heparin for a myocardial infarction; two Received 19 October 2000 quency and relevance of these so-called patients developed symptoms suggestive of and in revised form 23 March 2001 “precipitating factors” is not clear, and their pituitary apoplexy within 48 hours after Accepted 23 May 2001 role in the pathophysiology, prognosis, and surgery (one coronary artery bypass and one www.jnnp.com J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.71.4.542 on 1 October 2001. Downloaded from Precipitating factors in pituitary apoplexy 543 Table 1 Comparison of patients with pituitary apoplexy with and without identified condition (p=0.044). The delay in diagnosis associated conditions (5.5 and 5.6 days) and treatment (2.2 days after diagnosis) of the pituitary apoplexy was Associated condition No associated condition n=9 (30%) n=21 (70%) p Value similar in both groups. Sex 4 women/5 men 10 women/11 men NS Mean age (range) 59 y (21–82) 48 y (22–90) NS Discussion Known pituitary adenoma 1 (11%) 5 (23.8%) NS The syndrome of acute, symptomatic pituitary Neuro-ophthalmic deficit: 8 (88.8%) 17 (81.1%) NS apoplexy is rare, and its presentation is highly Headache 9 (100%) 21 (100%) NS 1 3–14 Ophthalmoplegia 6 (66.6%) 11 (52.4%) NS variable. There is no population that seems Optic nerve compression 4 (44%) 7 (33%) NS to have a propensity for pituitary apoplexy. The Chiasmal visual field defect 4 (44%) 10 (47.6%) NS Altered mental status 5 (55%) 4 (19%) <0.05 age range is broad, from the 1st to the 9th dec- Systemic hypertension 5 (55%) 8 (38%) NS ade, with a peak in the 5th decade. There is no Neuroimaging: sex predominance. There is no histological Haemorrhage 6 (66.6%) 9 (42.8%) NS Infarction 3 (33.3%) 12 (57.1%) NS subtype of pituitary tumour that confers a 18 Prognosis: higher risk. Whereas early investigators Death 0 0 NS suggested that pituitary apoplexy occurred pri- Unknown 2 (22.2%) 7 (33.3%) NS Pituitary dysfunction 5/9 (55.5%) 11/21 (52.4%) NS marily in patients with large macroadenomas Complete recovery 2/7 (28.5%) 10/14 (71%) 0.06 with suprasellar extension,2 it is now evident Neurological sequelae 1/7 (14.3%) 0 (0%) NS that tumours of almost any size may undergo Neuro-ophthalmic sequelae 5/7 (71.4%) 2/14 (14.3%) <0.01 189 Ophthalmoplegia 1/6 (16.6%) 2/11 (18.2%) NS haemorrhage and apoplexy. Most impor- Severe optic neuropathy 3/4 (75%) 1/7 (14.3%) <0.05 tantly, most cases of pituitary apoplexy (80% in Visual field defect 4/4 (100%) 2/10 (20%) <0.01 our series) occur in patients who have as of yet Mean delay in diagnosis (range) 5.5 days (1–14) 5.6 days (1–14) NS Mean delay in treatment (range) 2.2 days [0–7] 2.2 days (0–)] NS undiagnosed pituitary adenomas, with the apoplectic episode often the presenting symp- 2 p Calculated using ÷ and Student’s t tests. tom of the pituitary tumour. transurethral prostatectomy); one had apo- Pituitary apoplexy has been described in plexy immediately after a normal vaginal deliv- association with a wide variety of medications, ery; one patient was being treated for lower procedures, and pathological states, although limb cellulitis; and one patient had pituitary the reason for most of these associations is apoplexy a few weeks after discontinuation of unclear. The pathophysiological changes that bromocriptine prescribed for a prolactinoma. lead to pituitary apoplexy are still open to Six of these patients were in the hospital for speculation. It is well recognised that pituitary adenomas are particularly prone to haemor- their underlying disease when they developed 18 the first symptoms of pituitary apoplexy. rhage and necrosis. Several authors have In addition to immediate correction of the proposed that a rapidly growing adenoma that hormonal deficiency, 27 patients (90%) under- outstrips its blood supply may lead to ischae- went surgical decompression (transphenoidal mic necrosis of the gland followed by haemor- resection in 26 and frontal craniotomy in one). rhage. Others propose direct compression of The mean time to surgery was 2.2 days (range the pituitary infundibulum by an expanding mass, thus compromising the blood flow from from 0 to 9 days) after diagnosis was the portal vessels, resulting in necrosis of the established, except for two patients who recov- entire gland with haemorrhage as a secondary http://jnnp.bmj.com/ ered spontaneously and underwent transphe- occurrence. Various other mechanisms have noidal resection of a pituitary adenoma 2 been proposed for haemorrhage and infarction months after the apoplexy. One patient re- of pituitary adenomas, including inherent ceived radiation only, and two patients were fragility of tumour blood vessels and athero- managed medically only (one improved spon- sclerotic embolisation. The mechanism of taneously and one was unstable cardiologi- infarction and haemorrhage in the non- cally). adenomatous pituitary is even more diYcult to Comparison of clinical, endocrinological, explain. Therefore, the idea that extrinsic on September 26, 2021 by guest. Protected copyright. and radiological characteristics of patients with factors such as systemic diseases or medica- (n=9) and without (n=21) associated diseases tions may trigger changes in the vascular is detailed in table 1. The only statistically sig- supply of some pituitary glands (with or nificant diVerence between the two groups was without pituitary adenoma), thereby producing a higher frequency of altered mental status in an apoplectic necrosis or haemorrhage of the patients with identified associated conditions pituitary, is attractive.
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