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Pituitary Apoplexy Mimicking Aneurysmal Rupture of Anterior Communicating Artery

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Pituitary Apoplexy Mimicking Aneurysmal Rupture of Anterior Communicating Artery KISEP J Korean Neurosurg Soc 34 : 249-251, 2003 Case Report Pituitary Apoplexy Mimicking Aneurysmal Rupture of Anterior Communicating Artery Young-Gyu Kim, M.D., Jong-Sun Lee, M.D., Moon-Sun Park, M.D., Ph.D., Ho-Gyun Ha, M.D., Ph.D. Department of Neurosurgery, Eulji University School of Medicine, Daejeon, Korea Pituitary apoplexy presenting with subarachnoid haemorrhage(SAH) is rare and thus may be easily mistaken for aneurysmal rupture. The authors report a case of pituitary apoplexy presented with SAH mimicking aneurysmal rupture of anterior communicating artery. A 70-year-old woman presented with sudden severe headache, vomiting and drowsiness. Computerized tomography showed diffuse SAH in basal cistern and enhancing sellar mass lesion that was overlooked. Because cerebral angiography showed a suspicious small aneurysmal sac at the origin of anterior communicating artery, we regarded it as an aneurysmal rupture. Craniotomy was performed but we could not find any aneurysm. There was a definite hemorrhagic mass lesion in the sellar and suprasellar area. Histopathological examination revealed a micronodular pituitary adenoma with hemorrhage. The authors stress that pituitary apoplexy must be included in the differential diagnosis of SAH, and proper preoperative radiologic imaging and careful interpretation is demanding for rule out the possibility of pituitary apoplexy. KEY WORDS : Pituitary apoplexy Subarachnoid hemorrhage Anterior communicating artery Aneurysm. Introduction Case Report ituitary apoplexy is a well known clinical syndrome cha- 70-year-old woman presented with sudden severe P racterized by headache, visual disturbance and ophtham- A headache, vomiting and drowsiness. There was no oplegia due to hemorrhagic or ischemic necrosis of pituitary noteworthy medical problems except a history of poorly con- tumor. It is an uncommon disease and occurs in 0.6~10% of trolled hypertension. On admission, she was drowsy and her all pituitary tumors2,3,5,6). neck was stiff. Pupils were isocoric and light reflex was normal. Because the neovascularization is incomplete and tumor There was no focal neurological deficit. We did not check the vessels are relatively fragile, the tumor may undergoes ische- visual field, since she complained no visual symptom. Skull mic, necrotic and hemorrhagic change6). Subarachnoid hemo- x-ray showed no sellar abnormality. An emergency computed rrhage(SAH) may occur secondarily following extravasation tomography(CT) demonstrated diffuse SAH in basal cistern due to hemorrhagic necrosis of pituitary tumor. As meningeal (Fig. 1). But we overlooked the suprasellar mass lesion which irritation and compression of parasellar structure increases, was slightly enhancing. As carotid angiogram revealed a the patient can experience headache, vomiting, visual distur- suspicious small aneurysm at the origin of anterior commun- bance, limitation of extraocular eye movement, mental change icating artery(Fig. 2) and clinical symptoms were compatible and panhypopituitarism3). The possibility of SAH or intracerebral hemorrhage secon- dary to extravasation of tumor bleeding was described but indeed, it has been published rarely4,7). We report a case of pituitary apoplexy presented with SAH that was initially misdiagnosed as a ruptured anterior communicating artery aneurysm. Received：April 24, 2003 Accepted：June 20, 2003 Address for reprints：Jong-Sun Lee, M.D., Department of Neurosurgery, Eulji University School of Medicine, 24-14 Mok- dong, Jung-gu, Daejeon 301-726, Korea A B Tel：042) 259-1277, Fax：042) 256-3461 E-mail : [email protected] Fig.1. Computed tomogram demonstrating diffuse subarachnoid hemorrhage in basal cistern (A) and enhancing sellar lesion (B). VOLUME 34 September, 2003 249 Pituitary Apoplexy Mimicking Aneurysm with aneurysmal SAH, enter the subarachnoid space, which resulting in the clinical a ruptured anterior co- presentation of SAH. Thus SAH from ruptured aneurysm mmunicating aneury- must be ruled out. sm was suspected. It has long been known that pituitary adenoma is associated We decided to per- with cerebral aneurysm, but definite relationship is not defin- form aneurysmal neck ed yet. Wakai, et al.9) reported that the incidence of aneurysm clipping via pterional in the patients with pituitary adenoma was 7.4% and higher approach. We could than the general population, but Pant, et al.8) reported it as not find any aneurys- 5.4%, and statistically meaningless. Fig. 2. Right carotid angiogram oblique mal sac in the surgical Pituitary apoplexy is a rare disease, and requires high index view showing a vascular loop suspected field, but there was a of suspicion. Typical symptoms include headache, vomiting, as an aneurysmal sac at the origin of an- terior communicating artery and vascular definite hemorrhagic visual field disturbance, limitation of extraocular eye movement 10) narrowing at A1 and M1 segments. mass lesion in the etc. Wakai, et al. reported that 80% of the 38 patients with sellar and suprasellar pituitary apoplexy presented with visual symptoms. These area. It was diagnosed symptoms are caused by compression of parasellar structure histopathologically as and meningeal irritation. When brain stem or hypothalamus micronodular pituitary are involved, mental change, hypothermia, hyperthermia, hyp- adenoma. Relatively otension, arrhythmia, respiratory irregularity can occur. regular sized tumor Simple lateral skull X-ray and contrast enhanced brain CT cells were arranged are useful for early diagnosis. Enlarged sella, sellar hematoma like plate and cord on or enhancing sellar mass may be detected. If available, thin the background con- section sellar magnetic resonance(MR) imaging and MR Fig. 3. Microphotograph reveals sinusoidal growth pattern of the tumor cells (H&E,×400). taining the blood ves- angiography should be performed to evaluate the tumor and sels and hemorrhage surrounding vasculature. When SAH presents due to extrava- (Fig. 3). The patient was transiently improved after operation sation from necrotic pituitary tumor, CT angiography, MR then took a turn for the worse. In spite of continuous hormonal angiography or conventional cerebral angiography should be replacement therapy, all hormone level was subnormal except obtained to rule out ruptured aneurysm. thyroxine and cortisol. The patient was discharged against If pituitary apoplexy is suspected, pituitary function test also medical advice from the hospital on day 24. should be performed and proper replacement therapy should be carried out. Once the pituitary apoplexy is suspected, hem- Discussion atoma and tumor can be removed via transsphenoidal route. But any aneurysmal lesion is suspected transcranial explora- emorrhagic necrosis of the pituitary gland was first rep- tion should be chosen. In author's case, as the pituitary lesion H orted by Bleibtreu1) in 1905 and Brougham et al.2) was overlooked on brain CT, sellar MR image did not been named it pituitary apoplexy. Pituitary apoplexy means hemo- obtained and thus transsphenoidal surgery did not been even rrhage and necrosis of pituitary gland including asymptomatic considered. panhypopituitarism. But clinically, it means only when men- ingeal irritation sign or symptomatic parasellar structure com- Conclusion pression is present3). According to a series of cases, the range of incidence of ituitary apoplexy is uncommon and its clinical manifes- pituitary apoplexy reaches 0.6% to 10% and this wide range P tation may be similar to that of a ruptured aneurysm. Es- comes from incomplete analysis of symptoms and surgical pecially when it is presented by SAH, immediate differential findings2,3,5,6). Mohr, et al.6) insisted that 25% of all pituitary diagnosis is often impossible. Futhermore, coexistence of tumors show hemorrhage or necrosis microsco-pically, and intracranial aneurysm with pituitary tumor should be also these changes come from the fragility of neovas-cularization. ruled out. Thus, it is important to have a suspicion that SAH Because of anatomical proximity of the sellar turcica to the may be caused by pituitary apoplexy. And proper preoperative basal cistern, extravasated blood from a pituitary tumor may radiologic imaging and careful interpretation is demanding. 250 J Korean Neurosurg Soc 34 YG Kim, et al. References adenomas. Surg Neurol 20 : 280-287, 1983 1. Bleibtreu L : Ein Fall von Akromeglia(zerstorung der Hypophysis 6. Mohr G, Hardy J : Hemorrhage, necrosis and apoplexy in pituitary durch Bluntag). Munch Med Wochenschr 52 : 2079-2080, 1905 adenomas. Surg Neurol 18 : 181-189, 1982 2. Brougham M, Heusner AP, Adams RD : Acute degenerative changes 7. Oliver RM, Craft TM, Shaw KM : Bleeding intracranial aneurysm? in adenomas of the pituitary body-with special reference to pituitary pituitary apoplexy. Br J Clin Pract 45 : 150-151, 1991 apoplexy. J Neurosurg 7 : 421-439, 1950 8. Pant B, Arita K, Kurisu K, Tominaga A, Eguchi K, Uozumi T : Incidence 3. Cardoso ER, Peterson EW : Pituitary apoplexy : a review. Neuro- of intracranial aneurysm associated with pituitary adenoma. Neurosurg surgery 14 : 363-373, 1984 Rev 20 : 13-17, 1997 4. Chen ST, Chen SD, Ryu SJ, Hsu TF, Heimburger RF : Pituitary apoplexy 9. Wakai S, Fukushima T, Furihata T, Sano K : Association of cerebral with intracerebral hemorrhage simulating rupture of an anterior cerebral aneurysm with pituitary adenoma. Surg Neurol 12 : 503-507, 1979 artery aneurysm Surg Neurol 29 : 322-325, 1988 10. Wakai S, Fukushima T, Teramoto A, Sano K : Pituitary apoplexy : its 5. Kaplan B, Day AL, Quisling R, Ballinger W : Hemorrhage into pituitary incidence and clinical significance. J Neurosurg 55 : 187-193, 1981 VOLUME 34 September, 2003 251.
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