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Pituitary Tumor Apoplexy: Characteristics, Treatment, and Outcomes

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Pituitary Tumor Apoplexy: Characteristics, Treatment, and Outcomes Neurosurg Focus 16 (4):Article 6, 2004, Click here to return to Table of Contents Pituitary tumor apoplexy: characteristics, treatment, and outcomes MEG VERREES, M.D., BAHA M. ARAFAH, M.D., AND WARREN R. SELMAN, M.D. Department of Neurosurgery and Division of Endocrinology, Department of Internal Medicine, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio Pituitary tumor apoplexy is an uncommon event heralded by abrupt onset of severe headache, restriction of visual fields, deterioration of visual acuity, and weakness of ocular motility frequently coupled with clinical indications of decreased endocrine function. Hemorrhage into or necrosis of a preexisting sellar mass, usually a pituitary macroade- noma, produces an expansion of sellar contents. Compression of adjacent structures elicits the variable expression of symptoms referable to displacement of the optic nerves and chiasm and impingement of the third, fourth, and sixth cra- nial nerves. Damage to or destruction of the anterior pituitary leads to multiple acute and/or chronic hormone defi- ciencies in many patients. Medical management may be used in rare cases in which the signs and symptoms are mild and restricted to meningismus or ophthalmoplegia deemed to be stable. In patients with visual or oculomotor lability or an altered level of consciousness, expeditious surgical decompression, accomplished most commonly through a transsphenoidal approach, should be performed to save life and vision and to optimize the chance of regaining or main- taining pituitary function. KEY WORDS • pituitary adenoma • pituitary tumor apoplexy • pituitary apoplexy • pituitary hemorrhage • pituitary infarction • pituitary necrosis BACKGROUND AND EPIDEMIOLOGICAL syndrome is associated with a pituitary adenoma in the CONSIDERATIONS overwhelming number of cases and is linked with healthy glands in only a few isolated instances. Pituitary tumor apoplexy (the second syllable of the Pituitary adenomas comprise approximately 10% of in- suffix “-plexy,” originating from the Greek term meaning tracranial tumors;68,72 the reported incidence of apoplexy to strike or to have a stroke) refers to the abrupt onset of a in these lesions ranges from 0.650 to 27.7%.49 Values quot- severe headache frequently coupled with nausea, vertigo, ed at the high end of this range may reflect the inclusion meningismus, and/or a decreased level of conscious- 1,3,9,14,15,19,21,65 of cases in which blood discovered during surgical or his- ness. Ophthalmoplegia, deterioration of visual topathological examination was obtained from specimens acuity, and restriction of visual fields are also frequently of asymptomatic patients.8,24,47,81 Most reports of series encountered (Table 1). The episode is most often obvious indicate that the incidence of apoplexy among pituitary and discrete, but may have a more subtle onset, or even be 15,27,40,44,47,49,53,57,80,81 adenomas is 2 to 7% when clinical signs coupled with sur- clinically silent. gical or histopathological evidence are considered.1,8,23,46, Signs and symptoms are attributed to the rapid expan- 47,52,81 Recurrence following apoplexy is rare and has only sion of an infarcted and/or hemorrhagic pituitary adenoma been documented in a few cases.1,7, 8,15,37,59 The clinical syn- that extends laterally into the cavernous sinus or reaches drome usually evolves from within a few hours to 3 superiorly to displace the optic nerves and chiasm. Com- days.19,42 puterized tomography or MR imaging indicate sellar and/ All types of tumors are at similar risk for developing ap- or suprasellar abnormalities that are consistent with hem- oplexy. Nearly 50% of apoplectic events occur in patients orrhage and necrosis. who were not previously known to harbor a pituitary le- Bailey6 described the first case of pituitary tumor asso- sion.14,24,41,64 Men are affected more commonly than wom- ciated with hemorrhage in 1898; in 1950, Brougham and en and in some series the ratio of male to female patients colleagues13 examined five patients and called the collec- is as divergent as 2:1.8,21,24,36,59,79,83 The age range of affect- tion of signs and symptoms due to necrosis and/or hemor- ed individuals stretches from the first through the eighth rhage “pituitary apoplexy.” We believe that the term “pi- decade, with most cases presenting among individuals in tuitary tumor apoplexy” is more suitable because the the fifth or sixth decade.1,12,15,19,24,48,59,65 Abbreviations used in this paper: CSF = cerebrospinal fluid; PRESENTATION, DIAGNOSIS, AND CT = computerized tomography; DI = diabetes insipidus; IHA = PATHOPHYSIOLOGY inferior hypophysial artery; MR = magnetic resonance; SAH = sub- arachnoid hemorrhage; SHA = superior hypophysial artery. Clinical unawareness of the presence of a preexisting Neurosurg. Focus / Volume 16 / April, 2004 1 Unauthenticated | Downloaded 10/01/21 05:03 AM UTC M. Verrees, B. M. Arafah, and W. R. Selman TABLE 1 nerve is the next most frequently affected.47,56,65 The fourth Signs and symptoms of pituitary tumor apoplexy cranial nerve is the least commonly involved in plural de- fects and it is rare for this nerve to be affected separately. headache (frontal or retroorbital) Facial pain, altered facial sensation, hypesthesia, and/or restriction of visual fields loss of corneal reflex are occasionally mentioned as asso- decrease in visual acuity 13,20,58,65 ophthalmoplegia ciated symptoms. nausea Endocrine abnormalities associated with hypopituitar- vomiting ism, pressure transmitted to the brainstem, or hypothala- vertigo mic compression may account for a diminished level of meningismus consciousness.21,70,80 Vasospasm due to SAH following decreased level of consciousness the apoplectic event may provoke hemispheric signs.17, facial pain or altered or impaired facial sensation 25,65,80 epilepsy Acute diminishment of the caliber of the intracav- fever ernous carotid artery and decreased blood flow secondary hemiparesis to constriction from pressure of edematous, hemorrhagic Horner syndrome material or from being wedged against the anterior clinoid process have also been postulated as accounting for epi- sodes of lethargy or hemiplegia.19,25,58,60,64,65,79,80 Cortical pituitary mass often renders apoplexy an overlooked irritation from extension of hemorrhage into the brain par- possibility; consequently, the diagnosis is often delayed enchyma may elicit seizures.58 Encroachment on the sym- and the clinical signs are mistaken as produced by a pathetic plexus can lead to the Horner sign. Attenuation of different cause.1,13,15,19,21,24,34,39,42,53,60,80 The nonspecific na- venous channels draining into the sinus may trigger prop- ture and variability of signs and symptoms further con- tosis and swelling of the eyelid. found expeditious establishment of an appropriate diagno- Signs of mass effect on the optic nerves and chiasm are sis.1, 24,29,40,80 commonly noted at presentation in patients with pituitary Headache is the most commonly reported symptom and adenomas (243 of 247 patients in a series conducted by is present in up to 100% of affected patients; it is almost Cushing),67 yet only 5 to 15% of patients with adenomas universally described as severe and abrupt, and located are noted to have optomotor defects.15,20,67,68,70 In contrast, retroorbitally or bifrontally.8,9,15,19,21,24,53,59,65,80 A deteriora- although chiasmal abnormalities continue to be a promi- tion in visual acuity leading to blindness, visual field de- nent sign in patients with necrosis or hemorrhage, the inci- fects, and ophthalmoplegia are frequently associated with dence of optomotor palsies increases to 60 to 100% in the ictus, as are nausea, vomiting, lethargy, meningismus, these patients.47,70,80 and a decreased level of consciousness.9,10,19,36,38,76,81 Al- The reason for the disparity in the frequency or pattern tered facial sensation or facial pain, hemiparesis, seizures, of occurrence between chiasmal and optokinetic signs as- or miosis and ptosis associated with Horner syndrome are sociated with adenomas, as opposed to pituitary tumor less frequently encountered.19,24,42 apoplexy, has been attributed to the vulnerability of the The coupling of deficits and the general variability of optic nerves and chiasm to even gradual stretching, which signs and symptoms reflect the extension and contour of occurs with an adenoma, compared with the relative toler- necrotic or hemorrhagic material in addition to insinuation ance and greater mobility of the third, fourth, and sixth of the mass into the cavernous sinus and the subarachnoid cranial nerves, which are comparatively undisturbed by space. Headache occurs secondary to meningeal irritation the more insidious effects of an adenoma. These more from the presence of blood entering the basal cisterns or durable nerves frequently do not show signs of compro- as a consequence of dural stretching.20,50,60,80,81 Blood gain- mise unless or until they are abruptly compressed.18,34,67,80 ing access to the suprasellar cistern through a dilated aper- The diagnosis of pituitary tumor apoplexy is frequently ture in the diaphragma sella may provoke the develop- complicated by signs and symptoms that may resemble ment of a chemical meningitis signaled by fever, nuchal those of other intracranial pathological entities (Table 2). rigidity, and photophobia.60 Adrenal insufficiency pro- Headache, photophobia, stiff neck, and oculomotor palsy vides another reasonable explanation for the pyrexia. may mimic a ruptured intracranial aneurysm,24
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