Pituitary Apoplexy

22 Aug

QUICK HITS:

-Pituitary apoplexy refers to pituitary infarction

-It is a rare condition.  Often occurs spontaneously from hemorrhage or an infarction of a pre-existing pituitary adenoma.  It can also refer to sudden infarction of the pituitary in the absence of a pituitary adenoma.

Pregnancy and trauma have also been associated with the condition.

-Think Pituitary Apoplexy in a patient with sudden severe headache with vision changes and a known history of a stable pituitary adenoma!

-Common precipitating factors include recent major surgery, being on anticoagulation, and hypertension.

CLINICAL MANIFESTATIONS:

-Common symptoms include headache, vomiting, visual field defects, and ocular paresis.

Hyponatremia (caused from SIADH) has also been demonstrated in case reports although it is less common

-Of the ocular palsy findings, 3rd nerve and 6th nerve palsies are most common.

DIAGNOSIS:

CT scans are generally only useful to find hemorrhage within the adenomas.  This will generally be visible within the first 3 days following hemorrhage, and appear as intrasellar or suprasellar hyperdensity.

MRI is the modality of choice.  Often MRI/MRA are performed to visualize the adjacent carotid arteries to rule out aneurysm as a cause.

MANAGEMENT:

-Initial management should include fluids and corticosteroids.  Many patients improve with supportive care alone.

Neurosurgery should be involved early the literature does not appear clear whether supportive measures alone are sufficient or whether patients have an increased benefit from surgical decompression in mild to moderate cases.  In severe cases (vision loss) urgent Neurosurgery involvement and surgical decompression are the standard of care.

-Many patients have significant ocular improvement after either conservative measures or surgery

-The thought is that the optic nerves are particularly able to withstand prolonged ischemia

-Some studies have shown normal vision if the optic nerves are decompressed within a week

Submitted by J. Grover.

References: Agrawal D, Mahapatra AK.  “Pituitary Apoplexy and Inappropriate ADH Secretion.”  Journal of Clinical Neuroscience.  2003 10(2); 26-261. Lubina A, Ochovsky D, Berezin M et al.  “Management of Pituitary Apoplexy:  Clinical experience with 40 Patients.”  Acta Neurochirurgica (wien).  2005 (147): 151-157.  Maccagnan P, Macedo CLD et al.  “Conservative Management of Pituitary Apoplexy:  A Prospective Study.”  J Clin Endocrinol Metab 1995; 80; 2190-2197.  Nawar RN, Abdel Mannan D, et al.  “Pituitary Tumor Apoplexy:  A Review.”  J Intensive Care Med.  2008.  Mar-Apr; 23(2) 75-90. Sibal L, Ball SG, et al. “Pituitary Apoplexy:  A Review of Clinical Presentation, Management and outcome in 45 cases.”  Pituitary.  2004; 7(3): 157-163.; picture

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2 Responses to “Pituitary Apoplexy”

  1. Mercedes Gomez November 10, 2014 at 23:20 #

    Reblogged this on Comunidad Salud and commented:
    Importante información para todos los medicos y para la población general. Como siempre lo he dicho la información abre puertas.

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