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Pituitary Apoplexy 2005-6

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  • 1.  
  • 2.  
  • 3.  
  • 4.  
  • 5.  
  • 6.  
  • 7. Pituitary Apoplexy Kyla Lokitz Morning Report 7/18/05
  • 8. Pituitary Apoplexy
    • A clinical syndrome resulting from acute hemorrhage or infarction of the pituitary gland characterized by the onset of:
      • Headache
      • Vomiting
      • Visual Disturbances
      • Opthalmoplegia – CN III most common
      • Meningismus
      • Fever
      • Decreased Consciousness
      • Death
  • 9. Epidemiology
    • 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).
  • 10. Predisposing Factors:
    • Arterial hypertension
    • Sudden head trauma
    • Cardiac surgery
    • Transient elevation of intracranial pressure
    • Diabetes
    • Acromegaly
    • Cushing’s Syndrome
    • Estrogens
    • Anticoagulation
    • Bromocriptine
    • Dynamic pituitary function tests
    • GnRH analogues
    • Radiotherapy
  • 11. Pathophysiology
    • 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
  • 12. Diagnosis
    • Laboratory Data:
      • 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
      • 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)
  • 13. Treatment
    • 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
  • 14. Surgical Treatment Indicated with:
    • Diminished level of consciousness
    • Hypothalmic disturbances
    • Visual impairment
      • 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).
  • 15. Conservative Therapy
    • Favored in patients without or with mild neuro-opthalmic signs.
      • Retrospective studies have shown spontaneous improvement in neuro-opthalmic symptoms with conservative management (Sibal et al . 2005)
  • 16. References
    • 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.