11/148. gonadotropin-releasing hormone-induced partial empty sella clinically mimicking pituitary apoplexy in a woman with a suspected non-secreting macroadenoma. pituitary apoplexy has been reported as a rare complication of dynamic testing used for the study of pituitary functional reserve. In 1993, a diagnosis of non-secreting macroadenoma with moderate functional hyperprolactinaemia was made in a 43-year-old woman. Soon after the start of therapy with bromocriptine up to 5 mg/die, the patient complained of nausea and postural hypotension. As the symptoms persisted even when the dose was reduced to 2.5 mg/die, the patient was transferred to therapy with quinagolide at the dosage of 37.5 microg/die. PRL levels quickly normalized (range 1.4-5.7 ng/ml) as well as menstrual cycles, and no side-effect was reported. In 1995 a sellar magnetic resonance imaging (MRI) showed no shrinkage of the known macroadenoma. In 1996, few hours after a gonadotropin-releasing-hormone (GnRH) test, which showed normal LH and FSH response and with baseline PRL levels in the normal range, the patient started complaining of severe frontal headache, nausea and vomiting. No gross visual defects were present. An emergency computed tomography (CT) showed no evident hemorrhagic infarction in the macroadenoma. The symptoms completely resolved in few days with steroidal and antiemetic therapy. A new MRI performed in 1998 showed a partial empty sella and PRL levels were in the normal range under dopaminergic treatment. The pituitary functional reserve proved normal on dynamic testing. The temporal association between the onset of symptoms and the GnRH test strongly suggests an association between the two events. No evident signs of pituitary apoplexy (either on emergency CT or hormonal evaluation) were detected. The authors suggest that GnRH can cause severe side-effects that mimic pituitary apoplexy without related morphological evidence and that, in our particular case, it can have caused the gradual disappearance of the non-secreting macroadenoma. Moreover, a causal role of the chronic dopaminergic treatment cannot be completely ruled out. ( info) |
12/148. Emergency department presentation of pituitary apoplexy. pituitary apoplexy is an acute infarction of pituitary gland, and potentially life-threatening condition that may be highly variable in its clinical presentation. We report a 54-year-old man presenting to the emergency department with an isolated oculomotor nerve palsy. Computed tomography (CT) scan revealed an isodense mass within sellar region and subsequently, magnetic resonance imaging (MRI) revealed a pituitary apoplexy causing a compression of right oculomotor nerve. The patient received hydrocortisone immediately, and did well with medical management. An isolated oculomotor nerve palsy is very rarely the presenting sign of pituitary apoplexy. When correctly diagnosed and treated, the third nerve palsy appears to be reversible. A pathophysiology, differential diagnosis, and treatment is described. ( info) |
13/148. Chiasmal apoplexy due to hemorrhage from a pituitary adenoma into the optic chiasm: case report. OBJECTIVE AND IMPORTANCE: Chiasmal apoplexy, defined as hemorrhage into the optic chiasm, generally is caused by an intrachiasmal vascular malformation. We report the first case of chiasmal apoplexy due to hemorrhage from a pituitary macroadenoma into the optic chiasm. CLINICAL PRESENTATION: A 52-year-old man presented with headache, sudden and severe deterioration of visual acuity in the left eye, and a bitemporal visual field deficit. magnetic resonance imaging revealed a large intra- and suprasellar homogeneously enhancing mass, which elevated a markedly thickened optic chiasm. After emergent transsphenoidal resection of the pituitary adenoma, vision did not improve. INTERVENTION: A pterional craniotomy was subsequently performed, during which a hematoma was found and evacuated from within the substance of the left optic nerve and chiasm. The hematoma cavity was found to communicate with the sella through a defect in the diaphragm. Vision improved dramatically after the operation. CONCLUSION: Chiasmal apoplexy resulting from pituitary adenoma should be distinguished from pituitary apoplexy, particularly because it requires a different surgical treatment. Clinical and radiographic features that may help distinguish the two are discussed. ( info) |
| confusion occurring in pituitary apoplexy is well described. We describe a case of pituitary apoplexy associated with confusion, occurring as a result of non-convulsive status epilepticus. electroencephalography should be performed in pituitary apoplexy associated with confusion if this treatable and potentially serious complication is not to be missed. ( info) |
| A 49-year-old female presented with a ciliated craniopharyngioma manifesting as repeated intratumoral hemorrhage. Histological examination suggested that the hemorrhage originated from the many thin blood vessels in the cyst wall stroma associated with inflammation. Symptomatic hemorrhage in cystic craniopharyngioma may mimic pituitary apoplexy but the etiology is quite different. Minor hemorrhage may recur unless the cyst wall is totally removed. ( info) |
16/148. Apoplexy of a pituitary macroadenoma with reversible third, fourth and sixth cranial nerve palsies following administration of hypothalamic releasing hormones: MR features. pituitary apoplexy in patients with pituitary macroadenomas can occur either spontaneously or following various interventions. We present a case of a 71-year-old woman who developed third, fourth, and sixth cranial nerve palsies following administration of the four hypothalamic releasing hormones for routine preoperative testing of pituitary function. The MR examination showed interval tumor growth with impression of the floor of the third ventricle. There were also changes in signal intensity characteristics of the mass, suggestive of intratumoral bleeding. A transsphenoidal surgery with subtotal resection of the pituitary adenoma was performed. Microscopical examination revealed large areas of necrosis and blood surrounded by adenomatous tissue. Third, fourth, and sixth cranial nerve palsies completely resolved within 4 months. We conclude that MR imaging is useful in the demonstration of pituitary apoplexy following preoperative stimulation tests, but we suggest that these tests should be abandoned in patients with pituitary macroadenomas. ( info) |
17/148. Spontaneous resolution of a non-functioning pituitary adenoma following an apoplexy. A rare case of non-functioning pituitary adenoma, which completely resolved following an apoplectic event without producing hypopituitarism, is described. ( info) |
| We present a case of spontaneous haemorrhage into an empty sella turcica with the features of subclinical pituitary apoplexy. A 66-year-old woman with a previously resected pituitary adenoma presented four months later with progressive headache and visual deterioration. Cranial MRI demonstrated hyperacute blood products in a recurrent pituitary adenoma. Operative findings were of subacute blood in an empty sella turcica. There was no operative or subsequent histological evidence of tumour recurrence. The intrasellar haemorrhage was evacuated via a trans-sphenoidal approach, resulting in a rapid improvement in visual function. Endocrine deficits required thyroxine, corticosteroid and desmopressin supplementation. Haemorrhage into an empty sella turcica has not been previously described and needs to be suspected as a clinical entity in patients presenting with the features of pituitary apoplexy. awareness of this clinical condition will prevent preoperative misdiagnosis. ( info) |
19/148. Apoplexy of pituitary macroadenoma after combined test of anterior pituitary function. pituitary apoplexy has been reported as a very rare complication of combined tests of anterior pituitary function and of TRH or gonadotropin-releasing hormone (GnRH) administration in pituitary tumor. A 34-year-old man with a GH-secreting pituitary macroadenoma and diabetes mellitus received an injection of 400 microg TRH, 100 microg GnRH, and 0.15 U/Kg regular insulin. Twenty minutes later, he complained of a severe headache and vomited. visual acuity and visual field did not change and his headache was persistent during the next 24 hours of conservative management. magnetic resonance imaging (MRI) of the sella turcica done the day after the event showed definitive elevation of the optic chiasm and slight enlargement of tumor and focal areas of mixed high signal and low signal intensities in the macroadenoma on noncontrast T1-weighted images. headache subsided markedly within a day of octreotide therapy. Transsphenoidal removal of the pituitary tumor was performed 9 days after the hormone study. Ischemic necrosis and hemorrhage were confirmed in the acidophilic adenoma with positive immunostaining for GH. Postoperative course was uneventful and his serum insulin-like growth factor-1 (IGF-1) level and blood glucose levels were normalized. Three months after the surgery the dynamic test was repeated without adverse effects. To our knowledge, this is a very rare case of apoplexy of GH-secreting pituitary adenoma after a combined stimulation test of anterior pituitary function. ( info) |
20/148. Perioperative management of a patient requiring surgery for pituitary apoplexy and severe angina pectoris. We describe the management of a 71-yr-old man with pituitary apoplexy and severe angina pectoris who underwent treatment of an intra-cranial haemorrhage and open-heart surgery requiring anticoagulant therapy within a very short period. Subtotal removal of the pituitary tumour was undertaken under stable cardiovascular conditions. But ventricular fibrillation occurred after the neurosurgery in the intensive care unit. After the patient was defibrillated, intra-aortic balloon pumping was necessary to assist coronary artery blood flow. Twenty hours after neurosurgery, oozing from the surgical wound stopped and coronary artery bypass grafting with full heparinization was performed uneventfully. ( info) |