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A 50-year-old man presented with pituitary apoplexy resulting in internal carotid artery occlusion manifesting as sudden onset of severe headache, right ptosis, and left hemiparesis, associated with visual impairment. Computed tomography showed a nodular mass, located in the sellar and suprasellar regions with early signs of acute cerebral ischemia. Magnetic resonance (MR) imaging indicated that the mass compressed the bilateral cavernous sinuses, resulting in obliteration of the cavernous portion of the right internal carotid artery. Right middle cerebral artery territory infarction was also found. Conservative therapy with steroids was given in the acute stage and repeated MR imaging showed recanalization of the internal carotid artery with reduction of the tumor size. The tumor was removed through the transsphenoidal approach to obtain a definitive diagnosis in the chronic stage. The histological diagnosis was consistent with non-functioning pituitary adenoma. Eye movement of this patient showed full recovery after the operation. Pituitary apoplexy resulting in internal carotid artery occlusion is rare. Surgical decompression through the transsphenoidal approach is appropriate, but the optimal timing should consider severe disturbance of visual acuity and visual field in the acute stage.
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PMID:Pituitary apoplexy causing internal carotid artery occlusion--case report. 2127 45

We present a rare case with pituitary apoplexy after three-vessel off-pump coronary artery bypass grafting (OPCAB). The patient exhibited right third cranial nerve palsy; ptosis of the right eye with completely dilated pupils and a loss of reflex to light after the effects of anesthesia completely subsided. The patient underwent endonasal transsphenoidal resection of the pituitary gland 14 days after the OPCAB, and the symptoms completely disappeared 40 days after the resection. OPCAB is recommended for patients with known pituitary tumor who require coronary artery bypass grafting, but OPCAB also has a risk of pituitary apoplexy. The present case report is the first to describe pituitary apoplexy after OPCAB. Pituitary apoplexy is a very rare complication after cardiac surgery, but cardiac surgeons should know the disease and quickly diagnose it to avoid severe brain injury.
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PMID:Pituitary apoplexy with third cranial nerve palsy after off-pump coronary artery bypass grafting. 2152 63

Pituitary apoplexy is defined as a sudden loss of blood supply to the pituitary gland, leading to tissue necrosis and hemorrhage. Its clinical symptoms are characterized by sudden onset of headache, nausea, vomiting, ophthalmic symptoms and hormonal dysfunction. A 65-year-old woman presented with left-sided ptosis and blurred vision. These ophthalmic symptoms gradually worsened for one month without headache, visual acuity and field deficit. Neuro-ophthalmic examination revealed left oculomotor nerve palsy. Magnetic resonance imaging (MRI) revealed a round mass lesion in the left cavernous sinus, which was initially suspected as thrombosed cerebral aneurysm or hemorrhagic Rathke's cleft cyst. The mass lesion was finally diagnosed as pituitary apoplexy. The patient underwent trans-sphenoidal surgery and oculomotor nerve palsy improved after the surgery. Early diagnosis and treatment including surgical decompression are crucially important in patients with oculomotor nerve palsy in pituitary apoplexy, but the symptoms of pituitary apoplexy may slowly progress. It should be noted that pituitary apoplexy could be misdiagnosed as cerebral aneurysm or Rathke's cleft cyst.
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PMID:Pituitary apoplexy presenting atypical time course of ophthalmic symptoms. 2257 5

Pituitary apoplexy (PA) typically results from infarction or hemorrhage in a pituitary adenoma, while PA in nonadenomatous pituitary gland is uncommon. Prothrombotic states have never been recognized as precipitating factors for PA. The authors report a case of an elderly female who received prophylactic fractionated heparin therapy due to sepsis, consequent rhabdomyolysis, and overt disseminated intravascular coagulation. On the seventh day of heparin therapy, she reported sudden vision loss, ptosis, diplopia, and severe headache. Severe thrombocytopenia and positive antibodies to the complex of platelet factor 4 and heparin confirmed heparin-induced thrombocytopenia type 2 (HIT). Magnetic resonance imaging disclosed a homogenous pituitary tumor mass with pronounced sphenoid sinus mucosa thickening and two hypointense zones within the tumor mass on contrast-enhanced images consistent with focal ischemic necrosis. The tumor was confirmed to be squamous cell carcinoma with no signs of necrosis. Ischemic necrosis was found within marginal pituitary tissue. This is the first reported case of ischemic PA associated with pituitary metastasis and the first case in which HIT triggered PA. Our case demonstrates that prothrombotic states such as HIT can precipitate ischemic PA. Pituitary metastasis can present with ischemic PA, but radiological features differ from those described in pituitary adenomas. Segregated low-signal intensity zones within the tumor mass on postcontrast images indicate partial infarction of the tumor, which could be a special feature of ischemic PA in pituitary metastasis and has never been described in pituitary adenomas. These are all novel findings and might enlighten the pathogenesis of PA.
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PMID:Pituitary metastasis presenting as ischemic pituitary apoplexy following heparin-induced thrombocytopenia. 2312 46

Pituitary apoplexy followed by cerebral infarction is rare. In this report, we present a 42-year-old man who had been diagnosed of pituitary adenoma presented with a sudden onset of unconsciousness, left hemiplegia and right ptosis. Investigations revealed the development of pituitary apoplexy. The extension of tumor mass compressed the supraclinoid portion of the right internal carotid artery, resulting in the cerebral infarction in the right anterior and middle cerebral artery territory. Left anterior cerebral artery territory infarction was also found, which could be caused by vasospasm provoked by pituitary apoplexy. The patient underwent decompression surgery via transsphenoidal approach after four weeks' conservative treatment, and pathological examination revealed hemorrhage and necrosis of the pituitary adenoma. His symptoms improved within five months' follow-up. Since pituitary apoplexy producing cerebral infarction is rare, clinicians should be alert to that possibility, and delayed transsphenoidal surgery following conservative management with steroids is the appropriate management of such an occurrence.
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PMID:Cerebral infarction caused by pituitary apoplexy: case report and review of literature. 2526 55

Pituitary adenoma apoplexy is a well-known clinical syndrome induced by insulin infusion, cardiac surgery, trauma, and hypothalamic releasing factors. Pituitary apoplexy can cause secondary cerebral infarct and internal carotid artery occlusion. With blockade of tumor perfusion, apoplexy triggers a sudden onset of headache, visual impairment, cranial nerve palsy, disturbances of consciousness, eyelid ptosis, and hemiparesis. However, pituitary adenoma cells with high metabolic demand cannot survive with deficient blood supply and glucose concentrations. Moreover, a number of case reports have shown that spontaneous remission of syndromes, such as acromegaly, may be caused by pituitary adenoma after apoplexy. Therefore, understanding mechanism that underlies the balance between pituitary adenoma apoplexy and subsequent spontaneous remission of syndromes may suggest new approaches for treatment of pituitary adenoma apoplexy.
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PMID:Complex effects of apoplexy secondary to pituitary adenoma. 2780 76

Pituitary apoplexy is a potentially life-threatening clinical condition caused by rapid enlargement of a pituitary adenoma because of haemorrhage or infarction. The clinical features are typically acute in onset. We report an interesting case of 25-year-old man with complaints of sudden onset of headache and ophthalmoplegia in the right eye one month previously. He had ptosis and complete ophthalmoplegia in the right eye with visual acuity 6/24 and 6/12. Imaging showed a peripheral rim-enhancing mass lesion in the right parasellar and cavernous sinus with a dural tail. He underwent craniotomy and subtotal excision of the lesion. Histopathology was reported as pituitary apoplexy. Hormonal analysis was within normal limits. At two years of follow-up he had complete resolution of ophthalmoplegia and improvement in his vision. It is very uncommon to see pituitary apoplexy evolved in right parasellar region presenting as peripheral rim-enhancing mass lesion.
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PMID:Pituitary apoplexy presenting as a peripheral rim enhancing parasellar mass lesion with dural enhancement along the tentorium. 2858 57

Background. Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The typical clinical presentation of PA includes acute onset of severe headache, visual disturbance, cranial nerve palsy, and altered level of consciousness. Case Report. A 78-year-old man presented to the emergency department with one-day history of ptosis and diplopia and an acute-onset episode of altered level of consciousness which was resolving. He denied having headache, nausea, or vomiting. Physical examination revealed third-cranial nerve palsy and fourth-cranial nerve palsy both on the right side. Noncontrast computed tomography (CT) scan of the head was unremarkable. Brain magnetic resonance imaging (MRI) showed a pituitary mass with hemorrhage (apoplexy) and extension to the right cavernous sinus. The patient developed another episode of altered level of consciousness in the hospital. Transsphenoidal resection of the tumor was done which resulted in complete recovery of the ophthalmoplegia and mental status. Conclusion. Pituitary apoplexy can present with ophthalmoplegia and altered level of consciousness without having headache, nausea, or vomiting. A CT scan of the head could be negative for hemorrhage. A high index of suspicion is needed for early diagnosis and timely management of pituitary apoplexy.
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PMID:Pituitary Apoplexy Presenting as Ophthalmoplegia and Altered Level of Consciousness without Headache. 2985 89

Pituitary apoplexy is a rare endocrine emergency. The extent to which hyperglycaemia is a contributory risk factor in the precipitation of pituitary apoplexy is not known. A 38-year-old man with poorly controlled diabetes presented to the emergency department with sudden onset of nausea and headache with drooping of his right eyelid for about 4 days. On physical examination, he had orthostatic hypotension, ptosis of the right eye, lateral and downward positioning of the eye and absent pupillary reflex. Visual field testing of the left eye revealed superolateral quadrantanopia. MRI of the brain showed pituitary macroadenoma with necrosis. Investigations showed hyperglycaemia, decreased T3, T4 with normal Thyroid stimulating hormone (TSH), low serum Leutinizing hormone (LH), Follicle stimulating hormone (FSH), testosterone and low normal serum prolactin levels. About 21% of non-functioning pituitary adenomas present with apoplexy as was seen in our patient. It is likely that his uncontrolled diabetes precipitated this episode of apoplexy as hyperosmolarity and dehydration, caused by hyperglycaemia can lead to changed pituitary microvascular environment increasing the risk of pituitary infarction.
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PMID:Uncontrolled diabetes as a rare presenting cause of pituitary apoplexy. 3082 66


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