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Many neurologic disorders, such as eclampsia, pseudotumor cerebri, stroke, obstetric nerve palsies, subarachnoid hemorrhage, pituitary tumors, and choriocarcinoma, can develop in the pregnant patient. Maternal mortality from eclampsia, which ranges from 0 to 14%, can be due to intracerebral hemorrhage, pulmonary edema, disseminated intravascular coagulation, abruptio placentae, or failure of the liver or kidneys. Associated fetal mortality ranges from 10 to 28% and is directly related to decreased placental perfusion. Pseudotumor cerebri can be associated with serious visual complications; thus, the therapeutic goal is to prevent loss of vision. The risk of stroke in the pregnant patient is 13 times the risk in the nonpregnant patient of the same age. The major causes of stroke in pregnant patients are arterial occlusion and cerebral venous thrombosis. Lumbar disk prolapse is common in pregnant patients, and lumbosacral plexus injuries can occur during labor or delivery. In addition, peripheral nerve compression or entrapment syndromes are thought to be caused by the retention of fluid during pregnancy. The incidence of subarachnoid hemorrhage during pregnancy is 1 in every 10,000 patients, a rate 5 times higher than in nonpregnant women. Because of a proliferation of prolactin-secreting cells, the pituitary gland can enlarge dramatically during pregnancy, a change that can disclose a previously unknown tumor or cause a known pituitary tumor to become symptomatic. The incidence of choriocarcinoma is 1 in 50,000 full-term pregnancies but 1 in 30 molar pregnancies. This malignant tumor has a high rate of cerebral metastatic lesions. In addition to these disorders that develop during pregnancy, the pregnant state can affect numerous preexisting neurologic conditions, including epilepsy, headaches, multiple sclerosis, myasthenia gravis, spinal cord injury, and brain tumors. We discuss advice for patients with such conditions who wish to become pregnant, recommendations for medical and surgical management, and surgical considerations for neurologic complications during pregnancy.
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PMID:Selected neurologic complications of pregnancy. 225 22

Although metastatic tumors of the pituitary gland and the sellar region are not common, they may radiographically mimic a pituitary tumor. Because the metastasis frequently involves the posterior lobe and because lateral extension to the cavernous sinus is common, patients may present with ptosis, diplopia, or diabetes insipidus. Decrease in anterior pituitary function is less common. Metastatic tumors contain abundant vascular networks, as evidenced by frequent blush on cerebral angiography and increased bleeding at operation. We report the case of a 57-year-old woman who presented with rapid onset of bilateral ptosis and ophthalmoplegia and was found to have a metastatic carcinoma within the pituitary gland.
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PMID:Metastatic tumor of the pituitary gland. 343 67

Since the first reports of pituitary oncocytoma by Kovacs and Horvath, and Landolt and Oswald increasing numbers of cases have been reported with the advent of electron microscopy. It has been posturated that more cases were not precisely diagnosed because of lack of electron microscopic study. We reported two cases of pituitary oncocytoma and discussed clinicopathological aspects. Case 1 A 66-year-old woman had a 6 year history of visual impairment. Neurological examination revealed loss of vision on the left and decreased visual acuity (0.3) with temporal hemianopsia on the right. The endocrinological study revealed moderate panhypopituitarism. Plain skull X-ray, computed tomography and cerebral angiography showed the findings of a pituitary tumor with suprasellar extension. Subfrontal removal of the tumor followed by irradiation was performed. Case 2 A 50-year-old man was well until 8 years previously, when he experienced loss of libido. Three years before entry, the left sided exophthalmos and ptosis were noted. Neurological examination showed a severe visual impairment with a bitemporal field defect, bilateral optic atrophy and disturbance of eye movements on the left. Endocrinological study revealed panhypopituitarism. Radiological studies showed a pituitary tumor with a suprasellar extension and an invasion into the left orbital cavity. Transcranial and then transsphenoidal partial removal of the tumor were done followed by irradiation. Histological examination of the tumors revealed a poorly granurated adenoma with very weak affinity to acid dyes.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Pituitary oncocytoma]. 650 55

A case of giant intracranial aneurysm which almost completely occluded the internal carotid artery and was diagnosed angiographically by prolonged injection technique was reported. A 62-year-old house-wife was admitted to the Department of Neurosurgery of The Asahi General Hospital, complaining of headache, nausea, and left ptosis. Neurological examination revealed left IInd, IIIrd, IVth, and VIth cranial nerve palsy. Films and laminagrams of the skull demonstrated the double floor of the sella trucica. Plain CT scan showed an oval high density area without surrounding low density area in the left middle cranial fossa. A left carotid angiogram revealed almost complete occlusion of the internal carotid artery at the foramen lacerum. Good cross filling through the anterior communicating artery was seen in the right carotid angiogram. Pre-operative diagnosis was pituitary tumor which extended to the middle cranial fossa. Left fronto-temporal craniotomy was performed and the tumor was suspected to be a giant intracranial aneurysm. Post-operative carotid angiogram by prolonged injection technique also showed a blood channel in the aneurysm and a part of the aneurysm. Left carotid ligation was carried out following intracranial surgery and her symptoms were remarkably improved. Apart from left VIth cranial nerve palsy she showed no abnormal neurological findings at discharge. Usefulness of the prolonged injection technique for differential diagnosis of the parasellar tumor was stressed.
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PMID:[Giant intracranial aneurysm visualized by prolonged injection angiography--case report (author's transl)]. 742 64

A 50-year-old female presented with progressive painless vision loss in the left eye and was subsequently diagnosed to have a pituitary macroadenoma, consistent with a prolactinoma, which was compressing the chiasm primarily on the left and involving the left cavernous sinus. She was treated with oral bromocriptine, resulting in marked shrinkage of the tumor and significant visual field recovery. Subsequently, she again began noting progressive vision loss in both eyes and was initially thought to have pituitary tumor regrowth. Repeat brain MRI, however, showed chiasmal prolapse with inferior tethering into an empty sella. Surgical fat padding to reposition the chiasm resulted in visual improvement with a different visual field pattern in the left eye. The clinical manifestations and etiopathogenesis of the empty sella syndrome are discussed.
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PMID:Her vision was tied down. 1626 71

LHRH analogs have become a promising modality in prostate cancer therapy as an alternative to surgical castration, and the use of these agents is generally considered to be safe. Since now, only few cases of an apoplexy of previously undiagnosed pituitary adenoma (usually gonadotropinoma) at the beginning of therapy have been described in the medical literature. We present a case of a 74 year old patient who was diagnosed of prostate cancer at the age of 68. There was no evidence of metastatic disease. Radical prostatectomy was performed and LHRH analog gosereline (Zoladex 3.6 mg s.c.) was administered. During the first day after gosereline injection the patient developed headaches that became more severe over the next 3 days. Then the patient experienced nausea and vomiting, double vision and eyelid ptosis. On the 5th day the patient temporarily lost consciousness and was admitted to hospital. Imaging (computerized tomography, magnetic resonance imaging) revealed the presence of a pituitary tumor and hemorrhage within the gland. There was no evidence of pituitary dysfunction in hormonal studies. Neurosurgical intervention was postponed for 5 days after admission. Pathological mass with signs of recent hemorrhage was removed via transsphenoidal route. The tumor had negative immunohistochemical GH, ACTH and PRL staining. Neurological impairment resolved within 9 months after the operation. As a result the patient required adrenal and thyroid replacement. During 6 years of follow-up there was no evidence of prostate cancer recurrence.
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PMID:Apoplexy of clinically silent pituitary adenoma during prostate cancer treatment with LHRH analog. 1715 26

A 73-year-old woman presented with disturbance of right eyelid opening with ptosis and impairment of right ocular movement, and later was found to have Cushingoid features. Endocrine examinations revealed that plasma ACTH and cortisol levels were elevated, lack of circadian rhythm, resistant to low-doses (0.5, 1, 2 mg) and high-dose (8 mg) dexamethasone, and responsive to CRH and DDAVP. Magnetic resonance imaging (MRI) revealed a large pituitary tumor invading the right cavernous sinus. After two months treated with bromocriptine (5 mg/day), she showed clinical improvement with normalization of plasma ACTH and cortisol levels, and improvement of right eyelid opening and ocular movement. MRI, however, revealed no apparent reduction in the size of pituitary tumor. This is a rare case of bromocriptine-responsive Cushing's disease.
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PMID:Bromocriptine-responsive Cushing's disease; clinical and biochemical remission accompanied by amelioration of impaired ocular movement. 1763 11

A 40-year-old man presented with a sudden severe headache and complete right-sided ptosis. Neuro-ophthalmic examination revealed a right oculomotor nerve palsy. Computed tomography of the brain showed a round isodense intrasellar mass. Magnetic resonance imaging demonstrated a pituitary tumor with some areas of infarction and invasion into the right cavernous sinus, which was diagnosed as pituitary apoplexy. The patient received intravenous steroid for 10 days with no recovery of the oculomotor nerve palsy. He underwent trans-sphenoid tumor resection followed by complete recovery of the oculomotor nerve and no sign of tumor in postoperative MRI, two weeks after the surgery.
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PMID:Pituitary apoplexy presenting as acute painful isolated unilateral third cranial nerve palsy. 1858 83

We report the case of a 60 year old male who complained of headache and blurry vision--that progressed to left ophthalmoplegia and ptosis--after receiving a dose of leuprolide for Prostate cancer therapy. Imaging showed a hemorrhagic sellar mass. The patient underwent transsphenoidal debulking, and the tissue obtained demonstrated immunohistochemical staining for LH. A literature review revealed nine previously reported cases of pituitary apoplexy after GnRH agonist therapy for prostate cancer. In most cases, the sellar tissues stained for LH, consistent with a gonadotropinoma. The pathophysiology of these events is unclear, but recent animal models suggest possible explanations. The predominance of gonadotropinomas is important because they do not usually present with hypersecretory symptoms. Particular attention to clinical findings suggestive of a non functioning pituitary tumor in patients receiving GnRH agonist therapy is critical as routine screening with MRI is not practical.
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PMID:Apoplexy in non functioning pituitary adenoma after one dose of leuprolide as treatment for prostate cancer. 1984 40

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


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