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A patient with a pituitary adenoma secreting adrenocorticotropin hormone manifested panhypopituitarism after an episode of pituitary apoplexy. The previously elevated urinary levels of 17-ketogenic steroids dropped sharply, and plasma cortisol became undetectable. The apoplexy also resulted in a partially empty sella on which the dorsum sellae collapsed. Recurrent Cushing's disease developed and was cured by transsphenoidal resection of a microadenoma.
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PMID:Cushing's disease with pituitary apoplexy leading to hypopituitarism, empty sella, and spontaneous fracture of the dorsum sellae. Case report. 22 16

In 12 cases of pituitary apoplexy, a preexisting unsuspected adenoma was found. The initial manifestations were sudden onset of headache (12 patients), signs of meningeal irritation (10) with fever (four), altered consciousness (12), and ophthalmologic disturbances (eight). The diagnosis was retrospective in three cases. Radiologic investigations were always suggestive if carefully considered. The plain skull roentgenograms, in particular, showed an enlarged sella turcica in 11 cases. Three patients had prolactin adenomas, and nine had nonfunctional adenomas. Medical treatment was successful in only three patients; surgery was performed in 10 cases by means of a sublabial transseptal microsurgical approach. Postoperative neurologic complications were serious in two cases. Endocrine insufficiencies were common: eight cases of permanent panhypopituitarism, two cases of pluritropic anterior pituitary dysfunction, and three cases of persistent hyperprolactinemia.
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PMID:Twelve cases of pituitary apoplexy. 837 8

Ten consecutive patients with subarachnoid hemorrhage (SAH) of unknown cause were examined for sellar abnormalities and pituitary dysfunction. The diagnosis of SAH rested on a typical history and the demonstration of blood in the cerebrospinal fluid (computed tomography (CT), lumbar puncture). Initial CT and four-vessel angiography were performed in all patients, and five had repeat angiography. Endocrinological assessment was done after the initial angiography, and abnormal findings from this first study were reassessed 3 months later. The follow-up study included a high resolution CT scan of the sellar region. One patient had panhypopituitarism. Insufficient growth hormone secretion alone or combined with a low plasma concentration of estradiol or testosterone was found in another seven patients. The sella was ballooned or enlarged in three patients, and four patients had at follow-up a partly empty sella. A spontaneous development of a partly empty sella from an adenoma with suprasellar extension was observed in the patient with panhypopituitarism. This patient had experienced pituitary apoplexy with resulting SAH. Based on sellar enlargement, an empty sella, and pituitary dysfunction, this pathogenesis was suggested in another three patients. Our findings suggest that hemorrhagic necrosis in a pituitary adenoma may be an important cause of SAH with normal angiography.
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PMID:Subarachnoid hemorrhage with normal cerebral angiography: a prospective study on sellar abnormalities and pituitary function. 380 31

Pituitary apoplexy is a neuroendocrine emergency produced by hemorrhage or infarction of pituitary tumors, and its accurate diagnosis has relied mainly on clinical manifestations and computed tomography (CT) scan of sella in the past. A case is reported of pituitary apoplexy which was demonstrated on magnetic resonance imaging (MRI). The 72-year-old male patient was admitted to the Nephrology Section of VGH-Taipei with symptoms of general malaise, poor appetite for four months and apparent hyponatremia (Na 102 mEq/L) on laboratory findings. Under the impression of syndrome of inappropriate secretion of antidiuretic hormone (SIADH), fluid restriction and infusion of isotonic saline were prescribed, but in vain. The patient was transferred to the Endocrinology Section because of lowered serum cortisol, T3, T4, and hs-TSH levels. Dynamic pituitary function tests confirmed the diagnosis of panhypopituitarism. Contrast enhanced CT scan of sella revealed displacement of the pituitary stalk to the right side. T1-weighted MRI showed persistent high intensity in left sella and T2-weighted MRI showed persisting isointense to white matter. The hyponatremia and clinical symptoms resolved within a few days after replacement therapy with glucocorticoid and thyroid hormone. It was concluded that MRI is more sensitive than CT scan for detecting subacute or chronic pituitary apoplexy.
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PMID:Pituitary apoplexy diagnosed by magnetic resonance imaging: a case report. 775 60

Pituitary adenoma apoplexy was considered an acute life-threatening condition until more benign and even asymptomatic courses were found by advanced neuroimaging procedures. Necrosis and hemorrhage in the pituitary adenoma can cause acute enlargement of the tumor. sometimes with rupture of the tumor capsule and bleeding into the subarachnoid space and surrounding parts of the brain. Clinical symptoms include acute or subacute headache in combination with signs of meningeal irritation and neuroophthalmological and cerebral dysfunction. Severe panhypopituitarism may be an additional complication. Acute blindness due to compression of the optic chiasm and symptomatic compression of basal cerebral arteries require immediate transsphenoid tumor resection. If panhypopituitarism is suspected, immediate hormone substitution is necessary.
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PMID:[Adenomatous hypophyseal apoplexy. Clinical, diagnostic and therapeutic aspects of a frequently misdiagnosed emergency state]. 778 16

Hypophyseal apoplexy is not always easy to confirm morphologically or analytically. We present a patient with Cushing's syndrome due to hypophyseal apoplexy and optochiasmic pachyarachnoiditis which produced serious visual alterations. The adenoma necrotized behind an area of hypophyseal apoplexy which cured the patient's Cushing's disease. The second case was admitted with hypophyseal apoplexy, presenting hypophyseal tumoration with signs of hemorrhage and subsequent panhypopituitarism.
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PMID:[Pituitary apoplexy in 2 hypophyseal tumors]. 810 82

Eight children with either panhypopituarism, severe growth hormone deficiency or neurosecretory dysfunction for growth hormone with a common history of umbilical cord encirclement around the neck underwent magnetic resonance imaging of the pituitary gland and the hypothalamus. Panhypopituitarism was associated with small to absent adenohypophysis, narrow or absent stalk and ectopic neurohypophysis whereas patients with partial GHD showed normal anatomical structures. Etiology of the endocrinopathy could be a primary malformation of the pituitary gland, an apoplexy of the gland or disturbation within the hypothalamus. We believe that the latter cause is predominant in umbilical cord encirclement.
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PMID:[Magnetic resonance tomography studies of the hypophysis in children with growth hormone deficiency, born with umbilical cord entanglement]. 885 23

A 68-year-old man with coronary artery disease was admitted for chest pain and ventricular tachycardia. After electric cardioversion, therapeutic heparinization was started for myocardial ischemia and nontransmural infarction. On day 3, headache and fever developed, followed by an altered sensorium and hyponatremia. Infectious etiology for the fever was excluded, and results of computed tomography of the brain were normal. Later magnetic resonance imaging (Day 10) demonstrated a pituitary macroadenoma with hemorrhage. Treatment for panhypopituitarism with stress-dose steroids stabilized the patient, and the fever and hyponatremia resolved. Transsphenoidal resection of the pituitary adenoma was performed without incident. This is the first reported case of pituitary apoplexy after heparin anticoagulation for acute myocardial infarction, although chronic anticoagulation in other settings has been reported as a precipitant of apoplexy. The uncommon presentation of a "central" fever and confusion in a patient with previously undiagnosed adenoma posed a diagnostic challenge. Subtle presentations of panhypopituitarism, knowledge of which should lead to suspicion and early diagnosis of pituitary apoplexy, will prevent anticoagulant-induced central nervous system catastrophes and potential fatalities.
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PMID:Heparin therapy for myocardial infarction: an unusual trigger for pituitary apoplexy. 936 41

Critical issues in diagnosis and treatment of pituitary disease are surveyed. The most relevant clinical aspects of hyperprolactinemia, acromegaly, Cushing's disease, secondary hyperthyroidism, syndrome of inappropriate ADH secretion, panhypopituitarism, growth hormone deficiency, gonadotropin deficiency, ACTH deficiency, TSH deficiency, and diabetes insipidus are discussed. Diagnostic and therapeutic issues in the approach to pituitary adenomas, craniopharyngiomas and pituitary apoplexy are analyzed.
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PMID:Diagnosis and treatment of pituitary disease. 966 58

In this study, 55 patients with Cushing's syndrome (CS) (50 female, 5 male; mean age 34 +/- 12.3 yr) who attended our clinics between the years 1983 and 2000 were retrospectively evaluated for clinical and laboratory features and modalities and results of therapy, due to a few similar studies over the last ten years. Cushing's disease was diagnosed in 39 patients (71%), adrenal adenoma in 13 patients (23.6%) and adrenal carcinoma in 3 patients (5.5%). Centripedal obesity, moon face, hypertension, hirsutism and purplish stria were the most frequent findings. Loss of normal serum F circadian rhythm was found in all patients with CS. The overnight 1 mg oral dexamethasone suppression test and low-dose dexamethasone suppression test (LDDST) yielded 100% and 100% diagnostic sensitivity for CS, respectively. Sensitivity and specivity of the high-dose dexamethasone suppression test (HDDST) in distinguishing Cushing's disease was found to be 82% and 100%, respectively. All of the patients with adrenal CS were not suppressed with HDDST. Sellar CT and/or MRI accurately identified the tumor in 58% of these patients. Recurrence was observed in 3 (11%) of the 28 patients with Cushing's disease, treated by transsphenoidal adenomectomy. Recurrence was diagnosed 1.5, 3 and 6 yr after the operation in these 3 patients. One patient had residue tumor. In our case series, bilateral adrenalectomy plus pituitary irradiation achieved the highest remission rate (100%) in Cushing's disease. In 2 out of 4 patients (50%) treated by left adrenalectomy associated with pituitary irradiation, recurrence was observed. Panhypopituitarism due to tumor apoplexy was observed in one of the patients with Cushing's disease. All of the patients with adrenal CS, the tumor was accurately localized with imaging methods before the operation. The appropriate operative procedure resulted in complete remission in patients with adrenal adenoma. Consequently, Cushing's disease was the most common form of CS. The overnight 1 mg oral DST and 24-h urine free F excretion (UFC) as screening tests, 2-day LDDST as diagnostic test and 2-day HDDST as differential diagnostic test were good studies. More successful outcomes have been achieved in treatment of Cushing's disease with the development of pituitary surgery in the recent years, as well as in our case series. Surgery is also curative for adrenal adenoma patients. Survival remains poor among carcinoma patients.
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PMID:Clinical laboratory findings and results of therapy in 55 patients with Cushing's syndrome. 1260 37


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