| OCR Text |
Show Clinical Correspondence Section Editors: Robert Avery, DO Karl C. Golnik, MD Caroline Froment, MD, PhD An-Guor Wang, MD Case of Pituitary Apoplexy After Surgery Ian J. McClain, BA, Philip M. Skidd, MD P ituitary apoplexy (PA) is a rare disease typically precipitated by acute infarction or hemorrhage within the pituitary gland (1). Most cases of PA are related to the presence of a pituitary adenoma (2). Although incidence data are incomplete, PA has been reported to occur in between 1% and 26% of pituitary adenomas (3). Histologically, vessels supplying adenomas are immature, have fragmented basement membranes, and may be prone to hemorrhage or hemorrhagic infarction (4). A presumed mechanism for PA is believed to relate to the tumor either outgrowing or compressing pituitary blood supply leading to ischemia (3). Major hemodynamic shifts such as those associated with trauma or major surgery have previously been linked as inciting events (3). We present a case of pituitary apoplexy occurring in a previously unidentified underlying pituitary adenoma in the context of elective surgery without significant perioperative hemodynamic shift. A previously asymptomatic 75-year-old woman with a history of essential hypertension and no relevant ocular history presented to the emergency department with complaints of headache, vomiting, diplopia, and inability to open the right eye the day after elective rotator cuff repair. Her surgery was uncomplicated without significant perioperative blood loss or hemodynamic instability. The total time of arthroscopic rotator cuff repair as measured from start of intubation to end of extubation was 209 minutes with anesthetic induction using intravenous propofol and fentanyl given for pain control. Initial physical examination in the emergency department revealed ptosis, anisocoria, and near-complete III, IV, and VI nerve palsies of the right eye. Visual fields showed bitemporal hemianopsia, and visual acuity was 20/100 in the right eye and 20/30 in the left eye. Computed tomography revealed a large sellar mass, and MRI revealed a sellar and suprasellar mass extending into the right cavernous sinus and sphenoid sinus with a significant mass effect on the optic chiasm (Fig. 1). The differential diagnosis was hemorrhagic pituitary adenoma, craniopharyngioma, Rathke cleft cyst, pituitary carcinoma, and giant berry aneurysm. The patient underwent urgent transsphenoidal endoscopic resection of the pituitary mass with a presurgical diagnosis of pituitary tumor with right cavernous sinus syndrome. Postsurgical pathology revealed pituitary macroadenoma with hemorrhage. She was discharged after 5 days otherwise uneventful in the hospital. Formal neuro-ophthalmic examination was performed approximately 1 month later and then at regular 1-year intervals for a period of 4 years. At the initial 1-month examination she continued to exhibit ptosis, complex strabismus, and right III, IV, and VI nerve palsies. Automated visual fields showed bitemporal hemianopsia. Visual acuities with correction were 20/30 in the right eye without significant pinhole improvement; 20/40 in the left eye with pinhole improvement to 20/25. Approximately 1 year later, the patient’s ptosis and ophthalmoplegia had almost completely resolved, and her visual field deficits were stable if not mildly improved. Her central vision was correctible to 20/20 in both eyes. She remained stable at subsequent follow-up, without progression of visual deficits. Larner College of Medicine (IJM, PMS), University of Vermont, Burlington, Vermont; and Departments of Surgery (PMS), and Neurological Sciences (PMS), University of Vermont Medical Center, Burlington, Vermont. The authors report no conflicts of interest. Address correspondence to Ian J. McClain, BA, 46 Colchester Avenue, Burlington Vermont 05401; E-mail: ian.mcclain@med.uvm.edu McClain and Skidd: J Neuro-Ophthalmol 2022; 42: e385-e386 FIG. 1. Postgadolinium contrast T1 saggital and axial images (top). Pregadolinium and postgadolinium contrast T1 and T2 coronal images (bottom). e385 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence Previous literature has described numerous events inciting pituitary apoplexy in those with underlying pituitary adenomas, including blood loss (e.g., trauma, major surgery, and postpartum hemorrhage), coagulopathy (e.g., anticoagulation or antiplatelet therapy and primary coagulopathy), and systemic illness (e.g., hypertension) (3). Our review of the literature found only a few cases of PA linked to surgery in the absence of significant hemodynamic shifts. Our case illustrates that PA can occur even during routine surgeries and suggests that other factors may be at play. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: I. J. McClain and P. M. Skidd; b. Acquisition of data: I. J. McClain and P. M. Skidd; c. Analysis and interpretation of data: I. J. McClain and P. M. Skidd. e386 Category 2: a. Drafting the manuscript: I. J. McClain and P. M. Skidd; b. Revising it for intellectual content: I. J. McClain and P. M. Skidd. Category 3: a. Final approval of the completed manuscript: I. J. McClain and P. M. Skidd. REFERENCES 1. Biousse V, Newman NJ, Oyesiku NM. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry. 2001;71:542–545. 2. Nawar RN, AbdelMannan D, Selman WR, Arafah BM. Pituitary tumor apoplexy: a review. J Intensive Care Med. 2008;23:75–90. 3. Ranabir S, Baruah MP. Pituitary apoplexy. Indian J Endocrinol Metab. 2011;15(suppl 3):S188–S196. 4. Hirano A, Tomiyasu U, Zimmerman HM. The fine structure of blood vessels in chromophobe adenoma. Acta Neuropathol. 1972;22:200–207. McClain and Skidd: J Neuro-Ophthalmol 2022; 42: e385-e386 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
