Review
Surgical treatment of pituitary apoplexy in association with hemispheric infarction

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Highlights

Abstract

We report a patient with pituitary apoplexy in whom cerebral infarction developed, possibly secondary to vasospasm. Pituitary apoplexy is a clinical syndrome caused by acute hemorrhage or infarction of the pituitary gland. Our patient’s clinical symptoms and radiographic findings greatly improved after surgical resection of the apoplectic pituitary gland. An extensive literature review was performed, including all previously reported cases of pituitary apoplexy leading to cerebral infarction. The clinical features, pathophysiological mechanisms, management and outcome of cerebral infarction following pituitary apoplexy are discussed. We show that cerebral infarction following pituitary apoplexy is associated with much poor prognosis. Early surgical decompression of the tumor and hemisphere should be performed in patients with severe or progressive neurological deficits, however, those with less severe presentations may be treated conservatively or with delayed elective surgery.

Introduction

Pituitary apoplexy (PA) is a clinical syndrome caused by acute hemorrhage or infarction of the pituitary gland, and is characterized by the sudden onset of severe headache, visual impairment, ophthalmoplegia and altered mental status. The incidence of apoplexy in patients with pituitary adenoma is approximately 2–7% [1]. Cerebral infarction is a rare complication of PA, and only isolated patients have been reported. In this report, we describe a patient with PA who developed ischemic stroke and improved significantly after pituitary and hemisphere decompressive surgery. We also review similar patients reported in the literature and summarize their clinical characteristics.

Section snippets

Case report

A 23-year-old man presented with severe headache, nausea, fever and decreased visual acuity of his right eye for 1 day, followed by a sudden loss of consciousness. He had no significant previous medical history. On examination, his blood pressure was 130/80 mmHg, and body temperature was 37.1 °C. Signs of acromegaly, including frontal bossing and hand enlargement were identified, and neck stiffness was present. Spontaneous and reflex movements to painful stimuli were present in his right limbs but

Methods

We conducted a literature search in both MedLine (National Library of Medicine, Bethesda, MD, USA) and EMBASE (Elsevier, Amsterdam, The Netherlands) using the following keywords: “pituitary adenoma” OR “pituitary apoplexy”, AND “stroke” OR “cerebral infarct/infarction” OR “cerebral ischemia/ischaemia” OR “cerebral vasospasm” OR “cerebrovascular accident”. Only English language literature was included in the review. A PA and cerebral infarction diagnosis must have been based on the acute onset

Discussion

Cerebral infarction following PA is rare, with only 36 patients reported in the English language literature to date (Supp. Table 1). Only a few patients (8%) had a known history of pituitary adenoma. Some precipitating factors such as angiography, head trauma, and pituitary surgery were identified in 22% of patients (Table 1).

The most common symptoms of PA-related stroke were altered consciousness (97%), signs of intracranial hypertension, (86%), motor weakness (75%), and visual disturbance

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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    These authors have contributed equally to the manuscript.

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