Request PDF on ResearchGate | Apoplejía pituitaria. Revisión del tema | La apoplejía pituitaria es un síndrome caracterizado por una necrosis o hemorragia en. La apoplejía pituitaria es normalmente el resultado de un infarto hemorrágico que acontece a un adenoma hipofisario. La presentación clínica comprende un. Abstract. ZAMORA, Adrián; MARTINEZ, Paola and BAYONA, Hernán. Pituitary tumor apoplexy. Acta Med Colomb [online]. , vol, n.3, pp
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Pituitary apoplexy as sociated with ptosis. Pituitary tumours are the most common sellar masses, frequently presenting with visual impairment and endocrine abnormalities. Apopleuia cases of pituitary tumour presenting with ptosis are reported. Pituitary adenomas are common intracranial tumours, constituting They are more common in women than men, usually presenting with endocrine abnormalities.
Ptosis is a previously reported but rare presenting feature and may result from haemorrhage into the tumour. A patient with sudden onset of ptosis, particularlywith a complete oculomotor palsy is most likely to be diagnosed as a posterior communicating artery aneurysm and not a pituitary tumour.
The following patients remind us that pituitary apoplexy is an uncommon but important associated finding in acute unilateral ptosis.
A year-old Caucasian male presented with a two-day history of severe headaches and a one-day history of leftsided ptosis preceded by diplopia.
There was no history of loss of consciousness, neck stiffness or features suggestive of seizure activity. The previous medical history was noncontributory. On examination, there was a complete oculomotor nerve palsy.
Emergency computed tomography CT of the brain demonstrated no subarachnoid haemorrhage. An unruptured posterior communicating artery aneurysm was suspected and urgent cerebral angiography performed.
Digital subtraction angiography of the carotid and vertebral circulation revealed persistent narrowing of the left carotid siphon but no aneurysm. Subsequent magnetic resonance angiography MRA also revealed narrowing of the left carotid siphon and images of the brain showed a pituitary tumour of inhomogenous but mainly high signal intensity on T1 weighted images T1WI and iso-intensity on T2 weighted images T2WIin keeping with a haemorrhagic tumour.
Minimal peripheral enhancement following administration of intravenous gadolinium was noted. The mass expanded the sella, compressing the left cavernous sinus and the left internal carotid artery with superior displacement of the optic chiasm Fig. Coronal CT images suggested a breach in the floor of the sella turcica.
Visual field assessment revealed left nasal loss and mild constriction of the right nasal field. He subsequently developed palsies of left trochlear and abducens nerves, as well as inappropriate secretion of antidiuretic hormone. At trans-sphenoidal surgery, there was erosion of the floor of the pituitary fossa with tumour extension into the sphenoid sinus. Histology confirmed a pituitary adenoma with extensive areas of haemorrhage and necrosis, consistent with apoplexy.
In the early postoperative period, there was complete resolution of his ptosis. Mild residual diplopia had resolved by three months. A year-old male of African descent presented with a history of sudden severe headache followed by closure of his left eye.
There was a previous history of hypertension but not diabetes mellitus. On examination, he was found to have partial left oculomotor there was pupillary sparing and trochlear nerve palsies.
Emergency CT demonstrated no subarachnoid haemorrhage but showed an isodense uprasellar mass with an enlarged pituitary fossa. Computed tomography angiography revealed a pituitary tumour with mild enhancement on delayed images. The MRI showed a minimally enhancing sellar mass of predominantly high signal intensity on T1WI with a central hypo-intense area. There was superior compression of the central optic chiasma Fig.
At surgery, a haemorrhagicpituitary adenoma was found. The ptosis resolved completely postoperatively. Both patients were male, had surgically confirmed pituitary apoplexy and presented with left sided ptosis.
Anisocoria was not a consistent feature and extraocular muscle palsies varied between patients. Both tumours were demonstrable on CT. The MRI demonstrated the haemorrhage to greater advantage than did computed tomography. Unilateral ptosis may be congenital or acquired.
Acquired causes include posterior communicating artery Piuitaria aneurysms, diabetes mellitus, contact lenses, myasthenia gravis and Horner’s syndrome. Lesions of the oculomotor nerve can involve the nucleus in the midbrain or nerve fascicles within the ventral apopleiia, subarachnoid space, cavernous sinus, superior orbital fissure or orbit. Aneurysms of the PCA are an important cause of oculomotor nerve lesions from compression qpoplejia the nerve outside the central nervous system CNSas it passes near the junction of the PCA with the supraclinoid portion of the internal carotid artery near the cavernous sinus.
Clinical findings include dysfunction of the extraocular muscles innervated by the oculomotor nerve, with associated pupillary applejia. Third nerve lesions from diabetes mellitus or hypertension typically spare pituitaaria function although it is not always possible to differentiate between medical and compressive causes of these lesions based entirely on clinical findings as in case two.
Isolated unilateral ptosis due to superior rectus weakness without other ophthalmic muscle or papillary abnormality may be due to involvement of the superior branch of the oculomotor nerve in the orbit and is rarely the initial feature of a pituitary tumour with apoplexy 5,9, The topographical anatomy of the oculomotor nerve with the peripheral zpoplejia of the pupilomotor fibres may explain the tendency for compressive lesions to involve the pupil and non-compressive lesions to spare it 5.
Pituitary adenoma is the most common tumour of the sella turcica and suprasellar cistern. A tumour confined to the sella usually presents with hormonally related symptoms.
Non-secreting tumours are usually large at diagnosis, frequently extending into the suprasellar cistern with compression of the optic chiasm, producing visual field deficits, particularly bitemporal hemianopsia 6.
West Indian Medical Journal – Pituitary apoplexy associated with ptosis
Cranial nerve palsies are decidedly uncommon, being more regularly seen in parasellar neoplasms such as meningiomas, less commonly with neurinomas, when the oculomotor nerve is the most likely to be affected, followed in frequency by the abducens and trochlear. Patients may present with acute ptosis. Oculomotor nerve palsies generally develop as the end stage of an expanding tumour, combined with visual loss. Large tumours may extend high in the brain obstructing the foramina of Monro, causing hydrocephalus.
Headache is common and may be the only presenting symptom. Rarely, sudden haemorrhage into the tumour causes severe headache, often with acute chiasmal compression or oculomotor nerve palsy from rapid expansion of the tumour, pituitary apoplexy. The presence of mixed oculomotor palsies or bilateral ophthalmoplegia and an afferent papillary defect or chiasmal patterns of field loss help to differentiate apoplexy from aneurismal subarachnoid haemorrhage. There is no proven association between pituitary tumours and aneurysms but they may coexist due to the frequency of occurrence of both.
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Pituitary apoplexy is a surgical emergency. It has been reported postoperatively, in association with pregnancy, following treatment of a macroprolactinoma and related to adhesive arachnoiditis.
These cases are an important reminder that pituitary tumours and other sellar masses are an additionalconsideration in the differential diagnosis of patients presenting with ptosis.
Tumours of the central nervous system.
West Indian Med J ; Central nervous system neoplasms. Brant W, Helms C eds.
Apoplejía pituitaria. Revisión del tema | Neurocirugía (English edition)
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Clin Endocrinol Oxf ; Optochiasmatic syndrome from adhesive arachnoiditis with coesxisting hypophyseal adenoma: Ann Ophthalmol ; 9: Services on Demand Article. Article in pdf format Article in xml format Article references How to cite this article Automatic translation Send this article by e-mail.
Case 1 A year-old Caucasian male presented with a two-day history of severe headaches and a one-day history of leftsided ptosis preceded by diplopia. Case 2 A year-old male of African descent presented with a history of sudden severe headache followed by closure of his left eye. How to cite this article.