1 Pituitary Apoplexy 내분비 대사 내과 R3 송 란

2 Definition Clinical features Precipitating factor Pathophysiology Diagnosis Management Prognosis

3 Definition Acute disorder presenting with characteristic, severe neurological symptoms as a result of sudden ischemic or hemorrhagic infarction of a pre-existing –although in some cases previously unsuspected – pituitary adenoma First case –catastrophic hemorrhage may develop in a pituitary adenoma - Bailey, 1898 “ pituitary apoplexy ” –Seminal clinicopathologic report of five patients who died of pituitary hemorrhage or infarction - Brougham et al. J Neurosurg 1950;7:421-39

4 Clinical features Table 3. Common presenting symptoms and signs in patients with pituitary apoplexy Deficiency of pituitary hormones (81%) - Gonadotrophin deficiency :76% - Corticotrophin deficiency :60% - Thyrotrophin deficiency :57% - Prolactin deficiency :40% N ENG J MED 2003;349

5 Pituitary adenoma : most common Sudden head trauma Arterial hypertension ( BP > 160/90 mmHg ) Transient elevation of intracranial pressure Diabetes mellitus Major surgery ( eg. coronary artery bypass graft ) Dynamic tests of pituitary function GnRH analogue Anticoagulation therapy Bleeding disorders Bromocriptine therapy Radiotherapy Precipitating factor

6 Pituitary adenoma Incidence Mohr and Hardy,Surgical Neurology, % Bills et al. Neurosurgery, % Symon and Mohanty,Neurochirurgica, % Randeva et al. Clinical Endocrinology, % Wakai et al.Journal of Neurosurgery, % Size : significant factor –larger adenoma  higher risk of infarction/haemorrhage Endocrinologically active vs. inactive  unknown - Arita et al. J Neurosurg 2006,104

7 Dynamic tests of pituitary function Apoplexy of a pituitary adenoma after dynamic testing with gonadotropin-releasing hormone - Arafeh et al. Am J Med 1989;87 Pituitary apoplexy induced by corticotrophin-releasing hormone in a patient with Cushing's disease – Rotman et al. Clin Endocrinol 2003;58 Pituitary apoplexy associated with a triple bolus test – Bernstein et al. J Neurosurg 1984;61 Thyrotropin-releasing hormone (TRH) –Serum level of norepinephrine  vasoactive –Directly activate the tumor cells Gonadotropin-releasing hormone(GnRH) –Increase the cell metabolism Insulin –Hypoglycemia  Counterregulatory catecholamine release Bromocriptine –Lead to rapid shrinkage of the prolactin-secreting tumor cell  extracellular accumulation of fluid and tissue debris

8 Pathophysiology Pituitary adenoma –Rapidly growing adenoma around blood supply  haemorrhage  ischaemic necrosis of the gland –Expanding mass  direct compression of the pituitary infundibulum  compromising the blood flow from the portal vessels  necrosis of the entire gland with haemorrhage –Inherent fragility of tumour blood vessels & atherosclerotic embolisation

9 Nonadenomatous pituitary Pathophysiology Reduced blood flow in the pituitary gland Cardiac surgery Lumbar laminectomy Hemodialysis Increased blood flow in the pituitary gland Diabetic ketoacidosis Malignant hypertension Stimulation of pituitary gland Estrogen administration Pregnancy Pituitary function test Bromocriptine Surgical stress Anticoagulated state Anticoagulant drugs Thrombolytic agents Thrombocytopenia

10 CT : poor technical quality MRI : imaging method of choice Diagnosis - James et al. J Neurosurg 2006; 104 :892–898 Grade IaGrade Ib Grade II

11 Coneservative management –Fluid and electrolyte monitoring –Replacement of deficient hormones –Corticosteroids Surgical decompression –Severe neuro-ophthalmic signs : total visual loss –Transsphenoidal decompression Radiotherapy –Recurrent tumor Management

12 Prognosis - Lubina et al. Acta Neurochir,2005; 147: 151–157 Ref.[1] Neurosurgery 33: 602–609 Ref.[16] Clin Endocrinol 51: 181–188

13 Visual outcome –Length of the visual history –Severity of the initial visual deficit –Appearance of the optic disc Prognosis Harpal et al. Clinical Endocrinology,1999; 51; 181–188 Operation : within first 8 days