Cerebral ischaemia in pituitary apoplexy

Abstract

Pituitary apoplexy is a potentially fatal condition that can have serious consequences even after successful treatment. One of the potential complications of this syndrome is occlusion of the internal carotid arteries, which causes cerebral ischaemia. This can occur through one of two mechanisms--direct compression of the artery or vasospasm caused by factors released from haemorrhagic or necrotic material. We illustrate two examples of cerebral ischaemia with pituitary apoplexy, one with compression and one with vasospasm, both ending in a successful resolution. In both, magnetic resonance imaging, angiography, and hormonal studies allow diagnosis, and urgent surgical decompression should be the treatment of choice. We review the literature and discuss the mechanisms.

Surgical treatment of pituitary apoplexy in association with hemispheric infarction

“…Table 1). In most patients, only unilateral intracranial vessels are compressed, however, bilateral ICA compromise was documented in five [3,4,12,17,19]. Three patients were found with symptomatic carotid obstruction secondary to compression of a gradually enlarging pituitary adenoma, supporting mechanical arterial compression as the mechanism of stroke [23][24][25].…”

“…PA can result in rapid tumor expansion, which can cause mechanical compression of the intracranial vessels at the circle of Willis. In 19 patients with PA-related cerebral stroke, the stroke occurred as a result of direct compression of the intracranial vessels [3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. The cavernous or supra-clinoid portion of the ICA is usually affected, whereas, compression of the MCA and ACA are less common (Supp.…”

“…Cerebral vasospasm could be another mechanism of cerebral infarction in these patients [5,17,[26][27][28][29][30][31][32][33][34]. Cerebral vasospasm is attributed to SAH [27,29,30,33,34] and the release of vasoactive substances from the hemorrhagic or necrotic pituitary adenoma [5,17,28,[31][32][33] or damaged hypothalamus [17].…”

Clinical Reasoning: A 42-year-old man with severe headache, fever, and acute coma

“…7,8 However, occlusion of the ICA cannot always be fully explained by mechanical obstruction. For this patient, the pituitary tumor expanded around the terminal portion of the ICA, and blood flow of the ACAs and MCA significantly improved after tumor removal, suggesting a compressive etiology.…”

“…The pathophysiology of vasospasm following pituitary apoplexy remains unknown. 7,9 Transdiaphragmatic rupture of the sellar adenoma or extravasation of blood from the hemorrhagic or necrotic adenoma into the subarachnoid space is a likely cause. 9 Secretion of potent vasoactive substances by the tumor may also contribute to vasospasm.…”