Oculomotor nerve palsy following coronary artery bypass graft surgery: can pituitary apoplexy complicate the post-operative course of cardiac surgery?

Abstract

Oculomotor nerve palsy, due to pituitary apoplexy, has been previously reported in the literature. However, the association with coronary artery bypass graft surgery (CABG) is rarely investigated. This article reports a case of pituitary apoplexy presenting with oculomotor nerve palsy following CABG. A 65-year-old male, known to have ischemic heart disease, diabetes mellitus and hypertension, presented with ptosis, diplopia and anisocoria that developed after 1 day of CABG. Radiological imaging demonstrated a pituitary adenoma with acute/subacute hemorrhage causing mild mass effect on the cavernous sinus. Considering the acute state of bypass surgery and pre-existing cardiac co-morbidities, expectant management was considered. The visual acuity and palsy gradually improved. Pituitary apoplexy, following CABG, is a rare phenomenon in the post-operative period. High index of suspicious is required to promptly identify high-risk patients to avoid further neurological sequelae.

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

“…( Table 1 ) Headache was severe, often described as the most painful headache episode an individual has ever experienced, and graded, for example, as high as 9 on a scale from 0 to 10, with 10 being the most severe in one study [ 31 ]. For practical purposes we point out that headache was absent in some cases; thus, an index of suspicion should be provided by other endocrine and non-endocrine clinical elements [ 43 , 86 , 196 , 197 , 198 , 199 , 200 , 201 , 202 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 , 212 , 213 , 214 , 215 , 216 ]. For instance, Enatsu et al reported a 65-year-old woman admitted for a nonfunctioning pituitary adenoma-associated PA who presented third cranial nerve palsy and sudden decrease in visual acuity unaccompanied by headache [ 196 ].…”

“…For instance, Enatsu et al reported a 65-year-old woman admitted for a nonfunctioning pituitary adenoma-associated PA who presented third cranial nerve palsy and sudden decrease in visual acuity unaccompanied by headache [ 196 ]. Another example is a 65-year-old male who developed PA as a post-operative complication after a coronary artery surgery; he only presented diplopia and third cranial nerve palsy [ 214 ]. Other circumstances without headaches involve a comatose status.…”

“…Complete blindness was reported in two papers [ 199 , 212 ]. Visual field defects varied from (mostly common) hemianopia [ 33 , 39 , 55 , 80 , 126 , 135 , 179 , 187 , 197 ] to cranial nerve palsies manifesting as diplopia in the majority of these cases [ 32 , 34 , 35 , 49 , 50 , 58 , 63 , 66 , 68 , 75 , 84 , 85 , 91 , 92 , 114 , 115 , 117 , 127 , 130 , 142 , 147 , 150 , 157 , 163 , 164 , 186 , 191 , 194 , 195 , 207 , 214 ] followed by ptosis [ 34 , 35 , 50 , 59 , 75 , 77 , 79 ,…”

“…Iatrogenic components may include diagnostic tests and procedures: dexamethasone suppression test [ 118 ], clomiphene use [ 66 ], combined endocrine stimulation tests [ 43 ], regadenoson myocardial perfusion scan [ 153 ], and MRI scan [ 46 ]. Among non-pituitary-surgery-related triggers, we identified major surgery [ 66 , 128 , 132 , 168 , 201 ], laparoscopic surgery [ 199 ], coronary artery bypass surgery [ 34 , 66 , 214 ], mitral valvuloplasty [ 84 ], endonasal surgery [ 127 ], and lumbar fusion surgery in prone position [ 80 , 116 ]. Interestingly, Naito Y et al reported a case of PA in a 14-year-old girl with Carney complex who underwent successful resection of a cardiac myxoma, but the day after surgery she experienced headache and visual disturbances requiring urgent surgical decompression for PA [ 132 ].…”

Keep an Eye on the Eye of your Patient: An Update on the Management of Post-CABG Pituitary Apoplexy

“…1,2 It has been hypothesized that pituitary apoplexy during on-pump cardiac surgery is likely related to cerebral hypoperfusion, low perfusion pressures, hemodilution and non-pulsatile flow experienced while on cardiopulmonary bypass. 3 Pituitary adenoma tissue is markedly more susceptible to ischemia and hemorrhage at baseline, likely due to both the thin-walled and abnormal sinusoidal nature of the tumor's vasculature; thrombotic events of atherosclerotic plaques and microvascular embolization while on-pump have also been implicated. 4 While the literature does include approximately 20 reports of pituitary apoplexy-induced ophthalmoplegia after both on and off-pump coronary revascularization, never before has pituitary adenoma recurrence after prior resection and subsequent apoplexy leading to severe ophthalmoplegia after on-pump CABG been described.…”