Pituitary apoplexy following cardiopulmonary bypass: considerations for a staged cardiac and neurosurgical procedure

Abstract

Pituitary apoplexy in a pre-existing pituitary tumor can result in serious and permanent neurologic deficits following cardiac surgical procedures. Several factors related to the altered physiology of cardiopulmonary bypass (CPB) contribute separately or in combination to the development of this syndrome. Over the last year we have encountered two such cases in whom emergency and prompt decompression of the adenoma resulted in an improvement of the initial clinical presentation but nevertheless persistence of residual and devastating ocular manifestations. In the literature six similar cases have been reported following cardiac surgical procedures, with similar outcomes. In this report we describe our experience and management of these two patients, and that published in the literature. We propose a possible role for a staged cardiac and neurosurgical procedure as a prophylactic measure in patients with known pituitary tumor. The role of cerebral monitoring is also discussed.

The natural course of non-functioning pituitary macroadenomas

“…In patients with macroadenomas, the incidence of apoplexy is probably higher (21). The occurrence of pituitary apoplexy has been described following pituitary function tests (36), coronary artery bypass surgery (35,37), cholecystectomy (38), head trauma (39), and vaginal delivery (40). Moreover, apoplexy has been associated with hypertension (35) and anticoagulant therapy (40).…”

Can cardiac surgery cause hypopituitarism?

“…Intrasellar pressure in patients with pituitary adenomas was shown to be above central venous and intracranial pressure [26], suggestive of an additional arterial supply at a less than normal arterial pressure, leading to the theory that pituitary adenomas might exhibit a critical perfusion pressure below normal arterial pressure. Anticoagulation and tissue swelling may constitute further permissive factors for pituitary tumour apoplexy [27]. Psychosocial impairment, depression and reduced mental QoL were noted in a considerable part of the investigated patients with more severe impairment in patients shortly after surgery.…”

Lesson of the week: Hypopituitarism after coronary artery bypass grafting Commentary: Hypoadrenalism should also be considered in cases of persistent hyponatraemia

“…Surgical decompression was necessary in 11 cases; all of these patients had pituitary adenomas and three had been diagnosed before surgery. 4 5 8 The apoplectic presentations were presumed to be secondary to necrosis, haemorrhage, and acute swelling of the pre-existing pituitary tumour.…”