Pituitary haemorrhage and infarction: the spectrum of disease

Abstract

Background Pituitary apoplexy is an acute syndrome of haemorrhage or infarction into the pituitary. The condition is relatively well described. Less well described is sub-acute presentation of the same condition Objective To compare the clinical presentation and natural history of subacute pituitary haemorrhage/ infarction with pituitary apoplexy (acute). Method Retrospective analysis of a consecutive cohort of 55 patients (33 with pituitary apoplexy, 22 with subacute disease) presenting to University Hospital Plymouth between 1994 and 2019. Comparison of the clinical, endocrinological and radiological features at presentation. Comparison of clinical treatment and subsequent outcomes for the two groups Results There were no significant differences in predisposing factors for the two groups. Acute headache was more frequent in the acute group. Chronic headache was common in both groups prior to presentation. Low sodium was more common at presentation in the acute group (11/26 vs 2/19 p= 0.02) otherwise there were no differences in endocrine deficit at presentation. A significant proportion showed an improvement in endocrine function at follow up (acute 8/31, subacute 5/21 p = 1.0). MRI characteristics were variable at presentation and follow up in both groups. Ring enhancement with contrast was more frequent in acute (14/20 vs 3/11 p= 0.03). This appearance resolved at follow up in the majority. Conclusions Pituitary apoplexy has a characteristic and dramatic presentation. Subacute pituitary haemorrhage/ infarction shows similar natural history and outcome. These would appear to represent a spectrum of the same condition.

Towards a pituitary apoplexy classification based on clinical presentation and patient journey

“…By classifying apoplexy patients according to the time of onset and severity of symptoms, more justice is done to the new spectrum of disease approach to pituitary apoplexy as recently proposed by Iqbal et al [4]. Iqbal et al described the underestimation of the subacute apoplexy subtype.…”

“…Between April 1 and May 31, 2021, a total of 780 possible apoplexy patients were screened: 709 of them were selected from a LUMC database including all operated patients for a pituitary adenoma, whereas 71 additional patients were identified by a search for pituitary apoplexy in the conclusion texts of radiology reports in the LUMC patient information system between 2005 and 2021. Inclusion criteria for the present study were [1]: clinical symptoms at initial presentation [2], MRI or CT-scan of the pituitary suggestive of pituitary apoplexy [3], sufficient clinical data available in the LUMC patient record, and [4] sufficient clinical data on the care process prior to referral to the LUMC. Based on the first two criteria, we included a total of 103 patients.…”

“…For this study, we proposed and used the following classification system for pituitary apoplexy based on the initial patients presentation with (A) acute, (B) subacute, and (C) non-acute symptoms. We based this classification system on clinical experience with apoplexy patients in our specialized center and the recently described subacute apoplexy presentation by Iqbal et al [4]. Generally, patients present at different caregivers based on the acuteness of symptoms.…”

“…It is increasingly acknowledged that not all patients present with the above-described well-known presentation of acute symptoms. Recently, Iqbal et al described pituitary hemorrhage and infarction as a spectrum of disease, including a subacute variant of pituitary apoplexy [4]. Pituitary apoplexy e.g., signs of hemorrhage or infarction may be first detected by neuroradiologists as an incidental finding, so a proportion may stay undiagnosed and/or present with symptoms that mimic a non-apoplectic pituitary mass.…”

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

“…In terms of the PitNET stain profile (regardless clinical expression) non-functional type was followed by somatotroph PitNETs [ 32 , 38 , 42 , 46 , 53 , 56 , 66 , 76 , 78 , 86 , 92 , 93 , 98 , 100 , 108 , 109 , 121 , 128 , 136 , 141 , 148 , 152 , 156 , 166 , 168 , 169 , 171 , 175 , 192 , 217 ], lactotroph PitNETs [ 66 , 75 , 77 , 90 , 98 , 100 , 113 , 121 , 126 , 128 , 141 , 166 , 168 , 169 , 174 , 175 , 183 , 202 , 206 ], gonadotroph PitNETs […”