Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy

Hage, Rabih; Eshraghi, Sheila R.; Oyesiku, Nelson M.; Ioachimescu, Adriana G.; Newman, Nancy J.; Biousse, Valérie; Bruce, Bonnie

doi:10.1016/j.wneu.2016.07.026

Cited by 41 publications

(24 citation statements)

References 40 publications

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“…Of these, pituitary adenoma is a rare cause and has been reported to be in about 14% cases 11. Usually these cases are advanced and have concomitant vision loss 12 13. Lau et al reported a case of a pituitary adenoma presenting with complete, bilateral oculomotor nerve palsies, with minimal loss of visual ﬁelds, and intact abducens and trochlear nerves 3.…”

Section: Discussionmentioning

confidence: 99%

Pituitary adenoma presenting as acute onset isolated complete third cranial nerve palsy without vision changes

Natarajan

Tatineni²,

Ponnapalli

et al. 2020

BMJ Case Rep

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We report a case of isolated unilateral complete pupil involving third cranial nerve palsy due to pituitary adenoma with parasellar extension into the right cavernous sinus. The patient was referred to us from neurosurgery with sudden onset binocular vertical diplopia with complete ptosis, and mild right-sided headache of 5-day duration. Ocular examination revealed pupil involving third cranial nerve palsy in right eye while rest of the examination including automated perimetry was normal. MRI brain with contrast revealed a mass lesion with heterogenous enhancement in the sella suggestive of a pituitary macroadenoma with possible internal haemorrhage (apoplexy). In addition, the MRI showed lateral spread to the right cavernous sinus which was causing compression of the right third cranial nerve. The patient was systemically stable. This report highlights a unique case as the lesion showed a lateral spread of pituitary adenoma without compression of the optic chiasm or other cranial nerves.

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Section: Discussionmentioning

confidence: 99%

Pituitary adenoma presenting as acute onset isolated complete third cranial nerve palsy without vision changes

Natarajan

Tatineni²,

Ponnapalli

et al. 2020

BMJ Case Rep

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“…Neurological deficits can be directly attributed to increased sphenoid sinus pressure, due to acute enlargement of the pituitary adenoma and mass effects on adjacent cranial nerves. 11 The visual field deficits and decreased visual acuity are caused by suprasellar expansion with pressure on the optic chiasm or optic nerves. The III, IV and VI cranial nerves may experience compression, and diplopia, ophthalmoplegia and ptosis usually occur within a few hours after the onset of headache.…”

Section: Discussionmentioning

confidence: 99%

Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature

Fan

Bao

Wang

2018

CIA

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BackgroundWhether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA.Case descriptionWe describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient’s poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family’s wishes, we continued the conservative treatment and watched closely for any changes in the patient’s condition. After 6 months of conservative treatment, the patient’s symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient’s hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone.ConclusionIn older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients’ condition closely and continue conservative treatment, which may yield good results.

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“…The apoplectic pituitary adenoma can expand toward the cavernous sinus, compressing the III, IV, and/or IV cranial nerves (CN), leading to various degrees of ocular palsy (diplopia and ophthalmoplegia) in 40-70% of the patients [52,55,74,75].…”

Section: Visual Disturbancementioning

confidence: 99%

Pituitary Apoplexy

Jemel¹,

Alaya²,

Boubaker³

et al. 2019

Pituitary Diseases

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Pituitary apoplexy is a rare clinical emergency due to acute ischemic infarction or hemorrhage of the pituitary gland. As this disorder most often involves a pituitary adenoma, especially nonfunctioning tumors, the syndrome should be referred to as pituitary tumor apoplexy. The precise physiopathology is not completely clear. Although in most cases it occurs spontaneously, pituitary apoplexy can be precipitated by many risk factors. The main symptom is headache of sudden onset associated with visual disturbances, signs of meningeal irritation, and/or endocrine dysfunction. Corticotropic deficiency is a potentially life-threatening disorder. Magnetic resonance imaging is the most sensitive to confirm the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. Earlier studies used to consider urgent decompression of the lesion surgically, but nowadays, more recent studies favor conservative management in selected patients (those without important visual acuity or field defects and with normal consciousness). This wait-and-see approach gives evidence of excellent outcomes in terms of oculomotor palsy, pituitary function, and subsequent tumor growth. Surgical decompression may be necessary in some cases. Once the acute phase is over, the patient should be reevaluated for hormonal deficiencies. Moreover, spontaneous remission of syndromes, such as acromegaly, may be caused by pituitary adenoma apoplexy.

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Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy

Cited by 41 publications

References 40 publications

Pituitary adenoma presenting as acute onset isolated complete third cranial nerve palsy without vision changes

Pituitary adenoma presenting as acute onset isolated complete third cranial nerve palsy without vision changes

Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature

Pituitary Apoplexy

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