Vasospasm and Cerebral Infarction from Pituitary Apoplexy

Abstract

Pituitary apoplexy is a potentially life-threatening acute or subacute clinical syndrome occurring from enlargement of the pituitary gland, and pituitary insufficiency, from hemorrhage or ischemia from an unknown pituitary lesion, most frequently being a non-functioning macroadenoma. A close, and multidisciplinary management is required. The purpose of this case report is to increase awareness to pituitary apoplexy presentation and management by reporting clinical features and neuroradiological findings observed in a 70-year-old patient with an unknown pituitary lesion. He presented with pituitary apoplexy and brain ischemia at magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps. MR angiography (MRA) showed diffuse vasospasm of anterior and posterior circulation. Both MRI and cytochemical examination of the cerebrospinal fluid ruled out subarachnoid hemorrhage. Due to concomitant diseases, and absence of visual deficit, the management was conservative by medical and substitutive therapy, without surgery. Clinical follow-up showed clearcut improvement, and this was consistent with MRI and MRA evidence of vasospasm regression, and clearcut pituitary lesion shrinkage. Pituitary lesions with hemorrhagic infarction presenting with pituitary apoplexy may be associated with vasospasm and brain ischemia at diagnosis, also in the absence of subarachnoid hemorrhage. A correct MR evaluation of patients with PA should include DWI, ADC maps, and MRA. Notably, early diagnosis of PA-associated vasospasm and cerebral ischemia avoids the possibility of their detection only after neurosurgery.

Surgical treatment of pituitary apoplexy in association with hemispheric infarction

“…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]. Among the 11 infarction patients in whom cerebral vasospasm was suspected to be the more likely etiology in the literature, only five had bilateral infarction [17,27,30,32,33].…”

“…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].…”

Pituitary Apoplexy Leading to Cerebral Infarction: A Systematic Review

“…In general, tumours compress unilateral arteries, but 5 cases of bilateral ICA compression [7, 9, 19, 26, 29] and 3 cases of bilateral ACA compression have been reported in the literature [18, 28, 39]. Cerebral vasospasm is another mechanism of cerebral infarction caused by PA [2, 7, 8, 11-13, 15, 17, 18, 21, 22, 27, 28, 31, 32, 40]. First, pituitary tumour haemorrhage enters the subarachnoid space.…”

Pituitary apoplexy complicated by vasospasm and bilateral cerebral infarction

“…Cerebral infarction secondary to arterial vasospasm is an extremely rare complication of PA, and only a few cases have been reported 2 3…”