Pituitary apoplexy

Pituitary Apoplexy

1. PITUITARY APOPLEXY ADE WIJAYA, MD Oktober 2017

2. OUTLINE Introduction Anatomy of pituitary Epidemiology Precipitating factors Patophysiology Clinical manifestation (headache, neuroophtalmology, endocrine dysfunctions, others) Diagnosis and differential diagnosis Management Conclusion

3. Introduction MEDICAL EMERGENCY! Bailey, first describe in 1898 A high index of clinical suspicion is essential to diagnose this condition as prompt management may be life and vision saving Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15. Bailey P. Pathological report of a case of acromegaly, with special reference to the lesion in the hypophysis cerebri and in the thyroid gland; and a case of haemorrhage into the pituitary. Phila Med J . 1898;1:789–792.

4. Anatomy of pituitary The Pituitary. 4 th Edition

5. Epidemiology  6.2 cases per 100 000 inhabitants its incidence 0.17 episodes per 100 000 per year  2-12 % of pituitary adenoma the diagnosis of pituitary tumor was unknown at time of apoplexy in more than 3 out of 4 cases If the nonfunctioning pituitary adenomas (NFPAs) (often incidentalomas) were already known and that a decision was made to manage them conservatively, the risk of PA was calculated to be between 0.2 and 0.6 events per 100 person-years in 2 metaanalyses 5 th and 6 th decade a male preponderance ranging from 1.1 to 2.3/1  Subclinical apoplexy ? Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

6. Precipitating Factors Hypertension, M ajor surgery, especially coronary artery bypass grafting, D ynamic testing of the pituitary gland, anticoagulation therapy, C oagulopathies , Angiographic procedures Treatment with GnRH agonist in prostate cancer Anticoagulant Pregnancy Head trauma Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15. Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

7. pathophysiology Normal Pituitary Vascularization: Hypophysial portal system & Direct arterial blood supply Anterior: superior hypophysial artery Posterior: inferior hypophysial artery (both originated from internal carotid) Pituitary Apoplexy: Vascularization predominated by direct arterial blood supply Blood supply reduced compared to normal pituitary Reduced angiogenesis / fragile blood vessels Sensitive to glucose deprivation Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

8. CLINICAL MANIFESTATION Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645. Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15.

9. Headache 80 % of Patients Acute thundeclasp or subacute Retroorbital, bifrontal, or diffuse Nausea and vomitus Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15. Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

10. Neuroophtalmology > 50 % Due to compression Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15. Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

11. Others M eningeal irritation, such as photophobia (40%), nausea, vomiting (57%), meningismus (25%), and sometimes fever (16 %). Focal neurologic deficits Anosmia Epistaxis CSF rhinorrhea due to erosion of the bone of the sella turcica Facial pain Acute adrenal insufficiency Loss of consciousness Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15. Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

12. Endocrine dysfunctions Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

13. Corticothropic deficiency Most common (50-80 %) Most life threathening hormonal complication Cause severe hemodynamic problems and hyponatremia acute secondary adrenal insufficiency Empiric corticosteroid treatment Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

14. Other pituitary hormones deficiency Gonadothropic deficiency Thyrotropic deficiency Growth hormone deficiency Prolactin deficiency Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

15. Diabetes insipidus and pituitary hypersecretion Diabetes insipidus  common post operative complication either transient or permanent PA can complicate a secreting pituitary adenoma such as prolactinoma and secreting pituitary adenoma Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

16. Diagnosis Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645. Singh, T. D., Valizadeh, N., Meyer, F. B., Atkinson, J. L., Erickson, D., & Rabinstein, A. A. (2015). Management and outcomes of pituitary apoplexy.  Journal of neurosurgery ,  122 (6), 1450-1457.

17. Differential diagnosis • SAH due to ruptured intracranial aneurysm or arteriovenous malformation • Bacterial/viral meningitis • Brainstem infarction • Cavernous sinus thrombosis Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15. Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

18. MANAGEMeNT Steroid: hydrocortisone 50 mg every 6 hours, or a bolus of 100–200 mg followed by 50–100 mg every 6 hours iv (or im), or 2–4 mg/h by continuous iv administration. Transsphenoid approach Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy.  Endocrine reviews ,  36 (6), 622-645.

19. Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in adult patients. Endocrine connections ,  5 (5), G12-G15.

20. CONCLUSION Classic pituitary apoplexy is a medical emergency High index of clinical suspicion MRI for diagnosis Empiric corticosteroid treatment Neurosurgery vs Conservative

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