Lee In Hee, Kim Ho Kyun, Ahn Dong Jik
Department of Internal Medicine.
Department of Radiology, Daegu Catholic University School of Medicine.
Medicine (Baltimore). 2020 Jan;99(5):e18987. doi: 10.1097/MD.0000000000018987.
Pituitary apoplexy (PA) and posterior reversible encephalopathy syndrome (PRES) are rare neurologic diseases that show acute neuro-ophthalmologic symptoms such as headache, decreased visual acuity, and altered consciousness. These diseases are rarely found in patients with end-stage renal disease (ESRD) on hemodialysis, and simultaneous occurrence of these 2 diseases has not been reported.
The patient was a 75-year-old man with a history of hypertension, diabetes mellitus, and non-functioning pituitary macroadenoma. He had been receiving hemodialysis for ESRD for 3 months before his presentation to the emergency room. The patient complained of headache, vomiting, and dizziness that started after the previous day's hemodialysis. The patient had voluntarily discontinued his antihypertensive medication 2 weeks before presentation and had high blood pressure with marked fluctuation during hemodialysis. Complete ptosis and ophthalmoplegia on the right side suggested 3rd, 4th, and 6th cranial nerve palsies.
Magnetic resonance imaging of the brain revealed a pituitary tumor, intratumoral hemorrhage within the sella, and symmetric vasogenic edema in the subcortical white matter in the parieto-occipital lobes. Based on these findings, the patient was diagnosed with PA and PRES.
Intravenous administration of hydrocortisone (50 mg every 6 hours after a bolus administration of 100 mg) was initiated. Although surgical decompression was recommended based on the PA score (5/10), the patient declined surgery.
Headache and ocular palsy gradually improved after supportive management. The patient was discharged on the 14th day of hospitalization with no recurrence 5 months post-presentation. Current therapy includes antihypertensive agents, oral prednisolone (7.5 mg/day), and maintenance hemodialysis.
Neurologic abnormalities developed in a patient with ESRD on hemodialysis, suggesting the importance of prompt diagnosis and treatment in similar instances.
垂体卒中（PA）和后部可逆性脑病综合征（PRES）是罕见的神经系统疾病，表现为急性神经眼科症状，如头痛、视力下降和意识改变。这些疾病在接受血液透析的终末期肾病（ESRD）患者中很少见，且这两种疾病同时发生的情况尚未见报道。
该患者为一名75岁男性，有高血压、糖尿病和无功能垂体大腺瘤病史。在其就诊于急诊室前，因ESRD接受血液透析已3个月。患者主诉在前一天血液透析后开始出现头痛、呕吐和头晕。患者在就诊前2周自行停用了降压药，且在血液透析期间血压高且波动明显。右侧完全上睑下垂和眼肌麻痹提示第3、4和6对脑神经麻痹。
脑部磁共振成像显示垂体肿瘤、蝶鞍内肿瘤内出血以及顶枕叶皮质下白质对称性血管源性水肿。基于这些发现，患者被诊断为PA和PRES。
开始静脉注射氢化可的松（在静脉推注100mg后每6小时50mg）。尽管根据PA评分（5/10）建议进行手术减压，但患者拒绝手术。
经过支持治疗，头痛和眼肌麻痹逐渐改善。患者在住院第14天出院，就诊后5个月无复发。目前的治疗包括降压药、口服泼尼松龙（7.5mg/天）和维持性血液透析。
一名接受血液透析的ESRD患者出现了神经异常，提示在类似情况下及时诊断和治疗的重要性。
