Boston University School of Medicine, Boston, MA, USA.
Department of Optometry, VA Boston Healthcare System, Jamaica Plain, Boston, MA, USA.
J Med Case Rep. 2023 Feb 10;17(1):53. doi: 10.1186/s13256-022-03738-4.
Pituitary apoplexy is acute infarction with or without hemorrhage of the pituitary gland. It is a rare but potentially life-threatening emergency that most commonly occurs in the setting of pituitary adenoma. The mechanisms underlying pituitary apoplexy are not well understood, but are proposed to include factors of both hemodynamic supply and adenoma demand. In the case of patients with known pituitary macroadenomas undergoing major surgery for other indications, there is a theoretically increased risk of apoplexy in the setting of "surgical stress." However, risk stratification of patients with nonfunctioning pituitary adenomas prior to major surgery is challenging because the precipitating factors for pituitary apoplexy are not completely understood. Here we present a case in which intraoperative hypovolemia is a possible mechanistic precipitating factor for pituitary apoplexy.
A 76-year-old patient with a known hypofunctioning pituitary macroadenoma underwent nephrectomy for renal cell carcinoma, during which there was significant intraoperative blood loss. He became symptomatic with ophthalmoplegia on the second postoperative day, and was diagnosed with pituitary apoplexy. He was managed conservatively with cortisol replacement therapy, and underwent therapeutic anticoagulation 2 months after pituitary apoplexy for deep vein thrombosis. His ophthalmoplegia slowly resolved over months of follow-up. Pituitary apoplexy did not recur with therapeutic anticoagulation.
When considering the risk of surgery in patients with a known pituitary macroadenoma, an operation with possible high-volume intraoperative blood loss may have increased risk of pituitary apoplexy because intraoperative hypovolemia may precipitate ischemia, infarction, and subsequent hemorrhage. This may be particularly relevant in the cases of elective surgery. Additionally, we found that we were able to therapeutically anticoagulate a patient 2 months after pituitary apoplexy for the management of deep vein thrombosis without recurrence of pituitary apoplexy.
垂体卒中是垂体腺的梗死伴或不伴出血，是一种罕见但潜在危及生命的急症，最常发生于垂体腺瘤。垂体卒中的发病机制尚不清楚，但据推测与垂体腺瘤的供需两方面的血液动力学因素有关。对于已知患有垂体大腺瘤并因其他指征接受大手术的患者，在“手术应激”的情况下，理论上发生卒中的风险增加。然而，在大手术前对无功能性垂体腺瘤患者进行风险分层具有挑战性，因为垂体卒中的诱发因素尚不完全清楚。在此，我们报告了一例术中低血容量可能是垂体卒中的机械性诱发因素的病例。
一名 76 岁患者患有已知的垂体功能低下型大腺瘤，因肾细胞癌行肾切除术，术中失血明显。他在术后第 2 天出现眼肌麻痹症状，被诊断为垂体卒中。他接受了皮质醇替代治疗的保守治疗，并在垂体卒中后 2 个月因深静脉血栓形成接受了治疗性抗凝治疗。他的眼肌麻痹在数月的随访中逐渐缓解。治疗性抗凝治疗未使垂体卒中复发。
在考虑已知垂体大腺瘤患者手术风险时，手术中可能失血量大的手术可能会增加垂体卒中的风险，因为术中低血容量可能会引发缺血、梗死和随后的出血。这在择期手术中可能更为相关。此外，我们发现我们能够在垂体卒中后 2 个月对深静脉血栓形成进行治疗性抗凝治疗，而不会复发垂体卒中。
