J Korean Med Sci.  2008 Dec;23(6):1113-1117. 10.3346/jkms.2008.23.6.1113.

Pituitary Apoplexy Producing Internal Carotid Artery Compression: A Case Report

• Yang SH
• Lee KS
• Lee KY
• Lee SW
• Hong YK

• KMID: 1107542
• DOI: http://doi.org/10.3346/jkms.2008.23.6.1113

Abstract

We report a case of pituitary apoplexy resulting in right internal carotid artery occlusion accompanied by hemiplegia and lethargy. A 43-yr-old man presented with a sudden onset of severe headache, visual disturbance and left hemiplegia. Investigations revealed a nodular mass, located in the sella and suprasellar portion and accompanied by compression of the optic chiasm. The mass compressed the bilateral cavernous sinuses, resulting in the obliteration of the cavernous portion of the right internal carotid artery. A border zone infarct in the right fronto-parietal region was found. Transsphenoidal tumor decompression following conservative therapy with fluid replacement and steroids was performed. Pathological examination revealed an almost completely infarcted pituitary adenoma. The patient's vision improved immediately after the decompression, and the motor weakness improved to grade IV+ within six months after the operation. Pituitary apoplexy resulting in internal carotid artery occlusion is rare. However, clinicians should be aware of the possibility and the appropriate management of such an occurrence.

Keyword

Pituitary Apoplexy; Cerebral Infarction; Cerebrovascular Disorders; Paresis

MeSH Terms

Adult
Carotid Artery Diseases/*diagnosis/etiology/therapy
*Carotid Artery, Internal/pathology/surgery
Diagnosis, Differential
Embolization, Therapeutic
Humans
Magnetic Resonance Angiography
Male
Pituitary Apoplexy/complications/*diagnosis
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Computed tomography scan (A) showing a heterogeneous mass of high density in the right side. Coronal magnetic resonance (MR) image showing heterogeneous high-signal intensity on the T2-weighted image (B), slightly elevated signal intensity on the T1-weighted image (C) and focal enhancement with gadolinium (D), suggesting a necrotic or hemorrhagic site.

• 

  Fig. 2 Non-visualization of the right internal carotid artery on MRA (A) and linear high signal intensity in the right fronto-parietal region on a diffusion-weighted image (B).

• 

  Fig. 3 Microscopic examination showing the infarct region in which viable cells are seen only around the vascular channels (H&E, ×100 [A] and ×200 [B]).

• 

  Fig. 4 Anteroposterior (A) and lateral view (B) of a conventional angiography performed one week after the operation, and MRA (C) showing the restoration of cerebral blood flow.

Reference

1. Dubuisson AS, Beckers A, Stevenaert A. Classical pituitary tumour apoplexy: clinical features, management and outcomes in a series of 24 patients. Clin Neurol Neurosurg. 2007. 109:63–70.

2. Akutsu H, Noguchi S, Tsunoda T, Sasaki M, Matsumura A. Cerebral infarction following pituitary apoplexy-case report. Neurol Med Chir (Tokyo). 2004. 44:479–483.

3. Cardoso ER, Peterson EW. Pituitary apoplexy and vasospasm. Surg Neurol. 1983. 20:391–395.

4. D'Haens J, Baleriaux D, Mockel J, Flamment-Durand J, Brotchi J. Ischemic pituitary apoplexy and cerebrovascular accident. Neurochirurgie. 1983. 29:401–405.

5. Itoyama Y, Goto S, Miura M, Kuratsu J, Ushio Y, Matsumoto T. Intracranial arterial vasospasm associated with pituitary apoplexy after head trauma-case report. Neurol Med Chir (Tokyo). 1990. 30:350–353.

6. Pozzati E, Frank G, Nasi MT, Giuliani G. Pituitary apoplexy, bilateral carotid vasospasm, and cerebral infarction in a 15-year-old boy. Neurosurgery. 1987. 20:56–59.

7. Bernstein M, Hegele RA, Gentili F, Brothers M, Holgate R, Sturtridge WC, Deck J. Pituitary apoplexy associated with a triple bolus test. Case report. J Neurosurg. 1984. 61:586–590.

8. Clark JD, Freer CE, Wheatley T. Pituitary apoplexy: an unusual cause of stroke. Clin Radiol. 1987. 38:75–77.

9. Lath R, Rajshekhar V. Massive cerebral infarction as a feature of pituitary apoplexy. Neurol India. 2001. 49:191–193.

10. Majchrzak H, Wencel T, Dragan T, Bialas J. Acute hemorrhage into pituitary adenoma with SAH and anterior cerebral artery occlusion. Case report. J Neurosurg. 1983. 58:771–773.

11. Rosenbaum TJ, Houser OW, Laws ER. Pituitary apoplexy producing internal carotid artery occlusion. Case report. J Neurosurg. 1977. 47:599–604.

12. Sakalas R, David RB, Vines FS, Becker DP. Pituitary apoplexy in a child. Case report. J Neurosurg. 1973. 39:519–522.

13. Schnitker MT, Lehnert HB. Apoplexy in a pituitary chromophobe adenoma producing the syndrome of middle cerebral artery thrombosis; case report. J Neurosurg. 1952. 9:210–213.

14. Aoki N, Origitano TC, al-Mefty O. Vasospasm after resection of skull base tumors. Acta Neurochir (Wien). 1995. 132:53–58.

15. Hyde-Rowan MD, Roessmann U, Brodkey JS. Vasospasm following transsphenoidal tumor removal associated with arterial change of oral contraception. Surg Neurol. 1983. 20:120–124.

16. Zayour DH, Selman WR, Arafah BM. Extreme elevation of intrasellar pressure in patients with pituitary apoplexy: relation to pituitary function. J Clin Endocrinol Metab. 2004. 89:5649–5654.