Peer-Review ReportPituitary Tumor Apoplexy in Adolescents
Introduction
Pituitary apoplexy can occur as the result of infarction, hemorrhage, or a combination of hemorrhagic infarction in a pituitary tumor. It is a clinical syndrome identified by a rapid onset of signs and symptoms caused by either hemorrhage or infarction of a pituitary tumor 4, 16, 32. Contributing to pituitary apoplexy is relatively rapid enlargement of a pituitary tumor resulting in compression of surrounding structures, potentially causing pituitary insufficiency 2, 4, 5, 6, 7, 9. Potential predisposing factors that have been documented in the literature include coagulation disorder, dopamine agonist therapy, coronary artery bypass surgery, anticoagulant therapy, radiotherapy, head trauma, diabetes mellitus, pregnancy, hypophyseal dynamic testing, carotid angiography, or upper respiratory tract infections (33). Some authors prefer to distinguish pituitary apoplexy from subclinical presentations, where magnetic resonance imaging (MRI) indicates isolated areas of hemorrhage or infarction that is later confirmed intraoperatively and on pathologic analysis 7, 13, 14, 22, 33. Therefore, the incidence of this clinical syndrome varies depending on definitions used by the reporting authors. In the adult population subclinical hemorrhage has been reported in 14%−22% of pituitary macroadenomas (31). However, symptomatic pituitary apoplexy is seldom seen, occurring in 0.6%−9% of the population 16, 31.
The overwhelming majority of data and information for this clinical presentation comes from the adult literature. Patients typically experience a rapid onset of symptoms that varies from headache with or without endocrine dysfunction, visual deficits, ophthalmoplegia, altered mental status, or coma 4, 20, 28, 31, 34. Literature regarding pituitary apoplexy in the pediatric or adolescent population is restricted to case reports or individual cases that are part of a larger series discussing pituitary adenomas in this population 18, 19, 21, 23. There is no reported patient series dedicated to pituitary apoplexy or subclinical apoplexy in the pediatric or adolescent population after our review of the literature. Therefore, there remain gaps in our knowledge of the differences between adults and children in the presentation, severity of symptoms, and outcomes of this disease between the 2 groups. In this study, from a single pediatric neurosurgical center, we review the clinical presentation, radiologic features, histopathology, and outcomes of 9 adolescent patients treated for pituitary apoplexy and subclinical apoplexy secondary to hemorrhage during a 6-year period.
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Clinical Materials and Methods
The retrospective series includes patients with pituitary mass hemorrhage who were treated at Rady Children's Hospital San Diego (RCHSD), California, by a single neurosurgeon between 2008 and 2013. Chart reviews were performed in accordance to University of California San Diego and RCHSD Human Research Protections Program guidelines. The diagnosis of pituitary apoplexy or subclinical apoplexy was determined from the clinical presentation and neuroimaging features. Patient with clinical (acute)
Presenting Symptoms
All patients presented with a Glasgow Coma Scale of 15. Duration of symptoms ranged from 3 days to 1 year in our group. Time to presentation to RCHSD neurosurgery department ranged from 1 to 39 days. Headache was the most common symptom present in 9 patients (100%), followed by visual impairment seen in 6 patients (66%). Four patients (44%) had dizziness, and 3 had nausea (33%) (Table 1). No patients in the study presented with nonfunctional vision or blindness. From the 6 patients with
Discussion
Although pituitary tumors are common intracranial neoplasms in the adult population constituting 8%−12% of all intracranial neoplasms 12, 23, 27, 36, they are uncommon in children. In the largest series of pituitary adenomas in patients younger than 20 years of age, Mindermann and Wilson (19) reported an incidence of 6.1% from all intracranial neoplasms. Brougham et al. (3), in 1950, were the first to establish the diagnosis of pituitary apoplexy in the literature backed by pathologic
Conclusions
Pituitary apoplexy remains a clinical condition that has the potential for serious neurologic and endocrine symptoms with the possibility of disabling sequalae. The spectrum of this condition can be quite heterogeneous. Subclinical apoplexy is a well known clinical entity in adults and based on our results manifests as a similar phenotype in adolescents. On the basis of our results, it is possible that this age group is less susceptible to tumor infarction and more resilient to tumor hemorrhage
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2018, NeurochirurgieCitation Excerpt :Fortuitous discovery of an intra-tumor haemorrhage on dedicated pituitary MRI of pituitary adenomas with no clinical symptoms of pituitary apoplexy is quite common. These radiological, but clinically asymptomatic, observations are called subclinical haemorrhage (SH) [1–6]. SH was defined by the presence of haemorrhage within a pituitary adenoma confirmed on pituitary MRI with no clinical symptoms.
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2016, Anales de PediatriaDiagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.