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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 41  |  Issue : 4  |  Page : 186-187

The acute stage of pituitary apoplexy complicated with sinusitis


1 Department of Surgery, Division of Neurosurgery, Kaohsiung Armed Forces General Hospital, Kaohsiung; Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
2 Department of Surgery, Division of Urology, Kaohsiung Armed Forces General Hospital, Kaohsiung; Department of Surgery, Division of Urology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3 Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Date of Submission20-Jun-2020
Date of Decision11-Nov-2020
Date of Acceptance11-Jan-2021
Date of Web Publication05-Apr-2021

Correspondence Address:
Dr. Chi-Tun Tang
Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Secection 2, Chenggong Road, Neihu District, Taipei City 114
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_147_20

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  Abstract 


The timely diagnosis and optimal therapy of the pituitary apoplexy is challenging. We report a case about our treatment experience for the acute stage of pituitary apoplexy complicated with sinusitis. It is the strong predictor for the acute stage of pituitary apoplexy when magnetic resonance imaging(MRI) presented the both signs simultaneously, the pituitary ring sign and the sphnoid sinus mucosal thickening. Once the diagnosis of pituitary apoplexy is established, hypocortisolism and hyponatremia should be considered intensely. Surgical decompression via transsphnoid approach has favorable prognosis for the visual involvement of the pituitary apoplexy. Effective antibiotic for sphenoid sinusitis before surgery may could minimize the postoperative risk of intracranial infection. Otherwise, the sign of the sphenoid sinus mucosal thickening is not a contraindication for the transnasal transsphnoidal surgery.

Keywords: Pituitary apoplexy, acute sinusitis, pituitary ring sign, sphenoid sinus mucosal thickening, transphenoidal surgery


How to cite this article:
Li CZ, Li CC, Tang CT. The acute stage of pituitary apoplexy complicated with sinusitis. J Med Sci 2021;41:186-7

How to cite this URL:
Li CZ, Li CC, Tang CT. The acute stage of pituitary apoplexy complicated with sinusitis. J Med Sci [serial online] 2021 [cited 2021 Oct 25];41:186-7. Available from: https://www.jmedscindmc.com/text.asp?2021/41/4/186/313092




  Introduction Top


Pituitary apoplexy (PA) is a potentially life-threatening disorder caused by acute hemorrhage or/and ischemic infarction of the pituitary gland. It could lead to endocrine dysfunction, electrolyte imbalance, and visual impairment, especially in the acute stage of the PA. The better prognosis of PA relies on the immediate diagnosis and optimal therapy. There are some imaging findings could help us to quick diagnosis the acute stage of PA, such as the pituitary ring sign and the sphenoid sinus mucosal thickening. Surgical decompression through the transphenoidal route is favorable for the patients of PA with visual involvement. Sometimes, the patients of PA may be complicated with sinusitis. Here, we present a case to demonstrate the optimal therapeutic strategy for the patients of the acute stage in PA complicated with sinusitis.


  Case Report Top


A 45-year-old male presented to our emergency room with a 3-day history of high fever, severe headache, and double vision. Laboratory date revealed leukocytosis, hyponatremia, and hypocortisolism. His consciousness level was alert. Ophthalmologic examination revealed bitemporal hemianopia, and the left eye was deviated to the left with ptosis, severe limitation in supraduction, infraduction, and adduction consistent with pupil-sparing third-cranial nerve palsy. The noncontrast brain computed tomography (CT) revealed an expanded and hyperdense lesion in the sellar turcica with the fluid accumulation in the sphenoid sinus [Figure 1]a. The brain magnetic resonance imaging (MRI) revealed a large pituitary mass with optic chiasm compression and extension to the left cavernous, Knosp grade III. The MRI signals exhibited heterogeneous intensity on T1-weighed imaging and hypointensity on T2-weighed imaging. Remarkably, the T1-weighted contrast-enhanced MRI demonstrated the pituitary ring sign and the sphenoid sinus mucosal thickening [Figure 1]b. The diagnosis of PA complicated with sinusitis was established. After hospitalization, the administration of hydrocortisone for hypocortisolism, broad-spectrum antibiotics for rhinitis, and the sodium correction for hyponatremia was prescribed immediately. On the 3rd hospital day, the patient's body temperature and blood biochemistry data came back within normal range, the transnasal transsphenoidal decompression for the pituitary apoplexy (PA) was performed. During the sphenoid sinus stage of surgery, the yellowish pus was found in the sphenoid sinus. We suctioned the pus as possible, made obliteration of mucosa and irrigated the sphenoid sinus with massive normal saline. After well-cleaning of the sphenoid sinus to decrease the risk of intracranial infection, we just made the dural incision for decompression. The histopathology examination showed pituitary tumor with necrosis and hemorrhage. The patient was discharged on the tenth hospital day without complication. At the last follow-up, 6 months after the surgery, the visual field and the third nerve function in the left eye became normal. The oral steroid therapy was still prescribed for hypoadrenalism.
Figure 1: (a) The brain computed tomography revealed fluid accumulation in the sphenoid sinus (white hallow arrow). (b) The T1-weighted contrast-enhanced magnetic resonance imaging demonstrated the pituitary ring sign (white arrow) and the sphenoid sinus mucosal thickening (white hallow arrow)

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  Discussion Top


PA was first described in 1950. It is an emergent neurological condition resulting from the sudden disruption of hemorrhage or infarction into a pituitary adenoma, with the incidence of about 2%–7% among patients with pituitary adenomas. The timely diagnosis of PA is challenging. The brain MRI is the first-line useful imaging technique for PA diagnosis. There are some radiological findings in MRI for PA. Nevertheless, the presence of both signs, the pituitary ring sign and the sphenoid sinus mucosal thickening, is a strong predictor for PA in the acute stage.[1] Liu and Couldwell reported the patients with sphenoid sinus mucosal thickening also had the higher rate of cranial nerve deficit and endocrine abnormality.[2] Once the diagnosis of PA with visual involvement is established, surgical decompression and medical treatment for the abnormality of endocrine and electrolyte should be considered intensely, especially hypoadrenalism (about 70% in the patients of PA) and hyponatremia (about 40% in the patients of PA).[3] Surgical decompression generally associates with favorable outcome in patients with visual impairment. Endoscopic transnasal transsphnoidal surgery is well used for treating pituitary lesion. The sphenoid sinus mucosal thickening is not a contraindication to the surgical transsphenoidal route. However, the most symptoms of PA include headache, nausea/vomiting, and visual impairment; fever is less and unspecific in the patient of PA. Moreover, therefore, because that our patient had fever and the brain CT finding showed the fluid accumulation in the sphenoid sinus, it raised our consideration of suspected sinusitis which may increase the risk of postoperative complication of intracranial infection. The optimal antibiotic treatment according to the clinical condition before transsphenoidal surgery could minimize this risk.[4]


  Conclusion Top


The standard therapeutic strategy to the patient with the acute stage of PA is still in debated. However, only appropriate management can improve the prognosis of the endocrine and neurological complication of the acute stage in PA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vaphiades MS. Pituitary ring sign plus sphenoid sinus mucosal thickening: neuroimaging signs of pituitary apoplexy. Neuroophthalmology 2017;41:306-9.  Back to cited text no. 1
    
2.
Liu JK, Couldwell WT. Pituitary apoplexy in the magnetic resonance imaging era: clinical significance of sphenoid sinus mucosal thickening. J Neurosurg 2006;104:892-8.  Back to cited text no. 2
    
3.
Albani A, Ferraù F, Angileri FF, Esposito F, Granata F, Ferreri F, et al. Multidisciplinary Management of Pituitary Apoplexy. Int J Endocrinol 2016;2016:7951536.  Back to cited text no. 3
    
4.
Bae WY, Kim SH, Kang MY, Koh TK. Efficacy of controlling rhinosinusitis on the prevention of complications in pituitary surgery with transsphenoidal approach. Auris Nasus Larynx 2014;41:.50-2.  Back to cited text no. 4
    


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