Pituitary apoplexy is an uncommon phenomenon typically characterized by vascular insufficiency or acute hemorrhage into a pituitary adenoma. The overall incidence of pituitary apoplexy ranges between 1 and 25% of all pituitary adenomas. With the widespread use of MRI technology, the diagnosis of asymptomatic intratumoral hemorrhage is closer to 10%. The authors report a case of a 27-year-old female in her 36th week of pregnancy who presented with severe onset headache and acute left-sided vision loss. MRI of the brain revealed a large hemorrhagic mass occupying the sella turcica. The patient underwent an emergent endoscopic endonasal transsphenoidal resection for pituitary apoplexy. Postoperatively, the patient’s neurologic deficit resolved. Minimally invasive endoscopic endonasal transsphenoidal resection of pituitary apoplexy can be safely utilized in third trimester pregnant women presenting with acute severe neurologic deficits.
Schloffer and Hochenegg performed the first successful transsphenoidal surgery in 1908 while in Vienna [
This 27-year-old pregnant woman, presented initially at 19 weeks gestation with intermittent headaches, nausea, and vomiting for two months duration. She was admitted to an outside hospital and was diagnosed with a prolactin secreting pituitary adenoma. At that time, the patient was noted to have normal visual acuity in both eyes with no evidence of field cut as well. The patient was treated with bromocriptine therapy given the diagnosis of prolactinoma. At 36-week-gestation, the patient presented to our hospital with severe onset headache and acute vision loss in the left eye. MRI of the brain revealed a suprasellar, hemorrhagic mass measuring approximately
Sagittal T1 MRI of brain without contrast shows area of hyperintensity within the sella and suprasellar regions (red arrow). This likely represents pituitary apoplexy within the known macroadenoma.
The patient was taken to the operating room to undergo an endoscopic endonasal transsphenoidal resection of the pituitary apoplexy. The patient’s head was immobilized using a three-pin head fixation device. The operation was performed endoscopically through both nostrils. The left middle turbinate was fractured outward to widen the corridor to the sphenoethmoid recess in order to facilitate the identification of the sphenoid ostium. Bilateral anterior sphenoidectomies were performed extensively with Kerrison rongeurs. The intersinus septum of the sphenoid sinus and sinus mucosa were then removed (Figure
Intraoperative view through the operative endoscope revealing the intersinus septum within the sphenoid sinus and the floor of the sella turcica.
Intraoperative view through the operative endoscope revealing the hemorrhagic pituitary apoplexy being removed in a piece meal fashion.
Postoperative sagittal T1 MRI of brain without contrast shows resolution of the prior areas of hyperintensity within the sella turcica (red arrow). The pituitary stalk is now visible (yellow arrow).
Frozen sections revealed mainly blood products with fragments of pituitary gland tissue. The histopathology was consistent with prolactinoma.
Prolactinomas and nonsecreting adenomas are the most common pituitary tumors. They represent 40% and 39% of all pituitary tumors, respectively [
During pregnancy, there is a normal increase in the volume and T1 hyperintensity of the anterior pituitary as demonstrated by MRI. This is explained by a relative increase in the number of lactotrophs of the pituitary gland. Normally, lactotrophs comprise from 15 to 20% of the gland. During pregnancy this number may increase to almost 50%, which accounts for the increase in prolactin production [
Macroprolactinomas account for the most common pituitary lesion in pregnant women. Approximately 35% of macroprolactinomas enlarge during pregnancy making their medical or surgical management a priority prior to the pregnancy [
Pituitary apoplexy is characterized by the abrupt destruction of pituitary gland tissue secondary to infarction or hemorrhage of the gland itself. This phenomenon is usually more common in macroprolactinomas and in some rare cases may be associated with lymphocytic adenohypophysitis [
Once the pituitary apoplectic event is identified in a pregnant woman, care must be directed to both mother and fetus in a manner designed to optimize the physiologic stability of both. A “team” approach is required, which includes a neurosurgeon, an ICU personal, and an obstetrician [
The endoscopic, endonasal, transsphenoidal surgery has comparable surgical outcomes to conventional microscopic transsphenoidal surgery [
Gondim et al. described a case of a patient with a macroadenoma in treatment with bromocriptine that was stopped after the patient became pregnant. In the third trimester, pituitary apoplexy developed requiring surgical treatment. The patient underwent a successful endoscopic endonasal resection of the pituitary apoplexy [
Our patient presented with headache and visual loss, with a known history of a pituitary tumor. As suspected, MRI confirmed pituitary apoplexy in this pregnant woman. The patient underwent a minimally invasive, endoscopic, endonasal pituitary apoplexy resection. Postoperatively, the patient’s visual disturbances resolved and she was safely able to undergo an elective Cesarean section one week later.
Pituitary apoplexy in pregnancy is a rare event. The new advances in endoscopic surgery permit a rapid, minimally invasive treatment, in cases associated with acute optic nerve compression. The endoscopic, endonasal approach is a safe alternative to open cranial surgery for the treatment of pituitary apoplexy in third trimester pregnant women.
The authors declare that there is no conflict of interests regarding the publication of this paper.
All of the listed authors have made substantial contributions in the conception and design of this short report. They have also participated in the acquisition and analysis of the data. All of the authors made contributions in drafting this original case report and approved its final draft for submission.