Pathological correlates of pituitary adenomas presenting with apoplexy

doi:10.1016/S0046-8177(98)90254-4

Human Pathology

Volume 29, Issue 11, November 1998, Pages 1255-1265

https://doi.org/10.1016/S0046-8177(98)90254-4 Get rights and content

Abstract

Pituitary adenomas presenting de novo with apoplectic symptoms are uncommon. Several series on pituitary adenomas with apoplexy have been reported but have emphasized clinical aspects, incidence, or radiographic appearance by computed tomography (CT) scan. We reviewed our 13 years' experience, focusing on pathological appearance. We identified 15 patients with pituitary adenomas whose first presentation to our institution was with apoplexy. By combining histological and intraoperative findings with more sensitive magnetic resonance imaging (MRI) scans, we were able to attribute 5 of 15 cases to bland infarction, five cases to hemorrhagic infarction, four cases to pure clot, and one to a remote hemorrhagic infarction leaving extensive residual fibrosis and hemosiderin. Despite extensive tumor necrosis, reticulin staining still allowed identification of specimens as adenomas. Immunohistochemical staining was informative in 13 of 15 cases and endocrine-inactive, weak gonado troph and null cell adenomas predominated. Cases with the greatest interval between symptom onset and surgery showed peripheral rim enhancement by MRI. Pathologically, this corresponded to granulation tissue, T cell lymphocytic infiltration, and atrophic pituicytes at the edge of the infarction or hemorrhage. Occasionally this reaction overshadowed the necrotic adenoma and contributed to diagnostic confusion. Our finding of lymphocytic inflammation in pituitary adenomas that have undergone an apoplectic event may suggest at least a modest immune-mediated response to damaged anterior pituitary tissue.

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Citation Excerpt :
Pituitary apoplexy is a clinical syndrome that is thought to be caused by infarction, hemorrhage, or hemorrhagic infarction within a preexisting pituitary adenoma.1-19 However, pituitary apoplexy is confounded by the inclusion, in some series, of pituitary adenomas with histopathologic or radiologic evidence of hemorrhage but without sudden onset of clinical symptoms.11,19 The classical term pituitary apoplexy presentation includes the abrupt onset of severe headache accompanied by neurologic, ophthalmologic, and/or endocrinologic deterioration because of sudden expansion of a mass within the sella turcica.1-19
Pituitary apoplexy is an acute clinical syndrome caused by infarction and/or hemorrhage of pituitary adenoma, which typically presents with severe headache, visual deterioration, and endocrine abnormalities. However, temporal lobe seizure (and temporal lobe epilepsy) has not been viewed as a symptom of pituitary apoplexy in the literature.
To elucidate further such a rare complication of temporal lobe seizure, we describe here the rare clinical manifestations of a 55-year-old previously healthy man with pituitary apoplexy harboring headache, combined palsies involving cranial nerves III to VI, endocrinologic disturbances, and temporal lobe seizure. In addition, we discuss the temporal lobe seizure (and temporal lobe epilepsy) associated with pituitary adenoma based on the literature.
Although further accumulation of clinical data is needed, we would like to emphasize the importance of recognition of temporal lobe seizure caused by pituitary apoplexy, and to suggest that early surgery could be considered as an option in patients displaying such a rare complication.
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^☆: Presented in Abstract Format at the 87th Annual Meeting of the United States and Canadian Academy of Pathology, Boston, MA, March 1998.

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Original contributionPathological correlates of pituitary adenomas presenting with apoplexy☆

Abstract

Endocrinol Metab Clin North Am

Surg Neurol

Am J Med

Pituitary apoplexy: A review

Neurosurgery

Pituitary apoplexy

Arch Neurol

Clinical versus subclinical pituitary apoplexy: Presentation, surgical management, and outcome in 21 patients

Neurosurgery

Clinical aspects of spontaneous necrosis of pituitary tumors (pituitary apoplexy)

J Neurol

Pituitary apoplexy: Endocrine, surgical and oncological emergency

Pituitary apoplexy: Its incidence and clinical significance

J Neurosurg

Hemorrhage within pituitary adenomas: How often associated with pituitary apoplexy syndrome?

AJR

Hemorrhagic pituitary adenomas: Clinicopathological features and surgical treatment

Neurosurgery

Original contribution
Pathological correlates of pituitary adenomas presenting with apoplexy☆