Pituitary Function After Pituitary Apoplexy
RISTO PELKONEN, M.D. ART0 KUUSISTO, M.D. JORMA SALMI. M.D. PENTTI EISTOLA. M.D. CHRISTINA RAIlTA, M.D. SIRKKA-LIISA KARONEN. MSc. ANTTI ARO, M.D. Helsinki.
Finland
Pituitary function was studied in nine patients who had recovered from pituitary apoplexy. All the patients recovered spontaneously; none required immediate surgery. Four of the patients had acromegaly, two had pituitary-dependent Cushing’s syndrome, and a “functionless” pituitary adenoma was found in three. Low serum growth hormone concentrations were observed in three patients wfth acromegaly whereas the concentration remained increased in the fourth one. of the two patients with Cushing’s syndrome, a selective ACTH-deficiency developed in one and Nelson’s syndrome appeared with excessfve secretion of ACTH in the other. Transient or per&tent hypofunction of the antertor pituitary occurred in all patfents. Three patients underwent hypophysectomy after respective intervals of three, eight and 12 months after pituitary apoplexy. The operation revealed a hemorrhage in one functionless adenoma and a large cyst in another one. In the third patient who had acromegaiy, no signs of the pituitary apoplexy were observed at operation. Pituitary apoplexy, originally described by Bleibtreu [ 11, is now a well defined clinical syndrome occurring in 5 to 10 per cent of patients with pituitary tumors [ 2-61. It may be associated with acromegaly, Cushing’s syndrome, prolactinoma and functionless adenoma, but opinions differ as to whether there is a predominance of a particular type of pituitary tumor [2-141. Although numerous reports on this dramatic condition have appeared, fairly little is known about its effect on endocrine function [8,9,1 l-181. This report is a detailed description of pituitary function after pituitary apoplexy in nine patients. MATERIALS AND METHODS
Patients. Between 1968 and 1977 approximately 250 patients with pituitary tumors and 30 patients with pituitary-dependent Cushing’s syndrome have been admitted to the Third Department of Medicine, University of Helsinki. Twelve of the patients met the criteria for pituitary apoplexy: (1) sudden headache and vomiting associated either with (2) acute deterioration of visual acuity, or ophthalmoplegia, or both or (3) acute change in pituitary function. However, only the patients who were admitted to this hospital within three
months after the onset of pituitary apoplexy have been included. Thus, the
From the Third Department of Medicine, and the Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland. Requestsfor reprints should be addressed to Dr. Risto Pelkonen, Third Department of Medicine, University of Helsinki, SF-00290 Helsinki 29. Finland. Manuscript accepted May 10, 1978
series consists of nine patients (three men, six women) with a median age of 48 years (Table I). Methods. Three of the patients (Cases 1, 5 and 6) were examined before they had pituitary apoplexy, and all the patients were examined within three months after its onset (Tables I through IV). A reexamination was performed after a follow-up period which varied from five months to five years. The investigations included an evaluation of pituitary function, examination of the visual fields and measurement of the volume of the sella turcica according to Di Chiro and Nelson [ 191. A pneumoencephalogram was obtained in all but one patient. Pituitary function was assessed as follows. The normal ranges are given in brackets.
November 1978
The American Journal of Medicine
Volume 85
773
PITUITARY FUNCTION AFTER PITUITARY APOPLEXY-PELKONEN ET AL.
TABLE I
Sex, Age, Pituitary Disease, Size of Pituitary, Extraocular Muscular Involvement and Specific Therapy in Nine Patients with Pituitary Apoplexy Si?X
Case No.
Pituitary Disease
end Aw (yr) F,71 F,36 M,60 M,30 F,32
F52 M.36 F.49 M,46
Acromegaiy Acromegaiy Acromegaiy Acromegaiy Cushing Cushing Functionless Functionless Functionless
Volume of Seiia (mm3) 1.270 1,700 4,950 4,200 3.550 1,500 3,050 3,400 2,650
Pneumoencephaiogram
Visual Fields
... Normal Supraseiiar, 15 mm Supraseiiar, 5 mm
Thyroid: Serum protein-bound iodine (4.0 to 8.0 pg/dl) or total thyroxine (T4) (3.8 to 10.5 pgldl) and the uptake of triiodothyronine (Ts) by Sephadexe (85 to 1.18 per cent) were determined. The free T4 index was calculated by multiplying the values for T3 uptake either with protein-bound iodine or T4 values. Serum thyroid-stimulating hormone (TSH) (1.6 to 6.9 @/ml) was determined before and after an intravenous injection of 200 Fg of thyrotropin-releasing hormone (TRH) (maximal increment 3.0 to 30 pU/ml). Pituitary-adrenal axis: Plasma cortisol(3.6 to 20.0 pgldl) was determined before and after a subcutaneous injection of 1 mg of glucagon (increment >6.5 Mg/dl). In the patients with Cushing’s syndrome, the urinary excretion of free cortisol (0.4 to 13 pg) was determined as well. Growth Hormone. Serum growth hormone (GH) (
RISTO PELKONEN, M.D. ART0 KUUSISTO, M.D. JORMA SALMI. M.D. PENTTI EISTOLA. M.D. CHRISTINA RAIlTA, M.D. SIRKKA-LIISA KARONEN. MSc. ANTTI ARO, M.D. Helsinki.
Finland
Pituitary function was studied in nine patients who had recovered from pituitary apoplexy. All the patients recovered spontaneously; none required immediate surgery. Four of the patients had acromegaly, two had pituitary-dependent Cushing’s syndrome, and a “functionless” pituitary adenoma was found in three. Low serum growth hormone concentrations were observed in three patients wfth acromegaly whereas the concentration remained increased in the fourth one. of the two patients with Cushing’s syndrome, a selective ACTH-deficiency developed in one and Nelson’s syndrome appeared with excessfve secretion of ACTH in the other. Transient or per&tent hypofunction of the antertor pituitary occurred in all patfents. Three patients underwent hypophysectomy after respective intervals of three, eight and 12 months after pituitary apoplexy. The operation revealed a hemorrhage in one functionless adenoma and a large cyst in another one. In the third patient who had acromegaiy, no signs of the pituitary apoplexy were observed at operation. Pituitary apoplexy, originally described by Bleibtreu [ 11, is now a well defined clinical syndrome occurring in 5 to 10 per cent of patients with pituitary tumors [ 2-61. It may be associated with acromegaly, Cushing’s syndrome, prolactinoma and functionless adenoma, but opinions differ as to whether there is a predominance of a particular type of pituitary tumor [2-141. Although numerous reports on this dramatic condition have appeared, fairly little is known about its effect on endocrine function [8,9,1 l-181. This report is a detailed description of pituitary function after pituitary apoplexy in nine patients. MATERIALS AND METHODS
Patients. Between 1968 and 1977 approximately 250 patients with pituitary tumors and 30 patients with pituitary-dependent Cushing’s syndrome have been admitted to the Third Department of Medicine, University of Helsinki. Twelve of the patients met the criteria for pituitary apoplexy: (1) sudden headache and vomiting associated either with (2) acute deterioration of visual acuity, or ophthalmoplegia, or both or (3) acute change in pituitary function. However, only the patients who were admitted to this hospital within three
months after the onset of pituitary apoplexy have been included. Thus, the
From the Third Department of Medicine, and the Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland. Requestsfor reprints should be addressed to Dr. Risto Pelkonen, Third Department of Medicine, University of Helsinki, SF-00290 Helsinki 29. Finland. Manuscript accepted May 10, 1978
series consists of nine patients (three men, six women) with a median age of 48 years (Table I). Methods. Three of the patients (Cases 1, 5 and 6) were examined before they had pituitary apoplexy, and all the patients were examined within three months after its onset (Tables I through IV). A reexamination was performed after a follow-up period which varied from five months to five years. The investigations included an evaluation of pituitary function, examination of the visual fields and measurement of the volume of the sella turcica according to Di Chiro and Nelson [ 191. A pneumoencephalogram was obtained in all but one patient. Pituitary function was assessed as follows. The normal ranges are given in brackets.
November 1978
The American Journal of Medicine
Volume 85
773
PITUITARY FUNCTION AFTER PITUITARY APOPLEXY-PELKONEN ET AL.
TABLE I
Sex, Age, Pituitary Disease, Size of Pituitary, Extraocular Muscular Involvement and Specific Therapy in Nine Patients with Pituitary Apoplexy Si?X
Case No.
Pituitary Disease
end Aw (yr) F,71 F,36 M,60 M,30 F,32
F52 M.36 F.49 M,46
Acromegaiy Acromegaiy Acromegaiy Acromegaiy Cushing Cushing Functionless Functionless Functionless
Volume of Seiia (mm3) 1.270 1,700 4,950 4,200 3.550 1,500 3,050 3,400 2,650
Pneumoencephaiogram
Visual Fields
... Normal Supraseiiar, 15 mm Supraseiiar, 5 mm
Thyroid: Serum protein-bound iodine (4.0 to 8.0 pg/dl) or total thyroxine (T4) (3.8 to 10.5 pgldl) and the uptake of triiodothyronine (Ts) by Sephadexe (85 to 1.18 per cent) were determined. The free T4 index was calculated by multiplying the values for T3 uptake either with protein-bound iodine or T4 values. Serum thyroid-stimulating hormone (TSH) (1.6 to 6.9 @/ml) was determined before and after an intravenous injection of 200 Fg of thyrotropin-releasing hormone (TRH) (maximal increment 3.0 to 30 pU/ml). Pituitary-adrenal axis: Plasma cortisol(3.6 to 20.0 pgldl) was determined before and after a subcutaneous injection of 1 mg of glucagon (increment >6.5 Mg/dl). In the patients with Cushing’s syndrome, the urinary excretion of free cortisol (0.4 to 13 pg) was determined as well. Growth Hormone. Serum growth hormone (GH) (
