Overview.
An acute syndrome characterized by sudden hemorrhage, ischemia, infarction, and necrosis of the pituitary gland and causing sudden paraspinal compression and intracranial hypertension or meningeal irritation.
Causes
1. Common Causes
Trauma, radiotherapy, inflammation, drugs such as bromocriptine, chlorpromazine, anticoagulants, alcoholism, which can lead to an instantaneous increase in intracranial and intravascular pressure events: coughing, sneezing, emotional excitement, angiography, certain pituitary function tests such as the TRH test, the GnRH test and so on.
2.Pathogenesis
Hemorrhage secondary to pituitary tumor; ischemic necrosis and secondary hemorrhage due to rapid tumor growth beyond its own blood supply capacity; vascular hemorrhage and infarction; hemorrhage secondary to physiologic and pathologic adenopituitary enlargement.
Symptoms
1. Symptoms of increased cranial pressure or signs of meningeal irritation
Sudden onset of symptoms of increased cranial pressure or signs of meningeal irritation.
2. Symptoms of compression of tissues adjacent to the pterygoid saddle
If the visual pathway, mesencephalon and midbrain are pressed upward, it will cause sharp decrease of visual acuity, visual field defect, and also damage to the olfactory nerve, which may even be life-threatening; if the thalamus is pressed downward, it will cause disturbance of blood pressure, body temperature, respiration and cardiac rhythm; and if it is pressed laterally into the cavernous sinus, it will cause paralysis of extra-ocular muscles, symptoms of the trigeminal nerve, damage to the middle cerebral artery, and influence on venous reflux.
3. Symptoms of hypothalamic-pituitary hypoplasia
Many patients with pituitary stroke lack the symptoms of the original pituitary adenoma, therefore, when encountering sudden increase in cranial pressure of unknown cause, especially when accompanied by visual impairment, paralysis of the eye muscles and other symptoms of compression, we should be alert to pituitary stroke.
Examination
1. Blood sugar test
Decrease in blood glucose;
2. Electrolyte level
Low serum sodium and chloride;
3. Measurement of endocrine function
Both pituitary prohormone and target gland hormone levels are lowered, and adenopituitary coexcitability test (TRH), mephedrone test, water-restriction-pressin test, hypertonic saline test, etc. may be performed as appropriate.
4. Imaging examination
(1) Cranial X-ray can show the enlargement of the pterygoid saddle, the disappearance of the anterior bed protrusion, and the thinning of the saddle base;
(2) CT scan of the brain, the pituitary gland shows low density or high density with peripheral enhancement. CT scan can clarify whether there is subarachnoid hemorrhage and whether it extends to the ventricles of the brain;
(3) MRI The T1- and T2-weighted images of the pituitary gland are high signal in stroke;
(4) Cerebral angiography is suitable for those who have meningeal irritation signs with monocular paralysis, or to differentiate from intracranial aneurysm rupture and hemorrhage.
Diagnosis
The diagnosis can be made according to the etiology, clinical manifestations and laboratory tests.
Treatment
Large amounts of hormone replacement therapy and hemostatic agents should be given. Those with uremia or abnormal secretion of antidiuretic hormone should be tested for water and salt metabolism; in the case of severe increase in cranial pressure, loss of vision, coma, and progressive deterioration of the condition, surgical decompression should be performed.