Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Insights into Imaging
Published in: Insights into Imaging 6/2014

Open Access 01-12-2014 | Review

Pituitary apoplexy: an update on clinical and imaging features

Authors: Alessandro Boellis, Alberto di Napoli, Andrea Romano, Alessandro Bozzao

Published in: Insights into Imaging | Issue 6/2014

Login to get access

Abstract

Pituitary apoplexy (PA) is a rare and potentially fatal clinical condition presenting acute headache, vomiting, visual impairment, ophthalmoplegia, altered mental state and possible panhypopituitarism. It mostly occurs in patients with haemorrhagic infarction of the pituitary gland due to a pre-existing macroadenoma. Although there are pathological and physiological conditions that may share similar imaging characteristics, both clinical and imaging features can guide the radiologist towards the correct diagnosis, especially using magnetic resonance imaging (MRI). In this review, we will describe the main clinical and epidemiological features of PA, illustrating CT and MRI findings and discussing the role of imaging in the differential diagnosis, prognosis and follow-up.
Teaching points
• Headache, ophtalmoplegia and visual impairment are frequent symptoms of pituitary apoplexy.
• CT is often the first imaging tool in PA, showing areas of hyperdensity within the sellar region.
• MRI could confirm haemorrhage within the pituitary gland and compression on the optic chiasm.
• Frequent simulating conditions are aneurysms, Rathke cleft cysts, craniopharingioma and mucocele.
• The role of imaging is still debated and needs more studies.
Literature
1.
Bailey P (1898) Pathological report of a case of acromegaly with special reference to the lesions in hypophysis cerebri and in the thyroid gland, and a case of hemorrhage into the pituitary. Phila Med J 1:789–792
2.
Brougham M, Heusner AP, Adams RD (1950) Acute degenerative changes in adenomas of the pituitary body—with special reference to pituitary apoplexy. J Neurosurg 7:421–439CrossRefPubMed
3.
Wakai S, Fukushima T, Teramoto A, Sano K (1981) Pituitary apoplexy: its incidence and clinical significance. J Neurosurg 55:187–193CrossRefPubMed
4.
5.
Dubuisson AS, Beckers A, Stevenaert A (2007) Classical pituitary tumour apoplexy: clinical features, management and outcomes in a series of 24 patients. Clin Neurol Neurosurg 109:63–70CrossRefPubMed
6.
Ebersold MJ, Laws ER, Scheithauer BW, Randall RV (1983) Pituitary apoplexy treated by transsphenoidal surgery. A clinicopathological and immunocytochemical study. J Neurosurg 58:315–320CrossRefPubMed
7.
Mohr G, Hardy J (1983) Haemorrhage, necrosis and apoplexy in pituitary adenomas. Surg Neurol 18:181–189CrossRef
8.
9.
Conomy JP, Ferguson JH, Brodkey JS, Mitsumoto H (1975) Spontaneous infarction in pituitary tumours. Neurologic and therapeutic aspects. Neurology 25:580–587CrossRefPubMed
10.
11.
Lavallée G, Morcos R, Palardy J, Aubé M, Gilbert D (1995) MR of nonhemorrhagic postpartum pituitary apoplexy. AJNR 16:1939–1941PubMed
12.
Sheehan HL, Stanfor JP (1961) The pathogenesis of postpartum pituitary necrosis of the anterior lobe of the pituitary gland. Acta Endocrinol 37:479–510
13.
Couture N, Aris-Jilwan N, Serri O (2012) Apoplexy of microprolactinoma during pregnancy: case report and review of literature. Endocr Pract 18(6):e147–e150CrossRefPubMed
14.
Semple PL, Jane JA, Lopes MBS, Laws ER (2008) Pituitary apoplexy: correlation between magnetic resonance imaging and histopathological results. J Neurosurg 108:909–915CrossRefPubMed
15.
Rogg JM, Tung GA, Anderson G, Cortez S (2002) Pituitary apoplexy: early detection with diffusion-weighted MR imaging. AJNR Am J Neuroradiol 23:1240–1245PubMed
16.
Bills DC, Meyer FB, Laws ER et al (1993) A retrospective analysis of pituitary apoplexy. Neurosurgery 33(4):602–609CrossRefPubMed
17.
Fraioli B, Esposito V, Palma L, Cantore G (1990) Hemorrhagic pituitary adenomas: clinicopathological features and surgical treatment. Neurosurgery 27(5):741–748CrossRefPubMed
18.
Onesti ST, Wisniewski T, Post KD (1990) Clinical versus subclinical pituitary apoplexy: presentation, surgical management and outcome in 21 patients. Neurosurgery 26(6):980–986CrossRefPubMed
19.
Pant B, Arita K, Kurisu K, Tominaga A, Eguchi K, Uozumi T (1997) Incidence of intracranial aneurysm associated with pituitary adenoma. Neurosurg Rev 20:13–17CrossRefPubMed
20.
Randeva H, Schoebel J, Byrne J, Esiri M, Adams C, Wass J (1999) Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinol 51:181–188CrossRef
21.
22.
Shahlaie K, Olaya J, Hartman J, Watson JC (2006) Pituitary apoplexy associated with anterior communicating artery aneurysm and aberrant blood supply. J Clin Neurosci 13:1057–1062CrossRefPubMed
23.
Mortimer AM, Bradley MD, Stoodley NG, Renowden SA (2013) Thunderclap headache: diagnostic considerations and neuroimaging features. Clin Radiol 68:e101–e113CrossRefPubMed
24.
Bonicki W, Kasperlik-Zaluska A, Koszewski W, Zgliczynski W, Wislawski J (1993) Pituitary apoplexy: endocrine, surgical and oncological emergency. Incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas. Acta Neurochir 120:118–122CrossRefPubMed
25.
Ayuk J, McGregor EJ, Mitchell RD, Gittoes NJL (2004) Acute management of pituitary apoplexy—surgery or conservative management? Clin Endocrinol 61:747–752CrossRef
26.
Chacko AG, Chacko G, Seshadri MS, Chandy MJ (2002) Hemorrhagic necrosis of pituitary adenomas. Neurol India 50:490–493PubMed
27.
Chanson P, Lepeintre JF, Ducreux D (2004) Management of pituitary apoplexy. Expert Opin Pharmacother 5:1287–1298CrossRefPubMed
28.
De Villiers JC, Marcus G (1988) Non-haemorrhagic infarction of pituitary tumours presenting as pituitary apoplexy. Adv Biosci 69:461–464
29.
Brennan CF, Malone RGS, Weaver JA (1956) Pituitary necrosis in diabetes mellitus. Lancet 271:12–16CrossRefPubMed
30.
Chapman AJ, Williams G, Hockley AD, London DR (1956) Pituitary apoplexy after combined tests of anterior pituitary function. Br Med J 291:26CrossRef
31.
Arafah BM, Harrington JF, Madhoun ZT, Selman WR (1990) Improvement of pituitary function after surgical decompression for pituitary tumour apoplexy. J Clin Endocrinol Metab 71:323–328CrossRefPubMed
32.
David M, Philippon J, Navarro-Artiles G, Racadot J, Weil BB (1969) Les forms hémorragiques des adénomes hypophysaires: aspects cliniques et étiologiques. Neurochirurgie 15:228–229
33.
Yamaji T, Ishibashi M, Kosaka K et al (1981) Pituitary apoplexy in acromegaly during bromocriptine therapy. Acta Endocrinol 98:171–177PubMed
34.
Nourizadeh AR, Pitts FW (1965) Haemorrhage into pituitary adenoma during anticoagulant therapy. J Am Med Assoc 193:623–624CrossRef
35.
Uhilein A, Balfour WM, Donovan PF (1957) Acute haemorrhage into pituitary adenomas. J Neurosurg 14:140–151CrossRef
36.
Pergolizzi RS, Nabavi A, Schwartz RB et al (2001) Intra-operative MR guidance during transsphenoidal pituitary resection: preliminary results. J Magn Reson Imaging 13:136–141CrossRefPubMed
37.
Bonneville JF, Bonneville F, Cattin F (2005) Magnetic resonance imaging of pituitary adenomas. Eur Radiol 15:543–548CrossRefPubMed
38.
Powell DF, Baker HL Jr, Laws ER Jr (1974) The primary angiographic findings in pituitary adenomas. Radiology 110:589–595CrossRefPubMed
39.
Pia HV, Obrador S, Martin JG (1972) Association of brain tumours and arterial intracranial aneurysms. Acta Neurochir 27:189–204CrossRefPubMed
40.
Osborn AG (1972) Pituitary apoplexy. In: Osborn A, Salzman KL, Barkovich AJ (eds) Diagnostic imaging. Brain, 2nd edn. Amirsys Inc, Salt Lake City, II-2-28-31
41.
Kaplan B, Day AL, Quisling R, Ballinger W (1983) Haemorrhage into pituitary adenomas. Surg Neurol 20:280–287CrossRefPubMed
42.
43.
Hardy PA, Kucharczyk W, Henkelman RM (1990) Cause f signal loss in MR images of old hemorrhagic lesions. Radiology 174:549–555CrossRefPubMed
44.
Jones KM, Mulkern RV, Mantello MT et al (1992) Brain hemorrhage: evaluation with fast spin-echo and conventional dual spin-echo images. Radiology 182:53–58CrossRefPubMed
45.
Piotin M, Tampieri D, Rüfenacht DA et al (1999) The various MRI patterns of pituitary apoplexy. Eur Radiol 9:918–923CrossRefPubMed
46.
Bonneville F, Cattin F, Marsot-Dupuch K, Dormont D, Bonneville JF, Chiras J (2006) T1 signal hyperintensity in the sellar region: spectrum of findings. Radiographics 26:93–113CrossRefPubMed
47.
Kurihara N, Takahashi S, Higano S et al (1998) Haemorrhage in pituitary adenoma: correlation of MR imaging with operative findings. Eur Radiol 8:971–976CrossRefPubMed
48.
Arita K, Kurisu K, Tominaga A et al (2001) Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy. J Neurosurg 95:897–901CrossRefPubMed
49.
Ostrov SG, Quencer RM, Hoffman JC, Davis PC, Hasso AN, David NJ (1989) Hemorrhage within pituitary adenomas: how often associated with pituitary apoplexy syndrome? Am J Roentgenol 153:153–160CrossRef
50.
Tosaka MN, Sato J, Hirato H et al (2007) Assessment of hemorrhage in pituitary macroadenoma by T2*-weighted gradient-echo MR imaging. Am J Neuroradiol 28:2023–2029CrossRefPubMed
51.
Fujisawa I, Nishimura K, Asato R et al (1987) Posterior lobe of the pituitary in diabetes insipidus: MR findings. J Comput Assist Tomogr 11:221–225CrossRefPubMed
52.
Kurokawa H, Fujisawa I, Nakano Y et al (1998) Posterior lobe of the pituitary gland: correlation between signal intensity on T1-weighted MR images and vasopressin concentration. Radiology 207:79–83CrossRefPubMed
53.
Fujisawa I, Kikuchi K, Nishimura K et al (1987) Transection of the pituitary stalk: development of an ectopic posterior lobe assessed with MR imaging. Radiology 165:487–489CrossRefPubMed
54.
Cox TD, Elster AD (1991) Normal pituitary gland: change in shape, size, and signal intensity during 1st year of life at MR imaging. Radiology 179:721–724CrossRefPubMed
55.
Miki Y, Asato R, Okumura R et al (1993) Anterior pituitary gland in pregnancy: hyperintensity at MR. Radiology 187:229–231CrossRefPubMed
56.
Hayashi Y, Tachibana O, Muramatsu N et al (1999) Rathke cleft cyst: MR and biomedical analysis of cyst content. J Comput Assist Tomogr 23:34–38CrossRefPubMed
57.
Binning MJ, Liu JK, Gannon J, Osborn AG, Couldwell WT (2008) Hemorrhagic and nonhemorrhagic Rethke cleft cysts mimicking pituitary apoplexy. J Neurosurg 108:3–8CrossRefPubMed
58.
Pusey E, Kortman KE, Flannigan BD, Tsuruda J, Bradley WG (1987) MR of craniopharyngiomas: tumor delineation and characterization. Am J Roentgenol 149:383–388CrossRef
59.
Rajasekaran S, Vanderpump M, Baldeweg S (2011) UK guidelines for the management of pituitary apoplexy. Clin Endocrinol 74:9–20CrossRef
60.
Gruber A, Clayton J, Kumar S, Robertson I, Howlett TA, Mansell P (2006) Pituitary apoplexy: retrospective review of 30 patients–is surgical intervention always necessary? Br J Neurosurg 20:379–385CrossRefPubMed
Metadata
Title
Pituitary apoplexy: an update on clinical and imaging features
Authors
Alessandro Boellis
Alberto di Napoli
Andrea Romano
Alessandro Bozzao
Publication date
01-12-2014
Publisher
Springer Berlin Heidelberg
Published in
Insights into Imaging / Issue 6/2014
Electronic ISSN: 1869-4101
DOI
https://doi.org/10.1007/s13244-014-0362-0

Other articles of this Issue 6/2014

Insights into Imaging 6/2014 Go to the issue

Pictorial Review

Multidetector computed tomography of mesenteric ischaemia

Pictorial Review

Pitfalls in the diagnosis of common benign bone tumours in children

Review

Stone disease in pregnancy: imaging-guided therapy

Original Article

Mammography equipment design: impact on radiographers’ practice

Pictorial Review

Imaging adults on extracorporeal membrane oxygenation (ECMO)

Pictorial Review

Post-treatment MRI aspects of photodynamic therapy for prostate cancer