A Preliminary Study On The Specific Clinical Features Of Ischemic Pituitary Adenoma Apoplexy

Background:Pituitary adenoma apoplexy is a secondary change after hemorrhage or infarction of pituitary adenoma,which can be divided into two basic types:hemorrhagic apoplexy and ischemic apoplexy.Current studies on pituitary adenoma apoplexy are limited to hemorrhagic type,but there are few reports on ischemic type apoplexy,only in some case reports and small sample size studies.The symptoms of acute or subacute onset of pituitary adenoma infarction mainly include sudden headache,vision loss,visual field damage,ophthalmoplegia and endocrine symptoms of impaired anterior pituitary function.Due to the lack of specific clinical features of ischemic pituitary adenoma apoplexy,it is extremely easy to be misdiagnosed and missed.Ischemic pituitary adenoma apoplexy as a clinical emergency,once missed diagnosis or missed the best treatment will lead to serious consequences,so we must pay attention to it.Objective: To explore the specific clinical features of ischemic pituitary adenoma apoplexy,to provide help for preoperative nonpathological diagnosis and treatment of this disease.Methods: The clinical manifestations,endocrinology and imaging findings of 26 patients with ischemic pituitary adenoma apoplexy confirmed by pathology from January 2010 to October 2019 were analyzed retrospectively.At the same time,26 patients with hemorrhagic pituitary adenoma apoplexy were included as the control group to compare the differences between the two groups.Results: 52 patients with pituitary adenoma apoplexy were enrolled in our study,including 26 patients with ischemic pituitary adenoma apoplexy and 26 patients with hemorrhagic.Epidemiological and clinical manifestations: The patients with ischemic pituitary adenoma apoplexy include 18 male and 8 females,sex ratio:2.5:1.Age range is from 23 to 74 years old(average 56.50±12.42 years old).Course of disease range is from 1.5 to 30 days(average 7.25±5.95 days).Main symptoms of ischemic pituitary adenoma apoplexy include headache(96%),vision loss or visual field damage(65%),ophthalmoplegia(46%),nausea or vomiting(46%),and so on.The scale of apoplexy classification is 0 ～8(average 1.92 ± 1.78).There was no significant difference in epidemiology and clinical manifestations compared with hemorrhagic apoplexy.Radiologic findings: Among them,22 cases(100%)of patients with enhancement MRI showed "ring enhancement ",16 cases with “spot enhancement” inside,with astatistical difference compared with hemorrhagic apoplexy group;8 cases of sphenoid sinus mucosal thickening were found,without statistical difference compared with hemorrhagic apoplexy group.Endocrinological findings: 25 patients(96%)were found with anterior pituitary dysfunction.And half of the whole patients were encountered panhypopituitarism(50%),followed by two axis damaged(38%)and single axis damaged(12%).And the most common anterior pituitary dysfunction was isolated gonadotropic deficiency(85%),then,followed by isolated thyrotropic isolated(54%)and corticotropic deficiency(50%).There is no statistical difference compared with hemorrhagic apoplexy in all of the above.The decreased rates of preoperative involvement hormones ranged from high to low in order of PRL(100%),T(100%),LH(75%),P(75%),TSH(69%),FT3(65%),E2(54%),FT4(54%),CORT(52%),ACTH(43%),FSH(38%)and GH(15%).There is no statistical difference compared with hemorrhagic apoplexy except PRL and T.Besides,PRL is the most statistically significant hormone.Surgery: All the patients of pituitary adenoma experienced tumor resection via transsphenoidal approach.Pathologic findings: All patients were found coagulation necrosis due to infarction in postoperative pathologic tissues,according to immunohistochemistry with the combination of immunostains for the main pituitary hormones,which were divided into negative immunohistochemical hormone markers adenoma(47%),gonadotroph adenoma(21%),plurihormonal adenomas(16%),somatotroph adenomas(11%)and lactotroph adenomas(5%).Conclusion: 1.As for dynamic enhancement or enhancement MRI,"ring enhancement" is highly sensitive.We first found and proposed that intra-tumoral "spot enhancement" could be consider as an important imaging feature of ischemic pituitary adenoma apoplexy;2.We first proposed the conclusion that decreasing level of PRL and T before operation is a significant endocrinologic features.3.We initially proposed the diagnosis basis of ischemic pituitary adenoma apoplexy:(1)The dynamic enhancement or enhancement MRI suggested that the tumor ring enhancement accompanied with the tumor internal spot enhancement;(2)The PRL and T decreased sharply.