Abstract
Sir: Pituitary apoplexy is characterized by a sudden onset of headache, visual symptoms, altered mental status, and hormonal dysfunction. This condition usually stems from an acute expansion of a pituitary adenoma, which may deprive the anterior pituitary gland and the tumor itself of vascular supply, thus causing ischemia and subsequent necrosis [1, 2]. During cardiac surgery, cardiopulmonary bypass-induced cerebral edema may contribute to the critical enlargement of silent pituitary adenomas [3]. Cardiopulmonary bypass may also cause infarction and/or hemorrhage in pituitary adenomas in view of an increase susceptibility to hypoperfusion or ischemia of the abnormal pituitary tissue and/or to an increased risk of bleeding as a result of anticoagulation [4, 5]. We present herein the case of a 70year-old man with exertional angina and diagnosis of three-vessel coronary artery disease admitted for elective coronary bypass surgery. Past medical history revealed hypercholesterolemia, peripheral vascular disease and chronic obstructive pulmonary disease. Neurological examination on admission was normal. After conventional general anesthesia and systemic heparin administration, on cardiopulmonary bypass, myocardial revascularization was achieved by anastomosis of the left internal mammary artery to the left anterior descending coronary artery, and vein grafts to the first diagonal, obtuse marginal, and right coronary arteries, respectively. Aortic cross clamp time and total cardiopulmonary bypass time were 64 and 118 min, respectively. In view of an initial uneventful post-operative course, the patient was awakened and extubated 4 h later. Soon thereafter, he started complaining of headache and visual field defects, with diplopia. Neurological examination revealed initially sole ptosis of the left eye, followed by unilateral dilated pupil with a left globe deviated inferiorly and laterally with inability to adduct or abduct. Funduscopy revealed neither papilloedema nor hemorrhage. He was conscious at all time, with no evidence of hypotension or shock, requiring volume and/or inotropic adjustment. An urgent brain CT-scan demonstrated a sellar mass with suprasellar extension. Magnetic resonance imaging confirmed the sellar tumor suggestive of pituitary macroadenoma extended to the left cavernous sinuses (Fig. 1a, b). On T2-weighted images, the lesion was isointense but showed increased signal intensity on T1-weighted images, suggestive of hemorrhage. There was no infarct or hemorrhage seen elsewhere in the brain. Tests of serum at early morning showed the following levels: thyroxine 0.8 lg/L (normal range 0.9–1.8 lg/L), luteinizing hormone 0.9 IU/L (normal range 2.4–15.9 IU/L), prolactin 0.7 lg/L (normal range 2.8–29.9 lg/ L), cortisol 5 lg/dL (normal range 5–25 lg/dL), TSH 0.5 mIU/L (normal range 0.4–4 mIU/L), ACTH 7 ng/L (normal range 9–52 ng/L), FSH 1.3 IU/L (normal range 1–14 IU/L), GH 0.9 ng/mL (normal
Published Version
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call