Pitüiter Apopleksi
Özet
Pitüiter apopleksi (PA), hipofiz bezindeki enfarktüs veya kanama sonucu aniden gelişen; şiddetli baş ağrısı, görme kaybı ve akut hipopitüitarizm ile karakterize tıbbi bir acil durumdur. Genellikle altta yatan, çoğu zaman teşhis edilmemiş bir hipofiz makroadenomu varlığında görülür. Patofizyolojisinde tümörün yüksek metabolik talebi, sınırlı kan akışı ve artmış kafa içi basıncı temel rol oynar. Tanı, klinik şüphenin ardından esas olarak MR görüntüleme ile doğrulanır; hastaların büyük çoğunluğunda hormonal eksiklikler, özellikle de hayati risk taşıyan ACTH eksikliği tespit edilir. Tedavi yaklaşımı multidisipliner olup, sıvı-elektrolit dengesinin sağlanması ve yüksek doz kortikosteroid replasmanı önceliklidir. Cerrahi müdahale (transsfenoidal dekompresyon), özellikle ciddi görme kaybı veya bilinç değişikliği olan vakalarda semptomların ilk 7 günü içinde önerilirken; nöro-oftalmolojik bulguları hafif veya durağan seyreden seçilmiş hastalarda konservatif takip ve tıbbi tedavi, cerrahi kadar etkili sonuçlar verebilmektedir.
Pituitary apoplexy (PA) is a medical emergency characterized by sudden-onset severe headache, visual impairment, and acute hypopituitarism resulting from infarction or hemorrhage in the pituitary gland. It typically occurs in the presence of an underlying, often undiagnosed, pituitary macroadenoma. The high metabolic demand of the tumor, limited blood flow, and increased intrasellar pressure play fundamental roles in its pathophysiology. Diagnosis is primarily confirmed by MRI following clinical suspicion; the majority of patients present with hormonal deficiencies, most notably life-threatening ACTH deficiency. The management approach is multidisciplinary, prioritizing fluid-electrolyte balance and high-dose corticosteroid replacement. Surgical intervention (transsphenoidal decompression) is recommended within the first 7 days for cases with severe vision loss or altered consciousness. However, in selected patients with mild or stable neuro-ophthalmological symptoms, conservative monitoring and medical therapy can yield outcomes comparable to surgical treatment.
Referanslar
Verrees M, Arafah BM, Selman WR. Pituitary tumor apoplexy: characteristics, treatment, and outcomes. Neurosurg Focus. 2004;16(4):E6.
Mayol Del Valle M, De Jesus O. Pituitary Apoplexy. StatPearls. Treasure Island (FL)2021.
Briet C, Salenave S, Bonneville JF, Laws ER, Chanson P. Pituitary Apoplexy. Endocr Rev. 2015;36(6):622-45.
Fernandez-Balsells MM, Murad MH, Barwise A, Gallegos-Orozco JF, Paul A, Lane MA, et al. Natural history of nonfunctioning pituitary adenomas and incidentalomas: a systematic review and metaanalysis. J Clin Endocrinol Metab. 2011;96(4):905-12.
Sun Md Z, Cai Md X, Li Md Y, Shao Md D, Jiang Ph DZ. Endoscopic Endonasal Transsphenoidal Approach for the Surgical Treatment of Pituitary Apoplexy and Clinical Outcomes. Technol Cancer Res Treat. 2021;20:15330338211043032.
Rajasekaran S, Vanderpump M, Baldeweg S, Drake W, Reddy N, Lanyon M, et al. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol (Oxf). 2011;74(1):9-20.
Kniestedt C, Stamper RL. Visual acuity and its measurement. Ophthalmol Clin North Am. 2003;16(2):155-70, v.
Ricciuti R, Nocchi N, Arnaldi G, Polonara G, Luzi M. Pituitary Adenoma Apoplexy: Review of Personal Series. Asian J Neurosurg. 2018;13(3):560-4.
Biousse V, Newman NJ, Oyesiku NM. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry. 2001;71(4):542-5.
Randall BR, Couldwell WT. Apoplexy in pituitary microadenomas. Acta Neurochir (Wien). 2010;152(10):1737-40.
Nakhleh A, Assaliya Naffa M, Sviri G, Shehadeh N, Hochberg I. Outcomes of pituitary apoplexy: a comparison of microadenomas and macroadenomas. Pituitary. 2021;24(4):492-8.
Moller-Goede DL, Brandle M, Landau K, Bernays RL, Schmid C. Pituitary apoplexy: re-evaluation of risk factors for bleeding into pituitary adenomas and impact on outcome. Eur J Endocrinol. 2011;164(1):37-43.
Veldhuis JD, Hammond JM. Endocrine function after spontaneous infarction of the human pituitary: report, review, and reappraisal. Endocr Rev. 1980;1(1):100-7.
Mayol Del Valle M, De Jesus O. Pituitary Apoplexy. StatPearls. Treasure Island (FL)2022.
Kruse A, Astrup J, Cold GE, Hansen HH. Pressure and blood flow in pituitary adenomas measured during transsphenoidal surgery. Br J Neurosurg. 1992;6(4):333-41.
Oldfield EH, Merrill MJ. Apoplexy of pituitary adenomas: the perfect storm. J Neurosurg. 2015;122(6):1444-9.
Arafah BM, Prunty D, Ybarra J, Hlavin ML, Selman WR. The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas. J Clin Endocrinol Metab. 2000;85(5):1789-93.
Barkhoudarian G, Kelly DF. Pituitary Apoplexy. Neurosurg Clin N Am. 2019;30(4):457-63.
Briet C, Salenave S, Chanson P. Pituitary apoplexy. Endocrinol Metab Clin North Am. 2015;44(1):199-209.
Dubuisson AS, Beckers A, Stevenaert A. Classical pituitary tumour apoplexy: clinical features, management and outcomes in a series of 24 patients. Clin Neurol Neurosurg. 2007;109(1):63-70.
Ayuk J, McGregor EJ, Mitchell RD, Gittoes NJ. Acute management of pituitary apoplexy--surgery or conservative management? Clin Endocrinol (Oxf). 2004;61(6):747-52.
Ahmed SK, Semple PL. Cerebral ischaemia in pituitary apoplexy. Acta Neurochir (Wien). 2008;150(11):1193-6; discussion 6.
Danesh-Meyer HV, Wong A, Papchenko T, Matheos K, Stylli S, Nichols A, et al. Optical coherence tomography predicts visual outcome for pituitary tumors. J Clin Neurosci. 2015;22(7):1098-104.
Marx C, Rabilloud M, Borson Chazot F, Tilikete C, Jouanneau E, Raverot G. A key role for conservative treatment in the management of pituitary apoplexy. Endocrine. 2021;71(1):168-77.
Almeida JP, Sanchez MM, Karekezi C, Warsi N, Fernandez-Gajardo R, Panwar J, et al. Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature. World Neurosurg. 2019;130:e988-e99.
Sipos L, Szucs N, Varallyay P. Pituitary apoplexy: Surgical or conservative management? Orv Hetil. 2021;162(38):1520-5.
