- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
DOI:10.4103/2152-7806.109654Copyright: © 2013 Hojo M This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Hojo M, Goto M, Miyamoto S. Chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy. Surg Neurol Int 28-Mar-2013;4:41
How to cite this URL: Hojo M, Goto M, Miyamoto S. Chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy. Surg Neurol Int 28-Mar-2013;4:41. Available from: http://sni.wpengine.com/surgicalint_articles/chronic-expanding-pituitary-hematoma-without-rebleeding-after-pituitary-apoplexy/
Background:Enlargement of intracerebral hematoma without rebleeding in chronic phase is a rare but well-known clinical condition, and is well-described as chronic expanding intracerebral hematoma. However, chronic enlargement of pituitary hematoma without rebleeding after pituitary apoplexy is extremely rare.
Case Description:We report a case of chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy. A 29-year-old male presented with sudden onset of headache and vomiting. Magnetic resonance imaging (MRI) demonstrated a pituitary mass lesion with hematoma, consistent with pituitary apoplexy. Neuro-ophthalmological examination revealed no visual field defect, and endocrinological evaluations showed an elevated prolactin level. Pituitary apoplexy due to a prolactinoma was the most likely diagnosis. He was conservatively treated because he exhibited no visual disturbance. Three weeks after the onset, he gradually began to complain of blurred vision and neuro-ophthalamological examination revealed bitemporal upper quadrant hemianopsia. MRI showed enlargement of the pituitary hematoma without any finding suggestive of rebleeding. This enlarged mass lesion compressed the chiasm. The patient was operated on via transsphenoidal approach. After dural opening, xanthochromic fluid spouted out, but no fresh clot could be detected within the cyst. After the operation, the visual field disturbance resolved completely. The possible mechanism of hematoma enlargement is considered to be expansion due to the serum exudation from capillaries of the hematoma capsule. This pathogenetic mechanism is common in enlargement of chronic subdural hematoma.
Conclusions:This case is the first report of chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy.
Keywords: Chronic expanding hematoma, pituitary apoplexy, pituitary adenoma, prolactinoma, transsphenoidal surgery
Pituitary apoplexy is a rare clinical syndrome caused by the rapid enlargement of a pituitary adenoma because of hemorrhage or infarction.[
Enlargement of intracerebral hematoma without rebleeding in chronic phase is a rare but well-known clinical condition, and is well-described as chronic expanding intracerebral hematoma.[
A 29-year-old male presented with a sudden onset of severe headache accompanied by vomiting, and visited a local hospital. A physician could not detect any abnormal finding by computed tomography (CT) scans. Two weeks after the onset, magnetic resonance imaging (MRI) revealed a pituitary mass with hematoma consistent with pituitary apoplexy [Figure
MR images obtained 2 weeks (a, b) and 3 weeks (c) after onset, (a) coronal T1-weighted image demonstrated intra-and suprasellar mass with a central area of high signal intensity consistent with hematoma of subacute phase. The hyperintense signal may correspond to hemoglobin degradation content as extracellular methhemoglobin, (b) sagittal postgadolinium T1-weighted image showed rim enhancement of hematoma capsule, (c) coronal T1-weighted image demonstrated enlargement of pituitary hematoma resulting in compression of the chiasm (arrows). No sign of rebleeding was detected. Compared with MR images obtained 2 weeks after onset (a), the compression of chiasm was markedly worsened for this one week (c, arrows)
Three weeks after the onset, he gradually began to complain of blurred vision. Neuro-ophthalmological examination revealed bitemporal upper quadrant hemianopsia. MRI showed the enlargement of the pituitary mass lesion resulting in the compression of the chiasm [
He was operated on via transsphenoidal approach. The dura of the sella was tensive. After dural opening, xanthochromic fluid spouted out, but no fresh clot could be detected within the hematoma cavity [
The clinical features of pituitary apoplexy are typically sudden in onset, including acute headache, nausea, vomiting, visual field defect, and ocular paresis.[
The phenomenon of chronic expansion of hematoma is well-known in CSDH. In CSDH, various theories have been proposed to explain the enlargement of hematomas. Intermittent cycles of bleeding, coagulation, fibrinolysis, and rebleeding from the vascularized outer membrane are widely accepted to be the pathophysiology of hematoma expansion.[
It was highly likely that the intrasellar pituitary hematoma expanded without rebleeding through the same mechanism as CSDH: Expansion due to serum exudation from capillaries of the hematoma capsule. To the authors’ knowledge, this is the first documented case of chronic expanding intrasellar hematoma without rebleeding after pituitary apoplexy. Although it is unusual clinical condition, expansion of intrasellar pituitary hematoma without rebleeding at chronic stage should be taken into account in the treatment of pituitary apoplexy.
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