Unilateral Tuberothalamic Artery Ischemia Caused by Pituitary Apoplexy

Abstract

Background and Importance Pituitary apoplexy (PA) occasionally occurs in patients with pituitary adenoma and may cause severe functional deficits. Headache, pituitary insufficiency, visual impairment, and cranial nerve palsies are the most frequent symptoms in patients with PA. Secondary cerebral ischemia develops in only a limited number of PA patients. Two pathogenic mechanisms were previously proposed. One states that ischemia may be due to major vessel encasement or to vessel compression, as a result of extended tumor growth. The second states that cerebral vasospasm following PA may cause ischemia. We present another mechanism. After PA, a sudden increase in suprasellar tumor volume can lead to compression of perforating arteries causing hypoperfusion and subsequent focal ischemia of the thalamus, basal ganglia, and internal capsule.

Clinical Presentation We present the case of a 75-year-old woman who, after having PA, developed cerebral ischemia in the territory of the left anterior thalamus and internal capsule that is primarily supplied by the tuberothalamic artery. Computed tomography and magnetic resonance imaging are used to describe how mechanical compression of the tuberothalamic artery caused this rare phenomenon. The recent literature, vascular anatomy, and pathophysiologic aspects of PA are discussed.

Conclusion PA can lead to compression of perforating arteries, for example, the tuberothalamic artery supplying the thalamus or lenticulostriate region, and thus cause hypoperfusion and subsequent focal cerebral ischemia. This may occur when perforating cerebral arteries are affected and compressed by the sudden increase in tumor volume due to hemorrhage or tumor swelling.

Keywords

pituitary apoplexy - cerebral ischemia - thalamus

• References

• 1 Giammattei L, Mantovani G, Carrabba G. , et al. Pituitary apoplexy: considerations on a single center experience and review of the literature. J Endocrinol Invest 2016; 39 (07) 739-746
• 2 Nawar RN, AbdelMannan D, Selman WR, Arafah BM. Pituitary tumor apoplexy: a review. J Intensive Care Med 2008; 23 (02) 75-90
• 3 Hage R, Eshraghi SR, Oyesiku NM. , et al. Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy. World Neurosurg 2016; 94: 447-452
• 4 Yang T, Bayad F, Schaberg MR. , et al. Endoscopic endonasal transsphenoidal treatment of pituitary apoplexy: outcomes in a series of 20 patients. Cureus 2015; 7 (10) e357
• 5 Zhan R, Li X, Li X. Endoscopic endonasal transsphenoidal approach for apoplectic pituitary tumor: surgical outcomes and complications in 45 patients. J Neurol Surg B Skull Base 2016; 77 (01) 54-60
• 6 Zhang C, Feng F, Zhu Y, Wang R, Xing B. Cerebral infarction caused by pituitary apoplexy: case report and review of literature. Turk Neurosurg 2014; 24 (05) 782-787
• 7 Chokyu I, Tsuyuguchi N, Goto T, Chokyu K, Chokyu M, Ohata K. Pituitary apoplexy causing internal carotid artery occlusion—case report. Neurol Med Chir (Tokyo) 2011; 51 (01) 48-51
• 8 Sussman ES, Ho AL, Pendharkar AV, Achrol AS, Harsh IV GR. Pituitary apoplexy associated with carotid compression and a large ischemic penumbra. World Neurosurg 2016; 92: 581.e7-581.e13
• 9 Yang SH, Lee KS, Lee KY, Lee SW, Hong YK. Pituitary apoplexy producing internal carotid artery compression: a case report. J Korean Med Sci 2008; 23 (06) 1113-1117
• 10 Verma R, Singh S, Patil TB. Thalamic infarction in pituitary apoplexy syndrome. BMJ Case Rep 2012;2012
• 11 Clark JD, Freer CE, Wheatley T. Pituitary apoplexy: an unusual cause of stroke. Clin Radiol 1987; 38 (01) 75-77
• 12 Ahmed SK, Semple PL. Cerebral ischaemia in pituitary apoplexy. Acta Neurochir (Wien) 2008; 150 (11) 1193-1196 ; discussion 1196
• 13 Lange M, Pagotto U, Renner U, Arzberger T, Oeckler R, Stalla GK. The role of endothelins in the regulation of pituitary function. Exp Clin Endocrinol Diabetes 2002; 110 (03) 103-112
• 14 Xu RK, Wu XM, Di AK, Xu JN, Pang CS, Pang SF. Pituitary prolactin-secreting tumor formation: recent developments. Biol Signals Recept 2000; 9 (01) 1-20
• 15 Alewijnse AE, Peters SL, Michel MC. Cardiovascular effects of sphingosine-1-phosphate and other sphingomyelin metabolites. Br J Pharmacol 2004; 143 (06) 666-684
• 16 del Zoppo GJ, Hallenbeck JM. Advances in the vascular pathophysiology of ischemic stroke. Thromb Res 2000; 98 (03) 73-81
• 17 Fenstermacher J, Nakata H, Tajima A. , et al. Functional variations in parenchymal microvascular systems within the brain. Magn Reson Med 1991; 19 (02) 217-220
• 18 Nolte CH, Endres M, Jungehülsing GJ. Vascular syndromes of the thalamus [in German]. Nervenarzt 2011; 82 (02) 231-241
• 19 Schmahmann JD. Vascular syndromes of the thalamus. Stroke 2003; 34 (09) 2264-2278
• 20 Tatu L, Moulin T, Bogousslavsky J, Duvernoy H. Arterial territories of the human brain: cerebral hemispheres. Neurology 1998; 50 (06) 1699-1708
• 21 Bogousslavsky J, Regli F, Assal G. The syndrome of unilateral tuberothalamic artery territory infarction. Stroke 1986; 17 (03) 434-441
• 22 Percheron G. The anatomy of the arterial supply of the human thalamus and its use for the interpretation of the thalamic vascular pathology. Z Neurol 1973; 205 (01) 1-13
• 23 Sáez de Ocariz MM, Nader JA, Santos JA, Bautista M. Thalamic vascular lesions. Risk factors and clinical course for infarcts and hemorrhages. Stroke 1996; 27 (09) 1530-1536
• 24 Pezzini A, Del Zotto E, Archetti S. , et al. Thalamic infarcts in young adults: relationship between clinical-topographic features and pathogenesis. Eur Neurol 2002; 47 (01) 30-36
• 25 Song YM. Topographic patterns of thalamic infarcts in association with stroke syndromes and aetiologies. J Neurol Neurosurg Psychiatry 2011; 82 (10) 1083-1086
• 26 Wang X, Fan YH, Lam WW, Leung TW, Wong KS. Clinical features, topographic patterns on DWI and etiology of thalamic infarcts. J Neurol Sci 2008; 267 (1-2): 147-153
• 27 Carrera E, Michel P, Bogousslavsky J. Anteromedian, central, and posterolateral infarcts of the thalamus: three variant types. Stroke 2004; 35 (12) 2826-2831
• 28 Kim SH, Yeo DK, Shim JJ, Yoon SM, Chang JC, Bae HG. Morphometric study of the anterior thalamoperforating arteries. J Korean Neurosurg Soc 2015; 57 (05) 350-358
• 29 Kim J, Choi HY, Nam HS, Lee JY, Heo JH. Mechanism of tuberothalamic infarction. Eur J Neurol 2008; 15 (10) 1118-1123
• 30 Ferruzzi J, Bersi MR, Humphrey JD. Biomechanical phenotyping of central arteries in health and disease: advantages of and methods for murine models. Ann Biomed Eng 2013; 41 (07) 1311-1330