Pituitary Apoplexy after Cardiac Surgery: Case Report

Introduction: Pituitary apoplexy is a severe but rare complication in patients with pituitary lesions, frequently secondary to hemorrhage or infarction of pituitary tumors. The classic clinical manifestations include headache and visual and endocrine disturbances. Treatment is still controversial between surgical management for severe cases and conservative management for mild cases.

The leading cause of pituitary apoplexy is pituitary adenomas, more frequently macroadenomas, especially nonfunctioning ones. This condition is related to some risk factors, one of which is anticoagulation as a precipitant for bleeding.

Case Report: A 60-year-old male patient with a history of closure of atrial septal defect and atrial fibrillation, undergoing anticoagulation with Rivaroxaban. The echocardiogram documented the persistence of atrial septal defect and severe tricuspid insufficiency with progressive functional class deterioration. He was hospitalized for cardiovascular surgery to close the interatrial defect with tricuspid valvuloplasty and dual-chamber pacemaker insertion. Two days after surgery, the patient presented signs of low cardiac output with a sudden decrease in visual acuity in the right eye and loss of vision in the left eye.

A simple and contrasted skull CT scan was ordered (MRI was not performed because the pacemaker was incompatible with a resonator). The images showed a pituitary macroadenoma with acute bleeding suggestive of pituitary apoplexy. The hormonal profile showed alteration in thyroid hormones, so that hormonal substitution was started. During hospitalization, the patient also presented bacteremia due to S. epidermidis; therefore, the surgical procedure was deferred.

After broad-spectrum antibiotic management, he was taken to surgery for resection of the pituitary lesion, with an intraoperative finding of a heterogeneous lesion with areas of calcification and bleeding. The pathology report indicated a lesion with marked ischemic necrosis concerning pituitary apoplexy. After surgery, the patient improved bilateral visual acuity, reaching to perceive figures in the left eye. Considering the risk-benefit ratio and due to cardiovascular history, anticoagulation was restarted. He did not present other complications during the postoperative period, so he was discharged.

One month after surgery, the patient's visual acuity in both eyes improved significantly, reaching a visual acuity of 20/25 in the right eye and 20/20 in the left eye.

Discussion: Pituitary apoplexy after cardiovascular surgery is rare, and very few cases have been reported in the literature. However, it is considered that cardiovascular surgical procedures and anticoagulation are precipitating factors of this pathology.

The reason why cardiac surgery can cause pituitary apoplexy is not known. One assumption is that a decrease in blood pressure is a variable for the development of ischemia at the level of the pituitary lesion, also related to the possible formation of microemboli and hemodynamic changes at the brain level (in some surgeries such as coronary bypass).

Other symptoms are ophthalmoplegia, anisocoria, hemiparesis, and altered hormonal profile with decreased prolactin levels due to ischemic necrosis.

Pituitary apoplexy due to cardiovascular surgery and anticoagulation is unusual. The patient in the clinical case presented other conditions that impeded immediate surgical management, despite which the symptoms improved after the procedure.

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Artikel online veröffentlicht:
01. Februar 2023