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A 63-year-old woman was seen
because of sudden onset of headache about one month ago. The
pain was intermittent and could be partially relieved by
analgesics. It was dull and full sensation in character,
lasted about 2 to 3 hours in duration, and was located at the
right temporal and occipital regions. There was no radiation,
provocative factors or prodrome. In recent two days before
this admission, she had severe headache, nausea, vomiting and
dizziness despite medications, and she visited ER for help.
There was no cough, fever, weight loss, visual or mental
disturbance. She did not consume alcohol, tobacco or medicine.
She had no history of animal contact, travel or trauma
recently. She had three children, and no complications related
to the three pregnancies and deliveries were known to herself.
On examination, she had clear
consciousness. Her body height was 160 cm and weight was 58
kg. The body temperature was 37°C, the pulse rate 84 per
minute and the respiratory rate 20 per minute. Her blood
pressure in supine position was 101/60 mmHg. Her conjunctivae
were pink and the sclerae were anicteric. The pupils were
isocoric with prompt light reflexes. The neck was supple
without lymphadenopathy, engorged jugular veins, palpable
thyroid gland or carotid bruit. The chest was symmetric
expansion and breath sounds were bilaterally clear. The heart
beats were regular without audible murmur. The abdomen was
soft without purple striae. Normoactive bowel sounds and
impalpable liver and spleen were noticed. Her extremities were
freely movable without edema. There was no cyanosis,
petechiae, purpura or pigmentation. Neurological examinations
were unremarkable.
< Laboratory data
>
1.CBC
|
WBC |
RBC |
HB |
HCT |
MCV |
MCHC |
PLT |
|
K/μL |
M/μL |
g/dL |
％ |
fL |
g/dL |
K/μL |
|
5.62 |
3.77 |
11.3 |
32.2 |
85.4 |
35.1 |
270 |
2. BCS+e-
|
ALB |
TP |
T-Bil |
AST |
ALT |
ALP |
γ-GT |
LDH |
|
g/dL |
g/dL |
mg/dL |
U/L |
U/L |
U/L |
U/L |
U/L |
|
4.4 |
7.1 |
0.5 |
24 |
25 |
165 |
23 |
210 |
|
UN |
CRE |
Na+ |
K+ |
Mg2+ |
Ca2+ |
Glucose |
|
mg/dL |
mg/dL |
mmol/L |
mmol/L |
mmol/L |
mmol/L |
mg/dL |
|
8.4 |
0.4 |
120.8 |
4.0 |
0.88 |
2.29 |
87 |
3. Other tests
|
hsTSH |
free T4 |
T3 |
ACTH* |
Cortisol* |
|
0.1- 4.5 �搟gIU/mL |
0.60-1.75 ng/dL |
80-180 ng/dL |
10-65 pg/mL |
5-25 �搟gg/dL |
|
1.34 |
1.11 |
107 |
10.2 |
4.8 |
|
hGH |
DHEA-SO4
|
MA |
Osmolality (urine)* |
|
0.06-5 ng/mL |
4.6-15.4 μmol/L |
|
mOsm/Kg |
|
3.7 |
1.1 |
1：40(-) |
379 |
**high sensitivity thyroid-stimulating
hormone＝hsTSH, free thyroxine＝free T4, triiodothyronine＝T3,
corticotropin＝ACTH, *＝random, growth hormone＝hGH,
DHEA-SO4＝dehydroepiandrosterone sulfate,
MA＝microsomal antibodies.
< Course
and treatment >
Computerized tomography of the
head without administration of contrast medium revealed
negative finding. A lumbar puncture was performed and analysis
of the cerebrospinal fluid specimen disclosed a few red blood
cells. Because subarachnoid hemorrhage could not be ruled out,
magnetic resonance imaging (MRI) of the head was performed
which showed a mass lesion with bleeding in the pituitary
fossa (Fig
1). Pituitary apoplexy with acute secondary adrenal
insufficiency was diagnosed. No significant neurological or
visual field defect was noted. She began to receive
acetaminophen (500 mg Q.I.D), hydration and adrenal
corticosteroids supplement with hydrocortisone 100 mg q12h.
The symptoms, including headache, nausea, vomiting, and
dizziness, resolved gradually. Follow-up serum sodium
concentration gradually elevated to 132 mmol/L and
corticosteroids was reduced in dose, which was subsequently
discontinued 2 weeks later. Blood tests after she received
luteinizing hormone-releasing hormone (GnRH) (100 μg) and
thyrotropin-releasing hormone (TRH) (400 μg) were carried out
to investigate pituitary function. Both FSH and LH levels rose
following GnRH challenge. Prolactin and hsTSH responded
normally to TRH challenge. She was followed regularly at OPD
without any hormone supplement.
< 討論 >
腦下垂體中風(pituitary
apoplexy)，有別於一般的腦中風，通常是因為腦下垂體的腫瘤發生出血栓塞或壞死，使得蝶鞍內壓力遽昇，導致臨床症狀急遽惡化。然而，有些病患的腦下垂體卻是正常的，腦下垂體中風發生在生產時或生產後、腦外傷或使用抗凝血劑患者；也可能和糖尿病、放射線治療或開心手術有關。病患最常出現嚴重頭痛、視力受損(通常是壓到視交叉而導致雙顳側半盲)，或單側或雙側眼球運動缺損，通常會有腦膜炎症狀如脖子僵硬及神智不清，所以必須和蛛網膜下腔出血(subarachnoid
hemorrhage, SAH)、腦膜炎及腦瘤作鑑別診斷，也有可能出現急性續發性腎上腺功能不足(acute
secondary adrenal insufficiency)的症狀，包括噁心、嘔吐、低血壓、休克或死亡。
腦下垂體中風的24至48小時內最好的診斷的工具為包含腦下垂體的頭部電腦斷層，典型可以看到腦下垂體變大且有出血的表徵。4天後至30天時可以利用核磁共振照影。
治療包括荷爾蒙補充及神經外科治療。急性期只須考慮是否給予腎上腺荷爾蒙治療急性續發性腎上腺功能不足及有效減輕腦水腫，不需補充其他的荷爾蒙。經蝶竇腦下垂體減壓術提供非常緊急及有效的治療，可以保留一些腦下垂體功能。然而，急性期過後，應該評估腦下垂體功能，因為很多病患都可能出現永久性的腦下垂體荷爾蒙缺少。
< References
>
- Biousse V, Newman NJ, Oyesiku NM:
Precipitating factors in pituitary apoplexy. J Neurol
Neurosurg Psychiatry 2001;71:542.
- da Motta LA, et al: Pituitary apoplexy. Clinical course,
endocrine evaluations and treatment analysis. J Neurosurg
Sci 1999; 43:25.
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Case Discussion
繼續教育考題