The Journal of Arthroplasty Vol. 24 No. 5 2009

Case Report

Pituitary Apoplexy After Joint Arthroplasty

Vivek Goel, MRCS, MS (Orth),* Ujjwal K. Debnath, FRCS, MS (Orth), yJagmohan Singh, FRCS, z and Howard L. Brydon, FRCS z

Abstract: Pituitary apoplexy is a rare but potentially life-threatening conditioncaused by the sudden enlargement of a pituitary adenoma secondary to infarctionand hemorrhage. The clinical syndrome is characterized by sudden onset ofheadache, ocular palsies, visual disturbances, and altered state of consciousness.We report 2 patients who had postoperative pituitary apoplexy after total hip andtotal knee arthroplasty. Asymptomatic pituitary adenomas are difficult to diagnosepreoperatively. Its existence is an unlikely suspect until the clinical symptomsdevelop after surgery. This is the first reported case following total hip athroplasty.Key words: pituitary apoplexy, joint arthroplasty, total knee arthroplasty.© 2009 Elsevier Inc. All rights reserved.

Pituitary apoplexy (PA) is a rare but potentiallylife-threatening clinical syndrome caused by thesudden enlargement of a pituitary adenomasecondary to infarction and hemorrhage [1-3]. Itmay be the first presentation of a previouslyundiagnosed pituitary adenoma that is character-ized by sudden onset of headache, ocular palsies,visual disturbances, and altered state of conscious-ness [4]. Many predisposing factors have beenimplicated in the pathogenesis; however, occur-rence of PA after joint athroplasty surgery isextremely rare. It has been cited on one occasionafter bilateral total knee athroplasty [5]. Wepresent 2 cases of PA in previously undiagnosed

From the Department of Trauma and Orthopaedics, RoyalGwent Hospital, Newport, United Kingdom; yDepartment of Traumaand Orthopaedics, University Hospital of Wales, Cardiff, UnitedKingdom; and zUniversity Hospital of North Staffordshire Stoke onTrent, United Kingdom.

Submitted December 9, 2007; accepted June 4, 2008.No benefits or funds were received in support of this study.Reprint requests: Vivek Goel, MRCS, MS(Orth), 2, Wasdale

Close, West Bridgeford, NG2 6RG Nottingham, UK.© 2009 Elsevier Inc. All rights reserved.0883-5403/08/2405-0029$36.00/0doi:10.1016/j.arth.2008.06.021

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pituitary adenoma that presented with headaches,ocular palsy, and visual disturbance in theimmediate postoperative period after total hiparthroplasty and total knee arthroplasty. Weemphasize the importance of a high index ofsuspicion for early diagnosis and management ofthis potentially fatal neurological complicationafter joint athroplasty surgery.

The patients were informed that data concerningthem would be submitted for publication.

Case History

Case 1

In May 2002, a medically fit 76-year-old manunderwent an elective left total hip athroplasty forosteoarthritis. He had uneventful intraoperative orimmediate postoperative period. On the followingday, he developed sudden onset of headache andcomplete vision loss in his left eye. Examinationrevealed Glasgow Coma Scale of 15/15, completeleft third and fourth cranial nerve palsy, total loss ofvision in the left eye and temporal hemianopia inthe right eye. On suspicion of a neurologicalemergency, he had cranial computed tomography

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Fig. 1. T1wMRI sagittal section showing pituitary ade-noma in a 76-year-old man who underwent total hipathroplasty.

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(CT) scan that showed mass in the left pituitary fossaand cerebral angiogram excluded carotid arteryaneurysm. High-dose dexamethasone infusion wascommenced immediately (2 mg every 6 hours).

Fig. 2. T1wMRI axial section showing pituitary adenomain the above patient.

Subsequently, magnetic resonance scan (MRI) ofthe brain confirmed intersellar mass with a supra-sellar extension on the left side (Figs. 1 and 2). Therewas associated compression of the optic chiasma andcavernous sinus. The patient underwent prompttransnasal transphenoidal decompression of thepituitary tumor. The histopathology specimenshowed predominantly ischemic necrosis withdebris and patchy hemorrhage at places consistentwith PA [6]. Pituitary function tests were withinnormal limit.

Postoperatively, the patient showed improvementwith recovery of visual acuity and extraocularmovements. Postoperative cranial CT scan showeda good decompression of the pituitary tumor. At2 years follow-up, the patient came walkingcomfortably in our clinic with complete recoveryof ophthalmoplegia and improved vision in his lefteye and had normal vision in his right eye.

Case 2

In March 2003, a previously healthy 61-year-oldman underwent an elective left total knee athro-plasty for osteoarthritis. In the intraoperative andpostoperative period, cardiovascular and respiratoryparameters remained normal.

On the following day of surgery, he presentedwith sudden onset of headache, nausea, vomitingalong with ptosis in the right eye. On examina-tion, he had complete ophthalmoplegia on hisright eye with bitemporal hemianopia and sensory

ig. 3. Computed tomography scan showing the pituitarydenoma in a 61-year-old man who underwent total knee

Fa

athroplasty.

Pituitary Apoplexy After Joint Arthroplasty � Goel et al 826.e9

loss (touch and pain) in the distribution of lefttrigeminal (Vth) nerve. Immediate CT scan of headwith reconstruction confirmed the intersellartumor, and a cerebral aneurysm was excluded(Fig. 3). Unfortunately during the scanning, hedeveloped acute chest pain, which was confirmedas acute myocardial infarction. He underwentemergency angioplasty and coronary stentingafter stabilization. He was started on high-dosedexamethasone intravenously.A magnetic resonance scan of the brain was not

feasible because of his coronary stent. After cardiacstabilization, he underwent craniotomy and decom-pression of pituitary adenoma. (The transphenoidalroute was not appropriate due to the presence ofmoderate-sized sphenoid sinus osteoma as observedon the CT scan of the sinus.) Histopathologicalexamination showed largely necrotic material withtiny piece of recognizable pituitary adenoma,features consistent with PA.In the first week after surgery, complete ophthal-

moplegia and vision improved. Postoperatively, CTscan showed good decompression of tumor. At 2years follow-up, he had complete recovery ofophthalmoplegia and visual acuity.

Discussion

Although different predisposing events have beenimplicated in PA, the pathogenesis still remainsunclear [2,7]. Bailey [8] in 1898 described thissyndrome in a 50-year-old acromegalic man, whichwas confirmed at autopsy. But ‘pituitary apoplexy’(PA) was first named by Brougham et al [4] in 1950.This pathological syndrome is characterized byheadache (76%), visual acuity and visual fielddefect (62%), ocular palsy (40%), nausea andvomiting (21%), altered mental status (19%), andhemiparesis (4.3%) [9]. During an acute episode,the expanding pituitary mass may compress thesurrounding structures, that is, cavernous sinus andneurovascular bundle, resulting in cranial nervepalsies and ophthalmoplegia [10].Pituitary apoplexy has been described after

various surgical procedures. Most commonly, ithas been reported after cardiac surgeries, abdom-inal surgeries, thyroidectomy, and laparoscopiclumbar spinal fusion [11-15]. A single case hasbeen reported in the English literature afterbilateral knee athroplasty [5]. The authors sug-gested that heparinization with low-molecular-weight heparin may be the primary cause of PA.Because we did not use low-molecular-weightheparin in both our patients, we exclude this ascause of the PA.

In common with the previously reported cases ofPA, there was no suspicion of pituitary diseasebefore the acute episode in both the presentedcases. A recent study on natural course of theincidental pituitary adenomas suggests that 20%became symptomatic, and in 9.5%, PA developedwithout any precipitating cause [16]. Althoughthere may not be any established cause forprecipitation of PA, we emphasize the importanceof early recognition and treatment. The diagnosismay be delayed and can be difficult because theneurological features are nonspecific. Computedtomography or MRI scan can confirm the clinicaldiagnosis. The MRI scan is superior to CT scan inidentifying hemorrhagic nature of the tumor bydemonstrating an increased T1 signal intensity [1].In our second case, MRI could not be done due tothe presence of coronary stent.

There is some evidence to suggest that pituitaryadenoma have a relatively compromised bloodsupply in that blood vessels are thicker than thewall of the sinusoids in the normal gland. It issuggested that constriction of these abnormal vesselsmight lead to ischemic, necrosis, and hemorrhage.When impairment of cerebral function occurs aftersurgery, the predisposing factors leading to theevent may be age of the patient, history of cerebralvascular damage, disordered coagulation, and intra-cardiac thrombi [17]. Cardoso and Peterson [2](1984) had postulated that intrinsic vasculopathy inthe pituitary adenoma renders them more suscep-tible to infarction or hemorrhage. In our case of totalhip arthroplasty, although there was no evidence ofintraoperative or immediate postoperative catastro-phy, we hypothesize that there may have beentransient episode of hypotension in the postopera-tive period leading to the vascular insult in a highlysusceptible pituitary adenoma. In our case of totalknee athroplasty, we believe that the occurrence ofmyocardial infarction and neurological complica-tions within a short span of time suggests thatmicroembolism could be a probable cause for boththe events.

Bills at al [1] (1993) concluded from their study of38 patients that a significant improvement in thevision is evident if the surgery was performed withinthe first week after the acute episode. Da Motta et al[18] (1999) reported a higher mortality in non–surgically treated patient. The recommended man-agement is transphenoidal decompression andinstitution of high-dose corticosteroid administra-tion [1,3].

Both of our cases were treated by surgicaldecompression and showed marked improvementin the clinical symptoms during follow-up.

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Conclusion

Asymptomatic pituitary adenomas are difficult todiagnose preoperatively, and its existence is notlikely to be suspected. The presented cases demon-strate that PA could be precipitated even after jointathroplasty surgery. This is the first reportedevidence of PA after total hip athroplasty in theliterature. We recommend that early diagnosis andimmediate surgical intervention are required toimprove the final outcome.

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