Ann Thorac Surg 2007;84:1388-1390
© 2007 The Society of Thoracic Surgeons
Case Reports
Pituitary Apoplexy and CABG: Should We Change Our Strategy?
Eli Levy, MDa,*,
Amit Korach, MDa,
Gideon Merin, MDa,
Moshe Feinsod, MDb,
Brian Glenville, MDa
a Division of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
b Division of Clinical Neuroscience, Rambam (Maimonides) Medical Center, Haifa, Israel
Accepted for publication May 7, 2007.
* Address correspondence to Dr Levy, Hadassah University Hospital, P.O.B. 12000, Jerusalem, 91120, Israel (Email: elinava{at}netvision.net.il).
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Abstract
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Patients with pituitary adenoma that had coronary artery bypass grafting with cardiopulmonary bypass had pituitary apoplexy develop with neurologic deficits and even death. Four patients with pituitary adenoma underwent coronary artery bypass grafting operations (3 patients had coronary artery bypass grafting on bypass, 1 of them with known pituitary adenoma. All of them had pituitary apoplexy develop with neurologic deficits). One patient with known pituitary adenoma who had a coronary artery bypass grafting operation off pump was neurologically intact. Our recommendation is to consider operating on patients with pituitary adenoma who need coronary artery bypass grafting operation off pump, and to prevent pituitary apoplexy that cardiopulmonary bypass may cause.
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Introduction
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Pituitary apoplexy is a syndrome caused by sudden enlargement of a preexisting adenoma of the pituitary by infarction, hemorrhage, or edema. The manifestations of this syndrome may include the acute onset of unilateral or bilateral visual fields deficits, ophthalmoplegia, rhinorrhea, endocrinological imbalance, headache, or even coma.
The symptoms of sudden enlargement of a pituitary adenoma are a reflection of the neighboring structures that are compressed (ie, optic nerve and chiasm, hypothalamus, cavernous sinuses, and sphenoid sinuses [1]).
Many precipitating factors have been reported (ie, radiation therapy, trauma, anticoagulation, pregnancy after induction of ovulation with clomiphene, prolonged coughing and positive-end pressure ventilation [1]).
Clinical manifestations include headache, lethargy, confusion, obtundation, unilateral ptosis, meiosis, and ophthalmoplegia involving cranial nerves III, IV, VI, visual field deficits, and hemiparesis. Endocrinological deficits are variable in that one may see adrenal insufficiency with hypotension and syncope, hypothyroidism, and gonadotrophin deficiency [2].
From 1983 to 2004 we operated on 4 patients who had pituitary adenoma (Table 1). Three patients had coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), because of coronary artery disease and angina pectoris, using intravenous heparin (3 mg/kg). One of the patients had an incidental finding of pituitary adenoma before the CABG operation seen on a brain computed tomographic scan that was done after a road accident with head trauma. The other 2 patients were known to have pituitary adenoma only after the CABG operation. All 3 of these patients had neurologic deficits (Table 1). A head computed tomographic scan of the patient with the known pituitary adenoma before the CABG operation showed a large pituitary adenoma with suprasellar extension and protrusion into the sphenoid and cavernous sinuses (Fig 1). All 3 patients had trans-sphenoidal pituitary apoplexy resection at 1, 2, and 4 weeks after the CABG operation. One patient was neurologically intact, 1 was left with bi-temporal upper quadrants field deficits, and 1 patient who had the known pituitary adenoma, had near blindness and ptosis of his left eye. The forth patient who had unstable angina pectoris and cardiac catheterization demonstrated 90% narrowing of the left anterior descending coronary artery and a 50% to 70% narrowing of the right coronary artery. Simultaneously, the patient had disturbances in his vision especially from his left eye. Magnetic resonance imaging demonstrated large pituitary adenoma pressing on the optic chiasm. The patient had one coronary artery bypass grafting, left internal mammary artery to the left descending coronary artery without using CPB, or namely, an off-pump coronary artery bypass (OPCAB), using intravenous heparin (1.5 mg/kg). The postoperative course was uneventful and the patient went home on postoperative day 6. One month after the cardiac operation the patient was operated on again, and the pituitary adenoma was resected trans-sphenoidally. The postoperative course was uneventful with marked improvement in the vision of the left eye.
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Fig 1. Sagittal (top) and coronal (bottom) head computed tomographic scans of patient number 3 showing large pituitary adenoma (arrow) with suprasellar extension and protrusion into the sphenoid and cavernous sinuses.
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Comment
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There have been several reports in the literature of pituitary apoplexy after cardiac surgery; most of them were in previously silent tumors. According to the data of CABG and pituitary apoplexy published in the last 20 years, there were 15 patients, and all of them were performed using CPB. Two of these patients died and 13 survived. Thirteen patients had neurosurgery (12 of these patients had trans-sphenoidal resection of the adenoma, and all of them survived). One patient died who had a craniotomy with decompression of the optic nerve and an intracapsular removal of the pituitary tumor. This patient had a known pituitary adenoma before the CABG operation. Two patents were treated conservatively (1 died and 1 survived).
A review of the literature dealing with anticoagulation alone and pituitary apoplexy revealed only four case reports in the last 20 years. All of these were in the context of treatment of an acute coronary syndrome and coronary angiography [3].
Despite the large number of patients treated with anticoagulation, pituitary apoplexy remained a rare finding. This is not so after CPB. The number of nonsurgical patients who received anticoagulation is much larger than the patients who had CABG with CPB. This suggests that the use of CPB, with its consequent hemodynamic detrimental effect of nonpulsatile flow and lower perfusion pressures [4], combined with its potential for particulate embolization [5, 6], coagulation problems (ie, platelets consuming, coagulation factors impairment), and hemodilution [7], may be the reason for more pituitary apoplexy events.
Therefore we suggest that pituitary adenoma patients who require CABG surgery (as did 2 of our patients) should undergo the operation using the off-pump technique. Using the off-pump technique maintains pulsatile flow with an adequate systemic perfusion pressure, as opposed to standard CPB. Particulate embolization risk is much lower in the off-pump coronary artery bypass technique, whereas hemodilution and coagulation problems other than heparin are much reduced.
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References
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- Slavin ML, Budubin M. Pituitary apoplexy associated with cardiac surgery Am J Ophtalmol 1984;98:291-296.[Medline]
- Cooper DM, Bazaral MG, Furlan AJ, et al. Pituitary apoplexy: a complication of cardiac surgery Ann Thorac Surg 1986;41:547-550.[Abstract]
- Oo MM, Krishna AY, Bonavita GJ, Rutecki GW. Heparin therapy for myocardial infarction: an unusual trigger for pituitary apoplexy Am J Med Sci 1997;314:351-353.[Medline]
- Bacerius J, Gummert JF, Walther T, et al. On-pump versus off-pump coronary artery bypass grafting: impact on postoperative renal failure requiring renal replacement therapy Ann Thorac Surg 2004;77:1250-1256.[Abstract/Free Full Text]
- Sharony R, Bizekis CS, Kanchuger M, et al. Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study Circulation 2003;108(Suppl II):II15-II20.[Medline]
- Lund C, Hol PK, Lundblad R, et al. Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery Ann Thorac Surg 2003;76:765-770.[Abstract/Free Full Text]
- Nuttull GA, Erchul DT, Haight TJ, et al. A comparison of bleeding and transfusion in patients who undergo coronary artery bypass grafting via sternotomy with and without cardiopulmonary bypass J Cardiothorac Vasc Anesth 2003;17:447-451.[Medline]
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Abstract
Introduction
