Anesth Analg 2004;98:46-48
© 2004 International Anesthesia Research Society
CARDIOVASCULAR ANESTHESIA
Pituitary Apoplexy Presenting as Unilateral Third Cranial Nerve Palsy After Coronary Artery Bypass Surgery
Zongfu Chen, MD,
Andrew W. Murray, MB, ChB, and
Joseph J. Quinlan, MD
Department of Anesthesiology, University of Pittsburgh Medical Center, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
Address correspondence and reprint requests to Dr. Zongfu Chen, Department of Anesthesiology, Presbyterian University Hospital, 200 Lothrop St., Pittsburgh, PA 15213. Address e-mail to chenzf{at}anes.upmc.edu
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Abstract
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The new onset of pituitary apoplexy is a rare perioperative complication of coronary artery bypass surgery. A variety of clinical presentations of pituitary apoplexy have been reported including absence of clinical symptoms or headache, sudden deterioration of mental status, visual changes, Addisonian crisis, and ophthalmoplegia, including third cranial nerve palsy and/or ptosis. Early diagnosis and treatment usually results in excellent outcome. We report a case of pituitary apoplexy that presented with only a unilateral dilated pupil, ptosis, and vision change within 3 h after coronary artery bypass surgery. The patient recovered fully after early pituitary tumor resection and hormonal therapy.
IMPLICATIONS: Unilateral pupil dilation is a rare perioperative complication after coronary artery bypass surgery. We report a case of pituitary apoplexy that presented clinically as unilateral dilated pupil, ptosis, and visual loss shortly after coronary artery bypass surgery.
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Introduction
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Pituitary apoplexy is a clinical syndrome characterized by sudden onset of headache, visual symptoms, altered mental status, and hormonal dysfunction caused by acute hemorrhage or infarction of the pituitary gland (1). Pituitary apoplexy after coronary artery bypass surgery is a very rare perioperative complication, with variable clinical presentations, including ophthalmoplegia, vision change, visual field deficit, mental status deterioration, or even coma. The outcome depends on early diagnosis and proper intervention. We report a case of pituitary apoplexy that initially presented with a unilateral dilated pupil and ptosis within 3 h after coronary artery bypass surgery. After early pituitary tumor resection and hormonal therapy, recovery was excellent.
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Case Report
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A 62-yr-old man with a medical history significant for hypertension, congenital renal disease, and triple vessel coronary artery disease presented with chronic stable angina and was admitted for elective coronary artery bypass surgery. The patient’s maintenance medications included metoprolol, aspirin, and amlodipine. Physical examination at admission did not reveal any gross neurological or endocrine abnormalities. Visual fields were not evaluated before surgery. The baseline blood pressure was 120s/60s. General anesthesia was induced with thiopental, fentanyl, midazolam, and succinylcholine and maintained with isoflurane, fentanyl, midazolam, and pancuronium. The total dose of fentanyl and midazolam was 850 µg and 17 mg, respectively. The total anesthesia time was 5 h 40 min. The patient was monitored throughout the procedure with American Society of Anesthesiologists’ standard monitoring plus pulmonary artery catheter, transesophageal echocardiography, and bispectral index monitor. Routine cardiopulmonary bypass (CPB) technique (membrane oxygenator, nonpulsatile flow) was used with both superior and inferior vena cava cannulations. The initial dose of heparin was 300 U/kg, which increased the activated clotting time from 127 to 442. The activated clotting time was monitored and maintained at >400 with additional heparin. The patient’s pupils and neck were checked after CPB was initiated which revealed normal pupil size bilaterally and no sign of obstruction from the superior vena caval cannula. Heparin was neutralized by protamine (3 mg/100 µ heparin) at the end of surgery. Five diseased coronary arteries were bypassed. Total CPB and aorta clamping time were 163 and 99 min, respectively. No antifibrinolytics were involved. The patient was weaned from CPB without incident and appeared to have tolerated the procedure well, without any hypertensive, hypotensive, or hypoxic episodes. No air or other emboli was detected by transesophageal echocardiography at the end of CPB. The mean arterial blood pressure during CPB ranged from 60 to 70 mm Hg and the average bispectral index values ranged from 37 to 62 (values were predominantly in the 40s). Approximately 3 h after surgery, the patient was found to have a near complete right third cranial nerve palsy with dilated right pupil and ptosis. There was no other neurological deficit and the patient followed commands properly. After tracheal extubation (14 h after surgery), right eye blurred vision was also noticed. An ophthalmologic examination revealed that the patient’s visual acuity was 20/100 and 20/30 for right and left eye, respectively, with normal visual fields bilaterally and unilateral right third cranial nerve palsy. Neurosurgical consultation was obtained. The imaging studies, including cranial computed tomography and magnetic resonance imaging (MRI), revealed a suprasellar mass consistent with pituitary apoplexy (Fig. 1). Cerebral infarction and hemorrhagic stroke were excluded. Magnetic resonance angiography failed to reveal any evidence of intracranial aneurysm or other vascular disease. The patient’s third cranial nerve function was significantly improved during postoperative day 2 and 3 and he was generally recovering well from cardiac surgery. All the electrolytes were within normal range. Endocrine studies revealed normal levels of cortisol, prolactin, and thyroid. A stress dose of hydrocortisone was given 24 h before hypophysectomy. Four days after initial bypass surgery, the patient underwent an endoscopic endonasal transsphenoidal resection of pituitary tumor. A necrotic pituitary tumor, clot within the tumor, and tumor invasion of the cavernous sinus were identified intraoperatively. A pathology investigation confirmed pituitary adenoma with bleeding. The patient recovered very well, with almost full recovery of visual function and significant improvement of third nerve palsy. He was discharged to home 3 days after the second operation. Eight-month follow-up revealed almost normal third cranial nerve function and MRI study at 4 mo after surgery suggested that there was no residual pituitary tumor (Fig. 2).
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Figure 1. A, T1 weighted axial magnetic resonance image (MRI) demonstrated macroadenoma (arrow) with bilateral cavernous sinus extension (arrow). B, T1 weighted sagittal MRI demonstrated suprasellar extension (open arrow).
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Figure 2. T1 weighted sagittal magnetic resonance image 4 mo after surgery with no evidence of residual tumor.
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Discussion
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Ophthalmoplegia caused by pituitary adenoma is a rare perioperative complication after coronary artery bypass surgery. Most reported cases have been described as pituitary apoplexy, usually caused by an expanding mass within the sella turcica as a result of hemorrhage and/or necrosis or infarction within the tumor and adjacent pituitary tissue. Since the 1960s, pituitary apoplexy was reported as a perioperative complication after cardiac surgery in 17 cases (2–8). A variety of clinical presentations of pituitary apoplexy were reported including either absence of clinical symptoms or headache, sudden deterioration of mental status, coma, visual changes (including blindness), Addisonian crisis, and ophthalmoplegia including third cranial nerve palsy and/or ptosis (4,5–8). The onset of ophthalmoplegia ranged from immediate to weeks after cardiac surgery. In six reported cases, ophthalmoplegia occurred shortly after surgery, similar to this case. However, among these six cases, no case was only associated with unilateral single third cranial nerve palsy, presenting with ptosis and mydriasis, with spontaneous improvement and vision change without other neurological and endocrine deficit. The very early onset, a presentation limited to a third cranial nerve palsy, and vision change without any other clinical symptom and spontaneous recovery of third cranial nerve palsy make this case unique.
The differential diagnoses of third cranial nerve palsy during the perioperative period of cardiac surgery include undiagnosed intracranial tumor, especially with a tumor involving the parasellar region or cavernous sinus, ruptured intracranial aneurysm, and small vessel ischemia. Devere et al. (9) reported six cases with acquired supranuclear ocular motor paresis after cardiac surgery. Ischemic small cerebral vessel disease was found in four cases. The unique clinic presentations of acquired supranuclear ocular motor paresis with impaired volitional ocular motor function but intact random and reflexive eye movement (9) make it easily differentiated. However, a definitive diagnosis still depends on neuroimaging studies.
The successful management of pituitary apoplexy depends on early diagnosis and effective intervention. Neuroimaging studies including computed tomography scan and MRI enable rapid diagnosis and can exclude other intracranial disorders such as ischemic lesions, other tumors, and vascular disease. Pituitary function tests are also crucial for guiding hormonal replacement therapy.
Without proper treatment, pituitary apoplexy could be fatal or cause permanent neurological or endocrine damage (1). Surgical intervention for prompt decompression is the most common choice of treatment (2,4–6), especially for sudden change of visual field, severe and/or rapid deterioration of acuity, or mental status change. However, each individual case must be scrutinized meticulously to evaluate the cardiopulmonary reserve for tolerating anesthesia and surgical stress, especially when pituitary apoplexy occurs shortly after coronary artery bypass surgery. Careful evaluation of coagulation status is also mandatory. Most patients tolerate surgery well and complete recovery is possible even in severe cases (2,4–7). Hormonal replacement therapy is needed before and after surgical resection of the pituitary tumor in most cases and can be used alone as an alternative to surgery (2–5). Persistent vision change, mental status deterioration, and/or ocular motor dysfunction may still necessitate surgical depression.
The root cause of new onset of pituitary apoplexy after cardiac surgery remains poorly defined. Hypotension, hypoxia, cerebral hypoperfusion, anticoagulation, microembolism, and thrombosis, especially during CPB, may all contribute to postoperative changes of abnormal pituitary tissue. It is plausible that fragile pituitary adenoma tissue is more susceptible to ischemic challenge during surgery or the perioperative period (4,6,10). The infarcted tumor and/or pituitary tissue, in addition to intraoperative anticoagulation, may lead to subsequent hemorrhage. The ischemic tumor or pituitary tissue may swell and increase in volume, which may compress the surrounding structures.
In conclusion, we report a patient with pituitary apoplexy who presented with isolated third cranial nerve palsy, ptosis, and vision loss after coronary artery bypass surgery. A full recovery was achieved after an endoscopic endonasal resection of pituitary tumor.
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References
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- Randeva H, Schoebel J, Byrne J, et al. Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinol 1999; 51: 181–8.[Medline]
- Kontorinis N, Holthouse DJ, Carroll WM, et al. Third nerve palsy after coronary artery bypass surgery. J Thorac Cardiovasc Surg 2001; 122: 400–1.[Free Full Text]
- Loubani M, Galinanes M. Pituitary gland macroadenoma: a cause of transient blindness after cardiac surgery. Ann Thorac Surg 2001; 72: 929–31.[Abstract/Free Full Text]
- Pliam MB, Cohen M, Cheng L, et al. Pituitary adenomas complicating cardiac surgery: summary and review of 11 cases. J Card Surg 1995; 10: 125–32.[Medline]
- Wiesmann M, Gliemroth J, Kehler U, Missler U. Pituitary apoplexy after cardiac surgery presenting as deep coma with dilated pupils. Acta Anesthesiol Scand 1999; 43: 236–8.[Medline]
- Mattke AF, Vender JR, Anstadt MR. Pituitary apoplexy presenting as Addisonian crisis after coronary artery bypass grafting. Tex Heart Inst J 2002; 29: 193–9.[Medline]
- Alzetani A, Fisher C, Costa R, Ohri SK. Ptosis postcardiac surgery: a case of pituitary apoplexy. Ann Thorac Surg 2002; 73: 300–1.[Abstract/Free Full Text]
- Bhattacharyya A, Tymms DJ, Naqvi N. Asymptomatic pituitary apoplexy after aortocoronary bypass surgery. Int J Clin Pract 1999; 53: 394–5.[Medline]
- Devere T, Lee A, Hamill MB, et al. Acquired supranuclear ocular motor paresis following cardiovascular surgery. J Neuroophthalmol 1997; 17: 189–93.[Medline]
- Kovacs K, Yao J. Pituitary necrosis following major heart surgery. Z Kardiol 1975; 64: 52–7.[Web of Science][Medline]
Accepted for publication August 13, 2003.
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Abstract
Introduction
