Intraoperative hypovolemia as a possible precipitating factor for pituitary apoplexy: a case report.
Intraoperative hypovolemia as a possible precipitating factor for pituitary apoplexy: a case report.
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DOI：
10.1186/s13256-022-03738-4
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发表时间：
2023-02-10
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脑垂体卒中是一种急性脑梗塞，伴有或不伴有脑垂体出血。这是一种罕见的，但可能危及生命的紧急情况，最常发生在设置垂体腺瘤。垂体卒中的潜在机制还不清楚，但建议包括血流动力学供应和腺瘤需求的因素。在已知患有垂体大腺瘤的患者因其他适应症而接受大手术的情况下，理论上在“手术应激”的情况下卒中的风险增加。然而，无功能垂体腺瘤患者在大手术前的风险分层是具有挑战性的，因为垂体卒中的促发因素还不完全清楚。在这里，我们提出了一个案例，术中血容量不足是一个可能的机制垂体卒中的促发因素。 一名76岁的患者患有功能低下的垂体大腺瘤，因肾细胞癌接受肾切除术，术中失血严重。他在术后第二天出现眼肌麻痹症状，并被诊断为垂体卒中。患者接受皮质醇替代疗法保守治疗，并在垂体卒中后2个月接受抗凝治疗以治疗深静脉血栓形成。他的眼肌麻痹在几个月的随访中慢慢消退。抗凝治疗后卒中未复发。当考虑已知垂体大腺瘤患者的手术风险时，可能存在大量术中失血的手术可能增加垂体卒中的风险，因为术中血容量不足可能导致缺血、梗死和随后的出血。这在择期手术的情况下可能特别相关。此外，我们发现我们能够在垂体卒中后2个月对患者进行抗凝治疗，以管理深静脉血栓形成，而不会复发垂体卒中。
Pituitary apoplexy is acute infarction with or without hemorrhage of the pituitary gland. It is a rare but potentially life-threatening emergency that most commonly occurs in the setting of pituitary adenoma. The mechanisms underlying pituitary apoplexy are not well understood, but are proposed to include factors of both hemodynamic supply and adenoma demand. In the case of patients with known pituitary macroadenomas undergoing major surgery for other indications, there is a theoretically increased risk of apoplexy in the setting of “surgical stress.” However, risk stratification of patients with nonfunctioning pituitary adenomas prior to major surgery is challenging because the precipitating factors for pituitary apoplexy are not completely understood. Here we present a case in which intraoperative hypovolemia is a possible mechanistic precipitating factor for pituitary apoplexy. A 76-year-old patient with a known hypofunctioning pituitary macroadenoma underwent nephrectomy for renal cell carcinoma, during which there was significant intraoperative blood loss. He became symptomatic with ophthalmoplegia on the second postoperative day, and was diagnosed with pituitary apoplexy. He was managed conservatively with cortisol replacement therapy, and underwent therapeutic anticoagulation 2 months after pituitary apoplexy for deep vein thrombosis. His ophthalmoplegia slowly resolved over months of follow-up. Pituitary apoplexy did not recur with therapeutic anticoagulation. When considering the risk of surgery in patients with a known pituitary macroadenoma, an operation with possible high-volume intraoperative blood loss may have increased risk of pituitary apoplexy because intraoperative hypovolemia may precipitate ischemia, infarction, and subsequent hemorrhage. This may be particularly relevant in the cases of elective surgery. Additionally, we found that we were able to therapeutically anticoagulate a patient 2 months after pituitary apoplexy for the management of deep vein thrombosis without recurrence of pituitary apoplexy.