Case Report
Stroke and Pituitary Apoplexy Revealing an Internal Carotid Artery Dissection Tae-Hee Cho, MD, PhD,* Sylvain Rheims, MD, PhD,† Thomas Ritzenthaler, MD,* Yves Berthezene, MD, PhD,‡ and Norbert Nighoghossian, MD, PhD*
A 40-year-old hypertensive woman experienced a left hemispheric stroke revealing an acute pituitary apoplexy and a dissection limited to the lacerum segment of the left internal carotid artery. The relationship between pituitary apoplexy and arterial dissection is discussed. Key Words: Stroke—dissection—pituitary apoplexy— magnetic resonance imaging. Ó 2014 by National Stroke Association
A 40-year-old hypertensive woman sustained a diffuse, persistent headache for 2 weeks. Two days before admission, she presented with an acute exacerbation of the headache. On admission, nonfluent aphasia, right-sided hemiparesis, and horizontal diplopia from left abducens nerve palsy were found (National Institutes of Health Stroke Scale:8). Diffusion-weighted imaging showed acute ischemic lesions in the watershed zone of the left middle cerebral and anterior cerebral arteries (Fig 1). Magnetic resonance imaging also revealed an acute pituitary hemorrhage and a dissection limited to the lacerum segment of the left internal carotid artery (ICA). Aspirin was preferred over anticoagulation because of the risk
From the *Urgences neurovasculaires, H^ opital Pierre Wertheimer, Hospices Civils de Lyon; CREATIS, CNRS UMR 5220 – INSERM U1044 – Universite Lyon 1, Lyon, France; †Neurologie fonctionnelle et epileptologie, H^ opital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; and ‡Neuroradiologie, H^ opital Pierre Wertheimer, Hospices Civils de Lyon, CREATIS CNRS UMR 5220 – INSERM U1044 – Universite Lyon 1, Lyon, France. Received April 14, 2014; revision received July 3, 2014; accepted July 16, 2014. No financial disclosure. Address correspondence to Norbert Nighoghossian, MD, PhD, H^ opital Neurologique Pierre Wertheimer, 59 boulevard Pinel, 69677 Bron, France. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.07.016
of expansion of the pituitary hemorrhage. No recurrent ischemia, visual impairment, or any significant endocrine dysfunction was observed. At 6 months, the patient had partially recovered (modified Rankin Scale: 2) and the ICA dissection had healed (Fig 1). Pituitary apoplexy is caused by an acute enlargement of the pituitary gland related to hemorrhage and/or infarction of a preexisting hypophyseal adenoma or within a nontumorous gland. Cerebral ischemia may seldom occur through either direct compression of the internal carotid artery or vasospasm, presumably caused by the release of necrotic tissue.1,2 In the present case, the time course of the headache and the limited hypophyseal mass effect, without compression or vasospasm of the intracavernous ICA, suggest that spontaneous ICA dissection was the probable cause of the pituitary apoplexy. A single previous report described a similar association with an magnetic resonance imaging– confirmed dissection of the petrous and cavernous segments of the ICA.3 This patient had no previous history of neuroendocrine disorder and the pituitary hemorrhage had no significant mass effect on the ICA. We hypothesize that embolism from the dissection to the superior hypophyseal arteries, arising from the ophthalmic segment of the ICA, is the likely pathomechanism. Similarly, embolism to the inferolateral trunk of the ICA may explain the transient abducens nerve palsy observed in our patient.4
Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 10 (November-December), 2014: pp e473-e474
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T.-H. CHO ET AL.
Figure 1. (A) Diffusion-weighted imaging: watershed ischemic lesions in left ICA territory. Pituitary enlargement consistent with acute hemorrhage (arrows) in T2 (B) and nonenhanced T1-weighted imaging (C). Time of flight angiography (D) and corresponding maximum intensity projection (E) showing a dissection in the lacerum segment of the left ICA (arrows). Follow-up angiography at 6 months (F). ICA, internal carotid artery.
In conclusion, we report a rare case of intracranial ICA dissection associated with pituitary apoplexy and ischemic stroke.
References 1. Ahmed SK, Semple PL. Cerebral ischaemia in pituitary apoplexy. Acta Neurochir (Wien) 2008;150:1193-1196.
2. Dogan S, Kocaeli H, Abas F, et al. Pituitary apoplexy as a cause of internal carotid artery occlusion. J Clin Neurosci 2008;15:480-483. 3. Provenzale JM, Hacein-Bey L, Taveras JM. Internal carotid artery dissection associated with pituitary apoplexy: MR findings. J Comput Assist Tomogr 1995;19:150-152. 4. Vargas ME, Desrouleaux JR, Kupersmith MJ. Ophthalmoplegia as a presenting manifestation of internal carotid artery dissection. J Clin Neuroophthalmol 1992; 12:268-271.
Stroke and Pituitary Apoplexy Revealing an Internal Carotid Artery Dissection Tae-Hee Cho, MD, PhD,* Sylvain Rheims, MD, PhD,† Thomas Ritzenthaler, MD,* Yves Berthezene, MD, PhD,‡ and Norbert Nighoghossian, MD, PhD*
A 40-year-old hypertensive woman experienced a left hemispheric stroke revealing an acute pituitary apoplexy and a dissection limited to the lacerum segment of the left internal carotid artery. The relationship between pituitary apoplexy and arterial dissection is discussed. Key Words: Stroke—dissection—pituitary apoplexy— magnetic resonance imaging. Ó 2014 by National Stroke Association
A 40-year-old hypertensive woman sustained a diffuse, persistent headache for 2 weeks. Two days before admission, she presented with an acute exacerbation of the headache. On admission, nonfluent aphasia, right-sided hemiparesis, and horizontal diplopia from left abducens nerve palsy were found (National Institutes of Health Stroke Scale:8). Diffusion-weighted imaging showed acute ischemic lesions in the watershed zone of the left middle cerebral and anterior cerebral arteries (Fig 1). Magnetic resonance imaging also revealed an acute pituitary hemorrhage and a dissection limited to the lacerum segment of the left internal carotid artery (ICA). Aspirin was preferred over anticoagulation because of the risk
From the *Urgences neurovasculaires, H^ opital Pierre Wertheimer, Hospices Civils de Lyon; CREATIS, CNRS UMR 5220 – INSERM U1044 – Universite Lyon 1, Lyon, France; †Neurologie fonctionnelle et epileptologie, H^ opital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; and ‡Neuroradiologie, H^ opital Pierre Wertheimer, Hospices Civils de Lyon, CREATIS CNRS UMR 5220 – INSERM U1044 – Universite Lyon 1, Lyon, France. Received April 14, 2014; revision received July 3, 2014; accepted July 16, 2014. No financial disclosure. Address correspondence to Norbert Nighoghossian, MD, PhD, H^ opital Neurologique Pierre Wertheimer, 59 boulevard Pinel, 69677 Bron, France. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.07.016
of expansion of the pituitary hemorrhage. No recurrent ischemia, visual impairment, or any significant endocrine dysfunction was observed. At 6 months, the patient had partially recovered (modified Rankin Scale: 2) and the ICA dissection had healed (Fig 1). Pituitary apoplexy is caused by an acute enlargement of the pituitary gland related to hemorrhage and/or infarction of a preexisting hypophyseal adenoma or within a nontumorous gland. Cerebral ischemia may seldom occur through either direct compression of the internal carotid artery or vasospasm, presumably caused by the release of necrotic tissue.1,2 In the present case, the time course of the headache and the limited hypophyseal mass effect, without compression or vasospasm of the intracavernous ICA, suggest that spontaneous ICA dissection was the probable cause of the pituitary apoplexy. A single previous report described a similar association with an magnetic resonance imaging– confirmed dissection of the petrous and cavernous segments of the ICA.3 This patient had no previous history of neuroendocrine disorder and the pituitary hemorrhage had no significant mass effect on the ICA. We hypothesize that embolism from the dissection to the superior hypophyseal arteries, arising from the ophthalmic segment of the ICA, is the likely pathomechanism. Similarly, embolism to the inferolateral trunk of the ICA may explain the transient abducens nerve palsy observed in our patient.4
Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 10 (November-December), 2014: pp e473-e474
e473
e474
T.-H. CHO ET AL.
Figure 1. (A) Diffusion-weighted imaging: watershed ischemic lesions in left ICA territory. Pituitary enlargement consistent with acute hemorrhage (arrows) in T2 (B) and nonenhanced T1-weighted imaging (C). Time of flight angiography (D) and corresponding maximum intensity projection (E) showing a dissection in the lacerum segment of the left ICA (arrows). Follow-up angiography at 6 months (F). ICA, internal carotid artery.
In conclusion, we report a rare case of intracranial ICA dissection associated with pituitary apoplexy and ischemic stroke.
References 1. Ahmed SK, Semple PL. Cerebral ischaemia in pituitary apoplexy. Acta Neurochir (Wien) 2008;150:1193-1196.
2. Dogan S, Kocaeli H, Abas F, et al. Pituitary apoplexy as a cause of internal carotid artery occlusion. J Clin Neurosci 2008;15:480-483. 3. Provenzale JM, Hacein-Bey L, Taveras JM. Internal carotid artery dissection associated with pituitary apoplexy: MR findings. J Comput Assist Tomogr 1995;19:150-152. 4. Vargas ME, Desrouleaux JR, Kupersmith MJ. Ophthalmoplegia as a presenting manifestation of internal carotid artery dissection. J Clin Neuroophthalmol 1992; 12:268-271.
