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Introduction

The term pituitary apoplexy (PA) was initially introduced by Brougham in 1950 (1), defined as an emergency condition caused by hemorrhage or infarction of the pituitary gland. However, PA can be generally neglected in 25% of pituitary tumors and there may only be radiological or histopathological evidence of infarction and/or hemorrhage without any clinical manifestation (2). In the present article, PA refers to clinically diagnosed PA with classical symptoms.

The prevalence of PA reported in different studies ranges from 0.6 to 7% (3–7), suggesting that numerous cases were undiagnosed and did not receive any clinical attention (8). While the pathophysiology of PA remains elusive, several risk factors have been identified, such as fluctuation of blood pressure (BP), use of anticoagulant drugs, major surgeries, pregnancy and pituitary function test (9–11). Clinical symptoms vary from person to person, commonly manifesting as sudden onset of headache, visual field defect, diplopia, ophthalmoplegia, decreased consciousness, increased urine volume, nausea and vomiting (12–14). Dysfunctions in the hypothalamic-pituitary hormone axis can result in a lack of various pituitary-related hormones, which may lead to physiological disorders in several ways (Fig. 1). Hypothyroidism and adrenal insufficiency secondary to PA may weaken the body's tolerance to surgical trauma. Glucocorticoid and thyroid hormones both have a role in post-operative stress. Glucocorticoids help maintain BP and blood sugar, facilitate fat mobilization, combat cellular damage and suppress inflammatory responses (15), and thyroid hormones can speed up the metabolism and increase peripheral cells' utilization of glucose (16). The choice of treatment between hormonal replacement therapy and trans-sphenoidal resection is determined based on the severity of neuro-ophthalmic symptoms and the patient's capacity to undergo a second surgery (2).

Figure 1. Hypothalamic-pituitary hormone axis and its main functions. ACTH, adrenocorticotropic hormone; ADH, antidiuretic hormone; CRH, corticotropin-releasing hormone; FSH, follicle-stimulating hormone; GH, growth hormone; GHRH, growth hormone releasing hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone; PRH, prolactin releasing hormone; PRL, prolactin; TRH, thyrotropin-releasing hormone; TSH, thyroid stimulating hormone.

However, presenting as the initial sign of unknown pituitary tumors, it can be a challenging task to diagnose PA post-surgery due to its symptomatic overlap with postoperative complications. It is a rare postoperative complication that may have severe consequences if not treated timely and properly. Due to the lack of reviews on PA after surgery, the current article presented a clinical case and summed up the characteristics of relevant cases published over the years.

Case report

A 64-year-old female with a history of subtotal hysterectomy 20 years prior presented with vaginal bleeding persisting for three months and was admitted in Shengjing Hospital of China Medical University (Shenyang, China) in March 2023. The patient's body mass index was 24.2 kg/m2 (body height, 164 cm; body weight, 65 kg). The obstetric history included two pregnancies-one ending in abortion and the other in a vaginal birth. At the age of 44 years, the patient underwent a subtotal hysterectomy and left adnexectomy due to multiple uterine leiomyomas and a lateral ovarian cyst, with postoperative pathology confirming benignity. Irregular human papillomavirus (HPV) and thinprep cytology test (TCT) screening were conducted post-surgery, and the last screening was 2 years prior and the results remained negative. After undergoing minor but persistent vaginal bleeding for 3 months, the patient tested HPV-16 positive and negative for intraepithelial lesion or malignancy on TCT. The pelvic ultrasound, computerized tomography (CT) and positron emission tomography-computed tomography (PET-CT) identified a moderately hyperechoic mass in the cervical stump region, which was highly suggestive of cancer (Fig. 2). Gynecological examination revealed normal vulvar development with signs of aging and a smooth vaginal canal. An exogenous lesion with a diameter of ~2.5 cm was observed at the stump of the cervix, exhibiting lesion contact bleeding. The anterior fornix was shallow and the pelvic cavity was with no obvious abnormalities in the adnexal areas. The patient reported no comorbidities, aside from a sulfonamide allergy. General examination was unremarkable, except for admission BP of 148/96 mmHg. According to the latest guideline of hypertension in China (17), hypertension was defined as systolic BP ≥140 mmHg/or diastolic BP ≥90 mmHg. The patient's BP was monitored and a cardiologist was consulted. During hospitalization, the patient's BP was stable, ranging from 120/80 to 140/90 mmHg. The patient cooperated well in the physical examination. The bilateral pupils were equally large and round with a diameter of 3 mm and had no limitation of eye movement or visual field defect. The patient exhibited full mobility in all four limbs with normal muscle force and strength and neither had a history of pituitary adenoma nor manifested any related symptoms. The patient underwent tissue biopsy and cervical stump adenocarcinoma was diagnosed. After comprehensive pre-operative evaluations, including PET-CT, the patient underwent open extensive stump cervicectomy, pelvic lymph node dissection and transcystoscopic bilateral ureteral stenting. Pelvic drainage and vaginal drainage were used. The surgery proceeded smoothly with an intraoperative bleeding volume of 100 ml. Intraoperative anesthesia and medication details are provided in Fig. S1 [Illustrator 27.7 (Adobe, Inc.) was used to generate the translated version of this image]. The patient's BP remained stable during the operation and no hypotension was detected prior to or after the surgery. After the gynecological operation, the patient was treated with intravenous cefazolin sodium (Sinopharm CNBG Zhongnuo Pharmaceuticals Co., Ltd.) 0.5 g per 8 h, intramuscular enoxaparin sodium [Sanofi Aventis (Beijing) Pharmaceutical Co., Ltd.] 40 mg per day, intravenous methylprednisolone (Pharmacia & Upjohn Co., Ltd.) 20 mg per day and other supportive care (methylprednisolone is administered as a common treatment at the Enhanced Recovery After Surgery ward to alleviate peri-operative stress and inflammation). From postoperative day 1 (POD1), the patient complained of the sudden onset of a headache [pain visual analogue scale (VAS) score (18), 4/10] and drowsiness. Since the pre-operative PET-CT did not indicate any pituitary tumor (Fig. 3A), it was inferred that the patient's symptoms may be due to general anesthesia and the postoperative analgesia pump and the pump was turned off immediately. On POD2, the patient still reported headaches and a neurosurgery consultation was started. The neurosurgery doctor suggested recording a head CT but the patient perceived her headache to be of mild severity and signed to refuse relevant tests. On POD3, the patient's BP fluctuated between 120/70 and 145/85 mmHg. It was not until the patient's headache worsened (pain VAS 7/10) and a new complaint of blurred vision and blepharoptosis of the left eye occurred on POD4 that she consented to further examination. The patient's Glasgow coma scale score was 3-5-6 points (19). A head CT scan and an ophthalmic consultation were carried out immediately, revealing multiple lacunar infarctions and local density increases in the sella turcica and suprasellar regions (Fig. 3B). Enhanced pituitary MRI showed a 2.4×1.7×2.6 cm occupation in the sellar area with a heterogeneous signal, indicating a pituitary macroadenoma with apoplexy (Fig. 3C and D). Ophthalmic assessments showed bitemporal hemianopsia and abnormal findings in the fundus photography and visual pathway images (data not shown). Laboratory tests indicated panhypopituitarism (Table I). The patient was promptly transferred to the neurosurgery ward. Considering the visual field defect was stable, there was no indication of an emergency surgery and hydrocortisone (Tianjin Jinyao Amino Acid Co., Ltd.; 100 mg/day) replacement therapy was used to complete enhanced head CT and arterial angiography, and transsphenoidal hypophysical lesion resection through the neuroendoscope under general anesthesia was carried out successfully on POD12. After the neurosurgery operation, the patient took desmopressin acetate tablets [Huilin (Sweden) Pharmaceuticals Co., Ltd.] 0.1 mg to treat postoperative diabetes insipidus, sustained-release potassium tablets (Shenzhen Zhonglian Pharmaceutical Co., Ltd.) 1 g three times per day to treat hypokalemia and prednisolone acetate tablets (Tianjin Tianyao Pharmaceuticals Co., Ltd.) 10 mg at 8:00 a.m. and 5 mg at 4:00 p.m. each day. Postoperative pathology was performed by reticulin fiber staining with kit no. G3535 from Solarbio Science and Technology (Beijing) Co., Ltd (20), and it indicated hemorrhage of pituitary tumor (Fig. 4). The patient reported complete resolution of headaches, bitemporal hemianopia and visual field improvement the day after the operation and was discharged from the hospital a week later. The patient reported mild blurry vision during the follow-up of six weeks after the neurosurgery operation. After discharge, the patient underwent follow-up every three months, and her hormone levels completely returned to normal. The patient was advised to undergo hormone level assessments and pituitary imaging every six months, with continued lifelong follow-up.

Figure 2. Preopreative imaging examination. (A) The ultrasound indicated blood flow signals visible in the cervical stump mass. (B) CT and (C) positron emission tomography-CT showed a mass in the cervical stump.

Figure 3. Imageological examination. (A) No obvious abnormalities were detected in the pituitary gland (arrow) on pre-operative positron emission tomography-CT scans. (B) Local density increase in the sella turcica and suprasellar regions (arrow) was observed in the transverse section on CT on POD4. (C and D) Contrast-enhanced sellar MRI showed a 2.4×1.7×2.6 cm-sized mixed signal (arrow) expanding from the sellar fossa and suprasellar region and compressing the optic chiasm in the (C) coronal and (D) sagittal section on POD4. POD4, postoperative day 4.

Figure 4. Postoperative paraffin pathology of pituitary tumor. (A) Gross observation: A clump of fragmented tissue measuring 3.5 cm, mostly greyish-white in color with some parts dark red. (B) Under the microscope: Massive hemorrhage and necrosis were observed and only tumor cell remnants were seen [stained for reticulin with kit no. G3535 from Solarbio Science and Technology (Beijing) Co., Ltd.; magnification, ×200].

Table I. Hormone and ion levels of the patient at different stages.

Table I.

Hormone and ion levels of the patient at different stages.

Time-point	K+, mmol/l	Na+, mmol/l	FT3, pmol/l	FT4, pmol/l	TSH, µmol/l	ACTH-8:00 a.m., pg/ml	Cortisol-8:00 a.m., µg/dl	FSH, µIU/ml	LH, µIU/ml	Prolactin, ng/ml
Pre-operation	3.78	139	4	9.42	1.75	16.74	15.6	23.45	6.09	38.28
Between two operations	3.27↓	135↓	2.48	6.81↓	0.19↓	3.83↓	5.63↓	3.77↓	<0.2↓	1.13↓
Post-operation	3.24↓	137	<1.54↓	8.48↓	0.2↓	2.25↓	11.94	2.49↓	<0.2↓	1.57↓
6 weeks after the operation	4.49	141	3.24	12.22	0.9	11.9	10.11	2.41↓	0.62↓	3.75
Normal ranges	3.5–5.5	136-145	2.43–6.01	9.01–19.05	0.3–4.8	7.2–66.3	6.02–18.4	6.74–113.59	10.87–58.64	2.74–19.64

[i] K⁺, potassium ion; Na⁺, sodium; FT3, free triiodothyronine; FT4, free thyroxine; TSH, thyroid stimulating hormone; ACTH, adrenocorticotropic hormone; FSH, follicle-stimulating hormone; LH, luteinizing hormone; ↓, decreased.

Discussion

PA is a rare postoperative complication that may be life-threatening if not diagnosed and treated properly. It is usually caused by a sudden ischemic or hemorrhagic infarction of a preexisting pituitary adenoma, while only pituitary apoplexy rarely occurs in normal pituitary glands. Bonicki et al (3) reported that PA occurs in 5% of patients with pituitary adenomas; however, >40% of PA cases have never been diagnosed with a pituitary tumor prior to onset (21). PA is related to a variety of inducible factors, but its exact pathogenesis remains elusive. Due to the specific features of the pituitary vascular system, pituitary tissue is more susceptible to hypoperfusion, ischemia and intraoperative embolism, particularly during pump-on surgery. During the literature review for the current study, it was found that predisposing factors of PA included not only transient hypertension or hypotension, but also diabetes, angiographic test, cardiac surgery, hemodialysis, pituitary dynamic function test, radiation therapy, positive pressure mechanical ventilation and anticoagulant therapy (22).

To the best of our knowledge, the present study was the first case report of PA after gynecological malignancy. Since the pre-operative PET-CT did not indicate any pituitary tumor, postoperative symptoms such as headache, visual field defect, ptosis and hypopituitarism were confused with common postoperative complications and PA was not detected in the initial stage. This may be for the following two primary reasons. First, PET-CT lacks specificity and sensitivity in the hypothalamic-pituitary region, potentially resulting in undetected pituitary microadenomas. Furthermore, the pituitary adenoma became enlarged due to hemorrhage post-surgery, thereby facilitating detection. However, headaches likely occurred due to extravasation of blood into the subarachnoid space, causing meningeal irritation (22). Bitemporal hemianopia is the most common type of visual field defect caused by a pituitary tumor, which occurs due to the PA pressing on the middle of the optic chiasma (14). Ptosis presented as a result of oculomotor nerve compression and hypopituitarism was a sign of pituitary dysfunction. Besides, severe hypoglycemia and hyponatremia may occur due to a reduced glucocorticoid effect because of low cortisol response, as well as water overload caused by adrenocorticotropic hormone deficiency.

A total of four primary factors contributing to the occurrence of PA were identified for the present case. First, general anesthesia carries a greater risk of low BP than local anesthesia. General anesthesia may also lead to reduced cerebral perfusion. Second, surgery can cause intravascular fluid to spread into the interstitial space, leading to edema and a drop in BP. Third, blood loss may also be a contributing factor. Although only 100 ml of blood loss was stated in the surgical record, the patient underwent a major resection and lymph node dissection with postoperative nausea and vomiting, which indicated the possibility of local bleeding after abdominal closure and blood loss may be difficult to estimate accurately. Fourth, anticoagulant therapy is another risk factor, as it increases the risk of bleeding from damaged pituitary tissue.

PA can also occur in various types of surgery, particularly in surgery of the circulatory system. A literature search was conducted through PubMed, using ‘pituitary apoplexy’ and ‘surgery or operation’ as key terms to identify relevant articles published between 1984 and 2023. The search was limited to articles in English and only studies with sufficient information were included in the literature review (Table II). Based on the literature review, PA after surgery mostly occurred in males (76%), with an average age of 53 years for women and 68 years for men. Only 8% of cases had known pituitary disease (23,24). Clinical symptoms usually occur on the operation day or on POD1 (72%) and headache (76%) was the main and the earliest complaint in most cases. This symptom was possibly triggered by dural stretching and meningeal irritation caused by extravasation of blood and necrotic tissue into the subarachnoid space (25). Further examination of the literature indicated that visual disturbances were mentioned in 64% (visual deterioration in 24%, diplopia in 24%, visual defects in 20% and loss of light reflex in 20%), which was caused by pressure on different parts of the optic nerve and oculomotor nerve involvement may present as ptosis (44%). In addition, adrenal insufficiency may reduce the level and the efficiency of glucocorticoids and eventually cause arterial hypotension and/or hypoglycemia, as well as varying degrees of consciousness change, which was noted in 12% of cases in the present review.

Table II. Summary of information on PA cases during and after surgery from the literature review and the present case.

Table II.

Summary of information on PA cases during and after surgery from the literature review and the present case.

Authors, year	Age, years/sex	Prior lesion	Operation method	Clinical presentation	Onset time	Pituitary imaging MRI/CT	Potential risk factors	Treatment hormone replacement therapy	Surgery	Prognosis	(Refs.)
Mura et al,	85/male	–	Laparoscopic	Left palpebral	During the	CT: Pituitary gland	Preoperative	Dexamethasone	–	–	(34)
2014			colorectal	ptosis,	operation	increase;	anticoagulant	4 mg ×2/day
			resection	anisocoria,		MRI: Pituitary gland	therapy,
				divergent		increase with	intraoperative
				strabismus,		hematoma	BP fluctuation
				mydriasis
				without photo-
				motor reflex
McClain et al,	75/female	–	Elective	Headache,	POD1	CT: A large sellar	History of	–	Urgent	Ptosis and	(35)
2022			rotator	vomiting,		mass;	essential		transsphenoidal	ophthal-
			cuff repair	diplopia,		MRI: A sellar and	hypertension		endoscopic	moplegia
				inability to		suprasellar mass			resection of the	completely
				open the		effect compressing			pituitary mass	recovered
				right eye		the optic chiasm				and visual
										field deficits
										stabilized
Liberale et al,	73/male	–	Subrenal	Diplopia, right	On the	MRI: A large sellar	Preoperative	Cortisone	Transsphenoidal	Partially	(36)
2006			aortic	palpebral	operation	mass compressing	anticoagulant	acetate 50 mg/	adenectomy	recovered the
			abdominal	ptosis,	day	back carotid arteries	therapy	morning and		right third
			aneurysm	mydriasis,		and the optical		25 mg/evening,		oculomotor
			repair by	divergent		chiasma		sodique		palsy and
			subcostal	strabism				levothyroxin,		remained
			bilateral					50 g/day		stable during
			laparotomy							the 4-year
										follow-up
Naito et al,	14/female	–	Recurrent	Headache	POD1	CT: A tumor	Hemodynamic	l-T4 treatment	–	Improved	(37)
2019			cardiac	and visual		surrounding the	instability	for 3 months		visual field
			myxoma	impairment		hypothalamopituitary	during surgery,			of both eyes
			resection			lesion;	use of			before
			surgery			MRI: An intra- and	anticoagulant			discharge
						supra-sellar tumor
						compressing optic
						chiasma and bilateral
						optic nerves
Hidiroglu et al,	47/male	–	Coronary	Ptosis of both	POD2	CT: A solid mass	–	–	Transsphenoidal	–	(38)
2010			artery bypass	eyes, headache		compressing the optic			adenectomy
			grafting			chiasm
			operation
Yakupoglu et al,	74/male	–	Open three-	Right ophtha-	6 h after	CT: A mass on the	Hemodynamic	Intravenous	Transcranial	Full recovery	(39)
2010			vessel	lmoplegia with	the	pituitary gland;	changes	hydrocortisone	adenoma	of ptosis,
			CABG and	ptosis, right	operation	MRI: Pituitary		50 mg/day, oral	excision	visual field
			insertion of	mydriasis,		macroadenoma with		levothyroxine		deficits and
			a saphenous	headache		haemorrhage and		0.2 mg/day		mental
			vein graft			infarction				changes
										within
										2 weeks of
										surgery
Yoshino et al,	78/male	–	Right upper	Headache,	POD6	MRI: A high-	–	Hydrocortisone	–	Complete	(40)
2014			and middle	sudden		intensity area inside		200 mg/day		recovery
			lobectomy	increase in		the pituitary gland
			and lymph	urine volume
			node
			dissection
Joo et al, 2018	73/male	–	Lumbar	Severe	POD2	CT and MRI:	Intraoperative	Hydrocortisone	Transsphenoidal	Improved	(41)
			fusion	headache,		A mass in the sellar	BP fluctuation	300 mg/day	hypophysectomy	ptosis and
			surgery	ophthalmalgia		fossa and suprasellar				anisocoria
			in prone	and ptosis		region, compressing
			position	on right eye		the optic chiasm
Goel et al, 2009	76/male	–	Elective left	Sudden	POD1	CT: A mass in the	Transient	Dexamethasone	Transnasal	Complete	(42)
			total hip	headache,		left pituitary fossa;	episode of	2 mg/6 h	transphenoidal	recovery
			athroplasty	total left vision		MRI: Intersellar mass	hypotension in		decompression
				loss and		with a suprasellar	the postoperative		of the pituitary
				temporal right		extension on the	period		tumor
				hemianopia		left side, compressing
						the optic chiasma
						and cavernous sinus
Goel et al, 2009	61/male	–	Elective left	Sudden	POD1	CT: An intersellar	Microembolism	High-dose	Craniotomy and	Complete	(42)
			total knee	headache,		tumor		dexamethasone	decompression	recovery
			athroplasty	nausea,				intravenously	of pituitary
				vomiting,					adenoma
				right ptosis
Kim et al, 2015	69/male	–	Open heart	Severe	After the	MRI: A sellar mass	Excessive	High-dose	Transsphenoidal	Complete	(43)
			mitral	headache,	operation	with hemorrhage	anticoagulation,	steroids	resection of the	recovery
			valvuloplasty	visual field		pituitary	hemodynamic		tumor
				defects,		macroadenoma	instability
				double vision
Mizuno et al,	73/male	–	Elective	Right ptosis	4 h after	CT and MRI:	Strong	–	Endonasal	Complete	(44)
2011			coronary	with completely	the surgery	A large	heparinization,		transsphenoidal	recovery
			artery bypass	dilated pupils,		suprasellar mass	BP fluctuation		resection of the
			grafting	light reflex		with bleeding	during CPB		pituitary gland
				loss, headache
Thurtell et al,	79/male	–	Coronary	Blindness,	Following	CT: A large pituitary	Hemodilution,	Intravenous	Transsphenoidal	Remained	(45)
2008			artery bypass	no light	extubation	mass;	hypotension,	dexamethasone	decompression	blind with
			grafting	perception,		MRI: The mass	anticoagulation	sodium		no light
				miosis		extended into the		phosphate 8 mg		perception
						suprasellar cistern				on follow-up
						and compressed the
						optic chiasm
Thurtell et al,	64/male	–	Coronary	Blindness,	Following	CT: A large pituitary	Hemodilution,	Intravenous	Transsphenoidal	Remained	(45)
2008			artery bypass	no light	extubation	mass;	hypotension,	dexamethasone	decompression	blind with
			grafting	perception,		MRI: The mass	anticoagulation	sodium		no light
				miosis		extended into the		phosphate		perception
						suprasellar cistern		12 mg		on follow-up
						and compressed
						the optic chiasm
Matsusaki et al,	56/female	–	Living donor	Headache,	POD10	CT: A high-density	Intraoperative	Prednisolone,	–	Complete	(46)
2011			liver trans-	thirst, frequent		area in the pituitary	hypotension,	20 mg/days		recovery
			plantation	urination		gland;	coagulopathy,
						MRI: A suspicious	transient
						area between the	hypertension,
						anterior and posterior	dopamine
						of the pituitary gland	agonist therapy
Telesca et al,	70/male	–	Elective	Headache,	Following	CT and MRI: A sellar	–	High-dose	–	Complete	(47)
2009			coronary	visual field	extubation	mass with suprasellar		steroids		recovery
			bypass	defects,		extension
			surgery	diplopia
Fyrmpas et al,	67/male	Non-	Bilateral	Reduced	POD2	CT and MRI:	Hypertension,	Corticosteroid	Microscopic	Regained	(23)
2010		secreting	endoscopic	vision,		Haemorrhage within	diabetes,	replacement	endoscopic	vision and
		pituitary	middle	diplopia,		the pituitary tumor	anticoagulation	therapy	transsphenoidal	oculomotor
		macro-	meatal	headache			therapy,		resection	nerve
		adenoma	antrostomy,				prolonged			function
			ethmoidec-				intraoperative			partly
			tomy and				hypotension
			polypectomy
Absalom et al,	61/male	Non-	Coronary	Sudden onset	40 h after	CT: A 3-cm	Preoperative	Mannitol 80 g	Craniotomy, de-	Dead of	(24)
1993		secreting	artery bypass	of headache,	the surgery	suprasellar mass	anticoagulant	and	compression of	acute
		pituitary	grafting	nausea,		with a large	therapy, sudden	dexamethasone	the optic nerves,	myocardial
		tumor		vomiting		bleeding area in	coronary	10 mg iv	intracapsular	infarction
						the pituitary	revascularization		removal of
									pituitary tumor
Madhusudhan	62/male	–	Right total	Bilateral	POD5	CT: A low	Preoperative	Hydrocortisone	–	Complete	(48)
et al, 2011			shoulder	frontal		attenuation signal	anticoagulant	and thyroxine		recovery
			replacement	headaches,		in the pituitary	therapy,	supplements,
				binocular		fossa;	postoperative	testosterone
				diplopia,		MRI: The pituitary	hypoperfusion	replacement
				increased		stalk was markedly		therapy
				urinary output,		deviated to the right
				confusion,		with an enhancing
				drowsiness		area in the pituitary
						fossa, suggesting an
						adenoma
Cohen et al,	50/female	–	Liposuction	Persistent	After the	MRI: An intrasellar	Large dose of	–	Transsphenoidal	Complete	(49)
2004			on abdomen,	headache,	surgery	and suprasellar mass	local anesthetic,		resection of the	recovery
			hips and	nausea,		extending into the	hypovolemia,		pituitary mass
			thighs	vomiting		right cavernous sinus	fluid overload
Shapiro, 1990	60/female	–	Coronary	Headache,	POD1	CT: A right-sided	Reduced	Hydrocortisone	Transsphenoidal	Third nerve	(50)
			artery bypass	severe right		sellar mass with	perfusion	50 mg every	surgery	palsy
			surgery	ptosis,		extension into the	pressure during	6 h		persisted
				unresponsive		sphenoid sinus;	cardiopulmonary			post-
				pupil on the		MRI: A pituitary	bypass,			operatively
				right side		tumor with surroun-	anticoagulant
						ding hemorrhage	therapy
Tansel et al,	60/male	–	Coronary	Unexplained	Following	MRI: Pituitary	Protamine	Hydrocortisone,	–	In good	(51)
2010			artery bypass	episodes of	extubation	infarction	hypersensitivity	testosterone,		condition
			grafting	hypotension,				thyroxin		except for
				dysrhythmia,						a certain
				electrolyte						degree of
				imbalances,						visual
				somnolence,						disturbance
				agitation,
				respiratory
				distress, high
				fever
Slavin and	57/male	–	Three-vessel	Mild periorbital	Awakening	CT: An intrasellar	Intraoperative	Corticosteroids	Transsphenoidal	Complete	(52)
Budabin, 1984			coronary	pain, unable	from	mass with right	or postoperative		hypophysectomy	recovery
			bypass	to open right	anesthesia	parasellar extension	hypotension,			except for a
			surgery	eye, headache			anticoagulation,			mild visual
							positive pressure			field defect
							ventilation
Slavin and	55/male	–	Mitral valve	Bilateral	After the	CT: An intrasellar	Intraoperative	Corticosteroids	Transsphenoidal	Complete	(52)
Budabin, 1984			replacement	blepharoptosis	surgery	mass with large	or postoperative		hypophysectomy	recovery
			under cardio-	and partial oph-		radiolucent areas	hypotension,			except for
			pulmonary	thalmoplegia		encroaching on the	anticoagulation,			a mild right
			bypass	on each side,		right cavernous sinus	positive pressure			abduction
				bilateral			ventilation			defect
				confrontation
				visual fields
				disclosed nasal
				field defects
Present case,	64/female	–	Extensive	Sudden onset	POD1	CT: Multiple	Reduced cerebral	Hormone	Microscopic	Complete	–
2024			stump	of headache,		lacunar infarctions	perfusion,	replacement	endoscopic	recovery
			cervicectomy,	drowsiness		and local density	anticoagulant	therapy	transsphenoidal	except for a
			pelvic lymph			increase in saddle	therapy		resection	mild blurry
			node			and suprasellar				vision
			dissection			region;
						MRI: The pituitary
						was enlarged and
						mixed signals were
						seen

[i] POD, post-operative day; BP, blood pressure; CPB, cardiopulmonary bypass.

The diagnosis of PA is based on imaging evaluation, mainly by MRI, which is more sensitive than CT. Pituitary MRI is the radiological examination of choice (26). It can identify areas of bleeding and necrosis and determine the relationship between the tumor and neighboring structures, such as the optic chiasm, cavernous sinuses and hypothalamus (27). However, CT is also an examination that cannot be ignored, which can exclude headaches caused by subarachnoid hemorrhage and make a tentative diagnosis of intrasellar mass in most cases (28). In the present review, 80% of cases were detected by CT and 80% by MRI.

Endocrine deficiencies can exist at the onset and urgent evaluation of hormonal levels is suggested. According to the latest guidelines from Oxford and Royal College of Physicians (29), empirical hormonal replacement is indicated in each patient with secondary adrenal insufficiency no matter whether to perform a surgery or not. Applying hydrocortisone 100–200 mg intravenously and then applying either continuous intravenous infusion 2–4 mg/h or intramuscular injection 50–100 mg/6 h are suggested. Reviewing the series of patients with PA, 84% of cases received hormonal replacement therapy regardless of whether surgery was performed, while 72% of cases ended up receiving neurosurgical intervention. Applying exogenous hormones alone has certain inherent imperfections, as different hormones can influence the regulation of each other to a certain extent (30). The indications for surgery following hormonal replacement are as follows: i) Evidence of worsening or persistent neurological symptoms, such as visual impairment and ophthalmoplegia (paralysis or weakness of the eye muscles); ii) altered mental state; iii) patient is stable (no progressive deterioration in visual or mental state) and shows improvement with conservative treatment (26). Most cases (84%) achieved partial or complete remission in the visual field and ophthalmoplegia after prompt treatment. However, most studies demonstrate that surgical treatment, usually within 7 days of the event, leads to a higher rate of recovery from visual impairment (31). Nevertheless, certain retrospective studies confirm that there is no significant difference in the recovery of vision and endocrine function between patients with pituitary tumors treated conservatively and those undergoing surgical decompression (32,33). Currently, there is a lack of high-level evidence-based medical evidence for choosing a treatment approach. The UK guidelines for the management of pituitary tumor apoplexy recommend that the treatment plan should be determined through multidisciplinary collaboration, considering emergency surgical treatment based on the patient's pituitary apoplexy score evaluation (9).

A limitation of this study was the omission of ophthalmic assessment figures. These results were not included in our hospital's electronic medical records. Consequently, only copies of photographs of these results are available. Additionally, paper reports were not preserved, precluding the possibility of scanning them for enhanced clarity.

In conclusion, this review emphasized that even as an uncommon postoperative complication, PA is potentially life-threatening. It may occur in postoperative patients either with diagnosed or undiagnosed prior pituitary adenoma. Early diagnosis is essential for the timely treatment of hypopituitarism and prevention of serious neurological complications. In short, the wise surgeon should: i) Recognize PA after surgery in a timely manner by obtaining early neuroimaging tests and pituitary-related hormone tests and remember MRI is more sensitive than CT in observing early changes of hemorrhage or infarction. ii) Take initial action, such as applying intravenous glucocorticoids and mannitol. Transsphenoidal surgery should be considered and performed at the early stage of PA, if possible, to achieve better recovery. iii) If vision and the visual field are not affected, or vision defects are stable or temporary, hormonal replacement therapy alone may be considered, which is more appropriate for patients with surgical contraindications and may also spare patients from unnecessary surgery.

Supplementary Material

Supporting Data

Acknowledgements

Not applicable.

Funding

Funding: No funding was received.

Availability of data and materials

The data generated in the present study may be requested from the corresponding author.

Authors' contributions

KL and XY conceived the study and revised the manuscript. CS made substantial contributions to the acquisition and analysis of the data and drafted the tables of the manuscript. LJ drafted the figures of the manuscript and interpreted the data. All authors read and approved the final manuscript. XY and KL checked and confirmed the authenticity of the raw data.

Ethics approval and consent to participate

Not applicable.

Patient consent for publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Competing interests

The authors declare that they have no competing interests.

Glossary

Abbreviations

Abbreviations:

References