Keep an Eye on the Eye of your Patient: An Update on the Management of
Post-CABG Pituitary Apoplexy
Joshua E. Insler, M.D.1
Gabriele Maria Iacona, M.D.2 *
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic,
Cleveland, OH
- Department of Cardiac Surgery, MedStar Washington Hospital Center,
Georgetown University, Washington, D.C.
- * Denotes corresponding author
Word Count: 810
Corresponding author:
Gabriele Maria Iacona, M.D.
MedStar Washington Hospital Center, Georgetown University
3800 Reservoir Rd NW, Washington, DC 20007
Gabriele.m.iacona@medstar.net
CASE PRESENTATION
The patient was a 62-year-old male with a history of hypertension,
hyperlipidemia, and prior transsphenoidal resection of a pituitary
adenoma in 2008 with a three-month history of left-sided ptosis,
diplopia, and exophthalmos. He presented to the emergency department
after experiencing two weeks of dizziness and chest pain where he was
ultimately found to have an NSTEMI. He denied flashes, floaters,
galactorrhea, and a CTA head/neck and CT head at the time of
presentation were both unremarkable. The patient underwent an urgent
left heart catheterization which revealed extensive three-vessel
coronary artery disease, with the left anterior descending and
circumflex arteries more than 70% occluded and the right main coronary
artery more than 90% occluded; a transthoracic echocardiogram
demonstrated an ejection fraction of 50% with moderate hypokinesis of
the interior and inferolateral walls. The patient was urgently taken to
the operating room for coronary artery bypass grafting (CABG) x4 (LIMA
to LAD, RIMA to DIAG, SVG to OM-PDA). Cross clamp time was 98 minutes,
and core cooling temperature while on-pump was 34 C; ACT was between
625-786, and the lowest hemoglobin while on pump was 7.2.
However, on postoperative zero he developed worsening ptosis, a
fixed, dilated pupil, and impaired left eye adduction with his eye
fixated in a down-and-out position. A code stroke was called and stroke
neurology was consulted, who found the patient to have oculomotor
neuropathy with an NIH Stroke Score of 1; a CT head obtained at that
time was grossly unremarkable. On postoperative day three, an MRI/MRA
brain demonstrated significant sellar enlargement containing a markedly
heterogeneous 13 mm by 13 mm lesion with anterior enhancement, directly
abutting the right internal carotid artery with rightward pituitary
stalk deviation and involvement of the left cavernous sinus without
abutment of the optic chiasm (Figure 1). Furthermore, his almost-near
panhypopituitarism further suggested pituitary adenoma recurrence with
hemorrhage and apoplexy into the suprasellar space.
He was ultimately evaluated by neurosurgery, ophthalmology, and
endocrinology all of whom recommended repeat resection of pituitary
adenoma one month following his discharge, and he was ultimately
discharged home with only his baseline degree of preoperative ptosis and
exophthalmos on postoperative day eight.
COMMENT
Pituitary apoplexy is a rare, potentially life-threatening
complication which has been described after both on and off-pump
CABG.1 In anywhere from 15% - 85% of patients, it
may manifest as headache, ophthalmoplegia, ptosis, and anisocoria, with
symptom onset typically by postoperative day two—- however, symptoms
may present in the immediate postoperative period or up to several weeks
following surgery.1,2 It has been hypothesized that
pituitary apoplexy during on-pump cardiac surgery is likely related to
cerebral hypoperfusion, low perfusion pressures, hemodilution and
non-pulsatile flow experienced while on cardiopulmonary
bypass.3 Pituitary adenoma tissue is markedly more
susceptible to ischemia and hemorrhage at baseline, likely due to both
the thin-walled and abnormal sinusoidal nature of the tumor’s
vasculature; thrombotic events of atherosclerotic plaques and
microvascular embolization while on-pump have also been
implicated.4
While the literature does include approximately 20 reports of pituitary
apoplexy-induced ophthalmoplegia after both on and off-pump coronary
revascularization, never before has pituitary adenoma recurrence after
prior resection and subsequent apoplexy leading to severe
ophthalmoplegia after on-pump CABG been described. Of these existing
case reports, only three patients were known preoperatively to have a
pituitary adenoma, with one having received stress-dose steroids prior
to the induction of general anesthesia and all ultimately undergoing
transsphenoidal resection after hospital
discharge.5,6,7 Patients with preexisting pituitary
adenomas are at greater risk of apoplexy after CABG, and as such require
preoperative urgent evaluation/imaging given the permanent, deleterious
neurologic and endocrinologic complications—- including hypothyroidism
and Addisonian crisis—- which may result.5,6 Our
patient had previously undergone transsphenoidal resection of a
pituitary adenoma years before his CABG, however given the chronicity of
his symptoms he did not follow with a neurologist and moreover did not
have preoperative imaging to suggest pituitary adenoma recurrence.
With respect to surgical strategy, the largest case series reporting on
the outcomes of 4 patients with either known or incidentally-found
pituitary adenomas undergoing CABG recommended against the routine use
of cardiopulmonary bypass, noting that revascularization in these
patients should be done off-pump to minimize the likelihood of pituitary
apoplexy and the ensuing complications which may
arise.7 Whether or not off-pump surgery is safer than
on-pump CABG requires further investigation—- yet, in the absence of
data or evidence supporting the ideal perioperative management of CABG
in patients found to have a pituitary adenoma, it is clear that an
individualized approach is required for each patient, including a
discussion of the risk of permanent neurological deficits which may be
sustained during CABG. Our recommendation for all patients in either the
elective or urgent perioperative settings with concerning, new-onset
neurologic symptoms is to undergo head imaging to assess for the
presence of a pituitary adenoma. In a majority found to have pituitary
adenoma preoperatively, we recommend pursuing off-pump CABG whenever
possible; if surgery is non-urgent, we recommend pursuing neurosurgical
evaluation for possible transsphenoidal resection prior to CABG to
minimize the risk of inducing pituitary apoplexy.
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