Pituitary macroadenomas: are combination antiplatelet and anticoagulant therapy contraindicated? A case report
© Tan et al; licensee BioMed Central Ltd. 2007
Received: 15 May 2007
Accepted: 30 August 2007
Published: 30 August 2007
Pituitary apoplexy is a life-threatening endocrine emergency that is caused by haemorrhage or infarction of the pituitary gland, commonly within a pituitary adenoma. Patients classically present with headache, ophthalmoplegia, visual field defects and altered mental state, but may present with a typical symptoms such as fever and altered conscious level.
A 57-year-old female with a known pituitary macroadenoma was treated for suspected acute coronary syndrome with aspirin, clopidogrel and full dose enoxaparin. She developed a severe and sudden headache, nausea and vomiting and visual deterioration. A CT scan showed haemorrhage into the pituitary macroadenoma. She underwent neurosurgical decompression. Post-operatively her visual fields and acuity returned to baseline. She was continued on hydrocortisone and thyroxine replacement on discharge.
This case illustrates the risks of anticoagulation in a patient with a known pituitary macroadenoma, and raises the issue of whether these tumours present a relative contraindication to the use of dual antiplatelet and anticoagulation in acute coronary syndrome.
Pituitary apoplexy is defined as haemorrhage or infarction of the pituitary gland. This occurs often in the context of a pituitary adenoma, although it can occur in normal pituitaries in patients with post partum haemorrhage (Sheehan's syndrome) . This is an emergency because of the combination of secondary adrenal insufficiency, with compression of the optic chiasm and the III, IV, V and VI cranial nerves .
The prevalence of classical pituitary apoplexy in retrospective case series of patients undergoing pituitary surgery varies from 5%  to 9.1% . In patients with non-functioning macroadenomas, who were not operated on and followed up for 85 +/- 13 months, 14% developed pituitary apoplexy . The majority present with no previous history of pituitary adenoma, and their tumour is discovered when the apoplexy occurs . Many precipitating factors have been described, from dopamine agonists , anticoagulation , head trauma , pituitary irradiation , to dynamic endocrine testing, most likely triggered by TRH administration .
Post-operatively her visual fields and acuity returned to baseline (Figure 3). Her pyrexia ceased and CRP decreased. The ECG returned to normal. Cardiological investigations including exercise stress testing and a myocardial perfusion scan did not show evidence of ischaemic heart disease, implying that the global ST depression noted pre-operatively was the result of her pituitary apoplexy. She was discharged home on hydrocortisone and thyroxine replacement.
We describe a case of pituitary apoplexy in a patient who was already known to have a pituitary adenoma, and who was treated for acute coronary syndrome. With the modern treatment of acute coronary syndrome, an anticoagulation cocktail that includes aspirin, heparin and clopidogrel is employed. The addition of clopidogrel to aspirin and heparin has been demonstrated to reduce the incidence of further vascular events over aspirin and heparin alone. However, this is at the expense of a significant increase in rates of major bleeding (mainly gastrointestinal) from 2.7% to 3.7% . The apoplectic crisis initially presented with fever, headache, nausea, and vomiting, and ST segment depression on ECG, a finding that has been reported with subarachnoid haemorrhage , but has not previously been reported in association with pituitary apoplexy. The risks of death or serious visual loss in the event of apoplexy are considerable, especially if there is diagnostic delay occasioned by a non-classical presentation, e.g. with fever of unknown origin, hyponatraemia and altered consciousness . This situation can be compounded by non-diagnostic investigations such as non-specific changes in the CSF , or an apparently normal CT scan of the brain, which has been shown to be of lower sensitivity in detecting pituitary apoplexy compared to MRI scanning .
Anticoagulation is well known as a precipitating factor for pituitary apoplexy. Like our patient, one case study has reported a patient with pituitary apoplexy precipitated by aspirin, clopidogrel and enoxaparin, although in that case the patient did not have a previously known pituitary adenoma . Our case therefore highlights some important practice points: in patients who are already known to have a pituitary adenoma, this condition should be considered a relative contraindication for anticoagulation. These patients should be warned about the potential risks of anticoagulation with respect to their pituitary adenoma. If these patients are anticoagulated, a high index of suspicion of pituitary apoplexy should guide the clinician if they fall acutely ill: early hydrocortisone replacement should be instituted.
Written consent has been obtained from the patient described in this case report.
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