Coronavirus Disease 2019 and Pituitary Apoplexy: A Single-Center Case Series and Review of the Literature

Abstract

Background: Pituitary apoplexy (PA) is a rare, but life-threatening, condition characterized by pituitary infarction and hemorrhage, most often in the setting of a preexisting adenoma. The risk factors and mechanisms associated with PA are poorly understood. Although neurovascular manifestations of coronavirus disease 2019 (COVID-19) infection have been documented, its association with PA has not yet been determined.

Methods: From a prospectively collected database of patients treated at a tertiary care center for pituitary adenoma, we conducted a retrospective medical record review of PA cases during the COVID-19 pandemic from March 2020 to December 2020. We also conducted a literature review to identify other reported cases.

Results: We identified 3 consecutive cases of PA and concomitant COVID-19 infection. The most common symptoms at presentation were headache and vision changes. The included patients were successfully treated with surgical decompression and medical management of the associated endocrinopathy, ultimately experiencing improvement in their visual symptoms at the latest follow-up examination. COVID-19 infection in the perioperative period was corroborated by polymerase chain reaction test results in all the patients.

Conclusions: With the addition of our series to the literature, 10 cases of PA in the setting of COVID-19 infection have been confirmed. The present series was limited in its ability to draw conclusions about the relationship between these 2 entities. However, COVID-19 infection might represent a risk factor for the development of PA. Further studies are required.

Keywords: COVID-19; Coronavirus; Neurosurgery; Pituitary adenoma; Pituitary apoplexy.

Figure 1

Imaging studies for patient 1. Preoperative (A) sagittal and (B) coronal T1-weighted contrast-enhanced magnetic resonance imaging scans demonstrating a 2.8-cm mixed hyperintense-hypointense sellar lesion, compatible with a pituitary adenoma with blood products at different stages of degradation. (C and D) Preoperative axial gradient echo sequencing images confirming accentuated flow signal in the sellar lesion (black arrows).

Figure 2

Imaging studies for patient 2. Preoperative (A) coronal T1-weighted, precontrast, (B) coronal T1-weighted contrast-enhanced, and (C) sagittal T1-weighted contrast-enhanced magnetic resonance imaging scans demonstrating pituitary apoplexy in a 1.8-cm macroadenoma with interval enlargement. (D and E) Preoperative axial susceptibility-weighted imaging scans demonstrating signal in the adenoma consistent with hemorrhage (white arrows). Postoperative (F) coronal T1-weighted contrast-enhanced, (G) sagittal T1-weighted contrast-enhanced, and (H) axial T1-weighted contrast-enhanced magnetic resonance imaging scans demonstrating adequate decompression of the optic apparatus.

Figure 3

Imaging studies for patient 3. Preoperative (A) coronal T1-weighted contrast-enhanced, (B) sagittal T1-weighted contrast-enhanced, and (C) axial T1-weighted contrast-enhanced magnetic resonance imaging scans and (D) axial computed tomography scan demonstrating a sellar lesion with suprasellar extension and a fluid level compatible with intratumoral subacute bleeding. Postoperative (E) coronal T1-weighted contrast-enhanced, (F) sagittal T1-weighted contrast-enhanced, and (G) axial T1-weighted contrast-enhanced magnetic resonance imaging scans demonstrating decompression of the optic chiasm with residual tumor extending into the right cavernous sinus.

Figure 4

Proposed pathophysiologic mechanism underlying coronavirus disease 2019 (COVID-19) propagation of pituitary apoplexy in patients with underlying adenoma. ACE-2R, angiotensin-converting enzyme-2 receptor.