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J Neurol Surg Rep 2015; 76(02): e205-e210
DOI: 10.1055/s-0035-1554909
Case Report
Georg Thieme Verlag KG Stuttgart · New York

Pituitary Apoplexy After Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitor: A Novel Complication

Rebecca A. Kasl
1   Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Heather M. Kistka
1   Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Justin H. Turner
2   Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
,
Jessica K. Devin
3   Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Lola B. Chambless
4   Division of Neurological Surgery, Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
› Author Affiliations
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Publication History

05 September 2014

09 April 2015

Publication Date:
24 August 2015 (online)

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Abstract

Pituitary adenomas are common in the general population. They can be complicated by intratumoral hemorrhage, otherwise known as apoplexy, which frequently presents with neurologic deficits that may necessitate urgent surgical decompression. Many risk factors for pituitary apoplexy have been suggested in the literature. We present a case of symptomatic apoplexy in a woman following the intravitreal administration of the vascular endothelial growth factor (VEGF) inhibitor ranibizumab. Ophthalmoplegia resolved and visual acuity significantly improved following gross total resection of the tumor via an endoscopic endonasal surgical approach. The association between intravitreal injection of a VEGF inhibitor and pituitary apoplexy has not been previously described, but physicians performing these procedures should be aware of this potential complication.

Keywords

pituitary apoplexy - hemorrhage - vascular endothelial growth factor inhibitor - ranibizumab
 

  • References

  • 1 Nawar RN, AbdelMannan D, Selman WR, Arafah BM. Pituitary tumor apoplexy: a review. J Intensive Care Med 2008; 23 (2) 75-90
    CrossrefPubMedGoogle Scholar
  • 2 Turgut M, Ozsunar Y, Başak S, Güney E, Kir E, Meteoğlu I. Pituitary apoplexy: an overview of 186 cases published during the last century. Acta Neurochir (Wien) 2010; 152 (5) 749-761
    CrossrefPubMedGoogle Scholar
  • 3 Chang CV, Felicio AC, Toscanini AC, Teixeira MJ, Cunha-Neto MB. Pituitary tumor apoplexy. Arq Neuropsiquiatr 2009; 67 (2A): 328-333
    CrossrefPubMedGoogle Scholar
  • 4 Chng E, Dalan R. Pituitary apoplexy associated with cabergoline therapy. J Clin Neurosci 2013; 20 (12) 1637-1643
    CrossrefPubMedGoogle Scholar
  • 5 Knoepfelmacher M, Gomes MC, Melo ME, Mendonca BB. Pituitary apoplexy during therapy with cabergoline in an adolescent male with prolactin-secreting macroadenoma. Pituitary 2004; 7 (2) 83-87
    CrossrefPubMedGoogle Scholar
  • 6 Randeva HS, Schoebel J, Byrne J, Esiri M, Adams CB, Wass JA. Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinol (Oxf) 1999; 51 (2) 181-188
    CrossrefPubMedGoogle Scholar
  • 7 Semple PL, Jane Jr JA, Laws Jr ER. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosurgery 2007; 61 (5) 956-961 ; discussion 961–962
    CrossrefPubMedGoogle Scholar
  • 8 Jin Kim Y, Hyun Kim C, Hwan Cheong J, Min Kim J. Relationship between expression of vascular endothelial growth factor and intratumoral hemorrhage in human pituitary adenomas. Tumori 2011; 97 (5) 639-646
    PubMedGoogle Scholar
  • 9 Xiao Z, Liu Q, Mao F, Wu J, Lei T. TNF-α-induced VEGF and MMP-9 expression promotes hemorrhagic transformation in pituitary adenomas. Int J Mol Sci 2011; 12 (6) 4165-4179
    CrossrefPubMedGoogle Scholar
  • 10 Lou E, Peters KB, Sumrall AL , et al. Phase II trial of upfront bevacizumab and temozolomide for unresectable or multifocal glioblastoma. Cancer Med 2013; 2 (2) 185-195
    CrossrefPubMedGoogle Scholar
  • 11 Gilbert MR, Dignam JJ, Armstrong TS , et al. A randomized trial of bevacizumab for newly diagnosed glioblastoma. N Engl J Med 2014; 370 (8) 699-708
    CrossrefPubMedGoogle Scholar
  • 12 Friedman HS, Prados MD, Wen PY , et al. Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. J Clin Oncol 2009; 27 (28) 4733-4740
    CrossrefPubMedGoogle Scholar
  • 13 Kamba T, McDonald DM. Mechanisms of adverse effects of anti-VEGF therapy for cancer. Br J Cancer 2007; 96 (12) 1788-1795
    CrossrefPubMedGoogle Scholar
  • 14 Kim M, Lee SC, Lee SJ. Intravitreal ranibizumab for acute central serous chorioretinopathy. Ophthalmologica 2013; 229 (3) 152-157
    CrossrefPubMedGoogle Scholar
  • 15 Fasih U, Shaikh N, Rahman A, Sultan S, Fehmi MS, Shaikh A. A one-year follow-up study of ocular and systemic complications of intravitreal injection of bevacizumab (Avastin). J Pak Med Assoc 2013; 63 (6) 707-710
    PubMedGoogle Scholar
  • 16 Brouzas D, Koutsandrea C, Moschos M, Papadimitriou S, Ladas I, Apostolopoulos M. Massive choroidal hemorrhage after intravitreal administration of bevacizumab (Avastin) for AMD followed by contralateral sympathetic ophthalmia. Clin Ophthalmol 2009; 3: 457-459
    PubMedGoogle Scholar
  • 17 Pal A, Capatina C, Tenreiro AP , et al. Pituitary apoplexy in non-functioning pituitary adenomas: long term follow up is important because of significant numbers of tumour recurrences. Clin Endocrinol (Oxf) 2011; 75 (4) 501-504
    CrossrefPubMedGoogle Scholar
  • 18 Ostrom QT, Gittleman H, Farah P , et al. CBTRUS statistical report: Primary brain and central nervous system tumors diagnosed in the United States in 2006-2010. Neuro Oncol 2013; 15 (2) (Suppl. 02) ii1-ii56
    PubMedGoogle Scholar
  • 19 Saeger W, Lüdecke DK, Buchfelder M, Fahlbusch R, Quabbe HJ, Petersenn S. Pathohistological classification of pituitary tumors: 10 years of experience with the German Pituitary Tumor Registry. Eur J Endocrinol 2007; 156 (2) 203-216
    CrossrefPubMedGoogle Scholar
  • 20 Yamada S, Ohyama K, Taguchi M , et al. A study of the correlation between morphological findings and biological activities in clinically nonfunctioning pituitary adenomas. Neurosurgery 2007; 61 (3) 580-584 ; discussion 584–585
    CrossrefPubMedGoogle Scholar
  • 21 Leyer C, Castinetti F, Morange I , et al. A conservative management is preferable in milder forms of pituitary tumor apoplexy. J Endocrinol Invest 2011; 34 (7) 502-509
    PubMedGoogle Scholar
  • 22 Ayuk J, McGregor EJ, Mitchell RD, Gittoes NJ. Acute management of pituitary apoplexy—surgery or conservative management?. Clin Endocrinol (Oxf) 2004; 61 (6) 747-752
    CrossrefPubMedGoogle Scholar
  • 23 Bills DC, Meyer FB, Laws Jr ER , et al. A retrospective analysis of pituitary apoplexy. Neurosurgery 1993; 33 (4) 602-608 ; discussion 608–609
    CrossrefPubMedGoogle Scholar
  • 24 Semple PL, De Villiers JC, Bowen RM, Lopes MB, Laws Jr ER. Pituitary apoplexy: do histological features influence the clinical presentation and outcome?. J Neurosurg 2006; 104 (6) 931-937
    CrossrefPubMedGoogle Scholar
  • 25 Wakai S, Yamakawa K, Manaka S, Takakura K. Spontaneous intracranial hemorrhage caused by brain tumor: its incidence and clinical significance. Neurosurgery 1982; 10 (4) 437-444
    Google Scholar
  • 26 Bujawansa S, Thondam SK, Steele C , et al. Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom. Clin Endocrinol (Oxf) 2014; 80 (3) 419-424
    CrossrefPubMedGoogle Scholar
  • 27 Kim R. Introduction, mechanism of action and rationale for anti-vascular endothelial growth factor drugs in age-related macular degeneration. Indian J Ophthalmol 2007; 55 (6) 413-415
    CrossrefPubMedGoogle Scholar
  • 28 Lee JS, Park YS, Kwon JT, Nam TK, Lee TJ, Kim JK. Radiological apoplexy and its correlation with acute clinical presentation, angiogenesis and tumor microvascular density in pituitary adenomas. J Korean Neurosurg Soc 2011; 50 (4) 281-287
    CrossrefPubMedGoogle Scholar
  • 29 Arita K, Kurisu K, Tominaga A , et al. Relationship between intratumoral hemorrhage and overexpression of vascular endothelial growth factor (VEGF) in pituitary adenoma. Hiroshima J Med Sci 2004; 53 (2) 23-27
    PubMedGoogle Scholar
  • 30 Nuzzi R, Tridico F. Local and systemic complications after intravitreal administration of anti-vascular endothelial growth factor agents in the treatment of different ocular diseases: a five-year retrospective study. Semin Ophthalmol 2015; 30 (2) 129-135
    CrossrefPubMedGoogle Scholar
  • 31 Pellé G, Shweke N, Duong Van Huyen JP , et al. Systemic and kidney toxicity of intraocular administration of vascular endothelial growth factor inhibitors. Am J Kidney Dis 2011; 57 (5) 756-759
    CrossrefPubMedGoogle Scholar
  • 32 Zangari M, Fink LM, Elice F, Zhan F, Adcock DM, Tricot GJ. Thrombotic events in patients with cancer receiving antiangiogenesis agents. J Clin Oncol 2009; 27 (29) 4865-4873
    CrossrefPubMedGoogle Scholar
  • 33 Kuenen BC. Analysis of prothrombotic mechanisms and endothelial perturbation during treatment with angiogenesis inhibitors. Pathophysiol Haemost Thromb 2003; 33 (Suppl. 01) 13-14
    CrossrefPubMedGoogle Scholar
  • 34 Maccagnan P, Macedo CL, Kayath MJ, Nogueira RG, Abucham J. Conservative management of pituitary apoplexy: a prospective study. J Clin Endocrinol Metab 1995; 80 (7) 2190-2197
    PubMedGoogle Scholar
  • 35 McFadzean RM, Doyle D, Rampling R, Teasdale E, Teasdale G. Pituitary apoplexy and its effect on vision. Neurosurgery 1991; 29 (5) 669-675
    CrossrefPubMedGoogle Scholar
  • 36 Sibal L, Ball SG, Connolly V , et al. Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases. Pituitary 2004; 7 (3) 157-163
    CrossrefPubMedGoogle Scholar
  • 37 Chuang CC, Chang CN, Wei KC , et al. Surgical treatment for severe visual compromised patients after pituitary apoplexy. J Neurooncol 2006; 80 (1) 39-47
    CrossrefPubMedGoogle Scholar
  • 38 Onesti ST, Wisniewski T, Post KD. Clinical versus subclinical pituitary apoplexy: presentation, surgical management, and outcome in 21 patients. Neurosurgery 1990; 26 (6) 980-986
    Google Scholar
  • 39 Agrawal D, Mahapatra AK. Visual outcome of blind eyes in pituitary apoplexy after transsphenoidal surgery: a series of 14 eyes. Surg Neurol 2005; 63 (1) 42-46 ; discussion 46
    CrossrefPubMedGoogle Scholar
  • 40 Nemergut EC, Zuo Z, Jane Jr JA, Laws Jr ER. Predictors of diabetes insipidus after transsphenoidal surgery: a review of 881 patients. J Neurosurg 2005; 103 (3) 448-454
    CrossrefPubMedGoogle Scholar