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      Presumed pituitary apoplexy in 26 dogs: Clinical findings, treatments, and outcomes

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          Abstract

          Background

          Pituitary apoplexy refers to hemorrhage or infarction within the pituitary gland resulting in acute neurological abnormalities. This condition is poorly described in dogs.

          Objectives

          To document presenting complaints, examination findings, endocrinopathies, magnetic resonance imaging (MRI), treatments, and outcomes of dogs with pituitary apoplexy.

          Animals

          Twenty‐six client‐owned dogs with acute onset of neurological dysfunction.

          Methods

          Retrospective case series. Dogs were diagnosed with pituitary apoplexy if MRI or histopathology documented an intrasellar or suprasellar mass with evidence of hemorrhage or infarction in conjunction with acute neurological dysfunction. Clinical information was obtained from medical records and imaging reports.

          Results

          Common presenting complaints included altered mentation (16/26, 62%) and gastrointestinal dysfunction (14/26, 54%). Gait or posture changes (22/26, 85%), mentation changes (18/26, 69%), cranial neuropathies (17/26, 65%), cervical or head hyperpathia (12/26, 46%), and hyperthermia (8/26, 31%) were the most frequent exam findings. Ten dogs (38%) lacked evidence of an endocrinopathy before presentation. Common MRI findings included T1‐weighted hypo‐ to isointensity of the hemorrhagic lesion (21/25, 84%), peripheral enhancement of the pituitary mass lesion (15/25, 60%), brain herniation (14/25, 56%), and obstructive hydrocephalus (13/25, 52%). Fifteen dogs (58%) survived to hospital discharge. Seven of these dogs received medical management alone (median survival 143 days; range, 7‐641 days) and 8 received medications and radiation therapy (median survival 973 days; range, 41‐1719 days).

          Conclusions and Clinical Importance

          Dogs with pituitary apoplexy present with a variety of acute signs of neurological disease and inconsistent endocrine dysfunction. Dogs that survive to discharge can have a favorable outcome.

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          Most cited references73

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          Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

          The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time. Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations. Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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            ACVIM consensus statement: Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats

            An update to the 2007 American College of Veterinary Internal Medicine (ACVIM) consensus statement on the identification, evaluation, and management of systemic hypertension in dogs and cats was presented at the 2017 ACVIM Forum in National Harbor, MD. The updated consensus statement is presented here. The consensus statement aims to provide guidance on appropriate diagnosis and treatment of hypertension in dogs and cats.
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              Classical pituitary apoplexy: clinical features, management and outcome.

              The term classical pituitary apoplexy describes a clinical syndrome characterized by sudden headache, vomiting, visual impairment and meningismus caused by the rapid enlargement of a pituitary adenoma usually due to haemorrhagic infarction of the tumour. Most published reports looking at the clinical features and management of pituitary apoplexy have not differentiated between patients with clinical and subclinical apoplexy, the latter diagnosed at surgery. Furthermore, little is reported on the clinical outcome, in particular visual and endocrinological, and the role of radiotherapy. The purpose of this study was to observe not only the clinical presentation but also the possible predisposing events, investigations, management, clinical outcome as well as the role of radiotherapy in patients presenting with classical pituitary apoplexy. In a retrospective analysis 1985-96, the medical records of 21 male and 14 female patients (mean age 49.8 years, range 30-74) with classical pituitary apoplexy were reviewed. This represents all patients seen with this condition over the stated period. In all patients, pre- and post- operative measurements were made of FT4, FT3, TSH, PRL, LH, FSH, cortisol (0900 h), GH, oestradiol (females) and testosterone (males). Pituitary imaging was by computerized tomography (CT) scan, magnetic resonance imaging (MRI) or both. Patients were followed for up to 11 years (mean 6.3 years: range 0.5-11). Headache (97%) was the commonest presenting symptom, followed by nausea (80%) and a reduction of visual fields (71%). Hypertension, defined as a systolic > 160 mmHg and/or a diastolic > 90 mmHg, was seen in 26% of patients. MRI correctly identified pituitary haemorrhage in 88% (n = 7), but CT scanning identified haemorrhage in only 21% (n = 6). By immunostaining criteria, null-cell adenomas were the most common tumour type (61%). Transsphenoidal surgery resulted in improvement in visual acuity in 86%. Complete restoration of visual acuity occurred in all patients operated on within 8 days but only in 46% of patients operated on after this time (9-34 days). Long-term steroid or thyroid hormone replacement was necessary in 58% and 45% of patients, respectively. Of the male patients, 43% required testosterone replacement, and long-term desmopressin therapy was required in 6%. Only two patients (6%) with tumour recurrence after transsphenoidal surgery for the initial apoplectic event, subsequently required radiotherapy. In classical pituitary apoplexy, headache is the commonest presenting symptom and hypertension may be an important predisposing factor. MRI is the imaging method of choice. Transsphenoidal surgery is safe and effective. It is indicated if there are associated abnormalities of visual acuity or visual fields because, when performed within 8 days, it resulted in significantly greater improvement in visual acuity and fields than if surgery was performed after this time. Radiotherapy is not indicated immediately as the risk of tumour recurrence is small, but careful follow-up initially with annual imaging is indicated in this group.
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                Author and article information

                Contributors
                clmarian@ncsu.edu
                Journal
                J Vet Intern Med
                J Vet Intern Med
                10.1111/(ISSN)1939-1676
                JVIM
                Journal of Veterinary Internal Medicine
                John Wiley & Sons, Inc. (Hoboken, USA )
                0891-6640
                1939-1676
                21 April 2023
                May-Jun 2023
                : 37
                : 3 ( doiID: 10.1111/jvim.v37.3 )
                : 1119-1128
                Affiliations
                [ 1 ] Veterinary Hospital, College of Veterinary Medicine North Carolina State University Raleigh North Carolina USA
                [ 2 ] Department of Clinical Sciences, College of Veterinary Medicine North Carolina State University Raleigh North Carolina USA
                [ 3 ] Comparative Neuroimmunology and Neuro‐Oncology Laboratory North Carolina State University Raleigh North Carolina USA
                [ 4 ] Comparative Medicine Institute North Carolina State University Raleigh North Carolina USA
                [ 5 ] Department of Molecular Biomedical Sciences, College of Veterinary Medicine North Carolina State University Raleigh North Carolina USA
                [ 6 ]Present address: Garden State Veterinary Specialists Tinton Falls New Jersey USA
                [ 7 ]Present address: Department of Small Animal Soft Tissue Surgery, College of Veterinary Medicine University of Illinois Urbana‐Champaign Urbana IL
                Author notes
                [*] [* ] Correspondence

                Christopher L. Mariani, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA.

                Email: clmarian@ 123456ncsu.edu

                Author information
                https://orcid.org/0000-0003-3228-6536
                https://orcid.org/0000-0002-4432-9700
                https://orcid.org/0000-0003-3399-8500
                https://orcid.org/0000-0001-9592-6276
                https://orcid.org/0000-0002-5420-0601
                https://orcid.org/0000-0003-1349-3484
                Article
                JVIM16703
                10.1111/jvim.16703
                10229324
                37084035
                a7f09353-e4ef-449b-a3b6-15f05ce9e52e
                © 2023 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals LLC on behalf of American College of Veterinary Internal Medicine.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 25 October 2022
                : 24 March 2023
                Page count
                Figures: 2, Tables: 3, Pages: 10, Words: 7919
                Funding
                Funded by: Department of Clinical Sciences, NC State University
                Categories
                Standard Article
                SMALL ANIMAL
                Standard Articles
                Neurology
                Custom metadata
                2.0
                May/June 2023
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.2.8 mode:remove_FC converted:30.05.2023

                Veterinary medicine
                adenoma,carcinoma,endocrionopathy,hemorrhage,magnetic resonance imaging,suprasellar,survival

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