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Pituitary Apoplexy

Topic updated on 10/21/17 3:02pm

Snapshot
  • A 56-year-old male presents to the emergency department with a severe headache that occured suddenly. The patient also complains of not seeing very well. Physical examination is notable for a left-eye ptosis, dilated pupil, that is inferiorly and laterally deviated. A computerized tomography (CT) of the head is performed, which is shown to the right. Neurosurgery was immediately consulted.
Overview
  • Hemorrhage or infarction of the pituitary gland → pituitary gland volume increases
    • usually happens in macroadenomas
  • Differential diagnosis
    • subarachnoid hemorrhage
    • bacterial meningitis
Pathophysiology
  • Pituitary adenomas are at risk of bleeding and undergoing necrosis
    • possible explanation: 
      • adenoma outgrowing blood supply → ischemia → necrosis
      • adenoma compressing blood supply → ischemia → necrosis
      • fragility of blood vessels supplying the tumor  hemorrhage
Presentation
  • Excruciating headache of acute onset
  • Hypopituitarism
  • Visual symptoms
    • impairement of visual acuity or visual field
      • tumor expansion → compression of optic nerve, optic chiasm, or optic tract
    • diplopia
      • due to oculomotor nerve compression
  • ± altered consciousness
Diagnosis
  • CT or MRI of the head
    • intrasellar mass + necrotic and/or hemorrhagic features
    • CT without contrast - more useful if acute (24 - 48 hours)
      • initial imaging study of choice in the emergency setting
      • can help exclude subarachnoid hemorrhage
    • MRI - more useful if subacute (4 days - 1 month)
Treatment/Management
  • Debatable, but treatment is aimed at improving the patient's symptoms and relieving compression of surrounding structures (i.e., optic pathways)
    • neurosurgery seems the fastest at accomplishing this
    • a select few can be managed conservatively
      • i.e., those without visual symptoms and normal consciousness
  • Neurosurgical emergency
    • early transphenoidal surgical decompression
  • Corticosteroid therapy immediately 
    • majority of patients present with corticotropic deficiency
      • this may be life-threatening
  • Correction of eletrolyte disturbances


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