Snapshot
- A 56-year-old man presents to the emergency department with a severe headache that occurred suddenly. The patient also complains of not seeing very well. Physical examination is notable for left-eye ptosis and a dilated pupil that is inferiorly and laterally deviated. A computerized tomography (CT) of the head is performed, which is shown to the right. Neurosurgery is 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
- fragility of blood vessels supplying the tumor → hemorrhage
Presentation
- Excruciating headache of acute onset
- Hypopituitarism
- Visual symptoms
- impairment of visual acuity or visual field
- tumor expansion → compression of optic nerve, optic chiasm, or optic tract
- diplopia
- due to oculomotor nerve compression
- impairment of visual acuity or visual field
- ± 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 trans-sphenoidal surgical decompression
- Corticosteroid therapy immediately
- majority of patients present with corticotropic deficiency
- this may be life-threatening
- majority of patients present with corticotropic deficiency
- Correction of electrolyte disturbances