Endocrine Abstracts

Introduction: Pituitary aplopexy is rare (0.6 to 12.3%). Sudden expansion of pituitary tumor, from hemorrhage or infarction, may lead to permanent vision loss, paresis or death. We describe two cases of apoplexy as the initial manifestation of pituitary tumor.

Case 1: Male, 30 years, healthy, observed in the emergency room (ER) complaining of headache, visual deficit and left ptosis for 3 days. He had left ptosis and bilateral paresis of the IV pair. Magnetic resonance imaging (MRI) showed ‘sellar and suprasellar mass 2.7×2.4×1.9 cm, compatible with pituitary macroadenoma with intralesional hemorrhage’. Laboratory findings: FSH 3.4 mIU/ml, LH 1.6 mIU/ml, total testosterone 1.1 ng/ml, TSH 0.082 mIU/ml (0.4–4), FT₄ 0.4 ng/dl (0.8–1.9); IGF1 104 ng/dl (117–329), prolactin, ACTH and cortisol were normal. Transsphenoidal surgery performed three days later. Neuropathology: necrosis of pituitary adenoma. He had complete resolution of visual deficit, maintenance of secondary hypothyroidism and decreased IGF1 but without gonadal and adrenal insufficiency. MRI, 2 months later showed tumor residue with 7 mm. Currently on levothyroxine 0.075 mg id.

Case 2: Male, 66 years, observed in the ER for headache, diplopia and right ptosis. Background: atrial fibrillation, hypertension and dyslipidemia, all medicated. Physical examination: right ptosis and ophthalmoplegia, total involvement of III, IV and VI pairs. MRI: ‘sellar mass 3.0×1.9×2.2 cm compatible with pituitary macroadenoma’. Laboratory findings: FSH 4.7 mIU/ml, LH 3.5 mIU/ml, total testosterone 1.7 ng/ml, prolactin 121 ng/ml (<18), without other insufficiency. Transsphenoidal surgery was performed 1 week later. Neuropathology: prolactinoma with hemorrhagic necrosis. After surgery, he presented partial improvement of neurological deficits. Prolactin 22 ng/ml, IGF1 68 ng/dl (117–329), without other hormonal insufficiencies. MRI: residue 1.21×1.46×1.39 cm. No need for hormonal substitution therapeutic.

Conclusions: These cases call attention to the unpredictability of acute pituitary apoplexy. It should be considered in all patients with neuro-ophthalmological deterioration and acute headache. Early diagnosis and timely surgical treatment leads to significant improvement in visual and hormonal deficits.