Endocrine Abstracts

Introduction: Pituitary apoplexy is a rare but life threatening clinical syndrome characterised by acute neuro-ophthalmological features caused by haemorrhage and/or infarction of the pituitary gland. Although many precipitating factors are known, most apoplectic episodes occur spontaneously.

Case: A 59-year-old gentleman presented in 2005 with a 12-month history of bitemporal hemianopia. An MR scan revealed a pituitary macroadenoma. When he was reviewed in the pituitary clinic repeat assessment showed improvement of the visual field defect. His baseline pituitary hormonal profile was normal. In the absence of any signs of optic chiasmal compression and given that he had significant co-morbidity by way of CCF, a watch and wait policy was adopted. He remained clinically and radiologically stable for the next 5 years.

In 2010, he was admitted to a neighbouring hospital with acute aortic dissection. This was managed conservatively and was followed by a protracted period of rehabilitation. During his recovery he was found to have a bitemporal hemianopia and was therefore assessed in the pituitary clinic. His visual field defect had almost resolved with only a left infero-temporal defect persisting. A pituitary MRI scan showed marked reduction in size of pituitary adenoma and drooping of the optic chiasm. Endocrine assessment revealed TSH, gonadotropin and partial ACTH deficiency. It was felt likely that he had developed pituitary infarction secondary to aortic dissection. He was established on appropriate hormonal replacement. He subsequently underwent aortic valve replacement and aortic repair under steroid cover. He remains stable although there has been intermittent fluctuation in visual symptoms.

Discussion: The partial hypopituitarism and shrinkage of the pituitary tumour in this case is likely to be explained by pituitary infarction caused by sudden alterations in critical perfusion pressure as a result of acute aortic dissection on a background of cardiac failure.