Endocrine Abstracts

Introduction: Pituitary apoplexy presents as a medical emergency, and usually occurs in people with pituitary macroadenomas. Immediate multidisciplinary expertise and timely intervention is needed to mitigate the associated morbidity. There is controversy regarding the role and the timing of neurosurgical intervention versus conservative management approach to obtain best visual and endocrine outcomes. Here we present a case of a man presenting with pituitary apoplexy and managed conservatively to achieve remarkable improvement in vision and tumor size.

Case History: A 54 year old man with a history of nonfunctioning pituitary adenoma was referred to our care when he presented with acute severe headache, diplopia and visual disturbance. He was known to have a pituitary tumor that had been incidentally detected in 2013, and followed with annual imaging that had shown a gradual increase tumor size, not requiring intervention. On acute presentation with apoplexy he had bitemporal hemianopia with right sided 3rd and 6th cranial nerve palsies.

Investigations: Magnetic Resonance Imaging (MRI) of pituitary revealed subacute bleeding into the pituitary macroadenoma which bulged into suprasellar cistern and touched the optic chasm with minimal elevation, and extended into the right cavernous sinus. His serum sodium was 128 and the pituitary profile suggested panhypopituitarism with cortisol 61 nmol/L, TSH 0.73 miU/mL, Free T4 <5.2 pmol/L, LH 0.4 IU/L, FSH 1 IU/L, Testosterone <0.4 nmol/L and Prolactin 5 mIU/L. The diagnosis of pituitary apoplexy was made.

Management: He was started immediately on hydrocortisone 40 mg per day, thyroxine and testosterone replacement. He was managed conservatively, with frequent visual function assessments, which showed substantial improvement within few days without further deterioration of cranial nerve palsies. The 3rd and 6th cranial nerve palsies improved gradually while visual fields had recovered completely by sixth week. Repeat MRI after 6 weeks showed that the tumor height had decreased from 22 mm to 13 mm with no contact on the optic chiasm and complete resolution of the hemorrhage. On three month follow up, he is well with fully recovered vision but still has panhypopituitarism requiring anterior pituitary replacement therapy.

Discussion: This case illustrates the positive outcome of conservative management of pituitary apoplexy resulting in favorable neuro-ophthalmic outcome and reduction in tumor size. Thus conservative approach is permissible if vision is improving as outlined in the pituitary apoplexy guidelines (1).

Reference: 1. Rajasekaran S. et al. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol(Oxf).2011;74:9–20.