Endocrine Abstracts

Background

Pituitary apoplexy (PA) is a rare clinical syndrome, usually occurring in the pituitary adenoma due to a sudden bleeding and/or infarction. PA is usually seen in nonfunctional pituitary adenomas, but it can also be seen in ACTH secreting macroadenomas. The most common symptoms PA, which complicates 2 to 12% of pituitary adenomas, are severe and sudden headache, visual disturbances, or eye paralysis, and endocrinological abnormalities. PA is diagnosed by computed tomography or magnetic resonance imaging. Formerly considered as an urgent neurosurgical condition and treated only surgically, now PA is sometimes treated conservatively.

Clinical case

The 33-year-old woman was sent to the emergency department for persistent severe right-sided headache, nausea, vomiting, and impaired vision. Temporobasal subarachnoid hemorrhage on the right side, and aneurysm rupture was suspected on computed tomography (CT) of the brain. Patient was referred to ophthalmologist – right eye blindness and temporal hemianopsia in left eye were diagnosed. An additional MRI scan revealed a tumor in the sella turcica area. Patient was transferred to Vilnius University hospital Santaros Klinikos Center of Neurosurgery. Head CT angiography (CTA) was done to exclude intracranial vascular aneurysm. Subarachnoid hemorrhage, a large (24 × 15 × 26 mm) mass, significant pressure on the right segment of the right internal carotid artery (ACI) and dislocated optic chiasm were found. Blood samples showed increased ACTH, cortisol, and glucose levels (AKTH – 190 nmol/l, cortisol – 1068 nmol/l, glucose – 10 mmol/l), prolactin concentration was normal. During physical examination wide purple striae in the skin of the abdomen and arms, hirsutism, and cushingoid body appearance were noticed. The patient was never consulted by endocrinologist before. She underwent right pterional craniotomy and pituitary tumor removal. The final pathological diagnosis was necrosis and hemorrhage in the pituitary adenoma with probable ACTH expression and grain. Patient’s right eye vision after surgery did not recover and she developed panhipopituitarism. A replacement treatment with glucocorticoids, levothyroxin and sex hormones were given.

Conclusion

The presented clinical case shows how unnoticed and undiagnosed Cushing’s disease led to a pituitary adenoma apoplexy with various complications such as blindness in one eye and panhypopituitarism. Awareness of physicians of Cushing’s disease symptoms could have allowed earlier diagnosis of the disease and avoided complications caused by apoplexy.