Endocrine Abstracts

Introduction: Pituitary apoplexy is a rare endocrine emergency due to hemorrhage of the pituitary gland. The clinical presentation depends on the extent of bleeding and can deteriorate into a life-threatening condition if complicated by a subarachnoid hemorrhage, as previously described in 2 cases.

Case Description: A 60-year-old woman presented herself at the emergency department because of confusion for several hours. Clinical examination revealed anisocoria with mydriasis of the right pupil in an agitated woman able to move her four limbs but unable to execute commands. Seven months earlier, a macroprolactinoma with a craniocaudal diameter of 28 mm and compression of the optic chiasma was diagnosed, resistant to treatment with cabergoline and complicated by panhypopituitarism. CT scan of the brain was urgently performed and revealed an extensive suprasellar hemorrhagic mass and a subarachnoidal bleeding with extension to the lateral, third and fourth ventricles. The patient was sedated to enable placement of an external ventricular drain. CT angiography excluded an arterial aneurysm. The day after admission the patient awakened and executed commands. Visual field examination revealed bitemporal hemianopsia. MRI of the pituitary one month after admission showed a heterogenous suprasellar mass with a craniocaudal diameter of 28 mm. Endoscopic transsphenoidal resection of the pituitary mass was performed and anatomopathological examination showed necrotic tissue. Pituitary MRI 3 months postoperative revealed an important resorption of the hemorrhagic zone with a residual collection at the bottom of the sella turcica. Whether this collection is residual hematoma or adenoma could not be differentiated. Visual field examination 3 months postoperatively showed improvement, but was not normal with a bitemporal quadrantanopia. Panhypopituitarism persisted.

Conclusion: This case report described a woman with a pre-existing macroprolactinoma and a life-threatening presentation of pituitary apoplexy complicated by a subarachnoid bleeding with ventricular extension. Besides having a macroprolactinoma, this patient had no predisposing factors for apoplexy since it has shown that dopamine agonists are not associated with an increased incidence of apoplexy. Pituitary apoplexy has to be considered in an angiographically negative subarachnoid hemorrhage. However in every patient presenting with a subarachnoid bleeding, even if a medical history of a pituitary adenoma, a cerebral aneurysm always have to be excluded since this is much more frequent. The endocrine prognosis is poor because of frequently irreversible pituitary damage. This is the third case of a pituitary apoplexy complicated by a subarachnoid hemorrhage and ventricular extension with a cerebral aneurysm being excluded.