Endocrine Abstracts

Introduction: Pituitary apoplexy (PA) is a rare but potentially life-threatening complication that may occur in pituitary neuroendocrine tumors (PitNETs). Non-functioning PitNETs (NF-PitNETs), specifically macroadenomas, seem to have a higher risk of apoplexy.

Case description: A 45-year-old male presented to the emergency unit with a one-week history of binocular visual deterioration (blurred vision, diplopia, visual field defect) with left-side predominance, dull headache and nausea. His past medical history was significant for arterial hypertension. The ophthalmological examination showed that visual acuity was limited to hand motion in the left eye with visual field impaired in all directions and a decrease of visual acuity to 0.5 in the right eye without visual field deficits. Vital signs were normal. Apart from the visual impairment, the neurological examination was normal. Initial laboratory tests showed mild hyponatremia (Na⁺: 131 mmol/l). A computed tomography of the brain was performed and revealed a haemorrhagic sellar mass with suprasellar extension. The subsequent magnetic resonance imaging confirmed a large pituitary lesion measuring 20x27x29 mm with signs of intratumoral bleeding, compressing and displacing the optic chiasm, compressing posterobasal part of the frontal lobes, and reaching the floor of the third ventricle. The hormonal evaluation showed central hypothyroidism (TSH: 0.761 μIU/ml, FT4: 0.65 ng/dl, FT3: 1.21 pg/ml) and hypogonadotropic hypogonadism (LH: 1.8 mIU/ml, FSH: 4.26 mIU/ml, testosterone: 0.69 nmol/l); the corticotroph axis was preserved (ACTH: 25.3 pg/ml, random cortisol: 25.30 μg/dl). The patient received hydrocortisone intravenously and underwent endoscopic endonasal transsphenoidal surgery. A total resection of the pituitary lesion was achieved. Postoperatively, the ophthalmological deficits improved, however, due to panhypopituitarism, the patient continued oral hydrocortisone. Additionally, levothyroxine, testosterone, and growth hormone replacement therapy were introduced. Due to the transient diabetes insipidus, he required also temporary treatment with desmopressin which was discontinued 12 weeks after the surgery. Pathological examination revealed gonadotroph PitNET with tumor positive staining for FSH, LH and alpha-subunit. The patient is still followed up at our Department.

Conclusions: PA, although being a rare complication of PitNETs, is considered an endocrine emergency, requiring prompt diagnosis and appropriate treatment, especially in cases, when PA is the first manifestation of PitNET. Management of PA should be individualized, however, all patients should receive corticosteroids, regarding the coexistence of adrenal insufficiency. In the case of optic chiasm compression, a neurosurgical intervention should be urgently performed.