Endocrine Abstracts

Summary: Pituitary apoplexy (PA) is a rare clinical situation caused by pituitary infarction with or without hemorrhage. Although it is usually spontaneous, dopaminergic agonists (DA) are known to be predisposing factors, particularly Bromocriptine, more rarely Cabergoline. We report the case of a 31 years old female patient, with no notable pathological history, consulted for headaches and menstrual irregularities. Pituitary hormone levels were normal except for hyperprolactinemia at 110 ng/ml (<25). MRI showed a pituitary microadenoma of 7x3 mm. Cabergoline was started at a dose of 0.5 mg per week, which brought the prolactin level down to the normal range (21 ng/ml). Five months later, the patient presented to the emergency room with a sudden headache and decreased visual acuity. The physical examination revealed a patient in good general conditions without shock, the ophthalmological examination showed bilateral papilledema and preserved visual acuity. The visual field showed bilateral scotomas and the brain MRI revealed a necrotic-hemorrhagic transformation of the adenoma with an empty sella turcica. The endocrine work-up did not reveal any hormonal dysfunction. The patient was put on high doses of corticosteroids. The evolution is marked by a clear improvement of the visual field and papillary oedema. PA is a rare situation. The management of apoplexy is multidisciplinary, with hospitalization in a neurosurgical or endocrinological setting in close proximity to a neurosurgical center recommended. Glucocorticoid treatment should be started immediately in case of (near constant) corticotropic insufficiency, hemodynamic instability and altered consciousness. Decompression surgery is indicated in cases of impaired consciousness, recent or worsening severe visual impairment. Isolated oculomotor damage may be an indication for surgery for some teams but not for others. Conservative treatment is considered under the cover of corticosteroid therapy and clinical and ophthalmological monitoring. It is indicated in cases of contraindication to surgery (when the benefit/risk balance is against surgery), stable or long-standing moderate visual disorders or isolated oculomotor paralysis. Often reported with Bromocriptine, PA can also occur with Cabergoline. Due to the high mortality and morbidity of apoplexy, it should be borne in mind that close monitoring is necessary when treatment with DA is prescribed and the patient should be informed of this risk. Although DA precipitate risk, treatment can be continued for hormonal and anti-tumor remission.

Keywords: pituitary apoplexy prolactinoma, Cabergoline.