Abstract
Background. Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The typical clinical presentation of PA includes acute onset of severe headache, visual disturbance, cranial nerve palsy, and altered level of consciousness. Case Report. A 78-year-old man presented to the emergency department with one-day history of ptosis and diplopia and an acute-onset episode of altered level of consciousness which was resolving. He denied having headache, nausea, or vomiting. Physical examination revealed third-cranial nerve palsy and fourth-cranial nerve palsy both on the right side. Noncontrast computed tomography (CT) scan of the head was unremarkable. Brain magnetic resonance imaging (MRI) showed a pituitary mass with hemorrhage (apoplexy) and extension to the right cavernous sinus. The patient developed another episode of altered level of consciousness in the hospital. Transsphenoidal resection of the tumor was done which resulted in complete recovery of the ophthalmoplegia and mental status. Conclusion. Pituitary apoplexy can present with ophthalmoplegia and altered level of consciousness without having headache, nausea, or vomiting. A CT scan of the head could be negative for hemorrhage. A high index of suspicion is needed for early diagnosis and timely management of pituitary apoplexy.
Highlights
Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland
Pituitary apoplexy (PA) is a potentially life-threatening disorder caused by acute ischemic infarction or hemorrhage of the pituitary gland [1]
Pituitary apoplexy presenting with ophthalmoplegia and recurrent brief episodes of altered level of consciousness, without demonstrating headache, nausea, or vomiting has not been previously described in the literature
Summary
Pituitary apoplexy (PA) is a potentially life-threatening disorder caused by acute ischemic infarction or hemorrhage of the pituitary gland [1]. Pituitary adenomas are prone to bleeding and necrosis, possibly because they outgrow their blood supply or because tumor expansion causes ischemia and resultant infarction by compressing the vessels against the sellar diaphragm [2]. Patients can present with visual disturbances, diplopia, hypopituitarism, and impaired consciousness which, together with the radiological evidence of a pituitary lesion, establish the diagnosis [4]. Progressive visual, or neurological manifestations, surgical decompression is indicated [4], while the patients with mild stable clinical picture can be managed conservatively [4]. Pituitary apoplexy presenting with ophthalmoplegia and recurrent brief episodes of altered level of consciousness, without demonstrating headache, nausea, or vomiting has not been previously described in the literature. The following is an illustrative case of an unusual presentation of PA in an elderly man and a focused review of the literature
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