SAT-482 Pituitary Tumor Apoplexy Due to a Nonfunctioning Hemorrhagic Pituitary Macroadenoma

Abstract

BACKGROUND Pituitary apoplexy is characterized by acute neuroophthalmologic features due to bleeding in pituitary adenoma. Clinical manifestations occur due to local mass effect, spread of blood in subarachnoid space and deficiency of pituitary hormones. Clinical features include headache, visual impairment, external ophthalmoparesis, altered sensorium and hormone deficiencies. Causes of pituitary apoplexy are infarction, bleeding within the pituitary adenoma or metastasis. Surgery is indicated for decompression and relief of neuroophthalmic features. THE CASE A 65-year old male was admitted due to right eye ptosis, diplopia and blurring of vision. Two days prior, he was rushed to hospital due to headache and BP elevations. Plain cranial CT scan revealed age-related brain atrophy and gliosis. He was then discharged, with Losartan 100mg once daily, taken with good compliance. Examination showed stable vital signs. He was awake, coherent and oriented. Cranial nerves examination revealed right eye ptosis with medial, upward and downward gaze palsy. Pupillary sizes were 3 mm O.D. with nonreactive light reflex, 2 mm O.S. with brisk light reflex; no bitemporal hemianopsia. He was unable to read from 1.5 feet with both eyes. CT angiogram revealed suprasellar mass (1.4 x 2.3 x 1.2 cm), no evidence of vascular malformation. Cranial MRI with contrast defined the mass to be 2.6 cm lobulated sellar-suprasellar mass, compressing the optic chiasm, consistent of hemorrhagic pituitary macroadenoma. Hormonal studies showed low levels of serum cortisol (11.3 nmol/L; N 171- 536 nmol/L), FT4 (5.07 pmol/L N; 12-22 pmol/L), FT3 (2.5 pmol/L; N 3.1-6.8 pmol/L), LH (0.19 mIU/ml; N 0.57- 12.07 mIU/ml), testosterone (0.03 ng/mL; N 2.8-8ng/ml) and prolactin (2.26 ng/ml; N 3.46-19 ng/ml). TSH (0.30 uIU/ml; N 0.27-4.2 uIU/ml) and FSH (1.35 mIU/ml; N 0.95-11.95 mIU/ml) were normal. Hydrocortisone IV and levothyroxine were administered prior surgery. Patient underwent transphenoidal excision of pituitary tumor with no intraoperative complications. Biopsy of tumor revealed pituitary adenoma. Patient manifested postoperatively with improvement of ptosis and extraocular muscle movement on right eye. There was full lateral and downward gaze. Gradual recovery of upward and medial gaze on right eye was also seen. Patient was discharged with steroid and hormone replacement. CONCLUSION Pituitary apoplexy is a rare but life-threatening condition. Commonly implicated cause is pituitary macroadenoma. Immediate recognition allows prompt steroid administration and surgical decompression. Long-term hormone replacement is required. Recovery of visual symptoms is commonly realized. REFERENCE Rajesh Verma et al. Pituitary apoplexy syndrome as the manifestation of intracranial tuberculoma. BMJ Case Rep. 2014