Forced conservative management of a patient with pituitary tumour apoplexy and reduced conscious level
A Advani1, RA James2, A Jenkins3, JH Parr1, J Scott1, R Cooper1 & ST Wahid1
Historically, acute neurosurgical decompression has been considered treatment of choice for pituitary apoplexy with some studies advocating a conservative approach. We describe a patient, with reduced consciousness due to apoplexy of a gonadotroph adenoma, in whom there was spontaneous tumour shrinkage. A 68-year-old gentleman presented following a collapse with hypothermia, bradycardia and bitemporal hemianopia. Initial investigations showed low plasma sodium and glucose. Over 24 hours his conscious level deteriorated and he required ventilation. CT-scan revealed a 20×17 mm pituitary tumour and subsequent MRI confirmed a pituitary mass lesion with marked sellar expansion and high signal on pre-contrast T1 consistent with recent haemorrhage. He was commenced initially on steroids and subsequently triiodothyronine. Initial endocrine investigations confirmed the presence of an FSH-oma: FSH 36.2 U/l (1.39.2), LH 0.8 U/l (212), free T4 5.8 pmol/l (9.020.0), TSH 2.14 mIU/l (0.23.0), cortisol 153 nmol/l (200650), prolactin 86 mU/l (40375), growth hormone 0.3 mU/l, IGF1 7.0 nmol/l (1130), testosterone 1.6 nmol/l (5.430.4). Subsequently the patient developed an aspiration pneumonia and melaena requiring blood transfusion. As a result, acute neurosurgical intervention was prevented and over the course of the following days the patient regained consciousness. Seven weeks after initial presentation the patients FSH levels had fallen to 0.2 U/l and follow up MRI-scan confirmed marked shrinkage of the pituitary tumour with no optic chiasm compression. The patient continued to require pituitary replacement therapy and the bitemporal hemianopia remained. Acute co-morbidities did not allow neurosurgical decompression, the preferred intervention in this case of pituitary apoplexy with reduced consciousness. However, conservative management (advocated routinely by some) was associated with marked involution of the tumour and resolution of the conscious level. The neurosurgeon commented Had I operated on this patient I would have been very pleased with the radiological outcome!