Pituitary apoplexy is an acute medical emergency but there are no evidence based management guidelines, especially for neurosurgical intervention.
A 35-year old male presented with sudden onset severe headache. On examination blood pressure was 180/120 without any lateralising neurological signs. He appeared acromegalic with a short history of enlarging hands & feet. Emergency CT scan and a MR scan later confirmed haemorrhagic pituitary adenoma, 3 cm in height, moderately compressing the optic chiasm. Formal perimetry was normal and daily monitoring of visual fields by confrontation did not reveal evolving deficits. Random serum growth hormone (GH) levels were elevated >100 mU/l. He was discharged home on hydrocortisone and antihypertensives.
Formal endocrine investigations were carried out one month later and demonstrated mean GH through a 4-point day profile of 21 mU/l. Octreotide LAR was started and on 20 mg once monthly, GH profile was suppressed to 0.5 mU/l with progressive fall in IGF-1 to 51 nmol/l (reference range 1337 nmol/l). Basal 9 am serum cortisol was 367 nmol/l, suggesting adequate ACTH reserve. Other anterior pituitary function tests remained consistently normal. Serial MR Scans showed progressive reduction in size of the pituitary adenoma to 9 mm diameter, confined to pituitary fossa.
Many studies advise early decompressive surgery for pituitary apoplexy for better visual and endocrine outcome, although a recent series has suggested that conservative management may be more appropriate in many cases. In this case, despite some evidence of chiasmal compression, conservative management was justified by the lack of actual visual compromise, and allowed good control of the underlying acromegaly with significant tumor shrinkage. This may facilitate surgical treatment for longer-term disease control.
01 - 05 Apr 2006
European Society of Endocrinology