Seventy six year old man presented with sudden onset headache for 3 days. He was seen by the GP and treated for migraine. But no improvement in his headache and he developed drooping of left eyelid and blurring of vision. No other neurological symptom.
On examination left ptosis with normal visual fields to confrontation method. Initial differential diagnosis was isolated 3rd nerve palsy probably due to posterior communicating artery aneurysm. He was on aspirin 300 mg for last 10 years as suggested by cardiologist, which was reduced to 75 mg.
His CT Head with Angiogram showed large supra sellar mass measuring 2.3×1.7 cm with no evidence of aneurysm. MRI showed marked expansion of pituitary fossa with macro adenoma and evidence of apoplexy and chiasmal compression.
|Pituitary hormone profile|
Patient was reviewed by Neuro surgeon and in view of his eye symptoms he warrants surgical intervention.
He was commenced on Dexamethasone and underwent Trans sphenoidal resection. He was reviewed by Endocrinologist, who has suggested his apoplexy could be secondary to high dose aspirin. Commenced on Thyroxine and Testosterone replacement.
Histopathology showed mononuclear cell infiltrates with necrotic and haemorrhagic fragments suggestive of Pituitary Apoplexy.
Patient was reviewed in the outpatient clinic and his visual symptoms have improved dramatically.
In conclusion, pituitary apoplexy is often the initial manifestation of a pituitary adenoma, and the diagnosis should be considered in all patients with acute severe headache, particularly in the presence of neuro-ophthalmic signs. The majority of these patients have hypopituitarism at presentation, and steroid replacement (in deficient patients) during the acute stage could decrease morbidity and mortality.