A 35-year old female presented with a 5 day history of headache, diplopia and reduced visual acuity preceded by 6 months of lethargy and weight gain. Visual field testing revealed left temporal hemianopia. Magnetic resonance imaging (MRI) showed a benign pituitary adenoma with intra-tumoural haemorrhage compressing the optic chiasm. Neurosurgical opinion advised on transphenoidal surgery. However, in view of spontaneous resolution of diplopia and recovery of peripheral vision, the decision was made to treat the patient conservatively with surveillance MRI scans and neurosurgical follow-up. Endocrine assessment showed pan-hypopituitarism, and the patient was discharged on hydrocortisone and thyroxine. Surveillance MRI scans in 2003 and 2005 showed resolution of the tumour with an enlarged pituitary fossa with a rind of pituitary tissue at the base.
Ten years later she represented with sudden headache, decreased vision and right third nerve palsy. Repeat MRI showed recurrence of pituitary macroadenoma expanding the sella turcica and extending to the right cavernous sinus with intralesional haemorrhage in the right sided supracavenous component, confirming the unprecedented recurrence of a pituitary apoplexy. As in the previous episode, her symptoms resolved spontaneously and there was no requirement for surgery. She is currently still under surveillance with the view to undertake a transphenoidal hypophysectomy if indicated clinically or radiologically.
The incidence of pituitary apoplexy is between 5 and 16% in pre-existing pituitary adenomas. We have reported a case of recurrent pituitary apoplexy that was managed conservatively. Recurrent pituitary apoplexy is rarer with no evidence in recent studies to suggest increased incidence of recurrence in conservatively managed patients. The cause of the rare phenomenon of recurrent pituitary apoplexy is not fully understood. The working hypothesis is that of a good vascular supply in younger patients, which makes them prone to recurrent pituitary bleeds.