Background: PA is a clinical syndrome secondary to hemorrhage or infarction of pituitary tumour, presenting with sudden onset headache and oculomotor palsy. PA may be managed conservatively in patients without visual disturbances.
Aim: To describe PA patients illustrating typical aspects and peculiarities.
Results: Case 1, a 49 years old (yo) male, presented for loss of consciousness in the ER. MRI showed a giant pituitary tumour, which was operated transcranially. Pathology revealed a pituitary adenoma, with extreme hyperprolactinemia, uncontrolled by high-dose cabergoline (5 mg/week). Full remission was achieved following external irradiation and longterm cabergoline. At last follow-up, prolactinemia was normal off cabergoline. Panhypopituitarism was controlled on levothyroxin, prednisone and testosterone. Case 2, a 2.10 m tall male, presented with acromegalic features at age 59 and negative history for PA symptoms. MRI showed a pituitary cystic mass. IGF-I was normal (0.81 × ULN) and GH suppressed during OGTT, suggesting spontaneous cure, presumably due to asymptomatic PA. Case 3, a 62 yo male, presented with thunderclap headache and oculomotor nerve palsy. MRI showed a sellar mass compressing the chiasm, and he underwent transcranial surgery, resulting in empty sella. Pathology and hormonal evaluation demonstrated a non-functioning pituitary adenoma. He associated macular degeneration and developed severe loss of visual acuity and panhypopituitarism. At last follow up, the tumour showed recurrent intrasellar growth. Case 4, a 70 yo female on oral anticoagulants for atrial fibrillation, presented in an Emergency Department for severe headache, nausea and emesis. CT imaging showed a suprasellar mass abutting the chiasm, with subtle temporal superior right quadranopsia. Hormonal evaluation revealed a non-functional tumour with no pituitary insufficiency and symptoms resolved with conservative management. Case 5, a 78 yo male presented for severe headache and diplopia. He displayed typical acromegalic features, included progressive acral enlargement since his 30s. IGF-I was 8 × ULN and pituitary CT demonstrated a large macroadenoma. Delayed (1 month) transsphenoidal surgery led to complete biochemical remission.
Conclusions: Our cases illustrate key aspects of PA: diagnosis can be missed even with classical presentation, more so in asymptomatic patients. PA can lead to apparent cure of both non-functional and functional adenomas, yet longterm follow-up is required for the risk of recurrence. Optimal management (conservative vs. surgical) is still debated and should be individualized.
Keywords: pituitary apoplexy, severe headache sellar mass
18 - 21 May 2019
European Society of Endocrinology