Endocrine Abstracts

Introduction: Pituitary apoplexy is an endocrinological emergency that can be life-threatening if treatment is delayed. Apoplexy occurs either due to haemorrhage or infarction of a pituitary tumour.

Case History: A 19-year-old male, presented with a sudden severe headache and visual disturbances. The examination was normal with stable haemodynamic parameters and tanner staging 5. An urgent MRI pituitary revealed a haemorrhagic pituitary macroadenoma compressing the optic chiasm. Neuro-ophthalmology revealed bitemporal hemianopia (Apoplexy score 2). He was commenced on prophylactic steroid replacement. Further investigations were as below. A diagnosis of prolactinoma with apoplexy was made and he was commenced on Cabergoline. The repeat MRI pituitary after 6 months revealed significant size reduction with no optic chiasma compression. Prolactin levels were normalized. Unfortunately, He developed a second episode of apoplexy with deterioration of visual acuity and fields. MRI pituitary showed a significant interval upgrade in tumor size with subacute bleeding and compression of the optic chiasm, 3rd ventricle with para-sellar extension. At this point, the pituitary apoplexy score was 4/10, therefore, urgent surgery was offered. He made an excellent recovery.

Discussion: Pituitary apoplexy complicates about 2-12% of pituitary tumours with the majority being previously undiagnosed as in our case. This condition was first described as a haemorrhage into a pituitary tumour by Bailey in 1898 (1). The best management approach is largely controversial between conservative and surgery. To determine a uniform clinical assessment and decision-making, Rajasekaran et al have introduced a pituitary apoplexy score (PAS) based on 4 parameters such as visual acuity, visual field defects, ocular paresis, and Glasgow coma scale (2). A score of ≥ 3 indicates surgery. An early surgical treatment within 7-8 days is associated with a better neuro-ophthalmological and endocrinological outcome.

References: 1. Bailey. P. Pathological report of a case of acromegaly with special reference to the lesions in the hypophysis cerebri and in the thyroid gland; and a case of hemorrhage into the pituitary. Philadelphia Med J. 1898; 1: 789-792. 2. Rajasekaran. S, et al. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol (Oxf). 2011 Jan;74(1):9-20.