Pituitary apoplexy complicated by subarachnoid hemorrhage: the role of stress and cabergoline therapy

Mariam Akacka; Kouloud Boujelben; Mouna Elleuch; Hamdi Frikha; Salah Dhoha Ben; Mouna Mnif; Kacem Akid Faten Haj; Mohamed Abid; Nadia Charfi; Majdoub Nabila Rekik

doi:10.1530/endoabs.110.EP1239

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Endocrine Abstracts (2025) 110 EP1239 | DOI: 10.1530/endoabs.110.EP1239

ECEESPE2025 ePoster Presentations Pituitary, Neuroendocrinology and Puberty (220 abstracts)

Pituitary apoplexy complicated by subarachnoid hemorrhage: the role of stress and cabergoline therapy

Mariam Akacka ¹ , Kouloud Boujelben ¹ , Mouna Elleuch ¹ , Hamdi Frikha ¹ , Dhoha Ben Salah ¹ , Mouna Mnif ¹ , Faten Haj Kacem Akid ¹ , Mohamed Abid ¹ , Nadia Charfi ¹ & Nabila Rekik Majdoub ¹

Author affiliations

¹Hedi Chaker University Hospital, Endocrinology Department, Sfax, Tunisia

JOINT3307

Introduction: Giant prolactinomas, due to their size and invasive nature, can lead to serious complications. While cabergoline is effective in reducing the tumor and normalizing prolactin levels, it can cause rare but significant side effects, such as pituitary apoplexy, especially after rapid tumor reduction or physical and emotional stress.

Observation: A 45-year-old patient, with no significant family history, was diagnosed with a 7 cm invasive pituitary macroadenoma (Knosp 4), associated with a giant prolactinoma, hyperprolactinemia, and visual disturbances. Cabergoline was started due to surgical contraindication, resulting in a significant reduction in prolactin from 12,000 ng/ml to 246 ng/ml after one month. Three months later, ophthalmological exams were normal, except for the exclusion of a blind spot. Prolactin was below 0.5 ng/ml, and MRI showed a significant reduction in tumor size (35 mm). One year later, after a physically demanding move and significant psychoaffective stress, the patient developed headaches and vomiting. MRI revealed pituitary apoplexy with bilateral subarachnoid hemorrhage, without hydrocephalus. He was hospitalized, and in the absence of severe neurological signs or major visual disturbances, a conservative treatment approach was chosen.

Discussion: This case describes a giant prolactinoma treated with cabergoline, with an initially favorable response. However, after physical stress (moving), the patient developed pituitary apoplexy complicated by subarachnoid hemorrhage. Physical effort likely triggered the apoplexy due to the tumor’s proximity to the subarachnoid space. Although cabergoline is effective, it can rarely cause apoplexy, especially with large adenomas, due to rapid changes in tumor vascularization. Close follow-up is essential.