Acute Pituitary apoplexy-An important complication of pituitary macro adenoma

Preeti Chiran, Upendram srinivas-shankar, Nilufer Majid and Ramprakash Narayanan

Whiston Hospital, St Helens and Knowsley NHS Trust.

We present the case of a 73 year old lady with a background of epilepsy, alcohol dependence who presented to the emergency department with seizures. During her hospital stay she started getting increasingly confused, agitated and developed  partial ptosis of left eye and  eventually dropped her GCS to 7. Visual acuity was 6/60 in both eyes and there was no visual field deficit.

Investigations showed Na 125mmol/l, K 3.2mmol/l, FT3 = 3.7pmol/l  [nr3.5-6.5],

FT4= 9.7pmol/l[nr10-20] , prolactin 21mIu/l [nr0-400], FSH 2.2Iu/l, LH 0.3Iu/l, IGF-1<3.0nmol/l[nr9-38],GH 0.2microgram/l [deficiency<6.6], serum osmolarity 273mmol/l[nr285-295].

The biochemical profile was consistent with hypopituitarism with hypogonadism and hypothyroidism.

MRI of the head showed a large mass in the pituitary gland 21mmx27mmx14mm.

Appearances were consistent with a macro adenoma within which there was haemorrhage resulting in pituitary apoplexy. A diagnosis of pituitary apoplexy causing panhypopituitarism was made.

She was started on hydrocortisone 20mg am and 10mg teatime, and thyroxine. She was treated conservatively and made good progress. There was spontaneous resolution of partial left eye third nerve palsy.

As per the suggestion by radiology MDT she had a follow up MRI pituitary three months later which showed significant decrease in the size of the macro adenoma. Appearances were suggestive of some residual haemorrhage in the pituitary stalk and the pituitary body. The optic chiasma had retracted inferiorly towards the pituitary.

Conclusion-In this case conservative management resulted in the best outcome for the patient. There are no clear guidelines to help clinicians in deciding to manage pituitary apoplexy cases conservatively or use surgical management.