I would love to remove my head = pituitary apoplexy


R Eltayeb, N Kaimal


Abstract: Pituitary apoplexy is a medical emergency and rapid replacement with hydrocortisone may be lifesaving. Apoplexy is often the first manifestation of an underlying pituitary adenoma. We report a case of apoplexy in a patient with an undiagnosed pituitary adenoma who presented with sudden onset headache and subtle neurology in the form of minor left ptosis.


A 64-year-old male with a background of hypertension, asthma-COPD overlap syndrome and bronchiectasis presented to A&E with acute sudden onset headache, vomiting and dizziness. He denied any visual symptoms. Examination revealed very mild left sided ptosis with no other neurological deficit. Urgent non-contrast CT head showed no acute haemorrhage or infarction.


Due to the persistent symptoms and unexplained partial ptosis, an out of hours CT angiogram was requested. This showed a 4 x 5 mm aneurysm of the distal MCA, enlargement of the pituitary fossa and a possible pituitary mass. Urgent ophthalmology review confirmed left partial ptosis and bitemporal hemianopia with possible left ischemic optic neuropathy. Hormonal profile showed random cortisol of 144 nmol/l (whilst on prednisolone 30 mg/d for COPD), normal thyroid function tests and prolactin. Testosterone was low at 5.9nmol/l. Pituitary MRI with contrast done on the following day showed an enlarged pituitary measuring 2.1 X 2.2cm.


Heterogenous signal was noted on T1 weighted images with central low signal but peripheral high signal suggestive of blood products, in addition to the MCA aneurysm. He was transferred to the local neurosurgical centre and underwent transsphenoidal pituitary surgery. Postoperative visual field assessment showed full recovery. He was started on hydrocortisone replacement. The MCA aneurysm is being managed conservatively.


Learning points:


1.    Pituitary apoplexy often occurs in undiagnosed pituitary tumours

2.    Subtle neurology in association with other symptoms should trigger further evaluation

3.    Dual pathology can co-exist, such as aneurysm and apoplexy

4.    Multidisciplinary approach is crucial.