85 year old female presented to the ED with the worst headache of her life for four days. Past medical history was significant for migraines, diabetes mellitus, and recent zoster involving CN VII. The left sided headache radiated to her neck and was not aggravated by light or sounds. The patient was non-febrile and appeared non-toxic. No rash was evident and neurological exam was normal. Initial labs were significant for mild hyponatremia of 124. Non-contrast head CT and subsequent angiogram of head and neck showed no abnormalities. Her symptoms were initially attributed to post-herpetic neuralgia. Hospital course was complicated by increasing insulin requirement and worsening hyponatremia as low as 118. Over the next several days her pain improved, but she suddenly developed deficits in the vision of her left eye. An urgent MRI of the head showed a 1cm pituitary mass with mass effect on the optic chiasm and compression of the left optic nerve. A dedicated sellar MRI showed pituitary apoplexy. Additional work up showed elevated cortisol and ACTH, with low LH, FSH and TSH. The patient underwent transphenoidal resection with resolution of her headache and eye symptoms.
Pituitary apoplexy is an uncommon cause of headache and refers to hemorrhage into a pituitary mass. Risk factors include larger adenomas and conditions that induce hemorrhage such as thrombocytopenia, anticoagulation, trauma, and hypertension. The classical presentation is a sudden headache with progression to nausea, diminished visual acuity, opthalmoparesis, and decreased mental status. As the bleeding extends, it can compress contents of the sella, such as optic nerve, optic chiasm and cavernous sinus. The loss of secretory function can lead to panhypopituitarism and adrenal insufficiency. Our patient had an ACTH secreting adenoma with an episode of apoplexy causing clinical symptoms secondary to compression of nerves. The patient maintained elevated ACTH level which prevented adrenal insufficiency. The elevated cortisol level caused uncontrolled serum glucose and worsening hyponatremia.
The detection of pituitary apoplexy is an MRI diagnosis. As in our patient, CT scan will be negative in up to 80% of cases. MRI imaging should be done in concordance with administration of corticosteroids and hemodynamic stabilization if adrenal insufficiency is suspected. The treatment of pituitary apoplexy is typically via transphenoidal surgery. Post-op, as many as 83% of patients will have hypopituitarism and will require steroid replacement.
Pituitary apoplexy is an uncommon, but very important cause of headaches. High degree of clinical suspicion is merited, particularly if the patient is developing eye symptoms or hemodynamic instability from adrenal insufficiency. A prompt MRI should be performed to detect pituitary apoplexy, which can be missed on CT scan. Treatment is via surgical transphenoidal resection and medical management of hypopituitarism.
To cite this abstract:Potashinsky A, Palma M, Hong J. Perplexing Apoplexy. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 656. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/perplexing-apoplexy/. Accessed April 2, 2020.