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Case Reports and Clinical Images

Pituitary Apoplexy Presenting as Acute Headache

Shijie Zhou, MD*, Ameen Patel, MB, FRCP, MACP

Department of Medicine, McMaster University, Hamilton, Ontario, Canada

Abstract

Pituitary apoplexy (PA) is an acute and potentially vision-threatening clinical condition caused by hemorrhage or infarction of the pituitary gland. PA usually occurs in a pre-existing pituitary tumor. Severe headache is almost universal and is often accompanied by hormonal deficiencies that require immediate empiric treatment. Magnetic resonance imaging is the recommended diagnostic imaging modality. Patients without acute neurological decline can be managed conservatively.

Résumé

L’apoplexie hypophysaire est un état clinique aigu pouvant faire perdre la vue qui est causée par une hémorragie ou un infarctus de l’hypophyse. Elle survient généralement en présence d’une tumeur hypophysaire préexistante. Un mal de tête intense apparaît dans pratiquement tous les cas, accompagné souvent d’insuffisances hormonales qui nécessitent un traitement empirique immédiat. L’imagerie par résonance magnétique est la modalité d’imagerie diagnostique recommandée. Les patients ne présentant aucune détérioration neurologique aiguë peuvent être pris en charge de manière conservatrice.

Corresponding Author: Shijie Zhou: tina.zhou@medportal.ca

Submitted: 11 October 2021; Accepted: 24 January 2022; Published: 21 June 2022

Doi: http://dx.doi.org/10.22374/cjgim.v17i2.588

All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

Case

A 20-year-old female was admitted to hospital with severe and sudden onset of headache. She had no focal neurological complaints, nausea, or vomiting. She had no pre--existing medical conditions or relevant family history. Her only medication was ethinyl estradiol/drospirenone for birth control. She smoked a package of cigarettes daily but did not use alcohol or any recreational drugs. Her vital signs and examination were normal with no ocular palsies or vision impairment.

Computed tomography (CT) with contrast of the head established pituitary hemorrhage without suprasellar extension or mass effect (Figure 1). This was confirmed on -contrast-enhanced brain magnetic resonance imaging (MRI). There was no discrete evidence of a pituitary adenoma (Figure 2). There was no clinical or biochemical evidence of pituitary hormonal deficiency with normal random corticol, prolactin, free thyroxine, thyroid-stimulating hormone (TSH), insulin growth factor-1 (IGF-1), growth hormone (GH), luteinizing hormone (LH), follicular--stimulating hormone (FSH), and estradiol. A repeat MRI after 24 h established stable findings. No other structural abnormalities were observed on imaging.

Figure 1. Computed tomography of the head (axial view) established a 1-cm × 0.6-cm hyperdense area referring to pituitary hemorrhage.

Figure 2. Magnetic resonance imaging of the brain with gadolinium (sagittal view) indicated a T1 signal hyperintensity within the posterior aspect of the sella measuring approximately 1.2 × 0.8 × 0.7 cm, in keeping with pituitary hemorrhage.

Her headache resolved after 5 days, and she was discharged. After 1 year, repeat MRI with gadolinium demonstrated a stable well-defined area of T1 signal hyperintensity and T2 signal hypointensity within the posterior aspect of the pituitary gland.

Pituitary apoplexy (PA) is a rare clinical syndrome caused by acute hemorrhage or infarction, usually within a pituitary adenoma. It manifests as a sudden onset of severe headache, often accompanied by ocular palsy, visual disturbance, or endocrine abnormalities.1,2 Patients can have deficiencies in one or more of the anterior pituitary hormones. Risk factors include pituitary adenoma, head trauma, pregnancy, anticoagulants, surgery, and hypertension.2,3 Subclinical PA can exist in asymptomatic patients.

Pituitary apoplexy is suspected based on clinical presentation or biochemical endocrine abnormalities. Diagnosis is confirmed by MRI.2 Patients may require emergent hydrocortisone to combat hypocortisolemia-induced hemodynamic instability.3 Neurosurgical intervention is considered with ophthalmic involvement or acute deteriorations. Most patients have a good visual recovery with conservative treatment.3

Our patient was a mild case of PA, as headache was her only presenting symptom, which had a wide differential of its own, and normally wouldn’t suggest PA. Imaging was done because of unexplained headache. Once PA is identified, a full work-up is warranted to identify and treat potentially lethal complications regardless of symptoms.

Statement of Informed Consent

This case report was written and submitted with the consent of the patient.

REFERENCES

1. Widemberg Le, Glezer A, Marcello DB, Gadelha MR. Apoplexy in nonfunctioning pituitary adenomas. Pituitary. 2018;21: 138–44. 10.1007/s11102-018-0870-x

2. Bajwa R, Kaur PP, Paluzzi A. Headaches and hormones: A potentially lethal combination. BMJ. 2016;352:h6752. 10.1136/bmj.h6752

3. Rajasekaran S, Vanderpump M, Baldeweg S. et al. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol. 2011;74:9–20. 10.1111/j.1365-2265.2010.03913.x