Asymptomatic Pituitary Apoplexy: To Treat Or Not To Treat?

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 163-194-Pituitary Disorders & Case Reports
Basic/Clinical
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-191
Johnson Thomas*1 and Kenneth Howell Hupart2
1Nassau University Medical Center, East Meadow, NY, 2Nassau Univ Med Ctr, East Meadow, NY
Introduction

Pituitary apoplexy is defined as a medical emergency characterized by sudden severe headache, change in vision, opthalmoplegia and pituitary insufficiency caused by hemorrhagic pituitary infarction. Decompressive pituitary surgery has been the standard approach to patients with this syndrome. Here we present a case of radiologically detected pituitary apoplexy without the classic clinical features.

Case

42 year old female was evaluated in gynecology clinic for irregular menstrual periods with galactorrhea. Work up revealed a prolactin of 211 ng/ml.  The patient denied headache, nausea, vomiting and vision changes. A presumptive diagnosis of prolactinoma was made.MRI of the brain showed an enlarged pituitary measuring 19x18 mm with hemorrhage and upward compression of the optic chiasm. Alarmed by this finding, radiology referred the patient to the ER. She was admitted for pituitary apoplexy and an urgent endocrine consult was requested. Vitals signs were normal without orthostatic changes. Visual fields and acuity were normal and extra-ocular movements were intact. She was clinically euthyroid. Galactorrhea was still present. Neither symptoms nor signs of diabetes insipidus were present.

Lab tests revealed normal electrolytes. TSH =2.2 IU/L(0.35-3.7), Free T4=0.66 ng/dl(0.76-1.46), T3=92 ng/dl(70-190).

The plan for urgent decompressive surgery was aborted and she was discharged home with a repeat MRI to be performed in 1 week.  The patient remained stable and repeat imaging did not show any change. Elective transphenoidal pituitary resection was performed 3 weeks after her first MRI. Histopathology of the gland demonstrated hemorrhage compatible with pituitary apoplexy.

Discussion

In evaluating a suspected pituitary tumor our patient had an MRI diagnostic of pituitary apoplexy, yet she lacked all evidence of this clinical syndrome. Despite reports of silent pituitary apoplexy, there is no clinical consensus regarding its optimal management. The term “apoplexy” conjures an image of imminent threat and there is an urge to do hypophysectomy as soon as possible. Patients lacking clinical features of hypopituitarism or visual apparatus compression might be treated with close monitoring and can undergo elective surgery to decrease the mortality and morbidity associated with emergency surgery. Our patient’s stability for three weeks raises the question of the necessity for surgical management

Nothing to Disclose: JT, KHH

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