Pituitary apoplexy

Case contributed by Assoc Prof Frank Gaillard

Presentation

Acute headache and visual disturbance.

Patient Data

Age: 30 years
Gender: Female
X-ray

Lateral view of the skull demonstrates expansion of the pituitary fossa.

CT

The sella is expanded and contains multiple foci of hyperdense material, particularly peripherally, in keeping with hemorrhage, possibly into a mass. No other intracranial hemorrhage. No cerebral mass-effect or evidence of cerebral infarction. Ventricles and sulci age-appropriate.

MRI

The pituitary gland is enlarged and shows suprasellar extension. The gland is replaced by a lesion which is predominantly isointense on T1 with some peripheral areas of T1 hyperintensity corresponding with hyperdensity on CT. Heterogenous T2 signal, predominantly hyperintense with hypointense foci posterosuperiorly, correlating with T1 hyperintensity and consistent with blood product. Thin marginal enhancement but no solid, nodular or central enhancement. This lesion abuts the optic chiasm, which is displaced superiorly and is mildly flattened and splayed. The optic tracts demonstrate normal signal.

Conclusion: Recent hemorrhage into a cystic pituitary lesion, most likely a macroadenoma. In this clinical context, features are consistent with pituitary apoplexy. 

Case Discussion

The patient went on to have a resection. 

Histology

The sections, examined at multiple levels, show a collection of red blood cells and some fibrin. There is minimal viable tissue for histological assessment. This could represent pituitary apoplexy or hemorrhage within a cystic lesion. Clinicoradiological correlation is required.

FINAL DIAGNOSIS: Small amount of fresh hemorrhage. 

Discussion

In this instance, no histological evidence of adenoma was identified and thus the underlying lesion cannot be established with 100% certainty. The enlargement of the pituitary fossa, however, suggests that a macroadenoma is most likely. This is also supported merely by underlying frequency. The other possibility is that it is hemorrhage into a Rathke's cleft cyst although this is less likely. 

In any case, the clinical presentation is that of pituitary apoplexy

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Case information

rID: 76240
Published: 19th Apr 2020
Last edited: 19th Apr 2020
Inclusion in quiz mode: Included

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