Pituitary apoplexy

Case contributed by Dr Bruno Di Muzio

Presentation

Headaches, diplopia, and incomplete 3rd to 6th cranial nerve palsies on the left.

Patient Data

Age: 63-year-old
Gender: Male
CT

MRI Brain

Solid heterogeneous pituitary mass with associated remodelling enlargement the pituitary fossa and extension superiorly into the suprasellar cistern. Laterally the lesion bulges into the cavernous sinus.

MRI

MRI Brain

Pituitary mass, which is centrally non-enhancing, with intrinsic regions of high T1 signal suggestive of blood product is again demonstrated, with associated remodelling enlargement the pituitary fossa and extension superiorly into the suprasellar cistern abutting and compressing the chiasm. Laterally, the lesion bulges into the cavernous sinuses without definite invasion. This is more pronounced on the left, with a 3rd cranial nerve is compressed between the mass in the adjacent dura. Normal flow voids are noted within the internal carotid arteries.

Pathology

MICROSCOPIC DESCRIPTION: Sections show a hypercellular tumour composed of solid sheets nests and trabeculae. Tumour cells contain scant granular eosinophilic cytoplasm, round nuclei with finely granular chromatin and inconspicuous nucleoli. No mitoses are seen. No normal anterior pituitary tissue is included. There is extensive tumour coagulative necrosis, consistent with recent haemorrhagic infarction. Immunohistochemical results for pituitary hormones show focal FSH positive staining. The GH, LH, TSH, ACTH and Prolactin immunostains are all negative. The Topoisomerase proliferation index is approximately 1%.

DIAGNOSIS: Pituitary tumour: Silent gonadotroph cell pituitary adenoma with features of recent haemorrhagic infarction (pituitary apoplexy). 

Case Discussion

Features of a necrotic/haemorrhagic pituitary macroadenoma with impingement upon the optic chiasm, and cavernous sinus content, particularly on the left. 

Pituitary apoplexy represents a clinical syndrome related to an acute hemorrhagic or ischemic transformation of a pituitary macroadenoma or even the normal adenohypophysis. Clinically it is characterised by a headache, visual impairment, and ophthalmoplegia.

Bleeding in the pituitary gland is clinically silent in most cases 1.

Histology images and report were courtesy of the Royal Melbourne Hospital Pathology Department. 

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Case information

rID: 48396
Case created: 5th Oct 2016
Last edited: 1st Nov 2016
Tag: rmh
Inclusion in quiz mode: Included

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