IMPORTANT: We currently have a number of bugs related to image cropping and are actively trying to resolve them. In the meantime, we have disabled cropping. Apologies for any inconvenience. Stay informed: radiopaedia.org/chat

Pituitary apoplexy

Case contributed by Bruno Di Muzio
Diagnosis certain

Presentation

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

Patient Data

Age: 63-year-old
Gender: Male

MRI Brain

ct

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

MRI Brain

mri

Pituitary mass, which is centrally non-enhancing, with intrinsic regions of high T1 signal suggestive of blood product is again demonstrated, with associated remodeling 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 tumor composed of solid sheets nests and trabeculae. Tumor 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 tumor coagulative necrosis, consistent with recent hemorrhagic 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 tumor: Silent gonadotroph cell pituitary adenoma with features of recent hemorrhagic infarction (pituitary apoplexy). 

Case Discussion

Features of a necrotic/hemorrhagic 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 characterized 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. 

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.