PMON130 Pituitary apoplexy presenting as left basal ganglia hemorrhage
Authors: Zahid Maleeha , Shakil Jawairia 
Published: November 2022

Abstract

Introduction
The clinical manifestations of pituitary apoplexy (PA) are highly variable and are caused by a rapid increase in the size of intrasellar contents, leading to an increase in intrasellar pressure. Headache, visual disturbances, cranial nerve palsies, and pituitary insufficiency are the most frequent symptoms. Cerebral ischemia and hemorrhage are rare complications of PA. Here we present a case of a young male who presented with left basal ganglia hemorrhagic stroke and pituitary apoplexy.

Case Presentation
39-year-old male presented to emergency department for acute onset of nausea, vomiting and right sided weakness for past 2-3 days. Soon after, patient became acutely confused. On examination, he was hypertensive, tachycardiac, tachypneic and obtunded. His pupils were 3 mm, equal, sluggish. He was moving left side but no movements on the right side of his body. In view of rapidly deteriorating mental status, he was intubated for airway protection. Computed tomography (CT) of the head was performed which showed acute left basal ganglia hemorrhage measuring 4.2 cm with vasogenic edema and midline shift of 4 mm. Also noted was markedly expanded sella with a cystic mass containing fluid level measuring up to 4.3 cm. Complete blood count, coagulation profile and liver function tests were unremarkable. His sodium levels were 140 mmol/L, potassium 2.9mmol/L, chloride 101mmol/L and bicarbonate 22 mmol/L. Endocrine workup revealed free T4 0.7 ng/dl, TSH 2.32 mIU/L, FSH 3.0 mIU/ml, LH 4.9 mIU/ml, estradiol 7 pg/ml, testosterone 59 ng/dl, random cortisol 8 ug/dl, ACTH 5.1 pg/ml, growth hormone &lt;0.05 ng/ml, IGF-2 249 ng/ml and prolactin 10,470 ng/ml. MRI brain confirmed hemorrhagic pituitary macroadenoma and left basal ganglia parenchymal hematoma with mass effect and midline shift. Patient was diagnosed with hemorrhagic pituitary macroadenoma causing PA. He was started on intravenous steroids, levothyroxine, cabergoline and hypertonic saline. External ventricular drain was placed for obstructive hydrocephalus followed by left frontal burr hole for hematoma evacuation. Pathology was negative for infection, inflammation, neoplasm and amyloid angiopathy. CT angiography was negative for intracranial aneurysm, arteriovenous malformation, dural arteriovenous fistula, or tumor blushes. He subsequently underwent tracheostomy and gastrostomy placement and transferred to rehabilitation facility. Patient continued to improve neurologically, was subsequently decannulated.

Discussion
PA is reported to occurs in 2-12% of pituitary adenoma.1 Corticotropic deficiency is common and can be life threatening if left untreated. Empiric steroids should be administered to all patients with signs of PA without waiting for diagnostic confirmation. Intraparenchymal hemorrhage is an extremely rare complication of PA and thought to be related to vasospasm of the cerebral arteries.

Reference
1. Briet C, Salenave S, Bonneville JF, et. Al. Pituitary Apoplexy. Endocr Rev. 2015 Dec;36(6): 622-45. doi: 10.1210/er.2015-1042.
Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.