Pituitary Apoplexy
An 81-year-old man presented to the emergency department with sudden-onset headache and vision loss. He had a history of a nonfunctioning pituitary macroadenoma (Panel A, arrow) that had been monitored with serial imaging over the previous 4 years. On examination, the right eye had ptosis, a nonreactive pupil, and paralysis of elevation, depression, and adduction (Panel B) — findings consistent with right oculomotor nerve palsy. There was also no perception of light in either eye. Laboratory testing identified central hypothyroidism and central adrenal insufficiency. T1-weighted magnetic resonance imaging of the head revealed enlargement of the pituitary lesion with a new hemorrhage (Panel C, arrow). A diagnosis of pituitary apoplexy was made. Pituitary apoplexy is sudden-onset bleeding or infarction of the pituitary gland or tumor. It manifests as a severe headache and may be accompanied by diplopia, vision loss, or hypopituitarism. Visual deficits are an indication for surgical decompression. Intravenous hydrocortisone was administered, and emergency endoscopic endonasal resection of the macroadenoma was performed. On day 4 after the procedure, the patient’s visual acuity returned to baseline. He was discharged from the hospital with instructions to take prednisone and levothyroxine as maintenance therapy. At 3 months of follow-up, the right oculomotor nerve palsy had resolved.