Clinical Reasoning: A 42-year-old man with severe headache, fever, and acute coma

Abstract

A 42-year-old man underwent brain MRI at a local health facility for severe headache and was found to have a pituitary adenoma. Two days later, he presented to the emergency department of our hospital with high fever and sudden-onset coma. The patient had a history of intermittent moderate headache in the recent 8 months. No medical history of vascular risk factors was identified.On examination, his Glasgow Coma Scale score was 4/15, blood pressure was 133/86 mm Hg, and body temperature was 40°C. Blood oxygen saturation was 96% on room air and the respiratory rate was 19 breaths per minute. Neurologic examination revealed neck stiffness. The patient could open his eyes briefly and weakly in response to painful stimuli, with suspected right ptosis. His pupils were equal in diameter, and there was a right relative afferent pupillary defect. His gag reflex was present bilaterally. Spontaneous movements and motor responses to stimuli were absent. His extremities were flaccid and deep tendon reflexes were symmetric. The left Babinski sign was present. Cardiovascular examination was unremarkable. Blood tests revealed remarkable hyponatremia (126 mmol/L) and elevated leukocyte count (12.6 3 10 9 /L).Questions for consideration:

Surgical treatment of pituitary apoplexy in association with hemispheric infarction

“…The UK guidelines suggest that surgery should be performed within the first 7 days of symptom onset in patients with severe and progressive neuroophthalmological deficits [1]. However, some authors caution that early recanalization of the obstructed vessel after decompression, with subsequent reperfusion injury, may be harmful, converting an infarct into a hemorrhage [13,19,20,38]. Consistent with this, our data also suggest that patients who underwent delayed surgeries had better outcomes than those who had emergent surgeries (Table 2).…”

“…Cerebral infarction was reported to be caused by both mechanical compression and vasospasm in two patients [37,38]. The overlap between spasm and extrinsic compression did not permit a clear differentiation of these two mechanisms in some situations, as angiography and/or MRA was not always performed.…”

Pituitary Apoplexy Leading to Cerebral Infarction: A Systematic Review

“…In some cases, tumour decompression can restore blood flow to the compressed vessels and reduce intratumoural stress, thereby reducing the exudation of blood or vasoactive substances into the subarachnoid space; thus, some neurological deficits can be resolved [2, 30]. However, some authors have reported that surgical decompression might be detrimental to patient recovery if a head CT indicates cerebral infarction and might result in haemorrhagic infarction [10, 30, 47]. In our study, compared to patients who underwent emergency surgery, patients who underwent delayed surgery showed a better prognosis.…”