Pituitary Apoplexy Presenting as Isolated Third Cranial Nerve Palsy with Ptosis : Two Case Reports

Abstract

Pituitary apoplexy is a clinical syndrome caused by an acute ischemic or hemorrhagic vascular accident involving a pituitary adenoma or an adjacent pituitary gland. Pituitary apoplexy may be associated with a variety of neurological and endocrinological signs and symptoms. However, isolated third cranial nerve palsy with ptosis as the presenting sign of pituitary apoplexy is very rare. We describe two cases of pituitary apoplexy presenting as sudden-onset unilateral ptosis and diplopia. In one case, brain magnetic resonance imaging (MRI) revealed a mass in the pituitary fossa with signs of hemorrhage, upward displacement of the optic chiasm, erosion of the sellar floor and invasion of the right cavernous sinus. In the other case, MRI showed a large area of insufficient enhancement in the anterior pituitary consistent with pituitary infarction or Sheehan's syndrome. We performed neurosurgical decompression via a transsphenoidal approach. Both patients showed an uneventful recovery. Both cases of isolated third cranial nerve palsy with ptosis completely resolved during the early postoperative period. We suggest that pituitary apoplexy should be included in the differential diagnosis of patients presenting with isolated third cranial nerve palsy with ptosis and that prompt neurosurgical decompression should be considered for the preservation of third cranial nerve function.

Pituitary apoplexy: evaluation, management, and prognosis

“…symptom of pituitary tumor apoplexy. Won-Jun et al [9] describe two cases of pituitary apoplexy presenting as sudden onset unilateral ptosis and diplopia due to an isolated oculomotor nerve palsy. Both cases exhibited complete resolution of symptoms in the early postoperative period.…”

“…Patients experience diplopia as dictated by specific cranial nerve involvement; the oculomotor nerve (typically pupil-involving) accounts for 50% of patients with cranial nerve palsies, probably due to its supero-lateral course through the cavernous sinus in the same axial plane as the pituitary gland, leaving it more susceptible to the lateral pressure from an expanding mass [1 , 6,9,13].…”

“…Histologically, pituitary apoplexy tumors typically exhibit hemorrhagic necrosis [9]. Mou et al [10 ] analyzed 426 patients with pituitary adenoma, 83 of which presented with pituitary apoplexy.…”

A 64-year-old woman with dilated right pupil, nausea, and headache

“…9,14,15 In the majority of these cases, no precipitating factors were found. The precipitating factors include 2 cases of mild head injury 16 and 1 each of Sheehan's syndrome 5 and anticoagulation (present case). In contrast, Sibal et al 12 found that 40% of pituitary apoplexy cases had a precipitating factor.…”

“…Various degrees of cranial nerve palsy can result from compression of cranial nerves III, IV, V, and VI, with an expanding mass in the cavernous sinus. 5 However, isolated oculomotor nerve palsy without visual acuity or field deficits as the presenting sign of pituitary apoplexy is rare (Table 1). …”