Unusual Complication of Pituitary Macroadenoma: A Case Report and Review

Abstract

Patient: Male, 48Final Diagnosis: Pituitary apoplexy complicated by cerebral infarctionSymptoms: Disturbed conscious level • loss of visionMedication: —Clinical Procedure: —Specialty: RadiologyObjective:Unusual clinical courseBackground:Pituitary macroadenoma is a common benign tumor that usually presents with visual field defects or hormonal abnormalities. Cerebral infarction can be a complication of a large pituitary adenoma. We report a rare case of bilateral anterior cerebral arteries infarcts by a large pituitary macroadenoma with apoplexy.Case Report:A 48-year-old male patient presented with altered conscious level and sudden loss of vision for one-day duration. Magnetic resonance imaging of the brain showed a large seller and suprasellar hemorrhagic mass of pituitary origin, with associated bilateral areas of diffusion restriction in the frontal parasagittal regions, consistent with infarctions. Magnetic resonance angiography showed elevation and compression of A1 segment of both anterior cerebral arteries by the hemorrhagic pituitary macroadenoma. The patient underwent trans-sphenoidal resection of the pituitary adenoma, but unfortunately, ischemia was irreversible. Computed tomography (CT) done post-operatively showed hypodensity in the frontal and parietal parasagittal areas, which was also persistent in the follow up CT scans. The patient’s neurological function remained poor, with GCS of 8/15, in vegetative state.Conclusions:Vascular complications of the pituitary apoplexy, although uncommon, can be very severe and life threatening. Early detection of vascular compromise caused by hemorrhagic pituitary macroadenoma can prevent delay in intervention. Clinicians should also consider pituitary adenoma as a possible cause of stroke.

Pituitary Apoplexy Leading to Cerebral Infarction: A Systematic Review

“…There are 2 main pathophysiological mechanisms of the disease: one is the compression of intracranial blood vessels by a tumour and the other is blood vessel spasm caused by tumour bleeding [2]. In 25 patients with cerebral infarction caused by PA, infarction was due to direct intracranial vascular compression [4-6, 10, 14, 19, 21, 23-26, 29, 30, 33-35, 37-39, 41-44]. The tumour constantly grows and then presses on the adjacent MCA and ACA, causing the corresponding symptoms and signs.…”

“…When the tumour expands to the cavernous sinus on both sides, it can cause paralysis of the extraocular muscles and compression of the ICA. In general, tumours compress unilateral arteries, but 5 cases of bilateral ICA compression [7, 9, 19, 26, 29] and 3 cases of bilateral ACA compression have been reported in the literature [18, 28, 39]. Cerebral vasospasm is another mechanism of cerebral infarction caused by PA [2, 7, 8, 11-13, 15, 17, 18, 21, 22, 27, 28, 31, 32, 40].…”

“…Pituitary apoplexy (PA) manifests as acute pituitary infarction or haemorrhage, and the main symptoms are acute headache, impaired vision, and reduced level of consciousness [1, 2]. PA was first reported by Bailey in 1989, and the current incidence is approximately 0.6–22% [1, 3]. However, acute cerebral infarction caused by PA involving adjacent blood vessels in the brain is rare.…”

Pituitary Apoplexy Presenting as Ophthalmoplegia and Altered Level of Consciousness without Headache

“…The exact cause of the altered LOC could not be clearly determined in our patient but it could be possibly caused by a transient episode of increased intracranial pressure, cerebral vasospasm, or seizure episodes. Compression of the vascular structures or vasospasm can rarely cause reversible or irreversible cerebral ischemia in pituitary apoplexy cases [ 20 ]; while MRI did not indicate a compressive effect on the vascular structures, vasospasm could have happened. Subarachnoid hemorrhage was ruled out in our case, based on the results of the CT scan and CSF analysis.…”

“…This case report illustrates an unusual clinical presentations of PA: the patient had pupil-sparing CN III palsy, which is more characteristic of ischemic rather than compressive causes; CN IV palsy is not common in PA cases; and altered LOC in PA patients is usually associated with headache [ 24 ], nausea, vomiting, signs of meningismus, or evidence of subarachnoid hemorrhage none of which was present in our patient. There are some case reports that illustrated even more unusual or rare presentations of PA, such as PA presenting as bilateral anterior cerebral artery infarction [ 20 ] or diabetic ketoacidosis [ 25 , 26 ]. The importance is to recognize these atypical presentations so that definitive therapy can be instituted.…”