Location
Philadelphia, PA
Start Date
1-5-2024 1:00 PM
End Date
1-5-2024 4:00 PM
Description
INTRODUCTION: Pituitary adenomas, arising from the pituitary adenohypophyseal cell, are commonly classified by cell type, size, and hormone secretion. Approximately 48% are macroadenomas (≥10 mm), with around 53% being prolactinomas. Despite their frequency, only 1 in 1100 individuals show clinical symptoms, making detection challenging. These adenomas pose an additional risk, with up to 27.6% developing apoplexy—a medical emergency due to acute hemorrhage or infarction leading to gland necrosis. Symptoms vary widely, including sudden headache, altered mental status, visual impairment, ophthalmoplegia, or hormonal dysfunction, depending on mass effect compression. Less commonly, the tumor invades the cavernous sinus, causing cranial nerve palsies. Here, we present a case of a pituitary adenoma with unilateral vision loss and extraocular muscular paralysis with apoplexy.
METHODS: Case report and literature review.
RESULTS: A 73-year-old male presented with left-sided facial droop, dizziness, and malaise, accompanied by an erythematous left eye from the night before. Upon awakening, his left eye was closed, and he could not open it despite multiple efforts. He denied any recent trauma or illness, ocular or facial pain, vision changes, fever, or unexplained weight loss. Systemic vital signs were unremarkable.
On examination, the patient’s visual acuity with correction was 20/25 +2 OD and 20/70 OS. The right pupil was 4 mm, round, reactive, and with no relative afferent pupillary defect. The left pupil was 4 mm, fixed and nonreactive. Intraocular pressures were 15 mmHg OD and 17 mmHg OS. Color vision was 8/8 OD and 0/8 OS. The patient’s EOM revealed a downward and outward left eye, full in the right eye and with a complete deficit in the left eye. Visual fields were full of confrontation bilaterally. The anterior exam was pertinent for complete left-sided ptosis, +1 NS OD, and +2 NS OS. The posterior exam was deferred secondary to neurological monitoring.
Lab work showed prolactin, testosterone, and sodium imbalances and elevated inflammatory markers. Imaging revealed a 2.9 cm mass resembling a hemorrhaging pituitary macroadenoma. Surgical resection three days later revealed ischemic and hemorrhagic components of the adenoma that extended into the clivus and compressed the left cavernous sinus. Pathology indicated apoplexy with positive immunostaining of synaptophysin and chromogranin. Follow-up appointments showed partial vision improvement and left eyelid mobility.
DISCUSSION: Pituitary adenomas can be functional (hormone-secreting) or non-functional and classified by size (microadenoma <10mm, macroadenoma >10mm). Non-functional adenomas are usually detected incidentally or by mass-effect symptoms such as headaches, visual disturbances, hypopituitarism, or other symptoms related to compression of nearby structures. Incidences of related hyperprolactinemia and hyponatremia have been identified due to dopamine inhibition and SIADH, respectively. Pituitary apoplexy, an infarction or hemorrhage of the pituitary gland, often accompanies adenomas and presents with symptoms mentioned previously. The patient in this case report presented with a 2.9 cm mass with apoplexy with associated acute onset complete CNIII palsy due to compression of the left cavernous sinus. Surgical intervention was necessary due to rapid vision loss and extensive invasion. After the resection, the patient’s sodium levels normalized.
Embargo Period
7-3-2024
Included in
Pituitary apoplexy presenting with acute onset complete 3rd cranial nerve palsy
Philadelphia, PA
INTRODUCTION: Pituitary adenomas, arising from the pituitary adenohypophyseal cell, are commonly classified by cell type, size, and hormone secretion. Approximately 48% are macroadenomas (≥10 mm), with around 53% being prolactinomas. Despite their frequency, only 1 in 1100 individuals show clinical symptoms, making detection challenging. These adenomas pose an additional risk, with up to 27.6% developing apoplexy—a medical emergency due to acute hemorrhage or infarction leading to gland necrosis. Symptoms vary widely, including sudden headache, altered mental status, visual impairment, ophthalmoplegia, or hormonal dysfunction, depending on mass effect compression. Less commonly, the tumor invades the cavernous sinus, causing cranial nerve palsies. Here, we present a case of a pituitary adenoma with unilateral vision loss and extraocular muscular paralysis with apoplexy.
METHODS: Case report and literature review.
RESULTS: A 73-year-old male presented with left-sided facial droop, dizziness, and malaise, accompanied by an erythematous left eye from the night before. Upon awakening, his left eye was closed, and he could not open it despite multiple efforts. He denied any recent trauma or illness, ocular or facial pain, vision changes, fever, or unexplained weight loss. Systemic vital signs were unremarkable.
On examination, the patient’s visual acuity with correction was 20/25 +2 OD and 20/70 OS. The right pupil was 4 mm, round, reactive, and with no relative afferent pupillary defect. The left pupil was 4 mm, fixed and nonreactive. Intraocular pressures were 15 mmHg OD and 17 mmHg OS. Color vision was 8/8 OD and 0/8 OS. The patient’s EOM revealed a downward and outward left eye, full in the right eye and with a complete deficit in the left eye. Visual fields were full of confrontation bilaterally. The anterior exam was pertinent for complete left-sided ptosis, +1 NS OD, and +2 NS OS. The posterior exam was deferred secondary to neurological monitoring.
Lab work showed prolactin, testosterone, and sodium imbalances and elevated inflammatory markers. Imaging revealed a 2.9 cm mass resembling a hemorrhaging pituitary macroadenoma. Surgical resection three days later revealed ischemic and hemorrhagic components of the adenoma that extended into the clivus and compressed the left cavernous sinus. Pathology indicated apoplexy with positive immunostaining of synaptophysin and chromogranin. Follow-up appointments showed partial vision improvement and left eyelid mobility.
DISCUSSION: Pituitary adenomas can be functional (hormone-secreting) or non-functional and classified by size (microadenoma <10mm, macroadenoma >10mm). Non-functional adenomas are usually detected incidentally or by mass-effect symptoms such as headaches, visual disturbances, hypopituitarism, or other symptoms related to compression of nearby structures. Incidences of related hyperprolactinemia and hyponatremia have been identified due to dopamine inhibition and SIADH, respectively. Pituitary apoplexy, an infarction or hemorrhage of the pituitary gland, often accompanies adenomas and presents with symptoms mentioned previously. The patient in this case report presented with a 2.9 cm mass with apoplexy with associated acute onset complete CNIII palsy due to compression of the left cavernous sinus. Surgical intervention was necessary due to rapid vision loss and extensive invasion. After the resection, the patient’s sodium levels normalized.