A 64-year-old female was referred to a tertiary centre after rapid onset nausea, vomiting, headache, diplopia and a fixed dilated pupil. She had been commenced on treatment with therapeutic enoxaparin for a deep vein thrombosis two weeks prior to her presentation. On examination she was haemodynamically stable, had a dorsal fat pad, round face and right eye ptosis and a 5mm fixed dilated pupil that was non-reactive to direct and consensual light reflexes on that side. Visual acuity, eye movements and visual fields remained intact bilaterally. She was found to have inappropriately low gonadotropins, normal prolactin (11nIU/L), morning cortisol (352nmol/L) and thyroid function test (TSH 0.03mIU/L, fT4 13.2pmol/L, fT3 3.0pmol/L). MRI brain demonstrated a large pituitary lesion with suprasellar extension causing flattening of the optic chiasm consistent with haemorrhage within a pituitary macroadenoma.
The diagnosis of pituitary apoplexy with resultant occulomotor nerve palsy was made and the patient was commenced on dexamethasone 4mg four-times-a-day. A plan was made for surgical resection however, her admission was complicated by hypertension which delayed surgery. Since the patient’s ophthalmic symptoms resolved whilst awaiting an improvement in her blood pressure, her surgery was cancelled and she was discharged home on stress dose hydrocortisone.
Pituitary apoplexy (PA) complicates 2-12% of pituitary adenomas with precipitating factors identified in 10-40% of cases. Whilst once considered a neurosurgical emergency, PA’s management has become a matter of debate in recent years with increasing evidence favouring expectant management under the care of a multidisciplinary team in appropriately selected patients. Increasing evidence has demonstrated that patients with stable neuro-ophthalmic signs can be managed conservatively with close daily monitoring. The 2010 guidelines from the Pituitary Apoplexy Guidelines Development Group proposed a Pituitary Apoplexy Score, requiring further study and validation, as a means selecting patients appropriate for expectant management.