Answer of June 2009

Clinical History:

A 44 year ago man, suffered from visual disturbance for 1 year. Presented with sudden onset severe headache, repeated vomiting and then collapsed at home. Admitted to A&E department with GCS 4/15. Immediately intubated and urgent radiological imaging arranged as follows:

Diagnosis:

Pituitary apoplexy

Discussion:

Pituitary apoplexy is a clinical syndrome characterized by sudden onset of headache, signs of meningeal irritation, visual impairment and ophthalmoplegia caused by enlargement of a pituitary adenoma, due to tumour infarction or haemorrhage.

Pituitary apoplexy can cause narrowing of intracranial vessels by either mechanical obstruction due to an enlarged suprasellar mass or by vasospasm. Though this is a rare event, massive stroke can be resulted by occlusion of the arteries in the circle of Willis or cavernous segment of the internal carotid artery, like in this case.

Early surgical decompression through the trans-sphenoidal route may be advisable. However, surgical decompression may or may not restore the blood flow in the occluded vessel. One should also caution that decompression of the vessel might be harmful in the presence of an established infarct on CT scan, by converting it into a space occupying haemorrhagic transformation. The mass effect produced by the infarct and oedematous brain is usually the major cause of mortability.