Unusual Complication of Pituitary Macroadenoma: A Case Report and Review

Abstract

BACKGROUND 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.

Figure 1.

Coronal NECT showing fairly large sellar/suprasellar hyperdense hemorrhagic mass.

Figure 2.

MR Coronal T1 WI showing heterogeneous enhancing sellar/suprasellar mass with supratentorial obstructive hydrocephalus.

Figure 3.

MRI axial SWI showing dark blooming within the mass, indicating underlying hemorrhage.

Figure 4.

Cranial MRA TOF showing wide splaying, stretching, and upward anterior displacement of the A1 and proximal A2 segments of the ACA by the mass.

Figure 5.

MRI DWI (A) and ADC map (B) images showing bilateral frontal parasagittal restricted diffusion bright signal in DWI and dark signal in ADC indicating underlying acute infarctions.

Figure 6.

(A) Low power microscopic (H & E ×100) appearance of the adenoma with extensive areas of necrosis and hemorrhage seen in the upper half of the field. (B) High power microscopic view (H & E ×400) showing the pituitary adenoma on the left side of the view, and the details of the hemorrhagic necrosis (apoplexy) on the right.

Figure 7.

(A, B) Two days post-operative NECT of the head showing established large bilateral medial cerebral parasagittal hypodense recent infarcts along the territory of ACA.