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

Abstract

Background. Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The typical clinical presentation of PA includes acute onset of severe headache, visual disturbance, cranial nerve palsy, and altered level of consciousness. Case Report. A 78-year-old man presented to the emergency department with one-day history of ptosis and diplopia and an acute-onset episode of altered level of consciousness which was resolving. He denied having headache, nausea, or vomiting. Physical examination revealed third-cranial nerve palsy and fourth-cranial nerve palsy both on the right side. Noncontrast computed tomography (CT) scan of the head was unremarkable. Brain magnetic resonance imaging (MRI) showed a pituitary mass with hemorrhage (apoplexy) and extension to the right cavernous sinus. The patient developed another episode of altered level of consciousness in the hospital. Transsphenoidal resection of the tumor was done which resulted in complete recovery of the ophthalmoplegia and mental status. Conclusion. Pituitary apoplexy can present with ophthalmoplegia and altered level of consciousness without having headache, nausea, or vomiting. A CT scan of the head could be negative for hemorrhage. A high index of suspicion is needed for early diagnosis and timely management of pituitary apoplexy.

Figure 1

Brain MRI W/WO contrast 2 days before surgery. (a) Coronal T1-weighted image demonstrates a large sellar mass with suprasellar extension and slight mass effect on the optic chiasm. This mass exhibits marked hyperintense signal on T1-weighted image (arrow), which indicates blood products and recent hemorrhage. (b) Coronal T1-weighted postcontrast image shows normal enhancement of the cavernous sinus. No enhancing mass or nodule is evident in association with intrinsically T1 bright lesion. The mass abuts approximately 90 degrees of the right internal carotid artery contour. This abutment is less on the left side. The carotid arteries are patent and show normal caliber without any narrowing. No normal pituitary tissue is identified.

Figure 2

MRI (T1 weighted with contrast) one day after the surgery shows interval resection of the previously seen sellar mass/hemorrhage and resolution of mass effect on the optic chiasm.