Pituitary Apoplexy

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Step 1: View clinicals

A 57-year-old man presents with a retro-orbital headache for three days. The headache was sudden in onset, and has been persistent and severe, with no response to over-the-counter analgesics. Despite this, he refused to seek medical attention until earlier today, when his family members became highly concerned as he was acting confused, and claimed that 'he couldn't see clearly'. There is no history of severe or recurrent headaches in the past, or of any recent trauma. His medical history is only positive for mild hypercholesterolemia which is well controlled on diet alone. His surgical and family histories are unremarkable. A complete blood count, renal and liver profiles, and clotting screen are performed. The only significant finding is a serum sodium level of 117 mEq/l (normal: 135-145).


Step 2: Order all relevant investigations

MRI Brain

The MRI scan reveals a mass lesion in the sella and suprasellar area, measuring ~2.9 x 2.5 x 2.0 cm, and compressing the optic chiasm. The lesion is slightly hyperintense on T1 weighted images, and shows areas of hypointensity on T2 weighted images. Following administration of gadolinium contrast, the pituitary gland shows peripheral rim enhancement. Thickening of the sphenoid sinus mucosa is also noted.

Diagnostic Lumbar Puncture

You realize that a lumbar puncture is probably not a good idea right now.

Pituitary Function Tests

TSH: 0.2 mIU/L (0.4-4) Free T4: 3.1 mcg/dL (4.5-11.2) IGF-1: 15 nmol/L (4-25) FSH: 6.5 mIU/mL (1.5-12.4) LH: 5.1 IU/L (1.8-8.6) Prolactin: 1.1 ng/mL (2-18) ACTH Stimulation Test: At 0 min: 3 mcg/dL (5-7) At 30 min: 94 mcg/dL (18-20)

EEG

The EEG appears normal.


Step 3: Select appropriate management

Glucocorticoids
Surgical Decompression
Phenobarbital
Mannitol


Score: ★★☆