A Case Presentation and Review of Imaging Features Pituitary Apoplexy: A Case Presentation and Review of Imaging Features Leena Kamat, MD; Joseph R. Grajo, MD; Nicholas Constantine, MD; Robert Zamore, MD DEPARTMENT OF RADIOLOGY, USF HEALTH MORSANI COLLEGE OF MEDICINE University of South Florida • South Tampa Center for Advanced Healthcare • 2 Tampa General Circle • Tampa, FL 33606-3571 Introduction Pituitary apoplexy is defined as an acute clinical syndrome that may include headache, visual deficits, ophthalmoplegia, or altered mental status.1 It is the result of sudden infarction, either bland or hemorrhagic, within a normal or neoplastic pituitary gland. It typically is due to hemorrhage into a macroadenoma of the pituitary gland; rare cases are due to necrosis of the pituitary without massive hemorrhage.2 It applies to symptomatic cases only. It is simply not the occurrence of hemorrhage into an adenoma, which is common and frequently a subclinical process.1 Case Imaging Discussion Imaging features: A pre-existing adenoma is present in 65-95% cases of apoplexy.3 Computed tomography (CT) is better for visualizing intratumoral hemorrhage within the first 3 days. Non-enhanced CT imaging may demonstrate patchy or confluent hyperdensity suggesting hemorrhage. 4 Contrast-enhanced CT may reveal a pituitary mass with peripheral enhancement, with or without hemorrage.4 Magnetic resonance imaging (MRI) is the imaging method of choice. Abnormal restricted diffusion within an adenoma may be an early sign of apoplexy and contrast administration often reveals rim-enhancement. 5 In the early acute stage, T1-W MR imaging may show an enlarged gland that is iso- or hypointense to brain. 3 In the subacute stage, T1-W MR imaging may show a hyperintense gland. 3 On T2-W MR imaging, acute compression of the hypothalamus and optic chiasm may cause hyperintensity along the optic tracts. 3 Differential considerations include pituitary abscess, thrombosed intra-sellar aneurysm, or primary intra-pituitary hemorrhage.3 Predisposing factors: Several risk factors have been implicated in the development of apoplexy including: anticoagulation, radiation, bromocriptine therapy for existing macroadenoma, trauma, or peri- or post-partum state. 3 Management: Apoplexy is a neurosurgical emergency that requires urgent surgical decompression to prevent permanent visual loss and possible death from local pressure on the hypothalamus and brainstem.3 Transsphenoidal surgery is safe and effective. It is indicated if there are associated visual acuity or field abnormalities because, when performed within 8 days, results in significantly greater improvement in visual deficits than if surgery is performed after this time.1 b a Figure 1. DWI (a) and ADC (b) images from the initial MRI demonstrates no abnormal restricted diffusion within the sellar-based mass Case Summary History: A 34 year old female with several month history of weight gain, hirsutism, and blurry vision presented to the emergency room with worsening headaches. Upon admission, patient’s physical exam revealed cushingoid features with no focal neurological deficits. On hospital day 3, patient reported a severe, new left sided eye pain with an inability to move her left eye. Physical exam revealed complete ophthalmoplegia of the left eye with ptosis and sensory changes. Imaging: Upon admission, initial magnectic resonance imaging (MRI) was performed with and without contrast. Imaging revealed no abnormal restricted diffusion (Figure 1) and an enhancing sellar-based mass with suprasellar and left cavernous sinus extension (Figure 2). Findings were suspicious for a pituitary macroadenoma. On hospital day 3, when the patient developed acute left sided ophthalmoplegia, an emergent computed tomography (CT) scan without contrast was performed to evaluate for pituitary hemorrhage. The CT scan revealed no acute hemorrhage within the pituitary mass. Further workup with a MRI brain with and without contrast was performed. Findings demonstrated abnormal restricted diffusion (Figure 3) and non-enhancement of the sellar-based mass (Figure 4). Findings were new compared to the initial imaging and suspicious for bland pituitary infarction or apoplexy. Intervention: The patient was taken emergently to the operating room for transsphenoidal pituitary tumor resection. Pathologic evaluation of the submitted tissue revealed an adrenocorticotrophic adenoma with a large focus of necrosis. a b Figure 2. Axial pre-contrast (a) and post-contrast (b) T1-W MR images demonstrate an enhancing sellar-based mass with extension into the left cavernous sinus a b Figure 3. DWI (a) and ADC (b) images from the subsequent MRI demonstrate abnormal restricted diffusion within the sellar-based mass References Randeva H, Schoebel J, Byrne J, et al. Classical pituitary apoplexy: clinical features, management and outcome. Clinical Endocrinology. 1999; 51(2): 181-188. Kim J, Park B, Kim S, et al. Pituitary apoplexy due to pituitary adenoma infarction. J Korean Neurosurg Soc. 2008;43 (5): 246-9. Joseph F, Lockhat Z, Smal J, et al. Acute pituitary apoplexy complicated a pituitary macroadenoma. SA J of Radiology. 2010; 14 (4): 118-121. Ostrov S, Quencer R, Hoffman J, et al. Hemorrhage within pituitary adenomas: how often associated with pituitary apoplexy syndrome? AJR Am J Roentgenol. 1989;153 (1): 153-60. Rogg J, Tung G, Anderson G, et al. Pituitary apoplexy: early detection with diffusion-weighted MR imaging. AJNR Am J Neuroradiol. 2002;23 (7): 1240-5. a b Figure 4. Axial pre-contrast (a) and post-contrast (b) T1-W MR images demonstrate non-enhancement of the sellar-based mass