Pituitary apoplexy

Findings

Figure 1 and Figure 2: Non contrast CT head shows enlarged sella with a hyperdensity within it (Figure 1) with secondary thinning of bone (Figure 2).
Figure 3 and Figure 4: Coronal T1 and T2-weighted images show mass of mixed signal with isointense signal at inferior aspect and hyperintense signal at superior part, located in sellar region with suprasellar extension. Internal carotid artery on both sides show normal flow void signal.
Figure 5 and Figure 6: Sagittal T1-weighted image demonstrates the fluid level. Pituitary stalk is normal (Figure 5).


Diagnosis: Pituitary apoplexy


Pituitary apoplexy is defined as a clinical syndrome that may include headache, visual deficits, ophthalmoplegia, or altered mental status. It may occur either due to rapid expansion of an infarcted/hemorrhagic pituitary adenoma. Clinical risk factors are trauma, increased intracranial pressure, anticoagulation, bromocriptine therapy, diabetic ketoacidosis, radiation therapy, and open heart surgery. Apoplexy in pituitary adenomas may vary from 2% to 7%. Nearly 50% of apoplectic events seem to occur in patients who were not known to harbor pituitary lesion previously.

Noncontrast CT may show sellar/suprasellar mass with patchy hyperdensities. MR imaging findings may vary depending upon age of hemorrhage. Early/late subacute hemorrhage may show increased signal as seen in our case. Acute compression of the hypothalamus and/or optic chiasm may cause increase signal on T2 along the optic tracts. Presence of restricted diffusion within an adenoma may suggest an early sign of apoplexy in the form of acute hemorrhage or associated infarction.

Early diagnosis and treatment is necessary to prevent significant morbidity and mortality.