Fact-sheet: Pituitary apoplexy


Updated on 08/23/2017 at 6:47 AM

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Definition

Pituitary apoplexy is a relatively common complication of a pituitary adenoma, often revealing the tumor. It consists of intralesional necrosis, sometimes complicated by hemorrhage secondary to ischemia (not to be confused with primary intralesional hemorrhage, which has a less severe prognosis).
Pituitary apoplexy generally occurs in the setting of a macroadenoma with mass effect on the optic chiasm: hemorrhagic necrosis preferentially occurs when the adenoma is still contained within the sellar diaphragm (not in the case of giant adenomas).

Clinical features

Diagnostic and therapeutic emergency.
Spontaneous onset or triggered by a precipitating factor (trauma, pregnancy, surgery, anticoagulation).
- Severe headache
- Oculomotor palsy
- Asthenia
- Decreased visual acuity
- Altered consciousness

Laboratory findings

Panhypopituitarism.

CT

Non-contrast CT:
Intrasellar hyperdensity --> intralesional hemorrhage, sometimes complicated by subarachnoid hemorrhage and a retroclival hematoma.
Look for mucosal thickening of the sphenoid sinus walls, secondary to local inflammation and venous sinus engorgement, the absence of which virtually excludes the diagnosis.

MRI

Diagnosis sometimes difficult in the early phase:
- Typical intrasellar T1 hyperintensity sometimes absent in the early phase (hemorrhage still in the form of deoxyhemoglobin).
- Heterogeneous T2 signal with markedly hypointense areas (intralesional necrosis).
- Diffusion: intrasellar hyperintensity with restricted apparent diffusion coefficient, related to areas of intralesional ischemia. Important sequence for positive diagnosis, especially in cases of isolated necrosis without hemorrhagic transformation.
- Mucosal thickening of the sphenoid sinus walls, hypointense on T1, hyperintense on T2, and enhancing after injection: a very good sign present from the early phase.
- Intrasellar T2* hypointensity producing a "dark mass": intralesional hemorrhage.
- After injection: marked peripheral enhancement. No enhancement of the necrotic central portion.
Look for subarachnoid hemorrhage that may complicate intrapituitary hemorrhagic necrosis, a hematoma, or infiltration posterior to the clivus.

Management

Emergency hormone replacement.
Surgical treatment depending on mass effect.