Ann Pediatr Endocrinol Metab.  2022 Dec;27(4):320-324. 10.6065/apem.2142204.102.

Pituitary apoplexy in an adolescent male with macroprolactinoma presenting as middle cerebral artery territory infarction

• Agrawal P
• Newbold S
• Busaidi AA
• Kapoor RR
• Thomas N
• Aylwin SJ
• Buchanan CR
• Arya VB

• KMID: 2537245
• DOI: http://doi.org/10.6065/apem.2142204.102

Abstract

Pituitary apoplexy typically presents with acute headache, vomiting, visual disturbance, and confusion. Herein, we report a rare presentation of ischemic stroke due to pituitary apoplexy. A 16.5-year-old male presented with reduced Glasgow Coma Scale (GCS) score, slurred speech, right-sided hemiparesis, and bitemporal hemianopia. Magnetic resonance imaging of the brain showed a large hemorrhagic sellar/suprasellar mass and an area of cortical T2/FLAIR hyperintensity with corresponding diffusion restriction in the middle cerebral artery territory. Computed tomography (CT) intracranial angiogram showed luminal occlusion of the clinoid and ophthalmic segments of both internal carotid arteries (ICAs, left>right) due to mass pressure effect. Biochemical investigations confirmed hyperprolactinemia and multiple pituitary hormone deficiencies. Stress-dose hydrocortisone was commenced with cabergoline, followed by urgent endoscopic transsphenoidal debulking of the tumor (subsequent histology showing prolactinoma). Postoperative CT angiogram showed improved caliber of ICAs. Intensive neurorehabilitation was implemented and resulted in complete recovery of motor and cognitive deficits. At the last assessment (18.8 years), the patient remained on complete anterior pituitary hormone replacement without cabergoline. Pituitary apoplexy is a medical emergency requiring prompt recognition and treatment and should be suspected in patients presenting with sudden, severe headache; nausea; or visual disturbance and meningism. Ischemic stroke is a rare manifestation of pituitary apoplexy in the pediatric population.

Keyword

Pituitary adenoma; Pituitary apoplexy; Stroke; Prolactinoma

Figure

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  Fig. 1. (A–C) Large hemorrhagic pituitary macroadenoma on preoperative magnetic resonance imaging (MRI). Coronal (A) and sagittal (B) unenhanced T1-weighted MRI scans show a large sellar, suprasellar, and bilateral parasellar mass with hemorrhagic fluid-fluid level that contains T1 hyperintense signal and mild enhancement on the sagittal contrast-enhanced T1-weighted MRI scan (C). (D–F) Successful tumor debulking on postoperative coronal (D) and sagittal (E) unenhanced T1-weighted MRI and sagittal contrast-enhanced T1-weighted MRI scan (F).

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  Fig. 2. (A–C) Acute left middle cerebral infarction. Axial T2-weighted magnetic resonance imaging (MRI) (A) scan shows an area of high signal intensity in the left middle cerebral artery (MCA) territory, with restricted diffusion on diffusion-weighted MRI (B) and apparent diffusion coefficient (ADC) map (C). (D–F) Chronic left middle cerebral infarct 7 months later. Axial T2-weighted MRI scan (D) shows encephalomalacia in the left MCA territory with free diffusion on diffusion-weighted MRI scan (E) and ADC map (F).

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  Fig. 3. (A, C) Preoperative computed tomography (CT) angiography of the intracranial arteries shows lateral displacement of the internal carotid arteries (ICAs). (A) Axial image shows luminal occlusion of the ophthalmic segments of both ICAs and (C) axial maximum intensity projection (MIP) image shows luminal stenosis of the cavernous segments of both ICAs (left > right). (B, D) Postoperative CT angiography of the intracranial arteries. Improved caliber of the ophthalmic segments on axial image (B) and the cavernous segment on axial MIP (D) image of the bilateral ICAs.

Reference

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