Pituitary Apoplexy Complicated by Pulmonary Embolism in a Neurologically Complex Patient: A Diagnostic Challenge.

Abstract

Pituitary apoplexy is a rare endocrine emergency resulting from either acute haemorrhage or infarction within the pituitary gland. Although apoplexy occurs most frequently in a pre-existing pituitary adenoma, apoplexy could be the first presentation of a previously unknown adenoma. Acute headaches, visual disturbances, and neurological symptoms are common presenting symptoms in apoplexy; however, these symptoms may overlap with other neurological emergencies, which necessitate a holistic approach of clinical, radiological, and hormonal evaluation for suspected cases of apoplexy to confirm the diagnosis. Here we present a diagnostically challenging case of a 66-year-old man who presented with a sudden severe headache. His background history included a presumed intraventricular neurocytoma under surveillance. Initial CT head scan suggested possible haemorrhage within a known intraventricular mass (neurocytoma) with no obvious changes within the pituitary gland. However, subsequent MRI head demonstrated radiological features consistent with pituitary apoplexy. Later in his admission, he exhibited bilateral peripheral visual field constriction and early papilledema on fundoscopy. Hormonal testing showed evidence of hypopituitarism. The patient was managed conservatively with intravenous hydrocortisone replacement. During admission, he developed bilateral pulmonary emboli, for which he was treated with anticoagulation. While he was on anticoagulation, he developed intracranial haemorrhage, which led to his death after discharge from the hospital. This case demonstrates the importance of considering pituitary apoplexy in a challenging radiological and clinical presentation. A pre-existing neurological lesion (neurocytoma) makes a holistic approach, including MRI imaging and early hormonal evaluation are essential for timely diagnosis and treatment of pituitary apoplexy. The clinical challenge of having concurrent haemorrhagic and thrombotic events necessitates an individualised approach after balancing the benefits and risks of using anticoagulation treatment.