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A 50-year-old man is evaluated in the emergency department for acute onset of a severe headache. He has not had trauma and has no significant medical history. The headache has worsened over the past 4 hours and he now has double vision. On physical examination, the temperature is 38.3 °C (100.1 °F), blood pressure 90/80 mm Hg, and pulse rate 120/min. His mental status is appropriate initially but he becomes progressively confused. He has a mildly stiff neck but no meningismus. Bedside testing of visual fields revealed a left hemianopsia and ptosis of his left eyelid. His left eye is in a downward abducted position and his pupil is dilated. The leukocyte count is 12,000/µL (12 × 109/L), and serum sodium is 131 meq/L (131 mmol/L). The rest of the blood count and electrolyte panel are normal.
Which of the following is the most likely diagnosis?
A Migraine headache
B Meningitis
C Pituitary apoplexy
D Subarachnoid hemorrhage
E Cerebral vascular accident
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D Subarachnoid hemorrhage
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hmm Na and BP are low, dont know, C Pituitary apoplexy?
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Correct Answer = C)
* Pituitary apoplexy is the sudden onset of headache, visual disturbances, opthalmoplegia, and mental status changes caused by the acute hemorrhage or infarction of the pituitary gland.
* Urgent neurosurgical evacuation of the hemorrhage is generally indicated for patients with pituitary apoplexy and rapidly progressing visual disturbances and/or mental status changes.
* A noncontrast CT scan can distinguish between pituitary apoplexy and subarachnoid hemorrhage as patients with pituitary apoplexy will demonstrate acute hemorrhage in the region of the sella turcica.
The most likely diagnosis in this patient is pituitary apoplexy. Pituitary apoplexy is defined as the sudden onset of headache, visual disturbances, opthalmoplegia and mental status changes caused by the acute hemorrhage or infarction of the pituitary gland. Patients classically present with a sudden severe headache and dysfunction of cranial nerves II, III, IV, and VI. These changes can be associated with alterations in mental status. Endocrine dysfunction occurs commonly and includes acute adrenal insufficiency and hypothyroidism. The mildly low serum sodium and low blood pressure could be signs of acute adrenal insufficiency. Therefore, empiric treatment with corticosteroids (usually intravenous hydrocortisone) for presumed ACTH deficiency is recommended along with general supportive care in these patients. This patient probably also has hypogonadism and hypothyroidism, but treatment of these deficiencies can usually be delayed until hormone levels can be obtained to confirm the diagnosis. Urgent neurosurgical evacuation of the hemorrhage is generally indicated for patients with rapidly progressing visual disturbances and/or mental status changes. Neurosurgical decompression can often be delayed in patients with less severe findings until evaluation of anterior pituitary hormone status is complete. Usually these patients have evidence of a pituitary adenoma that has hemorrhaged. Treatment of patients who do not require emergent neurosurgical intervention would be based on the size of the lesion, presence of mass effects, hormonal status of the patient (hyper- or hypofunction of the anterior pituitary), and whether the tumor is amenable to medical therapy.
Migraine headache would not be the most likely diagnosis since most of these patients do not present with worsening mental status or cranial nerve palsies. Meningitis is in the differential diagnosis but again unlikely given the findings on neurologic examination and a leukocyte count of 12,000/µL (12 × 109/L). It is important to distinguish pituitary apoplexy from subarachnoid hemorrhage. A noncontrast CT is one of the best methods for distinguishing between these two entities as patients with pituitary apoplexy will demonstrate acute hemorrhage in the region of the sella turcica. Imaging would also aid in ruling out cerebral vascular accident. In this case, brain imaging would be preferred as the initial test over lumbar puncture.
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