Vasospasm in pituitary apoplexy without subarachnoid haemorrhage: successful treatment with chemical angioplasty
EANS Academy. Kiik M. 09/25/19; 275700; EP04043
Martin Kiik
Martin Kiik

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Background: Pituitary apoplexy (PA) is a clinical syndrome caused by acute haemorrhage or infarction of the pituitary gland manifesting as severe headache, visual failure, and reduced consciousness. Stroke is a rare complication of PA, with 30% mortality. Mechanisms include direct compression of the cavernous carotids, hypotension or, rarely, vasospasm. However, vasospasm in PA in the absence of subarachnoid haemorrhage is exceedingly rare - we report an uncommon case of vasospasm in PA treated successfully with chemical angioplasty. Recognition of vasospasm and delayed cerebral ischaemia (DCI) in PA is important as the ischaemic deficit is reversible and timely treatment can lead to good clinical outcomes.
Case overview: A 35-year-old woman presented with rapidly progressive visual failure, loss of consciousness and catastrophic pituitary failure with dysphasia and a dense right hemiparesis. She was intubated and imaging (CT, MRI, MRA) revealed a large, erosive sellar/suprasellar mass with a capsular infarct and ischaemia in the middle cerebral artery (MCA) territory secondary to vasospasm without SAH. She recovered to GCS 15 with MRC grade 3/5 hemiparesis following hydrocortisone, fluid resuscitation and inotropic support but reported rapidly deteriorating visual acuity to light perception. She underwent emergency endoscopic transphenoidal resection of tumour. Postoperatively her vision improved significantly but she continued to have fluctuations in conscious level and neurological deficit. Repeat CT angiography revealed bilateral multifocal calibre variation affecting the distal internal carotid arteries. Following treatment with chemical angioplasty (intraarterial nimodipine), systemic nimodipine and hypertensives, she made a full recovery with normal vision and no deficits. Histopathology revealed a haemorrhagic TSH-secreting adenoma.
Discussion: Vasospasm and DCI in PA are rare. Unlike in established stroke, the deficits are reversible, and the outcome can be good if recognised and treated. We report one of few cases of vasospasm in pituitary apoplexy treated successfully with chemical angioplasty and review the literature.
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