Emergency Med Case Challenge: A 41-Year-Old on Sildenafil With a Headache While Sleeping

Mousa Abujbara, MD


August 22, 2022


The noncontrast CT scan of the brain showed a 2-cm sellar mass with suprasellar extension. Impingement on the optic chiasm and the hypothalamus was noted, with upward displacement. Increased density was observed on the right side of the mass, which was suggestive of hemorrhage. The sagittal and coronal T1- and T2-weighted MRI scans demonstrated a large soft-tissue mass in the pituitary fossa, with areas of intermediate-intensity and high-intensity signal suggestive of hemorrhage (Figure 3). Coronal gadolinium-enhanced T1-weighted images revealed that the mass had a heterogeneous pattern of faint peripheral enhancement (Figure 4).

Evidence suggested a mass effect on the right cavernous sinus, which was most evident in the coronal T1- and T2-weighted images. These findings are consistent with pituitary apoplexy as a result of hemorrhage with or without infarction, likely into a pituitary adenoma. Tests for evaluating the hormonal status of the patient revealed panhypopituitarism. Prior to the acute apoplectic episode, the patient had findings suggestive of central hypogonadism, probably as a component of his hypopituitarism caused by pituitary macroadenoma (diminished libido and bilateral gynecomastia). His neurologic finding (right-sided ptosis with a fixed and dilated pupil pointing downward and outward) was consistent with a right-sided third nerve palsy caused by extension of hemorrhage into the right cavernous sinus.

Pituitary tumor apoplexy is defined as hemorrhage or infarction of a pituitary gland associated with the presence of a pre-existing pituitary adenoma. It manifests as a sudden, severe headache, and it is sometimes associated with neurologic and hormonal dysfunction. The word "apoplexy" stems from a Greek term meaning to "have a stroke."[1] Neurologic symptoms and signs are secondary to displacement of the optic nerve and impingement of the third, fourth, and sixth cranial nerves. Hormonal dysfunction results from destruction of the anterior pituitary gland.

Pituitary tumor apoplexy is a rare disorder with an annual incidence of about 1.2 per million.[2] Men are affected twice as often as women, and all age groups can be affected, with most cases occurring in the fifth or sixth decades of life.[3] It is estimated to occur in 1.5%-27.7% of cases of pituitary adenoma.[4] Pituitary tumor apoplexy is only rarely associated with a healthy gland; however, approximately 50% of patients who present with pituitary tumor apoplexy are not diagnosed with a pituitary lesion prior to their presentation.[1] All types of pituitary tumors carry the same risk for apoplexy.


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