KISEP J Korean Neurosurg Soc 34 : 249-251, 2003
Case Report Pituitary Apoplexy Mimicking Aneurysmal Rupture of Anterior Communicating Artery
Young-Gyu Kim, M.D., Jong-Sun Lee, M.D., Moon-Sun Park, M.D., Ph.D., Ho-Gyun Ha, M.D., Ph.D. Department of Neurosurgery, Eulji University School of Medicine, Daejeon, Korea
Pituitary apoplexy presenting with subarachnoid haemorrhage(SAH) is rare and thus may be easily mistaken for aneurysmal rupture. The authors report a case of pituitary apoplexy presented with SAH mimicking aneurysmal rupture of anterior communicating artery. A 70-year-old woman presented with sudden severe headache, vomiting and drowsiness. Computerized tomography showed diffuse SAH in basal cistern and enhancing sellar mass lesion that was overlooked. Because cerebral angiography showed a suspicious small aneurysmal sac at the origin of anterior communicating artery, we regarded it as an aneurysmal rupture. Craniotomy was performed but we could not find any aneurysm. There was a definite hemorrhagic mass lesion in the sellar and suprasellar area. Histopathological examination revealed a micronodular pituitary adenoma with hemorrhage. The authors stress that pituitary apoplexy must be included in the differential diagnosis of SAH, and proper preoperative radiologic imaging and careful interpretation is demanding for rule out the possibility of pituitary apoplexy.
KEY WORDS : Pituitary apoplexy Subarachnoid hemorrhage Anterior communicating artery Aneurysm.
Introduction Case Report
ituitary apoplexy is a well known clinical syndrome cha- 70-year-old woman presented with sudden severe P racterized by headache, visual disturbance and ophtham- A headache, vomiting and drowsiness. There was no oplegia due to hemorrhagic or ischemic necrosis of pituitary noteworthy medical problems except a history of poorly con- tumor. It is an uncommon disease and occurs in 0.6~10% of trolled hypertension. On admission, she was drowsy and her all pituitary tumors2,3,5,6). neck was stiff. Pupils were isocoric and light reflex was normal. Because the neovascularization is incomplete and tumor There was no focal neurological deficit. We did not check the vessels are relatively fragile, the tumor may undergoes ische- visual field, since she complained no visual symptom. Skull mic, necrotic and hemorrhagic change6). Subarachnoid hemo- x-ray showed no sellar abnormality. An emergency computed rrhage(SAH) may occur secondarily following extravasation tomography(CT) demonstrated diffuse SAH in basal cistern due to hemorrhagic necrosis of pituitary tumor. As meningeal (Fig. 1). But we overlooked the suprasellar mass lesion which irritation and compression of parasellar structure increases, was slightly enhancing. As carotid angiogram revealed a the patient can experience headache, vomiting, visual distur- suspicious small aneurysm at the origin of anterior commun- bance, limitation of extraocular eye movement, mental change icating artery(Fig. 2) and clinical symptoms were compatible and panhypopituitarism3). The possibility of SAH or intracerebral hemorrhage secon- dary to extravasation of tumor bleeding was described but indeed, it has been published rarely4,7). We report a case of pituitary apoplexy presented with SAH that was initially misdiagnosed as a ruptured anterior communicating artery aneurysm.