Neurol Med Chir (Tokyo) 46, 594¿597, 2006 Pituitary Apoplexy Manifesting as Diffuse Subarachnoid Hemorrhage —Case Report— Kuniaki NAKAHARA,HidehiroOKA,SatoshiUTSUKI,HideoIIDA*,MariKURITA, Takahiro MOCHIZUKI*,andKiyotakaFUJII Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa; *Department of Neurosurgery, International Goodwill Hospital, Yokohama, Kanagawa Abstract A 46-year-old woman presented with hemorrhage from a non-functioning pituitary adenoma manifest- ing as sudden onset of severe headache. Computed tomography demonstrated diffuse subarachnoid hemorrhage (SAH) and a suprasellar mass with intratumoral hematoma. The patient underwent trans- nasal transsphenoidal removal of the pituitary adenoma. This type of SAH with intratumoral hemato- ma simulates rupture of an anterior cerebral artery aneurysm. Key words: apoplexy, pituitary adenoma, subarachnoid hemorrhage Introduction Pituitary apoplexy is now frequently identified by modern neuroimaging methods in 1.5% to 27.7% of patients with pituitary adenomas.5,6,9,12,22) Intra- tumoral hemorrhage is the most common type of hemorrhage, and may occur in isolation or in associ- ation with subarachnoid hemorrhage (SAH).22) We present a case of pituitary apoplexy associated with broad diffusion of SAH in the sylvian fissure, basal cistern,andfourthventricleoriginatinginthe pituitary adenoma. Case Report A 46-year-old previously healthy woman presented with sudden onset of severe headache, nausea, and vomiting which occurred during housework. She was admitted to our hospital on the day of onset. Fig. 1 Axial computed tomography scan on admis- Physical and neurological examination revealed no sion demonstrating broad diffusion of abnormal findings. Her visual acuity and visual field subarachnoid hemorrhage within the sylvi- remained intact. Computed tomography (CT) an fissure, basal cistern, and fourth ventri- demonstrated diffuse SAH within the sylvian fis- cle, and a slightly hyperdense mass in the sure, basal cistern, and fourth ventricle, and a suprasellar cistern. slightly hyperdense mass in the suprasellar cistern (Fig. 1). Cerebral angiography on the day of onset revealed marked elevation of the bilateral A1 por- tions of the anterior cerebral arteries. No aneurysm, Received February 20, 2006; Accepted August 15, other abnormal vessels, or tumor staining were 2006 identified. 594 Pituitary Apoplexy 595 Fig. 2 A: Preoperative axial T1-weighted magnetic resonance (MR) image demonstrating a hypoin- tense pituitary mass associated with intratumoral hemorrhage. B: Axial T2-weighted MR image showing the hyperintense mass with left paranasal sinusitis. C: Sagittal T1-weighted MR image with gadolinium demonstrating hyperintense intratumoral hemorrhage reaching the top of the tumor, in the area adjacent to the pituitary cistern. Ten days after the onset, magnetic resonance (MR) imaging demonstrated a pituitary mass associated with intratumoral hemorrhage expand- ing into the sphenoid sinus, and disappearance of the SAH. The central part of the hematoma within the pituitary mass was hypointense on T1-weighted imaging, and hyperintense on T2-weighted imaging, with hyperintense intratumoral hemorrhage reach- ing the top of the tumor on sagittal T1-weighted imaging with gadolinium-diethylenetriaminepenta- acetic acid, in the area adjacent to the pituitary cistern (Fig. 2). In addition, MR imaging showed left paranasal hypertrophic mucous membrane (Fig. 2B). The otolaryngologist proposed a diagnosis Fig. 3 Sagittal T1-weighted magnetic resonance of active sinusitis. image obtained 3 months after trans- The hematological and biochemical profiles were sphenoidal surgery revealing the residual normal and pituitary hormone status was normal pituitary adenoma. (prolactin 18.3 ng/ml, growth hormone [GH] 4.1 ng/ml, adrenocorticotropic hormone [ACTH] 13.7 pg/ml, luteinizing hormone [LH] 2.0 mIU/ml, fol- The patient's recovery was uneventful and licle-stimulating hormone [FSH] 2.7 mIU/ml, postoperative ophthalmological examination, in- thyroid-stimulating hormone [TSH] 1.5 mIU/ml). We cluding assessment of visual acuity, visual fields, recommended immediate surgery by craniotomy and extraocular movement, was unremarkable. because of the risk of meningitis due to sinusitis, but Postoperative pituitary hormone status was also the patient expressed a preference for trans- normal (prolactin 28.5 ng/ml, GH 4.9 ng/ml, ACTH sphenoidal surgery. By 4 months after the onset, the 29.2 pg/ml, LH 4.5 mIU/ml, FSH 2.8 mIU/ml, TSH paranasal sinusitis had subsided. 2.1 mIU/ml). The patient was discharged 10 days The patient underwent transnasal transsphe- after the surgery and has done well since. MR imag- noidal removal of the pituitary adenoma. The bulk of ing performed 3 months after surgery revealed no the tumor was found to be non-hemorrhagic, but a tumor recurrence (Fig. 3). The histological diagnosis small purplish hemorrhagic area was found near the was diffuse type nonfunctioning pituitary adenoma top of the lesion on the left side. The tumor was (Fig. 4). Immunohistological staining showed removed except the upper part consisting of hard positive reaction for chromogranin A, but not for fibrous tissue because of the possibility of liquorrhea prolactin, GH, ACTH, LH, or FSH. if totally removed. Neurol Med Chir (Tokyo) 46, December, 2006 596 K. Nakahara et al. be related to the widening of the orifice of the diaphragma sellae, and penetrated the arachnoid tissue from the pituitary adenoma. MR imaging is undoubtedly the imaging tool of choice, which clearly demonstrates the features of hemorrhage and infarction, suprasellar extension, compression of the chiasm, and extension into the cavernous sinuses.1,11,15,16) In this case, sagittal MR imaging demonstrated the intratumoral hemorrhage reaching the top of the tumor, in the area adjacent to the pituitary cistern. Emergency surgery is required if the patient presents with deteriorating vision, sudden onset of blindness, or diminished level of consciousness. Fig. 4 Photomicrograph illustrating diffuse type Early surgery, within the 1st week, is recommended adenoma. Hematoxylin and eosin stain, × in the presence of visual impairment. If the patient 200. shows stable or improving ophthalmoplegia, then conservative treatment is justified.18) In our case, Discussion urgent transsphenoidal surgery was not indicated because the visual acuity and visual field remained Pituitary apoplexy may be precipitated by head trau- intact and paranasal sinusitis was present. This rare ma,20) pituitary hormone stimulation,10) estrogen and form of pituitary apoplexy should be distinguished anticoagulant therapy,14) angiography and radiother- from SAH due to anterior communicating artery apy,19) and particularly preoperative radiotherapy.2) complex aneurysms. The present patient had been healthy from birth and hadnopasthistorywhichcouldaccountforthe References sudden onset of symptoms. We considered the apoplexy to be caused by vessels in the tumor 1) Bills DC, Meyer FB, Laws ER Jr, Davis DH, Ebersold becoming distorted with growth, leading to rupture MJ, Scheithauer BW, Ilstrup DM, Abboud CF: A 4) and hemorrhage. retrospective analysis of pituitary apoplexy. Neu- SAH is a rare manifestation of pituitary apo- rosurgery 33: 602–609, 1993 plexy,4,7,14,17,19,21,22) whereas visual loss is a cardinal 2) Glass B, Abbott KH: Subarachnoid hemorrhage sign, occurring in 30 of 38 cases with major pituitary consequent to intracranial tumors. Review of the apoplectic attack.22) The present case is unique literature and report of seven cases. Arch Neurol because of the broad diffusion of SAH within the Psychiatry 73: 369–379, 1955 sylvian fissure, basal cistern, and fourth ventricle 3) Hayward RD, O'Reilly GVA: Intracerebral hemor- without visual symptoms. Intracranial hemorrhage rhage. Accuracy of computerised transverse axial in the suprasellar cistern and callosal regions indi- scanning in predicting the underlying aetiology. Lancet 1(7949): 1–4, 1976 cates ruptured aneurysm of the anterior cerebral 4) Henryk M, Tadeusz W, Joanna B: Acute hemorrhage 3,23) artery complex in as high as 100% of cases. In our into pituitary adenoma with SAH and anterior patient, the presence of ruptured anterior cerebral cerebral artery occlusion. JNeurosurg58: 771–773, artery aneurysm was suggested by the sudden onset 1983 of headache and vomiting with CT findings of broad 5) Hollenhorst RW, Younge BR: Ocular manifestations diffusion of SAH involving the suprasellar cistern. produced by adenomas of the pituitary gland: analy- Acute visual loss due to compression of the anterior sis of 1000 cases, in Kohler PO, Ross GT (eds): Diagno- visual pathways would support the diagnosis of sis and Treatment of Pituitary Tumors. International SAH due to the rupture of an aneurysm,13,17) but was Congress Series No. 303.Amsterdam,Excerpta not present in this case. Medica, 1973, pp 55–68 6) Jenkins JS: Pituitary Tumors. London, Butterworths, The arachnoid membrane invariably extends 1973, pp 59–60 through the orifice of the diaphragma sellae and 7) Kirshbaum JD, Chapman BM: Subarachnoid hemor- spreads out on the upper surface of the anterior lobe rhage secondary to a tumor of the hypophysis with of the pituitary gland. A fluid-filled space within this acromegaly. AnnInternMed29: 536–540, 1948 arachnoid tissue, known as the pituitary cistern, is 8) Lang J: Dura mater of the pituitary region, in Wilson found in adults.8) In our patient, the hemorrhage had RR, Winstanley DP (eds): Clinical