Pituitary Case: 51-year-old Man with Severe Headache

00:01 Let's go through a case.

00:03 A 51-year old man comes to the emergency department for severe headache that developed suddenly.

00:09 Soon after the headache began, he was unable to see out of his left eye, and vision in his right eye became blurry.

00:17 He vomited in the emergency department.

00:20 Medical history is significant for erectile dysfunction, loss of libido, and mild headache over the past two years.

00:28 On physical examination, his temperature is 36.4 degrees Celsius.

00:33 His blood pressure is 140 over 90.

00:35 His pulse rate is 100 beats per minute.

00:39 On visual field testing, there is loss of vision in his left eye and in the upper quadrant of his right eye.

00:47 He also has left eye ptosis.

00:50 Other cranial nerves are intact.

00:52 The rest of his neuro exam is normal.

00:55 A CT scan of the head shows acute pituitary hemorrhage, and MRI shows a two by two by three centimeter pituitary mass with central hemorrhage.

01:07 The mass compresses the optic chiasm and the left cavernous sinus.

01:12 What is the next step in the treatment of this patient? Here we have a fairly complicated presentation.

01:20 Headache and vision changes suggest a stroke, but more specifically, a bleed within the brain.

01:26 Clinically, the air of the optic chiasm is suspected.

01:30 Erectile dysfunction and loss of libido provided on history also point towards a conclusion that a pituitary lesion may be involved.

01:40 If we put together the presence of the visual findings with the reproductive findings of loss of libido, we come up with the area of the brain localized to the anterior pituitary where increase in mass or hemorrhage is going to result in compression symptoms on the optic chiasm which lies close by.

02:00 The conclusion here is that the next step in treatment would be pituitary surgery.

02:05 Stress-dose steroids should also be provided because of a reduction in cortisol, and the assessment of his pituitary hormone function should take place as well.

02:15 Acute apoplexy of the pituitary is caused by pituitary hemorrhage and requires urgent transsphenoidal decompression to preserve vision.

02:25 Loss of libido and erectile dysfunction, usually due to reduced FSH and LH, suggest that a prolactinoma has developed that actually bled and compressed the patient's optic nerve.

02:37 Raised intracranial pressure can cause vomiting as manifests in this patient.

02:42 He also requires urgent stress-dose glucocorticoids because of the risk of secondary cortisol deficiency, which can be life threatening.

02:51 As the pituitary mass, so hemorrhage increases, and there is pressure on the pituitary, reduction in ACTH causes a reduction in systemic cortisol.

03:01 This can lead to circulatory shock, and as a consequence, giving the patient glucocorticoids immediately will mitigate this risk.

03:11 In the next two to four weeks, thyroid function will need to be assessed by checking thyroxine which has a longer half-life, so does not need to be emergently addressed.

03:23 Treatment of hypogonadism or growth hormone deficiency is also not urgent, but surgical decompression of the pituitary is mainly to preserve vision.