eMedicine Specialties > Ophthalmology > Endocrine Disorders

Pituitary Apoplexy: Differential Diagnoses & Workup

Author: Michael S Vaphiades, DO, Professor, Departments of Ophthalmology, Neurology, and Neurosurgery, Chief of Neuro-Ophthalmology and Electrophysiology Services, University of Alabama; Consulting Staff, Children's Hospital, Birmingham
Contributor Information and Disclosures

Updated: Aug 6, 2009

Differential Diagnoses

Aneurysmal Rupture
Optic Neuritis, Adult

Other Problems to Be Considered

Acute ophthalmoplegia

Workup

Laboratory Studies

  • Evaluate electrolytes, glucose, and pituitary hormones.

Imaging Studies

  • CT scan and MRI are radiologic tests used to evaluate the pituitary.
    • MRI is the most sensitive imaging study for evaluating the pituitary gland, possibly visualizing hemorrhage not seen on CT scan.
    • In the first 3-5 days, hemorrhage within the sella is isointense or hypointense on T1-weighted images. On T2-weighted sequences, the blood appears hypointense.
    • A characteristic MRI finding in ischemic (nonhemorrhagic) pituitary apoplexy is an enlarged pituitary gland bulging under the optic chiasm with peripheral enhancement surrounding an hypointense gland. The necrosis is the presumed etiology of the appearance of the hypointense center in the pituitary gland. Vaphiades coined the phrase pituitary ring sign to denote this MRI appearance.9 Vaphiades retrospectively reviewed the cranial MRIs of 3 patients with ischemic (nonhemorrhagic) pituitary apoplexy; all 3 patients displayed the pituitary ring sign.9
    • Binning and colleagues reported 6 cases of patients with Rathke cleft cyst apoplexy presenting with the clinical and imaging features of both hemorrhagic and nonhemorrhagic pituitary apoplexy.12
    • Kaplun and colleagues reported the MRI evolution of changes in the pituitary in 2 patients with Sheehan syndrome.13 The first case initially had the pituitary ring sign; yet, later, the MRI showed an empty sella with shrinkage of the pituitary. 

Histologic Findings

Histologically, many of these tumors display hemorrhagic necrosis in their substance. This has been postulated to result from unrecognized episodes of focal hemorrhage. Bills reviewed histories of 37 patients with symptomatic pituitary apoplexy.14 By immunostaining criteria, null-cell adenomas were the most frequent tumor type found.

More on Pituitary Apoplexy

Overview: Pituitary Apoplexy
Differential Diagnoses & Workup: Pituitary Apoplexy
Treatment & Medication: Pituitary Apoplexy
Follow-up: Pituitary Apoplexy
References
Further Reading
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Keywords

pituitary apoplexy, pituitary adenoma, neurologic impairment, endocrine stimulation, bromocriptine treatment, head trauma, pregnancy, pituitary irradiation

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Contributor Information and Disclosures

Author

Michael S Vaphiades, DO, Professor, Departments of Ophthalmology, Neurology, and Neurosurgery, Chief of Neuro-Ophthalmology and Electrophysiology Services, University of Alabama; Consulting Staff, Children's Hospital, Birmingham
Michael S Vaphiades, DO is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Osteopathic Association, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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