Pituitary Apoplexy Workup
- Author: Michael S Vaphiades, DO; Chief Editor: Hampton Roy, Sr, MD more...
At least one anterior pituitary deficiency is always present at the onset of pituitary apoplexy, with corticotropic deficiency being the most common and most life-threatening, affecting 60%-80% of patients. Electrolytes, glucose, and pituitary hormones must be evaluated.
CT scanning and MRI are radiologic tests used to evaluate the pituitary.
CT scanning is generally the initial imaging study of choice in the emergency department for patients who present with sudden-onset severe headache, visual loss, and/or ophthalmoplegia suggestive of SAH. CT scanning can help to exclude SAH from an aneurysm by showing an intrasellar mass with hemorrhagic components, seen in 80% of pituitary apoplexy cases.
MRI, as seen in the images below, 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. Vaphiades retrospectively reviewed the cranial MRIs of 3 patients with ischemic (nonhemorrhagic) pituitary apoplexy; all 3 patients displayed the "pituitary ring sign."
Kaplun and colleagues reported the MRI evolution of changes in the pituitary in 2 patients with Sheehan syndrome. The first case initially had the pituitary ring sign; yet, later, the MRI showed an empty sella with shrinkage of the pituitary.
Liu et al reported spontaneous partial or complete radiological disappearance of adenoma following pituitary apoplexy without the use of dopaminergic agonists (which may result in regression of pituitary adenoma).
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. By immunostaining criteria, null-cell adenomas were the most frequent tumor type found.
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