Selected remifentanil-propofol concentration pairs, especially higher propofol-lower remifentanil concentration pairs, can block the response to EI while avoiding IVD in spontaneously breathing volunteers. It is, however, difficult to block the response to EI and avoid both LOR and IVD. It may be necessary to accept some discomfort and blunt rather than block the response to EI to consistently avoid LOR and IVD.

Propofol alone would likely lead to inadequate conditions for esophageal instrumentation but would provide a rapid return to responsiveness and low probability of respiratory compromise once the procedure ended. The addition of remifentanil or fentanyl improved conditions for esophageal instrumentation and had an equally rapid return to responsiveness. The time required to achieve a low probability of respiratory compromise was briefly prolonged; this is likely inconsequential given that patients are responsive and can be prompted to breathe.

Pituitary apoplexy is a clinical syndrome of hemorrhage or infarction of a pituitary adenoma. It has classically been associated with pituitary macroadenomas. The authors report three cases of pituitary apoplexy that occurred in patients with pituitary microadenomas. The presentation, endocrine results, and radiological and clinical outcome of each patient are described. In each of these cases of pituitary apoplexy due to microadenoma, the presenting headache was mistakenly attributed to a different diagnosis. The authors propose that pituitary apoplexy associated with a microadenoma may be much more common than appreciated and could be misdiagnosed as headache of alternative cause. Clinicians and radiologists should be aware of this clinical presentation.

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