Pituitary Adenoma with Apoplexy with Arteriovenous Malformation

Abstract

A 25-year-old man admitted to our department with chief complaints of headache and giddiness for last 2 weeks. Two weeks back the patient had history of headache of sudden onset, severe in intensity with sudden loss of vision. He regained his vision without any deficit within minutes. There was no history of unconsciousness, seizures or focal deficit, and persistent diminution of vision. On examination the patient had visual acuity 6/6 in the both eyes with no field defects. On fundus examination no abnormality was detected. Hormone analysis showed level of prolactin greater than 200 ng/mL.Contrast-enhanced computed tomography (CECT) of the brain (►Figs. 1 and 2) on admission showed welldefined, contrast-enhancing, hyperdense lesion of size 24 Â 20 Â 17 mm. Lesion seen in parafalcine region of the right parietal lobe associated with prominent perilesional vessels appeared draining in superior saggital sinus suggestive of arteriovenous malformation (AVM). There is evidence of widening of sella with presence of soft tissue density lesion of size 20 Â 17 Â 20 mm pituitary adenoma.Magnetic resonance imaging (MRI) of the brain and sella showed a mass lesion in sella showing presence of solid and cystic component. The cystic component appeared hyperintense on T2 whereas solid component appeared isointense to gray matter on T1 and T2W images. Hemorrhage was noted within lesion showing fluid level and hypointense on T2W images. Mass was seen extending into the sphenoid sinus. A small AVM was noted along medial aspect of right parieto-occipital lobe showing presence of multiple vascular channels and early draining vein into the superior saggital sinus and into deep venous sinuses. There was associated mild perilesional gliosis. It showed heterogenous enhancement on postcontrast enhancement.Cerebral CT angiography showed AVM with nidus measuring 25 Â 22 mm in parafalcine region of the right high parietal lobe with the caliber of draining vein measuring 4 mm draining into superior saggital sinus. The AVM is supplied by the right callosomarginal artery, branch of right anterior cerebral artery.Cerebral digital subtraction angiography (►Fig. 3) showed AVM of size 7.95 Â 16.13 mm of the right parietal lobe supplied by the right pericallosal artery (branch of right Keywords ► arteriovenous malformation ► pituitary adenoma ► primary brain tumor AbstractBackground This is a rare association of pituitary adenoma with apoplexy with arteriovenous malformation as only single case was reported prior to this case as per our knowledge. Case Description A 25-year-old man presented with chief complaints of headache of sudden onset, severe in intensity with sudden loss of vision. Imaging shows pituitary adenoma with apoplexy with right parietal arteriovenous malformation. The patient was managed with embolization for parietal arteriovenous malformation and medically for pituitary adenoma with apoplexy. Conclusion Pituitary apoplexy can be treated conservatively if no features of mass effect present. Follow-up of the patient must be done r...