Sudden onset isolated complete third nerve palsy due to pituitary apoplexy

Pituitary tumour apoplexy (PA) is a rare clinical syndrome that occurs as a result of acute haemorrhage and/or infarction within a frequently undiagnosed pituitary tumour. The sudden enlargement of the pituitary mass undergoing PA is responsible for a wide range of acute symptoms/signs (severe headache, visual loss, diplopia, hypopituitarism, impaired consciousness) which, together with the radiological evidence of a pituitary lesion, establish the diagnosis. The optimal care of PA requires involvement of a multidisciplinary team including endocrinologist, neurosurgeon, neuroophthalmologist and the management strategy that depends on the clinical manifestations, as well as the presence of co-morbidities. Prompt surgical decompression is initially indicated in cases with severe or progressive impairment of the visual acuity or the visual fields or with altered mental state and leads to visual and neurological recovery in most of the patients. The patients with mild, stable clinical picture (including those with isolated ocular palsies) can be managed conservatively (support of fluid and electrolyte balance and stress doses of steroids in most cases) with favourable visual and neurological outcome. Frequent reassessment is mandatory because the clinical course can be unpredictable; if progression of symptoms occurs, later elective surgery is indicated and is beneficial, especially in terms of visual outcome. The endocrinological outcome is less favourable, irrespective of the treatment option, with many patients remaining on long-term replacement therapy. Despite the above guidelines, clear proof of optimal outcomes in the form of randomised controlled trials is lacking. Regrowth of the pituitary tumour years after a PA episode is possible and patients require long-term surveillance.

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“…Isolated acute cranial nerve (CN) palsies have been reported (82,83,84,85) and they usually indicate a milder episode having good prognosis …”

Section: Clinical Presentationmentioning

confidence: 99%

MANAGEMENT OF ENDOCRINE DISEASE: Pituitary tumour apoplexy

Căpățînă

Inder

Karavitaki

et al. 2015

European Journal of Endocrinology

125

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“…A rapid rise in intrasellar pressure causes compression of the adjacent cranial nerves resulting in cranial nerve palsy. 6 The most common presentation is with sudden onset of headache, visual field defects, ophthalmoplegia and diplopia. Isolated third nerve palsy as a presenting symptom of pituitary apoplexy is uncommon.…”

Section: Discussionmentioning

confidence: 99%

Post Partum Pituitary Apoplexy presenting as isolated Third Cranial Nerve Palsy : A Case Report

Sharma¹,

Prashar²,

Tuli³

2016

DJO

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Pituitary apoplexy is a potential life threatening endocrine emergency caused by an acute ischemic or haemorrhagic vascular accident involving the pituitary adenoma or the adjacent pituitary gland. Patients may present with headache, double vision or rapidly worsening visual field defects. MRI plays an important role in the diagnosis. We present a case report of post partum patient presenting with diplopia and sudden onset ptosis right eye. MRI revealed acute bleed in the pituitary gland. She was managed conservatively and the condition resolved.

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“…In these cases, the tumor had some mass effect on CN III at the level of the oculomotor trigone after erosion of the posterior clinoid [77]. Multiple CN palsies and even bilateral and asymmetric lesions have been reported [78][79][80]. Rarely, pituitary apoplexy may present as isolated sixth cranial nerve (abducens) palsy [81].…”

Section: Visual Disturbancementioning

confidence: 99%

Pituitary Apoplexy

Jemel¹,

Alaya²,

Boubaker³

et al. 2019

Pituitary Diseases

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Pituitary apoplexy is a rare clinical emergency due to acute ischemic infarction or hemorrhage of the pituitary gland. As this disorder most often involves a pituitary adenoma, especially nonfunctioning tumors, the syndrome should be referred to as pituitary tumor apoplexy. The precise physiopathology is not completely clear. Although in most cases it occurs spontaneously, pituitary apoplexy can be precipitated by many risk factors. The main symptom is headache of sudden onset associated with visual disturbances, signs of meningeal irritation, and/or endocrine dysfunction. Corticotropic deficiency is a potentially life-threatening disorder. Magnetic resonance imaging is the most sensitive to confirm the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. Earlier studies used to consider urgent decompression of the lesion surgically, but nowadays, more recent studies favor conservative management in selected patients (those without important visual acuity or field defects and with normal consciousness). This wait-and-see approach gives evidence of excellent outcomes in terms of oculomotor palsy, pituitary function, and subsequent tumor growth. Surgical decompression may be necessary in some cases. Once the acute phase is over, the patient should be reevaluated for hormonal deficiencies. Moreover, spontaneous remission of syndromes, such as acromegaly, may be caused by pituitary adenoma apoplexy.

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Sudden onset isolated complete third nerve palsy due to pituitary apoplexy

Cited by 6 publications

References 4 publications

MANAGEMENT OF ENDOCRINE DISEASE: Pituitary tumour apoplexy

MANAGEMENT OF ENDOCRINE DISEASE: Pituitary tumour apoplexy

Post Partum Pituitary Apoplexy presenting as isolated Third Cranial Nerve Palsy : A Case Report

Pituitary Apoplexy

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