FRI335 Late Surgical Management For Symptom Control In A Patient With History Of Pituitary Apoplexy

Disclosure: S. Zahra: None. F. Manas: None. S. Yavuz: None. Introduction: Pituitary Apoplexy is a rare life-threatening condition which presents with sudden onset headache, and neuro-ophthalmic symptoms. The diagnosis is challenging and requires a high index of clinical suspicion, especially in patients with pre-existing pituitary macroadenomas. MRI is the imaging modality of choice to confirm the diagnosis. The management is tailored according to the severity of clinical presentation. A conservative approach is recommended in stable patients with no or mild visual changes. Surgical management is usually reserved for patients with severely reduced visual acuity, and worsening mentation. Here we present a case of a patient with pituitary apoplexy who underwent late surgical resection due to persistent intractable headache. Case Presentation: 24 years old female with no significant past medical history presented to the emergency with worsening headache and blurry vision since last 2 weeks. The patient also complained of weight gain, fatigue, amenorrhea, and intermittent galactorrhea for the last 8 months. Physical examination was unremarkable, no visual deficit or neurological deficit was present. Blood work was remarkable for mildly elevated prolactin of 46.1 ng/ml (normal: 3.0-18.6 ng/ml) and low morning cortisol of 4.0ug/dl (normal:4.5-22.7 ug/dl). MRI of the brain revealed 13mm x 7.5mm focus of signal abnormality within the posterior aspect of the Sella, suggestive of a hemorrhagic adenoma. She was diagnosed with pituitary apoplexy with secondary adrenal insufficiency and was started on IV hydrocortisone. Neurosurgery was consulted, however no surgical interventions were recommended since the patient had no evidence of mass effect on optic chiasm or vision loss or changes in mentation. She was discharged on oral steroids. Her prolactin level, which was initially elevated likely due to compression of infundibulum from hemorrhage, normalized a few weeks after hospitalization. She was followed with MRI which showed a stable pituitary lesion. The patient continued to have intermittent episodes of headache which were initially managed conservatively but later the patient opted for elective surgery due to the persistence of intractable headaches. She underwent endoscopic transsphenoidal resection of pituitary tumor without any complications. At follow up visits, the patient’s symptoms had resolved, and her hypothalamic-pituitary axis evaluation and MRI was normal. Conclusion: The management of pituitary apoplexy is controversial due to its rarity and variation in the severity of symptoms at the time of presentation. In the recent past, conservative approaches have become more common in patients who are stable with little or no visual defects. The neurosurgical approach is usually reserved for patients with deteriorating mentation or worsening visual changes, but it can be used in patients with persistent severe symptoms. Presentation: Friday, June 16, 2023