SAT-LB083 Pituitary Apoplexy: What a Headache!

Introduction: Pituitary apoplexy describes rapid enlargement of the pituitary gland, most often caused by hemorrhagic infarction of an adenoma. Occurs in about 8% of patients with pituitary macroadenomas. Apoplexy commonly presents with severe headache, nausea, visual field defect, hemodynamic instability, or hormone abnormalities. When hormone anomalies occur, there is debate whether surgical or conservative management is preferred. Case Presentation: 26-year-old female no significant medical history presented to the emergency department with 2 years of secondary amenorrhea, galactorrhea, and hemianopsia. She began to have severe headaches a week prior to presentation. Laboratory data showed prolactin greater than 1000ng/mL, FSH 0.7mIU/mL, LH 0.1mIU/mL, and estradiol 15pg/mL. ACTH, IGF-1, TSH, and free T4 were within normal limits. Brain MRI showed a markedly enlarged pituitary gland with mass effect upon the optic chiasm and hemorrhage consistent with pituitary apoplexy. Trans-nasal, trans-sphenoidal pituitary tumor debulking was performed emergently with subsequent pathology revealing pituitary adenoma suggestive of prolactinoma. Hospital course was significant for post-surgical hypopituitarism and diabetes insipidus treated with cabergoline and hormone replacement, as well as aseptic meningitis treated with antibiotics, steroids, and a lumbar drain. Discussion: Pituitary apoplexy is a rare complication of a pituitary adenoma that can be life threatening. Diagnosis is made with both clinical signs and radiologic evidence of pituitary enlargement with MRI being the most effective imaging tool. After the patient has been stabilized, the next step towards management is unclear, as surgery has its risks and benefits. Generally, studies have shown that surgical decompression is significantly beneficial for patients presenting with neurological symptoms including visual disturbances and altered mental status as seen in this case. However, the literature is mixed on the effect of debulking surgery on hypopituitarism and hormone abnormalities. Older studies demonstrate a benefit from a surgical approach where more recent ones have suggested no significant difference in return of pituitary function when compared to conservative medical management focused on hormone replacement. In this case, the patient presented with visual disturbances and endocrine abnormalities and underwent surgery. Subsequently, she developed post-surgical complications including infection and panhypopituitarism. This case is unique due to an adverse event directly related to the treatment plan chosen. The literature shows that panhypopituitarism can persist after debulking, but it does not look into adverse events and negative outcomes that can occur due to surgery including worsening of the endocrine abnormalities and infection risk. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.