| Affiliation |
(AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (JG) Class of 2021, Baylor College of Medicine, Houston, Texas |
| Transcript |
So today, we're going to be talking about pituitary apoplexy. And apoplexy means ‘struck,' so the patients don't know they have a pituitary tumor, usually. And usually, it's a severe headache, often the worst headache of their life. And, as you know, the chiasm sits right above the sella, which holds the pituitary gland. And so, if you have a preexisting tumor inside of your pituitary gland and then it hemorrhages or develops necrosis acutely, it will rapidly expand. And if it rapidly expands upward, it will cause a visual field defect. And usually, the field defect is a bitemporal hemianopsia because it hits the chiasm, which is the crossing point between the two nasal fibers, but it can also produce field defects that are ipsilateral and a superior temporal field defect which is caused junctional scotoma. Or it can produce a monocular hemianopic field defect, called the junctional scotoma of Traquair. Or if it hits the optic tract, it can produce an incongruous homonymous hemianopsia. So lesions in patients who have apoplexy can be unilateral or bilateral optic nerve, chiasm, or the tract. And so when we see a patient who has an acute onset of painful field defect, whether it's bitemporal, junctional scotoma of Traquair, junctional scotoma, or homonymous hemianopsia, you know that's pituitary apoplexy. Imaging is required to look for this tumor, and usually what we're going to see is a rim of hyperintense signal intensity surrounding a hypointense core. So it can either present to us as a necrosis, a ‘necrotic' pituitary adenoma, or a hemorrhagic apoplexy. Both the necrotic and the hemorrhagic form of apoplexy present in the same way clinically. If the lesion extends laterally from the sella, it goes into the cavernous sinus. So the same stem - For example, a 30-year-old female who is post-partum has new onset pain, headache, and ophthalmoplegia…That also could be pituitary apoplexy, usually third nerve palsy. So, when confronted with any of these chiasmal-type field defects or acute ophthalmoplegias with severe pain - You should be thinking about pituitary apoplexy. We need to do an imaging study of the sella, looking for the hemorrhage or necrosis. That's usually CT followed by MRI. They should be admitted to the hospital because you kind of need your pituitary gland, and so we're going to check the hormones. The one that we're worried about, of course, is cortisol, but you need to check them all. And it usually requires an admission to the hospital and neurosurgical consultation. |
