November 21 2014 Presentation 76 yr old male presents to ED with 2 week history of significantly worsening headache 2 days prior to arrival the headache pain worsened and he was sensitive to light and also co nausea and vomiting ID: 909162
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Slide1
Case Report
Rachel Cooley MD
November 21, 2014
Slide2Presentation
76 yr old male presents to ED with 2 week history of significantly worsening headache
2 days prior to arrival the headache pain worsened and he was sensitive to light and also c/o nausea and vomiting
Tried Norco with no relief of pain
Past couple of years he has noticed “graying” of vision that worsens when he bends forward and at times has “tunnel vision”
Slide3Presentation
Past Medical History
Pituitary macroadenoma
Hypertension
Hyperlipidemia
Atrial FibrillationGERDCarotid Artery Stenosis
Past Surgical History
Appendectomy
Thyroidectomy
Slide4Presentation
Medications
Amiodarone
Norco
Levothyroxine
XareltoVitamin B complexPrednisoneLisinopril
Slide5Presentation
Social History
Married for 56 years
Truck driver after discharge from service in Army
Served in Army in artillery division
Quit smoking 35 years ago
Slide6Presentation
Review of Systems
Constitutional:
Positive for chills and malaise/fatigue
. Negative for fever and diaphoresis.
HENT: Positive for sore throat and neck pain. Respiratory
:
Negative
for cough, hemoptysis and sputum production.
Cardiovascular:
Negative
for chest pain, orthopnea and leg
swelling.
Gastrointestinal
:
Positive for nausea and vomiting.
Negative for abdominal pain, diarrhea, constipation, blood in stool and melena.
Musculoskeletal
: Positive for joint pain. Negative for myalgias.
Skin: Negative for itching and rash.
Neurological:
Positive for weakness
Slide7Presentation
Physical Exam
Vitals : 98.2
°
F Pulse: 64 Resp: 16
BP: 166/76 mmHg SpO2:
97
%
Pain
Score:
7
Constitutional
: W
ell-developed
and well-nourished.
No acute distress
Head
: Normocephalic and atraumatic.
Mouth/Throat
: Oropharynx is clear and moist.
Patient
is tender to palpation over left posterior occiput.
Eyes
: Conjunctivae and EOM are normal.
PERRL.
Retro-orbital
pain with extremes of eye abduction. Visual fields full to confrontation grossly.
Slide8Presentation
Cardiovascular: Normal rate, regular rhythm. No gallop, no rub, no murmur.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal. No distension. Nontender. No guarding.
Neurological: He is alert. No cranial nerve deficit. He exhibits normal muscle tone. Coordination normal.
Psych: Normal mood and affect. Thought content normal.
Slide9Labs
SODIUM
134
POTASSIUM 4.5
CHLORIDE 98
CARBON DIOXIDE 23 BUN 23 CREATININE 1.33 GLUCOSE 160CALCIUM 8.6
SGOT (AST) 39
SGPT (ALT) 58
ALKALINE PHOSPHATASE 39
BILIRUBIN, TOTAL 0.7
PROTEIN, TOTAL 7.1
ALBUMIN 4.0
WBC
18.5
HEMOGLOBIN
12.7
HEMATOCRIT 38.1
PLATELET COUNT 360
INR
1.9
Slide10Imaging
Slide11Imaging
Slide12Presentation
Imaging
CT head: no acute intracranial abnormality. Findings consistent with pituitary macroadenoma without significant change
MRI read from August at OSH: “solid enhancing mass arises from the sella turcica, measuring 2.8x1.4x1.5cm (width by AP by CC). It extends into the suprasellar cistern and displaces the optic chiasm superiorly and also extends into the right cavernous sinus and partially encircles (slightly greater than 50%) the ipsilateral right cavernous carotid artery. The pituitary stalk is thickened and deviated to the left.”
Slide13Clinical Course
Patient was admitted with pituitary macroadenoma with extrasellar extension
Endocrinology was consulted and recommended
ordering
FSH, LH, TSH, prolactin, IGF-1,
ACTHNeurosurgery consulted and recommended MRI with pituitary protocolSymptom control with Dilaudid and Phenergan
Slide14MRI
Slide15Clinical Course
Hospital Day 2
Labs:
Prolactin:
2
(3-30)LH: 0.7 (1.2-8.6)
FSH
: 2.1 (1.3-19.3)
TSH
:
0.07
NSG
recommended ophthalmology visual field testing. Also recommended reversal of INR
Patient’s HA was well controlled with Dilaudid. Antiplatelet agents were held. Plan to go to ophthalmology clinic the next day for formal visual field testing.
Slide16Clinical Course
Hospital Day 3
HA not controlled. Rating it a 10/10. C/o nausea and being very dizzy
PE: appears in distress. Lying in bed with cloth covering eyes.
Patient started on decadron 4mg IV q6h to avoid adrenal insufficiency. Also started patient on dilaudid PCA to help with pain control.
Ophthalmology assessed the patient and it was decided he was too unstable for VF testing. Will try again on Monday if headache improves.
Slide17Clinical Course
Hospital Day 4
Improvement in headache
Hospital Day 5
HA worse 8/10. Patient confused and not oriented. Agitated overnight.
Hospital Day 6Patient’s HA better controlled. Not oriented to where he is/why he is here. Concerns for hallucinations. Unstable for visual field testing today as he is requiring Dilaudid PCA.NSG didn’t recommend emergency surgery as his neuro status hadn’t acutely changed and there are no gross visual field deficits. Recommend treating sinusitis seen on presentation.
Slide18Clinical Course
Hospital Day 7-Discharge
Mental status improved. Continued treatment of sinusitis for 2 weeks. Transitioned to PO pain medications. Steroid taper
Outpatient follow-up with
Neurosurgery, Endocrinology and Ophthalmology
Slide19Pituitary Apoplexy
Slide20Overview of Pituitary Anatomy
Slide21What is it?
Rare and potentially fatal condition first described in 1898
Recognized as a clinical syndrome in 1950
Syndrome of violent headache, visual impairment, cranial nerve disturbance, vomiting, panhypopituitarism
Occurs in 1.6-1.8% of patients with macroadenomas
Slide22Pathogenesis
Unknown
Subacute, excessive growth of pre-existing adenoma which outgrows its blood supply leading to ischemic necrosis followed by hemorrhage
Tumor compression of the infundibulum and superior pituitary arteries leads to infarction of the pituitary gland
Slide23Risk Factors
Hypertension
Diabetes mellitus
Anticoagulants
Bromocriptine
Radiotherapy
Slide24Diagnosis
Requires findings on imaging + clinical symptoms
CT is often the first imaging study done
Shows areas of hyperdensity within the sellar region
Low sensitivity 21-46%
MRISensitivity 88-90%
Slide25Treatment
Patients who are unstable should immediately be started on steroids
Need for surgical intervention is controversial
No randomized controlled trials on optimal management
Follow-up is important
Repeat imaging 3-6 months after PA and every year for atleast 5 years
Slide26Patient Update
Seen in neurosurgery clinic 1 month after hospitalization
Repeat MRI showed “significant resolution of the suprasellar mass with no contact at all with the optic nerves or chiasm. A very small enhancing region was still noted in the sella.”
Recommend f/u MRI in 6 months
Slide27References
Boellis, B et al. Pituitary apoplexy: an update on clinical and imaging features. Insights Imaging. 2014 Oct 16
Bujawansa, S et al. Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom. Clinical Endocrinology (2014) 80, 419-424
Bi, W et al. Pituitary apoplexy. Endocrine. 2014 July 26
Rajasekaran, S et al. UK Guidelines for the Managament of pituitary apoplexy. Clinical Endocrinology (2011) 74, 9-20.
Slide28Thank you!