Pituitary Apoplexy with Subarachnoid Hemorrhage: Case Presentation and Literature Review

Introduction: Pituitary macroadenomas (PM) are common benign tumors of the CNS which can infrequently acutely undergo hemorrhage or necrosis resulting in pituitary apoplexy syndrome. Acute subarachnoid hemorrhage related to PM hemorrhage is rare, with only a few case reports published in the literature. We present a case of acute subarachnoid hemorrhage due to pituitary apoplexy with a literature review.

Case History: Our patient is a 55-year-old male who presented with a sudden and severe headache, monocular vision loss, and seizures. Noncontrast head CT revealed a large heterogenous pituitary mass with central hemorrhage and scattered subarachnoid blood in the interhemispheric and sylvian fissures with trace blood layering within the ventricles. Ruptured cerebral aneurysm causing pituitary apoplexy was the presumed diagnosis and the patient was transferred to our institution for a higher level of care. On a reevaluation CT, and follow-up MRI angiogram, and catheter angiogram, there was no evidence of cerebral aneurysms or arteriovenous malformations.

Endoscopic expanded transsphenoidal hypophysectomy was then performed for treatment of pituitary apoplexy syndrome with full decompression of the optic chiasm. The tumor capsule extending suprasellar was noted to be ruptured. Intraoperative frozen section and final pathology was consistent with hemorrhagic and infarcted pituitary lactotroph adenoma.

Discussion: Nontraumatic subarachnoid hemorrhage is most commonly caused by ruptured aneurysms. While patients with intracranial aneurysms can also have pituitary macroadenomas, the combination is uncommon, and it is even rarer for a ruptured aneurysm to be the direct cause of pituitary apoplexy. An even less reported cause of subarachnoid hemorrhage related to pituitary apoplexy is capsular rupture with subarachnoid extension of the pituitary macroadenoma hemorrhage.

In the largest case series of 93 pituitary adenomas with apoplexy syndrome, only 0.5% was found to be a tumor hematoma as a source of subarachnoid hemorrhage. Literature-reported causes of subarachnoid hemorrhage related to pituitary apoplexy include concomitant aneurysm rupture, closed head trauma, and postoperative residual tumor bleeding.

Fig. 1 Noncontrast CT Head obtained at presentation. (A) Large heterogenous sellar-suprasellar mass and acute subarachnoid hemorrhage in the frontal lobe. (B) Acute subarachnoid hemorrhage within the interhemispheric fissure, right sylvian fissure. Small amount of blood in the occipital horn of the lateral ventricles.

Fig. 2 MRA MIP collapsed image is negative for aneurysms or AVMs.

Publication History

Article published online:
15 February 2022