Pituitary Apoplexy with Hypopituitarism: A rare presentation with refractory hyponatremia

Mahendra Samy

Physician Assistant – Department of Neurosurgery, Kauvery Hospital, Cantonment, Trichy

Introduction

Pituitary apoplexy is a potentially life-threatening emergency caused by hemorrhage or infarction within a pituitary gland adenoma. It often presents with acute headache, visual disturbances, and altered sensorium. Hyponatremia as the initial presentation of pituitary apoplexy is uncommon and can be refractory to medical management. Here, we report a case of pituitary apoplexy in a patient with a pre-existing pituitary macroadenoma, presenting with persistent hyponatremia and requiring emergent surgical intervention.

Case Presentation

Initial Evaluation

A 54-year-old male with no known comorbidities presented with complaints of headache for 3 to 4 weeks, accompanied by blurring of vision in the bilateral temporal fields. An MRI brain scan performed and revealed a pituitary macroadenoma in the sella and suprasellar region.

MRI brain scan

On Examination

On admission, the patient was alert with a Glasgow Coma Scale (GCS) score of E4V5M6, moving all limbs spontaneously. Neurological assessment revealed bitemporal hemianopia, consistent with optic chiasm compression. No features suggestive of acromegaly were noted.

The above picture of the patient Visual field chart it shows bitemporal hemianopia

Vital Signs and Systemic Examination

  • Heart rate: 72 beats per minute
  • Blood pressure: 110/70 mmHg
  • SpO₂: 98% on room air

Systemic examination was unremarkable

  • Cardiovascular system: Normal heart sounds (S1, S2 present)
  • Respiratory system: Bilateral air entry present
  • Abdomen: Soft, no abnormalities detected

Endocrine and Laboratory Evaluation

The patient underwent a detailed pituitary hormonal assessment:

  • ACTH: <5 (Low)
  • Random cortisol: 3.3 μg/dL (Low)
  • Prolactin: 18.1 ng/mL (Slightly elevated)
  • TSH: 0.89 μIU/mL (Low)
  • Free T3: 1.52 pg/mL (Normal)
  • Free T4: 0.62 ng/dL (Low)

Additional laboratory findings included hyponatremia, hyperkalemia, and relatively low blood pressure, suggestive of hypopituitarism with secondary adrenal insufficiency. Hyponatremia was persistent despite initial correction with normal saline, requiring further management.

Initial Management

The patient was started on oral hydrocortisone (steroids) and thyroxine replacement. Due to persistent refractory hyponatremia, sodium correction was intensified with 3% NaCl, and hydrocortisone was switched to a parenteral form. Given the possibility of hypopituitarism, close monitoring of electrolytes and fluid balance was initiated.

Acute deterioration and emergency diagnosis

On the third day of admission, the patient developed severe headache, altered sensorium, and worsening sodium levels. An CT brain scan revealed pituitary hemorrhage, confirming pituitary apoplexy. Since hyponatremia, refractory to medical management in a patient with a worsening sensorium levels, is an indication for surgery, and urgent transnasal transsphenoidal endoscopic excision of the pituitary tumor was planned in spite of sodium being very low (117 mg/dl ).

Surgical Management

After that get high-risk informed consent, the patient underwent transnasal transsphenoidal endoscopic excision of the pituitary macroadenoma with double-layered closure using Duragen and a Haddad flap, along with lumbar external drainage.

Surgical Procedure

  • Patient was positioned supine, and a throat pack was placed.
  • The Haddad flap was raised by an ENT surgeon.
  • The sphenoid sinus was entered, and the sellar floor was drilled.
  • The dura was cauterized and opened in a cruciate manner.
  • The tumor was partially suckable with hemorrhagic clot, and total excision was performed until arachnoid descent was achieved.
  • Duragen was placed, and Tisseel glue was applied.
  • Fat and the Haddad flap were repositioned, sealed with glue, and nasal packing was performed.
  • A lumbar drain was inserted, and CSF drainage was confirmed.

Postoperative Course

The patient was closely monitored in the neuro ICU, with a focus on:

  • CSF leak assessment
  • Hourly urine output monitoring
  • Twice-daily serum sodium level monitoring
  • Neurological status and sensorium assessment
  • Fever and neck stiffness
  • Lumbar drain management

Within 48 hr, the patient showed gradual improvement in sensorium, normalization of serum sodium levels, and stable urine output, allowing transfer to the ward.

In-hospital recovery

  • Serum sodium levels remained stable throughout hospitalization.
  • Headache significantly improved.
  • Lumbar drain was removed on post-op day 3.
  • Bilateral nasal packing was removed on post-op day 5, revealing a well-healed Haddad flap.
  • The patient was mobilized without complications, and no CSF leak was observed.
  • Histopathology confirmed a pituitary neuroendocrine tumor.
  • Subjective improvement in vision was noted.

On postoperative day 7, the patient was discharged in a stable condition with ongoing hormonal replacement therapy.

Discussion

Pituitary tumors are usually non-functioning adenomas, and less than 10% present with pituitary apoplexy. Pituitary apoplexy results from hemorrhage or infarction within the tumor, leading to acute symptoms such as severe headache, altered mentation, and life-threatening hormonal disturbances.

Hyponatremia as an initial presentation of pituitary apoplexy is rare and often resistant to medical management. It is primarily due to adrenal insufficiency and SIADH (syndrome of inappropriate antidiuretic hormone secretion), necessitating both glucocorticoid replacement and aggressive sodium correction. Pituitary apoplexy is always a surgical emergency. When there is deceased sensorium, deterioration in vision, emergency surgery in pituitary apoplexy can be a life saving measures, improving mortality and morbidity.

Clinical Takeaways

  1. Pituitary apoplexy is a neurosurgical emergency requiring prompt recognition and intervention.
  2. Refractory hyponatremia can be an unusual but critical presentation of pituitary apoplexy.
  3. Hormonal assessment is essential in pituitary tumors, particularly in cases with electrolyte disturbances.
  4. Transnasal transsphenoidal surgery is the preferred approach for decompression and tumor removal.
  5. Neurointensivists play a critical role in the immediate postoperative period, ensuring the early identification and management of potential complications such as cerebrospinal fluid leaks, electrolyte imbalances (particularly hyponatremia or diabetes insipidus), hemodynamic instability, and changes in neurological status. Continuous monitoring in a neurocritical care unit allows for rapid response to any deterioration, optimizing recovery and reducing the risk of long-term complications
  6. Multidisciplinary management, including endocrinologists and neurosurgeons, ensures optimal patient outcomes.

Conclusion

This case highlights the challenges of diagnosing and managing pituitary apoplexy, particularly in patients presenting with refractory hyponatremia. Early recognition, timely hormonal replacement, and urgent surgical decompression are crucial in achieving a favorable outcome. In this case, despite severe metabolic and neurological deterioration, a multidisciplinary approach led to successful surgical intervention and recovery.

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