Introduction: Pituitary apoplexy is a rare, life-threatening condition resulting from hemorrhage or infarction of the pituitary gland, most commonly in patients with pre-existing pituitary tumors. It typically presents with a sudden headache, visual disturbance, ophthalmoplegia, and altered mental status. An uncommon but serious complication is ischemic stroke in the middle cerebral artery (MCA) territory, particularly in the absence of direct internal carotid artery (ICA) compression. Case: We report a case of a 36-year-old male who presented with headache, visual impairment, and fever. Initial computed tomography (CT) brain imaging demonstrated a heterogeneous sellar lesion with peripheral calcification measuring 2.4 × 3.2 × 2.7 cm, suggestive of a pituitary mass with possible apoplexy, without evidence of acute cerebral infarction. The patient subsequently developed dysarthria, hemianopia, and reduced consciousness, prompting repeat neuroimaging. Follow-up CT revealed a large hypodense area in the right fronto-parieto-temporal region consistent with ischemic infarction. Magnetic resonance imaging confirmed an acute infarct in the right MCA territory without hemorrhagic transformation. A sellar-suprasellar mass measuring 2.3 × 2.8 × 3.8 cm was identified, consistent with a pituitary macroadenoma with intratumoral hemorrhage compressing the optic chiasm, but without direct right ICA compression. Time-of-flight mineralocorticoid receptor antagonists demonstrated attenuated flow in the right ICA (C2–C7), suggesting intracranial ICA thrombosis and reduced perfusion in the right MCA and its branches. Laboratory evaluation revealed hyperthyroidism and hypocortisolism, with no evidence of coagulopathy. The patient was treated with corticosteroid replacement and carbimazole and referred for neurosurgical management. Conclusion This case highlights a rare association between pituitary apoplexy and MCA stroke, possibly mediated by vasospasm, inflammation, or hypercoagulability. More research is needed to understand this connection and improve treatment strategies.
Middle Cerebral Artery ; Pituitary Apoplexy ; Infarction

Introduction: Pituitary apoplexy is an acute endocrine emergency, as early recognition may influence the outcomes, often presenting with sudden headache, visual disturbances, ocular palsies, vomiting, or altered consciousness. Given that urgent surgical decompression is a common management, emerging evidence supports corticosteroid therapy in our patient with significant neuro-ophthalmic deficits. Case: A 65-year-old male with hypertension, dyslipidemia, type 2 diabetes mellitus, chronic kidney disease stage III, and ischemic heart disease presented with a 4-day history of fever, vomiting, bifrontal headache, and generalized abdominal pain. Initially, he was treated for presumed intraabdominal sepsis. On day 3 of admission, he developed acute right-sided complete ptosis with ophthalmoplegia involving cranial nerves III, IV, and VI. Prior to that, he had also reduced morning erections for 6 months before presentation. Biochemical evaluation revealed markedly reduced total testosterone (0.33 nmol/L) with inappropriately low–normal gonadotropins (luteinizing hormone 1.5 IU/L, follicle-stimulating hormone 2.3 IU/L), in keeping with secondary hypogonadism. Adrenocorticotropic hormone was suppressed, indicating secondary adrenal insufficiency. Thyroid function was preserved. Overall findings suggested partial hypopituitarism. Magnetic resonance imaging confirmed a cystic pituitary lesion measuring 1.4 × 2.6 × 1.8 cm with cavernous sinus involvement and features of pituitary apoplexy. His Pituitary Apoplexy Score was 4. He was offered surgical intervention but was not keen. He was treated with intravenous hydrocortisone, with rapid clinical improvement, including near-complete resolution of right eye ptosis and restoration of extraocular movements within 3 days, and was able to recover without surgery. The hydrocortisone was gradually tapered, and the patient was discharged well with Endocrine follow-up. Conclusion Timely corticosteroid therapy alone can result in rapid, near-complete neurological recovery in pituitary apoplexy, even with multiple cranial nerves involvement. In carefully selected patients without visual field compromise, conservative management may safely obviate the need for urgent surgical intervention, emphasizing the importance of early recognition and individualized treatment strategies.
Hydrocortisone ; Pituitary Apoplexy

Introduction: Pituitary apoplexy is a rare but potentially life-threatening endocrine emergency caused by hemorrhage or infarction of the pituitary gland. Its presentation often mimics other acute neurological conditions, posing diagnostic and management challenges. We report a case series of three patients presenting with similar neuro-ophthalmic complaints but differing in symptom onset and radiological features. Cases: The first case was a 25-year-old obese female who presented with acute headache, fever, and right eye ptosis with complete ophthalmoplegia for 2 days. Imaging demonstrated a heterogeneous pituitary macroadenoma with superimposed hemorrhage. Cortisol, prolactin, and insulin-like growth factor-1 levels were low. She received hydrocortisone replacement and underwent left pterional craniotomy with tumor debulking, resulting in marked visual improvement. The second case involved a 59-year-old male who presented with headache and bilateral blurred vision for 1 week, followed by acute right-sided ptosis. Imaging showed a heterogeneous sellar-suprasellar mass compressing the optic chiasm. He had central hypocortisolism, hypothyroidism, and hyponatremia. Surgical intervention was declined, and outpatient follow-up showed stable neuro-ophthalmic findings. The third case was a 30-year-old female who presented with a 2-week history of headache and right-sided blurred vision with temporal hemianopia. Imaging revealed a sellar-suprasellar mass with fluid-fluid levels compressing the optic chiasm. She had central hypocortisolism, hypothyroidism, and hypogonadism. Hydrocortisone replacement was initiated, followed by transsphenoidal surgery with tumor debulking. Her vision improved after the surgery. Conclusion Pituitary apoplexy may present with similar clinical features despite differing onset and radiological characteristics. Early corticosteroid therapy is essential, while surgical intervention should be reserved for patients with severe or progressive neuro-ophthalmic deficits. This case series highlights the importance of individualized, multidisciplinary management to achieve favorable outcomes.
Pituitary Apoplexy

Introduction: Acromegaly is usually diagnosed by elevated age- and sex-adjusted insulin-like growth factor-1 (IGF-1) levels reflecting chronic growth hormone (GH) excess. IGF-1 is preferred as a screening biomarker due to its longer half-life and reduced pulsatility compared with GH. However, IGF1 levels may be disproportionately low or only modestly elevated in certain clinical contexts, leading to diagnostic uncertainty. Pituitary apoplexy is one such condition in which acute tumor hemorrhage or infarction may disrupt sustained GH secretion and attenuate IGF-1 production Case: A 48-year-old female with hypertension, type 2 diabetes mellitus, and dyslipidemia presented with a 2-day history of severe headache, vomiting, and visual disturbance, on a background of progressive acral enlargement over 2 years. Examination revealed coarse facial features, prognathism, enlarged hands, and cranial nerve involvement. Magnetic resonance imaging demonstrated an invasive sellar– suprasellar pituitary macroadenoma with optic chiasmal compression and cavernous sinus encasement. Intravenous dexamethasone was initiated pre-operatively due to a significant mass effect. Biochemical evaluation showed markedly elevated random GH levels (>50 ng/mL) with only mildly elevated IGF-1 at 1.19 times the upper limit of normal, below the threshold at which confirmatory oral glucose tolerance testing may be omitted according to current guidelines. Other pituitary axes suggested evolving hypopituitarism. During admission, she developed severe hyperglycemia with marked insulin resistance, requiring high-dose insulin therapy (approximately 1.5 U/kg/day). She underwent urgent transsphenoidal surgery, with histopathology confirming a pituitary neuroendocrine tumor with extensive hemorrhage and infarction, consistent with pituitary apoplexy. Postoperatively, GH levels were suppressed to <5 ng/mL, insulin requirements decreased markedly, and hormone replacement was initiated for secondary adrenal insufficiency and central hypothyroidism. Conclusion This case highlights that IGF-1 levels below conventional diagnostic thresholds do not exclude clinically significant acromegaly, particularly in the setting of pituitary apoplexy. Integration of clinical phenotype, GH levels, and imaging findings is essential to avoid diagnostic delay and ensure timely management.
Acromegaly ; Insulin Resistance ; Pituitary Apoplexy

PURPOSE: To report a case of pituitary apoplexy presenting as isolated bilateral oculomotor nerve palsy. CASE SUMMARY: A 46-year-old male presented with bilateral ptosis and acute severe headaches for 6 days. He underwent head surgery and bilateral vitrectomy 12 years prior to his visit because of ocular and head trauma. He mentioned that previous visual acuities in both eyes were not good. The initial corrected visual acuity was finger counting in the right eye and 20/500 in the left eye. Ocular motility testing revealed the limitation of adduction, supraduction, and infraduction with complete bilateral ptosis in both eyes, and his left pupil was dilated. He was diagnosed with an isolated bilateral oculomotor nerve palsy. Magnetic resonance imaging indicated pituitary gland hemorrhage with a tumor, which was suspicious of pituitary apoplexy. The patient was treated intravenous with 1.0 g methylprednisolone to prevent the corticotropic deficiency. In addition, he underwent surgical decompression using a navigation-guided transsphenoidal approach and aspiration biopsy. He was confirmed with pituitary adenoma using a pathological examination. The patient's ocular movements began to dramatically improve by the third day postoperatively. At 4 months postoperative follow-up, his ocular movement and double vision were completely recovered. CONCLUSIONS: This was a rare case of pituitary apoplexy with bilateral isolated oculomotor nerve palsy, which was the first report in the Republic of Korea. A full recovery was achieved after early surgical treatment.
Biopsy, Needle ; Cranial Nerve Diseases ; Craniocerebral Trauma ; Decompression, Surgical ; Diplopia ; Fingers ; Follow-Up Studies ; Head ; Headache ; Hemorrhage ; Humans ; Magnetic Resonance Imaging ; Male ; Methylprednisolone ; Middle Aged ; Oculomotor Nerve Diseases ; Oculomotor Nerve ; Pituitary Apoplexy ; Pituitary Gland ; Pituitary Neoplasms ; Pupil ; Republic of Korea ; Visual Acuity ; Vitrectomy

Surgery, anticoagulation therapy, pregnancy, and hormone treatments, such as bromocriptine, are well-characterized precipitating factors for pituitary apoplexy. However, whether cytotoxic chemotherapy for systemic cancer could cause pituitary apoplexy has not been investigated. Here, we present a case of a 41-year-old woman who developed a severe headache with decreased visual acuity after intravenous cytotoxic chemotherapy to treat metastatic breast cancer. Preoperative neuroimaging revealed pituitary adenoma with necrosis. Operative findings and pathologic examination concluded extensive necrosis with a small intratumoral hemorrhage in a pre-existing pituitary adenoma. We reviewed two additional previously published cases of pituitary apoplexy after systemic chemotherapy and suggest that cytotoxic chemotherapy may induce pituitary apoplexy.
Adult ; Breast Neoplasms* ; Breast* ; Bromocriptine ; Drug Therapy* ; Female ; Headache ; Hemorrhage ; Humans ; Necrosis ; Neuroimaging ; Pituitary Apoplexy* ; Pituitary Neoplasms ; Precipitating Factors ; Pregnancy ; Visual Acuity

BACKGROUND: There have been various reports in the literature regarding the conservative management of pituitary apoplexy, pituitary incidentalomas and Rathke cleft cysts (RCCs). However, to the best of our knowledge, spontaneous involution of cystic sellar mass has rarely been reported. We report 14 cases of cystic sellar masses with spontaneous involution. METHODS: A total of 14 patients with spontaneous regression of cystic sellar masses in our hospital were included. The median age was 35 years (range, 5–67), and 8 patients were male. Clinical symptoms, hormone study and MRI were evaluated for all patients. The initial MRI showed all 14 patients with RCCs. Eight patients were presented with sudden onset of headache, and 1 patient with dizziness. Another patient, a 5-year-old child, was presented with delayed growth. Three patients had no symptoms via regular medical work up. All 14 patients had no visual symptoms. The follow-up period ranged from 5.7 to 42.8 months, with the mean of 17.3 months. RESULTS: The mean initial tumor size was 1.29 cm³ (range, 0.05 to 3.23). After involution, the tumor size decreased to 0.23 cm³ (range, 0 to 0.68) without any treatments. Repeated MRI showed a spontaneous decrease in tumor volume by 78% (range, 34 to 99). The initial MRI showed that the tumor was in contact with the optic chiasm in 7 patients, while compressing on the optic chiasm in 3 patients. Five patients were initially treated with hormone replacement therapy due to hormone abnormality. After the follow-up period, only 2 patients needed a long-term hormone replacement therapy. CONCLUSION: The spontaneous involution of RCCs is not well quantified before. Their incidence has not been well demonstrated, but this phenomenon might be underreported. Conservative management can be a treatment option in some RCCs without visual symptoms, even in those that are large in size and in contact with the optic nerve via imaging study.
Central Nervous System Cysts ; Child ; Child, Preschool ; Dizziness ; Follow-Up Studies ; Headache ; Hormone Replacement Therapy ; Humans ; Incidence ; Magnetic Resonance Imaging ; Male ; Optic Chiasm ; Optic Nerve ; Pituitary Apoplexy ; Tumor Burden

Anterior communicating artery (ACoA) aneurysms sometimes present with visual symptoms when they rupture or directly compress the optic nerve. Giant or large ACoA aneurysms producing bitemporal hemianopsia are extremely rare. Here we present an unusual case of bitemporal hemianopsia caused by a large intracranial aneurysm of the ACoA. A 41-year-old woman was admitted to our neurosurgical department with a sudden-onset bursting headache and visual impairment. On admission, her vision was decreased to finger counting at 30 cm in the left eye and 50 cm in the right eye, and a severe bitemporal hemianopsia was demonstrated on visual field testing. A brain computed tomography scan revealed a subarachnoid hemorrhage at the basal cistern, and conventional cerebral catheter angiography of the left internal carotid artery demonstrated an 18x8 mm dumbbell-shaped aneurysm at the ACoA. Microscopic aneurysmal clipping was performed. An ACoA aneurysm can produce visual field defects by compressing the optic chiasm or nerves. We emphasize that it is important to diagnose an aneurysm through cerebrovascular study to prevent confusing it with pituitary apoplexy.
Adult ; Aneurysm ; Angiography ; Arteries ; Brain ; Carotid Artery, Internal ; Catheters ; Female ; Fingers ; Headache ; Hemianopsia* ; Humans ; Intracranial Aneurysm* ; Optic Chiasm ; Optic Nerve ; Pituitary Apoplexy ; Rupture ; Subarachnoid Hemorrhage ; Vision Disorders ; Visual Field Tests ; Visual Fields

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome caused by the sudden enlargement of a pituitary adenoma secondary to hemorrhage or infarction. Pituitary apoplexy after cardiac surgery is a very rare perioperative complication. Factors associated with open heart surgery that may lead to pituitary apoplexy include hemodynamic instability during cardiopulmonary bypass and systemic heparinization. We report a case of pituitary apoplexy after mitral valvuloplasty with cardiopulmonary bypass. After early pituitary tumor resection and hormonal replacement therapy, the patient made a full recovery.
Cardiopulmonary Bypass ; Hemodynamics ; Hemorrhage ; Heparin ; Humans ; Infarction ; Mitral Valve Insufficiency ; Pituitary Apoplexy* ; Pituitary Neoplasms ; Postoperative Complications ; Thoracic Surgery

Adolescent ; Female ; Humans ; Pituitary Apoplexy ; complications ; physiopathology ; Pituitary Diseases ; etiology ; physiopathology