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TOPIC OF THE ISSUE: NEUROIMAGE
Year : 2012  |  Volume : 60  |  Issue : 3  |  Page : 314-315

Pituitary apoplexy presenting with pure third ventricular bleed: A neurosurgical image


Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication14-Jul-2012

Correspondence Address:
Sandeep Mohindra
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.98523

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How to cite this article:
Mohindra S, Savardekar A, Tripathi M, Garg R. Pituitary apoplexy presenting with pure third ventricular bleed: A neurosurgical image. Neurol India 2012;60:314-5

How to cite this URL:
Mohindra S, Savardekar A, Tripathi M, Garg R. Pituitary apoplexy presenting with pure third ventricular bleed: A neurosurgical image. Neurol India [serial online] 2012 [cited 2019 Aug 23];60:314-5. Available from: http://www.neurologyindia.com/text.asp?2012/60/3/314/98523


A 40-year-old female, with acromegalic features, presented with sudden-onset headache and vision loss followed by altered sensorium of three-day duration. Her acral enlargement and prognathism existed for the past five years. On neurological examination, her Glasgow Coma Scale score was E1VtM4 and she required intubation to secure the airway. Computed tomography (CT) of head showed pure anterior third ventricular bleed with obstructive hydrocephalus [Figure 1]. With a provisional diagnosis of anterior communicating artery (ACoM) aneurysmal rupture, CT-angiography (CTA) was performed. As CTA [Figure 2] did not reveal any aneurysm, contrast-enhanced magnetic resonance imaging (MRI) was performed [Figure 3] and [Figure 4]. A large sellar mass lesion, extending into the supra-sellar region was noted. Sagittal sections showed this lesion to be an apoplectic pituitary macro-adenoma with supra-sellar extension [Figure 4]. The posterior-superior surface of the supra-sellar component had burst into the third ventricle, traversing the lamina terminalis. Emergent endocrinological evaluation revealed growth-hormone-secreting pituitary adenoma (serum cortisol 1.7 μgm/dl, T4 8.0 μgm/dl, growth hormone 20.2 ng/ml). As the patient's neurological status was poor, ventriculo-peritoneal shunt was placed. There was no improvement in patient's clinical condition and she succumbed within 48 h of her presentation.
Figure 1: CT scan (axial section) showing blood in the anterior third ventricular region

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Figure 2: CT angiography showing no abnormality at anterior communicating artery region

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Figure 3: MRI scan (T2-weighted, axial section) showing hypo- to hyperintense intra-tumoral signals indicating pituitary apoplexy

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Figure 4: MRI scan (contrast-enhanced, sagittal section) demonstrating rupture of tumor capsule at postero-superior region and spillage of hemorrhage into third ventricle. The traversing of lamina terminalis is obvious

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Pituitary apoplexy, occurring in 2-7% of pituitary tumors, [1] is characterized by sudden-onset headache, vision loss, restricted ocular motility and mild pituitary insufficiency, caused by hemorrhage or infarction in the pituitary gland. During apoplexy, pressure gradient causes blood outflow through the path of least resistance, frequently into the subarachnoid space of the basal cisterns, or rarely into the third ventricle through its floor. [2] Pure third ventricular bleed as a feature of pituitary apoplexy is a rare occurrence and pure intra-third ventricular extension may be facilitated by adhesions formed between the tumor and floor of the third ventricle, due to previous micro-bleeds and extreme thinning of the floor caused by pressure from the supra-sellar component as depicted in the present case. It seems prudent to consider pituitary apoplexy as a differential diagnosis in cases of angiographically negative third ventricular bleed. [1] The greater sensitivity, precision, and tissue definition of MR imaging makes it the radiological investigation of choice. Sagittal section of contrast-enhanced MRI can reveal the defect in the tumor capsule and its site of rupture, as seen in the present case.

 
  References Top

1.Bills DC, Meyer FB, Laws ER Jr, Davis DH, Ebersold MJ, Scheithauer BW, et al. A retrospective analysis of pituitary apoplexy. Neurosurgery 1993;33:602-9.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Satyarthee GD, Mahapatra AK. Pituitary apoplexy in a child presenting with massive subarachnoid and intraventricular haemorrhage. J Clin Neurosci 2005;12:94-6.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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