7715 A Case of Cerebral Infarction Resulting From Pituitary Apoplexy

Abstract Disclosure: W.E. Jenkins: None. A. Elmaaz: None. A. Makdissi: None. Background: Acute cerebral infarction as a sequela of pituitary adenoma and apoplexy is a rare phenomenon with poor outcomes. The mechanism is typically direct mechanical compression of the internal carotid artery secondary to hemorrhage. There is a very small number of reported cases of non-hemorrhagic compression. We report a case of a pituitary adenoma causing tandem internal carotid-middle cerebral artery occlusion with resultant infarction, most likely due to non-hemorrhagic pituitary apoplexy. Clinical Case: A 76-year-old male with hypertension and type II diabetes mellitus presented to the emergency department with a sudden onset severe headache, left facial droop, and left-sided weakness. CT stroke study revealed a right-sided cavernous ICA occlusion and a tandem MCA occlusion with a large sellar mass extending into the right sphenoid and cavernous sinus. Ophthalmologic evaluation revealed right pupillary dilation and ophthalmoplegia concerning for orbital apex syndrome. Emergent thrombectomy, angioplasty, and stenting of the occlusion in the supraclinoid segment of the ICA were performed, and treatment with dual antiplatelet therapy was initiated. MRI confirmed a large 25x20x20 mm right paramedian sellar/suprasellar mass with encasement of the ICA, however there was no evidence of sellar hemorrhage. Given recent stenting and the patient's hemodynamic stability, the neurosurgical team opted for delayed surgical intervention. The patient was discharged with marked improvement in left-sided weakness, although his right pupil remained minimally reactive with visual perception only to light. Based on biochemical evaluation, the mass was deemed non-functional, as prolactin and IGF-1 were within normal limits. There was evidence of secondary hypothyroidism and hypogonadism. Transsphenoidal surgery was pursued, occurring 114 days from symptom presentation. Histopathology revealed foci of devitalized anterior pituitary consistent with infarction of a pituitary adenoma. He was started on IV hydrocortisone on the day of surgery and tapered to a daily replacement dose. Visual acuity in the right eye remained severely reduced after the operation. Conclusion: Our case displays that, while extremely rare, clinicians should be aware that pituitary adenomas can result in cerebral infarction secondary to mechanical compression of the internal carotid artery, typically caused by an apoplexy event, hemorrhagic or ischemic. Emergent medical and endovascular treatment of the infarction should take precedence, and if clinical stability allows, a delayed surgical approach to resect the pituitary mass may be appropriate. Presentation: 6/2/2024