MON-112 Medical Management of Pituitary Apoplexy

Abstract Disclosure: B.L. Chang: None. A.N. Mamelak: None. V. Bonert: None. Background: Pituitary apoplexy (PA) frequently occurs in patients with preexisting, often undiagnosed, pituitary macroadenomas. Rapid onset of PA, with presenting symptoms of “thunderclap” headache, nausea, altered mental status, visual field deficits, and diplopia in conjunction with hypopituitarism has traditionally been considered a neurosurgical emergency. However, several retrospective and a recent prospective observational study demonstrated that medical and surgical management of PA can yield similar 3-month outcomes, with frequent regression of apoplectic tumor volumes at 3 months, suggesting that emergent surgery is not always indicated. We report a case of successful medical management of PA in a patient with a documented pituitary macroadenoma with subsequent radiographic regression. Clinical Case: An 80-year-old female with type 2 diabetes, hypertension, and hyperlipidemia was diagnosed with an asymptomatic pituitary macroadenoma in 2021 during workup for headache. The mass was not removed, and it was followed with serial MRI surveillance. In 2024, she presented to an outside hospital with acute onset severe headache and right ptosis with diplopia. CT brain revealed an enlarged sella with some acute blood. MRI brain revealed a partially hemorrhagic and partially necrotic-appearing mass with tumor extension into the right cavernous sinus and mild compression of the optic chiasm. The tumor was substantially enlarged when compared to her prior MRI scans. Hormonal evaluation revealed deficiency in the thyroid (low TSH and T4) and gonadotroph (low FSH and LH) axes and low prolactin, with sparing of the cortisol axis. She was started on thyroid hormone replacement. She was discharged after headache improvement over the next few days with stable vision and mental status. At her neurosurgical reevaluation 6 weeks later, her headache and diplopia were significantly improved, and she was otherwise clinically stable. We recommended continued observation with serial imaging. Repeat hormonal evaluation confirmed hypopituitarism with low TSH and T4, suppressed FSH and LH, and low IGF-1, with normal AM cortisol. MRI pituitary 3 months after onset of symptoms demonstrated significant regression of the sellar mass. Thyroid hormone replacement therapy was continued with no further symptoms at subsequent outpatient follow-up visits. Conclusion: Regression in the size of a sellar mass in the setting of PA results in resolution of symptoms without the need for surgical intervention. This case is a detailed example of the emerging view that urgent neurosurgical intervention may not always be indicated in PA. Similar visual, oculomotor, and hormonal outcomes can be anticipated with medical management in many cases. Presentation: Monday, July 14, 2025