Chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy
A 29-year-old male presented with a sudden onset of severe headache accompanied by vomiting, and visited a local hospital. A physician could not detect any abnormal finding by computed tomography (CT) scans. Two weeks after the onset, magnetic resonance imaging (MRI) revealed a pituitary mass with hematoma consistent with pituitary apoplexy [Figure and ], and he was referred to our institute. Neuro-ophthalmological examination revealed no visual field disturbance. Endocrinological evaluation showed that the prolactin level was elevated at 583.2 ng/mL (normal value: 3.6-16.3 ng/mL). Pituitary apoplexy due to a prolactinoma was the most likely diagnosis. He also complained of general fatigue and appetite loss. The adenocorticotropic hormone (ACTH) level was slightly decreased: 8 pg/mL (normal value: 7-56 pg/mL). The testosterone level was also decreased: 24.1 ng/dL (normal value: 161-904 ng/dL). Thus, hypopituitarism was proved and replacement therapy was started. Because he exhibited no neuro-ophthalmological deficit, we continued medical treatment.\nThree weeks after the onset, he gradually began to complain of blurred vision. Neuro-ophthalmological examination revealed bitemporal upper quadrant hemianopsia. MRI showed the enlargement of the pituitary mass lesion resulting in the compression of the chiasm []. The intensity of the hematoma within the adenoma was changed from hyperintensity to hypointensity on T1-weighted image []. No sign of rebleeding was detected. Laboratory investigations revealed no abnormal values in hematological and coagulant parameters: Thrombocyte count, prothrombin time, and activated and partial thromboplastin times.\nHe was operated on via transsphenoidal approach. The dura of the sella was tensive. After dural opening, xanthochromic fluid spouted out, but no fresh clot could be detected within the hematoma cavity []. The wall of the hematoma cavity was fibrous and thick, and had characteristics similar to the outer membrane of chronic subdural hematoma (CSDH). Grayish adenoma was detected and removed with curettage. Histological examination confirmed the diagnosis of pituitary adenoma. Postoperative course was uneventful. Visual field disturbance was completely resolved and hypopituitarism was gradually improved. Postoperative MRI showed that the cyst was evacuated and the chiasm was decompressed.