6.9 Headache attributed to pituitary apoplexy

Identification: Sex/Age: Male, 58 years old.

Background: Known non-functioning pituitary adenoma (incidentally diagnosed 2 years ago on MRI), arterial hypertension.

Medications: Antihypertensives (no recent use of anticoagulants or antiplatelets).

History of Present Illness (HPI): Main symptom: Sudden and intense headache (10/10) for 12 hours, described as "stabbing" retro-orbital and frontal pain.

Characteristics:

Onset: Abrupt, during rest.

Aggravation: Associated with nausea/vomiting and worsens with head movements.

Associated symptoms:

Diplopia (right oculomotor nerve paralysis).

Postural hypotension and drowsiness (suspected acute adrenal insufficiency).

Physical/Neurological Examination:

General: Hypotension (BP 90/60 mmHg), tachycardia.

Neurological:

Right eyelid ptosis and mydriasis (III nerve paresis).

Bitemporal hemianopsia (chiasmatic compression).

Fluctuating level of consciousness (Glasgow Coma Scale 14).

Complementary Exams:

Brain MRI: Sudden increase in pituitary adenoma size (1.8 cm → 3.0 cm) with signs of intralesional hemorrhage (hyperintense on T1) and optic chiasm compression.

Laboratory:

Hormonal: Low serum cortisol (3 µg/dL), reduced TSH and free T4.

Electrolytes: Hyponatremia (Na+ 125 mEq/L).