A 60-year-old woman is brought to the emergency department following a motor vehicle accident. She hit a car from her side and claims that she did not see another car coming towards her. This accident took place at a small intersection with little traffic. Her past medical history is significant for Cushing's disease and an intra-abdominal operation 15 years ago for the disease. Physical examination showed a tanned female with normal vital signs. She has a few abrasions on her face and chest. Ophthalmologic examination reveals bitemporal hemianopsia. Her injuries are managed appropriately.

What is the next best step in the management of this patient?

Question

What is the next best step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The clinical features in this patient are suggestive of a mass lesion in the sellar and suprasellar region. Furthermore, the history of bitemporal hemianopsia and hyperpigmentation following an abdominal operation (bilateral adrenalectomy) is very suggestive of Nelson's syndrome. MRI and plasma ACTH levels are required for making the diagnosis. A pituitary microadenoma with suprasellar extension on MRI and extremely high plasma ACTH levels are diagnostic. (Choice A)X-ray of the skull may show an enlarged sella, but a plain x-ray is much less sensitive than MRI in the diagnosis and evaluation of pituitary masses. (Choice C)Bitemporal hemianopsia cannot be localized to any specific cranial arterial territory; therefore, CT angiography is not warranted. (Choice D)Waters' view is done to evaluate sinusitis. It is not used in the evaluation of pituitary adenomas. (Choice E)The clinical features are not suggestive of intraocular defect; thus, a slit lamp exam is unlikely to be helpful. Educational Objective: Bitemporal hemianopsia and hyperpigmentation following bilateral adrenalectomy for Cushing's disease is suggestive of Nelson's syndrome. A pituitary microadenoma with suprasellar extension on MRI and extremely high plasma ACTH levels are diagnostic.

A 60-Year-Old Woman Is Brought to the Emergency Department Following