A 50-year-old man is brought to the emergency department due to a severe, sudden-onset headache that started an hour ago. The patient reports that he has had mild headaches and decreased libido over the past 3 months. He has no other medical conditions and takes no medications. Physical examination reveals bilateral deficits involving the temporal visual fields and impaired extraocular eye movements. Shortly after being admitted to the hospital, he becomes acutely hypotensive and loses consciousness. The patient dies despite aggressive resuscitation efforts. Which of the following is most likely to be found on autopsy?

Question

A 50-year-old man is brought to the emergency department due to a severe, sudden-onset headache that started an hour ago.  The patient reports that he has had mild headaches and decreased libido over the past 3 months.  He has no other medical conditions and takes no medications.  Physical examination reveals bilateral deficits involving the temporal visual fields and impaired extraocular eye movements.  Shortly after being admitted to the hospital, he becomes acutely hypotensive and loses consciousness.  The patient dies despite aggressive resuscitation efforts.  Which of the following is most likely to be found on autopsy?

Quizplus · Accepted Answer

11ec160b_3918_f1d9_9249_a50a552862ce_MD0001_00 This patient had typical features of acute pituitary hemorrhage (pituitary apoplexy), including a severe headache, bitemporal hemianopsia (due to compression of the optic chiasm), and ophthalmoplegia (due to compression of the oculomotor nerve [CN III]). Pituitary apoplexy usually occurs in a preexisting pituitary adenoma, as in this patient with chronic headaches and low libido (likely due to hyperprolactinemia). The diagnosis can be confirmed on cross-sectional imaging (CT or MRI scan). Patients with pituitary apoplexy can develop cardiovascular collapse due to ACTH deficiency and subsequent adrenocortical insufficiency. Pituitary apoplexy is a medical emergency that requires urgent neurosurgical consultation and treatment with glucocorticoids . (Choice B) Hemorrhage into the putamen (basal ganglia) causes neurologic deficits that gradually worsen over minutes to hours. Typical features include contralateral hemiparesis and hemianesthesia due to disruption of the corticospinal and somatosensory tracts. It is most often seen in chronic hypertensive vasculopathy. (Choice C) Carotid dissection typically presents with unilateral headache, transient vision loss, ptosis, and miosis (partial Horner syndrome). It usually occurs following trauma, or can occur spontaneously in patients with chronic hypertension, connective tissue disease, or history of smoking. (Choice D) Typical symptoms of giant cell (temporal) arteritis include headaches, jaw claudication, and visual disturbances (eg, amaurosis fugax, anterior ischemic optic neuropathy). Patients frequently also have systemic symptoms (eg, fever, fatigue) and proximal muscle pain (polymyalgia rheumatica). (Choice E) Ischemic necrosis of the pituitary (Sheehan syndrome) most commonly occurs due to hypoperfusion of the enlarged pituitary during childbirth. It presents with chronic hypopituitarism (eg, failure to lactate). Severe headaches and visual field defects do not occur. (Choice F) Rupture of a saccular aneurysm near the optic chiasm can present similarly to pituitary apoplexy. However, this patient's chronic history of decreased libido and acute cardiovascular collapse is more suggestive of a pituitary etiology. (Choice G) Cerebral venous sinus thrombosis is most common in patients with underlying thrombophilia, pregnancy, oral contraceptive use, malignancy, or infection. Presenting features include headaches, vomiting, seizures, and focal neurologic deficits. Educational objective: Acute pituitary hemorrhage (pituitary apoplexy) is characterized by severe headaches, bitemporal hemianopsia (compression of the optic chiasm), and ophthalmoplegia (compression of the oculomotor nerve). It usually occurs in a preexisting pituitary adenoma. Pituitary apoplexy is a medical emergency that requires urgent treatment with glucocorticoids to prevent acute adrenal crisis and circulatory collapse. __________ References: Pituitary apoplexy: pathophysiology, diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26154095)

A 50-Year-Old Man Is Brought to the Emergency Department Due