A 36-year-old woman comes to the emergency department due to severe headache and vision disturbance. The symptoms began abruptly an hour ago, and since then she has also felt weak, dizzy, and nauseated. The patient has had no similar symptoms in the past. Medical history is significant for a prolactinoma diagnosed a month ago, which is being treated with cabergoline. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.6 C (99.7 F), supine blood pressure is 80/50 mm Hg with a decrease to 60/40 mm Hg on standing, and pulse is 110/min. On physical examination, the patient appears anxious and in moderate distress. There is mild ptosis and impaired adduction on the right. Bitemporal hemianopsia is present. Bilateral upper and lower extremity muscle strength and sensation are normal. The neck veins are flat, heart and lung sounds are normal, and there is no abdominal tenderness or extremity edema. Which of the following is the most likely underlying cause of this patient's hemodynamic changes?

Question

A 36-year-old woman comes to the emergency department due to severe headache and vision disturbance.  The symptoms began abruptly an hour ago, and since then she has also felt weak, dizzy, and nauseated.  The patient has had no similar symptoms in the past.  Medical history is significant for a prolactinoma diagnosed a month ago, which is being treated with cabergoline.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.6 C (99.7 F), supine blood pressure is 80/50 mm Hg with a decrease to 60/40 mm Hg on standing, and pulse is 110/min.  On physical examination, the patient appears anxious and in moderate distress.  There is mild ptosis and impaired adduction on the right.  Bitemporal hemianopsia is present.  Bilateral upper and lower extremity muscle strength and sensation are normal.  The neck veins are flat, heart and lung sounds are normal, and there is no abdominal tenderness or extremity edema.  Which of the following is the most likely underlying cause of this patient's hemodynamic changes?

Quizplus · Accepted Answer

This patient with a history of a pituitary adenoma who has severe headache, ptosis, and vision changes most likely has pituitary apoplexy. Pituitary apoplexy typically involves sudden hemorrhage into an enlarged pituitary adenoma (eg, prolactinoma). Most cases occur without a clear precipitating cause, although size appears to be a risk factor, possibly due to the expanding mass outgrowing or compressing its blood supply. Bleeding into the tight anatomic space of the sella turcica can cause sudden-onset, severe headache as well as visual disturbances (eg, diplopia, bitemporal hemianopsia) and eye dysfunction (eg, ptosis) due to compression of the oculomotor nerves or optic chiasm. In addition, there is typically loss of all pituitary function; in the acute setting the loss of ACTH is most important and can lead to adrenal crisis (acute adrenal insufficiency). optic chiasm Cortisol helps maintain vascular tone by potentiating the vasoconstrictive effects of catecholamines (eg, norepinephrine). In the absence of ACTH, the adrenal cortex ceases production of cortisol and severe hypotension and distributive shock can develop. Hypoglycemia may also be present. Treatment involves rapid volume resuscitation and prompt administration of intravenous glucocorticoids (eg, hydrocortisone, dexamethasone). Neurosurgical intervention may also be necessary. adrenal cortex (Choice B) Dopamine inhibits prolactin secretion, and dopamine agonists (eg, cabergoline, bromocriptine) are used as initial treatment for prolactinoma and can cause orthostatic hypotension. These drugs are not known to precipitate pituitary apoplexy (eg, sudden headache, visual disturbances, eye dysfunction). (Choice C) Pseudotumor cerebri (idiopathic intracranial hypertension) most commonly affects overweight, premenopausal women and can present with headaches and diplopia. However, it would not explain severe hypotension and instead tends to cause hypertension and bradycardia (via the Cushing reflex). (Choice D) Neurogenic shock results from loss of sympathetic tone due to spinal cord injury. Patients develop severe hypotension, but it is usually accompanied by bradycardia rather than tachycardia. Neurogenic shock is extremely unlikely in this patient with normal strength and sensation in all extremities. (Choice E) Subarachnoid hemorrhage most commonly occurs due to rupture of a saccular cerebral aneurysm and presents with the abrupt onset of severe headache. Visual disturbances may be present, but severe hypotension does not occur. Educational objective: Pituitary apoplexy involves sudden hemorrhage into an enlarged pituitary adenoma. Patients typically have sudden onset of severe headache and visual disturbances. There is also loss of pituitary function; because cortisol helps maintain vascular tone, the absence of ACTH-induced cortisol production can lead to adrenal crisis (acute adrenal insufficiency) with severe hypotension and distributive shock. References: Pituitary apoplexy. (http://www.ncbi.nlm.nih.gov/pubmed/26414232)

A 36-Year-Old Woman Comes to the Emergency Department Due to Severe