History
See the list below:
-
The presentation of a pituitary macroadenoma relates to its mass effect and pressure on surrounding structures.
-
Fifty to sixty percent present with visual symptoms due to compression of optic nerve structures.
-
Nonspecific headache can be seen.
-
Lateral extension can result in compression of the cavernous sinuses and may cause ophthalmoplegia, diplopia, and/or ptosis. Talkad et al recently reported an isolated, painful, postganglionic Horner syndrome as the initial sign of lateral extension of a large prolactinoma. [11]
-
Extension into the sphenoid sinuses can cause spontaneous cerebrospinal fluid (CSF) rhinorrhea.
-
In addition to visual symptoms, endocrine dysfunction, as described in Pathophysiology, can result.
Physical
Macroadenomas can compress optic nerve structures. The optic chiasm is the most frequently affected structure, and bitemporal field defects are the most common findings.
See the list below:
-
Neuro-ophthalmologic examination
Visual acuity can be decreased in one or both eyes.
Pupillary light reaction can be abnormal.
Color vision can be affected. Bitemporal hemiachromatopsia to red may be localized to the optic chiasm. This can be tested easily at bedside.
Visual fields
The hallmark abnormality associated with chiasmal compression is a bitemporal superior quadrantanopsia.
Larger lesions may be associated with a bitemporal hemianopsia.
Since the optic chiasm is usually adjacent to the tuberculum sellae, chiasmal compression is seen commonly.
Less frequently, the chiasm may be anterior or posterior to the tuberculum sellae (ie, prefixed or postfixed chiasm). Thus, the pattern of visual field defect can be variable. Any form of temporal field defect, even if monocular, can result from chiasmal compression.
The anterior chiasmal syndrome is not caused often by pituitary adenomas. However, bitemporal scotomata and, infrequently, homonymous defects due to optic tract compression may be seen
This visual field was plotted using a Goldman perimeter (ie, kinetic perimetry). It was obtained from a patient who reported visual loss and had a normal endocrine workup. The dark areas correspond to the impaired peripheral visual field. This visual field defect is consistent with an intrasellar lesion.
-
Ophthalmoscopic examination
Optic atrophy is seen frequently. It is generally a horizontal-oriented atrophy (ie, bow-tie) that corresponds to the topographic localization of the nasal retina within the optic nerve. Dropout of the nerve fiber layer in the nasal retina also may be noted.
Papilledema is exceptional, seen only in patients with pituitary apoplexy.
Less frequent optic atrophy with increased cup-to-disk ratio resembling glaucomatous optic atrophy can occur.
-
These abnormalities may be present in isolation or in association with physical changes associated with endocrine dysfunction.
Prolactinomas
In females, galactorrhea may be present on clinical examination. Women undergoing an infertility evaluation may be found to have a prolactinoma.
In males, galactorrhea is infrequent; testicles may be decreased in size and may be soft to palpation.
Acromegaly
A multitude of clinical signs can be appreciated by comparing the current facial appearance with prior photographs.
These changes include large hands and feet (with thick fingers and toes) and coarse facial features with frontal bossing. Women may appear masculinized. Other findings might include prognathism, carpal tunnel syndrome, and voice quality changes.
Cushing disease: Findings are prominent and include obesity, centripetal fat deposition, proximal myopathy, moon facies, buffalo hump, posterior subcapsular cataracts, arterial hypertension, bruises, and skin striae.
Hypopituitarism
Chronic hypopituitarism results in hypotension, generalized weakness, hypothermia, malaise, and depression.
Acute sudden hypopituitarism (ie, pituitary apoplexy) is associated with shock, coma, and death.
-
This is a characteristic bitemporal hemianopic visual field defect.
-
This contrast-enhanced coronal MRI was obtained in a patient who complained of visual loss.
-
This visual field was plotted using a Goldman perimeter (ie, kinetic perimetry). It was obtained from a patient who reported visual loss and had a normal endocrine workup. The dark areas correspond to the impaired peripheral visual field. This visual field defect is consistent with an intrasellar lesion.
-
Coronal T1 precontrast MRI A (left panel), B postcontrast (middle panel) and T2 (right panel) showing a sellar mass causing obvious left and upward displacement of the optic chiasm. The mass is a histologically proven pituitary macroadenoma, which presented initially with a large cystic subfrontal extension that was successfully resected in April of 2006. This patient has been observed closely for 2.5 years and despite obvious mass effect, he has no visual complaints and the neuro-ophthalmologic evaluation is normal. Although infrequent, clinicians should be aware of this possibility. Close follow-up is required.
-
Axial, sagittal, and coronal MRI of the sellae in a patient with a severe headache, normal neuro-ophthalmologic examination, and no evidence of endocrine failure. A hyperintense mass is observed in the sella with suprasellar extension. This case illustrates the clinical spectrum of pituitary apoplexy. Transsphenoidal resection confirmed the diagnosis of pituitary apoplexy.
