Case Presentation: A 46-year-old Hispanic male with no significant past medical history presents with acute onset of headache, nausea, and vomiting for the past day, preceded by six months of progressively worsening peripheral vision and blurry vision in the right eye. Patient described a right-sided headache that became generalized and worsened within a few minutes to 10/10 pain associated with ocular pain upon movement, photophobia, and blurry vision. Physical exam was notable for right sixth nerve palsy, bitemporal hemianopsia, and decreased vision in the right eye.  Brain MRI showed a 2 x 1.6 x 2.3 cm sellar mass with subacute hemorrhage, displacing the right cavernous sinus and compressing the optic chiasm. Labs were consistent with nonfunctioning adenoma with panhypopituitarism, and the patient was started on synthroid and steroids with improvement in his symptoms. He underwent endoscopic endonasal trans-sphenoidal resection of the pituitary adenoma. Final pathology was consistent with pituitary tumor apoplexy.  The patient was discharged on post-operative day six with no complications. 

Discussion: Pituitary apoplexy is relatively rare, and there are no randomized controlled trials on the optimal management of this condition. The Pituitary Apoplexy Score published by United Kingdom National Guidelines helps to guide whether a patient should be conservatively or surgically managed. One large retrospective study showed that initial conservative management with fluids and steroids yielded similar outcomes to surgery in patients with isolated ophthalmoplegia or with visual field deficits that were stable or improving. Indications for surgery included visual field deficits, visual acuity problems and decreased consciousness. This patient developed visual field deficits and thus required neurosurgery, which resulted in a good outcome. There is also a significant risk of recurrence of pituitary tumors that undergo apoplexy, necessitating long-term follow-up in these patients.

Conclusions: Pituitary tumor apoplexy is a rare condition often resulting from hemorrhage or necrosis of a pre-existing sellar mass, most commonly pituitary adenomas. The sudden increase in sellar content may result in compression of portal vessels and/or structures such as the optic chiasm. Risk factors for apoplexy include chronic small vessel ischemic disease, pregnancy, prior treatment with dopamine agonists, hematological malignancies, and use of anticoagulants. It is a rare cause of thunderclap headache that must be included on the differential, especially when a patient presents with ocular symptoms.