Midbrain hemorrhage mimicking pituitary apoplexy in patient using anticoagulation therapy.

J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital. Boston, MA, USA; Department of Neurological Surgery, University of Pittsburgh, School of Medicine. Pittsburgh, PA, USA; Department of Otolaryngology, University of Pittsburgh, School of Medicine. Pittsburgh, PA, USA; Chan Soon-Shiong Neuroscience Institute, John Wayne Cancer Institute at Saint John’s Health Center, Santa Monica, CA, USA. Pituitary apoplexy represents a hemorrhage or infarction of the pituitary gland and has its occurrence often related in the context of a pituitary adenoma. In classical pituitary apoplexy, headache, usually of sudden and severe onset, is the most common presenting symptom and hypertension and anticoagulation have been described as relevant predisposing factors. The risk of cranial nerve palsies leading to double vision and/or vision loss and the risk of acute panhypopituitarysm leading to death in the event of apoplexy have to be seriously considered. Thus a quick diagnosis confirmation is imperative to avoid delays on the management. We present a patient who had the typical clinical and history course associated with pituitary apoplexy but in whom, based on imaging examination for confirmation immediately before surgery, a precise midbrain hemorrhage was diagnosed. The known pituitary adenoma was unchanged and the surgery was cancelled. The present case adds a new perspective in which other site than the sella may be causing the pituitary apoplexy-mimicking symptoms in patients chronically treated with anticoagulants.