Pituitary apoplexy physical examination

Pituitary apoplexy Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Physical Examination

Vitals

• Low blood pressure

Skin

• Dry skin

Eye

• Visual acuity defects (52%) and visual field defects (64%) result from upward expansion of the tumor. Superior expansion of the tumor causes dysfunction of the optic nerve and optic chiasma. The most common visual field defect is a bitemporal superior quadrantic defect. Less commonly, optic tract involvement from a prefixed chiasm results in a contralateral homonymous hemianopia. Optic nerve compression from a postfixed chiasm is rare and may mimic optic neuritis with pain on eye movement, monocular visual acuity loss, and a central scotoma on visual field testing.
• Lateral expansion of the pituitary adenoma into the cavernous sinus is usually presented as compressive multiple cranial nerve palsies (nerves III, IV, V, and VI). If consciousness is maintained, diplopia may be present. Of the cranial nerves; 
  • Cranial nerve III (oculomotor nerve) is involved most commonly, resulting in a unilateral dilated pupil, ptosis, and eye that is deviated inferiorly and laterally.
  • Cranial nerve IV (trochlear nerve) palsy typically manifests as vertical diplopia, that worsens when the patient gazes in a direction opposite or tilts the head toward the direction of the affected eye.
  • Cranial nerve V (trigeminal nerve) involvement may produce facial pain or sensory loss.
  • Cranial nerve VI (abducent nerve) is least commonly involved, perhaps because of its sheltered position in the cavernous sinus. Its involvement produces horizontal diplopia, which results from inability to abduct the involved eye.
• Horner syndrome may develop from damage to the sympathetic fibers. Hemispheric deficits may also develop.

Extremities

• Atrophy of limbs

Neurologic

• The hemorrhagic expansion may disrupt the dural covering of the pituitary, and thus allowing blood to enter the subarachnoid space to produce meningeal irritation. Therefore, retro-orbital headache is the most common presenting symptom in a conscious patient.
• Altered level of consciousness is due to compression of the internal carotid artery which may present a rapid downhill course.
• Severe mental status change is an indication for rapid neurosurgical decompression.
• Delayed reflexes