Transient cerebral ischemia in pituitary apoplexy-induced internal carotid artery occlusion: illustrative case

Cerebral ischemia secondary to occlusion or vasospasm of adjacent large vessels is a rare but significant complication of pituitary apoplexy. Misdiagnosis can lead to delays in management and devastating neurological outcomes. This case is the first reported instance of an initial presentation with transient cerebral ischemic symptoms, in addition to a classic pituitary apoplexy syndrome, for this clinical entity of pituitary apoplexy with adjacent large vessel occlusion.

A 49-year-old man presented with a classic pituitary apoplexy syndrome of headache, vomiting, and hemianopia, with transient preceding expressive dysphasia and right-hand numbness. Computed tomography (CT) and CT angiography of the brain demonstrated a large apoplectic pituitary tumor and associated occlusion of the left internal carotid artery. Subsequent CT perfusion studies revealed a threatening large ischemic penumbra in the left middle cerebral artery territory. He underwent urgent transsphenoidal resection of the pituitary tumor, resulting in symptom resolution and the prevention of cerebral infarction.

The recognition of transient cerebral ischemic symptoms in pituitary apoplexy should encourage the exclusion of any large-vessel complications and resultant cerebral ischemia. Early assessment, particularly with angiography and perfusion studies, can assist in guiding management, which is usually surgical decompression, distinct from traditional treatment for cerebrovascular events. https://thejns.org/doi/10.3171/CASE24566.