Pituitary Macroadenoma: A Conservative Approach to Apoplexy

Pituitary apoplexy represents an acute neuroendocrine emergency that may present with headache and cranial nerve dysfunction. A 54-year-old woman presented with a two-day history of frontal and temporal headache and a painful left surgical third nerve palsy. Initial CT of the head was unremarkable, but MRI revealed an asymmetrically enlarged left pituitary gland with slight suprasellar extension and partial encroachment on the left cavernous sinus, without optic nerve or chiasmal compression. There were features suggestive of apoplexy. Biochemical tests showed normal pituitary hormone levels, except for mildly elevated insulin-like growth factor 1 (IGF-1) and slightly low thyroid-stimulating hormone (TSH), suggesting a slight growth hormone axis dysfunction without clinical acromegaly. While pituitary apoplexy is typically managed surgically, this case highlights successful conservative management with close clinical and radiological monitoring. The patient's symptoms stabilized without progression, demonstrating that select cases of pituitary apoplexy with cranial nerve involvement may be safely managed nonoperatively.