Pituitary apoplexy in a macroadenoma with cavernous sinus extension presenting with acute ophthalmoplegia

A man in his 30s presented with a thunderclap retro-orbital headache, nausea and acute binocular diplopia with right ptosis. This presentation illustrates the 'red flag' combination of thunderclap headache and pupil-involving third-nerve palsy in pituitary apoplexy. A vascular-first, then sellar-focused imaging pathway (CT → MR angiography (MRA) → sellar MRI) expedites diagnosis and protects vision. Brain MRI with sellar protocol revealed a haemorrhagic pituitary macroadenoma with suprasellar extension compressing the optic chiasm and lateral extension abutting the right cavernous sinus. Intracranial aneurysm was excluded on MRA. The initial pituitary panel was unremarkable. Stress-dose steroids were administered, and early endoscopic endonasal trans-sphenoidal decompression was performed. The headache remitted, and oculomotor deficits began to improve within 48 hours. This case highlights the value of immediate endocrine-neurosurgical-neuro-ophthalmology coordination, the superiority of MRI for staging intratumoral haemorrhage, the importance of immediate stress-dose steroid coverage and the role of structured decision tools (eg, Pituitary Adenomas (PAs)/Pituitary Adenoma Genomes/Genetics (PAGs) to individualise surgery versus conservative care.