Pituitary apoplexy in an adolescent male with macroprolactinoma presenting as middle cerebral artery territory infarction.

Pituitary apoplexy typically presents with acute headache, vomiting, visual disturbance and confusion. We report a rare presentation of ischaemic stroke due to pituitary apoplexy. A 16.5-year-old male presented with reduced Glasgow Coma Score, slurred speech, right-sided hemiparesis, and bi-temporal hemianopia. Magnetic Resonance Imaging of brain showed a large haemorrhagic sellar/suprasellar mass and an area of cortical T2/FLAIR hyperintensity with corresponding diffusion restriction in middle cerebral artery territory. CT intracranial angiogram identified luminal occlusion of the clinoid and ophthalmic segments of both internal carotid arteries (left > right), due to mass pressure effect. Biochemical investigations confirmed hyperprolactinemia and multiple pituitary hormone deficiencies. Stress dose hydrocortisone was commenced, together with cabergoline, followed by urgent endoscopic trans-sphenoidal debulking of tumour (subsequent histology - prolactinoma). Post-operative CT angiogram showed improved calibre of internal carotid arteries. Intensive neuro-rehabilitation was implemented and resulted in complete recovery in motor and cognitive deficits. At last assessment (18.8 years), he remained on complete anterior pituitary hormone replacement without cabergoline. Pituitary apoplexy is a medical emergency requiring prompt recognition and treatment, which should be suspected in patients presenting with sudden, severe headache, nausea or visual disturbance and meningism. Ischaemic stroke is a rare manifestation of pituitary apoplexy in the paediatric population.