Pituitary Abscesses Presenting as Pseudoapoplexy: Two Unusual Cases

Abscesses are rare lesions of the pituitary with an annual incidence among lesions seen by surgeons ranging between 0.4 and 1.1%. They may be primary or secondary, depending on the presence or absence of a coexisting sellar pathology. Patients usually present with chronic symptoms, mostly mild headaches and complaints related to hypopituitarism.

We report two cases of rapid clinical deterioration associated with pituitary abscesses. The first patient presented initially with sudden-onset headaches suggestive of subarachnoidal hemorrhage (SAH). Although head CT scan revealed a large sellar mass but no sign of SAH, lumbar puncture demonstrated hemorrhage. Subsequent high fever and exacerbation of headaches led to a second CSF sampling, which, this time, was consistent with meningitis. The final diagnosis was that of a pituitary adenoma secondarily infected (direct extension of an active sinusitis) with secondary SAH and meningitis. Our second patient presented with panhypopituitarism and visual field deficits that led to a presumptive diagnosis of pituitary macroadenoma on initial imaging. However, he presented again only 1 week after his initial neurosurgical assessment with complete loss of vision in his left eye and new-onset headaches. Repeat MRI scan showed a fulminant progression of a cerebral intraparenchymal contrast-enhancing lesion in continuity with the sellar mass. Following transsphenoidal decompression of the sellae, evacuation of the abscess, and a protracted course of intravenous antibiotics, a satisfactory outcome was achieved in both patients.

Both patients presented with symptoms suggestive of pituitary apoplexy. Moreover, this represents the first report of intraparenchymal brain abscess associated with a sellar abscess.