Abstract Details

PA is a medical emergency characterized by an acute vascular event of the pituitary gland. I3NP is a rare manifestation of PA.

To report a case of isolated 3^rd nerve palsy (I3NP) from pathologically proven pituitary apoplexy (PA) and perform a systematic literature review.

MEDLINE/EMBASE was searched for “pituitary”, “apoplexy”, “hemorrhage”, “infarct”, “oculomotor”, “third nerve”. Inclusion criteria: age≥18, I3NP from PA. Exclusion criteria: age<18, presence of other neurological findings, no hemorrhage/infarction in pituitary. Statistical analysis was performed using IBM® SPSS® Statistics20. Descriptive variables are reported as mean/median/frequencies. Pearson correlation, Chi-square test, independent-samples t-test were used to estimate associations.

A 76-year-old woman presented with severe headache and right-sided ptosis. Right eye exam revealed complete ptosis, pupillary constriction and accommodation paralysis, depression and abduction on primary gaze, -1 impairment of depression, adduction, elevation without other neurological findings. Brain MRI was suspicious for PA. Pathology after transsphenoidal decompression revealed an infarcted pituitary adenoma. Patient had complete resolution of I3NP by 3 weeks.

Systematic review: 182 abstracts were screened, 22 were selected describing 35 patients with I3NP from PA. Twenty-six patients (74%) had a complete I3NP. Headache was reported in 27 (90%). Thirty had hemorrhage and one had infarction. Cavernous sinus invasion was observed in 12 (50%). Twenty-eight were managed surgically (80%) and 8 medically (20%). Twenty-three (82%) had complete resolution of I3NP, 3 partial resolution, and 2 no improvement. Mean (±1SD) time-to-resolution was 33 (±21) days with surgery (n=17) and 64 (±43) days with medical management (n=3), [t (28)= 2.03, p=0.06]. Cavernous sinus invasion was not associated with time-to-resolution [t (13)= 0.73, p=0.48]. Our study limitations included sample size, occasional non-reported information, and heterogeneity of cases.

It is important to include PA in the differential diagnosis in patients with I3NP. The trend for sooner recovery of I3NP with surgical management requires further study.