Disclosures
No disclosures.

Purpose
To present a rare case of anterior circulation territories stroke due to bilateral ICA compression by an enlarged pituitary adenoma.

Case Report
A 60-year-old female who presented with sudden onset nausea, vomiting, and vision loss. She had no speech problem or focal weakness on presentation but became more obtunded and altered during her hospital course leading to a comatose state. The patient had intermittent nausea, vomiting, and progressive headache without further workup in the past year.

Imaging Findings
The non-contrast head CT showed a large homogenous non-hemorrhagic sellar mass lesion (35 x 31 x 37 mm) with suprasellar extension causing significant mass effect. The brain CTA revealed luminal narrowing and poor opacification of the bilateral cavernous ICA (more on the right side) and bilateral A1 segments. The CT perfusion demonstrated significant perfusion abnormality within bilateral anterior circulation territories. Therefore, emergent transsphenoidal hypophysectomy surgery was performed to decompress the ICAs. The brain DWI sequence showed a large area of restricted diffusion in anterior circulation with left basal ganglia hemorrhage; However, cerebral angiography showed the normalization of ICAs blood flow after decompression. The histopathologic examination was consistent with non-functional pituitary adenoma.

Summary
Pituitary apoplexy (PA) is a rare life-threatening endocrine emergency and it's characterized by a sudden increase in pituitary gland volume due to hemorrhages and/or infarcts. The acute presentation of PA could be the first manifestation of an underlying pituitary tumor especially in non-functional adenomas and can occur in 0.2% to 0.6% of patients. Clinical manifestations are highly variable (sudden onset headache, visual disturbance, altered mental status, and hormonal dysfunction) and unclear precipitating factors. The CT attenuation differs depending on the duration of apoplexy. The contrast CT rim enhancement is suggestive but not diagnostic for PA. CT might be more efficient than MRI in the acute stage and better for visualizing the hemorrhagic PA in the first few days but MRI can be more sensitive in detecting and following the PA findings in the subacute stage. To our knowledge, the bilateral ICA compression by enlarged pituitary adenoma secondary to PA is uncommon and deserved to be recognized.

Bilateral Internal Carotid Arteries Blood Flow Restriction Secondary to Compression by a Suddenly Enlarged Pituitary Adenoma.

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