Pituitary apoplexy causing thunderclap headache: easy to miss

CASE DESCRIPTION

An 82-year-old man developed a sudden onset headache with nausea and vomiting. The pain was severe and diffuse, reaching its maximum intensity in less than 1 min, and was refractory to simple analgesia. There was no history of headache. He was already in hospital following a pulmonary embolism and had a history of hypertension, coronary artery disease and atrial flutter. He had previously taken dual antiplatelet therapy but had recently switched to single antiplatelet therapy and unfractionated heparin because of the pulmonary embolism. His initial CT scan of head was reported as normal (figure 1).

The next day, with headache still persisting, he developed a painless left third cranial nerve palsy with pupil dilation. Repeat CT scan of head with CT angiography was reported normal (figure 1). An MR scan of brain with MR angiography finally revealed a pituitary macroadenoma with intralesional haemorrhage (<cross-ref type="fig"…

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