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N17) Headache and visual disturbance in a 35-year-old female
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with amenorrhea and visual deficits.
- Review the DDx considerations in a patient with amenorrhea and visual deficits.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with amenorrhea and visual deficits.
History
A 35-year-old female presents with five months or worsening headaches and visual disturbances. She reports worsening of her peripheral vision and finds herself bumping into walls. She denies any other neurological symptoms.
Physical Exam
Vital signs: BP 120/80 mmHg, HR 70 bpm, RR 14 breaths/min, Temp 98.6°F, SpO2 98% on room air.
Neuro: loss of vision in the bilateral temporal visual fields.
Labs
Pregnancy test: Negative.
Provisional Diagnosis
Select the Dx you believe is most appropriate
The most probable diagnosis is a Pituitary Macroadenoma. The patient's symptoms of headaches, and bitemporal hemianopia are consistent with impinging on the optic chiasm, possibly a pituitary macroadenoma.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
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The patient requires routine, but expedited workup as their condition is not immediately life-threatening.
First Imaging Study
What is the first imaging study you will order?
An MRI Brain with and without contrast is the most appropriate initial imaging study. It will help define the presence and extent of the pituitary mass, and provide valuable information for surgical planning if necessary.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Brain MRI
There is an abnormal mass.
There is a large suprasellar/sellar mass.
The mass explains the patient’s visual symptoms.
The mass is impinging onto the optic chiasm, and is therefore the most likely cause of the patient’s bitemporal hemianopia.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is required.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
Considering that this is a macroadenoma, and because the patient has no signs or symptoms like amenorrhea or galactorrhea (prolactinoma), acromegaly (growth hormone-secreting adenoma, or Cushing’s disease (ACTH-secreting adenoma), the patient most likely has a non-secreting adenoma.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires routine, but expedited workup.
Assessment and Plan
Please provide your assessment and plan for this patient
This is a 35-year-old female presenting with a pituitary macroadenoma, which is impinging on the optic chiasm and leading to bitemporal hemianopia. A neurosurgeon should be consulted for a possible transsphenoidal resection. The patient should also be referred to a neuro-ophthalmologist and endocrinologist following surgery.
Lessons Learned:
- Macroadenomas, which are pituitary adenomas larger than 1 cm in diameter, are typically non-secretory but can still disrupt pituitary function by their size and mass effect.
- Compression of the optic chiasm by a macroadenoma leads to a classic visual field defect, namely bitemporal hemianopia, due to the affected crossing fibers of the nasal retina in the optic chiasm.
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