Introduction: Pituitary adenomas represent 10 to 15% of intracranial tumors, and are classified according to their cell type, functionality, and size. Adenomas measuring >1 cm are classified as macroadenomas, and those measuring >4 cm are generally classified as giant adenomas. One rare, but potentially life-threatening complication of pituitary adenomas is pituitary apoplexy, which is a sudden hemorrhage into the pituitary gland. Risk factors include size of the adenoma, pregnancy, coagulopathy or anticoagulant use, and head trauma. Apoplexy usually presents with sudden onset severe headache and visual disturbances. All pituitary hormones may be lost, the most serious of them being ACTH and subsequent cortisol deficiency, which can cause sudden collapse, shock, and death.

Case presentation: An 80-year-old female with a past medical history of a nonfunctioning 4 cm pituitary macroadenoma and a recent DVT on anticoagulation with apixaban presented to the ER with acute onset nausea, vomiting, and a severe headache that started after a fall in which she hit her head. On initial presentation, she was alert and oriented, and no focal neurologic deficit was noted. Head CT and CTA demonstrated acute extensive subarachnoid hemorrhage surrounding and possibly involving the patient’s known large suprasellar mass, which was later confirmed on MRI. 

Final diagnosis: Pituitary apoplexy with extensive subarachnoid hemorrhage and panhypopituitarism

Outcome: The patient received prothrombin complex concentrate for reversal of apixaban, and was started on stress dose steroids for possible secondary adrenal insufficiency. She experienced a rapid deterioration of her neurologic function, and had to be emergently intubated. Repeat imaging showed interval worsening of subarachnoid hemorrhage and obstructive hydrocephalus, and the patient underwent emergent ventriculostomy with ventricular drain placement. Hormone replacement with levothyroxine was later added. The ventriculostomy drain remained in place, and drainage pressure was adjusted intermittently by neurosurgery. The patient remained comatose for 10 days after the procedure, and eventually died. The inciting factor was possibly the patient’s head trauma, but concurrent anticoagulant use likely played a large role in the development as well as severity this patient’s pituitary apoplexy. This highlights the importance of extensive counseling before initiation of anticoagulation in such patients.