Intracranial hypotension causing pituitary enlargement

Description

A woman aged 67 years was referred with pituitary enlargement identified on CT scan. Imaging was performed to investigate a progressive, incapacitating, 12-month history of nausea, vertigo, gait disturbance and recurrent falls. Her presentation included chronic occipitofrontal headaches, which had increased in severity and were exacerbated by upright posture. She had a history of lumboperitoneal (LP) shunting for idiopathic intracranial hypertension, systemic hypertension, ischaemic heart disease and pulmonary disease secondary to cigarette smoking. Physical examination demonstrated normal cranial nerves, bilateral upper motor neuron signs in both upper and lower limbs and severe gait instability.

Her anterior pituitary function testing showed mildly elevated prolactin levels (69.4 µg/L, range 5.2–26.7 µg/L). Adrenocorticotropic hormone (ACTH) deficiency could not be completely excluded on basal testing (ACTH 1.6 pmol/L, range 0.0–10.0 pmol/L; cortisol 245 nmol/L). Other pituitary axes were unremarkable. Formal perimetry confirmed normal visual fields. On MRI examination, the pituitary gland was homogenously enlarged (13x9x12 mm) with a...

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