C. Pituitary apoplexy
Based on the acute presentation of symptoms and signs starting immediately after surgery and change in the appearance of tumor on MRI (loss of central enhancement), a diagnosis of pituitary apoplexy was made. The ophthalmoplegia in ocular motor apraxia can be overcome with vestibular ocular reflex, which was not the case here. The absence of exophthalmos and normal intraocular pressure argue against the diagnosis of orbital compartment syndrome. Imaging does not support the diagnosis of cavernous sinus thrombosis.
Pituitary apoplexy is an acute-onset syndrome due to hemorrhaging and/or infarction of the pituitary gland. Postoperative pituitary apoplexy has been reported after cardiac surgery, abdominal surgery, thyroidectomy, laparoscopic lumbar spinal fusion, and knee arthroplasty.1 Risk factors proposed during surgery that could lead to pituitary apoplexy include prolonged mechanical ventilation, embolization, unstable blood pressure, anticoagulation, crystalloid hemodilution, previous treatment with dopamine agonists, and radiotherapy.2