Introduction
The pituitary gland is a pea-sized endocrine gland located at the base of the brain, resting upon the hypophyseal fossa of the sphenoid bone in the center of the middle cranial fossa. It sits within a protective bony enclosure called the Sella turcica, which is covered by the dural fold known as the diaphragma sellae. Pituitary adenomas are among the most common intracranial tumours encountered in clinical practice with a prevalence of 115 cases per 100,000 population and approximately 1 new case per 100,000 population per year.1 Adenomas smaller than 10mm are classified as microadenomas, while those larger than 10mm are termed macroadenomas.2 While the majority of pituitary adenomas are hormonally active, 15–30% of pituitary adenomas are termed clinically non-functioning, meaning they are not associated with a functional tumour secreting excess adrenocorticotropic hormone, growth hormone, prolactin, or thyroid stimulating hormone. Many clinically nonfunctioning pituitary adenomas may test positive for gonadotropin stains, but they don't directly release hormones to cause hormonal syndromes.3 They are therefore usually discovered during investigation of symptoms related to mass effect (i.e. headaches, visual changes) or, most commonly, as an incidental finding. The majority of microadenomas are incidentalomas, but in this case, it was a macroadenoma, which was incidentally found during an autopsy. The diagnosis is confirmed by testing hormonal levels and by radiographic imaging like CT, MRI of the pituitary. The preferred medical treatments for the condition typically encompass dopamine agonists, long-acting somatostatin analogs, and growth hormone receptor antagonists.4 When these therapies prove insufficient or in cases where tumor size or symptoms necessitate more direct intervention, transsphenoidal adenectomy emerges as the surgical treatment of choice. Additionally, radiation therapy may be employed as an adjunct or alternative method to manage the condition effectively.
Case Report
The incident pertains to a 42-year-old male security guard, employed at a local dhaba, who was involved in a road accident. He sustained a severe head injury after being struck by a van while crossing the road. The patient was admitted to our tertiary care centre with a Glasgow Coma Scale (GCS) score of E1V1M2. A poor prognosis was explained to the patient's family. Despite treatment efforts, the patient succumbed within a few hours. As is customary in such cases, his body underwent a forensic autopsy to ascertain the precise cause of death.
At autopsy, the scalp on reflection showed a diffuse contusion all over. The skull revealed a fissure fracture of size 20cm over the right occipitotemporal areas, extending into the right middle cranial fossa at the base of the skull. Diffuse subdural hemorrhage and subarachnoid hemorrhage were noted throughout the brain bilaterally, predominantly over the surface of the right cerebral hemisphere and the base of the left cerebral hemisphere in the anterior cranial fossa region. Further, the brain was intensely edematous.
A 5x5x3cm mass (Figure 1), weighing about 60gms, encapsulated within the pituitary gland with extension to the skull base in the Sella region (Figure 2). This mass was sent for histopathological examination, which confirmed it to be a "Pituitary neuroendocrine tumor, possibly gonadotropic in nature." (Figure 3). The cause of death in that cause was opined as ‘Head Injury’ owing to the presence of diffuse subdural and subarachnoid hemorrhage all over the brain bilaterally.
Discussion
This is a case of road traffic accident in which the cause of death was “Head Injury” and the pituitary adenoma was an incidental finding during autopsy. Pituitary adenomas may be classified as non-functional and functional. Non-functional adenomas are benign tumors and are usually not associated with clinical evidence of hormonal changes. On the other hand, functional adenomas exhibit a wide range of endocrine manifestations due to either hypo or hyperfunction of the pituitary gland. They may affect one or more hormones/hormonal systems, commonly involved are growth hormone and prolactin, leading to unexpected bone expansion and lactation in both males and females.5 Non-functioning pituitary adenoma (NFPA)is a major source of visual disorders, and is diagnosed later than functioning adenoma, often with larger tumor volume. Incidence of NFPA was 28–33.2% in pituitary adenoma populations, with or without visual involvement but 58% in case of pituitary adenoma specifically with visual involvement.6 These adenomas can also have a slow but severe impact on vision, causing bitemporal hemianopsia (interfering with peripheral vision) due to compression of the optic nerves or chiasma. Moreover, increased intracranial pressure often results in severe headaches. Additionally, various psychiatric manifestations such as depression, anxiety, and emotional instability may be noted in a few patients.
Pituitary tumor apoplexy refers to a clinical syndrome precipitated by the expansion of a pituitary adenoma by hemorrhage or infarction due to the expansion of the Sella turcica. Delayed diagnosis, mismanagement, and misdiagnosis of this condition can result in either permanent physical impairment or death.7 While sudden death following pituitary tumor apoplexy is rarely reported, postmortem examinations showed hemorrhage and necrosis of pituitary adenoma in few instances.
Pituitary adenomas can indeed have significant effects on individuals' health and well-being due to their potential to disrupt hormone production, compress surrounding structures in the brain, and cause a wide range of distressing symptoms. However, it is important to clarify that while hemorrhage within a preexisting pituitary tumor can lead to acute complications such as sudden-onset severe headache, visual disturbances, or hormonal imbalances, sudden death solely due to hemorrhage in a pituitary tumor is relatively rare.1
Patients with pituitary tumors were more likely to be diagnosed with a MHD, approximately 15% were diagnosed with a MHD within 1 year of their diagnosis. Independent risk factors included female gender and substance abuse.8
Within the medico-legal framework, manifestations such as peripheral vision impairment, headaches, behavioural alterations, and sudden demise attributed to pituitary apoplexy merit notable consideration. Hence, it is important to recognize and appropriately manage these tumors to minimize their impact on patients.
Conclusion
In this instance, a pituitary adenoma was fortuitously identified during postmortem examination, manifesting as a stage III adenoma. Stage III adenomas are typically characterized by macroadenomas, which exhibit enlargement and infiltration of the floor of the Sella turcica or extension into the suprasellar region. Surprisingly, despite it being a macroadenoma, it is notable that the deceased did not exhibit any signs or symptoms. Although it is an incidental finding and not contributing to the cause of death, we cannot underestimate the effect of the tumour on the visual acuity of the decedent. In the present case, visual impairment due to the tumour could also have partially led to the road traffic accident.
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