Pituitary apoplexy is a medical emergency resulting from acute hemorrhage or infarction of the pituitary gland. Symptoms include headache, diplopia, visual impairment, and encephalopathy. We present a diagnostically challenging case of pituitary apoplexy in a patient who presented with fever, headache, diplopia, cerebrospinal fluid showing neutrophilic pleocytosis with elevated protein, and neuroimaging showing a left basal ganglia infarct with diffuse cerebral vasospasm.

Pituitary macroadenomas have varying severity of presentations. Pituitary apoplexy should be considered in a patient with altered sensorium, severe headache, and cranial nerve deficits. Cerebral infarcts can result from mechanical compression from mass effect or arterial vasospasm secondary to vasoactive substances released from necrotic and hemorrhagic pituitary tumor. Prompt diagnosis and early intervention can reduce mortality and morbidity and is critical for successful patient outcomes.