Bilateral sixth cranial nerve palsy, the first presenting feature of hemorrhagic apoplexy of pituitary macroadenoma: A case report

We report on apoplexy of undiagnosed pituitary macroadenoma presenting as sudden onset bilateral sixth nerve palsy. A 36-year-old male patient presented with a complaint of sudden onset diplopia for one week associated with chronic headache for two years. On further investigations, isolated bilateral sixth cranial nerve palsy was found to cause diplopia in lateral gaze and at distance. Magnetic resonance imaging of the brain showed a well-defined lobulated mass of 19 × 22 × 24 mm in the sellar and suprasellar region with hemorrhage, compressing optic chiasma superiorly with extension into the superior cavernous sinus compartment on the left side. The neurosurgery team excised the tumour through an endoscopic endonasal transsphenoidal approach. Abducens nerve palsy recovered within one week. In our case diplopia due to bilateral sixth cranial nerve palsy was the first clinical presentation of hemorrhagic apoplexy of pituitary macroadenoma which is a potentially life-threatening condition. There was no other significant ocular symptoms. High index of suspicion, prompt diagnosis and multidisciplinary team management resulted into favourable outcome. Sudden onset diplopia and isolated bilateral sixth nerve palsy should be added to the spectrum of clinical presentations of hemorrhagic apoplexy of previously undiagnosed pituitary macroadenoma. •Ocular symptoms are important in diagnosing life-threatening complications of pituitary macroadenoma.•Diplopia due to nerve palsy can be the first presentation of pituitary apoplexy.•Sometimes sixth nerve may be affected first due to the growth pattern of the GH positive pituitary adenoma.•High index of suspicion, and prompt management can prevent the potentially severe consequences of pituitary apoplexy.