Intended for healthcare professionals

Endgames Case Review

Headaches and hormones: a potentially lethal combination

BMJ 2016; 352 doi: (Published 26 January 2016) Cite this as: BMJ 2016;352:h6752
  1. Ramdeep Bajwa, foundation year 2 doctor1,
  2. Paven Preet Kaur, foundation year 2 doctor2,
  3. Alessandro Paluzzi, consultant neurosurgeon3
  1. 1Deapartment of Medicine, City Hospital Birmingham, Birmingham, UK
  2. 2Department of General Medicine/Surgery, Townsville Hospital, Townsville, Qld, Australia
  3. 3Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
  1. Correspondence to: R Bajwa, Department of Emergency Medicine, Gold Coast University Hospital, Qld, Australia rameybajwa{at}

An 85 year old man presented to the emergency department with a five day history of headache, vomiting, and progressive visual loss in both eyes. He had no history of weight loss, seizures, or limb or facial weakness. He had hypertension, abdominal aortic aneurysm (under surveillance), hypothyroidism, and benign prostatic hypertrophy.

His blood pressure was 110/75 mm Hg, pulse 80 beats/min and regular, Glasgow coma score (GCS) 15. Peripheral neurological examination was normal. Cranial nerve examination showed bitemporal hemianopia with normal fundoscopy.

Initial investigations showed deranged biochemistry: sodium 126 mmol/L (reference range 135-145), potassium 3.6 mmol/L (3.5-5), urea 5.6 mmol/L (2.5-6.7), creatinine 101 µmol/L (70-150), C reactive protein 66 mg/L (<10). Full blood count and liver function tests were normal.

He was admitted to the acute medical unit after computed tomography of the head showed a mass arising from the pituitary fossa. Magnetic resonance imaging (MRI) showed a sellar mass compressing the optic chiasm and signal changes suggestive of haemorrhagic regions within the mass (fig 1).

Coronal T2 weighted magnetic resonance imaging of the head without contrast


  • 1. What are the differential diagnoses for patients presenting with bitemporal hemianopia?

  • 2. Given the biochemical and radiological abnormalities, how would you immediately management this patient?

  • 3. Will he need pituitary surgery?

  • 4. What long term follow-up would you arrange?


1. What are the differential diagnoses for patients presenting with bitemporal hemianopia?

Short answer

Pituitary adenomas, pituitary apoplexy, craniopharyngiomas, meningiomas, gliomas, and rarely intracranial aneurysms.


The optic chiasm is the anatomical territory where the nasal fibres of the optic nerve decussate. The retinal fibres that receive stimuli from the superior visual field take an inferior course through the optic chiasm, whereas fibres that receive stimuli from the inferior visual field take a superior course.

Bitemporal hemianopia is classically caused by …

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