[5] Vison loss due to compression first affects the superotemporal visual fields, then inferotemporal, inferonasal and finally superonasal fields. [3][7], Previously, pituitary adenomas were also divided by their staining pattern on histology[3] but this classification is no longer clinically significant due to the more specific immunohistochemistry stains that can differentiate the hormones being secreted. Certain patterns of visual field loss help to establish a possible underlying cause. Right RAPD The filter causes the light conduction velocity to be slower, perceived by the brain as the object having false depth. It can be arteritic or nonarteritic. Malenkovi V, Gvozdenovi L, Milakovi B, Sabljak V, Ladjevi N, Zivaljevi V. Preoperative preparation of patients with pituitary gland disorders. The most nasal retinal fibers have unpaired cortical representation, which is situated in the most anterior part of the contralateral parieto-occipital sulcus. The lesion is at the most posterior portion of the optic nerve ipsilateral to the central scotoma at its junction with the chiasm. 3.22d), 2. [11] Mutations in the aryl hydrocarbon receptor interacting protein (AIP) gene are associated with an increased risk of aggressively invasive growth hormone-secreting pituitary adenomas. Some atrophy is reported to be present in approximately 50% of pituitary lesions with visual field defects. It appears in people with damage to one hemisphere of their visual cortex, and occurs simultaneously with bilateral homonymous hemianopia or homonymous quadrantanopia. 3.17 and Fig. [28] Patients may experience overlapping images or divergent images corresponding to esodeviation, exodeviation, or hyperdeviation. [1][3] Various articles have reported both male and female predilections. Visual Field Defects Symptoms Vision loss in one eye may indicate a problem in the eye, whereas the same visual field defect in both eyes may signal a problem in the brain. optic disc or nerve problem) peripheral (along the visual pathways from the optic chiasm back). 3.6, Fig. This process is experimental and the keywords may be updated as the learning algorithm improves. Many of the features of GH-secreting adenomas are related to the stimulation of insulin-like growth factor I (IGF-I or somatomedin C) by the liver in response to excess growth hormone. Surgical debulking of pituitary tumors is often performed by otorhinolaryngology (ENT) or neurosurgery.[35]. Tell the patient to fixate on a central spot. Signs that you may have a visual field defect include: Bumping into things Knocking over objects when reaching Having difficulty reading Getting into a car accident Line up the patient across from you. [13] Various cell markers have also been implicated in the behaviors of various pituitary tumors, including type of hormone produced, recurrence, regression, and response to treatment. Is the test normal or not? It looks like an almost complete inferior altitudinal defect. The lesion is at the most posterior portion of the optic nerve ipsilateral to the central scotoma at its junction with the chiasm. Automated Static Perimetry Humphrey perimetry uses computerized programs to randomly test points in the patients central visual field with a standard stimulus size but varying stimulus intensities (Fig. Rarely these cells will be strongly acidophilic and are classified as densely granulated prolactinomas. The ocular symptomatology of pituitary tumours. What are the findings of a parietal lobe lesion? 4. 1. the types and severity of visual field defects in the Optic Neu-rititsTreatmentTrial(ONTT) . Because of the anatomy of the posterior ciliary arteries, optic nerve ischemia often results in a superior (more often) or inferior segmental optic nerve atrophy. o [ abdominal pain pediatric ] Thammakumpee K, Buddawong J, Vanikieti K, et al. Macular lesions produce central or paracentral defects, whereas most degenerative retinopathies, such as retinitis pigmentosa, produce progressive constriction of the peripheral and midperipheral visual field (Fig. 13. 3.12 and Fig. Roelfsema F, Biermasz NR, Pereira AM. [1] Periodic neuroimaging is also essential, as recurrence may occur even as late as 10 years post-surgery. 4. Follow https://twitter.com/NeuroOphthQandA to be notified of new neuro-ophthalmology questions of the week. 3.9). [20][21], Nelson syndrome describes the enlargement of an ACTH-secreting pituitary adenoma following surgical removal of the adrenal glands for treating Cushing syndrome. Depending on the etiology of the optic neuropathy, arcuate defects, altitudinal defects, and central, paracentral, or centrocecal scotomas are observed (Fig. In this case, the more negative a number, the more abnormal that point. Medical treatment is considered the primary treatment for prolactinomas. Confrontational visual field exam suggested superior altitudinal vision defect in the left eye which was confirmed in automated perimetry ( Fig. Temporal retina in the left eye ([3green] in Fig. Bilateral occipital lobe lesions will produce bilateral homonymous hemianopias, which may be asymmetric (Fig. Enter the email address you signed up with and we'll email you a reset link. 2. Patients with pituitary adenomas have a variable history, dependent on the functional (secretory) status of the tumor, its size, and any mass effect. Treatment for the nonarteritic read more (usually nonarteritic), optic disk drusen, high myopia, Loss of all or part of the medial half of both visual fields; does not cross the vertical median, More common: Glaucoma Overview of Glaucoma Glaucomas are a group of eye disorders characterized by progressive optic nerve damage in which an important part is a relative increase in intraocular pressure (IOP) that can lead to irreversible read more , bitemporal retinal disease (eg, retinitis pigmentosa Retinitis Pigmentosa Retinitis pigmentosa is a slowly progressive, bilateral degeneration of the retina and retinal pigment epithelium caused by various genetic mutations. Visual fields are also commonly documented prior and following neurosurgical intervention. Densely granulated somatotroph adenomas (DGSA) respond better to somatostatin analogues rather than sparsely granulated somatotroph adenomas (SGSA). Some common types of visual field defects and their more common differentials are outlined below. The visual field of each eye overlaps centrally. 5. Preoperative MRI evaluation of pituitary macroadenoma: imaging features predictive of successful transsphenoidal surgery. Recurrence of tumor is most likely to occur between 1-5 years following surgery, with prolactinomas having the highest incidence of recurrence. Where is the lesion of a junctional scotoma? [2], Many animal studies have suggested one or more genetic factors that may contribute to the formation of pituitary adenomas. Clinical Pearl: The earliest visual field defect in glaucoma is increased short term fluctuation. When the macula . 3. What is the visual field defect of a junctional scotoma? Abstract Background: A visual field defect is the most important neurologic defect in occipital lobe infarcts. Note the responses on a chart representing the visual field. 3. 2. Cushing syndrome describes the assortment of physiologic changes that occurs with elevated serum cortisol levels. Occipital Lobe: Sparing the Temporal Crescent. There remains in each eye a temporal crescent of visual field for which there are no corresponding points in the other eye. The altitudinal defect can be unilateral or bilateral. 9. The selective abnormality often creates a horizontal line across the visual field (known as "respecting the horizontal meridian"). Nonsolid tumors (macrocystic and macrohemorrhagic) have been suggested to be more effectively managed with transsphenoidal hypophysectomy in comparison with solid tumors.[34]. The incidence of pituitary adenomas presenting as monocular visual field defects was reported to be 9% (in a series of 1,000 patients). a. Transection causes a contralateral lower quadrantanopia. The higher the number, the better the vision at that point in the field. 3. 4, 5 However, acute-onset inferior altitudinal VFD is a hallmark of AION. Junctional scotoma, Bitemporal defects, Homonymous hemianopia defects (w/wo macular sparing, spared temporal crescent). Is the test normal? This is then reported on a computerized printout in various ways, some numerical, others pictorial. Can we ever stop imaging in surgically treated and radiotherapy-naive patients with non-functioning pituitary adenoma? The patient presents with multiple risk factors for ischemic disease to the ocular and occipital vessels . What values indicate an unreliable Humphrey Visual Field? Retro-chiasmal lesions normally cause homonymous visual field defects; the only exception is the temporal crescent or half moon syndrome, caused by a lesion in the anterior part of the contralateral parieto-occipital sulcus. 3.2.2 Visual Field Testing in the Office o [ pediatric abdominal pain ] 6. 3.25). Octreotide therapy for thyroid-stimulating hormone-secreting pituitary adenomas. These numbers are then converted to a gray scale representation of the field (upper right, Fig. It can quickly establish the pattern of visual field loss in the ill, poorly attentive, or elderly patient who requires continued encouragement to maintain fixation and respond appropriately. [22] Most of these tumors tend to remain indolent and only rarely cause pituitary apoplexy, worsening visual fields, or new endocrine dysfunction.[23]. The code is valid during the fiscal year 2023 from October 01, 2022 through September 30, 2023 for the submission of HIPAA-covered transactions. This page was last edited on January 17, 2023, at 09:56. Special attention should be directed to the horizontal and vertical axes of the visual field to see if there is a change in vision across an axis. If there's a problem superiorly, you're gonna cause a problem inferiorly. The cytoplasm of these cells may be acidophilic, basophilic, or chromophobic, and is generally uniform in its appearance. The lesion may be anywhere along the optic pathway; retina to occipital cortex. The WHO currently recommends against using the term atypical adenoma as there is no accurate prognosis 2023 Springer Nature Switzerland AG. The normal extent of field of vision is 50 superiorly, 60 nasally, 70 inferiorly and 90 temporally. 5. A Homonymous hemianopia denser superiorly (pie in the sky) 2. 5. 3.6, Fig. Most ophthalmologic complaints are secondary to mass effects caused by macroadenomas. Because this is not an autoimmune process, the hyperthyroid state induced by these adenomas is not associated with thyroid eye disease. Goldmann visual field showing a bitemporal hemianopsia. (This rule does not apply to optic tract lesions that are suspected when the homonymous hemianopia is associated with a RAPD on the side of the hemianopia and bilateral optic nerve pallor). What values indicate an unreliable Humphrey Visual Field? Mostly temporal pallor of the left optic nerve from atrophy of the temporal retina in the left eye. What is the visual field defect of a junctional scotoma? Superior extension of the pituitary mass can cause sudden vision loss or visual field loss. The information below is from: The temporal crescent syndrome. In the example provided in Fig. We report a patient with bilateral superior altitudinal hemianopia. Grid: Present a square grid of lines and ask the patient to fixate on a central point and to draw any area in which the lines disappear (Fig. Retro-chiasmal lesions almost always give rise to homonymous field defects with only one, exception. 5. However, this effect is seen in any condition that causes delayed optic nerve conduction such as multiple sclerosis and retinal disorders. Rarely, pituitary adenomas can compress the optic tract and produce a homonymous hemianopsia. It is characterized by the presentation of acute, severe headache, nausea, and altered consciousness. Dopamine agonists (e.g., bromocriptine or cabergoline) have been shown to normalize hyperprolactinemia as well as shrink tumors. Rarely compression of the third ventricle can produce Increased intracranial pressure. The test involves the following steps: [5], Following surgical excision of a pituitary adenoma, the sella can remain radiographically "empty." 1. A central scotoma in the eye ipsilateral to the lesion & a superotemporal defect in the fellow eye. Preoperative Peripapillary Retinal Nerve Fiber Layer Thickness as the Prognostic Factor of Postoperative Visual Functions After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma. 3.2). https://doi.org/10.1007/978-3-642-35951-4_1155-1, DOI: https://doi.org/10.1007/978-3-642-35951-4_1155-1, Publisher Name: Springer, Berlin, Heidelberg, eBook Packages: Springer Reference MedicineReference Module Medicine, Over 10 million scientific documents at your fingertips, Not logged in when looking at the lid color, you notice they are red, inflamed, and a little crusty. If it is homonymous, is the defect complete or incomplete? The first sign of recurrence may be visual loss; therefore, baseline visual fields and visual acuity testing are recommended 2-3 months after treatment and at intervals of 6-12 months afterwards depending on the course, completeness of the resection, and serial neuroimaging studies. Octreotide has the most effect on tumor shrinkage, and pegvisomant has no effect on tumor size or growth hormone secretion but may have better effect on the overall systemic effects of elevated growth hormone. The tangent screen is rarely used and is primarily helpful for evaluating patients suspected of nonorganic constriction of the visual field (Fig. About 40% of patients with an altitudinal defect at the start of visual loss progress to a diffuse or total vision loss. These other conditions typically do not cause serum prolactin levels as high as those seen in prolactinomas. What are the findings of a parietal lobe lesion? They are seen as hypointense areas within the substance of the relatively hyperintense pituitary gland. An embolic infarction of either a distal MCA or PCA branch can result in exclusive ischemia of the tip of the occipital lobe, thereby producing only a small homonymous hemianopia if there is inadequate collateral circulation. 1 However, glaucoma patients often dont present with an initial chief complaint of visual field loss, unless the disease is quite advanced. Lactotroph adenomas arise from Pit-1 lineage and mainly express prolactin (PRL) and estrogen receptor (ER). Mostly temporal pallor of the left optic nerve from atrophy of the temporal retina in the left eye. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. This is often performed with the guidance of an endocrinologist. There remains in each eye a temporal crescent of visual field for which there are no corresponding points in the other eye. Visual Field Deficits. A homonymous hemianopsia denser inferiorly (opposite of pie in the sky). Tumor extension into the cavernous sinus can affect cranial nerves III, IV, V, or VI and produce a limited or total cavernous sinus syndrome. Patients with visual loss may require more frequent follow up however including formal visual field testing. A contralateral homonymous hemianopia that is small and centrally located. Most incidentalomas are adenomas, and are not uncommon. Lesion group 3 results in mostly temporal atrophy of the left optic nerve (Fig. 6. 3.27). 3.22d) Bilateral superior altitudinal hemianopia is an uncommon clinical presentation of ischemic stroke. It commonly presents in a younger patient population and is associated with MEN 1 syndrome. 2. Tangent Screen What field defect results when a stroke affects the occipital lobe but spares the anterior portion of the occipital lobe? PubMed 3.10), which provides a gross picture of the size and severity of the field defects present. Terms Visual field defect - a portion of visual field missing. 3.26). A recorded number of 0 indicates that the patient could not detect even the brightest stimulus at that point. [3] One review found an average incidence of 16.7% (14.4% in autopsy studies and 22.5% in radiologic studies). She later presented with right-sided visual disturbance; her examination confirmed temporal crescent syndrome. 4. Deep lesions of the parietal lobe often impair optokinetic nystagmus when stimuli are moved in the direction of the damaged parietal lobe. The physiologic blind spot corresponds to the optic disc (which has no overlying photoreceptors) and is located approximately 15 degrees temporally in each eye. In interpreting a visual field test, what questions should be asked? In interpreting a visual field test, what questions should be asked? The VF defect is a homonymous hemianopia with sparing of the temporal crescent on the same side as the hemianopia. 3. Rates must be under: Supported by From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. 1. 2003. [3] Most prolactinomas are sparsely granulated; on histology these tumor cells are weakly acidophilic or chromophobic. The nasal visual field falls on the temporal retina. Part of Springer Nature. This is called the temporal crescent or the half moon syndrome. Figure 2. Less commonly, ophthalmologists may be the first to detect evidence of a pituitary adenoma. Neuroanatomy of the visual pathway and the blood supply. On T2-weighted images, the adenoma is more indistinct, as it appears isointense or only slightly hyperintense in comparison with the surrounding gland. If the middle cerebral artery is patent when the PCA is occluded, this focal area of the occipital lobe may be spared. The higher the number, the better the vision at that point in the field. The temporal crescent syndrome. This non-invasive test examines your fields of vision, and it is important for identifying vision problems that could be signs of eye disease or conditions that affect the brain (like a stroke). 1. [48], Pituitary apoplexy is a life-threatening complication of pituitary adenoma caused by a sudden hemorrhage or infarction of the tumor. The main symptom of hemianopia is losing half of your visual field in one or both eyes. _____________________________________________________. The most nasal retinal fibers have unpaired cortical representation, which is situated in the most anterior part of the contralateral parieto-occipital sulcus. Hypercortisolism now most commonly results as a result of iatrogenic therapeutic modalities. Reddy R, Cudlip S, Byrne JV, Karavitaki N, Wass JA. Colao A, Di Sarno A, Guerra E, De Leo M, Mentone A, Lombardi G. Drug insight: Cabergoline and bromocriptine in the treatment of hyperprolactinemia in men and women. Gonadotrophic adenomas secrete lutenizing hormone (LH) and follicle-stimulating hormone (FSH). NAION) Optic Chiasm: * Nasal fibres (temporal visual field) decussate at the chiasm * Bitemporal hemianopia [25], Diplopia may be due to a paretic diplopia from ocular motor cranial nerve (e.g., III, IV, VI) paresis from lateral extension of tumors into the cavernous sinus, or a non-pareteic diplopia as a result of "hemifield slide" (described below). A right RAPD (contralateral to lesion) because more fibers (53%) in the optic tract come from the opposite eyes nasal retina, having crossed in the chiasm. The altitudinal defect can be unilateral or bilateral. Place the patients head on a chin rest in front of a computer screen. As discussed above, a significant portion of pituitary adenomas are asymptomatic or indolent, leading their discovery to be incidental. [6] These tumors stain positively with periodic acid-Schiff (PAS) because of the carbohydrates present in POMC, the precursor molecule to ACTH. Transcription factors are helpful in determining if the tumor is actually two or more separate tumors in the same area, or if the tumor actually co-expresses two different pituitary hormones. [3], Pituitary adenomas have a monomorphic appearance and are arranged in sheets or cords. Relative to the point of fixation: The upper visual field falls on the inferior retina (below the fovea). In: Schmidt-Erfurth, U., Kohnen, T. (eds) Encyclopedia of Ophthalmology. The slow-growing nature of these tumors tends to cause optic atrophy before the tumor enlarges sufficiently to compress the third ventricle or produce sufficient mass effect to increase intracranial pressure (ICP). Clinical Pathways in Neuro-ophthalmology. This symptom was first overlooked and a delusion was suspected. The most nasal retinal fibers have unpaired cortical representation, which is situated in the most anterior part of the contralateral parieto-occipital sulcus. Most patients show improvement of visual acuity, visual fields, or both following surgical treatment. Lights of different sizes and brightness allow the drawing of isopters. [3] Gigantism most commonly occurs from mammosomatotroph adneomas. Neuro-ophthalmology Illustrated-2nd Edition. Wilbrands knee is composed of fibers originating in the inferonasal retina which after traversing via the optic nerve and crossing in the chiasm go anteriorly into the contralateral optic nerve up to 4 mm before passing posteriorly to the optic tract. 3.3). What are the bilateral VF defect patterns? But it can also cause a range of other symptoms, including: distorted sight. Ali K. Pract Neurol 2015;15:5355. 5. What are the findings of a left optic tract lesion? While the patient is asked to fixate on a central target, a white or colored circular stimulus is slowly moved from the periphery toward the center of the screen until the patient reports seeing the stimulus. Bilateral occipital lobe lesions will produce bilateral homonymous hemianopias, which may be asymmetric (Fig. Lesions of the lateral geniculate nucleus typically cause a contralateral homonymous hemianopia. 1. 6. [6][12], GH-secreting adenomas can be either densely-granulated or sparsely granulated, or mammosomatotrophs. While there may be many subtle or obvious signs of endocrine disturbance, description of these signs is beyond the scope of this discussion. If it is homonymous, is the defect complete or incomplete? [33], Macroadenomas are more obviously seen, as they extend beyond the anatomical borders of the sella. [1], Visual recovery following treatment of pituitary adenomas is largely dependent on pre-treatment visual acuity/visual fields/etc., age of patient, duration of symptoms, severity of visual defects, presence of optic atrophy, and size of the tumor. Ali K. Pract Neurol 2015;15:5355 Use to remove results with certain terms Cover one of the patients eyes. Present stimuli consisting of dots of white light projected one at a time onto the inner surface of the bowl, usually moving from the unseen periphery into the patients field of view. What field defect results when a stroke only affects the anterior portion of the occipital lobe? 1. Optic Radiations Glaucoma is the leading cause of visual field loss across all age groups. Mete O, Lopes MB. Automated perimetry is more sensitive, quantitative, and reproducible, but it is more time consuming and requires good patient cooperation and attention (Fig. Upper Altitudinal Hemianopia is caused as a result of destruction of bilateral destruction of lingual gyri. Face: Ask the patient to look at your nose and tell you if any parts of your face are missing. Various studies report that pituitary adenomas account for anywhere from 66% to 80% of endogenous Cushing syndrome cases. There is no effective treatment. Learning points 3.14, Fig. 3.1). Currently, rather than classifying a tumor as hormone-producing or functional adenoma, pituitary tumors are definedby their cell lineage and are further divided based on immunohistological stains and tumor markers. Lesions of the occipital lobe sparing this anterior most portion of the occipital cortex will spare the temporal crescent (Fig. Overview of the 2017 WHO Classification of Pituitary Tumors. (A) Right optic disc shows mild superior disc oedema; left optic disc has more diffuse swelling and peripapillary haemorrhage. An embolic infarction of either a distal MCA or PCA branch can result in exclusive ischemia of the tip of the occipital lobe, thereby producing a small homonymous scotomatous defect if there is inadequate collateral circulation (Fig. 3.11): 5. 3. 7. 3.13). Medical and surgical management of pituitary adenomas require a multidisciplinary team. Thieme, 2. Because the nerve fiber layer arising from the peripheral retina arches over the fovea, superior or inferior nerve fiber layer damage results in arcuate-shaped visual field defects. An adenoma expressing more than one pituitary hormone is considered a plurihormal pituitary adenoma, except in the instances of dual GH and PRL, and FSH and LH expression. 3.3 Interpretation of a Visual Field Defect, 3.3.1 Understanding a Humphrey Visual Field Printout. glaucoma) * Peripheral constriction (Eg. 1. [5] This can occur with vertical hemifield defects such as those seen in pituitary adenomas, as well as altitudinal hemifield defects from optic nerve disease. Well, the visual field defect affects both eyes, which tells you that it is behind the optic chiasm. Does the visual field defect involve one eye or two eyes? In men, the size of the adenoma is more likely to cause compressive symptoms while in women, there are more hormone imbalances. 2.Blind Right Eye (Right Optic Nerve) A lesion of the optic nerve and, of course, of the eye itself, produces unilateral monocular blindness. 2. [24], Headaches are one of the most common symptoms reported in pituitary adenomas, with a reported incidence of 45%. In addition to the visual field defects, there may be decreased visual acuity, which is always the same in both eyes (Fig. Rosseau GL. Bilateral homonymous hemianopias In this case, the more negative a number, the more abnormal that point. The most nasal retinal fibers have unpaired cortical representation, which is situated in the most anterior part of the contralateral parieto-occipital sulcus. A lesion in this area will give rise to monocular visual field defect affecting the contralateral eye. The visual field and retina have an inverted and reversed relationship. Ischemic Optic Neuropathy Ischemic optic neuropathy is infarction of the optic disk. Right eye examinations were found to be normal (visual acuity, pupillary light reflex, and visual field exam). Thieme Ceylan S, Anik I, Koc K. A new endoscopic surgical classification and invasion criteria for pituitary adenomas involving the cavernous sinus. Applied anatomy for pituitary adenoma resection. In: Miller NR, Newman NJ, eds. By repeating this in various parts of the visual field, an isopter can be plotted and then drawn on the screen with chalk or pins. 9. The densely granulated variant is more common and is usually basophilic, and the sparsely granulated variant is chromophobic. Use OR to account for alternate terms What are the findings of an occlusion of the posterior cerebral artery? The resulting manifestations of the disease process include peripheral field loss, which may progress to central vision loss and legal blindness without intervention in the advanced disease state. This is called Wilbrands knee and is responsible for the junctional scotoma in lesions of the posterior optic nerve. What disease can cause this? Chronic tumor compression can lead to optic atrophy. Ophthalmology is typically consulted to evaluate the patient's visual fields. b. Lesions that involve both cunei cause a lower altitudinal hemianopia (altitud . 3.20, and Fig. 2. Lesions of the optic radiations typically produce a contralateral homonymous hemianopia, worse superiorly when the lesion is in the temporal lobe and worse inferiorly when the lesion is in the parietal lobe. "Tumors of the Pituitary Gland." Characterization of the visual field defect often allows precise localization of the lesion along the visual pathways. Postsynaptic fibers from the lateral geniculate nucleus form the optic radiations, which separate into the inferior fibers (temporal lobe) and the superior fibers (parietal lobe) as they progress posteriorly toward the occipital cortex (Fig. 3.21 show different homonymous hemianopias. The laboratory tests may vary depending on the clinical presentation. They are the second most common type of hypersecreting pituitary adenomas. Modest elevations in prolactin however can occur without prolactin secreting tumor because of the effect of compression of the stalk (removing the inhibition from dopamine) and is called the stalk effect. 3. An embolic infarction of either a distal MCA or PCA branch can result in exclusive ischemia of the tip of the occipital lobe, thereby producing only a small homonymous hemianopia if there is inadequate collateral circulation. Patients with acute optic neuritis typically present with acute loss of vision. 2. 3.20, and Fig. What are the findings of an occlusion of the posterior cerebral artery? difficulty . Central, Cecocentral, Paracentral, Arcuate/Sector, Nasal Step, Altitudinal, Enlarged blind spots, Temporal Crescent Defect. The life-threatening emergency associated with pituitary apoplexy is adrenal crisis, as well as other acute endocrine abnormalities.