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Diplopias are caused by paresis of one or more of the extraocular muscles. Cranial nerves III, IV, and VI when passing through the cavernous sinus, lateral to the fossa, may be engulfed in lateral extension of pituitary adenomas, yet their function is almost never not lost except in pituitary apoplexy. When this occurs this usually presents predominately as a oculomotor nerve palsy; however, sporadic reports of isolated abducens nerve palsies have been made. In the absence of apoplexy, oculomotor nerve palsies are more commonly caused by other parasella pathologies, particularly, meningiomas of the cavernous sinus and trigeminal neuromas.

Headache is probably the most common neighborhood symptom. It is present in three quarters of patients at some stage in their histories on careful questioning. It is believed that headache results from stretching of the dural lining of the pituitary fossa and diaphragma sellae. As in many headaches caused by mass intracranial lesions, the pattern is more common in the early morning but is usually not severe, except in apoplexy. It may, however, dominate some patients' lives, particularly in acromegaly and, to a lesser extent, in prolactinoma. In the latter it may complicate dopamine agonist therapy (q.v.); in the former, somatostatin analogs have a surprising effect not related to lowering of growth hormone and insulin-like growth hormone factor (IGF)-1 levels. In all patients with headache, it is essential to take a careful drug use history, because regular use of non prescription medication containing paracetamol may lead to so-called analgesia headache. Changing to nonsteroidal anti-inflammatory medication is the first line of management for analgesia headache.

Rarely a patient may present with temporal lobe epilepsy when a giant tumor spreads laterally to involve the brain (Fig. 1). Major and minor seizures may occur, the latter involving olfactory hallucinations, an intense déjà vu experi-

Fig. 1. Coronal enhanced T1 magnetic resonance imaging (MRI) showing a massive prolactinoma that has extended laterally through the cavernous sinus on the left. The patient presented with temporal lobe epilepsy and a history of impotence.

ence, and a rising epigastric sensation. These features may appear as an aura preceding a major attack.

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