Pituitary apoplexy

It is a medical emergency and rapid replacement with hydrocortisone may be lifesaving. It is caused by haemorrhage and/or infarction of a tumour within the pituitary gland.

A high index of clinical suspicion is essential to diagnose this condition as prompt management may be life and vision saving.

Clinical presentation: –

A diagnosis of pituitary apoplexy should be considered in all patients who have acute severe headache and any of the following:

  1. Ocular palsies, most commonly a 3rd nerve palsy, due to involvement of the cavernous sinus
  2. Reduced visual acuity and visual field defects, most commonly a bi-temporal hemianopia, are due to optic chiasmal compression
  3. Fever, neck stiffness, photophobia or reduced consciousness (similar to SAH or meningitis)
Precipitating factors:
  • Hypertension
  • Major surgery, especially CABG
  • Pregnancy
  • Coagulopathies or anticoagulation therapy
  • Head trauma
  • Dynamic testing of the pituitary gland
Differential diagnosis: –
  1. SAH due to ruptured intracranial aneurysm or arteriovenous malformation
  2. Bacterial/viral meningitis
  3. Brainstem infarction
  4. Cavernous sinus thrombosis
Investigations: –
  • Brain MRI scan is the investigation of choice (confirm the diagnosis in > 90% of patients)
  • CT brain (± LP) to exclude SAH and meningitis should be undertaken if not ‎already done
  • Bedside assessment of visual acuity and fields
  • Urgent bloods: U&E, FBC, renal and liver ‎function tests, clotting profile
  • Endocrine evaluation with blood samples for random serum cortisol, TSH, free T4, prolactin, IGF1, LH, FSH, testosterone (men), oestradiol (women) for later analysis
Management: –
  1. Ensure haemodynamic stability and careful assessment of fluid & electrolyte balance
  2. Indications for empirical steroid therapy in patients with pituitary apoplexy are haemodynamic instability, altered consciousness level, reduced visual acuity and severe visual field defects. Steroid replacement is potentially lifesaving in these patients
    • In adults, hydrocortisone 100 mg IM followed by 50 – 100 mg six hourly by IM injection or 100 – 200 mg as bolus IV followed by 2 – 4 mg/hour by continuous IV infusion.
  3. Neuro-ophthalmic assessments can be undertaken when the patient is clinically stable
  4. Urgent referral to the joint neurosurgical/endocrine unit for definitive ‎management. Surgical intervention should be considered in patients with:‎
    • Severely reduced visual acuity
    • Severe and persistent visual field defects‎
    • Deteriorating level of consciousness