Pituitary Apoplexy

Pituitary apoplexy is acute haemorrhage or infarction of a pituitary tumour (usually macroadenoma) or gland.

• Occurs in 2 to 12% of adenomas, mostly non functioning.
• Precipitants: anticoagulation, head trauma, surgery (cardiac), dopamine agonist start, pregnancy, hypertension, GnRH analogue/dynamic testing, Sheehan syndrome.
• Complications: vision loss, ophthalmoplegia, adrenal crisis, death.

• Sudden severe headache, vomiting, visual loss/field defects, diplopia (III, IV, VI palsy), reduced consciousness.
• Meningism, fever, hypotension.
• Hypopituitarism, hyponatraemia.

• MRI pituitary (haemorrhage, sellar mass); CT may miss.
• Urgent hormonal assessment: cortisol, ACTH, free T4, TSH, prolactin, LH/FSH, IGF 1, electrolytes.
• Visual acuity, fields, eye movements.
• Exclude subarachnoid haemorrhage (CT, LP), meningitis.

• Hydrocortisone 100 mg IV immediately, then 50 mg every 6 hours (or infusion 200 mg/24 hours) after sampling; fluid and electrolytes.
• Neurosurgical referral: urgent transsphenoidal decompression for severe visual loss, deteriorating fields, reduced consciousness; conservative management in stable patients with mild deficits (comparable outcomes).
• Replace deficient axes: levothyroxine after steroids, sex hormones, desmopressin for diabetes insipidus.
• Dopamine agonist for prolactinoma-related apoplexy.
• Follow up hormones at 6 to 12 weeks, MRI at 3 months, visual fields.