Pituitary apoplexy is a neuroendocrine emergency caused by acute hemorrhage or infarction of a pituitary adenoma, typically presenting with:
Sudden headache
Visual impairment (e.g., bitemporal hemianopsia)
Ophthalmoplegia
Altered consciousness
Hypopituitarism (including adrenal insufficiency)
🚨 Initial Management (Emergency Phase) 1. Stabilization ABCs: Airway, Breathing, Circulation
ICU admission if altered consciousness
2. Immediate Medical Therapy High-dose corticosteroids (e.g., IV hydrocortisone 100 mg bolus, then 50–100 mg q6-8h)
Reduces edema
Prevents adrenal crisis
Intravenous fluids and electrolyte correction
3. Endocrine Workup Baseline labs: cortisol, TSH, fT4, LH/FSH, prolactin, IGF-1
Monitor sodium, glucose, osmolality
4. Neuroimaging Urgent MRI is gold standard
CT may show hyperdense lesion in acute hemorrhage
🔍 Definitive Treatment Strategy A. Surgical Management Indications:
Rapid deterioration of visual acuity or field deficits
Progressive ophthalmoplegia
Reduced consciousness
Approach:
Transsphenoidal decompression (preferred)
Timing: within 24–72 hours for best visual outcomes
B. Conservative Management Indications:
Stable or improving vision
Mild/no cranial nerve deficits
No reduced consciousness
Close monitoring with:
Serial neurological and ophthalmologic exams
Repeat MRI in 1–2 weeks
🔄 Follow-up and Long-term Care 1. Endocrine Replacement Lifelong hormone replacement if persistent hypopituitarism
Hydrocortisone, levothyroxine, sex steroids ± GH
2. Tumor Surveillance MRI at 3 months, then annually
3. Vision and QoL Monitoring Regular ophthalmologic evaluations
Neuropsychological and rehabilitation support
đź“š Clinical Pearls Corticosteroids are first-line regardless of surgery.
Not all patients with apoplexy need surgery.
Early endocrinology and neurosurgery consult is essential.
Recovery of function is variable—vision may improve, but pituitary function often does not.