Pituitary apoplexy

Pituitary apoplexy is a syndrome caused by haemorrhage or infarction of the pituitary gland, usually affecting a pituitary adenoma. Precipitating factors include high blood pressure, major surgery, pregnancy and head injury. The syndrome is associated with rapid onset of:

• severe headache (the presentation may be confused with a subarachnoid haemorrhage)
• neck stiffness
• visual field defect
• diplopia from cranial nerve palsies
• hypopituitarism (adrenocorticotrophic hormone [ACTH] deficiency is the most common deficiency).

Patients should be referred at diagnosis to a multidisciplinary team including an endocrinologist and a neurosurgeon.

If pituitary apoplexy has caused visual loss, surgical decompression is often required—it should be performed within 8 days of onset to avoid irreversible visual loss. Urgent neurosurgical management is rarely necessary.

Visual defects (visual loss or diplopia) resulting from apoplexy involving a prolactinoma can respond to acute dopamine agonist therapy (see Dopamine agonist therapy for prolactinoma). If visual defects do not resolve, surgical decompression can still be undertaken within 8 days of onset.

Diplopia from compression of the upper cranial nerves passing through the cavernous sinus often resolves spontaneously and is not an indication for immediate surgery.

For acute glucocorticoid replacement in a patient with pituitary apoplexy associated with a pituitary adenoma, hydrocortisone is preferred. Use:

Dexamethasone can be used to reduce oedema in pituitary apoplexy. Use: