Chapter 21 - Pituitary Apoplexy

Abstract

Pituitary apoplexy is the potentially life-threatening hemorrhage or infarction of the pituitary gland, often within an existing pituitary adenoma, leading to significant neurologic symptoms such as severe headache and meningismus, neuro-ophthalmologic deficits, and endocrine deficiencies. Risk factors and precipitating events include vascular causes (e.g., blood pressure fluctuations and anticoagulation therapy that increases bleeding risk) and increased pituitary demand (e.g., pregnancy, hormonal treatment, and pituitary testing). However, most cases do not have an identifiable precipitating event. Diagnosis is made by clinical assessment and confirmed by radiological detection of the pituitary apoplexy or a pituitary tumor, usually on magnetic resonance imaging (MRI). In the acute setting, particularly for those patients with hemodynamic instability, supportive care with fluid resuscitation, intravenous dextrose, and empiric hydrocortisone replacement should be started immediately after drawing blood to sample for hormonal assays. The management of pituitary apoplexy remains controversial, as there are no randomized controlled studies. However, most professional societies recommend that pituitary apoplexy presenting with acute visual deficits or impaired consciousness be managed surgically by an experienced pituitary neurosurgeon, whereas patients with mild and stable signs and symptoms could be managed conservatively. Mortality from pituitary apoplexy is low with timely intervention. Most patients achieve at least partial recovery of neurologic and neuro-ophthalmologic deficits, but many require long-term hormonal supplementation. Surveillance with periodic MRI is recommended to monitor for tumor recurrence or progression.