Snapshot A 56-year-old man presents to the emergency department with a severe headache that occurred suddenly. The patient also complains of not seeing very well. Physical examination is notable for left-eye ptosis and a dilated pupil that is inferiorly and laterally deviated. A computerized tomography (CT) of the head is performed, which is shown to the right. Neurosurgery is immediately consulted. Overview Hemorrhage or infarction of the pituitary gland → pituitary gland volume increases usually happens in macroadenomas Differential diagnosis subarachnoid hemorrhage bacterial meningitis Pathophysiology Pituitary adenomas are at risk of bleeding and undergoing necrosis possible explanation: adenoma outgrowing blood supply → ischemia → necrosis adenoma compressing blood supply → ischemia → necrosis fragility of blood vessels supplying the tumor → hemorrhage Presentation Excruciating headache of acute onset Hypopituitarism Visual symptoms impairment of visual acuity or visual field tumor expansion → compression of optic nerve, optic chiasm, or optic tract diplopia due to oculomotor nerve compression ± altered consciousness Diagnosis CT or MRI of the head intrasellar mass + necrotic and/or hemorrhagic features CT without contrast - more useful if acute (24 - 48 hours) initial imaging study of choice in the emergency setting can help exclude subarachnoid hemorrhage MRI - more useful if subacute (4 days - 1 month) Treatment/Management Debatable, but treatment is aimed at improving the patient's symptoms and relieving compression of surrounding structures (i.e., optic pathways) neurosurgery seems the fastest at accomplishing this a select few can be managed conservatively i.e., those without visual symptoms and normal consciousness Neurosurgical emergency early trans-sphenoidal surgical decompression Corticosteroid therapy immediately majority of patients present with corticotropic deficiency this may be life-threatening Correction of electrolyte disturbances