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Updated: Aug 6 2019

Pituitary Apoplexy

  • 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
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