Urgent considerations

See Differentials for more details

Pituitary apoplexy

A rare syndrome caused by infarction or hemorrhage (with or without infarction) of, in most cases, a preexisting pituitary adenoma. The resultant mass expands rapidly and compresses neighboring structures. The peak incidence of pituitary apoplexy is in the fifth decade of life, although it can affect all age groups. It most commonly occurs in patients with large macroadenomas, but can occur in tumors of any size, or other lesions (e.g., a Rathke cleft cyst, sellar tuberculoma, hypophysitis, pituitary abscess, or craniopharyngioma).[29] Pituitary apoplexy can also occur in normal pituitary tissue, during the peri- or postpartum period, as a consequence of hypovolemic shock (Sheehan syndrome).[29]

In about 80% of cases, pituitary apoplexy is the presenting symptom of an undiagnosed tumor, particularly a nonfunctional macroadenoma.[33]

Pituitary apoplexy usually presents with sudden onset of headache, visual loss, nausea and vomiting, cranial nerve palsies, hemiparesis, and impaired pituitary function. If the hemorrhage breaks into the subarachnoid space, pituitary apoplexy can be accompanied by meningeal irritation, neck stiffness, and photophobia. Severe hypotension and shock due to secondary adrenal deficiency (as a result of adrenocorticotropic hormone deficiency) may occur.

Supportive therapy with intravenous fluids and corticosteroids (dexamethasone 2-16 mg/day) results in clinical improvement in many patients. Transsphenoidal surgical decompression of the tumor can be undertaken within 24 to 48 hours of onset, in cases where conservative treatment is unsuccessful or in the presence of progressive vision loss and/or cranial neuropathy. Long-term follow-up to treat any residual tumor and/or pituitary dysfunction is required.[34]

Acute chiasmal compression

In any patient with a pituitary mass and evidence of acute chiasmal compression (sudden visual-field defects, oculomotor palsies), immediate transsphenoidal surgical decompression should be considered, with intravenous fluids and corticosteroids if anterior pituitary insufficiency is suspected. Bromocriptine may be tried before surgery in patients with a large prolactinoma.

Secondary adrenal insufficiency

Any patient with a pituitary mass, and any other patient where anterior pituitary insufficiency should be presumed, may have secondary adrenal insufficiency. Patients with suspected insufficiency and/or adrenal crisis should be given corticosteroids and intravenous fluids (to correct hypotension and dehydration); glucose should be given when necessary to correct hypoglycemia.

Pituitary abscess

Should be suspected in a patient with fever, headache, meningismus, and a known pituitary adenoma. The preferred management is surgical drainage by a transsphenoidal approach, with intravenous antibiotic therapy, and corticosteroid replacement if anterior pituitary insufficiency is suspected.

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