Pituitary Apoplexy
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Direct answer
Pituitary apoplexy is acute haemorrhage or infarction within a pituitary gland, most often a macroadenoma, presenting with sudden severe headache, visual loss and sometimes ophthalmoplegia or reduced consciousness. It is an emergency because ACTH deficiency can precipitate adrenal crisis and optic compression can cause permanent blindness. MRI confirms the diagnosis, and stress-dose hydrocortisone is started without waiting for cortisol results.
What you must remember
- Presentation: sudden severe headache, visual field loss, ophthalmoplegia from cavernous sinus involvement and reduced consciousness.
- Underlying adenoma: most cases arise in a macroadenoma, often non-functioning, and in the majority the adenoma was undiagnosed before the apoplexy.
- Triggers: anticoagulation, pregnancy, uncontrolled hypertension and recent surgery are recognised precipitants.
- Imaging: MRI shows haemorrhage better than CT, although CT may show a hyperdense sellar mass.
- Endocrine check: cortisol, thyroid, gonadal and prolactin axes; ACTH deficiency is the dangerous one.
- Steroids: stress-dose hydrocortisone immediately if adrenal insufficiency is possible.
- Surgery: urgent transsphenoidal decompression for progressive visual loss or declining consciousness; some patients are managed conservatively.
A man with a headache and a drooping eyelid
A 47-year-old man has two days of severe headache, vomiting and double vision. He has a drooping left eyelid, and his Glasgow Coma Scale is 13.
- Test the fields and pupils: visual field testing shows a bitemporal defect, and the left pupil is dilated and fixed.
- Image the sella: MRI shows a 2.5 cm pituitary macroadenoma with haemorrhage.
- Start steroids at once: intravenous hydrocortisone is started without waiting for the hormone results, because adrenal crisis can be fatal, and low ACTH and cortisol are often found.
- Refer urgently: neurosurgical referral follows, since the visual defect and ophthalmoplegia are progressing.
- Decompress and monitor: transsphenoidal decompression is performed, and visual fields and extraocular movements are monitored afterwards.
- Replace hormones: other pituitary axes are assessed, and steroid replacement continues long term if ACTH deficiency persists, with thyroid and gonadal function checked and visual fields repeated at follow-up.
- Watch sodium: sodium is monitored in the first days after surgery, because injury to the posterior pituitary can cause transient diabetes insipidus.
The combination of sudden headache, visual loss and ophthalmoplegia should always prompt consideration of apoplexy, because delay costs sight.
Where the exam tries to catch you
Examiners return to the same few traps.
- Trap: confusing pituitary apoplexy with subarachnoid haemorrhage because both give a sudden severe headache. Correct: apoplexy adds visual loss and ophthalmoplegia, and MRI shows a pituitary mass with haemorrhage that was often undiagnosed before the event.
- Trap: holding steroids until cortisol is measured. Correct: give stress-dose hydrocortisone first, because cortisol testing takes time and adrenal crisis is dangerous.
- Trap: not asking about precipitants. Correct: anticoagulation, pregnancy and uncontrolled hypertension are the classic precipitants.
- Trap: operating on every case. Correct: the decision to operate depends on visual compromise and consciousness, and a stable patient with no visual loss may be observed with serial MRI and visual testing.
Frequently asked questions
What are the classic clinical features of pituitary apoplexy?
The classic features of pituitary apoplexy are sudden severe headache, visual field loss, ophthalmoplegia and sometimes reduced consciousness. Vomiting and neck stiffness can also occur. Symptoms may develop over hours and often follow a precipitant such as anticoagulation.
Which imaging test confirms pituitary apoplexy?
MRI of the pituitary is the best test to confirm pituitary apoplexy because it shows haemorrhage and infarction within the gland and surrounding structures. CT can show a hyperdense sellar mass but is less sensitive. The diagnosis is clinical and radiological together.
Why is stress-dose hydrocortisone given in pituitary apoplexy?
Stress-dose hydrocortisone is given in pituitary apoplexy because the gland may fail to produce ACTH and cortisol, leading to adrenal crisis. Treatment is started before cortisol results return, since delay can be fatal. Steroid cover continues until adrenal function is assessed.
Which pituitary tumour type is most at risk of apoplexy?
Macroadenomas are most at risk of pituitary apoplexy, and non-functioning tumours are particularly common among affected patients. Large tumours outgrow their blood supply and are compressed within the sella, which favours haemorrhage. Known macroadenomas should be monitored closely.
When is urgent transsphenoidal surgery indicated in pituitary apoplexy?
Urgent transsphenoidal surgery is indicated in pituitary apoplexy with progressive visual loss, or declining consciousness, whereas isolated ophthalmoplegia often settles without surgery. Decompression relieves pressure on the optic chiasm and cavernous sinus structures. Stable patients without visual compromise may be managed conservatively with serial monitoring.