Overview
Also known as acute pituitary failure, pituitary apoplexy is the sudden enlargement of a pituitary tumour secondary to haemorrhage or infarction. It is a life-threatening medical emergency.
Epidemiology
- Most commonly with pituitary tumours, particularly non-functioning macroadenoma
- Affects men more than women
- Most cases happen in ages >40 years
Risk Factors
- Hypertension
- Major surgery
- Anticoagulation
- Coagulopathy
- Trauma
- Pregnancy
- Irradiation
- Pituitary function testing using GnRH/CRH etc.
Presentation
Any patient with a sudden-onset headache with neurological/ophthalmic signs should be considered to have pituitary apoplexy, some features are:
- Headaches – sudden-onset and usually unilateral before becoming generalised
- Vomiting
- Visual field defects due to optic chiasm compression – bitemporal hemianopia
- Visual acuity defects due to optic nerve compression
- Neck stiffness
- Ptosis
- Features of hypopituitarism (e.g. hypotension and hyponatraemia due to adrenal insufficiency)
Differential Diagnoses
Subarachnoid haemorrhage (SAH)
- Both have a sudden-onset headache and meningism
- SAH does not have hypopituitarism
- SAH usually does not have bitemporal hemianopia
Investigations
- Urgent MRI scan – diagnostic
- Consider CT if MRI contraindicated
- Pituitary function tests:
- Prolactin
- IGF-1
- FSH and LH
- Oestrogen and testosterone
- TFTs
- ACTH
- Morning cortisol
- U&Es
- FBC
Management
- 1st-line: IV hydrocortisone to provide steroids due to reduced ACTH to prevent an adrenal crisis
- Surgery
Complications and Prognosis
Complications
- Hypopituitarism
- Death
- Diabetes insipidus
Prognosis
- Pituitary apoplexy is potentially life-threatening
- Rapid diagnosis and early treatment can achieve complete recovery
