What is the most common symptom of apoplexy?

Most Common Symptom of Apoplexy

Headache is the most common symptom of pituitary apoplexy, occurring in up to 97% of cases. 1, 2

Understanding Pituitary Apoplexy

Pituitary apoplexy is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland, most commonly within a pre-existing pituitary adenoma. 3, 4

Key Clinical Presentation

• Headache (97%) - typically sudden and severe in onset 1, 2
• Nausea and vomiting (80%) 1
• Visual disturbances (71%) - including reduced visual fields and visual acuity 1, 5
• Ocular palsies/diplopia (45%) 2
• Decreased level of consciousness (13%) 2
• Meningismus (signs of meningeal irritation) 5

Pathophysiology

• Occurs due to sudden expansion of a mass within the sella turcica 5
• Most commonly happens in patients with pre-existing pituitary adenomas, many of whom are unaware of the tumor before apoplexy 5, 3
• Can be precipitated by hypertension (26% of cases) and other factors 1

Diagnostic Considerations

Imaging

• MRI is the imaging method of choice with significantly higher sensitivity than CT 1, 4
• MRI correctly identifies pituitary hemorrhage in 88% of cases, while CT only identifies it in 21% 1
• High-resolution protocols are recommended for evaluation of suspected pituitary apoplexy 6

Laboratory Findings

• Endocrinologic disturbances are common, including:
  • Hypopituitarism (73% of cases) 2
  • Cortisol deficiency 5
  • Diabetes insipidus (8% of cases) 2

Clinical Pitfalls

Differential Diagnosis

• Pituitary apoplexy is often misdiagnosed as subarachnoid hemorrhage due to similar presentation 2
• Must be distinguished from other causes of sudden headache:
  • Cerebrovascular accidents 5
  • Meningitis 5
  • Migraine 6

Timing of Intervention

• Early diagnosis is critical as surgical intervention within 8 days of symptom onset results in better visual outcomes than delayed surgery 1
• Complete restoration of visual acuity occurred in all patients operated on within 8 days but only in 46% of patients operated on after this time 1

Management Approach

• Immediate administration of high-dose corticosteroids for patients with hemodynamic instability, impaired consciousness, or severe visual deficits 4
• Transsphenoidal surgery is the treatment of choice, especially with visual abnormalities 5, 4
• Some patients with mild and stable symptoms may be managed conservatively 4
• Long-term hormone replacement therapy is often necessary (58% require steroid replacement, 45% require thyroid hormone replacement) 1

Early recognition of headache as the cardinal symptom of pituitary apoplexy, followed by prompt imaging and endocrinological evaluation, is essential for reducing morbidity and mortality in this neurosurgical emergency. 5, 4