What is the recommended course of action for a patient with a severe headache, confusion, dizziness, hypertension, and a history of pituitary brain tumor?

Urgent Neuroimaging and Endocrine Evaluation Required

This patient requires immediate brain MRI with contrast (including pituitary/sellar cuts) and urgent endocrinology consultation given the combination of severe headache worse when lying down, confusion, dizziness, hypertension, and history of pituitary tumor—this presentation raises concern for pituitary apoplexy, tumor progression with mass effect, or hypopituitarism with secondary adrenal insufficiency. 1

Immediate Diagnostic Workup

Neuroimaging

• Obtain brain MRI with and without contrast with dedicated pituitary/sellar cuts immediately for any patient with pituitary tumor history presenting with new severe headaches, confusion, or vision changes 1
• The positional nature of this headache (worse lying down/sitting) is atypical for typical brain tumor headaches, which classically worsen after supine position and improve with upright time, suggesting possible increased intrasellar pressure or alternative pathology 1, 2
• MRI will evaluate for tumor enlargement, hemorrhage (apoplexy), compression of optic chiasm, or hydrocephalus 1

Urgent Laboratory Assessment

• Draw morning (AM) ACTH and cortisol levels immediately to evaluate for adrenal insufficiency, which can present with confusion, dizziness, and hypotension (though hypertension can paradoxically occur in subclinical Cushing's) 1, 3
• Obtain TSH, free T4, and electrolytes to assess for central hypothyroidism and hyponatremia/SIADH 1
• Check complete blood count to rule out concurrent anemia/thrombocytopenia, which can present with severe headaches and confusion 1
• Consider standard-dose ACTH stimulation testing if morning cortisol is indeterminate (>3 mg/dL and <15 mg/dL) 1

Critical Management Considerations

Pituitary Apoplexy Protocol

• If imaging reveals hemorrhage or infarction within the tumor, this constitutes pituitary apoplexy requiring immediate stress-dose corticosteroids (hydrocortisone 100 mg IV or dexamethasone 4 mg IV if diagnosis unclear and stimulation testing needed) 1
• Hospitalize for normal saline resuscitation (at least 2L) and stress-dose steroids (hydrocortisone 50-100 mg IV every 6-8 hours) 1
• Neurosurgical consultation is warranted if there is visual field compromise or threatened optic chiasm compression 1

Adrenal Insufficiency Management

• If morning cortisol is low (<3 mg/dL) with low ACTH, initiate immediate corticosteroid replacement as this represents secondary (central) adrenal insufficiency from hypopituitarism 1
• For outpatient management if stable: hydrocortisone 15-20 mg in divided doses (2/3 morning, 1/3 early afternoon) 1
• All patients with confirmed adrenal insufficiency require education on stress dosing, emergency injectable steroids, and medical alert bracelet 1

Hypertension Context

• The combination of hypertension with pituitary tumor raises concern for subclinical Cushing's disease, which can present with hypertension and metabolic derangements even without obvious Cushingoid features 3
• However, acute confusion and dizziness are more consistent with hypopituitarism/adrenal crisis rather than cortisol excess 1, 3

Common Pitfalls to Avoid

• Do not delay imaging for laboratory results—the combination of severe headache, confusion, and pituitary tumor history mandates immediate MRI to exclude surgical emergencies like apoplexy with chiasm compression 1
• Never start thyroid hormone replacement before ensuring adequate corticosteroid replacement, as this can precipitate adrenal crisis in patients with concurrent central adrenal insufficiency 1
• Do not assume hypertension excludes adrenal insufficiency—patients can have paradoxical presentations, and the acute confusion/dizziness pattern is more concerning for hypocortisolism 1, 3
• Consider intracranial hypotension if headache pattern is strictly positional (worse upright), though this is less likely given the confusion and tumor history 4

Disposition

• If any of the following are present, immediate hospitalization is required: severe confusion (Grade 3-4), visual changes, inability to perform activities of daily living, or confirmed adrenal crisis 1
• Endocrinology consultation should occur within 24 hours even if outpatient management is planned 1
• If MRI reveals significant mass effect, hydrocephalus, or apoplexy, neurosurgical evaluation is mandatory 1