Immediate Management of Pituitary Apoplexy
Start intravenous hydrocortisone 50 mg every 6 hours immediately in all patients with suspected pituitary apoplexy, before any diagnostic confirmation or thyroid hormone replacement, as corticotropic deficiency can be life-threatening. 1, 2, 3
Initial Emergency Assessment
Immediate Hormone Evaluation
- Draw urgent blood samples for electrolytes, renal function, complete blood count, coagulation screen, and basal pituitary and peripheral hormones to rule out ACTH deficiency 1, 2
- Specifically assess thyroid function (TSH and free T4) for central hypothyroidism 1
- Measure gonadal hormones (testosterone in men, estradiol in women, FSH, LH) 1
- Critical pitfall: Never start thyroid hormone replacement before steroids—this can precipitate adrenal crisis in patients with concurrent adrenal insufficiency and hypothyroidism 1
Immediate Clinical Monitoring
- Monitor fluid and electrolyte balance closely, as imbalances are common and potentially life-threatening 1
- Assess for hemodynamic instability, impaired consciousness, visual acuity changes, and visual field defects—these indicate need for urgent surgical intervention 1, 2
Diagnostic Imaging
MRI of the sella without IV contrast is the optimal first-line imaging test to confirm diagnosis 4, 1
- Noncontrast sequences are highly sensitive for detecting hemorrhage, showing T1 hyperintensity, low T2 signal, or fluid-hemorrhage levels 4, 1
- Look for pituitary enlargement, stalk thickening, suprasellar convexity, heterogeneous enhancement, and hemorrhagic/necrotic components 1
- CT may be used only in emergency settings when MRI is unavailable and rapid diagnosis is essential 4
- Perform formal visual field assessment once the patient is clinically stable 2
Treatment Algorithm
Indications for Urgent Surgical Intervention (within 7 days)
Surgery is indicated for: 1, 2
- Progressive neurological deterioration
- Hemodynamic instability
- Impaired consciousness
- Reduced visual acuity
- Severe visual field defects
Transsphenoidal surgery by experienced pituitary surgeons is the preferred approach, with endoscopic technique potentially providing better visualization and superior outcomes in preserving pituitary function compared to microscopic approach 1
Conservative Management Criteria
Approximately one-third of patients can be managed conservatively if they have: 5, 2
- Mild and stable neuro-ophthalmic signs
- Good response to medical therapy
- No progressive neurological deterioration
Conservative management consists of: 5, 2
- Continued intravenous glucocorticoids
- Strict monitoring of fluid and electrolyte levels
- Careful clinical observation for any deterioration requiring surgical intervention
Post-Acute Monitoring
Immediate Postoperative Complications
- Watch for diabetes insipidus and SIADH, which are common after pituitary surgery 1
- Continue strict fluid and electrolyte monitoring 1
- Risk factors for postoperative complications include female sex, CSF leak during surgery, drain placement, and invasion/manipulation of the posterior pituitary 1
Long-Term Management
- All patients with adrenal insufficiency should obtain and carry a medical alert bracelet 1
- Long-term follow-up by a multidisciplinary team (experienced pituitary neurosurgeon, ophthalmologist, endocrinologist) is essential 2
- Monitor for development of new hormone deficiencies, including growth hormone deficiency 6