What is the emergency management of pituitary apoplexy?

Emergency Management of Pituitary Apoplexy

Immediately initiate intravenous hydrocortisone 50-100 mg every 6-8 hours in all patients with suspected pituitary apoplexy, as this is life-saving for acute adrenal insufficiency and must be started before any other interventions. 1, 2

Immediate Stabilization

Corticosteroid replacement is the cornerstone of emergency management:

• Start IV hydrocortisone 50-100 mg every 6-8 hours immediately upon suspicion, before awaiting laboratory confirmation 3, 2
• This stress-dose steroid regimen addresses the potentially life-threatening secondary adrenal insufficiency that occurs in pituitary apoplexy 1, 4
• Do not delay steroid administration for diagnostic testing—clinical suspicion alone warrants treatment 4

Fluid and electrolyte management:

• Administer at least 2 liters of normal saline for volume resuscitation 3
• Monitor fluid and electrolyte balance strictly, as both diabetes insipidus and SIADH can complicate pituitary apoplexy 1
• Measure serum sodium and osmolality every 4-6 hours initially 1
• Monitor urine output hourly to detect polyuria (suggesting diabetes insipidus) or oliguria with hyponatremia (suggesting SIADH) 1

Urgent Diagnostic Workup

Obtain these laboratory studies immediately:

• Morning (9 AM) cortisol and ACTH, or random if patient is acutely ill 3, 1
• TSH, free T4 to assess for central hypothyroidism 1
• Electrolytes, particularly sodium 3
• LH, FSH, testosterone (men), estradiol (premenopausal women) 3, 1
• Prolactin and IGF-1 3

Imaging:

• MRI of the sella with pituitary protocol is the optimal diagnostic test 1
• Look for pituitary enlargement, hemorrhagic components (T1 hyperintensity, low T2 signal, or fluid-hemorrhage level), heterogeneous enhancement, and suprasellar extension 1
• CT may be more readily available in the acute setting (first 24-48 hours) and is sensitive for hemorrhage 2

Surgical vs. Conservative Decision Algorithm

Immediate surgical indications (transsphenoidal decompression):

• Progressive or severe visual field defects 1, 5
• Deteriorating visual acuity 5
• Progressive neurological deterioration 1
• Altered level of consciousness 2, 5
• Severe mass effect with threatened optic chiasm compression 3

Conservative management is appropriate when:

• Visual deficits are absent, stable, or improving 5
• Patient is hemodynamically stable after steroid and fluid resuscitation 6
• No altered consciousness 2, 5
• Close monitoring is feasible with ability to escalate to surgery if deterioration occurs 5

Approximately 70% of patients require surgery, while 30% can be managed conservatively with excellent outcomes if properly selected 6, 5

Critical Management Principles

Hormone replacement sequencing:

• Always initiate corticosteroid replacement before thyroid hormone replacement to avoid precipitating adrenal crisis 1
• If both adrenal insufficiency and hypothyroidism are present, start steroids first, then add thyroid hormone after at least 1 week 3, 1

Analgesia for severe headache:

• Use paracetamol and NSAIDs as first-line 3
• Consult neurology if headache is resistant to these agents 3

Visual assessment:

• Perform formal visual field testing if any visual symptoms are present 3
• Patients with abnormal visual fields must inform driver licensing agencies 3

Steroid Tapering Protocol

For patients managed conservatively or post-operatively:

• Continue IV hydrocortisone 50-100 mg every 6-8 hours until stable 3
• Taper stress-dose corticosteroids down to oral maintenance doses over 5-7 days 3
• Transition to oral hydrocortisone 15-20 mg daily in divided doses (typically 2/3 morning, 1/3 early afternoon) 3
• For patients with mass effect requiring high-dose steroids: use prednisone 1 mg/kg/day, taper over 1-2 weeks, then transition to physiologic maintenance at 5 mg prednisone equivalent 3

Never discontinue steroids abruptly 3

Mandatory Endocrinology Consultation

• Refer to or consult endocrinology immediately for all grades of severity 3
• Endocrinology expertise is essential for hormone replacement optimization and long-term management 6

Patient Education and Safety

Before discharge, ensure patients receive:

• Education on "sick day rules" and stress dosing 3, 1
• Prescription for emergency intramuscular steroid injection with instructions for use 3, 1
• Medical alert bracelet or necklace indicating adrenal insufficiency 3, 1

Post-Acute Monitoring

Watch for biphasic or triphasic patterns:

• Initial diabetes insipidus followed by SIADH is common after pituitary surgery 1
• Triphasic pattern (diabetes insipidus → SIADH → permanent diabetes insipidus) can occur 1
• Serial urine specific gravity and osmolality measurements are essential 1

Common pitfall: Assuming preserved posterior pituitary function based on initial concentrated urine—transient AVP deficiency can develop even with initially normal function 1

Long-Term Considerations

• Most patients require lifelong glucocorticoid replacement (72-87% in both surgical and conservative groups) 5
• Thyroid hormone replacement is needed in 60-72% of patients 5
• Monitor for tumor regrowth with serial MRI, as approximately 3-6% may require additional intervention 5
• Long-term follow-up may reveal new hormone deficiencies, including growth hormone deficiency 4