Pituitary apoplexy

Pituitary apoplexy is a clinical syndrome caused by hemorrhage into a pituitary adenoma. Classic pituitary tumor apoplexy presents with headache, visual changes, and ophthalmoplegia secondary to irritation or dysfunction of cranial nerves II, III, IV, V, and/or VI that course in the vicinity of sellar region. Pituitary dysfunction can also occur, and some patients present with hemodynamic instability secondary to acute adrenal insufficiency and with alteration of level of consciousness in severe cases. Initial management is focused at diagnosing pituitary tumor hemorrhage, which includes imaging and laboratory investigations, as well as ensuring hemodynamic stability of patient and administration of high-dose steroids in cases of acute adrenal insufficiency. Ophthalmological assessment of visual fields is also useful. Transsphenoidal microsurgical or endoscopic decompression of sellar region is indicated in patients with severe or worsening deficits. A subset of patients with mild symptomatology and/or improving with steroid administration may be managed conservatively. No clear guidelines exist for management of pituitary apoplexy, and a referral to neurosurgery, endocrinology, and ophthalmology is needed to determine optimal treatment strategy of patients with pituitary tumor apoplexy.