Pituitary apoplexy: A review of presentation, management and outcome
B Vaidya1, L Sibal1, P Kane2, N Brady3, V Connolly1, RA James4 & W Kelly1
Pituitary apoplexy is a rare but potentially life-threatening condition caused by pituitary infarction or haemorrhage. We have retrospectively analysed 16 patients (10 male, 6 female) with pituitary apoplexy, who presented to our institutions between 1992-2002. The mean age at presentation was 49 years (range 24-72). Only two (12%) patients had previously known pituitary tumours. Pituitary apoplexy was precipitated by major surgery in two patients (coronary artery bypass graft and total cystectomy), and one patient had a coagulation defect. Common presenting features included headache (94%), vomiting (68%), ophthalmoplegia (61%), visual field defect (38%), reduced visual acuity (38%), fever (32%), meningism (18%) and altered consciousness (18%). Fourteen (88%) patients had partial or pan-hypopituitarism. Eleven (69%) patients had non-functioning adenoma, 3 (19%) had prolactinoma, 1 (6%) had Cushing's disease, and 1 (6%) had a normal pituitary gland. Eight (50%) patients were managed conservatively, 7 (44%) underwent trans-sphenoidal surgery, and 1 (6%) was treated with both trans-sphenoidal surgery and radiotherapy. Seven (64%) of the 11 patients with visual defects at presentation made full visual recoveries; 3 of these 7 patients were treated conservatively and 4 had surgery. None of the 14 patients with hypopituitarism had a full endocrine recovery.
In conclusion, pituitary apoplexy is often the initial manifestation of a pituitary adenoma, and the diagnosis should be considered in all patients with acute severe headache, particularly in the presence of neuro-ophthalmic signs. The majority of these patients have hypopituitarism at presentation, and steroid replacement (in deficient patients) during the acute stage could decrease morbidity and mortality.