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pituitary apoplexy

Etiology: 1) Hemorrhagic infarction of the pituitary 2) risk factors a) pituitary macroadenoma, including radiation-treated pituitary tumor b) pregnancy (Sheehan's syndrome) c) anticoagulation d) diabetes mellitus e) increased intracranial pressure f) vasculitis: temporal arteritis Clinical manifestations: 1) may be asymptomatic if hemorrhage is small or slow - onset generally acute [2] 2) acute & large hemorrhage a) severe headache - nausea/vomiting b) ophthalmoplegia c) visual defects 1] bitemporal hemianopia 2] decreased visual acuity 3] extraocular muscle disorder d) meningismus (stiff neck) e) depressed sensorium f) acute adrenocortical crisis g) death may occur 3) cranial nerve palsies may be noted - cranial nerve 3 palsy - cranial nerve 4 palsy - cranial nerve 6 palsy 3) late sequelae a) hypopituitarism b) empty sella syndrome c) regression of hypersecretory syndrome in an infarcted functioning pituitary tumor Radiology: - CT of the head - MRI of pituitary imaging test of choice [2] Complications: - leading cause of mortality is adrenal insufficiency secondary to ACTH deficiency [2] Management: 1) neurosurgical consultation - transsphenoidal neurosurgical decompression [2,5] - oculomotor palsy 2) stress dose glucocorticoids for pituitary-related adrenal insufficiency [2] - give empirically prior to establishing diagnosis [] - dexamethasone & mannitol for intracranial hypertension 3) levothyroxine for hypothyroidism due to pituitary insufficiency 4) +/- growth hormone for growth hormone deficiency

Related

empty sella syndrome meningism ophthalmoplegia (ophthalmoparesis)

Specific

Sheehan's syndrome

General

apoplexy pituitary disease

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 197
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 19 American College of Physicians, Philadelphia 1998, 2012, 2015, 2022
  3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
  4. Sibal L, Ball SG, Connolly V et al Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases. Pituitary. 2004;7(3):157-63. PMID: 16010459
  5. Rajasekaran S, Vanderpump M, Baldeweg S et al UK guidelines for the management of pituitary apoplexy. Clin Endocrinol (Oxf). 2011 Jan;74(1):9-20 PMID: 21044119
  6. NEJM Knowledge+ Endocrinology