Pituitary apoplexy
Background
- Loss of pituitary gland function due to hemorrhage or infarction of the gland
- Uncommon endocrinological emergency, requires high level of suspicion based on history
- Presentation may range from mild and insidious to severe and sudden
- In a majority of cases, a pre-existing pituitary adenoma is involved
- Adenomas may compress upon blood supply; friability of the mass may lead to bleeding
- Although several hormone axes may be deranged, HPA/adrenal and thyroid axes likely require the most immediate attention
Risk Factors
- Pituitary adenoma
- Trauma
- Recent endocrine stimulation testing
- Hormone modulators, including dopamine agonists, GnRH agonists
- Prior pituitary gland irradiation or instrumentation
- Prior cerebral angiography
- Pregnancy (Sheehan's syndrome)
- Anticoagulation
Clinical Features
- Headache, usually acute onset and retro-orbital or frontal
- Visual changes, including blurry vision, Visual field defects, diplopia, ophthalmoplegia
- Nausea and vomiting
- Fatigue
- Hypoglycemia
- Adrenal crisis
- Altered mental status
- Hypogonadism
Differential Diagnosis
Adrenal crisis
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Mild traumatic brain injury
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Evaluation
Labs
- CBC
- CMP
- Coagulation studies
- Hormone levels[1]
- TSH, FT4
- Random cortisol
- LH/FSH
- Prolactin
- IGF-1
- Testosterone, estradiol
- LP may show a mixed picture, including xanthochromia and pleocytosis
Imaging
- Head CT without contrast
- Low sensitivity and may not detect acute findings. MRI required for confirmation of diagnosis
- May show sellar mass with active hemorrhage
- Brain MRI
- Identifies both hemorrhagic and ischemic/necrotic lesions, based on MRI sequence
Management
- IV fluids
- Correction of electrolyte abnormalities
- Corticosteroids, usually IV hydrocortisone bolus at 100-200mg, followed by drip at 2-4mg/hr[2]
- Consider thyroid hormone replacement
- Neurosurgical consult for possible transsphenoidal decompression, if severe symptoms
- Ophthalmology and endocrinology consults as appropriate
Disposition
- Admit to floors vs ICU
Medication Dosing
Hydrocortisone 100-200mg IV bolus, then 2-4mg/hr infusion IV
See Also
External Links
References
- ↑ Almudena Vicente, Beatriz Lecumberri, María Ángeles Gálvez, Clinical practice guideline for the diagnosis and treatment of pituitary apoplexy, Endocrinología y Nutrición (English Edition), Volume 60, Issue 10, 2013, Pages 582.e1-582.e12, ISSN 2173-5093
- ↑ Desai S, Seidler M. Metabolic & Endocrine Emergencies. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e. McGraw Hill; 2017. Accessed December 07, 2023.