Synopsis
Recognise acute haemorrhage or infarction within a pituitary lesion, give life-saving cortisol support, document neuro-ophthalmic severity and coordinate urgent MRI and specialist decompression decisions.
- Pituitary apoplexy is a clinical emergency caused by haemorrhage or infarction in the pituitary, usually within an adenoma; imaging haemorrhage without an acute syndrome is not synonymous with apoplexy.
- Think of it in sudden severe headache with visual acuity or field loss, diplopia, ptosis, vomiting, meningism, photophobia or reduced consciousness, even when no pituitary tumour was previously known.
- Exclude subarachnoid haemorrhage and meningitis in parallel, but do not let an unrevealing routine head CT close the diagnosis because pituitary MRI is more sensitive.
Key red flags
Haemodynamic instability, altered consciousness, reduced visual acuity or severe field defects are explicit indications for immediate empirical glucocorticoid in suspected apoplexy.
Investigation priorities
Confirm sellar haemorrhage or infarction and show compression of optic, cavernous and hypothalamic structures.
Management branches
Acute severe headache is accompanied by visual, ocular-motor, meningeal or consciousness change.
- Perform ABCDE assessment, bedside glucose, neurological and focused visual examination while establishing intravenous access and monitoring.
- Draw cortisol and other pituitary samples if immediately available, then give empirical parenteral hydrocortisone for instability or significant neuro-ophthalmic features.
The patient is stable with preserved or improving vision and no deteriorating consciousness.
Key medicines
Emergency intravenous hydrocortisoneGive 100 to 200 mg intravenously as an initial adult bolus under Society guidance, followed by the local infusion or divided parenteral regimen.
Isotonic sodium chlorideGive monitored intravenous 0.9% sodium chloride according to haemodynamics, sodium, urine output and cardiac or renal reserve.