Synopsis
Recognise optic-chiasm compression and pituitary dysfunction, investigate a sellar or suprasellar mass safely, and distinguish planned multidisciplinary care from pituitary apoplexy with threatened vision or adrenal crisis.
- A pituitary-region mass may compress the optic chiasm, disturb anterior or posterior pituitary function, invade the cavernous sinus or be discovered incidentally; imaging appearance alone does not establish the lesion type.
- Chiasmal compression classically causes bitemporal field loss, but acuity can remain normal early and patterns vary with the direction of compression; test each eye formally rather than relying on confrontation alone.
- Pituitary apoplexy is an adult neuroendocrine emergency: acute headache plus neuro-ophthalmic or consciousness change requires resuscitation, urgent endocrine–neurosurgical contact, MRI and timely hydrocortisone when indicated.
Key red flags
Abrupt severe headache with reduced visual acuity, a new visual-field defect, diplopia, ptosis, ophthalmoplegia or reduced consciousness: suspect pituitary apoplexy.
Haemodynamic instability, altered consciousness, reduced acuity or a severe field defect in suspected adult apoplexy: these are explicit indications for empirical hydrocortisone replacement.
Rapidly progressive bitemporal or junctional field loss, optic-disc pallor or declining acuity suggests threatened optic pathway function and needs urgent specialist assessment.
Hypotension, vomiting, hyponatraemia or hypoglycaemia with a pituitary mass may be cortisol deficiency; do not attribute every symptom to raised intracranial pressure.
Polyuria and polydipsia can indicate posterior pituitary or stalk involvement and make a simple pituitary adenoma less certain; measure paired serum and urine indices and seek endocrine advice.
Fever, meningism, thunderclap headache or a third-nerve palsy also raises subarachnoid haemorrhage, meningitis or cavernous-sinus pathology, which must be assessed in parallel.
Ask about bumping into doorframes, difficulty noticing traffic or people to either side, reading problems and loss of confidence driving. Check acuity, colour vision, pupils, confrontation fields, fundi and ocular movements; arrange formal perimetry because early bitemporal loss may escape bedside testing.
Consider apoplexy in acute severe headache with neuro-ophthalmic signs, known pituitary tumour, meningism or reduced consciousness. Do not wait for the entire syndrome: threatened vision or haemodynamic compromise is enough to activate emergency endocrine and neurosurgical care.
Investigation priorities
Quantify optic nerve and chiasm function in each eye and create a baseline for urgent decisions and follow-up.
Management branches
An adult develops sudden severe headache, vomiting, a severe new field defect and hypotension with a sellar mass.
- Resuscitate and check glucose, neurological state, acuity, fields and ocular movements; call the joint endocrine–neurosurgical service immediately and treat competing SAH or meningitis pathways when indicated.
- Draw urgent safety bloods and pituitary samples if immediately feasible, then give empirical adult hydrocortisone because haemodynamic instability and severe visual loss meet Society for Endocrinology criteria; do not wait for cortisol results.
A stable adult has several months of peripheral visual loss and MRI shows a suprasellar pituitary-region mass contacting the chiasm.