UK guidelines for the management of pituitary apoplexy

Abstract

SummaryClassical pituitary apoplexy is a medical emergency and rapid replacement with hydrocortisone maybe life saving. It is a clinical syndrome characterized by the sudden onset of headache, vomiting, visual impairment and decreased consciousness caused by haemorrhage and/or infarction of the pituitary gland. It is associated with the sudden onset of headache accompanied or not by neurological symptoms involving the second, third, fourth and sixth cranial nerves. If diagnosed patients should be referred to a multidisciplinary team comprising, amongst others, a neurosurgeon and an endocrinologist. Apart from patients with worsening neurological symptoms in whom surgery is indicated, it is unclear currently for the majority of patients whether conservative or surgical management carries the best outcome. Post apoplexy, there needs to be careful monitoring for recurrence of tumour growth. It is suggested that further trials be carried out into the management of pituitary apoplexy to optimize treatment.

Pituitary apoplexy: pathophysiology, diagnosis and management

“…Most PA cases improve with both surgical and expectant management and the most appropriate approach in the acute phase is controversial (28). Although guidelines, as the one from UK, proposed an algorithm for PA management, a randomized trial comparing both strategies is needed for strong evidence (2,29). However, seems intuitive that surgery, usually by the transsphenoidal route, is indicated if consciousness and/or vision are impaired, despite glucocorticoid replacement and electrolyte support.…”

“…reviewed PA in adolescents, a very rare entity (8). Amongst 60% to 80% of cases, pituitary adenoma was not a previously known condition (2). Macroadenomas, especially non-functioning and prolactinomas, are most susceptible to apoplexy, nevertheless apoplexy in microadenomas has been reported (9).…”

“…However, a proposed hypothesis involves tumor vascular occlusion due to tumor growth, tumor blood flux reduction and tumoral abnormal (immature) vascularization. VEGF mRNA may be increased in pitui-tary tumors, especially in non-functioning pituitary adenomas, which could be related to an abnormal vascularization (15 Precipitating factors can be identified in about 40% of PA cases, with arterial hypertension the most frequent (2). Other common risk factors include anticoagulant therapy, and new oral anticoagulants (17).…”

“…Hyponatremia, observed in up to 40% of cases, can be secondary to hypocortisolism or inappropriate antidiuretic hormone secretion. Transient diabetes insipidus is rarely encountered (2).…”

“…The term pituitary apoplexy was coined by Brougham in 1950, and the first index case was, in fact, described by Bailey, in 1898 (1). Routine imaging and histopathological evaluation may detect asymptomatic pituitary hemorrhage, known as subclinical apoplexy, and is much more frequent then PA (2). Apoplexy means "sudden attack" in Greek, and, as a result, an abrupt increase of tissue volume within the sellar region can cause headache, visual impairment, cranial nerve palsies and, even, impairment of consciousness, besides causing pituitary hormone deficiencies as ACTH.…”