Factsheet 2 - A Guide to Pituitary Apoplexy

Bleeding or reduced blood flow in the Pituitary gland can result in pituitary damage. This is called pituitary apoplexy. If there is only reduced blood flow with no bleeding, this condition is also called pituitary infarction. It usually happens in people with pre-existing pituitary tumours. The Greek word ‘apoplexy’ literally means sudden brain dysfunction.

The pituitary gland is situated in a bony hollow and is surrounded by important structures, such as the nerves responsible for vision. In apoplexy the gland swells suddenly and this can cause pressure in the surrounding brain structures. The swelling can also cause the pituitary gland to stop producing one or more of the pituitary hormones.

Up to 5% of patients with pituitary tumours may develop at some point apoplexy. In fact, studies have shown that bigger tumours (macroadenomas) carry a higher risk of apoplexy compared with smaller ones (microadenomas). High or low blood pressure, head injury, certain medications such as warfarin, cardiac surgery and very rarely certain endocrine dynamic tests may increase the risk of apoplexy.

Pituitary apoplexy is important to be diagnosed and treated. If it remains untreated apoplexy may cause seriously ill health and even death. The most common symptoms are headache, nausea or vomiting, changes in eye sight, such as double vision, restriction in eye movement and drowsiness. These symptoms are not unique in apoplexy but may occur in other conditions such as meningitis, subarachnoid haemorrhage or rarely migraine, from which pituitary apoplexy has to be distinguished. The best way to diagnose pituitary apoplexy is a Magnetic Resonance Imaging (MRI) scan. The bleeding or pituitary infarction may not show on a Computerised Tomography (CT) scan. Blood tests are also important to check if the hormones produced by the pituitary gland are adequate.

In the event of pituitary apoplexy urgent treatment is required. This consists of intravenous fluids, corticosteroids and close monitoring. Surgery may be required to relieve the pressure and swelling around the pituitary gland. This usually can be done by making a small incision inside the nostril (Transsphenoidal surgery). With treatment the majority of patients recover and if the vision was affected it often gradually improves. If the vision was severely affected at the beginning, it may not fully recover. If the pituitary gland does not function properly after recovery patients may need hormone replacement therapy. Patients will need regular check ups at a specialist endocrine clinic to monitor the condition.

A national working group has in 2010 developed guidelines for the management of pituitary apoplexy to increase awareness amongst doctors and make standardise and improve the treatment of this rare but potentially life threatening condition.

Indicative References
1. Murad-Kejbou S, Eggenberger E. Pituitary apoplexy: evaluation, management, and prognosis. Current Opinion in Ophthalmology 2009; 20:456-61.
2. Nawar R, AbdelMannan D et al. Pituitary Tumor Apoplexy: A Review. Journal of Intensive Care Medicine 2008; 23(2): 75-90.
3. Randeva HS, Schoebel J et al. Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinology (Oxf) 1999; 51:181-188.

©2011 Version 3 (To be reviewed by 2013)