Pituitary Apoplexy Treatment & Management

Updated: Jul 12, 2021
  • Author: Michael S Vaphiades, DO; Chief Editor: Edsel B Ing, MD, MPH, FRCSC, PhD, MA  more...
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Treatment

Medical Care

The management of pituitary apoplexy is controversial in that some advocate early transsphenoidal surgical decompression in all patients, whereas others adopt a conservative approach for selected patients (without visual acuity or field defects and with normal consciousness). [25]

Medical treatment consists of the following:

  • Medically stabilize the patient.
  • Immediately evaluate electrolytes, glucose, and pituitary hormones.
  • Administer high-dose corticosteroids (most patients have hypopituitarism).
  • Administer appropriate endocrinologic replacement therapy alone or combined with transsphenoidal surgical decompression of the tumor.
  • Avoid the "head down" position, when possible. [38]

 

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Surgical Care

Evacuation of the tumor by a neurosurgeon should be planned once the patient is medically stable, especially in the setting of altered consciousness, visual acuity and, visual field loss. [25, 39, 40]

Shepard et al identified 64 patients with pituitary apoplexy, 47 (73.4%) underwent intended conservative management, while 17 (26.6%) had early surgery. Tumor volumes were greater in the early surgical cohort. Among those with visual acuity and field deficits, visual outcomes were similar between both groups. Conservative management failed in 7 patients (14.9%) and required surgery. Younger age, female sex, and patients with field deficits or chiasmal compression were more likely to experience unsuccessful conservative management. The authors concluded that the majority of patients with pituitary apoplexy can be successfully managed without surgical intervention assuming close neurosurgical, radiological, and ophthalmological follow-up is available. [41]

Cavalli et al. retrospectively reviewed 30 patients with pituitary apoplexy 86.7% ofpatients presented with visual disturbances (70% acuity, 50% field, 50% diploplia), 10 (33%) patients underwent emergency surgery and 8 underwent delayed elective surgery. At early and late follow-up the outcome was not significantly different between groups. The authors concluded that good results are possible with conservative management in selected cases. Emergency surgery provides better visual outcomes and a tumor vertical diameter >35 mm should tip the balance in favor of surgical management in presence of visual deficit. [42]

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Consultations

Consultations to consider include the following:

  • Neurosurgery for potential surgical therapy

  • Medicine for general medical management

  • Endocrinology for hormonal management

  • Ophthalmology for documentation of visual acuity, perimetry, and motility

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Further Inpatient Care

Monitor metabolic status, visual acuity, visual fields, and ocular motility.

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