Pituitary tumor apoplexy: Pathophysiology, clinical manifestations, and management

Pituitary tumor apoplexy represents a rare clinical syndrome caused by hemorrhagic infarction of an existing, often previously unrecognized, large adenoma. We present our approach and experience in the field, and we provide a summary of pertinent published literature addressing diagnosis, management, and pathophysiology of the clinical manifestations of pituitary tumor apoplexy. Although many precipitating factors are known, most episodes occur spontaneously and present clinically with relatively sudden onset of severe headache, visual field defects, and ophthalmoplegia. Either computed tomography (nonenhanced and enhanced) or magnetic resonance imaging in a symptomatic patient can define pertinent anatomical changes and aid in establishing diagnosis. Immediate treatment with corticosteroids is necessary. Patients with the mild form of the syndrome respond quickly to steroids and can be managed conservatively with continued glucocorticoid therapy Most patients with persistent neural deficits require urgent trans-sphenoidal decompression. Unless surgery is delayed, results of transsphenoidal decompression are usually very good, and improvements in neurological symptoms and endocrine function are noted within hours to daps of the procedure. Patients need to be closely followed up after the episode because a large number continue to have residual tumor requiring additional therapy, or they have pituitary hormone abnormalities that need treatment. Close interaction between neurosurgeons and endocrinologists in the management of patients with pituitary tumor apoplexy is essential for optimal outcome.