Pituitary apoplexy; a review on the etiology, management and outcomes

Abstract

Pituitary apoplexy (PA) is an uncommon but urgent medical condition characterized by sudden hemorrhage or infarction within a pituitary adenoma, a benign tumor of the pituitary gland. This event constitutes a critical endocrine and neurosurgical emergency, demanding rapid diagnosis and intervention to prevent serious complications or death. The underlying pathogenesis of PA involves vascular compromise within the tumor microenvironment, often precipitated by a combination of systemic risk factors such as hypertension or anticoagulation therapy, and tumor-specific features including rapid tumor growth or fragile blood vessels. Clinically, PA typically presents with a sudden onset of severe headache, visual disturbances resulting from optic chiasm compression, and varying degrees of hypopituitarism leading to acute hormonal deficiencies, which can include adrenal insufficiency and hypothyroidism. These symptoms develop swiftly, making clinical suspicion crucial for early detection. Diagnosis is primarily based on neuroimaging, with magnetic resonance imaging being the gold standard to identify hemorrhage or infarction within the adenoma. Concurrent hormonal assays are essential to assess pituitary function and guide urgent endocrine management. Treatment begins with immediate stabilization, including correction of fluid and electrolyte imbalances and administration of high-dose corticosteroids to address potential adrenal crisis. The decision between surgical decompression and conservative management hinges on the severity of neurological impairment and imaging findings. Surgical intervention is reserved for patients with severe visual deficits or deteriorating consciousness, while stable cases may be managed conservatively with close monitoring. With advances in multidisciplinary approaches involving endocrinologists, neurosurgeons, and radiologists, patient outcomes have significantly improved. Visual recovery is often favorable, but many patients experience persistent endocrine dysfunction requiring long-term hormonal replacement. Ongoing research aims to refine risk stratification criteria and develop individualized treatment protocols to further improve prognosis and quality of life in patients with PA.

Keywords: Pituitary apoplexy, Brain, Pituitary gland, Sella turcica, Neurohypophysis