Pituitary Apoplexy: An Updated Review

Abstract

Pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland. It is clinically characterized by the sudden onset of headache. Depending on the severity, it may also be accompanied by nausea, vomiting, visual disturbances, varying degrees of adenohypophyseal hormone deficiency, and decreased level of consciousness. Corticotropic axis involvement may result in severe hypotension and contribute to impaired level of consciousness. Precipitating factors are present in up to 30% of cases. PA may occur at any age and sometimes develops during pregnancy or the immediate postpartum period. PA occurs more frequently in men aged 50-60, being rare in children and adolescents. It can develop in healthy pituitary glands or those affected by inflammation, infection, or tumor. The main cause of PA is usually spontaneous hemorrhage or infarction of a pituitary adenoma (pituitary neuroendocrine tumor, PitNET). It is a medical emergency requiring immediate attention and, in many cases, urgent surgical intervention and long-term follow-up. Although the majority of patients (70%) require surgery, about one-third can be treated conservatively, mainly by monitoring fluid and electrolyte levels and using intravenous glucocorticoids. There are scoring systems for PA with implications for management and therapeutic outcomes that can help guide therapeutic decisions. Management of PA requires proper evaluation and long-term follow-up by a multidisciplinary team with expertise in pituitary pathology. The aim of the review is to summarize and update the most relevant aspects of the epidemiology, etiopathogenesis, pathophysiology, clinical presentation and clinical forms, diagnosis, therapeutic strategies, and prognosis of PA.

Keywords: conservative management; hemorrhage; hypopituitarism; infarction; pituitary apoplexy; pituitary gland; surgery.

Figure 1

Mechanisms of pituitary injury and associated clinical symptoms in pituitary apoplexy.

Figure 2

Compressive symptoms resulting from hemorrhage in pituitary apoplexy depending on adjacent structures involved.

Figure 3

Imaging studies in a patient with acute pituitary apoplexy due to intratumoral bleeding. A 58-year-old woman with sudden onset of headache and visual loss in the postoperative period after aortic valve replacement. A CT scan of the brain (A) showed a sellar lesion (3 × 2.8 × 2 cm) with heterogeneous suprasellar extension with hyperdense content compatible with intralesional hemorrhage. MRI of the pituitary gland showed an expansive process involving the entire sella turcica with extension to the suprasellar cistern and the anterior region of the third ventricle. On paramagnetic contrast T1-weighted ((B), coronal; (C), sagittal) and T2-weighted ((D), coronal) sequences the signal is heterogeneous with a hyperintense area in the tumor dome and left posterolateral region.

Figure 4

Distribution of conservative and surgical approaches in different series of patients with pituitary apoplexy [7,10,36,52,105,113,114,115,116,117,118,119,120].

Figure 5

Suggested therapeutic management of pituitary apoplexy due to pituitary hemorrhage associated with compressive symptoms due to compression of adjacent structures.