Pituitary apoplexy.

OBJECTIVE: Pituitary apoplexy is a rare yet potentially fatal disease. We reviewed the combined experience of the University of Virginia in Charlottesville, VA, and Groote Schuur Hospital, University of Cape Town, South Africa, with 62 cases of pituitary apoplexy.

METHODS: An Internet web site with a database was constructed, and the records of 62 patients were entered into the database from both institutions and then systematically analyzed.

RESULTS: The average age of patients was 51.1 years; 60% were male, and the average length of follow-up was 55 months. The average time of presentation was 14.2 days after the ictus, and 81% had no previous history of pituitary tumor. Headache was the most common presenting symptom (87%). Diminished visual acuity was found in 56% of patients, bitemporal hemianopia in 34%, ocular palsies in 45%, and diminished level of consciousness in 13%. Seventy-three percent of the patients had laboratory evidence of hypopituitarism, and 8% had diabetes insipidus. Fifty-eight patients underwent surgery, 3 were treated conservatively, and 1 died before intervention. Histological examination revealed hemorrhagic infarction in 47%, simple infarction in 40%, and frank hemorrhage in 8%. Seventy-nine percent had a good outcome, although 83% required subsequent hormonal replacement therapy.

CONCLUSION: Pituitary apoplexy is often misdiagnosed because the majority of patients have undetected pituitary adenomas, and the presentation is often mistaken for subarachnoid hemorrhage. Most cases of pituitary apoplexy occur spontaneously, although precipitating factors have been suggested. Magnetic resonance imaging is the imaging modality of choice. Treatment includes high-dose corticosteroid administration and surgery. Transsphenoidal surgery is indicated in patients with diminished levels of consciousness, hypothalamic dysfunction, and visual deterioration. Conservative management for patients with isolated cranial nerve palsies has been advocated but remains controversial.