Table 9 Management of pituitary apoplexy

1) Support the patient’s hemodynamic status

IV fluid administration (normal saline or Ringer’s lactate)

BP support

Watch the rate of sodium correction (should increase by 12 mEq/L or less in 24 h) ➔ minimizes the risk of central pontine myelinolysis

2) Obtain CT scan of brain when possible, to visualize hemorrhage

3) Draw blood for baseline serum cortisol level

4) Give stress dose of 100 mg IV of hydrocortisone in patients with suspected adrenal insufficiency. This is followed by a short course of high-dose hydrocortisone (50 mg IV at 6 h intervals) with a subsequent slow taper based on response ➔ glucocorticoids treat adrenal insufficiency and reduce the swelling associated with the tumor and hemorrhage

5) Surgical management

• Endoscopic or microsurgical transsphenoidal decompression

• When is it done?

o Usually done in patients with acute vision loss, worsening visual field deficit, or ophthalmoplegia

OR

o Calculate “Pituitary Apoplexy Score.” A PAS score of 4 or more, or a worsening score while the patient is under observation warrants surgery

OR

o If no improvement in the patient’s symptoms after 1 week of steroid administration