Pituitary apoplexy is a medical emergency caused by hemorrhage or infarction of the pituitary gland. It occurs in around 6.2 cases per 100,000 people annually and is more common in men in their 50s and 60s. Symptoms include a sudden severe headache, ophthalmoplegia, and endocrine dysfunction like corticotropic deficiency. Diagnosis is made using CT or MRI imaging of the pituitary. Treatment involves hydrocortisone replacement and sometimes transsphenoidal surgery to decompress the gland. Prompt management is important to prevent vision loss and other complications.

1. PITUITARY APOPLEXY ADE WIJAYA, MD
Oktober 2017

2. OUTLINE
• Introduction
• Anatomy of pituitary
• Epidemiology
• Precipitating factors
• Patophysiology
• Clinical manifestation (headache, neuroophtalmology, endocrine
dysfunctions, others)
• Diagnosis and differential diagnosis
• Management
• Conclusion

3. INTRODUCTION
MEDICAL EMERGENCY!
Bailey, first describe in 1898
A high index of clinical suspicion is essential to diagnose this
condition as prompt management may be life and vision saving
Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in
adult patients.Endocrine connections, 5(5), G12-G15.
Bailey P. Pathological report of a case of acromegaly, with special reference to the lesion in the hypophysis cerebri and in the thyroid gland; and a case of haemorrhage into the pituitary. Phila Med J .
1898;1:789–792.

4. ANATOMY OF PITUITARY
The Pituitary. 4th

5. EPIDEMIOLOGY
6.2 cases per 100 000 inhabitants
its incidence 0.17 episodes per 100 000 per year
2-12 % of pituitary adenoma
the diagnosis of pituitary tumor was unknown at time of apoplexy in more
than 3 out of 4 cases
If the nonfunctioning pituitary adenomas (NFPAs) (often incidentalomas) were
already known and that a decision was made to manage them conservatively,
the risk of PA was calculated to be between 0.2 and 0.6 events per 100
person-years in 2 metaanalyses
5th and 6th decade
a male preponderance ranging from 1.1 to 2.3/1
Subclinical apoplexy ?
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

6. PRECIPITATING FACTORS
Hypertension,
Major surgery, especially
coronary artery bypass grafting,
Dynamic testing of the pituitary
gland, anticoagulation therapy,
Coagulopathies,
Angiographic procedures
Treatment with GnRH agonist in
prostate cancer
Anticoagulant
Pregnancy
Head trauma
Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in
adult patients.Endocrine connections, 5(5), G12-G15.
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

7. PATHOPHYSIOLOGY
Normal Pituitary Vascularization:
Hypophysial portal system
&
Direct arterial blood supply
Anterior: superior hypophysial
artery
Posterior: inferior hypophysial
artery
(both originated from internal
carotid)
Pituitary Apoplexy:
Vascularization predominated by
direct arterial blood supply
Blood supply reduced compared
to normal pituitary
Reduced angiogenesis / fragile
blood vessels
Sensitive to glucose deprivation
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

8. CLINICAL MANIFESTATION
Headache
Others
NO
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.
Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in
adult patients.Endocrine connections, 5(5), G12-G15.

9. HEADACHE
80 % of Patients
Acute thundeclasp or subacute
Retroorbital, bifrontal, or diffuse
Nausea and vomitus
Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in
adult patients.Endocrine connections, 5(5), G12-G15.
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

10. NEUROOPHTALMOLOGY
III,IV,VI
palsies
Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in
adult patients.Endocrine connections, 5(5), G12-G15.
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

11. OTHERS
Meningeal irritation, such as photophobia (40%), nausea, vomiting
(57%), meningismus (25%), and sometimes fever (16%).
Focal neurologic deficits
Anosmia
Epistaxis
CSF rhinorrhea due to erosion of the bone of the sella turcica
Facial pain
Acute adrenal insufficiency
Loss of consciousness
Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in
adult patients.Endocrine connections, 5(5), G12-G15.
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

13. ENDOCRINE DYSFUNCTIONS
Corticotropic
deficiency
Other pituitary
hormone
deficiencies
Diabetes
insipidus
Pituitary
hypersecretion
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

14. CORTICOTHROPIC DEFICIENCY
Most common (50-80 %)
Most life threathening hormonal complication
Cause severe hemodynamic problems and hyponatremia
acute secondary adrenal insufficiency
Empiric corticosteroid treatment
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

15. OTHER PITUITARY HORMONES
DEFICIENCY
Gonadothropic deficiency
Thyrotropic deficiency
Growth hormone deficiency
Prolactin deficiency
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

16. DIABETES INSIPIDUS
AND
PITUITARY HYPERSECRETION
Diabetes insipidus  common post operative complication either transient
or permanent
PA can complicate a secreting pituitary adenoma such as prolactinoma and
secreting pituitary adenoma
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

17. DIAGNOSIS
CT
hormoneMRI
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.
Singh, T. D., Valizadeh, N., Meyer, F. B., Atkinson, J. L., Erickson, D., & Rabinstein, A. A. (2015). Management and outcomes of pituitary apoplexy. Journal of neurosurgery, 122(6), 1450-1457.

18. DIFFERENTIAL DIAGNOSIS
• SAH due to ruptured intracranial aneurysm or arteriovenous
malformation
• Bacterial/viral meningitis
• Brainstem infarction
• Cavernous sinus thrombosis
Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant, G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of pituitary apoplexy in
adult patients.Endocrine connections, 5(5), G12-G15.
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

19. MANAGEMENT
conservative
surgery
Steroid: hydrocortisone 50 mg every 6 hours, or a
bolus of 100–200 mg followed by 50–100 mg every
6 hours iv (or im), or 2–4 mg/h by continuous iv
administration.
Transsphenoid approach
Briet, C., Salenave, S., Bonneville, J. F., Laws, E. R., & Chanson, P. (2015). Pituitary apoplexy. Endocrine reviews, 36(6), 622-645.

20. Baldeweg, S. E., Vanderpump, M., Drake, W., Reddy, N., Markey, A., Plant,
G. T., ... & Wass, J. (2016). SOCIETY FOR ENDOCRINOLOGY
ENDOCRINE EMERGENCY GUIDANCE: Emergency management of
pituitary apoplexy in adult patients.Endocrine connections, 5(5), G12-G15.

21. CONCLUSION
Classic pituitary apoplexy is a medical emergency
High index of clinical suspicion
MRI for diagnosis
Empiric corticosteroid treatment
Neurosurgery vs Conservative

22. THANK YOU