Acute Hypopituitarism crisis or Pituitary Apoplexy
An acute hypopituitary crisis or pituitary apoplexy, derived from the Greek word apoplēxia meaning ‘striking away’, is a potentially life- threatening condition due to acute ischaemic infarction or haemorrhage of the pituitary gland characterized by sudden onset headache, vomiting, visual impairment, ophthalmoplegia, and altered consciousness. Apoplexy is often the first presentation of a pre- existing pituitary tumour resulting in acute hypopituitarism causing haemodynamic instability, mainly due to ACTH deficiency. Prompt corticosteroid replacement along with intravenous fluids is vital to treat haemodynamic instability, followed by hormonal, radiological and visual status evaluation as demonstrated in Figure 1.
Fig1. Algorithm for the management of pituitary apoplexy. Reproduced with permission from Ed Turner HE, Eastell R, Grossman A. Oxford Desk Reference: Endocrinology, 1st edition. Oxford: Oxford University Press; 2018. Copyright 2018 Oxford University Press.
Surgery versus conservative management for treatment of apoplexy remains controversial. A pituitary apoplexy scoring system using neuro- ophthalmic criteria to assess apoplexy severity to guide the management may be useful. The majority of patients do well with conservative management, but need close monitoring of neurological and visual status, and surgical decom pression is to be considered if neuro- ophthalmic signs persist or worsen.
chronic Hypopituitarism crisis or Pituitary coma
Chronic hypopituitarism or pituitary coma is a rare, but life- threatening presentation of severe, long- standing, untreated hypo pituitarism, usually precipitated by stress including infection, trauma, surgery, or infarction. Treatment is firstly full replacement with parenteral hydrocortisone, as described previously in this chapter, followed by correction of other factors which may precipitate or worsen coma including hypothermia, salt and water depletion due to hypoadrenalism and/ or diabetes insipidus (DI), hyponatraemia due to excessive desmopressin or hypothalamic dysfunction and gradual replacement of hypothyroidism. Radiation- induced hypopituitarism may cause a hypopituitarism crisis if patients are suboptimally managed, as the time of onset of new pituitary deficiencies varies. In the majority of cases, this takes few years to develop, therefore requiring patient education of the symptoms to look out for, together with life- long monitoring and prompt treatment of deficiencies to avoid hypoadrenal crisis and/ or death.
