Pituitary apoplexy

Pituitary apoplexy is one of the few medical emergencies where best management is still poorly defined. Because of the lack of rigorous clinical studies, controversy still surrounds the role and timing of surgery and its effectiveness compared with medical management. Pituitary apoplexy guidelines have recently been developed and published by a multidisciplinary group in the United Kingdom, with the aim of providing consensus recommendations.1 To establish best practices and future prospective studies, the group also proposed an audit for national outcomes assessment⇓.

These guidelines emphasised key features of the management of apoplexy. Firstly, as shown in the linked lesson of the week by Prescott and colleagues (doi:10.1136/bmj.d1221), glucocorticoid replacement remains the single most important acute medical intervention.2 Secondary adrenal insufficiency is a major source of morbidity and mortality in untreated pituitary apoplexy,3 and it contributed to moderate hyponatraemia and prolonged hospital stay in the case report. Indications for empirical steroids, as defined in the guidelines, include haemodynamic instability, altered consciousness, reduced visual acuity, or severe visual field defects. For patients who do not fulfill these criteria, the guidelines recommend measuring cortisol at 9 am, and …