, Volume 48, Issue 1, pp 69–75 | Cite as

Pituitary apoplexy

  • Wenya Linda Bi
  • Ian F. Dunn
  • Edward R. LawsJr.Email author
Mini Review


Pituitary apoplexy is a clinical syndrome of sudden headache and visual decline associated with acute hemorrhagic or ischemic change of an intrasellar mass, and comprises only a subset of hemorrhagic pituitary lesions. The most common presenting symptoms include headache, nausea, diminished visual acuity or visual field, ophthalmoplegia/paresis, and impaired mental status. Multiple risk factors have been reported, although the majority of cases have no identifiable precipitants. MRI is the most sensitive diagnostic modality, with specific imaging findings dependent on the timing post-hemorrhage. Early clinical suspicion is imperative to allow for corticosteroid replacement and hemodynamic stabilization when indicated. Transsphenoidal surgical decompression improves outcome in a majority of cases, although conservative management may be appropriate in select scenarios.


Pituitary apoplexy Thunderclap headache Pituitary adenoma Pituitary hemorrhage Adrenal insufficiency 


  1. 1.
    H.S. Randeva, J. Schoebel, J. Byrne, M. Esiri, C.B. Adams, J.A. Wass, Classical pituitary apoplexy: clinical features, management and outcome. Clin. Endocrinol. 51(2), 181–188 (1999)CrossRefGoogle Scholar
  2. 2.
    P.L. Semple, M.K. Webb, J.C. de Villiers, E.R. Laws Jr., Pituitary apoplexy. Neurosurgery 56(1), 65–72; discussion 72–63 (2005)Google Scholar
  3. 3.
    P. Bailey, Pathological report of a case of akromegaly, with special reference to the lesions in the hypophysis cerebri and in the thyroid gland; and a case of haemorrhage into the pituitary. Phila. Med. J. 1, 789–792 (1898)Google Scholar
  4. 4.
    M. Brougham, A.P. Heusner, R.D. Adams, Acute degenerative changes in adenomas of the pituitary body—with special reference to pituitary apoplexy. J. Neurosurg. 7(5), 421–439 (1950). doi: 10.3171/jns.1950.7.5.0421 CrossRefPubMedGoogle Scholar
  5. 5.
    S.S. Chhiber, A.R. Bhat, S.H. Khan, M.A. Wani, A.U. Ramzan, A.R. Kirmani, N.K. Malik, A.A. Wani, T. Rather, Apoplexy in sellar metastasis: a case report and review of literature. Turk. Neurosurg. 21(2), 230–234 (2011). doi: 10.5137/1019-5149.JTN.2716-09.1 PubMedGoogle Scholar
  6. 6.
    R.L. Rovit, J.M. Fein, Pituitary apoplexy: a review and reappraisal. J. Neurosurg. 37(3), 280–288 (1972). doi: 10.3171/jns.1972.37.3.0280 CrossRefPubMedGoogle Scholar
  7. 7.
    G. Mohr, J. Hardy, Hemorrhage, necrosis, and apoplexy in pituitary adenomas. Surg. Neurol. 18(3), 181–189 (1982)CrossRefPubMedGoogle Scholar
  8. 8.
    S. Wakai, T. Fukushima, A. Teramoto, K. Sano, Pituitary apoplexy: its incidence and clinical significance. J. Neurosurg. 55(2), 187–193 (1981). doi: 10.3171/jns.1981.55.2.0187 CrossRefPubMedGoogle Scholar
  9. 9.
    D.C. Bills, F.B. Meyer, E.R. Laws Jr., D.H. Davis, M.J. Ebersold, B.W. Scheithauer, D.M. Ilstrup, C.F. Abboud, A retrospective analysis of pituitary apoplexy. Neurosurgery 33(4), 602–608; discussion 608–609 (1993)Google Scholar
  10. 10.
    W. Bonicki, A. Kasperlik-Zaluska, W. Koszewski, W. Zgliczynski, J. Wislawski, Pituitary apoplexy: endocrine, surgical and oncological emergency. Incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas. Acta Neurochir. 120(3–4), 118–122 (1993)CrossRefPubMedGoogle Scholar
  11. 11.
    M.J. Ebersold, E.R. Laws Jr., B.W. Scheithauer, R.V. Randall, Pituitary apoplexy treated by transsphenoidal surgery. A clinicopathological and immunocytochemical study. J. Neurosurg. 58(3), 315–320 (1983). doi: 10.3171/jns.1983.58.3.0315 CrossRefPubMedGoogle Scholar
  12. 12.
    J.W. Findling, J.B. Tyrrell, D.C. Aron, P.A. Fitzgerald, C.B. Wilson, P.H. Forsham, Silent pituitary apoplexy: subclinical infarction of an adrenocorticotropin-producing pituitary adenoma. J. Clin. Endocrinol. Metab. 52(1), 95–97 (1981). doi: 10.1210/jcem-52-1-95 CrossRefPubMedGoogle Scholar
  13. 13.
    P. Maccagnan, C.L. Macedo, M.J. Kayath, R.G. Nogueira, J. Abucham, Conservative management of pituitary apoplexy: a prospective study. J. Clin. Endocrinol. Metab. 80(7), 2190–2197 (1995). doi: 10.1210/jcem.80.7.7608278 PubMedGoogle Scholar
  14. 14.
    S.G. Ostrov, R.M. Quencer, J.C. Hoffman, P.C. Davis, A.N. Hasso, N.J. David, Hemorrhage within pituitary adenomas: how often associated with pituitary apoplexy syndrome? AJR Am. J. Roentgenol. 153(1), 153–160 (1989). doi: 10.2214/ajr.153.1.153 CrossRefPubMedGoogle Scholar
  15. 15.
    W. Muller, H.W. Pia, Clinical aspects and etiology of massive hemorrhage in pituitary adenoma. Deutsche Zeitschrift fur Nervenheilkunde 170(4), 326–336 (1953)PubMedGoogle Scholar
  16. 16.
    A. Jahangiri, A.J. Clark, S.J. Han, S. Kunwar, L.S. Blevins Jr., M.K. Aghi, Socioeconomic factors associated with pituitary apoplexy. J. Neurosurg. 119(6), 1432–1436 (2013). doi: 10.3171/2013.6.JNS122323 CrossRefPubMedGoogle Scholar
  17. 17.
    V. Biousse, N.J. Newman, N.M. Oyesiku, Precipitating factors in pituitary apoplexy. J. Neurol. Neurosurg. Psychiatry 71(4), 542–545 (2001)CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    M. Peter, N. De Tribolet, Visual outcome after transsphenoidal surgery for pituitary adenomas. Br. J. Neurosurg. 9(2), 151–157 (1995)CrossRefPubMedGoogle Scholar
  19. 19.
    R.M. McFadzean, D. Doyle, R. Rampling, E. Teasdale, G. Teasdale, Pituitary apoplexy and its effect on vision. Neurosurgery 29(5), 669–675 (1991)CrossRefPubMedGoogle Scholar
  20. 20.
    H.J. Woo, J.H. Hwang, S.K. Hwang, Y.M. Park, Clinical outcome of cranial neuropathy in patients with pituitary apoplexy. J. Korean Neurosurg. Soc. 48(3), 213–218 (2010). doi: 10.3340/jkns.2010.48.3.213 CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    S.H. Kim, K.C. Lee, S.H. Kim, Cranial nerve palsies accompanying pituitary tumour. J. Clin. Neurosci. 14(12), 1158–1162 (2007). doi: 10.1016/j.jocn.2006.07.016 CrossRefPubMedGoogle Scholar
  22. 22.
    C.M. Robert Jr., J.A. Feigenbaum, E.W. Stern, Ocular palsy occurring with pituitary tumors. J. Neurosurg. 38(1), 17–19 (1973). doi: 10.3171/jns.1973.38.1.0017 CrossRefPubMedGoogle Scholar
  23. 23.
    C. Symonds, Ocular palsy as the presenting symptom of pituitary adenoma. Bull Johns Hopkins Hosp. 111, 72–82 (1962)Google Scholar
  24. 24.
    H. Kobayashi, M. Kawabori, S. Terasaka, J. Murata, K. Houkin, A possible mechanism of isolated oculomotor nerve palsy by apoplexy of pituitary adenoma without cavernous sinus invasion: a report of two cases. Acta Neurochir. 153(12), 2453–2456; discussion 2456 (2011). doi: 10.1007/s00701-011-1165-4
  25. 25.
    S.H. Petermann, N.J. Newman, Pituitary macroadenoma manifesting as an isolated fourth nerve palsy. Am. J. Ophthalmol. 127(2), 235–236 (1999)CrossRefPubMedGoogle Scholar
  26. 26.
    R.F. Saul, J.K. Hilliker, Third nerve palsy: the presenting sign of a pituitary adenoma in five patients and the only neurological sign in four patients. J. Clin. Neuroophthalmol. 5(3), 185–193 (1985)PubMedGoogle Scholar
  27. 27.
    G. Jefferson, Extrasellar extensions of pituitary adenomas: (Section of Neurology). Proc. R. Soc. Med. 33(7), 433–458 (1940)PubMedCentralPubMedGoogle Scholar
  28. 28.
    J.D.R. Monro, A case of sudden death: tumour of the pituitary body. Lancet 2, 1539 (1913)CrossRefGoogle Scholar
  29. 29.
    J. Ayuk, E.J. McGregor, R.D. Mitchell, N.J. Gittoes, Acute management of pituitary apoplexy—surgery or conservative management? Clin. Endocrinol. 61(6), 747–752 (2004). doi: 10.1111/j.1365-2265.2004.02162.x CrossRefGoogle Scholar
  30. 30.
    A. Uihlein, W.M. Balfour, P.F. Donovan, Acute hemorrhage into pituitary adenomas. J. Neurosurg. 14(2), 140–151 (1957). doi: 10.3171/jns.1957.14.2.0140 CrossRefPubMedGoogle Scholar
  31. 31.
    E.R. Cardoso, E.W. Peterson, Pituitary apoplexy: a review. Neurosurgery 14(3), 363–373 (1984)CrossRefPubMedGoogle Scholar
  32. 32.
    N. Cinar, Y. Tekinel, S. Dagdelen, H. Oruckaptan, F. Soylemezoglu, T. Erbas, Cavernous sinus invasion might be a risk factor for apoplexy. Pituitary 16(4), 483–489 (2013). doi: 10.1007/s11102-012-0444-2 CrossRefPubMedGoogle Scholar
  33. 33.
    K.N. Sarwar, M.S. Huda, V. Van de Velde, L. Hopkins, S. Luck, R. Preston, B.M. McGowan, P.V. Carroll, J.K. Powrie, The prevalence and natural history of pituitary hemorrhage in prolactinoma. J. Clin. Endocrinol. Metab. 98(6), 2362–2367 (2013). doi: 10.1210/jc.2013-1249 CrossRefPubMedGoogle Scholar
  34. 34.
    L.A. Weisberg, Pituitary apoplexy. Association of degenerative change in pituitary ademona with radiotherapy and detection by cerebral computed tomography. Am. J. Med. 63(1), 109–115 (1977)CrossRefPubMedGoogle Scholar
  35. 35.
    A.J. Chapman, G. Williams, A.D. Hockley, D.R. London, Pituitary apoplexy after combined test of anterior pituitary function. Br. Med. J. 291(6487), 26 (1985)CrossRefGoogle Scholar
  36. 36.
    T. Yamaji, M. Ishibashi, K. Kosaka, T. Fukushima, T. Hori, S. Manaka, K. Sano, Pituitary apoplexy in acromegaly during bromocriptine therapy. Acta Endocrinol. 98(2), 171–177 (1981)PubMedGoogle Scholar
  37. 37.
    V. Peck, A. Lieberman, R. Pinto, A. Culliford, Pituitary apoplexy following open-heart surgery. N. Y. State J. Med. 80(4), 641–643 (1980)PubMedGoogle Scholar
  38. 38.
    P.L. Semple, J.A. Jane Jr., E.R. Laws Jr., Clinical relevance of precipitating factors in pituitary apoplexy. Neurosurgery 61(5), 956–961; discussion 961–952 (2007). doi: 10.1227/01.neu.0000303191.57178.2a
  39. 39.
    R.L. Reid, M.E. Quigley, S.S. Yen, Pituitary apoplexy. A review. Arch. Neurol. 42(7), 712–719 (1985)CrossRefPubMedGoogle Scholar
  40. 40.
    S.H. Wong, K. Das, M. Javadpour, Pituitary apoplexy initially mistaken for bacterial meningitis. BMJ Case Rep. (2013). doi: 10.1136/bcr-2013-009223 Google Scholar
  41. 41.
    F.A. Neelon, M.S. Mahaley Jr., Chiasmal syndrome due to intrasellar abscess. Arch. Intern. Med. 136(9), 1041–1043 (1976)CrossRefPubMedGoogle Scholar
  42. 42.
    J. Xenellis, J. Stivaktakis, N. Karpeta, D. Rologis, E. Ferekidis, Pituitary apoplexy: a pathologic entity from an otolaryngologist’s view. ORL J. Otorhinolaryngol. Relat. Spec. 65(2), 121–124 (2003)CrossRefPubMedGoogle Scholar
  43. 43.
    L.M. Weinberger, F.H. Adler, F.C. Grant, Primary pituitary adenoma and the syndrome of the cavernous sinus: a clinical and anatomic study. Arch. Ophthalmol. 24, 1197–1236 (1940)CrossRefGoogle Scholar
  44. 44.
    R.P. Glick, J.A. Tiesi, Subacute pituitary apoplexy: clinical and magnetic resonance imaging characteristics. Neurosurgery 27(2), 214–218; discussion 218–219 (1990)Google Scholar
  45. 45.
    M. Piotin, D. Tampieri, D.A. Rufenacht, G. Mohr, M. Garant, R. Del Carpio, F. Robert, J. Delavelle, D. Melanson, The various MRI patterns of pituitary apoplexy. Eur. Radiol. 9(5), 918–923 (1999)CrossRefPubMedGoogle Scholar
  46. 46.
    P.C. Davis, J.C. Hoffman Jr., T. Spencer, G.T. Tindall, I.F. Braun, MR imaging of pituitary adenoma: CT, clinical, and surgical correlation. AJR Am. J. Roentgenol. 148(4), 797–802 (1987). doi: 10.2214/ajr.148.4.797 CrossRefPubMedGoogle Scholar
  47. 47.
    B. Agrawal, K. Dziurzynski, M.S. Salamat, M. Baskaya, The temporal association of sphenoid sinus mucosal thickening on MR imaging with pituitary apoplexy. Turk. Neurosurg. 22(6), 785–790 (2012). doi: 10.5137/1019-5149.JTN.4273-11.1 PubMedGoogle Scholar
  48. 48.
    K. Arita, K. Kurisu, A. Tominaga, K. Sugiyama, F. Ikawa, H. Yoshioka, M. Sumida, Y. Kanou, K. Yajin, R. Ogawa, Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy. J. Neurosurg. 95(5), 897–901 (2001). doi: 10.3171/jns.2001.95.5.0897 CrossRefPubMedGoogle Scholar
  49. 49.
    J.K. Liu, W.T. Couldwell, Pituitary apoplexy in the magnetic resonance imaging era: clinical significance of sphenoid sinus mucosal thickening. J. Neurosurg. 104(6), 892–898 (2006). doi: 10.3171/jns.2006.104.6.892 CrossRefPubMedGoogle Scholar
  50. 50.
    M.T. Schnitker, H.B. Lehnert, Apoplexy in a pituitary chromophobe adenoma producing the syndrome of middle cerebral artery thrombosis; case report. J. Neurosurg. 9(2), 210–213 (1952). doi: 10.3171/jns.1952.9.2.0210 CrossRefPubMedGoogle Scholar
  51. 51.
    S.K. Ahmed, P.L. Semple, Cerebral ischaemia in pituitary apoplexy. Acta Neurochir. 150(11), 1193–1196; discussion 1196 (2008). doi: 10.1007/s00701-008-0130-3
  52. 52.
    H. Seyer, F. Erbguth, D. Kompf, G. Koniszewski, R. Fahlbusch, Acute hemorrhage and ischemic necroses in hypophyseal tumors: hypophyseal apoplexy. Fortschr. Neurol. Psychiatr. 57(11), 474–488 (1989). doi: 10.1055/s-2007-1001144 CrossRefPubMedGoogle Scholar
  53. 53.
    S. Rajasekaran, M. Vanderpump, S. Baldeweg, W. Drake, N. Reddy, M. Lanyon, A. Markey, G. Plant, M. Powell, S. Sinha, J. Wass, UK guidelines for the management of pituitary apoplexy. Clin. Endocrinol. 74(1), 9–20 (2011). doi: 10.1111/j.1365-2265.2010.03913.x CrossRefGoogle Scholar
  54. 54.
    E.R. Laws Jr., J.C. Trautmann, R.W. Hollenhorst Jr., Transsphenoidal decompression of the optic nerve and chiasm. Visual results in 62 patients. J. Neurosurg. 46(6), 717–722 (1977). doi: 10.3171/jns.1977.46.6.0717 CrossRefPubMedGoogle Scholar
  55. 55.
    J.B. Kerrison, M.J. Lynn, C.A. Baer, S.A. Newman, V. Biousse, N.J. Newman, Stages of improvement in visual fields after pituitary tumor resection. Am. J. Ophthalmol. 130(6), 813–820 (2000)CrossRefPubMedGoogle Scholar
  56. 56.
    J.W. Seuk, C.H. Kim, M.S. Yang, J.H. Cheong, J.M. Kim, Visual outcome after transsphenoidal surgery in patients with pituitary apoplexy. J. Korean Neurosurg. Soc. 49(6), 339–344 (2011). doi: 10.3340/jkns.2011.49.6.339 CrossRefPubMedCentralPubMedGoogle Scholar
  57. 57.
    A.R. Cohen, P.R. Cooper, M.J. Kupersmith, E.S. Flamm, J. Ransohoff, Visual recovery after transsphenoidal removal of pituitary adenomas. Neurosurgery 17(3), 446–452 (1985)CrossRefPubMedGoogle Scholar
  58. 58.
    P.L. Semple, J.A. Jane, M.B. Lopes, E.R. Laws, Pituitary apoplexy: correlation between magnetic resonance imaging and histopathological results. J. Neurosurg. 108(5), 909–915 (2008). doi: 10.3171/JNS/2008/108/5/0909 CrossRefPubMedGoogle Scholar
  59. 59.
    A. Pal, C. Capatina, A.P. Tenreiro, P.D. Guardiola, J.V. Byrne, S. Cudlip, N. Karavitaki, J.A. Wass, Pituitary apoplexy in non-functioning pituitary adenomas: long term follow up is important because of significant numbers of tumour recurrences. Clin. Endocrinol. 75(4), 501–504 (2011). doi: 10.1111/j.1365-2265.2011.04068.x CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Wenya Linda Bi
    • 1
  • Ian F. Dunn
    • 1
  • Edward R. LawsJr.
    • 1
    Email author
  1. 1.Department of Neurosurgery, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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