Endocrine Abstracts

Introduction: Pituitary apoplexy (PA) remains a rare endocrine diagnosis. Recent UK guidelines have emphasised the lack of evidence in the management of this condition. We present our experience of 23 current cases.

In classical acute PA, headache is the commonest presenting symptom. We found that a significant proportion (36%) of patients presented with subacute pituitary tumour apoplexy (SPA) – a term used to describe intra-adenomatous pituitary haemorrhage associated with clinical symptoms atypical of acute PA. These symptoms typically last longer than 24 h. In most previous case series, the incidence of SPA was found to be significantly lower than acute PA.

Presentation: Clinical suspicion of PA was high in 65% of cases: acute onset, severe headache in 65% of patients, and ocular palsy in 30% of cases with visual field defects in 13% of the patients. Over a third of patients presented with non-specific symptoms of fatigue, dizziness, nausea with -no or mild new headache, suggesting a diagnosis of SPA.

Management: The majority (83%) of cases were managed conservatively. Four (17%) of the patients with acute PA had severe neuro-ophthalmic signs and/or visual field defects and required and received urgent pituitary surgery with excellent post-operative outcome. None of the above cases required pituitary radiotherapy.

Subacute pituitary apoplexy subgroup: The group of patients with presumed SPA was on average younger than the acute PA subgroup. The requirement for long-term endocrinological hormone replacement in SPA is lower than in acute PA.

Conclusion: Although most cases presented with classical PA, a significant part presented with SPA. Clinicians need to be aware that SPA can present with non-specific symptoms.

Stable patients with PA or SPA without neurological or neuro-ophthalmic signs can be considered for a conservative management approach with careful monitoring in the context of a multi-disciplinary team which in our experience provides satisfactory outcomes.