Pituitary Apoplexy Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Is pituitary apoplexy suspected
   Sudden severe headache + visual/ocular motor signs — pituitary apoplexy suspected? (Sudden hemorrhage/infarction of the pituitary (usually a pre-existing adenoma) → rapid sellar expansion compressing the pituitary/optic chiasm/cavernous sinus. Presentation: sudden severe headache + nausea/vomiting + visual field defect (bitemporal hemianopia)/visual loss + ophthalmoplegia (CN III/IV/VI) + altered consciousness (apoplexy triad: headache + vomiting + visual disturbance), mimicking SAH/meningitis. Most urgent: acute adrenal insufficiency (ACTH deficiency) → hypotension/circulatory collapse/hyponatremia/hypoglycemia. Diagnosis: urgent MRI; check cortisol/ACTH/electrolytes/glucose.)
   • Pituitary apoplexy suspected → Suspected apoplexy → hydrocortisone + MRI
   • Does not fit → Does not fit · differentiate sudden headache
2. [End] Does not fit · differentiate sudden headache
   Differentiate along the sudden severe headache pathway: SAH (CT/LP), meningitis, stroke, glaucoma, etc., complete imaging; stay alert, recheck MRI and endocrine workup for those with a pituitary tumor history/visual field defect/ophthalmoplegia + hyponatremia.
3. [End] Suspected apoplexy → hydrocortisone + MRI
   Immediately give empiric IV hydrocortisone (stress dose 100–200 mg, then 50–100 mg q6–8h) (treats presumed adrenal insufficiency, life-saving, do not wait for confirmation) + hemodynamic/electrolyte/glucose support; urgent MRI, full endocrine panel (draw blood first). Multidisciplinary (neurosurgery/endocrinology/ophthalmology) — severe or progressive visual loss, altered consciousness → transsphenoidal surgical decompression (good outcome if early), stable without significant deficit may be managed conservatively; later hormone replacement (hypopituitarism is common).

Source guidelines & references

• Pituitary apoplexy (UK pituitary apoplexy consensus; Endotext; StatPearls)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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