Pituitary apoplexy with visual loss and hyponatraemia
A 46-year-old man presents with sudden severe headache, nausea, and blurred vision. He has right ptosis and a dilated right pupil, visual acuity of 6/18 on the right and 6/12 on the left, and a bitemporal hemianopia. Serum sodium is 126 mmol/L, 8 am cortisol is 180 nmol/L, and prolactin is mildly elevated at 950 mIU/L. MRI shows a 2.8 cm sellar and suprasellar mass with haemorrhage and chiasmal compression. He is alert but tired and has postural dizziness. He is not known to have a pituitary tumour. The ophthalmology team has documented the visual fields. The transsphenoidal surgeon is available within 24 hours.
1. Outline your immediate medical management before surgery. What would you give, in what order, and why?
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This is pituitary apoplexy with acute hypocortisolism and hyponatraemia. First assess airway, breathing, and circulation; obtain intravenous access and send paired serum and urine osmolality, urine sodium, thyroid function, and repeat cortisol. Give intravenous hydrocortisone 100 mg immediately, then 50 mg every 6 hours, because cortisol deficiency can cause hypotension and death; do not wait for confirmatory tests. Give isotonic saline cautiously for postural dizziness and hyponatraemia, aiming for a slow rise in sodium of no more than 8–10 mmol/L per 24 hours to avoid osmotic demyelination. Avoid hypotonic fluids. Do not give desmopressin unless diabetes insipidus is documented. Monitor urine output, sodium every 6 hours, and glucose. Involve endocrinology and ophthalmology. If the patient deteriorates visually or neurologically, escalate to urgent decompression. Thyroid hormone should be replaced after cortisol because starting thyroxine first can precipitate an adrenal crisis.
2. How would you decide between urgent transsphenoidal surgery and conservative management? What timing would you choose for this patient?
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The decision depends on visual and neurological severity, endocrine stability, and the patient’s fitness. Urgent surgery is indicated for severe or progressive visual loss, ophthalmoplegia, decreased consciousness, or hydrocephalus. This patient has a bitemporal hemianopia, reduced acuity, and a third nerve palsy, so he has a visual and cranial nerve deficit. He should undergo transsphenoidal decompression within 24–72 hours, and the available surgeon within 24 hours supports that plan. Conservative management with steroids and observation is reasonable for patients with mild or stable visual fields, no cranial nerve palsy, and no neurological deterioration, but this patient does not fit that category. Before surgery, correct cortisol deficiency and optimize sodium. The transsphenoidal approach is preferred because it avoids brain retraction and provides direct decompression. Discuss the risks of CSF leak, diabetes insipidus, incomplete resection, and recurrence. If surgery is delayed, reassess visual fields frequently and document the baseline.
3. What post-operative complications would you anticipate, and how would you manage them in the first 72 hours?
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Anticipate diabetes insipidus, syndrome of inappropriate antidiuretic hormone, cerebral salt wasting, CSF leak, meningitis, and adrenal insufficiency. Monitor urine output hourly, specific gravity, and serum sodium every 6–12 hours. If urine output exceeds 200 mL/hour for 2 consecutive hours with rising sodium, give desmopressin and replace fluids. If sodium falls, restrict free water and investigate the cause; do not correct too rapidly. Continue stress-dose hydrocortisone and taper according to endocrinology advice. Check visual acuity and fields daily. Inspect for CSF rhinorrhoea; if present, keep the head elevated, avoid nose blowing, and consider a lumbar drain or repair. Obtain pituitary hormone levels at 6 weeks to assess for permanent hypopituitarism. Educate the patient about sick-day steroid rules and provide a steroid alert card. Arrange endocrine and ophthalmology follow-up.