New guidelines address diagnosis, treatment of pituitary apoplexy

Issue: June 2011

Society for Endocrinology BES 2011

Pituitary apoplexy should be treated immediately by specialist medical teams to avoid permanent damage to eye nerves and the nerves controlling eye movement, according to new guidelines from the Society for Endocrinology.

“The Society for Endocrinology wants to ensure that all patients receive the safest and most effective treatment for pituitary conditions,” John Wass, MA, MD, FRCP, chair of the Pituitary Apoplexy Working Group, said in a press release. “Following a thorough review of the literature, these guidelines aim to provide clinicians with evidence-based information on the diagnosis and management of patients with suspected pituitary apoplexy.”

These are the first guidelines in the United Kingdom to specifically address the diagnosis and treatment of pituitary apoplexy, a condition which, in the U.K., occurs at an estimated rate of 6.2 cases per 100,000 people, according to a press release. Symptoms include sudden onset headache, nausea and vomiting, paralysis of some eye movements, visual impairment and decreased consciousness.

The guidelines, which are endorsed by the Pituitary Foundation, the Royal College of Physicians and the Society of British Neurological Surgeons, were created based on a review of available literature. Together, the working party held a multidisciplinary meeting and submitted its guidelines to experts from a variety of disciplines, including endocrinology, neurosurgery, ophthalmology and neuroradiology, for review.

The working group highlights the individual management of patients based on history and symptoms, as well as the following:

All patients presenting with acute severe headache, whether they exhibit other symptoms, particularly if they have been previously diagnosed with a pituitary tumor, should be evaluated for pituitary apoplexy.
All patients with suspected pituitary apoplexy should undergo urgent MRI, which provides a diagnosis in more than 90% of patients. If MRI is contraindicated or not possible, CT scan should be used; however, they provide a conclusive diagnosis in only 21% to 28% of cases.
If acute secondary adrenal insufficiency is suspected, immediately administer IV cortisol replacement in anticipation of the results of any confirmatory tests.
All patients with suspected pituitary hormones should have urgent blood samples taken to check their electrolytes and serum levels of pituitary hormones.
Conservative management and surgical management are the two main treatment options for pituitary apoplexy. The decision to choose one over the other should be made by a multidisciplinary team of experts, including an endocrinologist, neurosurgeon and ophthalmologist.
Surgery should be conducted by an experienced pituitary surgeon, rather than the on-call surgical team, unless immediate surgical intervention is needed.
All patients with pituitary apoplexy require long-term management based on the nature of the underlying pituitary tumor and the success of treatment. All patients should have a full endocrine review at 4 to 8 weeks and an MRI at 3 to 6 months after the event as part of standard management. Annual clinical review in a joint endocrine/neurosurgical clinic is also recommended.

The group also suggests that further research on the management of pituitary apoplexy be conducted to optimize treatment.

Disclosures: The members of the group report no relevant financial disclosures.

For more information:

Pituitary Apoplexy Guidelines Development Group. 25 CG1.1. Presented at: Society for Endocrinology BES 2011; April 11-14, 2011; Birmingham, U.K.

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