Pituitary 7: 157–163, 2004 C  2005 Springer Science + Business Media, Inc. Manufactured in The Netherlands. DOI: 10.1007/s11102-005-1050-3 Pituitary Apoplexy: A Review of Clinical Presentation, Management and Outcome in 45 Cases Latika Sibal 1 , Steve G. Ball 1 , Vincent Connolly 2 , Robert A. James 1 , Philip Kane 3 , William F. Kelly 2 , Pat Kendall-Taylor 1 , David Mathias 4 , Petros Perros 1 , Richard Quinton 1 , and Bijay Vaidya 2 1 Department of Endocrinology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, U.K; 2 Department of Endocrinology, The James Cook University Hospital, Middlesbrough, U.K; 3 Department of Neurosurgery, The James Cook University Hospital, Middlesbrough, U.K; 4 Departments of Otonasolaryngology, Newcastle University Teaching Hospitals, Newcastle upon Tyne, U.K. Published online: 11 July 2005 Abstract. Objective: To review clinical presentation, man- agement and outcomes following different therapies in patients with pituitary apoplexy. Methods: Retrospective analysis of case-records of patients with classical pitu- itary apoplexy treated in our hospitals between 1983– 2004. Results: Forty-five patients (28 men; mean age 49 years, range 16–72 years) were identified. Only 8 (18%) were known to have pituitary adenomas at presentation. Thirty-four (81%) patients had hypopituitarism at presen- tation. CT and MRI identified pituitary apoplexy in 28% and 91% cases, respectively. Twenty-seven (60%) patients underwent surgical decompression, whilst 18 (40%) were managed conservatively. Median time from presentation to surgery was 6 days (range 1–121 days). Patients with visual field defects were more likely than those without these signs to be managed surgically (p = 0.01). Complete or near-complete resolution occurred in 93% (13/14), 94% (15/16) and 93% (13/14) of the surgically treated patients with reduced visual acuity, visual field deficit and ocular palsy, respectively. All patients with reduced visual acu- ity (4/4), visual field deficit (4/4) and ocular palsy (8/8) in the conservative group had complete or near-complete re- covery. Only 5 (19%) patients in the surgical group and 2 (11%) in the conservative group had normal pituitary func- tion at follow up. One (4%) patient in the surgical group and 4 (22%) in the conservative group had a recurrence of pituitary adenoma. Conclusions: This large series suggests that the patients with classical pituitary apoplexy, who are without neuro-ophthalmic signs or exhibit mild and non- progressive signs, can be managed conservatively in the acute stage. Key words. pituitary apoplexy, pituitary adenoma, hypopi- tuitarism, visual loss Introduction Pituitary apoplexy is a rare but potentially life- threatening clinical syndrome resulting from acute haemorrhage or infarction of the pituitary gland [1–3]. It classically presents with a sudden onset of headache, vomiting, visual disturbances and decreased conscious- ness. Pituitary apoplexy usually occurs in the pres- ence of a pituitary adenoma, though it has also occa- sionally been described in a non-adenomatous pituitary gland [4]. The incidence of pituitary apoplexy present- ing with classical symptoms is about 3% in the series of surgically treated pituitary adenomas [5,6]. However, clinically silent histopathological evidence of pituitary haemorrhage (‘subclinical pituitary apoplexy’) is much more common, and has been observed in up to 25% of the surgically removed pituitary adenomas [7,8]. It is generally accepted that the initial management of pituitary apoplexy consists of careful monitoring of fluid and electrolyte balance coupled with immediate replacement of deficient hormones, in particular corti- costeroids [3]. However, the role and timing of pituitary surgery in this condition remains controversial. Some authors advocate urgent surgical decompression of the pituitary fossa [6,9–11], while others have suggested that restoration of neuro-ophthalmic function may still occur even when decompression is delayed [12,13]. In contrast, other authors favour a more conservative ap- proach in the management of pituitary apoplexy, partic- ularly in the absence of progressive neuro-ophthalmic signs [5,14–17]. Therefore, we have reviewed patients with pituitary apoplexy presenting to our centres in the last 21 years, with a particular emphasis on clinical out- comes following different therapies. Address correspondence to: Bijay Vaidya, Department of En- docrinology, Diabetes & Vascular Medicine, Peninsula Med- ical School, Royal Devon & Exeter Hospital, Exeter EX2 5DW, U.K. Tel.: 01392-402281; Fax: 01392-403027; E-mail: bijay.vaidya@pms.ac.uk