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endo.pituitary-apoplexy.core.v1

Pituitary apoplexy

endocrinologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

PLACEHOLDER manifest: points at prisma/seed/manifests/endo.adrenal-crisis.core.v1.ts — no dedicated endo.pituitary-apoplexy manifest authored yet (tracked in design brief Open Gaps). No problem-package folder under src/lib/tier3/problem-package/packages/ — design brief + atoms not yet authored. Pituitary Apoplexy Score (UK 2011: GCS + visual acuity + visual fields + ocular paresis) is not yet in clinical-tools-registry.ts — risk stratification mapped to closest available (calc.qsofa for adrenal-crisis/sepsis triage, calc.news2 for deterioration/ICU escalation); a dedicated calc.pituitary_apoplexy_score should be added. No rxcui assigned anywhere — RxNav validation deferred to PRODUCTION promotion (scripts/research/rxnav-validate.ts). Bayesian likelihood ratios for thunderclap-headache differential (apoplexy vs SAH vs meningitis vs cavernous sinus thrombosis) deferred — see brief Open Gaps.

Entry points (5)

  • symptom
    Sudden severe (thunderclap) headache + visual disturbance (Rajasekaran Clin Endocrinol 2011)
    thunderclap_headache_visual
  • vital_abnormality
    Hypotension / shock with sudden headache — secondary adrenal insufficiency (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    hypotension_with_headache
  • symptom
    Acute ophthalmoplegia / diplopia (cavernous sinus CN III/IV/VI) (Rajasekaran Clin Endocrinol 2011)
    acute_ophthalmoplegia
  • imaging
    Sellar/suprasellar mass with hemorrhage on MRI/CT (Rajasekaran Clin Endocrinol 2011)
    sellar_hemorrhage_mass
  • problem_list
    Known pituitary macroadenoma with acute decompensation (Briet Endocr Rev 2015)
    known_pituitary_adenoma

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Apoplexy peaks 5th–6th decade; pregnancy overlaps Sheehan and changes the differential (Rajasekaran Clin Endocrinol 2011)
  • headache_onsetrequired
    symptom • used at ENTRY
    Sudden/thunderclap onset is the cardinal feature; tempo separates apoplexy from subacute hypopituitarism (Rajasekaran Clin Endocrinol 2011)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension/shock signals acute secondary adrenal insufficiency and mandates empiric hydrocortisone before imaging (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
  • gcsrequired
    vital • used at RED_FLAGS
    Reduced consciousness is a surgical decompression trigger and an ICU criterion (Rajasekaran Clin Endocrinol 2011)
  • visual_acuity_fieldsrequired
    symptom • used at RED_FLAGS
    Bitemporal hemianopia (chiasm compression) and acuity loss drive the Pituitary Apoplexy Score and the surgery-vs-conservative decision (Rajasekaran Clin Endocrinol 2011)
  • ocular_motility
    symptom • used at RED_FLAGS
    CN III/IV/VI palsy from cavernous sinus extension; isolated ophthalmoplegia without acuity loss can be managed conservatively (Rajasekaran Clin Endocrinol 2011)
  • cortisol
    lab • used at INITIAL_WORKUP
    Random cortisol drawn pre-steroid to document the corticotrope axis — do NOT delay hydrocortisone for the result (Rajasekaran Clin Endocrinol 2011)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hyponatremia from cortisol-deficient SIADH-like state vs true SIADH vs (later) DI guides fluid composition (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
  • free_t4required
    lab • used at INITIAL_WORKUP
    Central hypothyroidism axis — levothyroxine must NOT be started before glucocorticoid (precipitates adrenal crisis) (Rajasekaran Clin Endocrinol 2011; Fleseriu JCEM 2016)
  • prolactin
    lab • used at INITIAL_WORKUP
    Low prolactin suggests extensive necrosis/poor recovery; high prolactin suggests a lactotroph adenoma substrate (Briet Endocr Rev 2015)
  • pituitary_mrirequired
    imaging • used at INITIAL_WORKUP
    Pituitary MRI is the diagnostic test; CT misses ~50% of apoplexy and is mainly to exclude SAH (Rajasekaran Clin Endocrinol 2011)
  • precipitant_screenrequired
    history • used at CONTEXT
    Anticoagulation, dynamic pituitary testing, dopamine agonists, major surgery/cardiac bypass, pregnancy, HTN, head trauma precipitate apoplexy (Briet Endocr Rev 2015)
  • current_meds
    medication • used at CONTEXT
    Anticoagulants/antiplatelets and dopamine agonists are common precipitants and alter peri-operative management (Briet Endocr Rev 2015)
  • pregnancy_statusrequired
    history • used at CONTEXT
    Postpartum presentation overlaps Sheehan syndrome; pregnancy changes imaging and the differential (Rajasekaran Clin Endocrinol 2011)

12-phase flow (12)

  1. 1FRAME
    Recognize apoplexy pattern: sudden severe headache + visual/ocular deficit ± hemodynamic compromise in a (often unknown) pituitary adenoma substrate; the urgent threat is secondary adrenal insufficiency (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    inputs: headache_onset, sbp, visual_acuity_fields
    advance: apoplexy pattern present and corticosteroid candidate identified (Rajasekaran Clin Endocrinol 2011)
  2. 2ENTRY
    Capture triggering presentation (thunderclap headache, hypotension+headache, acute ophthalmoplegia, sellar hemorrhage on imaging, known adenoma decompensating) (Rajasekaran Clin Endocrinol 2011)
    inputs: age, headache_onset
    advance: demographic + entry trigger documented (Rajasekaran Clin Endocrinol 2011)
  3. 3CONTEXT
    Capture precipitant screen (anticoagulation, dynamic pituitary testing, dopamine agonist, surgery/cardiopulmonary bypass, HTN, head trauma, pregnancy), known adenoma status, current meds (Briet Endocr Rev 2015)
    inputs: precipitant_screen, current_meds, pregnancy_status
    advance: precipitant + adenoma history + pregnancy status captured (Briet Endocr Rev 2015)
  4. 4RED_FLAGS
    Hemodynamic instability/secondary adrenal crisis, acute or progressive visual acuity/field loss, reduced consciousness/GCS drop, severe hyponatremia, meningismus mimicking SAH/meningitis (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    inputs: sbp, gcs, visual_acuity_fields, ocular_motility, sodium
    actions: calc.qsofa, calc.news2
    advance: red flags screened; empiric stress-dose hydrocortisone ordered WITHOUT waiting for cortisol/MRI when hemodynamic/visual/consciousness compromise present (Rajasekaran Clin Endocrinol 2011)
  5. 5INITIAL_WORKUP
    Random cortisol + ACTH pre-steroid; full anterior pituitary panel (free T4, TSH, prolactin, IGF-1, LH/FSH, testosterone/estradiol); CMP for Na/glucose; CBC; coagulation; URGENT pituitary MRI (CT only to exclude SAH); ophthalmology formal fields/acuity (Rajasekaran Clin Endocrinol 2011; Fleseriu JCEM 2016)
    inputs: cortisol, sodium, free_t4, prolactin, pituitary_mri
    actions: workup.pituitary_apoplexy, panel.hormone, panel.cmp, panel.thyroid, panel.cbc
    advance: baseline pituitary axes drawn pre-steroid; empiric hydrocortisone given; MRI + ophthalmology requested (Rajasekaran Clin Endocrinol 2011)
  6. 6BRANCHING_WORKUP
    Hyponatremia work-up branch (cortisol-deficient vs SIADH vs delayed central DI); CSF if meningitis cannot be excluded clinically; complete remaining axes (IGF-1, gonadal) once stabilized (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    inputs: sodium
    actions: workup.hyponatremia, workup.acute_headache, panel.csf
    advance: hyponatremia mechanism classified and meningitis excluded or treated empirically (Rajasekaran Clin Endocrinol 2011)
  7. 7DIFFERENTIAL
    Distinguish apoplexy from aneurysmal SAH, bacterial meningitis, cavernous sinus thrombosis, ophthalmoplegic migraine, and Sheehan syndrome (postpartum); phenotype hemorrhagic vs ischemic, functioning vs non-functioning adenoma (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    inputs: pituitary_mri
    actions: workup.acute_headache
    advance: apoplexy confirmed on MRI and competing thunderclap-headache causes excluded (Rajasekaran Clin Endocrinol 2011)
  8. 8RISK_STRATIFICATION
    Pituitary Apoplexy Score (UK 2011: GCS, visual acuity, visual fields, ocular paresis) guides conservative vs surgical pathway; qSOFA/NEWS2 for ICU triage when adrenal crisis/shock present (Rajasekaran Clin Endocrinol 2011)
    inputs: gcs, visual_acuity_fields, ocular_motility, sbp
    actions: calc.qsofa, calc.news2
    advance: Pituitary Apoplexy Score computed; surgical-vs-conservative pathway selected; ICU disposition decided if shock/AMS (Rajasekaran Clin Endocrinol 2011)
  9. 9TREATMENT
    Empiric hydrocortisone FIRST (100 mg IV bolus → 50 mg q6h or 200 mg/24h infusion) → fluid resuscitation + hyponatremia management → urgent neurosurgery + ophthalmology review → transsphenoidal decompression for severe/progressive visual loss or reduced consciousness vs conservative management with steroid + serial assessment per apoplexy score → hormone replacement (thyroxine ONLY after glucocorticoid) (Rajasekaran Clin Endocrinol 2011; Fleseriu JCEM 2016)
    inputs: sbp, sodium, free_t4, gcs, visual_acuity_fields
    advance: hydrocortisone + fluids + hyponatremia plan in flight and surgical-vs-conservative decision actioned (Rajasekaran Clin Endocrinol 2011)
  10. 10DISPOSITION
    ICU/HDU if shock, AMS, or progressive visual loss; urgent transsphenoidal surgery referral for severe/deteriorating deficits; conservative inpatient pathway with neurosurgery + endocrinology + ophthalmology co-management if mild and stable (Rajasekaran Clin Endocrinol 2011)
    advance: ICU vs ward decided and neurosurgery/endocrine/ophthalmology consults made (Rajasekaran Clin Endocrinol 2011)
  11. 11MONITORING
    Serial visual acuity + fields q-shift (more frequent if conservative), GCS hourly while unstable, electrolytes q4–6h (SIADH then watch for delayed DI), cortisol axis adequacy, fluid balance/urine output, post-op DI/SIADH surveillance (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    inputs: sodium, gcs, visual_acuity_fields
    actions: panel.metabolic, panel.hormone
    advance: visual function stable/improving and sodium + fluid balance within safe limits (Rajasekaran Clin Endocrinol 2011)
  12. 12FOLLOWUP
    Endocrinology re-evaluation of all anterior axes at 4–8 weeks (most need long-term replacement; ~80% deficient ≥1 axis), interval pituitary MRI, ophthalmology field re-assessment, steroid sick-day rules + emergency hydrocortisone kit + MedicAlert, neurosurgical follow-up of residual adenoma (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    advance: axis re-evaluation scheduled; sick-day rules taught; emergency kit prescribed; imaging + specialty follow-up booked (Rajasekaran Clin Endocrinol 2011)