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endo.pituitary-apoplexy.core.v1PRODUCTION
endo.pituitary-apoplexy.core.v1

Pituitary apoplexy

endocrinologyacuteadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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apoplexy pattern present and corticosteroid candidate identified (Rajasekaran Clin Endocrinol 2011)

Patient inputs (14)

Apoplexy peaks 5th–6th decade; pregnancy overlaps Sheehan and changes the differential (Rajasekaran Clin Endocrinol 2011)

Anticoagulation, dynamic pituitary testing, dopamine agonists, major surgery/cardiac bypass, pregnancy, HTN, head trauma precipitate apoplexy (Briet Endocr Rev 2015)

Postpartum presentation overlaps Sheehan syndrome; pregnancy changes imaging and the differential (Rajasekaran Clin Endocrinol 2011)

Sudden/thunderclap onset is the cardinal feature; tempo separates apoplexy from subacute hypopituitarism (Rajasekaran Clin Endocrinol 2011)

Hyponatremia from cortisol-deficient SIADH-like state vs true SIADH vs (later) DI guides fluid composition (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)

Central hypothyroidism axis — levothyroxine must NOT be started before glucocorticoid (precipitates adrenal crisis) (Rajasekaran Clin Endocrinol 2011; Fleseriu JCEM 2016)

Pituitary MRI is the diagnostic test; CT misses ~50% of apoplexy and is mainly to exclude SAH (Rajasekaran Clin Endocrinol 2011)

Hypotension/shock signals acute secondary adrenal insufficiency and mandates empiric hydrocortisone before imaging (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)

Reduced consciousness is a surgical decompression trigger and an ICU criterion (Rajasekaran Clin Endocrinol 2011)

Bitemporal hemianopia (chiasm compression) and acuity loss drive the Pituitary Apoplexy Score and the surgery-vs-conservative decision (Rajasekaran Clin Endocrinol 2011)

Anticoagulants/antiplatelets and dopamine agonists are common precipitants and alter peri-operative management (Briet Endocr Rev 2015)

Random cortisol drawn pre-steroid to document the corticotrope axis — do NOT delay hydrocortisone for the result (Rajasekaran Clin Endocrinol 2011)

Low prolactin suggests extensive necrosis/poor recovery; high prolactin suggests a lactotroph adenoma substrate (Briet Endocr Rev 2015)

CN III/IV/VI palsy from cavernous sinus extension; isolated ophthalmoplegia without acuity loss can be managed conservatively (Rajasekaran Clin Endocrinol 2011)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningapoplexy_with_hemodynamic_instability_adrenal_crisis — UK 2011
    Hypotension/shock in suspected apoplexy = acute secondary (ACTH-deficient) adrenal insufficiency with no hydrocortisone given (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningacute_or_progressive_visual_loss — UK 2011
    Acute or progressive visual acuity/field loss (chiasmal compression) (Rajasekaran Clin Endocrinol 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningreduced_consciousness_GCS_drop — UK 2011
    Reduced consciousness or falling GCS in confirmed/suspected apoplexy (Rajasekaran Clin Endocrinol 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hyponatremia — UK 2011
    Na <125 with neuro symptoms — cortisol-deficient SIADH-like state vs true SIADH vs delayed DI (Rajasekaran Clin Endocrinol 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostpartum_presentation_sheehan_overlap — UK 2011
    Postpartum patient with headache + hypopituitarism features — apoplexy vs Sheehan overlap (Rajasekaran Clin Endocrinol 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateisolated_ophthalmoplegia_stable — UK 2011
    Isolated ocular motor palsy (CN III/IV/VI) WITHOUT visual acuity loss or reduced consciousness, hemodynamically stable (Rajasekaran Clin Endocrinol 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Pituitary apoplexy acute — empiric steroid FIRST → resuscitate/Na → image + surgical decision → staged hormone replacement (Rajasekaran Clin Endocrinol 2011)
axis: pituitary_apoplexy_acutestep 1 - Step 1 — Empiric stress-dose hydrocortisone FIRST — do NOT delay for cortisol or MRI (Rajasekaran Clin Endocrinol 2011)
Selected step "Step 1 — Empiric stress-dose hydrocortisone FIRST — do NOT delay for cortisol or MRI (Rajasekaran Clin Endocrinol 2011)" — Suspected apoplexy with hemodynamic instability, visual compromise, or reduced consciousness (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
  • hydrocortisone
    first line
    glucocorticoid_short_acting
    100 mg IV/IM bolus STAT, then 50 mg IV q6h OR 200 mg/24h continuous infusion (≥2 mg/h) • IV • q6h or continuous infusion
    triggers: apoplexy_suspected, hemodynamic_instability, visual_compromise, reduced_consciousness
    UK 2011 — secondary (ACTH-deficient) adrenal insufficiency is the life-threatening facet; empiric hydrocortisone is the single most urgent step and is mortality-reducing; give before imaging confirmation
    rxcui 5492
  • dexamethasone
    second line
    glucocorticoid_long_acting
    4 mg IV (only if hydrocortisone unavailable, or high-dose anti-edema effect desired with significant chiasmal mass effect) • IV • q6h
    triggers: hydrocortisone_unavailable, significant_mass_effect_edema
    UK 2011 — alternative glucocorticoid; preserves cortisol-assay window; some use higher-dose dexamethasone for perichiasmal edema, but hydrocortisone is the default replacement steroid
    rxcui 3264

ed playbook — drug actions (5)

  1. 1. hydrocortisone IV STAT
    100 mg IV/IM bolus • IV • STAT
    trigger: Suspected apoplexy with shock/visual/consciousness compromise (Rajasekaran Clin Endocrinol 2011)
    Secondary adrenal insufficiency is the lethal facet — do NOT wait for cortisol or MRI (Rajasekaran Clin Endocrinol 2011)
  2. 2. 0.9% NaCl bolus
    500 mL–1 L over 1h • IV • over 1h
    trigger: Hypotension/volume depletion (Rajasekaran Clin Endocrinol 2011)
    Volume + Na repletion with cautious correction (Rajasekaran Clin Endocrinol 2011)
  3. 3. D50 if hypoglycemic
    25 g D50 IV push • IV • PRN
    trigger: Glucose <70 (Fleseriu JCEM 2016)
    Cortisol/GH-deficiency hypoglycemia (Fleseriu JCEM 2016)
  4. 4. hydrocortisone maintenance
    50 mg IV q6h OR 200 mg/24h infusion after bolus • IV • q6h or continuous
    trigger: Continuous coverage (Rajasekaran Clin Endocrinol 2011)
    Maintain stress dose pending stabilization (Rajasekaran Clin Endocrinol 2011)
  5. 5. norepinephrine
    0.05–0.5 mcg/kg/min titrated • IV • continuous
    trigger: MAP <65 despite fluids + steroid (Briet Endocr Rev 2015)
    Distributive cortisol-deficient shock adjunct (Briet Endocr Rev 2015)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Sudden severe (thunderclap) headache + visual disturbance (Rajasekaran Clin Endocrinol 2011); Hypotension / shock with sudden headache — secondary adrenal insufficiency (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015); Acute ophthalmoplegia / diplopia (cavernous sinus CN III/IV/VI) (Rajasekaran Clin Endocrinol 2011).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pituitary apoplexy** (endo.pituitary-apoplexy.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pituitary apoplexy acute — empiric steroid FIRST → resuscitate/Na → image + surgical decision → staged hormone replacement (Rajasekaran Clin Endocrinol 2011)** — step "Step 1 — Empiric stress-dose hydrocortisone FIRST — do NOT delay for cortisol or MRI (Rajasekaran Clin Endocrinol 2011)".
1. hydrocortisone 100 mg IV/IM bolus STAT, then 50 mg IV q6h OR 200 mg/24h continuous infusion (≥2 mg/h) IV q6h or continuous infusion (glucocorticoid_short_acting, first line) — UK 2011 — secondary (ACTH-deficient) adrenal insufficiency is the life-threatening facet; empiric hydrocortisone is the single most urgent step and is mortality-reducing; give before imaging confirmation
2. dexamethasone 4 mg IV (only if hydrocortisone unavailable, or high-dose anti-edema effect desired with significant chiasmal mass effect) IV q6h (glucocorticoid_long_acting, second line) — UK 2011 — alternative glucocorticoid; preserves cortisol-assay window; some use higher-dose dexamethasone for perichiasmal edema, but hydrocortisone is the default replacement steroid

Setting playbook (ed) — Recognize apoplexy, give STAT empiric stress-dose hydrocortisone, resuscitate, urgent MRI + ophthalmology, neurosurgery referral (Rajasekaran Clin Endocrinol 2011)
3. hydrocortisone IV STAT 100 mg IV/IM bolus IV STAT — Suspected apoplexy with shock/visual/consciousness compromise (Rajasekaran Clin Endocrinol 2011) (Secondary adrenal insufficiency is the lethal facet — do NOT wait for cortisol or MRI (Rajasekaran Clin Endocrinol 2011))
4. 0.9% NaCl bolus 500 mL–1 L over 1h IV over 1h — Hypotension/volume depletion (Rajasekaran Clin Endocrinol 2011) (Volume + Na repletion with cautious correction (Rajasekaran Clin Endocrinol 2011))
5. D50 if hypoglycemic 25 g D50 IV push IV PRN — Glucose <70 (Fleseriu JCEM 2016) (Cortisol/GH-deficiency hypoglycemia (Fleseriu JCEM 2016))
6. hydrocortisone maintenance 50 mg IV q6h OR 200 mg/24h infusion after bolus IV q6h or continuous — Continuous coverage (Rajasekaran Clin Endocrinol 2011) (Maintain stress dose pending stabilization (Rajasekaran Clin Endocrinol 2011))
7. norepinephrine 0.05–0.5 mcg/kg/min titrated IV continuous — MAP <65 despite fluids + steroid (Briet Endocr Rev 2015) (Distributive cortisol-deficient shock adjunct (Briet Endocr Rev 2015))

Non-pharmacologic actions:
- Cardiac monitor + IV access x 2 (Rajasekaran Clin Endocrinol 2011)
- Urgent pituitary MRI; CT only to exclude SAH (Rajasekaran Clin Endocrinol 2011)
- STAT ophthalmology for formal acuity/fields (Rajasekaran Clin Endocrinol 2011)
- Neurosurgery referral the same hour if visual loss or reduced consciousness (Rajasekaran Clin Endocrinol 2011)
- Withhold anticoagulation; arrange reversal if surgery likely (Rajasekaran Clin Endocrinol 2011)

AVOID / contraindication checks:
- Never_start_levothyroxine_before_glucocorticoid (Rajasekaran Clin Endocrinol 2011; Fleseriu JCEM 2016)
- Do_not_delay_empiric_hydrocortisone_for_cortisol_or_MRI (Rajasekaran Clin Endocrinol 2011)
- Correct_Na_max_8_to_10_mEq_per_24h_to_prevent_ODS (Rajasekaran Clin Endocrinol 2011)
- CT_misses_apoplexy_use_MRI_for_diagnosis (Rajasekaran Clin Endocrinol 2011)
- Do_not_use_desmopressin_for_cortisol_deficient_early_hyponatremia (Rajasekaran Clin Endocrinol 2011)
- Hold_and_reverse_anticoagulation_before_decompression (Rajasekaran Clin Endocrinol 2011)

Monitoring

Regimen monitoring:
- visual acuity + visual fields q-shift, more frequent if conservative (Rajasekaran Clin Endocrinol 2011)
- GCS hourly while unstable (Rajasekaran Clin Endocrinol 2011)
- electrolytes q4-6h — SIADH then watch delayed DI (Rajasekaran Clin Endocrinol 2011)
- strict fluid balance and urine output (Rajasekaran Clin Endocrinol 2011)
- cortisol axis adequacy on replacement (Fleseriu JCEM 2016)
- post-operative DI/SIADH surveillance after transsphenoidal surgery (Rajasekaran Clin Endocrinol 2011)

Setting (ed) monitoring:
- BP q15 min x 1h then q1h (Rajasekaran Clin Endocrinol 2011)
- Visual acuity/fields hourly while in ED (Rajasekaran Clin Endocrinol 2011)
- GCS hourly (Rajasekaran Clin Endocrinol 2011)
- Na/glucose on arrival and q4-6h (Rajasekaran Clin Endocrinol 2011)

Follow-up plan: 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)
- Close-out criterion: axis re-evaluation scheduled; sick-day rules taught; emergency kit prescribed; imaging + specialty follow-up booked (Rajasekaran Clin Endocrinol 2011)

Monitoring phase: 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)

Disposition

Current setting: ed — Recognize apoplexy, give STAT empiric stress-dose hydrocortisone, resuscitate, urgent MRI + ophthalmology, neurosurgery referral (Rajasekaran Clin Endocrinol 2011)

Disposition criteria:
- ICU/HDU for shock, AMS, or progressive visual deficit (Rajasekaran Clin Endocrinol 2011)
- Conservative inpatient pathway only if mild + stable deficits with steroid cover and serial review arranged (Rajasekaran Clin Endocrinol 2011)

Escalation triggers (move to higher acuity):
- Refractory hypotension despite fluids + steroid → ICU (Rajasekaran Clin Endocrinol 2011)
- Progressive visual loss or GCS drop → emergency neurosurgery + ICU (Rajasekaran Clin Endocrinol 2011)
- Severe hyponatremia with neuro symptoms → ICU + controlled correction (Rajasekaran Clin Endocrinol 2011)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hypotension/shock in suspected apoplexy = acute secondary (ACTH-deficient) adrenal insufficiency with no hydrocortisone given (Rajasekaran Clin Endocrinol 2011; Briet Endocr Rev 2015)
- [LIFE_THREATENING] Acute or progressive visual acuity/field loss (chiasmal compression) (Rajasekaran Clin Endocrinol 2011)
- [LIFE_THREATENING] Reduced consciousness or falling GCS in confirmed/suspected apoplexy (Rajasekaran Clin Endocrinol 2011)

Citations

- 2011 UK Pituitary Apoplexy Guideline (Rajasekaran, Clin Endocrinol) + 2016 Endocrine Society Hypopituitarism Guideline (Fleseriu JCEM) + Briet Endocr Rev 2015 review + 2021–2025 updates [PMID:21044119](https://pubmed.ncbi.nlm.nih.gov/21044119/)
- Cited evidence (PMID 26414232) [PMID:26414232](https://pubmed.ncbi.nlm.nih.gov/26414232/)
- Cited evidence (PMID 27736313) [PMID:27736313](https://pubmed.ncbi.nlm.nih.gov/27736313/)
- Cited evidence (PMID 16010459) [PMID:16010459](https://pubmed.ncbi.nlm.nih.gov/16010459/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2011 UK Pituitary Apoplexy Guideline (Rajasekaran, Clin Endocrinol) + 2016 Endocrine Society Hypopituitarism Guideline (Fleseriu JCEM) + Briet Endocr Rev 2015 review + 2021–2025 updates — PMID:21044119
  • Cited evidence (PMID 26414232) — PMID:26414232
  • Cited evidence (PMID 27736313) — PMID:27736313
  • Cited evidence (PMID 16010459) — PMID:16010459