Recognizing and Intervening in Pituitary Apoplexy

Elizabeth Zink, MS, ACNP, CCRN, CNRN

Disclosures

Topics in Advanced Practice Nursing eJournal. 2005;5(4) 

In This Article

Evaluation and Diagnosis

Physical Assessment

An accurate neurologic baseline is invaluable for detecting subtle neurologic changes. This baseline may be assessed preoperatively for patients undergoing surgical procedures or through a thorough history and physical examination. A review of systems targeting symptoms of hypopituitarism such as a history of amenorrhea, loss of libido, lethargy, or weight gain; and visual disturbances including double vision may also be helpful for differentiating anterior pituitary involvement. A complete neurologic examination must be performed including confrontational visual field testing and detailed cranial nerve (CN) assessments to detect impaired extraocular movements or ophthalmoplegia. Changes in sensation along the distribution of the ophthalmic and maxillary regions (V1 and V2, respectively) of the trigeminal nerve (CN V) should also be assessed. CN III, IV, V (v1 and v2), and VI pass through the skull base in close proximity to the sella turcica, making them vulnerable to compression. The optic chiasm is directly above the pituitary gland and is subject to compression as mass effect increases. Therefore, careful initial and ongoing assessment of visual fields is crucial to determining progression of the disease and making a definitive decision regarding surgical intervention.

Diagnostic Imaging

A rapid diagnostic CT scan without contrast is necessary to screen for intracranial hemorrhage in the setting of acute cranial nerve deficits, visual loss, and headache or obtundation. If the CT scan is suspicious for pituitary apoplexy, an MRI scan will distinguish the soft tissues of the pituitary from the surrounding bony structures, thus allowing accurate visualization of abnormalities. The MRI scan is superior to CT scanning for detecting ischemia and infarction in brain tissue. In some cases, when the technology is readily available and pituitary apoplexy is strongly suspected, an MRI scan may be undertaken as the initial diagnostic test.

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