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

Management

Pituitary apoplexy may require emergency surgical intervention; however, sometimes it can be managed more conservatively with medical therapies, particularly corticosteroid replacement if hypopituitarism is evident. Patients with evidence of optic chiasm compression or with an acute decrease in level of consciousness are typically considered candidates for emergency surgical resection of the infarcted or hemorrhagic tissue and decompression of structures surrounding the pituitary.

Surgical Management

Transsphenoidal resection is the most common method of resecting the pituitary in most cases; however, some circumstances may require an open craniotomy or other surgical approach. Transsphenoidal resection and decompression is usually accomplished via an incision under the upper lip.[8] In many cases, early resection of the necrotic or hemorrhagic tissue has been effective in restoring vision to patients with rapidly progressive visual loss.[9]

Postoperatively, patients should be closely monitored for signs and symptoms of inappropriate antidiuretic hormone syndrome, which causes fluid retention and dilutional hyponatremia, and diabetes insipidus, which causes polyuria and hypernatremia. This is accomplished in the inpatient setting by measuring the patient's intake and urinary output, urine specific gravity, and serum and urine sodium levels. Postoperative management of pituitary apoplexy also includes a thorough endocrinologic evaluation to determine whether chronic hormone replacement is necessary. The need for chronic hormone replacement depends on how much of the functioning pituitary gland was resected and the amount of pituitary stalk involvement. Tests to determine endocrine function include: serum cortisol, ACTH, free thyroxine, thyroid stimulating hormone, prolactin, luteinizing hormone, follicle stimulating hormone, alpha-subunit, insulin-like growth factor-1, and, in men, testosterone.[10] Patients already receiving steroid replacement at the time of the endocrinologic evaluation should undergo serum cortisol and ACTH measurements when the steroids are tapered and discontinued.

Neuro-ophthalmologic follow-up is essential to track recovery of visual field deficits and overall recovery of damage caused by compression of the optic chiasm by the apoplectic pituitary gland. Formal computerized visual field testing is generally performed as part of the neuro-ophthalmologic evaluation. Continued life-time follow-up by endocrinologists and neurosurgeons or neurologists is necessary to optimize hormone replacement and to detect progression or recrudescence of pituitary disease or tumor.

Medical Management

Patients with pituitary apoplexy may be followed medically by endocrinologists, neurologists, or neurosurgeons to monitor for hypo- or hyperpituitarism and progression of disease. Corticosteroids may be adjusted during the course of the patient's lifetime. Patients undergoing medical management with corticosteroids undergo formal visual field evaluations, using computerized perimetry to establish a baseline, at 6-month intervals or if a change in visual fields is detected clinically.[5]

The advanced practice nurse in all specialty areas and nurse practitioners in primary care are integral to facilitating the interdisciplinary management required to adequately manage the patient either medically or surgically.

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