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Pituitary apoplexy — MRCEM SBA MCQ

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HardNeurological emergenciesPituitary apoplexyMRCEM SBA

A 54-year-old man with a known pituitary macroadenoma presents with sudden severe headache, vomiting and double vision. Over the next hour, his vision deteriorates. He has a right third-nerve palsy, reduced visual acuity and bitemporal field loss. His blood pressure is 82/46 mmHg, capillary glucose is 4.9 mmol/L and serum sodium is 128 mmol/L. CT shows haemorrhage within an enlarged sellar mass. Blood has been taken for cortisol and other pituitary investigations, but the results are pending. Intravenous access and monitoring are in place. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Resuscitate with intravenous saline and hydrocortisone, then refer urgently to the pituitary team.

The abrupt headache, ocular palsy, worsening visual loss and haemorrhagic sellar mass indicate pituitary apoplexy. Hypotension raises immediate concern for acute cortisol deficiency. Give parenteral hydrocortisone promptly—100 mg intravenously or intramuscularly is an appropriate initial emergency dose—alongside intravenous 0.9% sodium chloride and haemodynamic monitoring. Blood for cortisol has already been taken; treatment must not wait for its result. Worsening vision requires urgent assessment by a specialist pituitary team, including endocrinology and neurosurgery. ([pubmed.ncbi.nlm.nih.gov](https://pubmed.ncbi.nlm.nih.gov/21044119/?utm_source=openai)) A delays potentially lifesaving steroid treatment for a laboratory result. B makes MRI a prerequisite for treatment and referral, despite a compelling clinical picture and CT finding; MRI can inform subsequent specialist management. C treats the immediate endocrine risk but misses the urgency of deteriorating vision. E correctly starts resuscitation but presumes the operative decision: deterioration warrants urgent neurosurgical consideration, not surgery arranged without specialist assessment. ([nnuh.nhs.uk](https://www.nnuh.nhs.uk/publication/download/pituitary-tumour-other-pituitary-emergency-ca5095-v7/))

Reference: Pituitary Tumour and other Pituitary Emergency (Approved October 2023) — https://www.nnuh.nhs.uk/publication/download/pituitary-tumour-other-pituitary-emergency-ca5095-v7/ UK guidelines for the management of pituitary apoplexy (2011) — https://pubmed.ncbi.nlm.nih.gov/21044119/ Adrenal insufficiency: identification and management — emergency management of adrenal crisis (2024) — https://www.nice.org.uk/guidance/NG243/chapter/recommendations