disease | Pituitary Crisis and Pituitary Apoplexy |
When the anterior pituitary function declines, the deficiency of adrenocortical hormones and thyroid hormones reduces the body's stress response capacity. In cases of infection, vomiting, diarrhea, dehydration, cold, hunger, or the use of sedatives or anesthetics, a crisis can be triggered. Pituitary tumors, such as follicular tumors, may experience internal hemorrhage, infarction, or necrosis, leading to tumor enlargement and causing acute neuroendocrine disorders, known as pituitary apoplexy.
bubble_chart Diagnosis
1. History, Symptoms, and Signs
(1) Types of Crisis:
1. Hypoglycemic unconsciousness; the most common, often occurring with insufficient food intake, hunger, fasting, or after insulin injection. Manifested as hypoglycemic symptoms; syncope (may include epileptic-like seizures, even unconsciousness) and hypotension. A history of hypopituitary function and detection of low blood sugar can confirm the diagnosis.
2. Infection-induced unconsciousness; characterized by high fever, post-infection unconsciousness, and severe hypotension.
3. Central nervous system depressant-induced unconsciousness; sedatives and anesthetics at normal doses can cause prolonged drowsiness or even unconsciousness. Diagnosis is straightforward based on medical history.
4. Hypothermic unconsciousness: often triggered by cold weather in winter, featuring abnormally low body temperature and unconsciousness.
5. Hyponatremic unconsciousness: usually caused by sodium loss and dehydration due to surgery or gastrointestinal dysfunction, leading to peripheral circulatory failure.
6. Water intoxication unconsciousness: due to pre-existing water excretion dysfunction, excessive water intake can cause water intoxication. Main symptoms include water retention syndrome, hyponatremia, and reduced hematocrit.
Main manifestations include: ① Sudden symptoms of increased intracranial pressure;
② Frequent symptoms of compression of adjacent structures in the sella turcica, such as upward compression of the visual pathway, diencephalon, and midbrain, causing vision loss, visual field defects, and changes in vital signs; downward compression of the thalamus causing disturbances in blood pressure, body temperature, respiration, and heart rhythm; lateral compression into the cavernous sinus causing extraocular muscle paralysis, trigeminal nerve symptoms, and venous return obstruction;
③ Symptoms of hypothalamic-pituitary dysfunction. Many pituitary apoplexy patients lack pre-existing symptoms of pituitary adenoma. Therefore, unexplained sudden intracranial pressure elevation, especially with compressive symptoms like vision impairment or extraocular muscle paralysis, should raise suspicion of pituitary apoplexy.
2. Auxiliary Examinations:
Same as for hypopituitarism.
3. Differential Diagnosis:
Should be distinguished from ruptured stirred pulse tumor, brain abscess, encephalitis, and retrobulbar neuritis.
bubble_chart Treatment Measures
1. Generally, start with an intravenous injection of 50% glucose (40–60 ml), followed by an infusion of 10% glucose (500–1000 ml) containing 100–300 mg of hydrocortisone. However, the dosage of hydrocortisone should not be excessive in cases of hypothermic unconsciousness.
2. For the hypothermic type: The treatment is similar to that for myxedema unconsciousness, but it is essential to administer an appropriate amount of hydrocortisone before (or at least concurrently with) thyroid hormone. Additionally, the use of central nervous system depressants such as chlorpromazine and barbiturates is strictly prohibited.
4. For water intoxication unconsciousness: Immediately administer small to moderate doses of glucocorticoids and restrict water intake.
5. For pituitary apoplexy: High-dose hormone replacement therapy and hemostatic agents should be administered. Water and electrolyte metabolism should be monitored in cases of diabetes insipidus or abnormal antidiuretic hormone secretion. In cases of severe intracranial hypertension, visual impairment, unconsciousness, or progressive deterioration, surgical decompression is required. {|104|}