Presentation and problems

1. Pituitary apoplexy has presented with a variety of neurological signs and symptoms after surgery, sometimes up to several days later.The majority of cases have been associated with cardiac surgery (Cooper et al 1986, Shapiro 1990), although not exclusively. In one patient the pituitary tumour had already been diagnosed, but pituitary surgery had been postponed in favour of coronary artery grafting (Absalom et al 1993). Signs of pituitary apoplexy occurred 40 h after bypass and craniotomy revealed bleeding into the tumour, but the patient died from myocardial infarction. In one patient a pituitary crisis occurred after cholecystectomy performed under combined general and epidural anaesthesia (Yahagi et al 1992). In another, severe headache started 6h after total hip replacement under spinal anaesthesia. A blood patch at 18 h failed to relieve the headache and progressive vision loss and partial third nerve palsy developed (Lennon et al 1998).Two patients died after partial resection of giant pituitary tumours and, at reexploration, massive swelling of the remaining tumour and haemorrhagic infarction were found (Goel et al 1995).The exact sequence of events leading to pituitary apoplexy is unknown. However, since the anterior pituitary has no direct arterial supply, it depends upon adequate portal venous perfusion (Slaughter et al 1993). Because of this, an adenoma may have a relatively compromised blood supply, possibly secondary to tumour compression, or pathological abnormalities of the vessels. It is thus susceptible to ischaemia, secondary to

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