Neurological Emergencies—What do you do now?
Remember your ABCs. This man is having significant problems with his circulation. Why?
Well, remember that pituitary apoplexy occurs when a (usually unknown) pituitary tumor either has an internal bleed or an infarct, expands rapidly, and compresses its surrounding structures:
- optic chiasm/optic nerves: blindness
- cranial nerves in cavernous sinus: diplopia
- normal pituitary gland: acute panhypopituitarism
Recall that ACTH from the pituitary gland goes to the adrenal glands and stimulates them to make cortisol. Recall also that the half-life of cortisol is very short, so that if ACTH is not continuously signaling the adrenals, you acutely lose your cortisol.
Addisonian crisis. Death unless corrected.
So what do you do now?
- You draw a serum cortisol to document what is going on
- You push 1 gram of solumedrol or whatever steroid is at hand
This should preserve the patient's life for your next two moves.
- You get a stat MR NOW to document the process.
- You call your neurosurgeon STAT to see the patient. This is a surgical emergency: if the optic nerves are decompressed quickly ( <12-24 h), good return
of vision is likely. If they are decompressed >24 h out, the patient stands a good likelihood of remaining blind.
