A 44-year-old man with a known 2 cm pituitary macroadenoma presents with sudden severe headache, bilateral visual loss, and vomiting. He is drowsy and BP is 96/60 mmHg. CT shows haemorrhage into the sella. Before definitive neurosurgical decompression, which immediate step is mandatory?
- A Immediate transsphenoidal surgery within the hour regardless of steroid status
- B High-dose intravenous hydrocortisone ✓
- C Intravenous desmopressin infusion
- D Oral cabergoline loading dose
Explanation
Pituitary apoplexy commonly destroys corticotroph function, producing life-threatening secondary adrenal insufficiency, and hypotension with drowsiness suggests cortisol deficiency is contributing. Parenteral high-dose hydrocortisone must be given immediately, before any surgical intervention, because anaesthesia and surgery in untreated adrenal collapse can be fatal. Decompression remains indicated for visual compromise but only after steroid cover. Desmopressin addresses diabetes insipidus, which is managed only if it develops, and dopamine agonists have no role in haemorrhagic infarction.
Reference: Williams Textbook of Endocrinology, 14th ed.
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Written and medically reviewed by the StethoPrep medical team.