A 44-year-old man with a known 2 cm pituitary macroadenoma suddenly develops severe headache, right ptosis, and diplopia. He is drowsy, BP is 96/60 mmHg, and sodium is 128 mEq/L. MRI shows haemorrhage within the adenoma compressing the optic chiasm. Which is the immediate priority?
- A Immediate transsphenoidal decompression
- B Intravenous hypertonic saline for the hyponatraemia
- C Intravenous hydrocortisone 100 mg followed by stress-dose replacement ✓
- D High-dose dexamethasone as a radio-protective measure before surgery
Correct answer: C. Intravenous hydrocortisone 100 mg followed by stress-dose replacement
Explanation
This is pituitary apoplexy with haemodynamic instability and possible ACTH deficiency causing secondary adrenal insufficiency. Glucocorticoid replacement precedes everything else because untreated cortisol deficiency can be rapidly fatal. Transsphenoidal surgery follows promptly for visual compromise or deteriorating consciousness, but never before steroids are given. Hyponatraemia may reflect ADH disturbance and is addressed after stabilisation.
Reference: Williams Textbook of Endocrinology, 14th ed.
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