A 48-year-old man with a known non-functioning pituitary macroadenoma on surveillance suddenly develops severe headache, complete right-sided ptosis, and collapse of vision in both temporal fields. Serum sodium is 126 mmol/L. What is the MOST appropriate immediate management?
- A Immediate transsphenoidal decompression before any medical therapy
- B Intravenous high-dose corticosteroid therapy followed by early transsphenoidal surgery ✓
- C Fluid restriction and demeclocycline for syndrome of inappropriate ADH secretion
- D Urgent external ventricular drain insertion
Explanation
This is pituitary apoplexy: haemorrhage or infarction into an existing adenoma causing sudden headache, ophthalmoplegia, and visual failure. All patients receive parenteral hydrocortisone immediately because acute secondary adrenal insufficiency is life-threatening. Surgery is then undertaken within days for deteriorating vision or ophthalmoplegia. Operating before steroid cover risks cardiovascular collapse from untreated cortisol deficiency. Hyponatraemia reflects ADH deficiency or excess and is managed after cortisol replacement. External ventricular drainage addresses hydrocephalus, not the sellar catastrophe.
Reference: Greenberg's Handbook of Neurosurgery, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.