Management of endocrine disease: update on the management of pituitary apoplexy

Pituitary apoplexy (PA) is a rare but potentially life-threatening endocrine emergency caused by sudden hemorrhage or infarction usually within a pituitary tumor. Clinical presentation is highly variable, ranging from isolated headache to severe visual loss or altered consciousness. Prompt recognition, multidisciplinary evaluation, and timely management are essential to improve outcomes. Recent prospective and real-world studies have challenged the traditional view that urgent surgery is always required. Conservative management has been proposed to be a safe and effective option, although comparisons with the outcomes after surgical intervention are limited by differences in the severity of the clinical picture at presentation of the PA. Clinical decisions remain complex and must consider tumor size, symptom progression, radiological features, and individual comorbidities. The Pituitary Apoplexy Score helps guide management but has limitations, as it does not capture key variables such as persistent headache or evolving visual symptoms. Immediate management focuses on hemodynamic stabilization, stress-dose glucocorticoid administration, and neuro-ophthalmological monitoring. Surgical decompression should be considered in patients with progressive visual deterioration or altered consciousness. Follow-up must include hormonal reassessment, ophthalmological evaluation, and imaging surveillance. Although rare, recurrence of PA and tumor regrowth may occur, requiring long-term monitoring. This review provides an updated and pragmatic approach for the diagnosis, acute care, and long-term follow-up of PA, summarizing current evidence and highlighting ongoing controversies, including surgical timing and predictors of conservative treatment failure.