Pituitary apoplexy in the setting of severe headache and unconsciousness

Pituitary apoplexy is a rare but life-threatening condition caused by acute ischaemia or haemorrhage within the pituitary gland, often occurring in pre-existing adenomas. We present a case of an unconscious patient with acute headache, initially managed empirically for suspected meningitis. Investigations, such as cerebrospinal fluid analysis, revealed initially xanthochromia, prompting evaluation for subarachnoid haemorrhage. Magnetic resonance imaging and pituitary function testing identified a pituitary macroadenoma with optic chiasm compression and hypopituitarism, leading to successful transsphenoidal resection. This case underscores the importance of including pituitary apoplexy in the differential diagnosis of unconsciousness and severe headache, as it can mimic meningitis or subarachnoid haemorrhage (SAH). While SAH may precipitate apoplexy, xanthochromia can also arise independently from pituitary haemorrhage. Given the risk of rapid clinical deterioration from adrenal insufficiency, clinicians should consider pituitary apoplexy early in the evaluation to facilitate prompt management while also evaluating for other significant differential diagnoses.