Overall, the main medications associated with pituitary apoplexy are either antithrombotic therapy or dopamine agonists such as bromocriptine and cabergoline.

To illustrate this, patients undergoing antithrombotic therapy for myocardial infarction or arrhythmias are at risk to develop pituitary apoplexy (Biousse et al. 2001). In a large series evaluating 1,540 pituitary lesions, 24 patients presented with pituitary apoplexy. Among them the authors personally observed an apoplectic episode in three patients receiving anticoagulating or antiaggregant therapy, in one patient with von Willebrand disease and in three patients with a prolactin-secreting adenoma following cabergoline treatment (Dubuisson et al. 2007).

A study in 2009 investigated predisposing factors in 83 patients with pituitary apoplexy. Bromocriptine therapy was reported in 16 % of these patients (Mou et al. 2009).

Other medications have also been associated with pituitary apoplexy. Recently, our group published a case of a 51-year-old acromegalic woman who developed pituitary apoplexy within the context of high blood pressure and a single dose of long-acting octreotide, suggesting the combination of hypertension and octreotide therapy may enhance the risk of pituitary apoplexy (Chang et al. 2010). Another interesting case of pituitary apoplexy due to GnRH agonist therapy (leuprolide) was also described in a 61-year-old male patient with locally advanced prostate cancer (Davis et al. 2006).

Diabetes or chronic systemic hypertension has also been considered to predispose to pituitary apoplexy because of degenerative changes in the gland’s microvasculature (Biousse et al. 2001). However, this association remains elusive. One recent study (Möller-Goede et al. 2011) evaluated 42 patients who had pituitary apoplexy against 84 in the control group without pituitary apoplexy and found actually that the risk for pituitary apoplexy was significantly elevated in patients with antithrombotic drugs (vitamin K antagonist or platelet inhibitors) (odds ratio = 2.96, CI = 1.16–7.58, P = 0.026), but not in patients with cardiovascular risk factors such as diabetes mellitus (odds ratio = 1.00, CI = 0.28–3.53, P = 1.00) and arterial hypertension (odds ratio = 0.93, CI = 0.38–2.29, P = 1.00).

As a perioperative complication of cardiac surgery, pituitary apoplexy is rare, but according to one study the pituitaries of 15.2 % of patients who died within 10 days of cardiac surgery demonstrated ischaemic necrosis compared to unselected autopsy cases, in which only 1.4 % showed similar pituitary abnormalities (Kovacs and Yao 1975).

Although this is not the rule, exceptionally no surgical management of pituitary apoplexy is required, as in the case of this 71-year-old man with a past medical history significant for type II diabetes mellitus, hypercholesterolaemia and unstable angina who underwent five-vessel coronary artery bypass grafting with no intraoperative complications (Mukhida and Kolyvas 2007). This may occur when the apoplectic event leads to a spontaneous resolution of a previously undiagnosed nonfunctioning pituitary macroadenoma following cardiac surgery.

There are other surgeries associated with pituitary apoplexy and described as case reports throughout the literature: bilateral adrenalectomy, prostatectomy, lumbar laminectomy and radiotherapy.

Head trauma (notably major injury) has been recognized as a predisposing factor for pituitary apoplexy. Nevertheless, this seems to be rare and statistical analyses of these cases are difficult (Möller-Goede et al. 2011). The mechanism of posttraumatic pituitary apoplexy is also unknown, but may be related to blood flow changes in pituitary adenomas due to fluctuations of intracranial pressure and blood pressure following severe head injury, leading to the apoplectic event in a pituitary adenoma (Biousse et al. 2001; Bao et al. 2007).