Background: Pituitary apoplexy is a rare clinical syndrome resulting from infarction or hemorrhage of a pituitary tumor. Here, we present a large single center retrospective cohort study of patients with apoplexy. Methods: Patients with symptomatic apoplexy treated from January 2000 to October 2022 were isolated from the Halifax Neuropituitary Program’s database, containing prospectively entered data. Patients treated surgically typically presented with vision deterioration or decreased consciousness. Patient demographics, tumor size, endocrinologic values, and clinical outcomes were analyzed. Results: Eighty-three patients met our inclusion criteria. Seventy-two percent of tumours (n=60) were biochemically non-functioning adenomas. Sixty (72.3%) patients were treated surgically, while twenty-three (27.7%) were treated conservatively. At time of presentation, patients treated surgically had a tumor size in maximum dimension of 2.7±1.4 cm versus 1.6±0.5 cm for those treated conservatively (p=0.0003). There were no significant differences in endocrinological values at time of presentation between groups. Fifteen percent (n=9) of patients treated surgically underwent an additional surgery (mean 2.8±2.0 years from index), of which 67% (n=6) were secondary to tumor recurrence. Conclusions: This is one of the largest reported series of apoplexy with long-term follow up. A subset of surgically treated patients will require additional intervention, highlighting the importance of ongoing follow up in this population.