Classical Pituitary Apoplexy Presentation and a Follow-Up of 13 Patients

Abstract

Thirteen patients who presented with signs and symptoms of pituitary disease gave a history of classical pituitary apoplexy. Six presented with acute symptoms and in 7 the history antedated the admission by a mean of 887 days (range 365–2,190 days). All patients had an enlarged eroded sella. CT scans revealed a bleed in the tumor in 11 (histologically confirmed in all 8 patients operated), evidence of residual tumor in 1 and an empty sella (ES) in 1 patient. Hypopituitarism was present in 9, 4 were endocrinologically normal, 8 had visual problems requiring decompressive surgery and radiotherapy (RT) was given to 7 patients. They were subsequently followed for a median period of 730 days (range 365–3,385 days). During this time an empty sella developed in 5, 2 of whom had no surgery or RT; 4 remained endocrinologically normal, and a second hemorrhage occured in 2 patients. Histological evidence of previous bleeds was noted in 6 of the 8 patients treated surgically. We conclude that apoplexy (1) may produce complete or partial tumor destruction with or without preservation of endocrine function; (2) recurrent, often silent, bleeding into a pituitary tumor appears to be a common event; (3) RT should be withheld unless recurrent tumor is documented (since at least 2 patients in this study have experienced spontaneous resolution of the tumor); and (4) the presence of an enlarged eroded fossa with an ES is reasonable presumptive evidence of an infarction of a pre-existing pituitary tumor.

Multidisciplinary Management of Pituitary Apoplexy

“…This risk appears to be comparable in secreting and nonsecreting tumours and is lower in patients treated with radiotherapy [108]. Recurrent pituitary apoplexy is a rare event, although few cases have been reported [109]. It appears to be more common in patients managed conservatively than in those surgically treated [52].…”

Pituitary apoplexy

“…[9] Most cases of pituitary apoplexy present in the fifth or sixth decade with a slight male preponderance ranging from1.1 to 2.25:1.0. [10–13] In a recent retrospective analysis of 42 pituitary apoplexy patients from 1980 to 2007, the sex ratio was 3:1 with median age of the patients of 53.5 (range 21–85) years. [14] In the largest series from India studied at Vellore, the sex ratio was approximately 2:1 with mean age of presentation of 40.4 (range 18-65) years.…”

“…[111451–54] There are also studies showing higher prevalence among functioning tumors. [102555] Among the secreting tumors the highest prevalence was seen in prolactinomas. [141651] Study by Dubuisson et al .…”

Late recurrent bleeding after surgical treatment for pituitary apoplexy

“…Recurrent apoplexy is well documented in patients who were managed non-surgically during their first apoplectic event 4;6;14;19;20 but it is rare after surgical treatment of the initial episode. Recurrent apoplexy following surgery was first reported by Ahmed et al 11 Other four cases reported since then are summarized in Table 1. With diligent, careful long-term follow-ups more cases should have been diagnosed.…”

“…2;4;14 Decreased perfusion pressure to the adenoma may even lead to spontaneous necrosis and disappearance of the tumour without significant symptoms. 11; 12 Alatakis has reported a patient with empty sella and pituitary apoplexy that occurred in the absence of tumour tissue. 12 Such cases suggest that a fraction of cases with empty sella may represent these burn-out tumour cases.…”