Management and outcomes of pituitary apoplexy

Abstract

OBJECT This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes. METHODS The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale). RESULTS Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15–91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3–10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups. CONCLUSIONS The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.

Multidisciplinary Management of Pituitary Apoplexy

“…The middle- and long-term outcome of patients with pituitary apoplexy is strictly related to (i) the pathomechanisms of pituitary damage, (ii) the involvement of optic tract and oculomotor nerves, and (iii) the occurrence of SAH [101]. At the same time, in our opinion, a multidisciplinary management as well as a skilled and dedicated surgical team could affect the outcome of pituitary apoplexy.…”

“…In the former condition, hypopituitarism is frequently permanent, while in the latter one recovery of endocrine function can be obtained by debulking of the pituitary mass [63, 106]. However, in terms of endocrine outcome, some studies showed that pituitary hormones deficiencies consequent to pituitary apoplexy infrequently recover and the persistence of hypopituitarism seems to be not related to management modalities [4, 96, 99, 101, 107]. …”

35 Emergencies and Acute Situations in Skull Base Surgery

“…There is a 10% risk of apoplexy in incidentally discovered macroadenomas. 1 • Pituitary adenomas often show asymptomatic bleeding, which is detected during surgery, on pathology, or on magnetic resonance imaging (MRI); 14 to 25% of patients with a pituitary adenoma have asymptomatic bleeding. [2][3][4][5] Pituitary apoplexy, therefore, is a clinical and not a pathological diagnosis.…”

“…If at any point during this monitoring process the patient becomes unstable or the patient's condition worsens, or if there is a deterioration in the level of consciousness, then surgery should be considered. 1,17 Outcome Death is very rare in pituitary apoplexy, and in generally is related to intraoperative complications (vascular injury) or acute secondary adrenal insufficiency. Extraocular cranial neuropathy in general resolves over time, regardless of the treatment.…”

Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage

“…The symptoms of pituitary adenomas, such as headache, visual function impairment, and pituitary function insufficiency, usually manifest as compression effects on the dura mater in the sella, the optic chiasm, and the pituitary gland (1)(2)(3)(4). Intratumoral hemorrhages occur frequently and can exacerbate the symptoms of the adenoma, but there are many grades of severity (5,6).…”