Surgical intervention for pituitary apoplexy: an analysis of functional outcomes

Abstract

OBJECTIVE Pituitary apoplexy is a clinical syndrome consisting of neurological and endocrine abnormalities secondary to hemorrhage or ischemia of an underlying pituitary adenoma. The authors investigated whether there was a significant difference in neurological, endocrine, and nonneuroendocrine outcomes for patients with pituitary apoplexy, based on the time between symptom onset and surgical intervention. METHODS The authors retrospectively analyzed the medical records of 32 patients who had presented to their institution with acute pituitary apoplexy and subsequently undergone endonasal transsphenoidal resection in the period from 2003 to 2014. All patients had undergone preoperative MRI demonstrating evidence of apoplexy in the form of intratumoral hemorrhage, ischemia, and necrosis. Neurological deficits, partial or complete endocrinopathy, and nonneuroendocrine abnormalities were analyzed both pre- and postoperatively. RESULTS Preoperatively, neurological deficits including visual loss and cranial nerve palsies were found in 31 (97%) of the 32 patients, endocrinopathy in the form of partial or panhypopituitarism was seen in 28 patients (88%), and nonneuroendocrine signs and symptoms were seen in 32 patients (100%). Thirteen patients (41%) underwent surgery within 72 hours of symptom onset ("early"), whereas 19 patients (59%) underwent surgery more than 72 hours from symptom onset ("delayed"). Early versus delayed resection did not appear to significantly improve visual deficits, total visual loss, resolution of oculomotor palsy, recovery from hypopituitarism, or nonneuroendocrine signs and symptoms such as headache and encephalopathy. Overall, visual improvement was seen in 77% of patients, complete restoration of normal vision in 38% of patients, and resolution of preoperative oculomotor palsies in 81% of patients. Only 6 (21%) of 28 patients showed evidence of partial hormone recovery following preoperative hypopituitarism. An absence of benefit for early surgery held true even when considering time to surgery from symptom onset as a continuous variable. CONCLUSIONS Neurological deficits such as visual loss and cranial neuropathies show moderate improvement following surgical decompression, as does preoperative hypopituitarism. The timing of surgical intervention relative to the onset of symptoms does not appear to significantly affect the resolution of neurological or endocrinological deficits.

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature

“…24 Rutkowski et al reported a gross-total resection rate of 67% in a similar cohort of patients. 25 In addition to the high-resection rate in the current series, no patients had any postoperative complications that is similar to that of other case series. 2,24 The effectiveness of the endoscopic transsphenoidal resection is best demonstrated in ►Table 2.…”

Clinical and biochemical characteristics of patients presenting with pituitary apoplexy

“…The median age of the patients presenting with pituitary apoplexy in our cohort was 46.7 (IQR 31.5–57.0) years, which is consistent with the mean ages (38–52 years) observed in other series ( 11 , 12 , 13 , 14 , 15 ). Pituitary apoplexy is often reported to occur more frequently in men than in women; however, we observed equal gender distribution in our series ( 6 , 11 , 14 , 15 ). All but one case of pituitary apoplexy in our series were in the context of a macroadenoma, especially non-functioning adenomas ( 5 , 10 , 18 , 19 ).…”

“…Patients with pre-existing pituitary adenoma have a 2–12% chance of pituitary apoplexy; however, pituitary apoplexy is frequently the first presentation of pituitary disease ( 1 , 4 , 6 , 11 , 12 , 13 , 14 ). Pituitary apoplexy is rare, and although described at all ages, it is most frequent in the fifth to sixth decades ( 1 , 6 , 11 , 12 , 13 , 15 ).…”

“…The initial management of pituitary apoplexy is supportive, including fluid resuscitation and correction of hormonal deficiencies. The potential for surgical management to improve recovery from neurological deficits remains a subject of conjecture in the absence of large randomised clinical trials ( 6 , 15 , 16 ). Thus, variability in the clinical course and recovery make the optimal management of pituitary apoplexy challenging.…”

Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature

“…PA is a clinical syndrome consisting of endocrine abnormalities and neurological deficits caused by underlying pituitary adenoma hemorrhage and/or ischemia, resulting in expansion, edema and necrosis. 5 , 6 The clinical manifestations of PA are diverse. Anterior pituitary hormone deficiency, especially ACTH deficiency, is prone to cause electrolyte disturbances, nausea and vomiting.…”