Modern Management of Pituitary Apoplexy via an Initially Conservative Surgical Paradigm

Introduction: Over recent decades, management of pituitary apoplexy has become more conservative and does not always require surgical evacuation/resection of the hemorrhagic adenoma. We analyzed the clinical outcomes in patients treated with either surgical intervention or conservative management of apoplexy to better understand both treatment modalities.

Methods: Retrospective single-institutional review-board approved review of patients with a diagnosis of pituitary apoplexy between 2011 and 2019. All patients demonstrated signs of the clinical syndrome of apoplexy, such as headache, visual disturbance, or endocrine abnormalities, and underwent MRI demonstrating evidence of hemorrhage or ischemia suggestive of apoplexy. Neurological, endocrine, and imaging findings were analyzed both before and after management. Appropriate statistical tests were applied.

Results: Forty-four patients were identified (25 men, 19 women, median age: 56 years). All patients presented alert and oriented. Twelve (27%) patients had a history of known pituitary adenoma. The most common presenting symptom was headache (84%), followed by decreased visual acuity (43%). Twenty-two (50%) patients presented with hypopituitarism in some form. Twenty (45%) patients were managed conservatively with careful monitoring and nonoperative management of symptoms, while 24 (55%) patients presented with indication for urgent surgery (acute visual acuity loss) and were treated with endoscopic endonasal transsphenoidal resection within 24 hours. Of the 20 conservatively managed group of patients, 7 (35%) later needed surgery due to progression of tumor seen on imaging and/or worsening of clinical symptoms. These patients receiving “delayed surgery” were much more likely to have visual field defects at presentation compared with patients successfully managed with conservative treatment alone (57 vs. 8%, relative risk = 4, p = 0.015). Patients receiving delayed surgery also presented with significantly lower mean neutrophil/leukocyte ratio than other patients (p = 0.011), and by the time of surgical decision, this ratio increased to equal the urgent surgery group. The average duration of postapoplexy follow-up was 24 months. Overall, patients had favorable neurologic and imaging outcomes at final follow-up with 91% having improved neurological symptoms and 100% having stable or improved imaging. No patient had tumor recurrence or progression during the follow-up period. Most (70%) patients needed some form of hormone replacement at the time of final follow-up.

Discussion: Pituitary apoplexy has overall favorable outcomes with low rates of tumor recurrence or progression, and high rates (91%) of neurological improvement. Most patients (70%) will require postoperative hormonal replacement after apoplexy. Even subtle visual symptoms correlate with a need for eventual surgical intervention, many patients who failed initial conservative management in our cohort had tiny visual field deficits, and these deficits improved after delayed surgery. These patients also demonstrated a progression of systemic inflammation through increases in mean neutrophil/leukocyte ratio. In conclusion, a conservative management paradigm (45% initially nonoperative) of pituitary apoplexy produces good results, with no negative outcome for those who went on to require delayed intervention. Close follow-up is appropriate for those apoplexy patients initially considered poor surgical candidates, especially if any subtle visual defect is noted.

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Publikationsverlauf

Artikel online veröffentlicht:
12. Februar 2021