The Presentation and Clinical Management of Pituitary Microadenoma Apoplexy

The presentation and management of pituitary microadenoma apoplexy is not well understood in large part because apoplexy events associated with these small tumors are exceedingly rare. Indeed, only nine such cases have been reported in the literature. To address this gap in our knowledge, we identified 17 patients who presented with symptoms consistent with pituitary apoplexy and had evidence of a pituitary microadenoma infarct or hemorrhage on MRI. Demographic and clinical data were collected as part of a retrospective chart review. A cutoff of 94 ng/mL was used to determine which patients were likely to have had prolactin secreting tumors as no tissue samples were taken. Additionally, a review of the literature was performed, which identified 9 previous cases of pituitary microadenoma apoplexy. Data from the case reports were integrated with our own, where indicated, to better characterize the breadth of these rare events. Interestingly, all 26 patients were women, and most were of reproductive age. The most common presenting symptom was headache, as reported by 20 patients. Although only 7 patients were thought to have prolactinomas, 16 patients reported a prodromal period defined by amenorrhea or galactorrhea that could not be attributed to other causes such as polycystic ovarian syndrome, hypothydroidism, or menopause. Most patients were managed safely through supportive therapy including the use of a dopamine agonist to mitigate the effects of hyperprolactinemia. Surgery was performed on 6 patients from the case reports, five of whom had failed conservative management for at least 1 year Based on our results, it appears that pituitary microadenoma apoplexy tends to follow a fairly benign course. Thus, optimal management in most patients constitutes close observation and medical therapy when appropriate, with surgical intervention warranted only in the most exceptional cases.