Pituitary Apoplexy: Management in a Specialized Pituitary Center

Background Pituitary apoplexy is a rare condition traditionally associated with visual deterioration, oculomotor deficits, and hormonal dysfunction. In severe cases, it may lead to deterioration of the level of consciousness and death. Surgery remains the main treatment option for symptomatic patients, especially those with progressive visual decline. In the current study, we evaluate the management of pituitary apoplexy in our center.

Methods A radiological database was searched for all patients with pituitary apoplexy signs evaluated in a single center from 2007 to 2014. Patients with acute symptoms, including new onset of headache with nauseas and vomiting, visual decline, cranial nerve palsy, and loss of consciousness, were selected. Clinical and radiological data were analyzed for assessment of outcomes.

Results A total of 210 patients had radiological signs suggestive of pituitary apoplexy. In this group, a population of 27 patients presented with acute symptoms and underwent surgical treatment. The mean age of patients submitted to surgery was 55.9 ± 16.4 (range: 28–83) years and mean follow-up of 35.6 ± 26.9 months. The large majority of patients had nonsecreting adenomas (24 patients, 88%), whereas secreting adenomas were present in three cases (two GH secreting and one ACTH secreting adenomas). Visual decline, hypopituitarism, and cranial nerve palsy were present in 81.5, 55.5, and 51.1% of patients, respectively. The mean interval between ictus and surgery was 7.8 ± 6.03 days. Gross total resection was achieved in 22 cases (81.4%). As surgical complications, there were two postoperative CSF leaks and one death secondary to myocardial ischemia and cardiogenic shock. Visual improvement was observed in 95.4% of patients. Partial improvement of cranial nerve dysfunction was noted in 57.1% (8 out 14 patients) 1 week after surgery and complete recovery was observed in 71.4% (10 out of 14 patients) at last follow-up. No postoperative hormonal improvement was observed and long-term hormonal replacement therapy was required in 59.2% of patients. During follow-up, two patients (7.4%) had recurrences that required additional surgical treatment.

Conclusion Endoscopic endonasal surgery is associated with high rates of visual improvement in patients with pituitary apoplexy. Patients with progressive visual deterioration, cranial nerves palsy, and reduction of level of consciousness should be considered for early surgical treatment. Hormonal status is not improved with surgical treatment, but may be negatively impacted after the operative procedure.

Timing of surgery remains controversial and further analysis with a matched control population is required for further analysis.