Visual Acuity Outcome in Patients with Acute Pituitary Apoplexy after Hyperacute Transsphenoidal Surgery

Background Pituitary apoplexy is a rare and acute clinical event that can have deleterious effects on visual function. Patients often present with acute decline in visual acuity and visual fields due to acute expansion of tumor volume. Delays in diagnosis and treatment may affect restoration of visual function and result in severe morbidity. Pituitary apoplexy occurs in 2 to 7% of pituitary adenomas; thus, given its relative rarity, it is difficult to study appropriate management and develop a consensus. Hyperacute neurosurgical decompression is defined as surgery within 24 hours of clinical presentation. The question of improved outcomes in conservative management versus hyperacute neurosurgical intervention, as it relates to visual acuity, is important given the critical nature of restoration of visual function after an apoplectic event.

Objective The purpose of this study is to examine the preoperative and postoperative visual acuity in one or both eyes of patients with pituitary apoplexy who were treated via hyperacute transsphenoidal sellar decompression within 24 hours of presentation, compared with later surgical intervention. We discuss the relationship between minimizing the delay before surgical intervention and increased restoration of visual acuity to baseline after clinical presentation.

Methods We conducted a retrospective analysis of 25 patients with pituitary apoplexy (42 eyes total) with a reduction in visual acuity due to the apoplexy. All patients who underwent transsphenoidal surgery and had a decline in visual acuity between 2012 and 2017 were included in the retrospective study. Patients were divided into three groups. The first group, consisting of 19 eyes, underwent transsphenoidal surgery within 24 hours. The second group included seven eyes and underwent surgery from 25 to 48 hours. The third group included 16 eyes and underwent surgery after 4 days. Outcome was analyzed immediately postoperatively, at first follow-up, and at final follow-up. There were 18 male patients (72%) and 7 female patients (28%) ranging from 16 to 78 years old. All patient presented with a pituitary macroadenoma, 16 (64%) of which demonstrated suprasellar extension on CT, while 5 (25%) were intrasellar and 3 (12%) were suprasellar with cavernous sinus extension.

Results Overall, 35 of 42 (83.33%) eyes demonstrated improvement in visual acuity after transsphenoidal surgery. Among patients who underwent hyperacute neurosurgical intervention within 24 hours of presenting with pituitary apoplexy, 18/19 (94.74%) eyes showed improvement from preoperative baseline in visual acuity at final follow-up. Among patients who underwent intervention from 25 to 48 hours, 5/7 (71.43%) of eyes saw improvement, while for patients who underwent intervention any time after 4 days, 12/16 (75%) of eyes saw improvement in visual acuity at final follow-up. Specifically, among patients who underwent intervention within 24 hours of presentation, 15/15 eyes (100%) showed improvement immediately postoperatively, 13/16 (81.25%) at first follow-up, and 6/7 eyes (85.71%) at final follow-up after first follow-up.

Conclusion Visual function outcome, particularly visual acuity, was increased among patients who underwent hyperacute neurosurgical intervention within 24 hours of presentation compared with patients who underwent later neurosurgical intervention.