Visual and Hormone Outcomes in Pituitary Apoplexy: Results of a Single Surgeon, Single Institution 15-Year Retrospective Review and Pooled Data Analysis

Scott C. Seaman; Mark C. Dougherty; Mario Zanaty; Leslie A. Bruch; Scott M. Graham; Jeremy D. W. Greenlee

doi:10.1055/s-0040-1713104

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2021; 82(04): 392-400
DOI: 10.1055/s-0040-1713104

Original Article

Visual and Hormone Outcomes in Pituitary Apoplexy: Results of a Single Surgeon, Single Institution 15-Year Retrospective Review and Pooled Data Analysis

Scott C. Seaman

¹Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States

,

Mark C. Dougherty

¹Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States

,

Mario Zanaty

¹Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States

,

Leslie A. Bruch

²Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States

,

Scott M. Graham

³Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States

,

Jeremy D. W. Greenlee

¹Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States

› Author Affiliations

Abstract

Introduction Pituitary apoplexy commonly presents with visual and hormonal deficits. While traditionally regarded as an emergency, there have been increasing trends toward conservative management. Our institutional practice consists of early surgery; therefore, we reviewed our series evaluating vision outcomes, hormone function, and complications compared with the present literature.

Methods We retrospectively reviewed our institution's medical records to identify pituitary apoplexy patients who were treated via the endoscopic endonasal approach by a single neurosurgeon (senior author). We recorded basic demographics, radiographic and operative features, and preoperative and postoperative vision and hormone status. Univariate and multivariate statistical analyses were performed. Pooled data analysis of visual outcomes in the current literature using Bayesian inference was performed.

Results We identified 44 patients with histologically confirmed pituitary apoplexy treated by endoscopic transsphenoidal decompression; 77% were treated within 24 hours of presentation. Total 45% had cranial nerve (CN) palsy, 36% anopsia, and 20% had visual acuity deficits. Postoperatively, 100% of CN palsies improved, 81% of anopsias improved, and 66.7% of visual acuity deficits improved. Long-lasting panhypopituitarism (25%) and hypothyrodism (22%) were common. Cavernous sinus involvement predicted residual tumor (p = 0.006). Pooled Bayesian inference showed 30% improvement in vision outcomes with surgical management compared with medical management with a number needed to treat of 3.3.

Conclusion Early surgery for pituitary apoplexy was associated with excellent visual outcomes and the need for long-term hormone replacement is common. Cavernous sinus involvement is an independent predictor of residual tumor. Pooled statistical analysis favors aggressive surgical management of apoplexy for improved visual outcomes.

Keywords

hormone dysfunction - hypopituitarism - vision outcomes - aggressive early surgery - timing of surgery - pooled analysis

Full Text

References

References
1 Fernandez A, Karavitaki N, Wass JA. Prevalence of pituitary adenomas: a community-based, cross-sectional study in Banbury (Oxfordshire, UK). Clin Endocrinol (Oxf) 2010; 72 (03) 377-382
2 Wakai S, Fukushima T, Teramoto A, Sano K. Pituitary apoplexy: its incidence and clinical significance. J Neurosurg 1981; 55 (02) 187-193
3 Bonicki W, Kasperlik-Załuska A, Koszewski W, Zgliczyński W, Wisławski J. Pituitary apoplexy: endocrine, surgical and oncological emergency. Incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas. Acta Neurochir (Wien) 1993; 120 (3-4): 118-122
4 Lemos J, Eggenberger E. Neuro-ophthalmological emergencies. Neurohospitalist 2015; 5 (04) 223-233
5 Ayuk J, McGregor EJ, Mitchell RD, Gittoes NJ. Acute management of pituitary apoplexy--surgery or conservative management?. Clin Endocrinol (Oxf) 2004; 61 (06) 747-752
6 Seo Y, Kim YH, Dho YS. et al. The outcomes of pituitary apoplexy with conservative treatment: experiences at a single institution. World Neurosurg 2018; 115: e703-e710
7 Sahyouni R, Goshtasbi K, Choi E. et al. Vision outcomes in early versus late surgical intervention of pituitary apoplexy: meta-analysis. World Neurosurg 2019; 127: 52-57
8 Nawar RN, AbdelMannan D, Selman WR, Arafah BM. Pituitary tumor apoplexy: a review. J Intensive Care Med 2008; 23 (02) 75-90
9 Semple PL, Webb MK, de Villiers JC, Laws Jr ER. Pituitary apoplexy. Neurosurgery 2005; 56 (01) 65-72 , discussion 72–73
10 Sibal L, Ball SG, Connolly V. et al. Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases. Pituitary 2004; 7 (03) 157-163
11 Yang T, Bayad F, Schaberg MR. et al. Endoscopic endonasal transsphenoidal treatment of pituitary apoplexy: outcomes in a series of 20 patients. Cureus 2015; 7 (10) e357
12 Lubina A, Olchovsky D, Berezin M, Ram Z, Hadani M, Shimon I. Management of pituitary apoplexy: clinical experience with 40 patients. Acta Neurochir (Wien) 2005; 147 (02) 151-157 , discussion 157
13 Singh TD, Valizadeh N, Meyer FB, Atkinson JL, Erickson D, Rabinstein AA. Management and outcomes of pituitary apoplexy. J Neurosurg 2015; 122 (06) 1450-1457
14 Kim YH, Cho YH, Hong SH. et al. Postoperative neurologic outcome in patients with pituitary apoplexy after transsphenoidal surgery. World Neurosurg 2018; 111: e18-e23
15 Hage R, Eshraghi SR, Oyesiku NM. et al. Third, fourth, and sixth cranial nerve palsies in pituitary apoplexy. World Neurosurg 2016; 94: 447-452
16 Woo HJ, Hwang JH, Hwang SK, Park YM. Clinical outcome of cranial neuropathy in patients with pituitary apoplexy. J Korean Neurosurg Soc 2010; 48 (03) 213-218
17 Abdulbaki A, Kanaan I. The impact of surgical timing on visual outcome in pituitary apoplexy: literature review and case illustration. Surg Neurol Int 2017; 8: 16
18 Rutkowski MJ, Kunwar S, Blevins L, Aghi MK. Surgical intervention for pituitary apoplexy: an analysis of functional outcomes. J Neurosurg 2018; 129 (02) 417-424
19 Tu M, Lu Q, Zhu P, Zheng W. Surgical versus non-surgical treatment for pituitary apoplexy: a systematic review and meta-analysis. J Neurol Sci 2016; 370: 258-262
20 Leyer C, Castinetti F, Morange I. et al. A conservative management is preferable in milder forms of pituitary tumor apoplexy. J Endocrinol Invest 2011; 34 (07) 502-509
21 Almeida JP, Sanchez MM, Karekezi C. et al. Pituitary apoplexy: results of surgical and conservative management clinical series and review of the literature. World Neurosurg 2019; 130: e988-e999
22 David NJ. Pituitary apoplexy goes to the bar: litigation for delayed diagnosis, deficient vision, and death. J Neuroophthalmol 2006; 26 (02) 128-133
23 Wittenborn JS, Zhang X, Feagan CW. et al; Vision Cost-Effectiveness Study Group. The economic burden of vision loss and eye disorders among the United States population younger than 40 years. Ophthalmology 2013; 120 (09) 1728-1735
24 Taipale J, Mikhailova A, Ojamo M. et al. Low vision status and declining vision decrease health-related quality of life: results from a nationwide 11-year follow-up study. Qual Life Res 2019; 28 (12) 3225-3236
25 Garcia GA, Khoshnevis M, Gale J. et al. Profound vision loss impairs psychological well-being in young and middle-aged individuals. Clin Ophthalmol 2017; 11: 417-427
26 Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR. Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002). Thyroid 2007; 17 (12) 1211-1223
27 Mulligan T, Frick MF, Zuraw QC, Stemhagen A, McWhirter C. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract 2006; 60 (07) 762-769
28 Araujo AB, O'Donnell AB, Brambilla DJ. et al. Prevalence and incidence of androgen deficiency in middle-aged and older men: estimates from the Massachusetts Male Aging Study. J Clin Endocrinol Metab 2004; 89 (12) 5920-5926
29 Graham SM, Iseli TA, Karnell LH, Clinger JD, Hitchon PW, Greenlee JD. Endoscopic approach for pituitary surgery improves rhinologic outcomes. Ann Otol Rhinol Laryngol 2009; 118 (09) 630-635
30 Pal A, Capatina C, Tenreiro AP. et al. Pituitary apoplexy in non-functioning pituitary adenomas: long term follow up is important because of significant numbers of tumour recurrences. Clin Endocrinol (Oxf) 2011; 75 (04) 501-504
31 Zoli M, Milanese L, Faustini-Fustini M. et al. Endoscopic endonasal surgery for pituitary apoplexy: evidence on a 75-case series from a tertiary care center. World Neurosurg 2017; 106: 331-338
32 Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary 2014; 17 (04) 307-319
33 Potter NJ, Graham SM, Chang EH, Greenlee JD. Bioabsorbable plate cranial base reconstruction. Laryngoscope 2015; 125 (06) 1313-1315
34 Soudry E, Psaltis AJ, Lee KH, Vaezafshar R, Nayak JV, Hwang PH. Complications associated with the pedicled nasoseptal flap for skull base reconstruction. Laryngoscope 2015; 125 (01) 80-85
35 Dlouhy BJ, Madhavan K, Clinger JD. et al. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 2012; 116 (06) 1311-1317
36 Ogawa Y, Niizuma K, Mugikura S, Tominaga T. Ischemic pituitary adenoma apoplexy-Clinical appearance and prognosis after surgical intervention. Clin Neurol Neurosurg 2016; 148: 142-146