Time Course of Symptomatic Recovery After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma Apoplexy in the Modern Era

Diagnosis and Treatment of Pituitary Apoplexy, A True Endocrine Emergency

Pituitary apoplexy (PA) is a clinical syndrome resulting from a hemorrhagic infarction of the pituitary gland. It is characterized by the sudden onset of visual disturbances, nausea, vomiting, headache and occasionally, signs of meningeal irritation and an altered mental status. The exact pathogenesis of PA remains to be elucidated, although tumor overgrowth of its blood supply remains the most popular theory. Main risk factors for the development of PA include systemic, iatrogenic, and external factors as well as the presence of an underlying pituitary tumor. The diagnostic approach of PA includes both neuroimaging and evaluation of pituitary secretory function. PA is a potentially life-threatening condition which should be managed with hemodynamic stabilization, correction of electrolyte abnormalities and replacement of hormonal deficiencies. PA treatment should be individualized based on the severity of the clinical picture which may vary widely. Treatment options include conservative management with periodic follow-up or neurosurgical intervention, which should be decided by a multidisciplinary team. We conducted a systematic review of the literature to unveil the frequency of PA predisposing factors, clinical and biochemical presentations, management strategies and outcomes.

Ultra-Early Treatment of Neurosurgical Emergencies with Endoscopic Endonasal Approach: Experience from Three Italian Referral Centers

PURPOSE

the aim of this multicenter study is to preliminarily assess the role of the Endoscopic Endonasal Approach (EEA) in ultra-early (i.e., within 12 h) management of selected neurosurgical emergencies in terms of clinical and radiological outcomes.

METHODS

26 patients affected by sellar/parasellar pathologies with rapid progression of symptoms were managed with EEA within 12 h from diagnosis in three Italian tertiary referral Centers from January 2016 to December 2019. Both clinical and radiological data have been collected preoperatively as well as post-operatively in order to perform retrospective analysis.

RESULTS

The average time from admission to the operating room was 5.5 h (±2.3). The extent of resection was gross-total in 20 (76.9%), subtotal in 6 (23.1%) patients. One patient experienced re-bleeding after a subtotal removal of a hemorrhagic lesion. Patients with a longer time from admission (>4 h) to the operatory room (OR) experienced stable impairment of the visual acuity (p = 0.033) and visual field (p = 0.029) in the post-operative setting.

CONCLUSIONS

The Endoscopic Endonasal Approach represents a safe, effective technique that can be efficiently used with good results in the management of selected neurosurgical emergencies in centers with adequate experience.

Determinants of visual and endocrinological outcome after early endoscopic endonasal surgery for pituitary apoplexy

Background:

Patients diagnosed with pituitary apoplexy and presenting with acute visual deterioration require urgent surgical resection. This is also commonly associated with pituitary hypopituitarism that requires hormonal replacement for correction. This study was undertaken to evaluate the clinical recovery of 45 patients diagnosed with symptomatic pituitary apoplexy who underwent early (within 72 h of symptom onset) endoscopic transsphenoidal surgical resection with an emphasis on visual, ocular craniopathy, and endocrinological outcome.

Methods:

This is a retrospective analysis of a consecutive series of patients diagnosed with pituitary apoplexy between 2011 and 2020 treated by early (within 72 h of symptom onset) endoscopic transsphenoidal surgical resection. All tumors were histologically proven as pituitary adenomas. Clinical and neuro-ophthalmological examinations, imaging studies, and endocrinological evaluation were retrospectively reviewed. Patients with a minimum of 6 months follow-up were included in the study. The influence of patients’ demographics, extent of visual and ocular motility impairment, preoperative endocrinological dysfunction, tumor size and extent, degree of resection, and surgical complications were analyzed as potential prognostic factors for recovery.

Results:

Forty-five patients were included in this retrospective study. Ages ranged from 27 to 57 years (mean: 42 years). All patients presented with headache and variable degrees of visual loss and visual field deficit. Ophthalmoplegia was present in 22 (48.9%) patients with 17 (37.8%) having bilateral ocular cranial nerve palsy. All patients had variable degrees of endocrinological deficiencies. All patients showed evidence of low cortisol, 14 (31.1%) showed hypothyroidism and 11 (24.4%) showed hypogonadism. There was evidence of hyperprolactinemia in 16 (35.6%) patients. All patients harbored a pituitary macroadenoma. Tumor resection was complete in 33 (73%) of patients, with residual tumor related to cavernous sinus or retrosellar extension. Operative complications were mainly related to short-term nasal complications occurring in 14 (31%) patients. Cerebrospinal fluid leak requiring revision surgery occurred in only one patient harboring a modified SIPAP Grade 3s tumor. Transient diabetes insipidus occurred in 9 (20%) patients, with 2 (4.4%) requiring long-term hormonal replacement. The mean follow-up was 25 months. Baseline visual improvement was achieved in 39 (86.7%) patients. Ocular cranial nerve palsy showed complete recovery in 17 (77.2%) patients. Endocrine follow-up showed that patients with panhypopituitarism (11 [24.4%]) failed to recover.

Conclusion:

The current surgical series showed safety in terms of low complication rate and efficacy in terms of clinical outcome. The significant prognostic factor related to visual recovery was the degree of preoperative visual deficit. Recovery of ocular cranial neuropathy showed a higher recovery rate when it was unilateral as opposed to bilateral. Pituitary hormonal recovery was less favorable with pituitary panhypopituitarism being a poor prognostic factor.

Revisiting Pituitary Apoplexy

Pituitary apoplexy (PA) is a rare clinical syndrome due to pituitary hemorrhage or infarction. It is characterized by the sudden onset of one or more of the following: severe headache, visual disturbance, nausea/vomiting, and or altered mental status. Most commonly, PA occurs in an underlying pituitary adenoma. The pathophysiology is not fully understood, but it is thought to involve elements of increased metabolic demand and/or compromise to the vasculature of the pituitary or pituitary tumor. Several risk factors have been described. Stabilization of the patient on presentation, replacement of hormonal deficiencies, and reversal of electrolyte abnormalities are the recommended initial steps in the management of patients with PA. Surgical decompression of the mass effect had been the recommended treatment for patients with PA; however, retrospective studies of patients with PA have demonstrated similar outcomes when a conservative approach is applied. This suggests that in highly selected clinical scenarios (mild visual deficit and improving symptoms), conservative management is possible. Further studies, however, are necessary to better stratify patients but are limited by the rarity of the condition and the acuity.

Surgery for Pituitary Tumor Apoplexy Is Associated with Rapid Headache and Cranial Nerve Improvement

Pituitary tumor apoplexy (PTA) classically comprises sudden-onset headache, loss of vision, ophthalmoparesis, and decreased consciousness. It typically results from hemorrhage and/or infarction within a pituitary adenoma. Presentation is heterologous, and optimal management is debated. The time course of recovery of cranial nerve deficits (CNDs) and headaches is not well established. In this study, a retrospective series of consecutive patients with PTA managed at a single academic institution over a 22-year period is presented. Headaches at the time of surgery were more severe in the early and subacute surgical cohort and improved significantly within 72 h postoperatively (p < 0.01). At one year, 90% of CNDs affecting cranial nerves (CNs) 3, 4, and 6 had recovered, with no differences between early (<4 d), subacute (4−14 d), and delayed (>14 d) time-to-surgery cohorts. Remarkably, half recovered within three days. In total, 56% of CN2 deficits recovered, with the early surgery cohort including more severe deficits and recovering at a lower rate (p = 0.01). No correlation of time-to-surgery and rapidity of recovery of CNDs was observed (p = 0.65, 0.72). Surgery for PTA is associated with rapid recovery of CNDs in the early, subacute, and delayed time frames, and with rapid headache improvement in the early and subacute time frames in 50% or more of patients.

Factors predicting neuro-endocrine recovery following transsphenoidal surgery in pituitary apoplexy patients

BACKGROUND

Pituitary apoplexy is a rare clinical syndrome. Only a few studies have examined factors associated with recovery of neuro-endocrine functions following transsphenoidal surgery. This study aimed to identify factors associated with neuro-endocrine recovery following surgery for pituitary apoplexy.

METHODS

The records of pituitary apoplexy patients who underwent transsphenoidal surgery at Songklanagarind Hospital between January 2005 and December 2020 were retrospectively reviewed. The primary outcomes were the recoveries of preoperative visual acuity (VA), visual field (VF), cranial nerve function, and pituitary hormone deficits. Using logistic regression analysis, various factors were analyzed for their associations with recovery of neuro-endocrine functions.

RESULTS

The study included 98 patients. Multivariate analysis showed that older age and greater suprasellar extension were associated with no recovery of VA (P = 0.042 and P = 0.018, respectively). Only 33% of patients aged > 55 years and suprasellar extension of lesion ≥ 25 mm gained recovery of VA, while 100% of patients with neither of these factors had recovery. Underlying hypertension was associated with no recovery of preoperative VF defect (P = 0.027). Wilson-Hardy classification-invasion grades 3-4 and lower preoperative serum prolactin level were associated with no recovery from preoperative hypoadrenalism and hypothyroidism (P = 0.016 and P = 0.007, respectively).

CONCLUSIONS

Older age, higher suprasellar extension, and hypertension were poor prognostic factors for visual recovery. Wilson-Hardy inferior invasion grade 3-4 and lower preoperative serum prolactin level were poor prognostic factors for recovery from hypopituitarism. Stratifying patients according to these prognostic factors may assist in selecting patients for surgery.

Predictive Clinical and Surgical Factors Associated with Recurrent Apoplexy in Pituitary Adenomas

Introduction Pituitary apoplexy is an uncommon clinical condition that can require urgent surgical intervention, but the factors resulting in recurrent apoplexy remain unclear. The purpose of this study is to determine the risks of a recurrent apoplexy and better understand the goals of surgical treatment.

Methods A retrospective chart review was performed for all consecutive patients diagnosed and surgically treated for pituitary apoplexy from 2004 to 2021. Univariate analysis was performed to identify risk factors associated with recurrent apoplexy.

Results A total of 115 patients were diagnosed with pituitary apoplexy with 11 patients showing recurrent apoplexy. This occurred at a rate of 2.2 cases per 100 patient-years of follow-up. There were no major differences in demographic factors, such as hypertension or anticoagulation use. There were no differences in tumor locations, cavernous sinus invasion, or tumor volumes (6.84 ± 4.61 vs. 9.15 ± 8.45 cm, p = 0.5). Patients with recurrent apoplexy were less likely to present with headache (27.3%) or ophthalmoplegia (9.1%). Recurrent apoplexy was associated with prior radiation (0.0 vs. 27.3%, p = 0.0001) and prior subtotal resection (10.6 vs. 90.9%, p = 0.0001) compared with first time apoplexy. The mean time to recurrent apoplexy was 48.3 ± 76.9 months and no differences in overall follow-up were seen in this group.

Conclusion Recurrent pituitary apoplexy represents a rare event with limited understanding of pathophysiology. Prior STR and radiation treatment are associated with an increased risk. The relatively long time from the first apoplectic event to a recurrence suggests long-term patient follow-up is necessary.

Optimizing pre-, intra-, and postoperative management of patients with sellar pathology undergoing transsphenoidal surgery

OBJECTIVE

Perioperative management of patients with sellar lesions is complex, requiring input from a multidisciplinary team of specialists for ongoing management of both endocrinological and neurosurgical issues. Here, the authors reviewed the experience of a single multidisciplinary center over 10 years to identify key postoperative practices that ensure positive outcomes for patients with sellar lesions who undergo transsphenoidal surgery.

METHODS

The authors performed a retrospective review of all transsphenoidal operations carried out by the senior author at a single center from April 2008 through November 2018. They included only adult patients and recorded perioperative management. They also reviewed the evolution of clinical practices for perioperative care at their institution to identify strategies for ensuring positive patient outcomes, and they reviewed the literature on select related topics.

RESULTS

In total, 1023 operations in 928 patients were reviewed. Of these, 712 operations were for pituitary adenomas (69.6%), and 122 were for Rathke cleft cysts (11.9%). The remainder included operations for craniopharyngiomas (3.6%), arachnoid cysts (1.7%), pituitary tumor apoplexy (1.0%), and other sellar pathologies (12.2%). Among the reviewed operations, the median hospital stay was 3 days (IQR 2-3). Patient management details during the pre-, intra-, and postoperative periods were identified, including both shared characteristics of all patients undergoing transsphenoidal surgery and unique characteristics that are specific to certain lesion types or patient populations.

CONCLUSIONS

Patients with sellar lesions who undergo transsphenoidal surgery require complex, multidisciplinary perioperative care to monitor for common adverse events and to improve outcomes, but there is a dearth of high-quality evidence guiding most perioperative practices. Here, the authors reviewed practices at their institution across more than 1000 transsphenoidal operations that may help ensure successful patient outcomes.

Temporal patterns of visual recovery following pituitary tumor resection: A prospective cohort study

Significant restoration of visual function can occur following pituitary tumor resection, although the time course of visual recovery remains poorly understood. This single-centre, two-year, prospective cohort study investigated the temporal patterns of visual recovery in consecutive patients undergoing pituitary tumor resection, between 2009 and 2018. Eyes were stratified based on pre-operative optical coherence tomography (OCT) retinal nerve fibre layer (RNFL) thickness measurements, with thin RNFL being defined as those within the fifth-percentile of age-matched normative values, and normal RNFL as those above the fifth-percentile. Visual function and OCT parameters were assessed pre-operatively, and at 6 weeks, 6 months, and 2 years post-operatively. 456 eyes of 228 patients (mean ± SD age, 53 ± 15 years) were included, of which 114 (25%) eyes had thin RNFL pre-operatively. Visual field recovery was observed in both groups during the first 6 weeks post-operatively (all Q ≤ 0.02), although improvements in visual field parameters between 6 weeks to 6 months were limited to eyes with thin RNFL (both Q < 0.05). No further improvements in visual function were detected beyond 6 months in both groups (both Q > 0.50). Similar trends were observed in linear regression analysis according to baseline visual function in both groups. In summary, eyes with normal RNFL thickness at baseline experienced most of their recovery within the first six weeks following surgery, while eyes with thin RNFL exhibited gradual improvements during the first six months. These findings have important implications when providing patient counselling and prognostication in the pre-operative setting.

Ophthalmological Management of Patients with Pituitary Adenomas

Pituitary tumours are a common cause of functional impairment and degeneration of the anterior visual pathway. Depending on localization and size, they clinically manifest as initially reversible visual field defects. As part of interdisciplinary tumour management, ophthalmologic examinations are of particular importance concerning diagnostics, indication for tumour resection and documentation of functional surgical results. Based on the relationship between clinical dysfunction and manifest atrophy, together with the patient's age and the duration of symptoms, the ophthalmologist can provide insights into the postoperative visual prognosis. Under good conditions, surgical tumour resection often results in significant improvements to visual fields and acuity. Long-term ophthalmological controls are required in cases of persistent visual loss, radiotherapy or tumour remnants abutting the visual pathway.

Pituitary apoplexy: how to define safe boundaries of conservative management? Early and long-term outcomes from a single UK tertiary neurosurgical unit

OBJECTIVES

(1) Describe presentation, management and outcomes of a single-centre series of patients with pituitary apoplexy. (2) Compare early and long-term outcomes of conservative and surgical management. (3) Identify predictive factors for visual recovery.

METHODS

Retrospective analysis of patients acutely managed by Sheffield's Neurosurgery over a 9-years period. Outcome comparison was made between 2 groups ('conservative' versus 'emergency') at early FU and 3 groups ('conservative' versus 'elective' versus 'emergency') at long-term FU.

RESULTS

Data from 30 patients (M:F = 2.8:1; mean age: 54 years; median FU: 31.5 months) were collected. 86,7% patients presented with visual disturbances (70% acuity, 50% field, 50% diploplia). 10 (33%) patients underwent emergency surgery and further 8 underwent delayed elective surgery.At early FU, resolution rates of VA (33% versus 38%), VF (40% versus 50%) and CN deficits (71% versus 40%) were not significantly different between groups.At long-term FU, resolution of VA (80% versus 20% versus 75%) and CN deficits (67% versus 50% versus 80%) was not significantly different between groups. Most patients who underwent surgery presented with severe VA deficit (20% versus 40% versus 63%) but severity of initial deficit wasn't correlated with long-term resolution.VF recovery rates showed significant difference between groups (p = 0.027): 67% versus 0% versus 88%.Endocrine outcomes were generally poor, regardless of the management strategy.Regarding possible predictive factors, age and tumour size correlated with visual outcomes. Especially in patients treated conservatively in the acute phase, no cases of complete resolution of VA or VF deficit were recorded when tumour was higher than 35 mm.

CONCLUSIONS

Good results are possible with conservative management in selected cases. Emergency surgery provides better visual outcomes. Decision-making process should be tailored to every single patient. We believe that a tumour vertical diameter >35 mm should tip the balance in favour of surgical management in presence of visual deficit.

[Pituitary apoplexy following coronary bypass surgery: A case report and literature review]

INTRODUCTION

Pituitary apoplexy is a >rare entity that presents with a sudden onset of headache associated with visual and endocrinological disturbances due to pituitary hemorrhage or infarction. It usually occurs in patients with an unknown pituitary adenoma. Cardiac surgery, and especially coronary artery bypass grafting, can be a precipitating factor in these patients.

CASE REPORT

We report an 82-year-old male patient who presented with sudden headache and delirium, a right sixth cranial nerve palsy, a right temporal hemianopsia, and a severe loss of left eye visual acuity in the immediate post-operative course of a coronary artery bypass surgery. Pituitary apoplexy was demonstrated on both MRI and CT-scan. Trans-sphenoidal surgical decompression was performed 13 days after coronary artery bypass grafting, with immediate beneficial effect on the delirium and a partial recovery of visual disturbances.

CONCLUSION

Pituitary apoplexy is a rare and life-threatening complication that may occur after cardiac surgery (coronary artery bypass, cardiac valve surgery), often precipitated by the use of cardiopulmonary bypass. It can occur after other surgical procedures (orthopedic, digestive, thoracic). The diagnosis must be considered during the early postoperative period in the presence of unusual and severe headache associated with visual disturbances.

Pituitary Apoplexy Case Series: Outcomes After Endoscopic Endonasal Transsphenoidal Surgery at a Single Tertiary Center

BACKGROUND

The management of pituitary apoplexy, caused by acute hemorrhage and/or infarction of a pituitary adenoma, is debated.

OBJECTIVE

To analyze clinical characteristics of patients undergoing endoscopic endonasal approaches (EEAs) for pituitary apoplexy.

METHODS

A retrospective review of patients at our institution from 2012 to 2018 undergoing EEA for pituitary apoplexy diagnosed clinically and with imaging/pathologic findings. Analysis included demographics, symptoms, neuroendocrine deficits, neuroimaging, complications, symptom resolution, and follow-up details.

RESULTS

Fifty patients (mean age, 53 years) were included. Preoperative symptoms included headache (86%), vision loss (62%), and cranial nerve paresis (40%). Mean tumor diameter was 2.7 cm and extrasellar extension was observed in 96% of tumors. Twenty-eight tumors were hemorrhagic (76%), 24 were necrotic (65%), and 13 (35%) had both features. Magnetic resonance imaging showed gross total resection in 58% of patients. Headache and vision loss improved in 87% and 86% of presenting patients. Cranial nerve paresis resolved in 72% of patients, partially improved in 11%, and remained unchanged in 17%. There were no deaths or carotid artery injuries. Surgical complications included postoperative cerebrospinal fluid leak (n = 4, 8%), epistaxis (n = 2, 4%), postoperative abscess (n = 1, 2%), and transient postoperative vision loss requiring reoperation (n = 1, 4%). Endocrinopathies improved in 21% of patients and panhypopituitarism persisted in 48% and developed in 6% of patients. Mean follow-up time was 26 months; 2 patients experienced recurrence.

CONCLUSIONS

EEA for pituitary apoplexy is effective in rapidly improving headache and visual symptoms. Although neuro-ophthalmic deficits often improve over time, panhypopituitarism persists in most patients after surgical resection.

The Effect of Timing of Surgery in Pituitary Apoplexy on Continuously Valued Visual Acuity

Background  Pituitary apoplexy is often treated urgently, but this is based on studies which assess vision categorically and dichotomizes the time interval between symptom onset and surgery which may introduce bias in measuring an association between the two. Objective  This study was aimed to assess for a relationship between continuously valued surgery delay and visual acuity recovery after pituitary apoplexy. Methods  In this retrospective study, all patients presenting with symptomatic pituitary apoplexy between 2004 and 2016 were identified from an institutional database. The primary endpoint was visual acuity improvement, measured as the difference in acuity from the pre- to postoperative period, and measured in Logarithm of the Minimal Angle of Resolution (LogMAR) units. Analysis was performed using continuous values of time delay and visual acuity to assess for an underlying association. Results  Thirty-two pituitary apoplexy patients were identified. Visual acuity deficits were reported in 81%. The median visual acuity was 0.35 LogMAR (Snellen's fraction 20/40) preoperatively, and 0.1 (20/25) postoperatively ( p  < 0.01). The time between symptom onset and surgery was not associated with improvement in visual acuity ( p  = 0.46). When the time delay and visual outcome were intentionally dichotomized, patients undergoing surgery within 2 days of symptom onset had 0.21 times the odds of a good visual outcome (95% confidence interval [CI]: 0.04-1.05). Conclusion  When assessed as continuously valued measures, the time from symptom onset to surgical intervention and the improvement in visual acuity are not associated, although intentional dichotomization of data produced conflicting results.

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature

Introduction  For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes. Methods  A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time. Results  A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation ( p  = 0.047) . Conclusion  Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.

Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature

OBJECTIVE

Pituitary apoplexy is associated with visual, cranial nerve, and endocrine dysfunction. In this article, the results of surgical and conservative management of pituitary apoplexy in a single center are evaluated and a review of the literature is presented.

METHODS

A retrospective analysis was made of patients with pituitary apoplexy who underwent surgery or conservative management at our center between January 2007 and June 2017. Surgery was typically selected for patients who presented with acute deterioration of visual status and/or level of consciousness. Patients with no visual field deficit and those who had medical contraindications to undergo a surgical procedure because of previous comorbidities typically had conservative treatment. Baseline characteristics and clinical and radiologic outcomes were reviewed. A review of the literature (1990-2018) was performed according to PRISMA guidelines. Studies comparing the results of conservative and surgical management were identified. Visual, cranial nerve, and endocrine outcomes and tumor recurrence were analyzed.

RESULTS

Forty-nine patients (73.1%) were managed surgically and 18 (26.9%) conservatively. After careful case selection, patients underwent surgical or conservative treatment. Patients who underwent conservative treatment had fewer visual deficits. At diagnosis, visual deficit (38.8% vs. 75.5%; P = 0.008) and cranial nerve palsy (27.7% vs. 51%; P = 0.058) were less common in the conservative group. Conservative and surgical treatments had similar visual and cranial nerve improvement rates (75% vs. 58.3%, P = 0.63 and 75% vs. 69.2%, P = 1.0, respectively). In the conservative group, tumor shrinkage was observed in 76.4% of cases. The systematic review retrieved 11 studies. No significant difference between conservative and surgical treatment for clinical outcomes (visual field recovery, odds ratio [OR], 1.45; 95% confidence interval [CI], 0.72-2.92; cranial nerve recovery, OR, 2.30; 95% CI, 0.93-5.65; and hypopituitarism, OR, 1.05; 95% CI, 0.64-1.74) or tumor recurrence (OR, 0.68; 95% CI, 0.20-2.34) was observed.

CONCLUSIONS

A tailored approach to pituitary apoplexy, one that does not include an absolute need for surgery, is appropriate. Conservative management is appropriate in selected patients presenting without visual deficits.

Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature

Background

Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA.

Case description

We describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient’s poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family’s wishes, we continued the conservative treatment and watched closely for any changes in the patient’s condition. After 6 months of conservative treatment, the patient’s symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient’s hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone.

Conclusion

In older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients’ condition closely and continue conservative treatment, which may yield good results.

Endoscopic Endonasal Surgery for Removal of Pituitary Adenomas: A Surgical Case Series of Treatment Results Using Different 2- and 3-Dimensional Visualization Systems

BACKGROUND

Endoscopic endonasal transsphenoidal surgery (EETS) is a common treatment for patients with pituitary adenomas (PAs). A disadvantage of endoscopic surgery has been the lack of stereoscopic vision and depth perception. Recent developments offer high-definition 3-dimensional (3D-HD) visualization with a higher resolution and better image quality compared with 3D standard endoscopy (3D-SD). In this study, we compared treatment results of surgically treated patients with PAs using 3 different visualization systems: 2-dimensional (2D)-HD, 3D-SD, and 3D-HD.

METHODS

Data from patients with primary PAs that were surgically treated between December 2008 and December 2017 were analyzed. Preoperative and postoperative tumor size and location, perioperative complications, and ophthalmologic, endocrine, and clinical outcomes were compared.

RESULTS

A total of 170 patients underwent endoscopic resection of a primary PA (54 patients with 2D-HD, 75 with 3D-SD, and 41 with 3D-HD). Preoperatively, no statistical differences were found for tumor size, extension, and endocrine and ophthalmologic status. Tumor resection was not statistically different among the 3 groups. Complete resection was performed in 33 patients (80%) in the 3D-HD group, 54 patients (72%) in the 3D-SD group, and 39 patients (72%) in the 2D-HD group. The number of complications was not different across the groups (P = 0.436). Ophthalmologic outcomes did not differ based on EETS technique. The rate of new pituitary insufficiency was slightly lower in the 3D-HD group compared with 2D-HD and 3D-SD groups (4.8%, 16.6%, and 12%, respectively; P = 0.290).

CONCLUSIONS

Although the resection rate was higher in the 3D-HD group, and subjective advantages of the 3D-HD endoscopes were noted, there were no significant differences in terms of gross total resection or new hormonal deficits among the 3 groups.

The dangers of the "Head Down" position in patients with untreated pituitary macroadenomas: case series and review of literature

PURPOSE

Cavernous sinus syndrome is a rare phenomenon, characterized by simultaneous neuropathies of cranial nerves III-VI. Various pathological processes have been reported as precipitating etiologies, including infection, inflammation, vascular lesions, and neoplasms.

PURPOSE

We report a unique case series of cavernous sinus syndrome attributable to prolonged Trendelenburg or prone positioning during non-cranial procedures and review the pertinent literature to enlighten on this rare but catastrophic phenomenon.

METHODS

Retrospective case series.

RESULTS

In the past year we encountered two patients who presented with acute cavernous sinus syndrome upon awakening from non-cranial operations. One patient underwent an extensive urologic resection of a bladder malignancy positioned in Trendelenburg for approximately 4 h. The second patient underwent a lumbar laminectomy and discectomy in prone position. Both patients were discovered to have infarcted large pituitary macroadenomas as the etiology of their acute ophthalmoplegias, and transnasal, transsphenoidal resection was performed acutely to decompress the cavernous sinus contents. Pathologic analysis of the resected specimens in each case confirmed necrotic, infarcted pituitary adenoma. Both patients made a complete recovery with no evidence of residual or recurrent tumor in short term follow-up.

CONCLUSION

We report a brief case series of acute cavernous sinus syndrome resulting from dependent positioning during non-cranial operations in patients with pituitary macroadenoma. Although rare, this highlights a potential danger of "head down" positioning in patients with intracranial pathology-particularly in or around the sella and cavernous sinus. Despite multiple cranial neuropathies upon presentation, both patients made complete recovery following surgical decompression of the cavernous sinuses.

Pituitary Apoplexy: Should Endoscopic Surgery Be the Gold Standard?

BACKGROUND

Pituitary apoplexy is an uncommon, potentially fatal condition due to spontaneous ischemia or hemorrhage in a pituitary adenoma. The treatment of this disorder has long been a matter of debate.

METHODS

Retrospective cohort study including all patients admitted with pituitary apoplexy in our department between 2005 and 2015 was undertaken. Clinical symptoms and signs on admission, treatment (conservative vs. surgical), neurologic deficit on discharge and at 6 months' follow-up, and endocrinologic evaluation at 6 months' follow-up were analyzed. The statistical analysis was performed with STATA 13.0. Endocrinologic and visual outcomes at 6 months in the different groups according to treatment were compared by applying an independent multinomial probit regression test. Outcomes between the conservative and the surgical (endoscopic and microscopic considered together) groups also were compared and the differences between surgical treated groups were analyzed with logistic regression analysis. P values <0.05 were considered significant.

RESULTS

Twenty-three patients were included in this study; 60.9% (n = 14) were treated surgically (5 microsurgically; 9 endoscopically) and 39.1% (n = 9) conservatively. Statistical analysis revealed no significant differences in the visual function between the 3 treatment groups in both univariate and multivariate analysis (P > 0.05). The endocrinologic outcome was better in the surgical group (P = 0.017; adjusted P = 0.027), with a significant difference between the conservative group and the endoscopic group (P = 0.004; adjusted P = 0.005). When we compared both surgical groups, the endoscopic group has a better endocrinologic outcome (P = 0.020; adjusted P = 0.012).

CONCLUSIONS

Our results support endoscopic intranasal transsphenoidal surgery as a treatment of pituitary apoplexy patients, as it probably decreases the need for long-term hormonal replacement.

Contribution of sellar dura integrity to symptom manifestation in pituitary adenomas with intratumoral hemorrhage

PURPOSE

Although hemorrhage within pituitary adenomas frequently exacerbates the symptoms, there are many grades of severity. Moreover, the contributing factors for symptom severity are still controversial.

METHODS

This retrospective study included 82 patients who underwent transsphenoidal surgery for pituitary adenomas with intratumoral hemorrhage. The grades of preoperative symptoms were classified into group A, asymptomatic or minor symptoms; group B, moderate symptoms sufficient for complain; and group C, severe symptoms disturbing daily life.

RESULTS

The hemorrhage volume within an adenoma was significantly higher in group C (92.6%) than in groups A (48.6%) and B (58.7%). Both headache and diplopia were dominant in group C, occurring in 72.2% and 27.8% of the patients, respectively. In group C, there was no significant difference in frequency between adenoma extensions into the sphenoid sinus (0%) and involvement of the cavernous sinus of Knosp grade 4 (0%), and extensions into the suprasellar region were not common (38.9%). The most distinctive feature was that "no extrasellar extension" was found only in group C (41.2%), and "multidirectional extension" was not detected in this group (0%). Multiple regression analysis revealed that the most powerful determining factors were the high frequencies of intratumoral hemorrhage and lack of extrasellar and multidirectional extensions.

CONCLUSION

Rapid volume expansion of a hematoma and lack of extension or unidirectional extension might lead to significant compression of the sellar and surrounding structures. Of note, the integrity of the sellar dura might contribute to the acute onset of symptom manifestations caused by hemorrhage in pituitary adenomas.

Visual outcomes after endoscopic endonasal pituitary adenoma resection: a systematic review and meta-analysis

PURPOSE

Patients with pituitary adenomas often present with visual deficits. While the aim of endoscopic endonasal transsphenoidal surgery (EETS) is to improve these deficits, permanent worsening is a possible outcome. The aim of this meta-analysis was to evaluate the effect of EETS for pituitary adenomas on visual outcomes.

METHODS

A meta-analysis was conducted according to the PRISMA guidelines. Pooled prevalence was calculated for complete recovery, improvement, and deterioration of visual field deficits, visual acuity and unspecified visual function in fixed- and random-effect models, including assessment of heterogeneity (I²) and publication bias (Begg's test).

RESULTS

Out of 2636 articles, 35 case series were included in the meta-analysis. Results are described for fixed-effect models. For patients with impaired visual acuity, only one study reported complete recovery (27.2%). Pooled prevalence for improvement was 67.5% (95% CI = 59.1-75.0%), but with considerable heterogeneity (I²: 86.0%), and 4.50% (95% CI = 1.80-10.8%) for patients experiencing deterioration. For patients with visual field deficits, the prevalence was 40.4% (95% CI = 34.8-46.3%) for complete recovery, 80.8% (95% CI = 77.7-83.6%) for improvement, and 2.3% (95% CI = 1.1-4.7%) for deterioration. For the unspecified visual outcomes, pooled prevalence of complete recovery was 32.9% (95% CI: 28.5-37.7%), but with considerable heterogeneity (I² = 84.2%). The prevalence was 80.9% (95% CI = 77.9-83.6) for improvement and 2.00% (95% CI = 1.10-3.40%) for deterioration. Random-effect models yielded similar results. Publication bias was non-significant for all the outcomes.

CONCLUSION

While visual deficits improved after EETS in the majority of patients, complete recovery was only achieved in less than half of the patients and some patients even suffered from visual deterioration.

Endoscopic Endonasal Surgery for Treatment of Pituitary Apoplexy: 16 Years of Experience in a Specialized Pituitary Center

OBJECTIVE

Symptomatic pituitary apoplexy is a rare but life-threatening condition caused by sudden hemorrhage or infarction of a pituitary adenoma. In the current study, we aim to evaluate the clinical presentation, management, and clinical outcomes in a cohort of patients who were treated for this condition in our center in the last 16 years.

METHODS

We performed a retrospective analysis of all patients who underwent endoscopic endonasal surgery for treatment of symptomatic pituitary apoplexy between 2001 and 2016 in our center.

RESULTS

A total of 39 patients were included in the study, mean age of 54.9 years (range, 18-70 years) and mean follow-up 5.1 years (range, 0.6-16 years). Most of the patients had nonfunctioning adenomas (32 patients). Headache (89%), visual impairment (79%), and hypopituitarism (86%) were the most common preoperative findings. Surgical treatment led to gross total resection in 31 patients (79.4%). During follow-up, visual fields and oculomotor improvement was observed in 23 (74.1%) and 21 (67.7%) of the patients, respectively. Intractable headache also improved in all patients. Hypopituitarism was present in 77% of patients after surgery. In this series, no cerebrospinal fluid leak, vascular injury, or infection was observed. There was no postoperative mortality.

CONCLUSIONS

The endoscopic endonasal transsphenoidal approach is an effective modality to treat pituitary apoplexy with a high rate of success and minimal risk in selected cases. Although reversion of preoperative visual deficits is often observed, hormonal deficits tend to persist, and require long-term hormonal therapy, even after successful endoscopic endonasal surgical resection.

Endoscopic Endonasal Surgery for Pituitary Apoplexy: Evidence On a 75-Case Series From a Tertiary Care Center

BACKGROUND

The optimal management of pituitary apoplexy (PA) remains debated. The aim of this study was to assess the outcome of the transsphenoidal approach for PA in a large surgical experience.

MATERIALS

Each consecutive case of PA consecutively operated by endoscopic endonasal approach from our tertiary care center, from 1998 to 2015, was included in this series.

RESULTS

Seventy-five patients (47 male; mean age 52.4 ± 16.2 years) were included. Mean follow-up was 69.3 ± 46.7 months. On admission, all patients presented with abrupt severe headache (100%), associated with anterior hypopituitarism in 51 patients (68%), visual disturbances in 55 (73.4%), ophthalmoplegia in 38 (50.7%), and a remarkable reduction of consciousness in 2 (2.6%). Apoplexy proved to be ischemic in 35 patients (46.7%) and hemorrhagic in 40 (53.3%). Patients with hemorrhagic necrosis presented more often with major suprasellar expansion (P = 0.012) Radical removal was achieved in 60 cases (80%). Surgical morbidity consisted in one case of postoperative cerebrospinal fluid leak (1.3%). Anterior hypopituitarism worsened in 15 cases (20%), and diabetes insipidus occurred in 4 cases (5.3%). Ophthalmoplegia improved/normalized in 71% and visual symptoms in 85.5% of the patients, with better results achieved in ischemic forms (P = 0.043). The 2 comatose patients regained normal consciousness.

CONCLUSIONS

The endoscopic endonasal approach represents a valid, effective, and safe technique in the management of PA. Favorable outcomes can be achieved by referring patients to dedicated pituitary centers with a multidisciplinary team. Further studies are still needed to define criteria for surgical indication and to identify outcome predictors.