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Abucham J. Surgical vs Nonsurgical Management for Pituitary Apoplexy. J Clin Endocrinol Metab 2024; 109:e1454-e1455. [PMID: 38006312 DOI: 10.1210/clinem/dgad691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/19/2023] [Accepted: 11/22/2023] [Indexed: 11/27/2023]
Affiliation(s)
- Julio Abucham
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP 04022-001, Brazil
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Mamelak AN, Little AS, Gardner PA, Almeida JP, Recinos P, Soni P, Kshettry VR, Jane JA, Barkhoudarian G, Kelly DF, Dodd R, Mukherjee D, Gersey ZC, Fukuhara N, Nishioka H, Kim EH, Litré CF, Sina E, Mazer MW, Cui Y, Bonert V. A Prospective, Multicenter, Observational Study of Surgical vs Nonsurgical Management for Pituitary Apoplexy. J Clin Endocrinol Metab 2024; 109:e711-e725. [PMID: 37698130 DOI: 10.1210/clinem/dgad541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/14/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
CONTEXT Pituitary apoplexy (PA) has been traditionally considered a neurosurgical emergency, yet retrospective single-institution studies suggest similar outcomes among patients managed medically. OBJECTIVE We established a multicenter, international prospective registry to compare presentation and outcomes in PA patients treated with surgery or medical management alone. METHODS A centralized database captured demographics, comorbidities, clinical presentation, visual findings, hormonal status, and imaging features at admission. Treatment was determined independently by each site. Key outcomes included visual, oculomotor, and hormonal recovery, complications, and hospital length of stay. Outcomes were also compared based on time from symptom onset to surgery, and from admission or transfer to the treating center. Statistical testing compared treatment groups based on 2-sided hypotheses and P less than .05. RESULTS A total of 100 consecutive PA patients from 12 hospitals were enrolled, and 97 (67 surgical and 30 medical) were evaluable. Demographics, clinical features, presenting symptoms, hormonal deficits, and imaging findings were similar between groups. Severe temporal visual field deficit was more common in surgical patients. At 3 and 6 months, hormonal, visual, and oculomotor outcomes were similar. Stratifying based on severity of visual fields demonstrated no difference in any outcome at 3 months. Timing of surgery did not affect outcomes. CONCLUSION We found that medical and surgical management of PA yield similar 3-month outcomes. Although patients undergoing surgery had more severe visual field deficits, we could not clearly demonstrate that surgery led to better outcomes. Even without surgery, apoplectic tumor volumes regress substantially within 2 to 3 months, indicating that surgery is not always needed to reduce mass effect.
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Affiliation(s)
- Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Medical Center, Phoenix, AZ 85013, USA
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | | | - Pablo Recinos
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Pranay Soni
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - John A Jane
- Departments of Neurosurgery, Virginia Tech Medical Center, Roanoke, VA 24014, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Saint John's Medical Center, Santa Monica, CA 90404, USA
| | - Robert Dodd
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Eui-Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | | | - Elliott Sina
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Mia W Mazer
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Yujie Cui
- Biostatistic Core, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Vivien Bonert
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Mattogno PP, Zoli M, D’Alessandris QG, Bongetta D, Caccavella VM, Rigante M, Della Pepa GM, Mazzatenta D, Lauretti L, Olivi A, Spena G, Zoia C. Ultra-Early Treatment of Neurosurgical Emergencies with Endoscopic Endonasal Approach: Experience from Three Italian Referral Centers. J Clin Med 2023; 12:5471. [PMID: 37685541 PMCID: PMC10487769 DOI: 10.3390/jcm12175471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
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.
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Affiliation(s)
- Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Matteo Zoli
- Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Institute of Neurological Sciences of Bologna, 40121 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40121 Bologna, Italy
| | | | - Daniele Bongetta
- Department of Neurosurgery, ASST Fatebenefratelli Sacco, 20100 Milan, Italy
| | - Valerio Maria Caccavella
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Mario Rigante
- Department of Otolaryngology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Diego Mazzatenta
- Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Institute of Neurological Sciences of Bologna, 40121 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40121 Bologna, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy
| | - Giannantonio Spena
- Neurosurgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cesare Zoia
- Neurosurgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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Gheorghe AM, Trandafir AI, Ionovici N, Carsote M, Nistor C, Popa FL, Stanciu M. Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET). Biomedicines 2023; 11:biomedicines11030680. [PMID: 36979658 PMCID: PMC10044830 DOI: 10.3390/biomedicines11030680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.
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Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra Ioana Trandafir
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Nina Ionovici
- Department of Occupational Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy & “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy & Thoracic Surgery Department, “Carol Davila” Central Emergency University Military Hospital, 013058 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania
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Carlos Rodrigues Junior J, Ely Bortolin da Silva V, Rossi Ujvari M, Alberto Aguillar Condori L, Batista de Sousa A. Laparoscopic Surgery-Induced Pituitary Apoplexy. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Biagetti B, Sarria-Estrada S, Cordero Asanza E, Chaachou-Charradi A, Ng-Wong YK, Cicuendez M, Hernandez I, Rojano-Toimil A, Costa P, Martinez-Saez E, Casteràs A, Simò R. Risk Factors, Radiological and Clinical Outcomes in Subclinical and Clinical Pituitary Apoplexy. J Clin Med 2022; 11:jcm11247288. [PMID: 36555904 PMCID: PMC9786023 DOI: 10.3390/jcm11247288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/25/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pituitary apoplexy (PA) can be symptomatic, namely acute apoplexy (APA), or asymptomatic or subclinical (SPA). OBJECTIVE To describe the clinical characteristics and evolution of the patients with APA compared to SPA Patients and methods: Retrospective, longitudinal database analysis. RESULTS We identified 58 patients with PA, and 37 accomplished the inclusion criteria (17 men, median age 47.7 years). A total of 29 (78.4%) had APA (17 underwent surgery, and 12 were conservatively managed), and 8 (21.6%) had SPA. The presence of non-functioning pituitary adenoma (NFPA) odds ratio (OR): 29.36 (95% confidence interval (CI): 1.86-462.36) and the largest size OR 1.10 (95% CI: 1.01-1.2) elevated the risk of having surgery. Hypopituitarism developed in 35.1% without significant differences between APA and SPA. In non-surgical patients, adenoma volume shrunk spontaneously at one year magnetic resonance imaging (MRI), without statistical differences between the conservatively treated and SPA group. CONCLUSIONS APA is more frequent in larger NFPAs, and this subset of patients has a higher risk of surgery. Hypopituitarism is quite frequent even in patients with SPA, and, therefore, long-term follow-up is mandatory. In the non-surgical group, the pituitary tumour shrinkage is clinically relevant after one year of PA. Consequently, surgery indication in NFPA should be delayed and reassessed if patients remain asymptomatic.
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Affiliation(s)
- Betina Biagetti
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
| | - Silvana Sarria-Estrada
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Esteban Cordero Asanza
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | | | - Yiken Karelys Ng-Wong
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Marta Cicuendez
- Neurosurgery and Neurotraumatology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Irene Hernandez
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Alba Rojano-Toimil
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Pilar Costa
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Elena Martinez-Saez
- Neuroradiology Section, Radiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Anna Casteràs
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
| | - Rafael Simò
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Diabetes and Metabolism Research Unit, Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain
- Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence: (B.B.); (R.S.); Tel.: +34-934894172 (B.B. & R.S.)
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Rai RS, Gelnick S, Pomeranz H, Verma R. Recovery of Complete Blindness and Internal Ophthalmoplegia After Transsphenoidal Decompression of Pituitary Apoplexy. Cureus 2022; 14:e28681. [PMID: 36199649 PMCID: PMC9526680 DOI: 10.7759/cureus.28681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 11/05/2022] Open
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Donegan D, Erickson D. Revisiting Pituitary Apoplexy. J Endocr Soc 2022; 6:bvac113. [PMID: 35928242 PMCID: PMC9342855 DOI: 10.1210/jendso/bvac113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Diane Donegan
- Division of Endocrinology, Diabetes and Metabolism, Indiana University , Indianapolis, Indiana 46220 , USA
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic Minnesota , Rochester, Minnesota 55905 , USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic Minnesota , Rochester, Minnesota 55905 , USA
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Alahmari M, Alkherayf F, Lasso A, Banaz F, Mohajeri S, Masoudian P, Lamothe A, Agbi C, Caulley L, Alshardan M, Kilty S. Recovery of Cranial Nerve Deficits in Patients Presenting with Pituitary Apoplexy: A Case Series. Skull Base Surg 2022; 83:e1-e6. [DOI: 10.1055/s-0040-1722668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Background Pituitary apoplexy (PA) is a rare complication of pituitary tumors that can present with a myriad of symptoms, including sudden onset cranial nerve deficits. After patient stabilization and hormone replacement, surgical decompression is often recommended. The timing of surgical decompression remains controversial. In this case series, we describe our institutional experience pertaining to the cranial nerve recovery in patients who underwent endoscopic endonasal transsphenoidal (EETS) surgery for PA while evaluating outcome based on tumor stage using the suprasellar infrasellar parasellar anterior posterior (SIPAP) classification.
Design Present study is a single-institution retrospective cohort.
Methods A retrospective review of all EETS cases for pituitary tumor resection between November 2009 and August 2018. Queries of the hospital database were completed by trained personnel to identify cases of PA treated using the EETS approach. Baseline characteristics, tumor type, endocrine data, and SIPAP classification based on preoperative magnetic resonance imaging (MRI) and operation characteristics were extracted from medical records. Postoperative results were extracted for the duration of the follow-up period available for each patient.
Results Fifteen cases of PA were identified. Patient follow-up period was a mean of 30 months. The cranial nerve deficits present at admission were visual deficit (33%); unilateral third nerve palsy (47%) and unilateral sixth nerve palsy (27%). No fourth nerve palsies were observed. Following EETS, 60% of patients with preoperative visual deficit had normal visual fields. For those with third and sixth nerve palsies preoperatively, 43 and 75%, respectively, had return to normal function postoperatively. SIPAP tumor characteristics were not related to postoperative cranial nerve recovery.
Conclusion In this series of surgically treated patients with pituitary apoplexy, all cranial nerve deficits normalized or improved following surgery. The tumor SIPAP classification was not associated with patient outcome. Though in a small series, the presented results suggest surgical treatment is beneficial for these patients.
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Affiliation(s)
- Mohammed Alahmari
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Fahad Alkherayf
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Andrea Lasso
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Fatmahalzahra Banaz
- Department of Otolaryngology Head and Neck Surgery, King Abdulaziz Hospital, Ministry of Health, Jeddah, Saudi Arabia
| | - Sepideh Mohajeri
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Pourya Masoudian
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Andre Lamothe
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Charles Agbi
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Caulley
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Mohammad Alshardan
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Shaun Kilty
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
- Dr. S. Kilty Medicine Prof. Corp., Ottawa, Ontario, Canada
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Taweesomboonyat C, Oearsakul T. Factors predicting neuro-endocrine recovery following transsphenoidal surgery in pituitary apoplexy patients. World Neurosurg 2021; 159:e40-e47. [PMID: 34861451 DOI: 10.1016/j.wneu.2021.11.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Chin Taweesomboonyat
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Thakul Oearsakul
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Abstract
PURPOSE OF REVIEW Pituitary adenoma resections comprise a large proportion of intracranial tumor surgeries. This patient population is medically and physiologically complex and requires careful perioperative planning and management on the part of the anesthesiologist. This review will summarize anesthetic considerations for pre, intra, and postoperative management of patients undergoing transsphenoidal pituitary surgery. RECENT FINDINGS An endoscopic approach is favored for patients undergoing transsphenoidal pituitary surgery. Hemodynamic monitoring is important to maintain cerebral perfusion and avoid risk of bleeding; however, 'controlled' hypotension may have adverse effects. Multimodal analgesia is effective for the management of postoperative pain and may reduce the risk of postoperative complications, including respiratory depression and postoperative nausea and vomiting. SUMMARY Transsphenoidal pituitary surgery is a preferred approach for the surgical management of nonfunctioning pituitary macroadenomas with symptoms of mass effect and functioning adenomas that cannot be otherwise managed medically. Understanding tumor pathologies and systemic effects are essential for preoperative planning and providing safe anesthetic care during the perioperative period.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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Nakhleh A, Assaliya Naffa M, Sviri G, Shehadeh N, Hochberg I. Outcomes of pituitary apoplexy: a comparison of microadenomas and macroadenomas. Pituitary 2021; 24:492-498. [PMID: 33462744 DOI: 10.1007/s11102-020-01124-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE We aimed to assess clinical characteristics of apoplexy of pituitary microadenomas compared to macroadenomas. METHODS We retrieved clinical records of patients > 18 years old, hospitalized in Rambam hospital between January 2001 and October 2017, with pituitary apoplexy and follow-up of at least one year. We compared clinical course and outcomes of apoplexy between patients with microadenomas and macroadenomas, and between patients who received conservative or surgical treatment. Statistical analysis was done using Fisher's exact and Mann-Whitney tests. RESULTS Twenty-seven patients with pituitary apoplexy were included in the final analysis: mean age was 40.7 ± 12.5 years, 13(48%) were female, 7(26%) had microadenomas, and 21(78%) harbored clinically nonfunctioning pituitary adenomas. Upon admission, hyponatremia, random cortisol level of < 200 nmol/L, and secondary hypothyroidism, were evident in 6/20, 8/18, and 4/18 patients with macroadenoma and 1/5, 2/5, and 1/6 patients with microadenoma, respectively (P = 1.0). Hypogonadotropic hypogonadism was evident in 9/12 men with macroadenoma. In 12 macroadenoma patients, the tumor abutted the optic chiasm, of whom eight had visual field defects. Fifteen patients with macroadenoma and two with microadenoma underwent transsphenoidal surgery. Median follow-up was 3 years. At last follow-up visit, patients with microadenoma had lower rates of corticotropic deficiency or secondary hypothyroidism compared to macroadenoma patients (1/7 vs. 13/20 respectively, p = 0.033). Only two patients with macroadenomas had persistent visual field defects. Outcomes were comparable between conservative and surgical treatment groups. CONCLUSIONS Long term pituitary hormone deficiencies are more common in pituitary apoplexy patients with macroadenomas. Apoplexy of pituitary microadenoma carries a more favorable prognosis.
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Affiliation(s)
- Afif Nakhleh
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel.
| | - Mai Assaliya Naffa
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
| | - Gill Sviri
- Department of Neurosurgery, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Efron St, Haifa, Israel
| | - Naim Shehadeh
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Efron St, Haifa, Israel
| | - Irit Hochberg
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, HaAliya HaShniya Street 8, 3109601, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Efron St, Haifa, Israel
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Küchlin S, Lagrèze WA. Ophthalmological Management of Patients with Pituitary Adenomas. Klin Monbl Augenheilkd 2020; 237:1306-1311. [PMID: 33202463 DOI: 10.1055/a-1291-9383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Sebastian Küchlin
- Eye Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Wolf Alexander Lagrèze
- Eye Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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14
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Hanson M, Li H, Geer E, Karimi S, Tabar V, Cohen MA. Perioperative management of endoscopic transsphenoidal pituitary surgery. World J Otorhinolaryngol Head Neck Surg 2020; 6:84-93. [PMID: 32596652 PMCID: PMC7296486 DOI: 10.1016/j.wjorl.2020.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/19/2020] [Indexed: 11/12/2022] Open
Abstract
The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.
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Affiliation(s)
- Martin Hanson
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Hao Li
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Sasan Karimi
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Viviane Tabar
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Marc A Cohen
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
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