Apoplexy in pituitary macroadenoma: eight patients presenting in 12 months

Natural history of pituitary apoplexy: a long-term follow-up study

BACKGROUND AND AIMS

Pituitary apoplexy (PA) is a rare neurosurgical emergency, associated with deficiency of one or more pituitary hormones. Few studies have explored the relative outcomes associated with conservative and neurosurgical intervention.

METHODS

A retrospective evaluation of all patients with PA reviewed at Morriston Hospital was undertaken and diagnosis was obtained from Morriston database (Leicester Clinical Workstation database) between 1998 and 2019 from clinic letters and discharge summaries.

RESULTS

Thirty-nine patients with PA were identified with a mean age of 74.5 years and 20 (51.3%) patients were women. Patients were followed up for a mean±SD 68.1±61.7 months. Twenty-three (59.0%) patients had a known pituitary adenoma. Commoner clinical presentations of PA were ophthalmoplegia or visual field loss. Following PA, 34 (87.2%) patients were noted to have a non-functioning pituitary adenoma (either pre-existing or new), while 5 (12.8%) patients had a pre-existing functional macroadenoma. Neurosurgical intervention was taken in 15 (38.5%) patients of which 3 (20.0%) patients also received radiotherapy, 2 (13.3%) patients had radiotherapy alone and the remainder managed conservatively. External ophthalmoplegia recovered in all cases. Visual loss remained in all cases. One (2.6%) patient with chromophobe adenoma had a significant second episode of PA requiring repeat surgery.

CONCLUSION

PA often occurs in patients with undiagnosed adenoma. Hypopituitarism commonly occurred following conservative or surgical treatment. External ophthalmoplegia resolved in all cases, however, visual loss did not recover. Pituitary tumour recurrence and further PA episodes are rare.

WHAT IS ALREADY KNOWN ON THIS TOPIC

WHAT THIS STUDY ADDS

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Pituitary Apoplexy Following Elective Total Hip Replacement

Pituitary apoplexy is an endocrine-related emergency most commonly caused by hemorrhage into a preexisting pituitary adenoma. Known risk factors for such hemorrhage include major surgical procedures, head trauma, pregnancy, anticoagulation, and the administration of hormone therapies for the correction of primary hypothalamic deficiencies. Elective orthopedic surgery is an uncommon precipitator of pituitary apoplexy that is rarely described. We report the case of a patient with a previously unknown pituitary macroadenoma who developed apoplexy as a complication of elective right total hip arthroplasty.

Suspected Pituitary Apoplexy: Clinical Presentation, Diagnostic Imaging Findings and Outcome in 19 Dogs

In human medicine, pituitary apoplexy (PA) is a clinical syndrome characterised by the sudden onset of neurological signs because of haemorrhage or infarction occurring within a normal or tumoral pituitary gland. The diagnosis is usually performed combining neurological signs and imaging findings. The aim of the present study is to describe the abnormal neurological signs, the diagnostic imaging findings, based on Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI), and the outcome in a population of dogs with suspected PA. Clinical cases were retrospectively reviewed. Nineteen cases of suspected PA were included. The majority of dogs showed behavioural abnormalities (11/19). Neurological signs more frequently identified were obtundation (7/19), vestibular signs (7/19) and epileptic seizures (6/19). The onset of neurological signs was per-acute in 14 out of 19 cases. Data regarding CT and MRI were available in 18 and 9 cases, respectively. Neurological signs resolved in less than 24 h in seven patients. The short-term prognosis was defined as favourable in the majority of our study population. The median survival time was of 7 months from the time of PA diagnosis. This is the first description of neurological signs, imaging findings and outcome in a large group of dogs with PA.

Ischemic Infarction of Pituitary Apoplexy: A Retrospective Study of 46 Cases From a Single Tertiary Center

Objective

Ischemic infarction of pituitary apoplexy (PA) is a rare type of pituitary apoplexy. This study aims to characterize ischemic PA via clinical presentations, imaging data, histopathological manifestations, and focus on the management and prognosis of the disease.

Methods

This study retrospectively identified 46 patients with ischemic PA confirmed using histopathology at a single institution from January 2013 to December 2020. The clinical presentations, imaging data, laboratory examination, management, and outcomes were collected. We then summarized the clinical presentations, imaging features, intraoperative findings, and histopathological manifestations, and compared the outcomes based on the timing of surgical intervention.

Results

Headache was the most common initial symptom (95.65%, 44/46), followed by visual disturbance (89.13%, 41/46), and nausea and vomiting (58.70%, 27/46). 91.3% of the patients had at least one pituitary dysfunction, with hypogonadism being the most common endocrine dysfunction (84.78%, 39/46). Cortisol dysfunction occurred in 24 (52.17%) patients and thyroid dysfunction occurred in 17 (36.96%). Typical rim enhancement and thickening of the sphenoid sinus on MRI were seen in 35 (85.37%) and 26 (56.52%) patients, respectively. Except for one patient with asymptomatic apoplexy, the remaining patients underwent early (≤ 1 week, 12 patients) and delayed (> 1 week, 33 patients) transsphenoidal surgery. Total tumor resection was achieved in 27 patients and subtotal tumor resection in 19 patients. At surgery, cottage cheese–like necrosis was observed in 50% (23/46) of the patients. At the last follow-up of 5.5 ± 2.7 years, 92.68% (38/41) of the patients had gained a significant improvement in visual disturbance regardless of surgical timing, and 65% of the patients were still receiving long-term hormone replacement therapy.

Conclusion

Patients with ischemic PA can be accurately diagnosed by typical imaging characteristics preoperatively. The timing of surgical intervention does not significantly affect the resolution of neurological and endocrinological dysfunctions. Preoperative endocrine dysfunctions are common and usually appear to be poor after surgical intervention.

Outcome in pituitary apoplexy patients, stratified by delay between symptom appearance and surgery: A single center retrospective analysis

BACKGROUND

There are surgical and conservative management strategies in pituitary apoplexy patients. The use of both methods may lead to delayed surgery in the treatment of pituitary apoplexy. The aim of this study was to evaluate the surgical indications and outcomes of a series of patients with pituitary apoplexy according to delay between surgery and symptom onset.

METHODS

A retrospective analysis was performed of 2711 cases with sellar pathologies treated with endoscopic transsphenoidal surgery in a single centre. Inclusion criteria were histopathological confirmation of haemorrhage or necrosis, acute onset and at least one of the following: symptoms of endocrine dysfunction; visual impairment; ophtalmoplegia; headache; or altered consciousness. Patients were divided into three groups based on the number of days from initial symptoms to surgery: early (1-7 day), delayed (8-21 days) and late (>21 day). The indication for and outcome of surgery was reviewed according to symptoms and timing of surgery.

RESULTS

Ninety-one patients with pituitary apoplexy underwent surgery. The median time from ictus until surgery was 16 days (1-120 days). Headache was the most common presenting symptom. Visual impairment and ophtalmoplegia were found in 26.4% and 23.1% of patients, respectively. Surgical intervention was successful in treatment of headache in 82 (97,6%) patients. In patients in the early or delayed groups a significant improvement was found between pre- and post-operative headache, ocular palsy, visual impairment, and hormone deficiencies. Patients in the late group also had a significant improvement in headache and visual symptoms after surgery.

CONCLUSION

Surgery was sufficient in headache, endocrine, and neuro-ophthalmic outcomes at first 21 days (early and delayed groups). Beyond 21 days (late group), surgery was not effective on recovery of pituitary function.

Apoplexy in sporadic pituitary adenomas: a single referral center experience and AIP mutation analysis

Objective

To analyze the clinical, laboratory, and radiological findings and management of patients with clinical pituitary apoplexy and to screen for aryl hydrocarbon receptor-interacting protein (AIP) mutations.

Methods

The clinical findings were collected from the medical records of consecutive sporadic pituitary adenoma patients with clinical apoplexy. Possible precipitating factors, laboratory data, magnetic resonance imaging (MRI) findings and treatment were also analyzed. Peripheral blood samples were obtained for DNA extraction from leukocytes, and the entire AIP coding region was sequenced.

Results

Thirty-five patients with pituitary adenoma were included, and 23 (67%) had non-functioning pituitary adenomas. Headache was observed in 31 (89%) patients. No clear precipitating factor was identified. Hypopituitarism was observed in 14 (40%) patients. MRI from 20 patients was analyzed, and 10 (50%) maintained a hyperintense signal in MRI performed more than three weeks after pituitary apoplexy (PA). Surgery was performed in ten (28%) patients, and 25 (72%) were treated conservatively with good outcomes. No AIP mutation was found in this cohort.

Conclusion

Patients with stable neuroophthalmological impairments can be treated conservatively if no significant visual loss is present. Our radiological findings suggest that hematoma absorption lasts more than that observed in other parts of the brain. Additionally, our study suggests no benefits of AIP mutation screening in sporadic patients with apoplexy.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

GLUT3 expression in cystic change induced by hypoxia in pituitary adenomas

Tumor cells require large amounts of energy to sustain growth. Through the mediated transport of glucose transporters, the uptake and utilization of glucose by tumor cells are significantly enhanced in the hypoxic microenvironment. Pituitary adenomas are benign tumors with high-energy metabolisms. We aimed to investigate the role of expression of glucose transporter 3 (GLUT3) and glucose transporter 1 (GLUT1) in pituitary adenomas, including effects on size, cystic change and hormone type. Pituitary adenomas from 203 patients were collected from January 2013 to April 2017, and immunohistochemical analysis was used to detect the expression of GLUT3 and GLUT1 in tumor specimens. GLUT3-positive expression in the cystic change group was higher than that in the non-cystic change group (P = 0.018). Proportions of GLUT3-positive staining of microadenomas, macroadenomas, and giant adenomas were 22.7 (5/22), 50.4 (66/131) and 54.0% (27/50), respectively (P = 0.022). In cases of prolactin adenoma, GLUT3-positive staining was predominant in cell membranes (P = 0.000006), while in cases of follicle-stimulating hormone or luteotropic hormone adenoma, we found mainly paranuclear dot-like GLUT3 staining (P = 0.025). In other hormonal adenomas, GLUT3 was only partially expressed, and the intensity of cell membrane or paranuclear punctate staining was weak. In contrast to GLUT3, GLUT1 expression was not associated with pituitary adenomas. Thus, our results indicate that the expression of GLUT3 in pituitary adenomas is closely related to cystic change and hormonal type. This study is the first to report a unique paranuclear dot-like GLUT3 staining pattern in pituitary adenomas.

Pituitary Apoplexy Presenting as Ophthalmoplegia and Altered Level of Consciousness without Headache

Background. Pituitary apoplexy (PA) is a clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The typical clinical presentation of PA includes acute onset of severe headache, visual disturbance, cranial nerve palsy, and altered level of consciousness. Case Report. A 78-year-old man presented to the emergency department with one-day history of ptosis and diplopia and an acute-onset episode of altered level of consciousness which was resolving. He denied having headache, nausea, or vomiting. Physical examination revealed third-cranial nerve palsy and fourth-cranial nerve palsy both on the right side. Noncontrast computed tomography (CT) scan of the head was unremarkable. Brain magnetic resonance imaging (MRI) showed a pituitary mass with hemorrhage (apoplexy) and extension to the right cavernous sinus. The patient developed another episode of altered level of consciousness in the hospital. Transsphenoidal resection of the tumor was done which resulted in complete recovery of the ophthalmoplegia and mental status. Conclusion. Pituitary apoplexy can present with ophthalmoplegia and altered level of consciousness without having headache, nausea, or vomiting. A CT scan of the head could be negative for hemorrhage. A high index of suspicion is needed for early diagnosis and timely management of pituitary apoplexy.

The impact of surgical timing on visual outcome in pituitary apoplexy: Literature review and case illustration

BACKGROUND

Neuro-ophthalmologic signs are common clinical manifestations of pituitary apoplexy. Managing sudden visual loss is critical for achieving a good outcome. The timing of pituitary surgery remains controversial. In fact, various points of view have been reported in the literature.

METHODS

We reviewed the impact of surgical intervention timing on visual outcome. The surgical intervention time was classified as urgent, early, intermediate, and late interventions based on the literature review. We report a case of a 40-year-old male patient who presented with headache and sudden visual loss for 3 days. He was diagnosed with pituitary apoplexy and had transnasal-transsphenoidal resection. Three days later, he achieved a complete recovery of his vision.

RESULTS

This paper is an addition to several studies that favor early surgical decompression of pituitary fossa for apoplexy cases with severe neuro-ophthalmologic involvement. There is an increasing trend for early surgical intervention for pituitary apoplexy in the literature, especially for severe visual deterioration.

CONCLUSION

The visual outcome appears to be better in early intervention as compared to late. Nevertheless, good visual recovery is also seen in late surgical intervention.

Pituitary apoplexy - bespoke patient management allows good clinical outcome

OBJECTIVE

To describe the clinical presentation, management and outcome of pituitary apoplexy from a single centre and retrospectively apply the Pituitary Apoplexy Score (PAS).

DESIGN

Retrospective review of patients presenting with classical pituitary apoplexy to a single neurosurgical centre in the Greater Manchester region.

RESULTS

A total of 31 cases with classical pituitary apoplexy were identified between 2005 and 2014. The mean age at presentation was 55 years, and there were 19 men. In only one patient was there prior knowledge of a pituitary adenoma. Eleven (35%) patients were managed conservatively and 20 (65%) patients managed surgically. Emergency surgery was carried out in 11 patients. At presentation, visual symptoms were present in a higher proportion of patients in the surgical group (90%) compared to the conservatively managed group (64%). At final follow-up, visual recovery was apparent in most patients in both the surgical (100%) and conservatively (86%) managed groups. The proportion of patients with hypopituitarism was high in both the surgical (86%) and conservative (73%) groups at presentation, and this failed to improve at final follow-up (90% vs 73%, respectively). The median PAS scores were higher in the surgical (PAS 2), compared to the conservatively managed group (PAS 0).

CONCLUSION

In pituitary apoplexy patients managed conservatively or surgically, there is good recovery of visual symptoms but not endocrine function. Patients should be managed on a case-by-case basis based on the severity of symptoms at presentation, progression of disease and surgical expertise available. Further prospective studies using the PAS are required to determine its usefulness in clinical practice.

Ischemic pituitary adenoma apoplexy-Clinical appearance and prognosis after surgical intervention

BACKGROUND

Several retrospective investigations have recommended more passive surgical indications for intratumoral hemorrhage of pituitary adenomas due to probable spontaneous resolution. However, no definitive analyses have compared pituitary adenomas with hemorrhagic apoplexy and intratumoral hemorrhage without evident apoplectic symptoms or pituitary adenoma infarction.

METHODS

This study retrospectively identified 43 patients with symptomatic pituitary apoplexy among 1067 patients with pituitary adenomas initially treated by surgery at a single institute between April 2005 and May 2015, with 27 cases of hemorrhagic (2.53%) and 16 cases of ischemic apoplexy (1.50%). The inclusion criteria involved evident and sudden onset of symptoms and simultaneous histological confirmation as hemorrhagic or ischemic pituitary apoplexy. Diagnostic differentiation with magnetic resonance (MR) imaging was performed to examine the agreement between MR imaging and histological findings, and the clinical appearance and mid-term prognosis were compared for ischemic pituitary apoplexy and hemorrhagic apoplexy.

RESULTS

Diagnostic matching with MR imaging could be performed in 41 of 43 patients (25 with hemorrhagic and 16 with ischemic apoplexy). Agreement with the histological finding was found in 32 of 41 patients overall (78%), 23 of 25 patients with hemorrhagic apoplexy (92%), and 9 of 16 patients with ischemic apoplexy (56%). The main reason for diagnostic discrepancy was thought to be the difficulty in identifying ischemic lesion. All patients in the ischemic group suffered progression of symptoms from initial onset including various cranial nerve palsies, aseptic meningitis, and decreased level of consciousness, whereas the hemorrhagic group suffered progression in 4 of 27 patients. Ischemic group showed a statistically stronger tendency to disease progression than the hemorrhagic group (P<0.001). Endocrinological examinations showed 4 patients required no hormone supplement therapies but the other 11 patients had persistent hypopituitarism and required hormone supplementation in the ischemic group, whereas 2 of 25 patients required hormone supplementation in the hemorrhagic group. Endocrinological recovery showed a significant difference between the ischemic group and hemorrhagic group (P<0.01).

CONCLUSIONS

Ischemic pituitary adenoma apoplexy has a more severe clinical course than hemorrhagic apoplexy. Development of preoperative diagnostic technology to differentiate ischemic from hemorrhagic apoplexy is required to improve the low rate of agreement between the histological and MR imaging findings in patients with ischemic apoplexy.

Multidisciplinary Management of Pituitary Apoplexy

Pituitary apoplexy is a rare clinical syndrome due to ischemic or haemorrhagic necrosis of the pituitary gland which complicates 2-12% of pituitary tumours, especially nonfunctioning adenomas. In many cases, it results in severe neurological, ophthalmological, and endocrinological consequences and may require prompt surgical decompression. Pituitary apoplexy represents a rare medical emergency that necessitates a multidisciplinary approach. Modalities of treatment and times of intervention are still largely debated. Therefore, the management of patients with pituitary apoplexy is often empirically individualized and clinical outcome is inevitably related to the multidisciplinary team's skills and experience. This review aims to highlight the importance of a multidisciplinary approach in the management of pituitary apoplexy and to discuss modalities of presentation, treatment, and times of intervention.

Incidence of Pituitary Apoplexy and Its Risk Factors in Chinese People: A Database Study of Patients with Pituitary Adenoma

Background

There are few studies of the incidence and clinical characteristics of pituitary apoplexy (PA) in pituitary adenoma patients, and the findings have been inconsistent.

Objective

The aim of the study was to retrospectively assess the incidence, clinical presentation, surgical management and postoperative complications of PA in pituitary adenoma patients.

Methods

A database was specifically designed to collect clinical, therapeutic, prognostic and histological information about pituitary adenoma patients. Using multivariate logistic regression, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to identify associated factors.

Results

A total of 2021 pituitary adenoma patients were recruited. 97 (4.8%) patients had PA. The incidence of PA was 10.11% in patients with pituitary macroadenoma, and 0.36% in patients with microadenoma. Variables for the logistic regression model independently associated with PA were sex (male vs. female, OR = 2.54, 95% CI: 1.59~4.07), tumor type (negative staining vs. positive staining, OR = 2.04, 95% CI: 1.29~3.23), and tumor size (macroadenoma vs. microadenoma, OR = 26.46, 95% CI = 9.66~72.46). Headache, visual deterioration, and vomiting were the most common symptoms in patients with pituitary adenoma. Patients with and without PA had similar frequency of visual deterioration, head trauma, acromegalic appearance, galactorrhoea, cold intolerance and Cushingoid appearance, but headache, vomiting, ptosis, diplopia, fever and blindness were significantly more common in patients with PA. Pearson Chi-Square tests revealed a significant difference in surgical approach between patients with and without PA (95.88% vs. 85.57%, P = 0.01).

Conclusion

Our findings suggest that PA is not a rare event. Male sex, non-functioning tumor, and macroadenoma are associated with an increased risk of PA. Compared with pituitary adenoma patients without PA, patients with PA have more severe symptoms.

Endoscopic Endonasal Transsphenoidal Approach for Apoplectic Pituitary Tumor: Surgical Outcomes and Complications in 45 Patients

Objective To assess the safety and effectiveness of the endoscopic endonasal transsphenoidal approach (EETA) for apoplectic pituitary adenoma. Design A retrospective study. Setting Qilu Hospital of Shandong University; Brain Science Research Institute, Shandong University. Participants Patients admitted to Qilu Hospital of Shandong University who were diagnosed with an apoplectic pituitary tumor and underwent EETA for resection of the tumor. Main Outcome Measures In total 45 patients were included in a retrospective chart review. Data regarding patient age, sex, presentation, lesion size, surgical procedure, extent of resection, clinical outcome, and surgical complications were obtained from the chart review. Results In total, 38 (92.7%) of 41 patients with loss of vision obtained visual remission postoperatively. In addition, 16 patients reported a secreting adenoma, and postsurgical hormonal levels were normal or decreased in 14 patients. All other symptoms, such as headache and alteration of mental status, recovered rapidly after surgery. Two patients (4.4%) incurred cerebrospinal fluid leakage. Six patients (13.3%) experienced transient diabetes insipidus (DI) postoperatively, but none of these patients developed permanent DI. Five patients (11.1%) developed hypopituitarism and were treated with replacement of hormonal medicine. No cases of meningitis, carotid artery injury, or death related to surgery were reported. Conclusion EETA offers a safe and effective surgical option for apoplectic pituitary tumors and is associated with low morbidity and mortality.

Apoplexy of pituitary adenomas: the perfect storm

OBJECT

Pituitary adenomas occasionally undergo infarction, apoplexy, which often destroys much of the tumor. It is well known that apoplexy can be precipitated by several acute factors, including cardiac surgery, other types of surgery, trauma, insulin infusion, and stimulation with administration of hypothalamic releasing factors.

METHODS

The prior focus on mechanisms underlying pituitary apoplexy has been on these acute events. Less attention has been given to the endogenous features of pituitary tumors that make them susceptible to spontaneous infarction, despite that most pituitary apoplexy occurs in the absence of a recognized precipitating event. The authors examine intrinsic features of pituitary adenomas that render them vulnerable to apoplexy-features such as high metabolic demand, paucity of angiogenesis, and sparse vascularity, qualities that have previously not been linked with apoplexy-and argue that it is these features of adenomas that underlie their susceptibility to spontaneous infarction. The sensitivity of freshly cultured pituitary adenomas to hypoglycemia is assessed.

RESULTS

Adenomas have high metabolic demand, limited angiogenesis, and reduced vessel density compared with the normal gland. Pituitary adenoma cells do not survive in the presence of reduced or absent concentrations of glucose.

CONCLUSIONS

The authors propose that the frequent ischemic infarction of pituitary adenomas is the product of intrinsic features of these tumors. These endogenous qualities create a tenuous balance between high metabolic demand and marginal tissue perfusion. Thus, the tumor is vulnerable to spontaneous infarction or to acute ischemia by any event that acutely alters the balance between tumor perfusion and tumor metabolism, events such as acute systemic hypotension, abruptly decreased supply of nutrients, hypoglycemia with insulin administration, or increase in the tumor's metabolic demand due to administration of hypothalamic releasing factors. It may be possible to take advantage of these intrinsic features of pituitary adenomas by using aspects of this vulnerability for development of new approaches for treatment.

Surgical results of large and giant pituitary adenomas with special consideration of ophthalmologic outcomes

OBJECTIVE

To analyze functioning and nonfunctioning pituitary adenomas (PAs)>3 cm, with special emphasis on preoperative and postoperative visual functions.

METHODS

The cases consisted of 49 women and 54 men with mean age of 43.2 years (range 19-66 years). All cases had a macroadenoma >3 cm in diameter. The transsphenoidal approach was performed in 117 procedures, and the transcranial approach was performed in 8 procedures. Radical tumor excision was achieved in 50 of 103 patients. Postoperative evaluation was done in 88 patients. Preoperative and postoperative visual acuity, visual field, and ocular fundi and their relationship with the pattern and duration of the symptoms and the size of the tumor were evaluated.

RESULTS

Normalization of visual acuity was obtained in 71.5% of patients, improvement occurred in 13.6%, symptoms persisted in 13.6%, and symptoms worsened in 1%. Postoperative improvement of visual field defects (VFDs) was observed in 74.1% of patients, and visual impairment score improved postoperatively in 92% of patients. Patients operated on <6 months before the onset of vision loss had better and more sustained visual improvement. One patient died, and 15.5% of patients experienced surgery-related complications.

CONCLUSIONS

This study shows that patients with severe visual impairment may have remarkable improvement if surgical decompression is done early. The transsphenoidal approach should be performed to correct the patient's visual impairment and to relieve the pressure on the optic apparatus caused by macroadenoma of any size.

Pituitary apoplexy

Pituitary apoplexy is rare endocrine emergency which can occur due to infarction or haemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. There is conflicting data regarding which type of pituitary adenoma is prone for apoplexy. Some studies showed predominance of non-functional adenomas while some other studies showed a higher prevalence in functioning adenomas amongst which prolactinoma have the highest risk. Although pituitary apoplexy can occur without any precipitating factor in most cases, there are some well recognizable risk factors such as hypertension, medications, major surgeries, coagulopathies either primary or following medications or infection, head injury, radiation or dynamic testing of the pituitary. Patients usually present with headache, vomiting, altered sensorium, visual defect and/or endocrine dysfunction. Hemodynamic instability may be result from adrenocorticotrophic hormone deficiency. Imaging with either CT scan or MRI should be performed in suspected cases. Intravenous fluid and hydrocortisone should be administered after collection of sample for baseline hormonal evaluation. Earlier studies used to advocate urgent decompression of the lesion but more recent studies favor conservative approach for most cases with surgery reserved for those with deteriorating level of consciousness or increasing visual defect. The visual and endocrine outcomes are almost similar with either surgery or conservative management. Once the acute phase is over, patient should be re-evaluated for hormonal deficiencies.

A conservative management is preferable in milder forms of pituitary tumor apoplexy

AIM

Our objective was to report a single-center experience of the management of pituitary tumor apoplexy.

PATIENTS AND METHODS

We retrospectively analyzed a series of 44 patients hospitalized for pituitary apoplexy between January 1996 and March 2008 at the Timone Hospital, Marseille, France.

RESULTS

Most frequent presenting symptoms were headaches (93%), visual impairment (85%) and vomiting (59%). Hypopituitarism was present at diagnosis in 88% of patients, with a high incidence of corticotroph deficiency (70%). A risk factor was found in 52% of patients, mostly hypertension. Apoplexy occurred in a previously undiagnosed pituitary adenoma in 32/44 cases (73%). The apoplectic event concerned 12 secreting, 27 non-functioning, 4 uncharacterized adenomas and one Rathke's pouch cyst. Nineteen patients underwent surgery within the first month, and one patient had conventional radiotherapy. Twenty-four patients, who had no ophthalmic or neurological signs, were conservatively treated in first intention; among them, 6 received high dose corticosteroids. After a median follow-up of 21 months, there was no significant difference in terms of endocrine or visual recovery between the operated and the conservatively treated groups, nor between patients treated with corticosteroids or not. Panhypopituitarism was observed in 52% of patients, but partial or complete visual recovery was present in the majority of patients (91%), whatever the therapeutic approach.

CONCLUSION

The outcome of patients treated with or without surgery for pituitary apoplexy without severe neuro-ophthalmic deficits seems to be identical, pleading for a conservative management of pituitary apoplexy in the absence of visual emergency.

A prospective study of nonfunctioning pituitary adenomas: presentation, management, and clinical outcome

A prospective study was performed to evaluate the presentation, therapeutic management, and clinical outcome of nonfunctioning pituitary adenomas (NFPAs). In most of 385 consecutive patients, NFPAs were macroadenomas. The mean follow-up duration was 5.5 ± 1.4 years. Presentation was dominated by headache, visual disturbance, and hypopituitarism. Pituitary apoplexy (clinical and subclinical) was observed in 88 patients. Appropriate steroids replacement was given before surgery. Endoscope-assisted transsphenoidal surgery (TSS) was performed, and was well tolerated by all patients. At discharge, visual disturbances were improved in 215 (87.6%) patients who had complained of visual impairment preoperatively. The shorter the time from presentation of pituitary apoplexy to surgery, the better the outcome in visual function. Seventy-two (18.7%) patients developed transient diabetes insipidus (DI) and 85 (22.1%) patients developed hyponatremia, but all these improved within six weeks. Hypocortisolism was confirmed in 84 (21.8%) patients with an abnormal postoperative day 2 (POD2) 0800 serum cortisol level and in 122 (31.7%) patients with an abnormal POD6 0800 serum cortisol level. Hypothyroidism occurred in 135 (35.1%) patients. Steroids replacement was thus given immediately. Eight (2.1%) patients needed lifetime hormone substitution. No adrenal crisis occurred. Five (1.3%) patients died within six weeks. Residual tumors were confirmed in 79 patients (20.8%) by postoperative four-month enhanced MR imaging. Tumor recurrence or regrowth occurred in 56 patients (14.7%) during the follow-up period. These patients required repeat TSS or radiosurgery. The findings of this study support the use of TSS as a feasible initial treatment for NFPAs. With appropriate perioperative management of abnormal fluid, electrolyte, and endocrinological function, TSS was associated with minimum morbidity and was well tolerated by patients regardless of age. However, close screening of pituitary function and adequate neuroradiological follow-up should be performed after surgery for detection of tumor recurrence or regrowth. The indications for repeat TSS and postoperative radiosurgery in residual or recurrent NFPAs should be better defined.

Hemorrhagic pituitary macroadenoma: characteristics, endoscopic endonasal transsphenoidal surgery, and outcomes

PURPOSE

This study aims to assess the effect of endoscopic endonasal transsphenoidal surgery (EETSS) of hemorrhagic pituitary macroadenoma (HPMA).

PATIENTS AND METHODS

We retrospectively reviewed 52 cases with HPMA collected from the Xijing Hospital from April 1995 to April 2009. There were 39 males and 13 females, ranging in age from 18 to 79 years (average 51.6 years). Patients presented with headache or acute ophthalmological symptoms after adenoma hemorrhage. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed pituitary macroadenoma with hemorrhage in all cases. Twenty-eight adenomas showed marked suprasellar extension, 19 showed moderate extension, and another 5 showed slight extension. All patients were promptly treated by emergency EETSS, usually within 24 h after hospitalization.

RESULTS

Total removal of tumor was achieved in 46 cases (88.5%), and subtotal removal in 6 cases (11.5%). Postoperative radiotherapy and reoperation of the tumor were required in five patients with either residual or relapsed tumors. Follow-up ranged from 8 to 93 months (mean 41.6 months) for 43 cases. Visual acuity and visual field recovery and improvement was recorded in 92.1% and 94.3% of patients who had preoperative visual symptoms, respectively.

CONCLUSIONS

The majority of macroadenomas are hemorrhagic, and they often occur in middle-aged, male subjects. Detection by imaging in the setting of pituitary apoplexy accurately predicts the nature of the apoplectic process and helps to guide the type and timing of surgery. Early EETSS is the most effective therapy and significantly improves visual outcomes and systemic conditions.

Pituitary apoplexy: an overview of 186 cases published during the last century

BACKGROUND

Pituitary apoplexy is a rare and life-threatening complication occurring in 0.6-10.5% of all cases of pituitary adenomas. Although the association between pituitary apoplexy and visual dysfunction has been recognized for a long time, the optimal management of this problem still remains controversial. The purpose of this overview was to present the surgical experience by analyzing the literature on the management of pituitary apoplexy for better treatment of these cases.

MATERIALS AND METHOD

To establish a new guideline for the surgical treatment of this entity, publications reported during the last century and databases containing medical literature were analyzed. In addition, an illustrative case with pituitary apoplexy presenting with complaints of sudden onset severe headache associated with nausea, vomiting, and a sudden loss of vision was described. In fact, the experience in our complicated patient prompted us to review the available literature on the management of pituitary apoplexy to date.

CONCLUSIONS

Based on an overview of 186 cases of apoplectic pituitary adenoma presenting with monocular or binocular blindness, we highlight the importance of correct diagnosis and an early, but not necessarily emergency, surgery within the first week of admission to optimize visual outcome of such patients. The illustrative case further exemplifies the value of close interaction between members of the management team for optimal outcome.

Pituitary apoplexy: retrospective review of 30 patients—is surgical intervention always necessary?

The objective of this article is to review clinical outcomes in patients presenting with pituitary apoplexy and compare the results of conservative and surgical management. It took the form of a retrospective review of 30 patients (23M, 7F; age range: 17-86 years) with pituitary apoplexy diagnosed between 1988 and 2004. Presenting features included headache in 27 patients, 'collapse' in three and vomiting in 14. Complete blindness occurred in four patients, monocular blindness in two, decreased visual acuity in 12, visual field loss in 10 and ophthalmoplegia in 15. Only five had no initial visual deficit. CT was the initial mode of imaging in 22 patients: three such scans were initially reported as 'normal' and a further 10 as pituitary tumour only, with no haemorrhage. Ten patients proceeded to early pituitary surgery and 20 were managed conservatively. There was one death 24 days after admission in a patient with multiple co-morbidities. Of the six patients with blindness, three (two conservatively treated) regained partial vision. Of the remaining 19 patients with visual deficits, 10 (two surgically treated) recovered fully and eight (four surgically treated) partly so. At latest follow-up the following pituitary hormone deficiencies were identified: ACTH 19; TSH 20; testosterone 18; ADH (diabetes insipidus) eight. Later recurrence of a pituitary adenoma was observed in seven cases (including six of the 10 surgically treated patients). There was no evidence that those patients managed surgically had a better outcome. Early neurosurgical intervention may not be required in most patients presenting with pituitary apoplexy.

Pituitary tumor apoplexy

Pituitary tumor apoplexy is a medical emergency due to acute infarction or hemorrhage in the pituitary gland. In this review, the authors discuss the sellar anatomy, the pituitary gland and adenomas' vascularization and the general aspects of the syndrome such as its ethiopatogenesis, predisposing factors, clinical features, treatment and prognosis.

Treatment and follow-up of clinically nonfunctioning pituitary macroadenomas

CONTEXT

Although the majority of pituitary macroadenomas are clinically nonfunctioning, treatments as well as follow-up strategy for this condition lack evidence from randomized studies.

EVIDENCE ACQUISITION

We evaluated the evidence of treatment and follow-up strategies for clinically nonfunctioning adenomas. PubMed was searched for articles on nonfunctioning adenomas in November 2007, and references of selected articles were assessed for potentially relevant articles.

EVIDENCE SYNTHESIS

All evidence for treatment and follow-up for nonfunctioning adenomas is based on observational studies. The most effective treatment is transsphenoidal surgery, indicated in patients with visual field defects. A wait-and-see approach may be considered in nonfunctioning macroadenomas not reaching to the optic chiasm. Some of these tumors ( approximately 10%) will show spontaneous regression, whereas in approximately 50% there will be progression within 5 yr observation. Postoperative radiotherapy should not be applied to all patients after surgery but can be considered in patients with large postoperative remnants of the tumor. During follow-up careful assessment and replacement of pituitary insufficiencies should be performed. Magnetic resonance imaging is advised with intervals of 1-3 yr and evaluation of visual fields when appropriate. Recurrence rates are reported to be 6-46% after transsphenoidal surgery, whereas after postoperative radiotherapy, recurrence rates of 0-36% are reported. Long-term sequelae of nonfunctioning macroadenomas are hypopituitarism, persistent visual field defects, and decreased quality of life. Whether nonfunctioning macroadenomas are associated with an increased mortality is still a matter of debate.

CONCLUSION

Clinically nonfunctioning pituitary macroadenomas, although benign in nature, need individualized treatment and lifelong radiological and endocrinological follow-up.

Pituitary Apoplexy due to Pituitary Adenoma Infarction

Cause of pituitary apoplexy has been known as hemorrhage, hemorrhagic infarction or infarction of pituitary adenoma or adjacent tissues of pituitary gland. However, pituitary apoplexy caused by pure infarction of pituitary adenoma has been rarely reported. Here, we present the two cases pituitary apoplexies caused by pituitary adenoma infarction that were confirmed by transsphenoidal approach (TSA) and pathologic reports. Pathologic report of first case revealed total tumor infarction of a nonfunctioning pituitary macroadenoma and second case partial tumor infarction of ACTH secreting pituitary macroadenoma. Patients with pituitary apoplexy which was caused by pituitary adenoma infarction unrelated to hemorrhage or hemorrhagic infarction showed good response to TSA treatment. Further study on the predisposing factors of pituitary apoplexy and the mechanism of infarction in pituitary adenoma is necessary.

Emergency transsphenoidal surgery for hemorrhagic pituitary adenomas

Hemorrhagic pituitary adenoma (HPA) is an acute clinical event in neurosurgery. Emergency surgical decompression is the most effective treatment. We retrospectively reviewed 65 cases collected from the Xijing Institute of Clinical Neuroscience from 1995 to 2005 with HPA. The majority of the patients (81.5%) experienced the acute symptoms of pituitary apoplexy including headache, ocular paresis, visual field deficits and hypopituitarism. On imaging features, 34 adenomas (52.3%) showed marked suprasellar extension, 17 (26.2%) showed moderate extension, and 6 (9.2%) had slight extension, another eight (12.3%) were intrasellar. All patients were treated promptly by emergency surgical decompression usually within 24h after the hospitalization. Twenty four patients operated on by the traditional transsphenoidal microsurgery; whereas 41 patients operated on by the endoscopic endonasal transsphenoidal surgery. Total removal of tumors was achieved in 59 cases (90.8%) and subtotal removal in 6 cases (9.2%). Postoperative radiotherapy, suppressive drug therapy and endocrine replacement therapy were required in seven patients with either remaining tumor or tumor recurrence. In a median follow-up period of 49 months for 54 cases, most patients' clinical symptoms had markedly improved. Visual acuity and visual fields improved in 88.4% and 92.7% of the patients who had preoperative visual symptoms, respectively. The majority of the HPA often occurred in patients with macroadenomas. With emergency surgical treatment, most patients with HPA could have quick improvement of symptoms, especially for altered consciousness and visual acuity or visual fields impairments.