Radiographic and Clinical Outcomes of Pituitary Apoplexy: Comparison of Conservative Management versus Early Surgical Intervention

Object: Early surgical intervention for patients with pituitary apoplexy (PA) is thought to improve visual outcomes and decrease mortality. Recently, it has been suggested that a subset of patients may have good clinical and ophthalmological outcomes without surgery. We therefore sought to define the radiographic and clinical outcomes of patients with PA who were managed conservatively versus with those who underwent early surgical intervention.

Methods: Patients with symptomatic PA were identified from a prospectively maintained database over a 12-year period. Radiographic, endocrinological, and ophthalmological characteristics of patients were assessed. Patients with progressive visual deterioration or ophthalmoplegia were candidates for early surgery (within 7 days). Patients who had no visual symptoms or whose visual symptoms improved on high dose steroids underwent intended conservative management. Log-rank analysis and univariate analysis compared clinical, radiographic, and ophthalmological outcomes between patients receiving early surgery versus conservative management.

Results: A total of 64 patients with PA were identified. 47 (73.4%) underwent intended conservative management while 17 (26.6%) were treated with early surgery. Patients receiving early surgery had increased rates of impaired visual acuity (VA, 45.8 vs. 27.7%, p = 0.009), visual field (VF) deficits (64.7 vs. 19.2%, p = 0.002), and cranial neuropathies (58.8 vs. 29.8%, p < 0.05). For those with VA/VF deficits, visual outcomes were similar between those managed conservatively versus with early surgery (p > 0.9). The median time to VA improvement (2.0 vs. 3.0 months, p = 0.9; HR: 0.9; 95% CI: 0.3–3.5) and the median time to VF improvement (2.0 vs. 1.5 months; HR: 0.8; 95% CI: 0.3–2.6), p > 0.9) were similar across both groups. Cranial neuropathy improvement was observed more frequently in the conservatively managed patients (OR: 4.8; 95% CI: 1.5–15.4, p < 0.01). Tumor regression occurred in 95.7% (45/47) of patients with initial conservative management with 74.5% of tumors showing evidence of regression 6 months post-apoplexy. Seven patients (14.9%) failed conservative management and required transsphenoidal surgery. 27 patients (19 in the conservative and 8 in the early surgery cohorts) responded to a prospectively administered Visual Function Questionnaire (VFQ-25). VFQ-25 scores were similar across both cohorts (conservative: 95.5 ± 3.8; surgery: 93.2 ± 5.1; p = 0.3). Younger age, women, patients with VF deficits, and patients with tumors causing chiasmal compression were more likely to fail conservative management on univariate analysis. Surgical outcomes were similar for patients receiving early surgery versus delayed surgery.

Conclusion: This represents the largest series of patients with PA who underwent conservative management. These data suggest that a majority of patients with PA can be successfully managed without surgical intervention assuming close neurosurgical, radiographic, and ophthalmological follow-up is available.

Publication History

Article published online:
12 February 2021