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Exp Clin Endocrinol Diabetes 2020; 128(05): 283-289
DOI: 10.1055/a-0640-2915
Article
© Georg Thieme Verlag KG Stuttgart · New York

Neuro-Endocrine Recovery After Pituitary Apoplexy: Prolactin as a Predictive Factor

Alexander Lammert
1   Praxis für Diabetes, Stoffwechsel- und Nierenerkrankungen, Grünstadt, Germany
2   5th Department of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Marc Sebastian Walter
3   Department of Neurosurgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Frank Anton Giordano
4   Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Mansour Al Zhgloul
5   Department of Neuroradiology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, Mannheim, Germany
,
Bernhard Karl Krämer
2   5th Department of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Stefanie Nittka
6   Institute for Clinical Chemistry, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Dirk Michael Schulte
3   Department of Neurosurgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Miriam Ratliff
3   Department of Neurosurgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Daniel Hänggi
3   Department of Neurosurgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
,
Marcel Seiz-Rosenhagen
3   Department of Neurosurgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
› Author Affiliations
Further Information

Publication History

received 17 March 2018
revised  26 May 2018

accepted 06 June 2018

Publication Date:
02 July 2018 (online)

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Abstract

Objective Pituitary apoplexy is a serious medical complication of a pre-existing pituitary adenoma characterized by a variety of clinical symptoms ranging from mild headache to neurologically impaired and finally comatose patients. Management options are surgery or conservative treatment (e. g., with dexamethasone). Surgery is commonly performed in case of severe acute neurological and visual symptoms. However, prospective studies demonstrating a benefit of surgery over conservative treatment in terms of visual, neurological and even endocrine outcomes are lacking. Decision making is still controversial, and recommendations for surgery are based on low evidence grades and focus on visual impairment. Endocrine function and especially markers identifying patients with potential for pituitary recovery after surgery are not well described in the literature.

Patients and Design We analysed data from 24 patients (m:f/16:8) with a median age of 64 yrs (38 to 83yrs) that underwent surgery for pituitary apoplexy regardless of time from symptom onset. Apoplexies were necrotic in 14 cases and haemorrhagic in 10 cases.

Results Preoperatively, 7 patients (29.2%) showed complete anterior pituitary insufficiency, 16 patients (66.6%) had partial anterior pituitary insufficiency and one patient (4.17%) had normal pituitary functions. Persistent panhypopituitarism was found in 7 patients (29.2%), whereas an overall improvement of pituitary function was noted in 13 (57.1%) patients. Preoperative prolactin (PRL) levels were significantly associated with recovery of endocrine functions, whereas specifically all patients with preoperative PRL levels of at least 8.8 ng/ml recovered partially or fully. Time to surgery (0–7 days vs. 1–4 weeks vs.>4 weeks) was not significantly associated with outcome.

Conclusions Our data emphasize that normal and high preoperative PRL levels are associated with better endocrine outcome after surgery. We conclude that patients benefit from surgical intervention even after delayed diagnosis with the serum PRL levels is being a valid biomarker for clinical decision making.

Key words

hypopituitarism - prolactin - hypocortisolism
 

  • References

  • 1 Rajasekaran S, Ravi S, Aiyer SN. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol (Oxf) 2011; 74: 9-20
    CrossrefPubMedGoogle Scholar
  • 2 Saeger W, Lüdecke DK, Buchfelder M. et al. Pathohistological classification of pituitary tumors: 10 years of experience with the German Pituitary Tumor Registry. Eur J Endocrinol 2007; 156: 203-216
    CrossrefPubMedGoogle Scholar
  • 3 Molitch ME, Russell EJ. The pituitary “incidentaloma” Lokal. Ann Intern Med 1990; 112: 925-931
    PubMedGoogle Scholar
  • 4 Chidiac RM, Aron DC. Incidentalomas. A disease of modern technology. Endocrinol Metab Clin North Am 1997; 26: 233-253
    CrossrefPubMedGoogle Scholar
  • 5 Arita K, Tominaga A, Sugiyama K. et al. Natural course of incidentally found nonfunctioning pituitary adenoma, with special reference to pituitary apoplexy during follow-up examination. J Neurosurg 2006; 104: 884-891
    CrossrefPubMedGoogle Scholar
  • 6 Molitch ME. Pituitary incidentalomas. Endocrinol Metab Clin North Am 1997; 26: 725-740
    CrossrefPubMedGoogle Scholar
  • 7 Glezer A, Bronstein MD. Pituitary apoplexy: Pathophysiology, diagnosis and management. Arch Endocrinol Metab 2015; 59: 259-264
    CrossrefPubMedGoogle Scholar
  • 8 Liu ZH, CHang CN, Pai PC. et al Clinical features and surgical outcome of clinical and subclinical pituitary apoplexy. J Clin Neurosci 2010; 17: 694-699
    CrossrefPubMedGoogle Scholar
  • 9 Russel SJ, Miller KK. Pituitary apoplexy. In: Swearingen B, Biller BMK. editors. Diagnosis and Management of Pituitary Disorders. Totowa, NJ, USA: Humana Press; 2008. pp 353-375
    CrossrefGoogle Scholar
  • 10 Gruber A, Clayton J, Kumar S. et al. Pituitary apoplexy: Retrospective review of 30 patients--is surgical intervention always necessary?. Br J Neurosurg 2006; 20: 379-385
    CrossrefPubMedGoogle Scholar
  • 11 Ayuk J, McGregor EJ, Mitchell RD. et al. Acute management of pituitary apoplexy – surgery or conservative management?. Clin Endocrinol (Oxf) 2004; 61: 747-752
    CrossrefPubMedGoogle Scholar
  • 12 Randeva HS, Schoebel J, Byrne J. et al. Classical pituitary apoplexy: Clinical features, management and outcome. Clin Endocrinol (Oxf) 1999; 51: 181-188
    CrossrefPubMedGoogle Scholar
  • 13 Pal A, Capatina C, Tenreiro AP. et al. Pituitary apoplexy in non-functioning pituitary adenomas: Long term follow up is important because of significant numbers of tumour recurrences. Clin Endocrinol (Oxf) 2011; 75: 501-504
    CrossrefPubMedGoogle Scholar
  • 14 Fleseriu M, Hashim IA, Karavitaki N. et al. Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101: 3888-3921
    CrossrefPubMedGoogle Scholar
  • 15 Leyer C, Castinetti F, Morange I. et al. A conservative management is preferable in milder forms of pituitary tumor apoplexy. J Endocrinol Invest 2011; 34: 502-509
    PubMedGoogle Scholar
  • 16 Sibal L, Ball SG, Connolly V. et al. Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases. Pituitary 2004; 7: 157-163
    CrossrefPubMedGoogle Scholar
  • 17 Nawar RN, AbdelMannan D, Selman WR. et al. Pituitary tumor apoplexy: A review. J Intensive Care Med 2008; 23: 75-90
    CrossrefPubMedGoogle Scholar
  • 18 Arafah BM, Harrington JF, Madhoun ZT. et al. Improvement of pituitary function after surgical decompression for pituitary tumor apoplexy. J Clin Endocrinol Metab 1990; 71: 323-328
    CrossrefPubMedGoogle Scholar
  • 19 Bills DC, Meyer FB, Laws Jr ER. et al. A retrospective analysis of pituitary apoplexy. Neurosurgery 1993; 33: 602-608 discussion 608-609
    PubMedGoogle Scholar
  • 20 Lindholm J, Kehlet H. Re-evaluation of the clinical value of the 30 min ACTH test in assessing the hypothalamic-pituitary-adrenocortical function LOKAL. Clin Endocrinol (Oxf) 1987; 26: 53-59
    CrossrefPubMedGoogle Scholar
  • 21 Arafah BM, Kailani SH, Nekl KE. et al. Immediate recovery of pituitary function after transsphenoidal resection of pituitary macroadenomas. J Clin Endocrinol Metab 1994; 79: 348-354
    PubMedGoogle Scholar
  • 22 Arafah BM. Reversible hypopituitarism in patients with large nonfunctioning pituitary adenomas. J Clin Endocrinol Metab 1986; 62: 1173-1179
    CrossrefPubMedGoogle Scholar
  • 23 Arafah BM, Kailani SH, Nekl KE. et al. The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas. J Clin Endocrinol Metab 2000; 85: 1789-1793
    PubMedGoogle Scholar
  • 24 Zayour DH, Selman WR, Arafah BM. Extreme elevation of intrasellar pressure in patients with pituitary tumor apoplexy: Relation to pituitary function. J Clin Endocrinol Metab 2004; 89: 5649-5654
    CrossrefPubMedGoogle Scholar
  • 25 Arafah BM, Brodkey JS, Pearson OH. Gradual recovery of lactotroph responsiveness to dynamic stimulation following surgical removal of prolactinomas: long-term follow-up studies. Metabolism 1986; 35: 905-912
    CrossrefPubMedGoogle Scholar
  • 26 Arafah BM, Nekl KE, Gold RS. et al. Dynamics of prolactin secretion in patients with hypopituitarism and pituitary macroadenomas. J Clin Endocrinol Metab 1995; 80: 3507-3512
    PubMedGoogle Scholar
  • 27 Bergsneider M, Mirsadraei L, Yong WH. et al. The pituitary stalk effect: Is it a passing phenomenon?. J Neurooncol 2014; 117: 477-484
    CrossrefPubMedGoogle Scholar