Pituitary Apoplexy: When to Operate?

Educational Objective: Pituitary apoplexy is classically defined by a combination of clinical and radiologic findings. Symptoms arise in an acute manner and include headache, visual changes, and dizziness. Imaging reveals hemorrhage or necrosis within the sella, most often in the presence of a tumor. Early surgical decompression is frequently indicated to correct life-threatening endocrine abnormalities, prevent vision loss and reverse cranial neuropathies. In this paper, we present the indications and timing for pituitary apoplexy managed surgically.

Methods: Three hundred forty-six pituitary adenomas treated with endoscopic transsphenoidal resection at a single institution during the past five years were retrospectively identified.

Results: A total of 29 or 8.4% of patients developed pituitary apoplexy. Apoplexy was significantly more likely to occur in younger, male patients with a tumor size close to three centimeters (p < 0.05). A history of smoking or hypertension, BMI and anticoagulation did not increase the risk. The overall average time from presentation to surgery was 2.6 days. Those patients with a neurologic or ophthalmologic deficit (83%) went to surgery earlier, on average within 1.3 days. The expedited approach resulted in an 85% improvement of vision loss or neuropathy.

Conclusion: This study shows that pituitary apoplexy is a rare but time sensitive condition. There were no factors that could predict a lack of return to normal function. However, 85% of patients had resolution of their symptoms if surgery was initiated within 3 days.