Association of Preoperative Hemorrhage with Postoperative Hormonal Dysfunction in Surgically Resected Pituitary Adenomas

Background: Of all brain tumors, adenomas have the highest proportions of preoperative hemorrhage with occurrence in 10 to 27% of all cases. Hemorrhage may present with apoplexy, an urgent clinical syndrome characterized by rapid onset of severe headache, nausea, vision changes, or changes in consciousness; however, hemorrhage may also remain clinically silent. Apoplexy has been well studied and identified as a risk factor for worse postsurgical outcomes. The presence of a clinically silent hemorrhage is not well understood as an individual factor and debate remains. Previous studies of pituitary adenoma at large found a 46 and 49% improvement, respectively, in pituitary function postoperatively. We aim to characterize and compare the postoperative outcomes in patients with clinically silent hemorrhages and apoplectic hemorrhage to patients without radiographic evidence of hemorrhage.

Methods: We conducted a retrospective analysis of all patients who were treated with an endoscopic endonasal transsphenoidal approach to pituitary adenomas. MRI and operative reports were reviewed for evidence of preoperative hemorrhage. All potential hemorrhage cases were reviewed by attending neuroradiologist and neurosurgeon to classify and characterize the tumor and hemorrhage. Medical records were reviewed for demographic information, preoperative symptoms, histology, extent of resection, and postoperative outcomes including pituitary function ([Figs. 1] and [2]).

Results: Of 180 patients, 36 were found to have preoperative hemorrhage. Of the 36 patients, 25 (69.4%) presented with apoplectic events while 11 (30.6%) presented silently. Postoperatively, 24 patients (66.7%) had gross total resection, while 12 (33.3%) were subtotal. Recurrent tumor growth occurred in four patients with two of them undergoing a second surgical resection. The vast majority of patients with cranial neuropathies experienced improvements postsurgically. Transient SIADH occurred in five patients (13.9%), transient DI in three patients (8.3%), and nontransient DI in three patients (8.3%). Preoperative hypopituitarism was present in 16 patients (44.4%), 22 patients (61.1%) remained on medications for pituitary dysfunction at last known follow-up, 6 patients (16.7%) were on medications temporarily postoperatively, and 1 patient (2.8%) had continued dysfunction but was not on medication. No postoperative medications for pituitary dysfunction were necessary in seven patients (19.4%). The mean follow-up was 19 months.

Conclusion: Our data suggest that patients with hemorrhage, both apoplectic and silent, are more likely to experience endocrinopathies. These data will be helpful in the preoperative counseling and perioperative management.

Fig. 1 Macroadenoma with silent hemorrhage measuring 3.8 × 3.2 × 4.5 cm.

Fig. 2 Macroadenoma with pituitary apoplexy measuring 3.5 × 4.8 × 5.6 cm.