Pituitary Apoplexy: Management and Outcomes at a Single-Center Over 15-Year Experience

Introduction: Pituitary apoplexy commonly presents with visual and hormonal deficits. While traditionally regarded as an emergency, there have been increasing trends toward conservative management. We present our institutional series in regard to vision outcomes, hormone function, and complications.

Methods: We retrospectively reviewed our series of apoplexy patients identified by review of pathological studies and confirmed by chart review. We recorded basic demographic features, radiographic and operative features, and preoperative and postoperative vision and hormone status. Univariate and multivariate statistical analyses were performed. We then pooled our data with the available literature for Bayesian inference.

Results: Forty-nine patients were identified and confirmed to have pituitary apoplexy and underwent transnasal transsphenoidal decompression with >70% within 24 hours of presentation. Mean BMI was 34.8; 65% of patients had a visual deficit, of which 40.8% had a cranial nerve palsy, 34% had anopsia, and 18% had a visual acuity deficit. Hypothyroidism (36.7%) and low testosterone (26%) were common. Postoperatively, 100% of CN palsies improved, 82% of anopsias improved, and 60% of visual acuity deficits improved. Most hormone abnormalities improved after surgery, but long-lasting panhypopituitarism (26%) and diabetes insipidus (20%) were common. Other than preoperative anticoagulation use associated with long-term adrenal insufficiency (p = 0.007), there were no independent predictors of long-term hormone dysfunction. Cavernous sinus involvement predicted residual tumor (p = 0.006). Mean length of stay was 4 days, and independent predictors were anticoagulation use (OR: 6.434, p = 0.011), postoperative diabetes insipidus (OR: 3.8204, p = 0.041), and postoperative visual acuity deficits (OR: 8.6759, p = 0.008). There were eight medical and two surgical complications with one CSF leak. Bayesian inference demonstrated an absolute risk reduction for persistent visual deficit of 0.303 with surgery compared with conservative management. This represents a number needed to treat (NNT) of 3.3 for improved visual outcomes with surgery.

Conclusion: Early surgery for pituitary apoplexy is associated with excellent long-term visual deficits, although visual acuity was more resistant to improvement than anopsia or cranial nerve palsies. The need for long-term hormone replacement is common and there are no preoperative features to predict which hormones will be altered other than general incidence measures. Cavernous sinus involvement is an independent predictor of residual tumor. Despite a high mean BMI, our CSF leak rate was nominal. Our data in addition to the pooled data across publications show long-term visual benefit with surgery.