Recovery of Cranial Nerve Deficits in Patients Presenting with Pituitary Apoplexy: A Case Series

Mohammed Alahmari; Fahad Alkherayf; Andrea Lasso; Fatmahalzahra Banaz; Sepideh Mohajeri; Pourya Masoudian; Andre Lamothe; Charles Agbi; Lisa Caulley; Mohammad Alshardan; Shaun Kilty

doi:10.1055/s-0040-1722668

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2022; 83(S 02): e1-e6
DOI: 10.1055/s-0040-1722668

Original Article

Recovery of Cranial Nerve Deficits in Patients Presenting with Pituitary Apoplexy: A Case Series

Mohammed Alahmari

¹Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada

,

Fahad Alkherayf

²Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada

³The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada

,

Andrea Lasso

¹Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada

³The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada

,

Fatmahalzahra Banaz

⁴Department of Otolaryngology Head and Neck Surgery, King Abdulaziz Hospital, Ministry of Health, Jeddah, Saudi Arabia

,

Sepideh Mohajeri

¹Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada

,

Pourya Masoudian

¹Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada

,

Andre Lamothe

¹Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada

,

Charles Agbi

²Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada

,

Lisa Caulley

¹Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada

³The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada

,

Mohammad Alshardan

²Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada

,

Shaun Kilty

¹Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada

³The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada

⁵Dr. S. Kilty Medicine Prof. Corp., Ottawa, Ontario, Canada

› Author Affiliations

Abstract

Background Pituitary apoplexy (PA) is a rare complication of pituitary tumors that can present with a myriad of symptoms, including sudden onset cranial nerve deficits. After patient stabilization and hormone replacement, surgical decompression is often recommended. The timing of surgical decompression remains controversial. In this case series, we describe our institutional experience pertaining to the cranial nerve recovery in patients who underwent endoscopic endonasal transsphenoidal (EETS) surgery for PA while evaluating outcome based on tumor stage using the suprasellar infrasellar parasellar anterior posterior (SIPAP) classification.

Design Present study is a single-institution retrospective cohort.

Methods A retrospective review of all EETS cases for pituitary tumor resection between November 2009 and August 2018. Queries of the hospital database were completed by trained personnel to identify cases of PA treated using the EETS approach. Baseline characteristics, tumor type, endocrine data, and SIPAP classification based on preoperative magnetic resonance imaging (MRI) and operation characteristics were extracted from medical records. Postoperative results were extracted for the duration of the follow-up period available for each patient.

Results Fifteen cases of PA were identified. Patient follow-up period was a mean of 30 months. The cranial nerve deficits present at admission were visual deficit (33%); unilateral third nerve palsy (47%) and unilateral sixth nerve palsy (27%). No fourth nerve palsies were observed. Following EETS, 60% of patients with preoperative visual deficit had normal visual fields. For those with third and sixth nerve palsies preoperatively, 43 and 75%, respectively, had return to normal function postoperatively. SIPAP tumor characteristics were not related to postoperative cranial nerve recovery.

Conclusion In this series of surgically treated patients with pituitary apoplexy, all cranial nerve deficits normalized or improved following surgery. The tumor SIPAP classification was not associated with patient outcome. Though in a small series, the presented results suggest surgical treatment is beneficial for these patients.

Keywords

pituitary apoplexy - cranial nerve deficit - pituitary adenoma

Full Text

References

References
1 Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol 2014; 4 (09) 767-770
2 Arafah BM, Harrington JF, Madhoun ZT, Selman WR. Improvement of pituitary function after surgical decompression for pituitary tumor apoplexy. J Clin Endocrinol Metab 1990; 71 (02) 323-328
3 Nawar RN, AbdelMannan D, Selman WR, Arafah BM. Pituitary tumor apoplexy: a review. J Intensive Care Med 2008; 23 (02) 75-90
4 Onesti ST, Wisniewski T, Post KD. Clinical versus subclinical pituitary apoplexy: presentation, surgical management, and outcome in 21 patients. Neurosurgery 1990; 26 (06) 980-986
5 Edal AL, Skjödt K, Nepper-Rasmussen HJ. SIPAP--a new MR classification for pituitary adenomas. Suprasellar, infrasellar, parasellar, anterior and posterior. Acta Radiol 1997; 38 (01) 30-36
6 Petermann SH, Newman NJ. Pituitary macroadenoma manifesting as an isolated fourth nerve palsy. Am J Ophthalmol 1999; 127 (02) 235-236
7 Kim YH, Cho YH, Hong SH. et al. Postoperative neurologic outcome in patients with pituitary apoplexy after transsphenoidal surgery. World Neurosurg 2018; 111: e18-e23
8 Woo HJ, Hwang JH, Hwang SK, Park YM. Clinical outcome of cranial neuropathy in patients with pituitary apoplexy. J Korean Neurosurg Soc 2010; 48 (03) 213-218
9 Muthukumar N, Rossette D, Soundaram M, Senthilbabu S, Badrinarayanan T. Blindness following pituitary apoplexy: timing of surgery and neuro-ophthalmic outcome. J Clin Neurosci 2008; 15 (08) 873-879
10 Vié AL, Raverot G. Modern neuro-ophthalmological evaluation of patients with pituitary disorders. Best Pract Res Clin Endocrinol Metab 2019; 33 (02) 101279
11 Lubbe DE, Mankahla N, Carrara H, Semple P. Surgical intervention for binocular blindness in pituitary apoplexy. Interdiscip Neurosurg 2019; 18: 100490
12 Giritharan S, Gnanalingham K, Kearney T. Pituitary apoplexy - bespoke patient management allows good clinical outcome. Clin Endocrinol (Oxf) 2016; 85 (03) 415-422
13 Kim SH, Lee KC, Kim SH. Cranial nerve palsies accompanying pituitary tumour. J Clin Neurosci 2007; 14 (12) 1158-1162
14 Hage R, Eshraghi SR, Oyesiku NM. et al. Third, fourth, and sixth cranial nerve palsies in pituitary apoplexy. World Neurosurg 2016; 94: 447-452
15 Warwar RE, Bhullar SS, Pelstring RJ, Fadell RJ. Sudden death from pituitary apoplexy in a patient presenting with an isolated sixth cranial nerve palsy. J Neuroophthalmol 2006; 26 (02) 95-97
16 Sahyouni R, Goshtasbi K, Choi E. et al. Vision outcomes in early versus late surgical intervention of pituitary apoplexy: meta-analysis. World Neurosurg 2019; 127: 52-57