Pituitary Apoplexy Precipitated by Noncranial Surgeries

Introduction: Pituitary apoplexy (PA) is a rare condition caused by sudden hemorrhage or infarction within the pituitary gland, primarily associated with pre-existing pituitary adenomas. Classically, PA presents with severe headache along with neuro-ophthalmologic and/or endocrine disturbances. Mechanisms of PA are still being investigated and include abnormal changes in vasculature, blood flow, and intrasellar pressure. While case reports of PA in association with noncranial surgeries have been reported, detailed evaluation of preoperative, intraoperative, and postoperative risk factors is limited. We report the first 6-year institutional experience of risk factors of PA associated with non-cranial surgeries.

Methods: A retrospective review was conducted of all patients who presented to the Neurosurgery or Otolaryngology service with PA from September 2017 to January 2024. Any patient who developed PA within 1 week after a non-cranial surgical procedure was included in the series. Pre-operative, intra-operative, and post-operative data was collected, including past medical history, vital sign parameters, medications (anesthetic agents, vasoactive agents, anticoagulants, and steroids), cranial imaging, PA presenting symptoms, and clinical course after transsphenoidal resection.

Results: A total of 56 patients presented with PA within a 76-month time frame. Of these, 4 (7.1%) presented within 1 week of a non-cranial surgical procedure. Two patients presented after cardiac procedures, specifically a mechanical valve replacement and coronary artery bypass graft; one patient presented after a mandibulectomy and one after a toe amputation. Pre- and intra-operative data for the last patient was unavailable, and he was thus excluded from the case series. All three patients were males who presented with oculomotor deficits and endocrine abnormalities, with all patients having hypothyroidism and two of three having adrenal insufficiency and hypogonadism. Other presenting symptoms included headache, emesis, and altered mental status. All non-cranial procedures were performed under general anesthesia with propofol and fentanyl; pressors were used in all cases and heparin anticoagulation was used in both cardiac interventions. Average time under anesthesia was 9.09 hours (range: 6.37–13.58 hours); average procedure time was 7.18 hours (range: 4.78–11.68 hours). Time to symptom onset was <24 hours after noncranial procedure. All patients had a history of hypertension and experienced wide blood pressure fluctuations intraoperatively (range systolic blood pressure 60–200; average intraoperative systolic variation: 120 mm Hg; average intraoperative diastolic variation: 56.7 mm Hg). 2 of the patients had known pituitary adenomas, and 1 patient was diagnosed with a pituitary adenoma after PA symptom onset post-operatively. All 3 patients had lesions > 2 cm.

Conclusion: Despite the differences in surgical context, several factors seemed to have predisposed these patients to PA: (1) significant fluctuations in intraoperative blood pressure, (2) preexisting hypertension and other comorbid conditions, and (3) the presence of macroadenomas exceeding 2 cm in diameter. Thus, in patients with known pituitary macroadenomas, risk stratification for PA may be helpful, especially based on adenoma size and past medical history, particularly hypertension, diabetes, and other conditions affecting vascular health. In these patients, sudden intraoperative changes in blood pressure should be avoided. For those with predisposing risk factors undergoing high-risk surgeries, especially cardiac procedures, obtaining a preoperative CT head may be warranted.

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Artikel online veröffentlicht:
07. Februar 2025