Timing of Surgery and Outcome in Pituitary Apoplexy

Abstract

Pituitary apoplexy is often heralded by the occurrence of one or more of the following: sudden onset of headache, decreased visual acuity, restricted visual fields, disorders of ocular motility and altered sensorium. The outcome of pituitary apoplexy depends upon the prompt recognition and appropriate treatment. Studies have shown that the outcome after surgical decompression is good if the intervention is done as early as possible with significant improvements noted in visual acuity, visual fields and extraocular palsies. Serviceable vision may be restored even in patients who are rendered blind preoperatively, if the surgical decompression can be done within the first week of the ictus. Recovery of extraocular nerve palsies is not related to the timing of surgery. There is evidence in the literature that early surgical decompression has a better chance of restitution of pituitary function than otherwise. Despite this, most patients with pituitary apoplexy will require long-term hormone replacement therapy for the hypopituitarism that follows this event probably because of the delay in surgical intervention. Even though the incidence of pituitary apoplexy is more in nonfunctional adenomas, there is no difference in outcome when apoplexy takes place in functional or nonfunctional adenomas. However, outcome is related to the histopathology of the adenomatous pituitary that has undergone apoplexy; patients with only infarction on histopathological examination have a better neurological outcome than those with haemorrhagic infarction, but the endocrinological outcome is the same in both groups. Patients with known precipitating factors for pituitary apoplexy are likely to have more severe neurological and endocrine impairment in the long term than those without known precipitating factors. Recurrence of pituitary adenoma occurs in about 11 % of patients with documented pituitary apoplexy, and hence, long-term follow-up is mandatory in patients who have suffered pituitary apoplexy. Rarely, recurrent pituitary apoplexy can take place in the residual pituitary adenoma after an initial apoplectic event. Death due to pituitary apoplexy occurs in less than 5 % of cases.