Management Of Pituitary Apoplexy Research Articles

Pituitary Apoplexy: An Updated Review.

Pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland. It is clinically characterized by the sudden onset of headache. Depending on the severity, it may also be accompanied by nausea, vomiting, visual disturbances, varying degrees of adenohypophyseal hormone deficiency, and decreased level of consciousness. Corticotropic axis involvement may result in severe hypotension and contribute to impaired level of consciousness. Precipitating factors are present in up to 30% of cases. PA may occur at any age and sometimes develops during pregnancy or the immediate postpartum period. PA occurs more frequently in men aged 50-60, being rare in children and adolescents. It can develop in healthy pituitary glands or those affected by inflammation, infection, or tumor. The main cause of PA is usually spontaneous hemorrhage or infarction of a pituitary adenoma (pituitary neuroendocrine tumor, PitNET). It is a medical emergency requiring immediate attention and, in many cases, urgent surgical intervention and long-term follow-up. Although the majority of patients (70%) require surgery, about one-third can be treated conservatively, mainly by monitoring fluid and electrolyte levels and using intravenous glucocorticoids. There are scoring systems for PA with implications for management and therapeutic outcomes that can help guide therapeutic decisions. Management of PA requires proper evaluation and long-term follow-up by a multidisciplinary team with expertise in pituitary pathology. The aim of the review is to summarize and update the most relevant aspects of the epidemiology, etiopathogenesis, pathophysiology, clinical presentation and clinical forms, diagnosis, therapeutic strategies, and prognosis of PA.

Effectiveness of endoscopic endonasal surgery for pituitary apoplexy: A comprehensive evaluation of presentation and clinical outcomes from a tertiary care center

BackgroundThe management of pituitary apoplexy (PA) is under debate. Therefore, we studied the clinical manifestations and neuroendocrine outcomes of PA after surgical management, as well as the efficacy and safety of the endoscopic endonasal transsphenoidal approach (EETA). MethodsThis retrospective study was conducted between January 2013 and May 2021, and included 62 cases of pituitary adenoma apoplexy that were managed with EETA. ResultsData from 62 patients were analyzed with a mean age of 50.7 ± 10.9 years, 90.3 % of whom were female. On admission, most patients presented with abrupt onset severe headache and vomiting, associated with endocrine dysfunction in 43.5 % and deteriorated visual acuity in 92 %. Third nerve palsy was the most noted ocular nerve palsy. After using EETA, the adenoma was resected totally, subtotally, and partially in 59.7 %, 29 %, and 11.3 % of the cases, respectively. Postoperative improvement in visual acuity was achieved in 90.3 % of patients, unchanged in 6.5 % with vision defects, and deteriorated in 3.2 %. Endocrine dysfunction improved to 19.3 % after being 43.5 %. Six patients (9.6 %) experienced transient diabetes insipidus (DI) that responded completely to desmopressin therapy for a time, and three cases were complicated with CSF leakage after the operation, but it resolved completely. No intracranial infection, carotid artery injury, or death occurred. ConclusionDespite the availability of alternative treatment options, the surgical intervention by EETA remains the most effective and reliable method for managing patients with PA who present with sudden visual or endocrine symptoms. EETA has been shown to result in significant improvements in both visual and endocrine function, with an acceptable complication rate that can be managed effectively in many cases. As such, EETA continues to represent the cornerstone in the management of PA and should be considered the first-line treatment option for amenable patients.

FRI335 Late Surgical Management For Symptom Control In A Patient With History Of Pituitary Apoplexy

Abstract Disclosure: S. Zahra: None. F. Manas: None. S. Yavuz: None. Introduction: Pituitary Apoplexy is a rare life-threatening condition which presents with sudden onset headache, and neuro-ophthalmic symptoms. The diagnosis is challenging and requires a high index of clinical suspicion, especially in patients with pre-existing pituitary macroadenomas. MRI is the imaging modality of choice to confirm the diagnosis. The management is tailored according to the severity of clinical presentation. A conservative approach is recommended in stable patients with no or mild visual changes. Surgical management is usually reserved for patients with severely reduced visual acuity, and worsening mentation. Here we present a case of a patient with pituitary apoplexy who underwent late surgical resection due to persistent intractable headache. Case Presentation: 24 years old female with no significant past medical history presented to the emergency with worsening headache and blurry vision since last 2 weeks. The patient also complained of weight gain, fatigue, amenorrhea, and intermittent galactorrhea for the last 8 months. Physical examination was unremarkable, no visual deficit or neurological deficit was present. Blood work was remarkable for mildly elevated prolactin of 46.1 ng/ml (normal: 3.0-18.6 ng/ml) and low morning cortisol of 4.0ug/dl (normal:4.5-22.7 ug/dl). MRI of the brain revealed 13mm x 7.5mm focus of signal abnormality within the posterior aspect of the Sella, suggestive of a hemorrhagic adenoma. She was diagnosed with pituitary apoplexy with secondary adrenal insufficiency and was started on IV hydrocortisone. Neurosurgery was consulted, however no surgical interventions were recommended since the patient had no evidence of mass effect on optic chiasm or vision loss or changes in mentation. She was discharged on oral steroids. Her prolactin level, which was initially elevated likely due to compression of infundibulum from hemorrhage, normalized a few weeks after hospitalization. She was followed with MRI which showed a stable pituitary lesion. The patient continued to have intermittent episodes of headache which were initially managed conservatively but later the patient opted for elective surgery due to the persistence of intractable headaches. She underwent endoscopic transsphenoidal resection of pituitary tumor without any complications. At follow up visits, the patient’s symptoms had resolved, and her hypothalamic-pituitary axis evaluation and MRI was normal. Conclusion: The management of pituitary apoplexy is controversial due to its rarity and variation in the severity of symptoms at the time of presentation. In the recent past, conservative approaches have become more common in patients who are stable with little or no visual defects. The neurosurgical approach is usually reserved for patients with deteriorating mentation or worsening visual changes, but it can be used in patients with persistent severe symptoms. Presentation: Friday, June 16, 2023

FRI353 Diabetes Insipidus - Pituitary Apoplexy Or Placental Vasopressinase?

Abstract Disclosure: N.M. Rodrigues: None. J. Palacios Merchan: None. M.B. Twahirwa: None. Background: Pituitary apoplexy is rare in pregnancy. Diabetes insipidus is rare at apoplexy onset, present in about 5% of patients presenting with apoplexy. Gestational DI can occur due to placental vasopressinase though this is more common in twin pregnancies and pre-eclampsia. Clinical Case: 28-year-old Hispanic woman was admitted at 34-weeks' gestation for 1 week of headache, visual symptoms, elevated blood pressure and polyuria. Her thirst was intact. She had a known history of 8 mm prolactinoma, which was diagnosed 2 years prior to admission. She was treated with Cabergoline 0.5 mg twice weekly, which was stopped once pregnancy was confirmed. A 24-hour urine collection was performed as part of her pre-eclampsia workup. Total volume was 11,250 mL, osmolality 97 mOsm/kg and sodium of 25 mmol/L. Serum sodium was 136 mmol/L. MRI of the brain showed pituitary apoplexy with large suprasellar area hemorrhage, compressing the pituitary gland and infundibulum, resulting in anterior displacement. The optic chiasm was also compressed and displaced superiorly. Her BP remained normal throughout admission and pre-eclampsia workup was negative. Lab work did not show significant hypopituitarism with TSH of 1.3 microIU/mL, Free T4 0.53 ng/dL, random Cortisol of 11.5 mcg/dL, IGF-1 167 ng/mL, Copeptin 3.8 pmol/L. Considering this was the third trimester of pregnancy as well as the chronicity of the bleed, thought to be 5-7 days, neurosurgery suggested conservative management. She continued to maintain normal serum sodium levels throughout admission. She was delivered at 35 weeks by Caesarean section. She received Hydrocortisone 100 mg IV before the surgery. She also received DDAVP 1 mcg IV before delivery since her sodium level increased to 145 mmol/L from a baseline of 133-136 mmol/L. The delivery was uneventful, and she had a healthy baby. After delivery, her urine output decreased to 180 cc/hour with significant improvement in thirst. Her serum sodium remained normal. This raises the question of whether DI was due to apoplexy or placental effect. Conclusion: Even though pregnancy causes hypertrophy of the lactotrophs, pituitary apoplexy is less common in microadenomas. Apoplexy in pregnancy is very rare, occurring only in 1 in 10,000 gestations. The clinical presentation in this case suggests a low threshold to order pituitary imaging in cases presenting with concerning sign symptoms of increase intracranial pressure. Guidelines are limited in the management of pituitary apoplexy in pregnancy. There are case reports and case series where patients with apoplexy were delivered with C- section at 34 weeks. In addition, the element of pregnancy induced DI makes this presentation unique. Presentation: Friday, June 16, 2023

Diagnosis and management of pituitary apoplexy: a Tunisian data

BackgroundPituitary apoplexy (PA) is defined as the hemorrhage or the infraction of a pituitary adenoma. Aiming to determine the epidemiological, clinical, paraclinical characteristics as well as management and outcomes of PA in our population, we conducted this cross-sectional study.MethodsThis cross-sectional study was conducted at the Department of Endocrinology of Hedi chaker university hospital, Sfax. Data was collected from medical charts of patients with pituitary apoplexy admitted in our department between 2000 and 2017.ResultsWe included 44 patients with PA. Their mean age was 50 ± 12.6 years. Among them, 31.8% had a known pituitary adenoma, and it was in all cases a macroadenoma, predominantly a prolactin secreting tumor (42.8%). A triggering factor of PA was encountered in 31.8% of cases and it was mainly: head trauma, dopamine antagonists, and hypertension. The clinical presentation of PA encompassed headaches (84.1%), visual disturbances (75%), and neurological signs (40.9%). Gonadotropin deficiency was the most frequent form of hypopituitarism noted (59.1%), followed by corticotropin deficiency (52.3%), thyrotropin deficiency (47.7%), and somatotropin deficiency (2.3%). Hormonal assessment at PA onset, concluded that 23 had a secreting adenoma: 18 prolactinomas, 3 ACTH-secreting adenomas, and 2 GH-secreting adenomas. In the 21 remaining cases, the tumor was non-functioning (47.7%).Pituitary MRI was performed in 42 cases (95.5%), revealing infraction and or hemorrhage in the pituitary gland in 33 cases; a heterogenous signal or a fluid level within the adenoma, in nine cases.Urgent administration of intra venous hydrocortisone was required in 19 cases. Mannitol administration was mandatory in a patient who had severe intracranial hypertension. Surgical management of the PA was imperative in 24 patients (54.5%): 15 suffered from severe visual impairment, 4 had an intracranial hypertension, 2 cases demonstrated an impaired consciousness, 2 patients experienced a tumor enlargement and one case had a severe Cushing’s disease. Operative complications found were rhinorrhea attributable to cerebral spinal fluid leakage, insipidus diabetes associated with rhinorrhea, isolated insipidus diabetes, and hydrocephalus in one case each. Long-term follow-up concluded that headaches persisted in five cases, owing to the tenacity of a macroprolactinoma regardless of cabergoline treatment in one case, the recurrence of an adenoma in two cases and its persistence despite the medical and the surgical treatment in two patients. Concerning the visual acuity defects, only two patients had persistent diminished visual acuity at long-term follow-up.Among 25 patients, 13 were diagnosed with definitive thyrotropin deficiency. Similarly, 14 patients had persistent corticotropin deficiency (CD). Additionally, CD was de novo diagnosed in two patients. Otherwise, gonadotropin deficiency prevailed in all cases. Persistent prolactin deficiency was seen in two patients. Disappearance of the pituitary tumor was encountered in 11 out of 24 cases at long-term follow-up. Overall, surgery was associated with better outcome than conservative management.Pituitary apoplexy is a challenging condition due to its variable course, its diagnosis difficulty and management, as gaps remain to determine the best approach to treat this condition.ConclusionsTo conclude, pituitary apoplexy is a challenging condition due to its variable course, its diagnosis difficulty and management, as gaps remain to determine the best approach to treat this condition. Further studies are thus needed.

Pituitary Apoplexy: A Retrospective Study of 36 Cases From a Single Center.

Background and objective Pituitary apoplexy (PA) is a possible life-threatening disorder due to spontaneous hemorrhage or impaired blood supply in the pituitary gland. It may present as an acute or subclinical form, and treatment options include either surgery or a conservative approach. The purpose of this study was to retrospectively analyze the clinical, imaging, and hormonal features, as well as the therapeutic outcomes, in a relatively short period of time in a series ofconsecutive patients with pituitary apoplexy (PA). Results Thirty-six patients were included, 50% presenting typical symptoms of PA. The presenting symptoms were headache (44.4%), visual abnormalities (44.4%), and digestive symptoms (22.2%). At diagnosis, hormonal deficiency was observed in 22 (61.1%) patients. Of the evaluated patients, 78.2% of the 23 operated cases and all unoperated cases presented tumor remnants. Vision improved in 81.8% of the operated and 100% of conservatively managed cases. Of all cases,69.4% remained with long-term hypopituitarism. Conclusion Complex management of PA frequently leads to visual improvement but long-standing hypopituitarism.

Management of pituitary apoplexy

Management of pituitary apoplexy

Clinical and laboratory features and management of pituitary apoplexy: Case series

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Abstract 103: The pituitary apoplexy score (PAS) in the evaluation and management of pituitary apoplexy: A single centre experience

Introduction: Pituitary apoplexy score (PAS) is a clinical tool, scored from 0 to10, consisting of GCS, visual acuity, visual field defects and ocular muscle function. It helps assess the clinical severity and outcome of patients with pituitary apoplexy (PA).Aims and Objectives: To apply PAS score retrospectively and determine its usefulness in the management of our PA patients.Results: Sixteen patients were included in the study (56.3% males) with mean age of 34.25 years. Presenting feature was headache in 87.5%, visual disturbance in 50%, seizures in 18.8% and focal deficit in 6.3%. The precipitating event was found in 3 (18.9%). The mean PAS in conservatively managed patients was 0.27 and in those surgically managed was 3.2. Emergent pituitary surgery was performed in 5 patients (31.3%) of which 4 had PAS of >3.Conclusion: Clinical severity based on PAS ≥ 3 appeared to influence the management towards emergency surgical intervention and can be a useful tool to monitor conservatively managed patients and intervene.

A key role for conservative treatment in the management of pituitary apoplexy.

The management of pituitary apoplexy, a rare emergency neuroendocrine condition, is controversial. The aim of the present study is to compare the outcomes of patients with pituitary apoplexy managed either by a conservative or surgical approach. A retrospective cohort study including patients diagnosed between 2007 and 2018 in a tertiary French university hospital. Pituitary Apoplexy Score (PAS) was retrospectively applied in the perspective of therapeutic decision support. Forty-six patients were treated for pituitary apoplexy either with conservative management (n = 27) or surgery (n = 19). At initial evaluation, visual field defects (VFD) and visual acuity impairment were more frequent in patients from the surgery group. At 1 year there were no statistical differences in the rates of complete/near-complete resolution of VFD (100 vs. 91.7%), visual acuity impairment (100 vs. 87.5%), and cranial nerve palsies (83.3 vs. 100%), between conservative and surgical treatment groups. There were more endocrine deficits at 1 year in the surgical group (p = 0.029). PAS (n = 41) was 3.4 on average in the early surgery group and 1.3 in the conservative treatment/delayed surgery group. Among patients with a score < 4, 31.3% were operated at first line and did not present better outcomes than patients managed conservatively. In all, 88.9% of patients with a score ≥ 4 underwent surgery. PAS may be a reliable parameter for defining therapeutic strategy. Patients with non-severe and nonprogressive neuro-ophthalmological deficits can be managed conservatively without negative impact on outcomes, thus surgery should be reserved only for those patients with a PAS ≥ 4.

Conservative management of pituitary apoplexy – a case series

Conservative management of pituitary apoplexy – a case series

A key role for conservative treatment in the management of pituitary apoplexy

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Pituitary Apoplexy Case Series: Outcomes After Endoscopic Endonasal Transsphenoidal Surgery at a Single Tertiary Center

The management of pituitary apoplexy, caused by acute hemorrhage and/or infarction of a pituitary adenoma, is debated. To analyze clinical characteristics of patients undergoing endoscopic endonasal approaches (EEAs) for pituitary apoplexy. A retrospective review of patients at our institution from 2012 to 2018 undergoing EEA for pituitary apoplexy diagnosed clinically and with imaging/pathologic findings. Analysis included demographics, symptoms, neuroendocrine deficits, neuroimaging, complications, symptom resolution, and follow-up details. Fifty patients (mean age, 53 years) were included. Preoperative symptoms included headache (86%), vision loss (62%), and cranial nerve paresis (40%). Mean tumor diameter was 2.7 cm and extrasellar extension was observed in 96% of tumors. Twenty-eight tumors were hemorrhagic (76%), 24 were necrotic (65%), and 13 (35%) had both features. Magnetic resonance imaging showed gross total resection in 58% of patients. Headache and vision loss improved in 87% and 86% of presenting patients. Cranial nerve paresis resolved in 72% of patients, partially improved in 11%, and remained unchanged in 17%. There were no deaths or carotid artery injuries. Surgical complications included postoperative cerebrospinal fluid leak (n= 4, 8%), epistaxis (n= 2, 4%), postoperative abscess (n= 1, 2%), and transient postoperative vision loss requiring reoperation (n= 1, 4%). Endocrinopathies improved in 21% of patients and panhypopituitarism persisted in 48% and developed in 6% of patients. Mean follow-up time was 26 months; 2 patients experienced recurrence. EEA for pituitary apoplexy is effective in rapidly improving headache and visual symptoms. Although neuro-ophthalmic deficits often improve over time, panhypopituitarism persists in most patients after surgical resection.

Endoscopic Endonasal Surgery for Pituitary Apoplexy: Evidence On a 75-Case Series From a Tertiary Care Center.

The optimal management of pituitary apoplexy (PA) remains debated. The aim of this study was to assess the outcome of the transsphenoidal approach for PA in a large surgical experience. Each consecutive case of PA consecutively operated by endoscopic endonasal approach from our tertiary care center, from 1998 to 2015, was included in this series. Seventy-five patients (47 male; mean age 52.4± 16.2 years) were included. Mean follow-up was 69.3 ± 46.7 months. On admission, all patients presented with abrupt severe headache (100%), associated with anterior hypopituitarism in 51 patients (68%), visual disturbances in 55 (73.4%), ophthalmoplegia in 38 (50.7%), and a remarkable reduction of consciousness in 2 (2.6%). Apoplexy proved to be ischemic in 35 patients (46.7%) and hemorrhagic in 40 (53.3%). Patients with hemorrhagic necrosis presented more often with major suprasellar expansion (P = 0.012) Radical removal was achieved in 60 cases (80%). Surgical morbidity consisted in one case of postoperative cerebrospinal fluid leak (1.3%). Anterior hypopituitarism worsened in 15 cases (20%), and diabetes insipidus occurred in 4 cases (5.3%). Ophthalmoplegia improved/normalized in 71% and visual symptoms in 85.5% of the patients, with better results achieved in ischemic forms (P = 0.043). The 2comatose patients regained normal consciousness. The endoscopic endonasal approach represents a valid, effective, and safe technique in the management of PA. Favorable outcomes can be achieved by referring patients to dedicated pituitary centers with a multidisciplinary team. Further studies are still needed to define criteria for surgical indication and to identify outcome predictors.

Abstract #801: Conservative Management of Pituitary Apoplexy

Abstract #801: Conservative Management of Pituitary Apoplexy

Management of pituitary apoplexy.

Management of pituitary apoplexy.

Management of pituitary apoplexy: the greater Manchester experience

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Incidence of Pituitary Apoplexy and Its Risk Factors in Chinese People: A Database Study of Patients with Pituitary Adenoma.

BackgroundThere are few studies of the incidence and clinical characteristics of pituitary apoplexy (PA) in pituitary adenoma patients, and the findings have been inconsistent.ObjectiveThe aim of the study was to retrospectively assess the incidence, clinical presentation, surgical management and postoperative complications of PA in pituitary adenoma patients.MethodsA database was specifically designed to collect clinical, therapeutic, prognostic and histological information about pituitary adenoma patients. Using multivariate logistic regression, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to identify associated factors.ResultsA total of 2021 pituitary adenoma patients were recruited. 97 (4.8%) patients had PA. The incidence of PA was 10.11% in patients with pituitary macroadenoma, and 0.36% in patients with microadenoma. Variables for the logistic regression model independently associated with PA were sex (male vs. female, OR = 2.54, 95% CI: 1.59~4.07), tumor type (negative staining vs. positive staining, OR = 2.04, 95% CI: 1.29~3.23), and tumor size (macroadenoma vs. microadenoma, OR = 26.46, 95% CI = 9.66~72.46). Headache, visual deterioration, and vomiting were the most common symptoms in patients with pituitary adenoma. Patients with and without PA had similar frequency of visual deterioration, head trauma, acromegalic appearance, galactorrhoea, cold intolerance and Cushingoid appearance, but headache, vomiting, ptosis, diplopia, fever and blindness were significantly more common in patients with PA. Pearson Chi-Square tests revealed a significant difference in surgical approach between patients with and without PA (95.88% vs. 85.57%, P = 0.01).ConclusionOur findings suggest that PA is not a rare event. Male sex, non-functioning tumor, and macroadenoma are associated with an increased risk of PA. Compared with pituitary adenoma patients without PA, patients with PA have more severe symptoms.

A case of pituitary apoplexy in pregnancy

SummaryPituitary apoplexy is a rare event in pregnancy. A 41-year-old woman with a known pituitary microadenoma presented with visual disturbance and headache during the second trimester of pregnancy. Magnetic resonance imaging (MRI) demonstrated pituitary apoplexy with chiasmal compression. After treatment with corticosteroid therapy, she underwent transsphenoidal excision of the pituitary adenoma. Visual abnormalities were completely restored and pituitary function preserved. There was no evidence of impact on the foetus. The literature on the subject is reviewed with emphasis on the management of the apoplectic patient with mild and stable neuro-ophthalmological signs.Learning points There are no clear guidelines on the management of pituitary apoplexy in pregnancy. A multidisciplinary approach can minimise morbidity and mortality.Pituitary apoplexy has an unpredictable clinical course and determining which clinical situations warrant early surgery needs to take into consideration the presence and severity of neurological signs and their stability.The management of conscious apoplectic patients with absent or mild and stable neuro-ophthalmological signs is controversial.

Endoscopic Endonasal Surgery: New Perspectives in Recurrent and Residual Pituitary Adenomas

The optimal management of pituitary apoplexy (PA) remains debated. The aim of this study was to assess the outcome of the transsphenoidal approach for PA in a large surgical experience.Each consecutive case of PA consecutively operated by endoscopic endonasal approach from our tertiary care center, from 1998 to 2015, was included in this series.Seventy-five patients (47 male; mean age 52.4 ± 16.2 years) were included. Mean follow-up was 69.3 ± 46.7 months. On admission, all patients presented with abrupt severe headache (100%), associated with anterior hypopituitarism in 51 patients (68%), visual disturbances in 55 (73.4%), ophthalmoplegia in 38 (50.7%), and a remarkable reduction of consciousness in 2 (2.6%). Apoplexy proved to be ischemic in 35 patients (46.7%) and hemorrhagic in 40 (53.3%). Patients with hemorrhagic necrosis presented more often with major suprasellar expansion (P = 0.012) Radical removal was achieved in 60 cases (80%). Surgical morbidity consisted in one case of postoperative cerebrospinal fluid leak (1.3%). Anterior hypopituitarism worsened in 15 cases (20%), and diabetes insipidus occurred in 4 cases (5.3%). Ophthalmoplegia improved/normalized in 71% and visual symptoms in 85.5% of the patients, with better results achieved in ischemic forms (P = 0.043). The 2 comatose patients regained normal consciousness.The endoscopic endonasal approach represents a valid, effective, and safe technique in the management of PA. Favorable outcomes can be achieved by referring patients to dedicated pituitary centers with a multidisciplinary team. Further studies are still needed to define criteria for surgical indication and to identify outcome predictors.