Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature

Abstract

Introduction For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes. Methods A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time. Results A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation (p = 0.047). Conclusion Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.

Determinants of visual and endocrinological outcome after early endoscopic endonasal surgery for pituitary apoplexy

“…is, in turn, points to the importance of pituitary gland identification and preservation during surgery. As noted by Souter et al, [25] the gland can be identified at the margin of the tumor resection by subtle differences in the color, tendency to bleed, and consistency.…”

“…One study suggests that surgical intervention after 1 week of symptom presentation can significantly impact postoperative visual field improvement. [6] Another study by Souter et al [25] showed that a longer time to surgery is associated with a worse outcome.…”

Endoscopic Endonasal Transsphenoidal Approach for the Surgical Treatment of Pituitary Apoplexy and Clinical Outcomes

“… 33 The relationship between pituitary protection and postoperative pituitary function in the sellar region surgery has been a hot topic in recent years. 34 , 35 …”

“…33 The relationship between pituitary protection and postoperative pituitary function in the sellar region surgery has been a hot topic in recent years. 34,35 CSF leakage is one of the most common complications of transnasal endoscopic surgery and depends on the characteristics of the tumor, surgical technique, and experience of the operator. Postoperative CSF leakage is mainly due to a failure to recognize or repair the problem during surgery.…”

Pituitary Apoplexy with raised intracranial pressure

“…ituitary adenomas apoplexy (PA) can present as a life-threatening condition which requires urgent surgical intervention, mainly because of the mass eff ect the tumor exerts on its surrounding structures as well as because of endocrinological dysfunction the tumor produces. 1 PA may occur spontaneously or with predisposing factors like surgical intervention, vasospasm, hypertension as a result of acute hemorrhage and/or infarction in the presence of a pre-existing pituitary adenoma. 2 Classic clinical presentations include sudden severe headache, visual impairment, nausea/vomiting and meningismus; which are determined by the extent of necrosis and hemorrhage of the tumor.…”