Pituitary apoplexy – bespoke patient management allows good clinical outcome

Giritharan, Sumithra; Gnanalingham, Kanna; Kearney, Tara

doi:10.1111/cen.13075

Cited by 56 publications

(52 citation statements)

References 37 publications

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“…In the former condition, hypopituitarism is frequently permanent, while in the latter one recovery of endocrine function can be obtained by debulking of the pituitary mass [63, 106]. However, in terms of endocrine outcome, some studies showed that pituitary hormones deficiencies consequent to pituitary apoplexy infrequently recover and the persistence of hypopituitarism seems to be not related to management modalities [4, 96, 99, 101, 107]. …”

Section: Prognosismentioning

confidence: 99%

Multidisciplinary Management of Pituitary Apoplexy

Albani

Ferraú

Angileri

et al. 2016

International Journal of Endocrinology

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Pituitary apoplexy is a rare clinical syndrome due to ischemic or haemorrhagic necrosis of the pituitary gland which complicates 2–12% of pituitary tumours, especially nonfunctioning adenomas. In many cases, it results in severe neurological, ophthalmological, and endocrinological consequences and may require prompt surgical decompression. Pituitary apoplexy represents a rare medical emergency that necessitates a multidisciplinary approach. Modalities of treatment and times of intervention are still largely debated. Therefore, the management of patients with pituitary apoplexy is often empirically individualized and clinical outcome is inevitably related to the multidisciplinary team's skills and experience. This review aims to highlight the importance of a multidisciplinary approach in the management of pituitary apoplexy and to discuss modalities of presentation, treatment, and times of intervention.

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Section: Prognosismentioning

confidence: 99%

Multidisciplinary Management of Pituitary Apoplexy

Albani

Ferraú

Angileri

et al. 2016

International Journal of Endocrinology

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“…To assess for the effect of dichotomizing, the time from symptom onset to surgery-as performed in other studiesthe time variable was dichotomized at 1, 2, 3, 5, 7, 10, and 14 days, most of which have been previously assessed as a dichotomization time in other studies. [10][11][12][13][14][15] Odds ratios of improved vision based on each dichotomized value were determined by univariate logistic regression, as shown in ►Fig. 3.…”

Section: Assessment Of Timing Of Surgery and Visual Outcomesmentioning

confidence: 99%

The Effect of Timing of Surgery in Pituitary Apoplexy on Continuously Valued Visual Acuity

Kelly

Fernando

Malenke

et al. 2020

J Neurol Surg B Skull Base

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Background Pituitary apoplexy is often treated urgently, but this is based on studies which assess vision categorically and dichotomizes the time interval between symptom onset and surgery which may introduce bias in measuring an association between the two. Objective This study was aimed to assess for a relationship between continuously valued surgery delay and visual acuity recovery after pituitary apoplexy. Methods In this retrospective study, all patients presenting with symptomatic pituitary apoplexy between 2004 and 2016 were identified from an institutional database. The primary endpoint was visual acuity improvement, measured as the difference in acuity from the pre- to postoperative period, and measured in Logarithm of the Minimal Angle of Resolution (LogMAR) units. Analysis was performed using continuous values of time delay and visual acuity to assess for an underlying association. Results Thirty-two pituitary apoplexy patients were identified. Visual acuity deficits were reported in 81%. The median visual acuity was 0.35 LogMAR (Snellen's fraction 20/40) preoperatively, and 0.1 (20/25) postoperatively (p < 0.01). The time between symptom onset and surgery was not associated with improvement in visual acuity (p = 0.46). When the time delay and visual outcome were intentionally dichotomized, patients undergoing surgery within 2 days of symptom onset had 0.21 times the odds of a good visual outcome (95% confidence interval [CI]: 0.04–1.05). Conclusion When assessed as continuously valued measures, the time from symptom onset to surgical intervention and the improvement in visual acuity are not associated, although intentional dichotomization of data produced conflicting results.

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“…Although impairment of visual fields or visual acuity has necessitated urgent decompressive surgery in most series (61), the optimal management strategy is still controversial. Potential approaches include immediate (within days) or delayed (within weeks) surgery or conservative management (61,62,63,64,65,66,67). The safety of delayed surgical intervention remains uncertain.…”

Section: Pituitary Tumour Apoplexymentioning

confidence: 99%

“…Bujawansa et al (64) in a series of 55 patients (23 had immediate surgery (within 7 days), 10 delayed surgery and 22 managed conservatively) showed rates of improvement to visual field defects and cranial nerve palsies 60-80% and 92-100% respectively, with no significant differences between treatment strategies. Giritharan et al (65) reported on 31 patients (11 had emergency surgery (within 7 days), 9 delayed surgery and 11 conservative management); all patients, except one in the conservatively managed group, had improvement or resolution of visual defects, while complete resolution was seen in 70, 75 and 71% of the immediate surgery, delayed surgery and conservatively managed patients, respectively. Selection bias must be considered when interpreting these data, as cases with milder symptoms at presentation are more often managed with delayed surgery or conservatively (61,62,63,64,66).…”

Section: Pituitary Tumour Apoplexymentioning

confidence: 99%

“…However, the remaining three (all with unilateral blindness) who underwent surgery at 2 weeks, 3 weeks and 2 months after presentation demonstrated poorer visual recovery with improvements to 6/60, 6/60 and 1/60 in their initially blind eyes (68). Current practice in the management of apoplexy is individualised and overall resolution or improvement of pre-operative visual deficits is observed in the majority of patients, ranging from 57 to 95% for visual fields and 86 to 93% for visual acuity (61,62,63,65,69). Prospective, randomised-controlled studies are needed to provide evidence-based guidance on this controversial issue.…”

Section: Pituitary Tumour Apoplexymentioning

confidence: 99%

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MANAGEMENT OF ENDOCRINE DISEASE: Visual morbidity in patients with pituitary adenoma

Lithgow

Batra

Matthews

et al. 2019

European Journal of Endocrinology

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Visual dysfunction is an important element in the morbidity encountered in patients with pituitary adenoma leading to functional impairment and compromised quality of life. It consists of many parameters (even in the absence of reported symptomatology) as a result of tumour growth in proximity to structures critical for vision (anterior visual pathway, cranial nerves within cavernous sinuses), and as an adverse consequence of therapeutic interventions. Adenoma resection leads to high rates of visual improvement and possibly continues beyond a year post surgery, but the exact timing of maximum effect requires elucidation. Retinal nerve fibre layer measurement may be a reliable, objective parameter predicting favourable visual outcomes, although its prognostic value when pathological, needs to be confirmed. For compromised vision after pituitary apoplexy, early surgical decompression remains usual practice until evidence-based guidance becomes available. The risk of radiation-induced visual toxicity is mainly influenced by total and per fraction dose of radiation and treatment modality. Careful selection of cases and of radiotherapy technique/planning are of major importance in minimising this risk. Dopamine agonists lead to visual recovery in a considerable number of prolactinoma patients. Visual morbidity should be considered a vital indicator in the metrics of quality of service/care in pituitary disease making regular, full ophthalmic examination an essential component of modern management of pituitary pathology at all time points of patient pathway. Well-designed studies minimising effects of bias and using tools and scoring systems reliably reflecting visual status will provide robust evidence on valid prognostication and patient stratification guiding clinical decision making.

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Pituitary apoplexy – bespoke patient management allows good clinical outcome

Cited by 56 publications

References 37 publications

Multidisciplinary Management of Pituitary Apoplexy

Multidisciplinary Management of Pituitary Apoplexy

The Effect of Timing of Surgery in Pituitary Apoplexy on Continuously Valued Visual Acuity

MANAGEMENT OF ENDOCRINE DISEASE: Visual morbidity in patients with pituitary adenoma

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