Surgical treatment for severe visual compromised patients after pituitary apoplexy

Abstract

Early decompression significantly improved visual outcomes and the need for hormone replacement was minimal. We postulated old age, underlying malignant diseases, and coagulation disorders played the predisposing factors of poor outcome in these cases.

Endoscopic Endonasal Transsphenoidal Treatment of Pituitary Apoplexy: Outcomes in a Series of 20 Patients

“…Improvement of subjective visual acuity decrease occurred in 66.7%, and 100% had a resolution of diplopia, consistent with the published trend of better reversal of ophthalmoplegic symptoms after surgical treatment of apoplectic patients [1][2]. In accordance with prior publications supporting early surgical intervention for better vision-related symptom reversal/improvement [6,[8][9][10], our data shows a lower rates of field cut improvement and overall later time-to-surgery (three of the four patients without improvement had surgery after one month of symptom onset). However, the total number of patients with documented visual field deficit in our series is too small to show a definitive trend of field cut improvement with early time-to-surgery.…”

“…A range of "a few hours to 80 days" of time-to-presentation was noted in another larger series of apoplexy patients [4]. The optimal time for surgical intervention is still under debate, although many advocate for early intervention [6,[8][9][10]. Our decisions on when to operate have been based on the severity and rate of progression of a patient's visual symptoms since hormonal deficiencies can be treated medically.…”

“…All of their patients were operated on within 24 hours of presentation. Chuang, et al [9] reported their experience with 13 apoplectic patients (12 were treated with an endoscopic approach, 1 open craniotomy). They divided their patients into "uncomplicated" and "complicated" groups (with underlying medical comorbidities preventing earlier surgeries), the former had surgery within 3.5 days and the second group had surgery within 8.7 days.…”

“…Although controversial, early surgery is advocated by some authors to achieve better postoperative results, depending on the specific preoperative symptoms [6,[8][9][10]. In the absence of significant or progressive visual symptoms, non-surgical management (i.e., hormone replacement) can be considered as the sole therapy.…”

“…Several authors have advocated the endoscopic endonasal approach as a method to increase the extent of resection and decrease pituitary deficiency after surgery based on the increased visualization afforded by the panoramic and angled views provided by the endoscopes [12,[14][15][16]. However, reports of treating apoplexy with endoscopic techniques are limited [9,[17][18]. The aim of this study was to analyze the effectiveness of endonasal endoscopic transsphenoidal surgery at treating pituitary apoplexy in a series of consecutive patients treated by the senior authors (THS and VKA) and compare these results to historical reports in which a microscope was used.…”