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

Abstract

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.

Ultra-Early Treatment of Neurosurgical Emergencies with Endoscopic Endonasal Approach: Experience from Three Italian Referral Centers

“…Those clinical manifestations are generally due to a pituitary or intralesional hemorrhage, more rarely to a rapid growth neoplasm or a severe infectious condition. Although the feasibility and safety of transcranial endoscopic procedures in emergency settings have been recently demonstrated [15], there are no large series yet in the literature about the management of urgencies in trans-sphenoidal endoscopic surgery [16,17], and almost all of them involve PA [18][19][20]. Our series confirms these data, reporting 18 patients (69.2%) affected by PA (13 non-functioning, five secreting prolactin).…”

Risk Factors, Radiological and Clinical Outcomes in Subclinical and Clinical Pituitary Apoplexy

“…A meta-analysis including 200 patients with PA aimed at evaluating visual recovery comparing early vs. late surgery did not find statistical differences [37]. Likewise, other studies found similar pituitary impairment and significant improvement in outcomes regardless of the timing of surgical intervention [16,17,[38][39][40]. The ongoing multicenter project conducted at Cedars-Sinai Hospital called "Pituitary Apoplexy Surgical Timing and Outcome Registry (PASTOR)" would l provide definitive evidence about treatment approaches and outcomes [41].…”

“…Nowadays, high doses of glucocorticoid are mandatory immediately after PA diagnosis, and neurosurgery is reserved for more severe cases or when the conservative approach fails [11][12][13][14][15]. However, the timing of surgery for improving visual outcomes is a matter of debate [16,17].…”

Pituitary Apoplexy: Risk Factors and Underlying Molecular Mechanisms

“…A conservative approach using high doses of glucocorticoid is mandatory immediately after diagnosis, and neurosurgery is reserved to more severe cases or when the conservative approach has failed [ 38 , 39 , 40 , 41 , 42 ]. However, there is not agreement on the best timing of surgery when there is visual impairment [ 43 , 44 ].…”