Delayed Postoperative Pituitary Apoplexy after Endoscopic Transsphenoidal Resection of a Giant Pituitary Macroadenoma

Introduction: Pituitary apoplexy in the postoperative period after surgical removal of a pituitary tumor is rare and has only been reported to occur after subtotal resection of giant pituitary macroadenomas (greater than 4 cm) in the immediate postoperative period (within 12 hours). All of the previously reported cases demonstrated acute neurologic worsening with eventual fatal outcomes due to massive tumor swelling, intratumoral hemorrhage, and infarction within the residual tumor. We describe a unique case of postoperative pituitary apoplexy that occurred in a delayed fashion on the third postoperative day from spontaneous hemorrhage into a small residual tumor. Early detection and immediate surgical intervention resulted in eventual gross total removal of the residual hemorrhagic tumor, decompression of the optic chiasm, and a favorable neurologic outcome.

Methods: A 59-year-old man underwent an endonasal endoscopic transsphenoidal removal of a giant suprasellar pituitary macroadenoma, which was causing progressive visual loss. Postoperatively, the patient's vision improved, and neuroimaging demonstrated decompression of the optic chiasm with some residual tumor in the left cavernous sinus.

Results: On the third postoperative day, the patient experienced acute worsening of vision with bitemporal hemianopsia from spontaneous hemorrhagic pituitary apoplexy into the residual tumor. An emergent endoscopic transsphenoidal exploration was performed to remove the remaining hemorrhagic tumor and to decompress the visual apparatus. Postoperatively, the patient regained his vision back to baseline.

Conclusion: This represents a unique case of postoperative pituitary apoplexy from a small volume residual tumor that occurred in the delayed postoperative period. This was successfully treated with emergent transsphenoidal decompression of the visual apparatus and complete removal of the tumor. The authors review the literature of postoperative pituitary apoplexy and emphasize the importance of rapid diagnosis and intervention to achieve significant recovery and a favorable neurologic outcome.