The Effect of Early vs. Late Surgery on Cranial Nerve Function in Pituitary Apoplexy

Background: Pituitary tumor apoplexy commonly causes cranial nerve palsies (CNPs). Based on visual acuity and visual field outcomes, some studies suggest maximum benefit of surgery occurs within 8 days of ictus. In practice, many patients present to neurosurgical attention later than this. The potential benefit of surgical intervention in these late-presenting patients has not yet been described.

Methods: A retrospective chart review of patients presenting to Barnes Hospital who underwent transsphenoidal sellar decompression for pituitary tumor apoplexy (2001–2016) was conducted. Patients without pathologic evidence of pituitary ischemia or hemorrhage were excluded. Time from symptom onset to surgical intervention was determined. Serial cranial nerve and ophthalmologic exams were reviewed for evolution of visual and oculomotor function.

Results: 45 patients fulfilled inclusion criteria. The cohort exhibited 68 total preoperative CNPs (33 CN II, 21 CN III, 1 CN IV, 1 CN V, 12 CN VI). Average time from symptom-onset-to surgery was 16.8 days (SD 20.3). Average follow-up time was 3.2 years (SD 3.7). Overall, 44% (95% CI 37–51%) of CNPs had resolved at one month, with 61% (95% CI 56–66%) demonstrating improvement. At one year 73% (95% CI 69–76%) had resolved, with 83% (95% CI 81–85%) demonstrating improvement. At 4, 8, and 14-day cutoffs for acuity of intervention, there were no significant differences between earlier and later treatment groups with respect to the proportion of CNPs that resolved by one month (≤ 4d 36%, >4d 45%, p = 0.70; ≤ 8d 32%, >8d 59%, p = 0.08; ≤ 14d 39%, > 14d 50%, p = 0.84) or by one year (≤ 4d 57%, >4d 77%, p = 0.49; ≤ 8d 59%, >8d 86%, p =.08; ≤ 14d 63%, >14d 83%, p = 0.60). There were no significant differences between earlier and later treatment groups in the proportion of CNPs that demonstrated improvement by one month (≤ 4d 48%, > 4d 64%, p = 0.41; ≤ 8d 51%, > 8d 73%, p = 0.24; ≤ 14d 56%, > 14d 67%, p = 0.99) or by one year (≤ 4d 69%, >4d 87%, p = 0.34; ≤ 8d 75%, > 8d 91%, p = 0.27; ≤ 14d 78%, >14d 89%, p = 0.96). There were trends toward superior rates of CNP resolution or improvement in the groups treated in delayed fashion.

Conclusion: Patients with pituitary tumor apoplexy who undergo transsphenoidal sellar decompression greater than 8 days post-ictus experience non-inferior outcomes with respect to CNP resolution and improvement compared with those with earlier operations. The temporal correlation of rapid CNP resolution/improvement following surgery also suggests a benefit of surgical decompression regardless of timing in a substantial proportion of patients.