Large/Giant Pituitary Macroadenomas Presenting with Apoplexy: Case Series

Introduction: Surgical outcomes of patients with pituitary apoplexy in the setting of large or giant pituitary macroadenomas are not well understood given its rarity. Our aim was to evaluate outcomes of patients with large or giant pituitary macroadenomas presenting with apoplexy that underwent surgery.

Methods: A retrospective case series of all patients with macroadenomas presenting with apoplexy at our institution from 2016 to 2018 was studied. Tumors were classified by maximum size into the following categories: small macroadenoma (10–25 mm diameter), large macroadenoma (26–39 mm diameter), or giant macroadenoma (≥ 40 mm diameter). Demographic and radiographic characteristics were collected including age, gender, comorbidities, presenting and duration of symptoms, precipitating factors, preoperative size of pituitary adenoma, percentage of hemorrhagic/ischemic component, Knosp grade, Hardy grade, apoplexy grade, length of hospitalization, pre and postoperative hormonal levels, perioperative steroids stress dose use, postoperative complications, and follow-up time.

Results: 68 patients underwent endoscopic endonasal surgery for resection of macroadenoma. 7 (10.2%) presented with apoplexy and 5 (7.4%) met inclusion criteria. All 5 patients were male and presented with headache (100%), endocrinopathies (100%), visual acuity deficit (80%), visual field deficit (60%), and oculomotor palsy (40%). Tumor size was large (25–40 mm) in 4 patients and giant (>40 mm) in 1 patient. Median tumor maximum diameter was 34.8 mm. The normal pituitary gland was able to be identified and spared during surgery in all cases and a gross-total resection rate of 80% was achieved. All patients obtained symptomatic improvement; however, two patients did not have complete improvement in their visual acuity. All patients required long-term steroid and thyroid replacement but none developed permanent diabetes insipidus. There were no statistically significant differences between those patients who showed complete and partial resolution of neurological symptoms for the analyzed criteria; there was a trend for only partial improvement in visual acuity with longer times between symptom onset and surgery.

Conclusion: Endoscopic endonasal resection as emergent treatment of pituitary apoplexy in patients with large and giant adenomas yielded a gross-total resection rate of 80% with improvement of presenting neurological symptoms. Posterior gland function was able to be preserved with identification and sparing of the gland during surgery. Longer duration of poor visual acuity likely led to only partial improvement after surgery. Further studies with larger sample sizes are necessary to further confirm these findings.

Fig. 1 

Pre- and postoperative T1 magnetic resonance imaging (MRI) without gadolinium of a giant pituitary adenoma examined in the current series. Preoperatively, the diameter of the tumor was 49 mm with extension through the floor of the sella and into the sphenoid sinus, in addition to the posterior ethmoid sinuses. Apoplexy was noted throughout the lesion, demonstrated by the heterogeneous hyperintensity seen throughout the lesion. Postoperatively, a gross-total resection was achieved.