The Effect of Timing of Surgery in Pituitary Apoplexy on Continuously Valued Visual AcuityFunding National Cancer Institute, (Grant/Award Number: “T32CA106183”)
11 April 2019
29 August 2019
24 January 2020 (online)
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.
The authors have no conflicts of interest to disclose. One author (P.D.K.) is supported by a training grant from the National Cancer Institute of the National Institutes of Health under award number T32CA106183. There are no drugs, materials, or devices described in this submission.
- 1 Aghi MK, Bodach ME, Tumialan LM. , et al. Guidelines on the management of patients with nonfunctioning pituitary adenomas: introduction and methodology. Available at: https://www.cns.org/sites/default/files/guideline-chapter-pdf/nfpa-chapter-1.pdf . Accesses September 17, 2019
- 2 Briet C, Salenave S, Chanson P. Pituitary apoplexy. Endocrinol Metab Clin North Am 2015; 44 (01) 199-209
- 3 Baldeweg SE, Vanderpump M, Drake W. , et al; Society for Endocrinology Clinical Committee. Society for Endocrinology Endocrine Emergency Guidance: emergency management of pituitary apoplexy in adult patients. Endocr Connect 2016; 5 (05) G12-G15
- 4 Tu M, Lu Q, Zhu P, Zheng W. Surgical versus non-surgical treatment for pituitary apoplexy: A systematic review and meta-analysis. J Neurol Sci 2016; 370: 258-262
- 5 Abdulbaki A, Kanaan I. The impact of surgical timing on visual outcome in pituitary apoplexy: Literature review and case illustration. Surg Neurol Int 2017; 8 (01) 16
- 6 Pyrgelis ES, Mavridis I, Meliou M. Presenting symptoms of pituitary apoplexy. J Neurol Surg A Cent Eur Neurosurg 2018; 79 (01) 52-59
- 7 Forbes JA, Wilkerson J, Chambless L. , et al. Safety and cost effectiveness of early discharge following microscopic trans-sphenoidal resection of pituitary lesions. Surg Neurol Int 2011; 2: 66
- 8 Bulters DO, Shenouda E, Evans BT, Mathad N, Lang DA. Visual recovery following optic nerve decompression for chronic compressive neuropathy. Acta Neurochir (Wien) 2009; 151 (04) 325-334
- 9 Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC; 2017. . Available at: https://www.stata.com . Accessed, December 15, 2019
- 10 Singh TD, Valizadeh N, Meyer FB, Atkinson JL, Erickson D, Rabinstein AA. Management and outcomes of pituitary apoplexy. J Neurosurg 2015; 122 (06) 1450-1457
- 11 Giritharan S, Gnanalingham K, Kearney T. Pituitary apoplexy - bespoke patient management allows good clinical outcome. Clin Endocrinol (Oxf) 2016; 85 (03) 415-422
- 12 Jho DH, Biller BM, Agarwalla PK, Swearingen B. Pituitary apoplexy: large surgical series with grading system. World Neurosurg 2014; 82 (05) 781-790
- 13 Vargas G, Gonzalez B, Guinto G. , et al. Pituitary apoplexy in nonfunctioning pituitary macroadenomas: a case-control study. Endocr Pract 2014; 20 (12) 1274-1280
- 14 Chen L, White WL, Spetzler RF, Xu B. A prospective study of nonfunctioning pituitary adenomas: presentation, management, and clinical outcome. J Neurooncol 2011; 102 (01) 129-138
- 15 Zhang X, Fei Z, Zhang W. , et al. Emergency transsphenoidal surgery for hemorrhagic pituitary adenomas. Surg Oncol 2007; 16 (02) 115-120
- 16 Bills DC, Meyer FB, Laws Jr. ER. , et al. A retrospective analysis of pituitary apoplexy. Neurosurgery 1993; 33 (04) 602-608 , discussion 608–609
- 17 Royston P, Altman DG, Sauerbrei W. Dichotomizing continuous predictors in multiple regression: a bad idea. Stat Med 2006; 25 (01) 127-141
- 18 Naggara O, Raymond J, Guilbert F, Roy D, Weill A, Altman DG. Analysis by categorizing or dichotomizing continuous variables is inadvisable: an example from the natural history of unruptured aneurysms. AJNR Am J Neuroradiol 2011; 32 (03) 437-440
- 19 Chen H, Cohen P, Chen S. Biased odds ratios from dichotomization of age. Stat Med 2007; 26 (18) 3487-3497
- 20 Heavner KK, Phillips CV, Burstyn I, Hare W. Dichotomization: 2× 2 (× 2× 2× 2...) categories: infinite possibilities. BMC Med Res Methodol 2010; 10 (01) 59
- 21 Briet C, Salenave S, Bonneville JF, Laws ER, Chanson P. Pituitary apoplexy. Endocr Rev 2015; 36 (06) 622-645
- 22 Zaidi HA, Cote DJ, Burke WT. , et al. Time course of symptomatic recovery after endoscopic transsphenoidal surgery for pituitary adenoma apoplexy in the modern era. World Neurosurg 2016; 96: 434-439
- 23 Muthukumar N, Rossette D, Soundaram M, Senthilbabu S, Badrinarayanan T. Blindness following pituitary apoplexy: timing of surgery and neuro-ophthalmic outcome. J Clin Neurosci 2008; 15 (08) 873-879
- 24 Grzywotz A, Kleist B, Möller LC. , et al. Pituitary apoplexy - a single center retrospective study from the neurosurgical perspective and review of the literature. Clin Neurol Neurosurg 2017; 163: 39-45
- 25 Rutkowski MJ, Kunwar S, Blevins L, Aghi MK. Surgical intervention for pituitary apoplexy: an analysis of functional outcomes. J Neurosurg 2018; 129 (02) 417-424
- 26 Gnanalingham KK, Bhattacharjee S, Pennington R, Ng J, Mendoza N. The time course of visual field recovery following transphenoidal surgery for pituitary adenomas: predictive factors for a good outcome. J Neurol Neurosurg Psychiatry 2005; 76 (03) 415-419
- 27 Agrawal D, Mahapatra AK, Post KD, Ludecke D. Visual outcome of blind eyes in pituitary apoplexy after transsphenoidal surgery: a series of 14 eyes. Surg Neurol 2005; 63 (01) 42-46 , discussion 46
- 28 Cennamo G, Auriemma RS, Cardone D. , et al. Evaluation of the retinal nerve fibre layer and ganglion cell complex thickness in pituitary macroadenomas without optic chiasmal compression. Eye (Lond) 2015; 29 (06) 797-802
- 29 Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001; 345 (09) 663-668