Timing of Surgical Intervention in Patients with Pituitary Apoplexy and Cranial Nerves Deficits: Single-Center Experience

Background: Pituitary tumors account for up to 15% of all intracranial tumors, 90% of which are adenomas. One of the rare but urgent presentations of a pituitary tumor is pituitary apoplexy (PA). Typically, patients with PA present emergently with a symptom cluster that may include sudden severe headache, nausea, vomiting, and new-onset impairment of the visual acuity with or without visual field defect. Occasionally, these patients may exhibit other cranial nerve palsies. These manifestations are due to the sudden increase of the tumor size caused by intratumor hemorrhage and/or infarction. Usually, hypopituitarism develops as a result of gland ischemia. After patient stabilization and hormonal replacement, surgical decompression is often recommended with controversy on the timing of intervention. In this case series, we describe our experience regarding the cranial nerve recovery in patients with pituitary apoplexy following the endoscopic endonasal transsphenoidal (EETS).

Study Design: Retrospective cohort, single-institutional study.

Methods: Institutional REB approval was attained for a retrospective review of all EETS cases for pituitary tumor resection between November 2009 and August 2018. Queries of the hospital database were completed by medical records personnel to identify cases of pituitary tumor apoplexy treated using the EETS approach. Patient characteristics, tumor type, endocrine data, and operation characteristics were then extracted from medical records pertaining to patient baseline characteristics. Postoperative results were extracted for the duration of the follow-up period available for each patient.

Results: A total of 15 cases of pituitary apoplexy were identified. Several cranial nerve deficits were present at admission. 33% of patients had a visual deficit; 47% had unilateral 3rd nerve palsy, and 27% had unilateral 6th nerve palsy. No patients had 4th nerve palsy. Following EETS, there was significant recovery for all cranial nerve deficits. Postoperatively, 60% of patients with preoperative visual deficit had normal visual fields and the other 40% showed improvement. For those with oculomotor nerve dysfunction preoperatively, 43% had returned to normal cranial nerve function, while 57% had improvement and abducens nerve palsy resolved in 75% postoperatively, while 25% demonstrated improvement.

Conclusion: Based on this series, surgical treatment should be offered to patients presenting with cranial nerve deficit in the setting of pituitary apoplexy. In this series, all cranial nerve deficits either returned to normal or improved following surgery. Though a small series, the presented results are superior to those reported in the literature for conservative management.

Publication History

Article published online:
12 February 2021