Clinical outcome of cranial neuropathy in patients with pituitary apoplexy

Abstract

Objective: Pituitary apoplexy (PA) is described as a clinical syndrome characterized by sudden headache, vomiting, visual impairment, and meningismus caused by rapid enlargement of a pituitary adenoma. We retrospectively analyzed the clinical presentation and surgical outcome in PA presenting with cranial neuropathy.

Methods: Twelve cases (3.3%) of PA were retrospectively reviewed among 359 patients diagnosed with pituitary adenoma. The study included 6 males and 6 females. Mean age of patients was 49.0 years, with a range of 16 to 74 years. Follow-up duration ranged from 3 to 20 months, with an average of 12 months. All patients were submitted to surgery, using the transsphenoidal approach (TSA).

Results: Symptoms included abrupt headache (11/12), decreased visual acuity (12/12), visual field defect (11/12), and cranial nerve palsy of the third (5/12) and sixth (2/12). Mean height of the mass was 29.0 mm (range 15-46). Duration between the ictus and operation ranged from 1 to 15 days (mean 7.0). The symptom duration before operation and the recovery period of cranial neuropathy correlated significantly (p = 0.0286). TSA resulted in improvement of decreased visual acuity in 91.6%, visual field defect in 54.5%, and cranial neuropathy in 100% at 3 months after surgery.

Conclusion: PA is a rare event, complicating 3.3% in our series. Even in blindness following pituitary apoplexy cases, improvement of cranial neuropathy is possible if adequate management is initiated in time. Surgical decompression must be considered as soon as possible in cases with severe visual impairment or cranial neuropathy.

Keywords: Cranial neuropathy; Pituitary adenoma; Pituitary apoplexy; Transsphenoidal approach.

Fig. 1

T1-weighted magnetic resonance imaging scans of the brain of patient (case 7). Sagittal (A) and coronal (B) sections reveal a hemorrhagic pituitary adenoma. No evidence of remaining enhancing tumor seen in postoperative first day follow up sellar MRI-sagittal (C) and coronal (D) sections.

Fig. 2

The relationship between the timing of surgery and recovery time of cranial neuropathy. The symptom duration before operation and the recovery period of cranial neuropathy correlated significantly (p = 0.0286).

Fig. 3

In case 8 and 9 of complete blindness following pituitary apoplexy, the tumors of both patients were removed via a TSA with the delay of 18 hours and 24 hours each. A : Pre-operative unilateral blindness showed partial recovery in both visual acuity and visual field in case 8. B : In case 9, pre-operative decreased visual acuity was partially recovered after operation. The improvement of the left monocular blindness occurred, not immediately, but several days after surgery. VA : visual acuity, VF : visual field, LP : light perception, HM : hand movement, MRI : magnetic resonance imaging.