Pituitary apoplexy: large surgical series with grading system

Abstract

Background: Pituitary apoplexy is an infrequent occurrence that can require timely treatment. The term "pituitary apoplexy" as used in the literature describes a heterogeneous spectrum. There is controversy about which subsets require urgent as opposed to elective surgical treatment or even medical treatment alone. We present a retrospective series of 109 consecutive cases of pituitary apoplexy from a single institution from 1992-2012 and develop a comprehensive classification system to analyze outcome.

Methods: Surgical and endocrine consult databases were reviewed to analyze patterns of presentation, imaging, treatment, and outcomes.

Results: Most of the patients in this series presented clinically with "classic" pituitary apoplexy (97%), had magnetic resonance imaging for evaluation (99%), underwent transsphenoidal surgery as their primary treatment (93%), and were found to have pituitary adenomas on histopathology (90%). We categorized patients into 5 grades based on clinical presentation. Tumor volume, cavernous sinus involvement, suprasellar extension, and need for ongoing endocrine replacement correlated with grade. Long-term endocrine replacement at follow-up was required in 62%-68% of patients with a higher grade compared with 0-23% of patients with a lower grade. Higher grade patients tended to undergo earlier surgery after symptom onset. Symptoms resolved or improved with treatment in 92%-100% of patients across all grades with good general outcomes for visual deficits and ocular motility problems, validating management decisions overall.

Conclusions: We offer a simple yet comprehensive grading system to classify the clinical spectrum of pituitary apoplexy, which has implications for management, outcomes, and categorization for future studies.

Keywords: Hemorrhagic macroadenoma; Pituitary adenoma; Pituitary apoplexy; Transsphenoidal surgery.