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Pituitary Apoplexy : Surgical Experience with 16 Patients

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Pituitary Apoplexy : Surgical Experience with 16 Patients online ML Comm www.jkns.or.kr J Korean Neurosurg Soc 42 : 83-88, 2007 Clinical Article Pituitary Apoplexy : Jae-Hyun Lee, M.D. Surgical Experience with 16 Patients Jae-Hyoo Kim, M.D. Kyung-Sub Moon, M.D. Sung-Pil Joo, M.D. Objective : Pituitary apoplexy, resulting from an acute infarction or hemorrhage mainly in pituitary adenomas, Jung-Kil Lee, M.D. is a rare yet major clinical event with neurological, ophthalmological and hormonal emergent consequences. The authors review our surgical experience with a series of 16 cases of pituitary apoplexy. Soo-Han Kim, M.D. Methods : The cases of pituitary apoplexy, operated via trans-sphenoidal approach in our hospital between 1998-2005, were retrospectively analyzed in terms of their clinicoradiological features, pathological findings and surgical outcomes. Results : The mean age of patients (9 male and 7 female) was 47.1 years. The average time of presentation after onset of symptom was 8.9 days. Pituitary apoplexy occurred as an initial manifestation of pituitary adenoma in all patients. Headache was the most common presenting symptom (94%). Visual disturbance was found in 56% of patients. Thirty-one percent of the patients had hypopituitarism. On magnetic resonance imaging, this entire catastrophic event accompanied with macroadenoma in a mean size of 22.5 mm. Only Department of Neurosurgery four patients needed postoperative hormone replacement therapy. Three of them showed preoperative Chonnam National University hypopituitary function, and one patient in normal pituitary function. There was no specific complication in Hospital & Medical School any of these patients. Gwangju, Korea Conclusion : Early trans-sphenoidal decompression with high-dose corticosteroid replacement showed good outcomes of pituitary apoplexy. KEY WORDS : Pituitary apoplexy·Pituitary adenoma·Transsphenoidal approach (TSA). INTRODUCTION Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome caused by rapid enlargement of a pituitary tumor due to hemorrhage or infarction13,14). It usually presents with a sudden onset of headache, nausea and vomiting, visual disturbances and altered level of consciousness8). The frequency of pituitary apoplexy presenting with classical symptoms is about 0.6-9% in the series of surgically treated pituitary adenomas7,12,13). But, hemorrhage or infarction of pituitary adenomas may be detected incidentally on imaging study, and these patients may have mild or no symptoms. Subclinical pituitary apoplexy is more common and has been reported in 25% of surgically removed pituitary adenomas9). Urgent surgical decompression of pituitary fossa is a preferred treatment but delayed decompression may also restore neuro-ophthalmic function. In addition, conservative medical therapy may offer an alternative option for patients without progressive neuro-ophthalmic signs. There were no specific postoperative complications. The authors performed a retrospective analysis to evaluate clinical presentation, postoperative courses, and pathological findings in a series of patients surgically treated for symptomatic pituitary apoplexy during last 8 years. MATERIALS AND METHODS Received：August 23, 2006 Accepted：July 13, 2007 Based on the data for brain tumor patients, 234 pituitary adenomas had been operated Address for reprints： between 1998 and 2005. The definition of pituitary apoplexy used in this study included Jae-Hyoo Kim, M.D. Department of Neurosurgery only patients with apoplectic onset symptoms, appropriate radiological and histopathological Chonnam National University confirmation of hemorrhage or necrosis in pituitary adenoma. During the this period, 16 Hospital & Medical School 8 Hak-dong, Dong-gu patients (9 males and 7 females, 6.8%) were surgically treated for acute presentation of pituitary Gwangju 501-757, Korea apoplexy. Using retrospective analysis of hospital records and video-tapes for these 16 patients, Tel：+82-62-220-6606 Fax：+82-62-224-9865 the authors reviewed the detail of clinical presentations, radiologic findings, endocrine studies, E-mail：[email protected] pathologic findings, postoperative complication and outcomes. 83 J Korean Neurosurg Soc 42｜August 2007 Table 1. Common presenting symptoms and signs in 16 patients with Table 4. Radiologic classification of tumor size and extension based on pituitary apoplexy the classification system from Hardy, modified by Wilson in patients with Symptoms and signs Number of patients (%) apoplexy Headache 15 (94%) ABCDE Nausea/vomiting 7 (44%) I- - - -- Decreased visual acuity 6 (38%) II 4 2 1 - - Visual field deficit 6 (38%) III 4 1 - - 1 Ocular palsy 4 (25%) IV 1 2 - - - Diplopia 2 (13%) Sella turcica destruction I; focal bulging, II; diffuse bulging, III; focal destruction, IV; diffuse destruction : Extrasellar extension A; suprasellar cistern only, B; Altered consciousness 1 ( 6%) up to 3rd ventricle floor, C; in or above 3rd ventricle, D; intradural lateral extension, E; extradural lateral extension Table 2. Neuroophthalmological evaluation in 16 patients with pituitary apoplexy Table 5. MRI and operative findings Symptoms and signs Number of patients (%) MRI No. Operative findings No. Decreased visual acuity 6 (38%) T1 T2 Extraocular movement abnormality 4 (25%) High low 7 hemorrhage with/without necrosis 6 III nerve palsy 2 (13%) High high 5 necrosis with cystic fluid 4 III+IV nerves palsy 1 ( 6%) Low high 4 cystic fluid 6 III+VI nerves palsy 1 ( 6%) Visual field defect 6 (38%) Table 6. Postsurgical outcomes of visual and cranial nerve function of patients with visual disturbances Bitemporal hemianopsia 4 (25%) Normal Improved Unchanged Worse Temporal hemianopsia+anopsia 1 ( 6%) Visual acuity 3 3 0 0 Temporal upper quadrantanopsia 1 ( 6%) Visual field 6 0 0 0 Table 3. Hormonal expression and secretion characteristics in patient Cranial nerve palsy 3 1 (VI) 0 0 with apoplexy Hormone expression* No. Hormone secretion† No. length of time from onset of symptoms until presentation FSH 4 Hyperfunction 2 in our department was 8.9 days, with a range from 1 day GH 2 Prolactin 1 to 30 days. In 14 patients, no precipitating factors were Prolactin 1 GH 1 identified. Apoplectic symptoms occurred after removal of FSH/LH 1 Hypofunction 5 angiolipoma of the thigh under general anesthesia in one TSH 1 ACTH 2 patient and a pituitary stimulation test in another. Unfor- Can’t check‡ 7 TSH 1 Panhypopituitarism 2 tunately, there were no imaging studies demonstrating any Normal function 9 hemorrhage in pituitary adenoma before these procedures. ＊hormonal expression in immunohistochemical study, †hormonal status However, these preoperative procedures could be regarded in laboratory findings, ‡unconfirmed specimen in immunohistochemical as precipitating factors based on the consecutive symptom study due to complete hemorrhage or necrosis after procedure. All patients underwent assessment of anterior pituitary The main presenting symptoms and signs are listed in function on admission and subsequent follow-up in department Table 1. Headache, typically of sudden onset, was the most of endocrinology. Assessment of anterior pituitary function common complaint, occurring in all but one patient. Headache was made by measuring random serum levels of Free T4, T3, was frequently associated with nausea, vomiting and visual TSH, LH, FSH, PRL, ACTH, cortisol, GH and IGF-1 or symptoms in 44% of patients. Neuroophthalmological combined pituitary stimulation test (Cocktail test). The evaluation was performed in all cases and revealed visual presence of hypopituitarism was defined by proven biochemical disturbance in 9 cases. Ocular movement abnormalities deficiency of at least one endocrine axis. The degree of visual were present in 4 patients; oculomotor palsies in 2, multiple disturbance was assessed by Snellen visual acuity and automated cranial nerve palsies in 2 (oculomotor and trochlear nerves : visual field testing (Humprey perimetry). 1, oculomotor and abducens nerves : 1). On visual field examination, bitemporal hemianopsia was found in 6 RESULTS patients included 1 case of right temporal hemianopsia and left anopsia and 1 case of both temporal upper quadrantanopsia. Clinical features Decreased visual acuity was present in 6 cases (Table 2). One In apoplexy group (9 males and 7 females), the mean age patient demonstrated stuporous mental status at presentation at diagnosis was 47.1 (range : 24-69) years. The average due to hyponatremia. 84 Pituitary Apoplexy｜JH Lee, et al. Table 7. Postsurgical endocrine outcomes of patients with apoplexy nonfunctioning pituitary adenomas. Follow-up endocrine function Five patients showed deficiency of one or Initial endocrine function * Hyperpituitarism Normal function Hypopituitarism (HRT ) more pituitary hormones; corticotrophin Hyperpituitarism (n=2) 1 1 0 deficiency was found in 2, thyrotrophin Normal function (n=9) 0 6 3 (1) deficiency with adrenal insufficiency Hypopituitarism (n=5) 0 2 3 (3) in 1 and panhypopituitarism in 2. Nine ＊hormone replacement therapy patients had normal pituitary functions, and two patients had hyperpituitarism; hyperprolactinemia was found in 1 and increased somatomedin-C in 1. The pituitary decompression via trans- sphenoidal approach was performed within 14 days after admission. Tumor cell type was defined by immunohisto- A B chemistry only in 9 of 16 cases, because of extensive hemorrhagic or necrotic changes. FSH was positive in 5 patients, GH in 2, TSH in 1, LH in 1, prolactin in 1 (Table 3). Radiologic features and operative findings All patients with apoplexy
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