Neuro-Endocrine Recovery After Pituitary Apoplexy: Prolactin as a Predictive Factor

Pituitary Apoplexy: An Updated Review

Pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland. It is clinically characterized by the sudden onset of headache. Depending on the severity, it may also be accompanied by nausea, vomiting, visual disturbances, varying degrees of adenohypophyseal hormone deficiency, and decreased level of consciousness. Corticotropic axis involvement may result in severe hypotension and contribute to impaired level of consciousness. Precipitating factors are present in up to 30% of cases. PA may occur at any age and sometimes develops during pregnancy or the immediate postpartum period. PA occurs more frequently in men aged 50-60, being rare in children and adolescents. It can develop in healthy pituitary glands or those affected by inflammation, infection, or tumor. The main cause of PA is usually spontaneous hemorrhage or infarction of a pituitary adenoma (pituitary neuroendocrine tumor, PitNET). It is a medical emergency requiring immediate attention and, in many cases, urgent surgical intervention and long-term follow-up. Although the majority of patients (70%) require surgery, about one-third can be treated conservatively, mainly by monitoring fluid and electrolyte levels and using intravenous glucocorticoids. There are scoring systems for PA with implications for management and therapeutic outcomes that can help guide therapeutic decisions. Management of PA requires proper evaluation and long-term follow-up by a multidisciplinary team with expertise in pituitary pathology. The aim of the review is to summarize and update the most relevant aspects of the epidemiology, etiopathogenesis, pathophysiology, clinical presentation and clinical forms, diagnosis, therapeutic strategies, and prognosis of PA.

Pituitary apoplexy score, toward standardized decision-making: a descriptive study

Pituitary apoplexy (PA), a rare and life-threatening complication of pituitary adenomas, prompts urgent glucocorticoid administration. The optimal surgical approach is debated, and the Pituitary Apoplexy Score (PAS) aids decision-making. Our retrospective study (2003-2022) assesses variables in PA patient groups (surgical vs. non-surgical), applying PAS to establish a significant threshold for surgical decisions. Additionally, we aim to compare the rates of ophthalmological and endocrine deficit between both groups and identify any associated variables. PAS discrepancies were observed, with averages of 1.7 ± 1.7 (p < 0.0001) for conservative and 3.9 ± 1.7 (p < 0.0001) for surgical groups, confirmed by multivariate analysis (p = 0.009). A PAS threshold of 5, showing over 80% positive predictive value, was established. Patients with low prolactin levels (< 5 ng/ml) had higher corticotropic deficiency prevalence at 3-month and 1-year follow-ups (p = 0.017 and 0.027). Our study supports PAS as a valuable PA management tool, suggesting potential variable adjustments. Multicenter studies are crucial due to PA's low incidence.

Revisiting Pituitary Apoplexy

Pituitary apoplexy (PA) is a rare clinical syndrome due to pituitary hemorrhage or infarction. It is characterized by the sudden onset of one or more of the following: severe headache, visual disturbance, nausea/vomiting, and or altered mental status. Most commonly, PA occurs in an underlying pituitary adenoma. The pathophysiology is not fully understood, but it is thought to involve elements of increased metabolic demand and/or compromise to the vasculature of the pituitary or pituitary tumor. Several risk factors have been described. Stabilization of the patient on presentation, replacement of hormonal deficiencies, and reversal of electrolyte abnormalities are the recommended initial steps in the management of patients with PA. Surgical decompression of the mass effect had been the recommended treatment for patients with PA; however, retrospective studies of patients with PA have demonstrated similar outcomes when a conservative approach is applied. This suggests that in highly selected clinical scenarios (mild visual deficit and improving symptoms), conservative management is possible. Further studies, however, are necessary to better stratify patients but are limited by the rarity of the condition and the acuity.

Factors predicting neuro-endocrine recovery following transsphenoidal surgery in pituitary apoplexy patients

BACKGROUND

Pituitary apoplexy is a rare clinical syndrome. Only a few studies have examined factors associated with recovery of neuro-endocrine functions following transsphenoidal surgery. This study aimed to identify factors associated with neuro-endocrine recovery following surgery for pituitary apoplexy.

METHODS

The records of pituitary apoplexy patients who underwent transsphenoidal surgery at Songklanagarind Hospital between January 2005 and December 2020 were retrospectively reviewed. The primary outcomes were the recoveries of preoperative visual acuity (VA), visual field (VF), cranial nerve function, and pituitary hormone deficits. Using logistic regression analysis, various factors were analyzed for their associations with recovery of neuro-endocrine functions.

RESULTS

The study included 98 patients. Multivariate analysis showed that older age and greater suprasellar extension were associated with no recovery of VA (P = 0.042 and P = 0.018, respectively). Only 33% of patients aged > 55 years and suprasellar extension of lesion ≥ 25 mm gained recovery of VA, while 100% of patients with neither of these factors had recovery. Underlying hypertension was associated with no recovery of preoperative VF defect (P = 0.027). Wilson-Hardy classification-invasion grades 3-4 and lower preoperative serum prolactin level were associated with no recovery from preoperative hypoadrenalism and hypothyroidism (P = 0.016 and P = 0.007, respectively).

CONCLUSIONS

Older age, higher suprasellar extension, and hypertension were poor prognostic factors for visual recovery. Wilson-Hardy inferior invasion grade 3-4 and lower preoperative serum prolactin level were poor prognostic factors for recovery from hypopituitarism. Stratifying patients according to these prognostic factors may assist in selecting patients for surgery.

Suprasellar extension independently predicts preoperative pituitary hormone deficiencies in patients with nonfunctioning pituitary macroadenomas: a single-center experience

PURPOSE

Nonfunctioning pituitary adenomas (NFPAs) are among the commonest benign tumors of the pituitary. Hypopituitarism is frequently present at the time of diagnosis, and this has been attributed to stalk portal vessel compression and/or destruction of normal anterior pituitary cells. The aim of our study was to examine possible factors at diagnosis associated with the presence of hypopituitarism.

METHODS

We retrospectively evaluated the records of patients with nonfunctioning pituitary macroadenomas from the database of our department. The inclusion criterion was the availability of imaging data regarding the extension of the lesion.

RESULTS

A total of 148 patients (89 men, 60.1%) with nonfunctioning macroadenomas and available imaging data were identified. Mean age at diagnosis was 56.0 ± 14.5 years, and hypopituitarism was found in 66.2%. The maximum diameter of the adenoma, the patient's age at diagnosis, and compression of the optic chiasm were significant factors predicting the presence of hypopituitarism (OR 1.077, p = 0.006; OR 1.025, p = 0.045; and OR 2.893, p = 0.042, respectively). Suprasellar adenomas with extension to adjacent sinuses, although larger than those with only suprasellar extension, did not differ as to the degree of hypopituitarism. Moreover, in suprasellar adenomas, prolactin levels, albeit not independently, were also related to hypopituitarism (OR 1.035, p = 0.045).

CONCLUSIONS

In patients with NFPAs, prognostic factors related to increased risk of hypopituitarism are age at diagnosis, size of the adenoma, and most importantly the presence of suprasellar extension. These data accentuate the necessity for surgical decompression in case of suprasellar extension, in order, apart from saving visual acuity, to possibly avoid or reverse hypopituitarism.

Coagulative necrotic pituitary adenoma apoplexy: A retrospective study of 21 cases from a large pituitary center in China

PURPOSE

Coagulative necrotic pituitary apoplexy (CNPA) is a clinical entity with unique intraoperative and histopathological manifestations. We aimed to improve the knowledge of this rare disease through the largest case series published to date.

METHODS

A retrospective review of 21 CNPA patients was performed from among 5095 patients who underwent surgery for pituitary adenomas at a single institution between January 2009 and June 2017. The demographic, clinical, endocrine, neuroimaging, intraoperative, and histopathological findings, management and prognosis were summarized.

RESULTS

Headache was the most common symptom that was observed in 21 patients, followed by visual disturbances (17/21, 81.0%), nausea and vomiting (16/21, 76.2%), electrolyte disturbance (13/21, 61.9%), and oculomotor palsies (10/21, 47.6%). Hypopituitarism with at least one anterior pituitary deficiency, especially panhypopituitarism (10/21, 47.6%), was present in 81.0% of patients. Most patients (81.0%) showed typical MRI appearances. All 21 patients underwent transsphenoidal surgery (TSS), and 16 patients had total tumor resection demonstrated by postoperative MRI. Cottage cheese-like necrosis was observed in 16 patients (76.2%) intraoperatively. Histopathology showed large areas of pink, acellular, coagulative necrotic areas in the central zone, and a pseudocapsule in the border zone. After follow-up for 4.3 ± 2.3 years, only 28.6% of patients still suffered from corticotropic deficiency, and 9.5% of patients had gonadotropic deficiency. These patients were administered the appropriate corresponding hormones for life.

CONCLUSIONS

CNPA can be correctly diagnosed preoperatively by typical clinical and MRI characteristics. Early surgery combined with hyperbaric oxygen therapy early postoperatively usually yields satisfactory endocrine and neuro-ophthalmic outcomes.