Pituitary Apoplexy:Clinical Features And Surgical Outcomes In A Series Of38Patients From A Single Neurosurgical Center

Pituitary apoplexy is a rare clinical entity due to hemorrhage or infarction of the pituitary gland, especially of a pituitary adenoma. Without prompt diagnosis and treatment, it can be life threatening. Patients may suffer from abrupt headache, visual impairment, nausea, vomiting, altered mental status or even death. From long-term follow up, visual defect and hypopituitarism may continue to exist. Transsphenoidal decompressive surgery is recommended to remove necrotic tissue to lower intrasellar pressure in order to relieve clinical symptoms and save vision. Because of the rarity, studies of large sample are lacking, clinical presentations and prognoses associated factors of pituitary apoplexy remain to be elucidated.ObjectTo reveal the clinical presentation and prognostic factors of pituitary apoplexy, so as to provide clinical evidence for future decision making and guideline development.Material and Methods38cases of pituitary apoplexy between October,2010and October,2012from neurosurgical department "of the Second Affiliated Hospital of Zhejiang University were reviewed,29patients were followed up. Data of demography, clinical presentation, neuro-imaging, endocrine test, treatment and follow-up was analyzed. Visual defect and hypopituitarism were common long-term complications and concerned most by both doctors and patients. Associated factors include presurgical prolactin level, degree of trophic hormone deficiency and visual impairement, and surgical timing. Pertinent literatures are reviewed to interpret the results.Result(1) Male patients was dominant (male/female:2.5/1), difference is significant.(2) Most common clinical presentation was visual impairment (81.58%), and11patients (28.94%) acquired severe visual impairment (finger counting at30centimeters, finger moving at30centimeters, light perception only or no light perception). Headache appeared in78.95%of the cases. Deficiency of thyrotrophin was detected in15patients (39.47%), followed by ACTH, and severe trophic hormone deficiency (2or more trophic hormones) was detected in13cases. Low prolactin level was detected in17patients (44.74%).(3) The diagnostic yield of MRI was81.25%(26/32), much high than that of CT scan revealing39.47%of the cases.(4) Prolactin level was related with degree of presurgical visual impairment and endocrine deficiency.9out of17patients with low prolactin level acquired severe visual impairment, in contrast, only2out of21patients with normal or high prolactin level did (P<0.01). Similarly,9out of17patients with low prolactin level acquired severe trophic hormone deficiency, in contrast, only4out of21patients with normal or high prolactin level did (P<0.05).(5) On long-term follow up,20.69%of the29patients showed no visual recovery.9patients were under hormone replacement therapy. Patients of early surgery had a better chance of visual recovery than that of late surgery (66.7%:43.5%), yet the difference was not significant. Patients with severe trophic hormone deficiency significantly needed more hormone replacement on long-term follow up (15.8%:60%).(6) Long-term visual recovery positively correlated-with presurgical prolactin level with a correlation index of0.568. Long-term hormone replacement negatively correlated with presurgical prolactin level with a correlation index of-0.444.Conclusion(1) The male sex may be a predisposing factor of pituitary apoplexy.(2) Long-term visual recovery may relate to surgical timing, however, our data did not directly indicate this relationship. Long-term hormone replacement was more dependent on degree of presurgical hormone deficiency.(3) A low prolactin level was associated with likelihood of severe visual impairment and trophic hormone deficiency and indicated a low likelihood of visual and endocrine recovery after pituitary apoplexy. Prolactin level can be a useful prognostic indicator in clinical practice.