Acute management of pituitary apoplexy--surgery or conservative management?

The rarity of pituitary apoplexy renders it a difficult subject for audit; hence there are no evidence-based standards of optimum care for such patients. The key controversy in management relates to the role of acute neurosurgical intervention. In recent years we have adopted a relatively conservative approach towards patients presenting with pituitary apoplexy. Against this background, we aimed to determine whether our less-interventional approach affected long-term clinical outcome in these patients.

A retrospective analysis was performed to evaluate clinical presentation, management and clinical outcomes in a cohort of patients who presented acutely with pituitary apoplexy during the period 1994-2004. Data from 33 patients (13 female) were included, with a mean age of 52 (range 27-79) years and mean follow-up duration of 3.7 (0.4-10.1) years.

The most common presenting symptoms were headache (97%), visual deficits (82%) and nausea/vomiting (78%). Fifteen patients (46%) underwent transsphenoidal surgery while 18 were managed conservatively. Indications for surgery were deteriorating visual deficit (n = 13), hemiparesis (n = 1) and altered conscious level (n = 1). Eight patients in the surgical group had ocular paresis that resolved in 63% following surgery, and seven had visual field defects with recovery in 57% postsurgery. Conservative management was reserved for patients with absent, or evidence of resolving, visual deficits at presentation. In this group, seven presented initially with ocular paresis and six with visual field defects but all made full recoveries. Of the patients managed neurosurgically, 87% required long-term glucocorticoid replacement and 60% required long-term thyroid hormone replacement. Conservatively managed patients required glucocorticoid replacement in 72% and thyroid hormone replacement in 72% of cases (P = NS between the two groups). Sex steroid replacement was required in 67% and 83% of patients managed neurosurgically and conservatively respectively (P = NS). At latest follow-up one patient in the conservatively managed group had required surgery and one in the surgically managed group had received pituitary radiotherapy, in both instances due to evidence of tumour regrowth on magnetic resonance imaging (MRI).

Our findings suggest that patients presenting with pituitary apoplexy in whom visual deficits are stable or improving may be managed expectantly as there is no identifiable deleterious effect on visual or endocrine outcome. One patient from each group experienced tumour regrowth that necessitated further treatment intervention, highlighting the importance of long-term follow-up in patients with pituitary apoplexy.