Pituitary Apoplexy Precipitated by Non-Cranial Surgeries: An Institutional Experience

Pituitary apoplexy (PA) is a rare, acute condition caused by hemorrhage or infarction within the pituitary gland, primarily associated with preexisting adenomas. Classically, PA presents with severe headache, neuro-ophthalmologic deficits, and/or endocrine disturbances. While the mechanisms of PA are under investigation, vascular changes, blood flow disruptions, and intrasellar pressure are implicated. We report the first 6-year institutional experience of risk factors of PA associated with non-cranial surgeries.

A retrospective review was conducted of patients presenting with PA from July 2017 to January 2024. Patients diagnosed with PA within 1 week of non-cranial surgery were included. Data encompassed medical history, surgical details, presenting symptoms, imaging, and outcomes.

Among 56 PA patients, 4 (7.1%) occurred after non-cranial surgeries, including cardiac procedures, mandibulectomy, and toe amputation. Three male patients (one excluded due to incomplete data) presented with oculomotor deficits and endocrine dysfunction. All had lesions greater than 2 cm. Common risk factors included hypertension, significant intraoperative blood pressure fluctuations (systolic range: 60-200 mm Hg), and lengthy anesthesia (average: 9.09 hours). Symptom onset occurred within 24 hours postsurgery.

Despite differences in surgical context, several factors seemed to predispose these patients to PA: wide fluctuations in intraoperative blood pressure, preexisting hypertension, and macroadenomas exceeding 2 cm. In patients with known macroadenomas, risk stratification may be helpful based on adenoma size and comorbid conditions affecting vascular health. Sudden intraoperative changes in blood pressure should be avoided. For those with predisposing risk factors undergoing high-risk surgeries, especially cardiac procedures that utilize anticoagulation, obtaining a preoperative computed tomography (CT) head may be warranted.