Approach Considerations
Treatment should be individualized for each patient. Surgical intervention, when necessary, should be undertaken early and the majority of the patients will have residual hormonal deficits requiring hormone replacement. [2]
Medical Care
The management of pituitary apoplexy is controversial in that some advocate early transsphenoidal surgical decompression in all patients, whereas others adopt a conservative approach for selected patients (without visual acuity or field defects and with normal consciousness). [26]
Medical treatment consists of the following:
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Medically stabilize the patient.
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Immediately evaluate electrolytes, glucose, and pituitary hormones.
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Administer high-dose corticosteroids (most patients have hypopituitarism).
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Administer appropriate endocrinologic replacement therapy alone or combined with transsphenoidal surgical decompression of the tumor.
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Avoid the "head down" position, when possible. [39]
Surgical Care
Evacuation of the tumor by a neurosurgeon should be planned once the patient is medically stable, especially in the setting of altered consciousness, visual acuity, and visual field loss. [26, 40, 41]
Shepard et al identified 64 patients with pituitary apoplexy, 47 (73.4%) underwent intended conservative management, while 17 (26.6%) had early surgery. Tumor volumes were greater in the early surgical cohort. Among those with visual acuity and field deficits, visual outcomes were similar between both groups. Conservative management failed in 7 patients (14.9%) and they required surgery. Younger age, female sex, and patients with field deficits or chiasmal compression were more likely to experience unsuccessful conservative management. The authors concluded that the majority of patients with pituitary apoplexy can be successfully managed without surgical intervention assuming close neurosurgical, radiologic, and ophthalmologic follow-up is available. [42]
Cavalli et al retrospectively reviewed 30 patients with pituitary apoplexy; they found that 86.7% of patients presented with visual disturbances (70% acuity, 50% field, 50% diploplia), 10 (33%) patients underwent emergency surgery, and 8 underwent delayed elective surgery. At early and late follow-up, the outcome was not significantly different between groups. The authors concluded that good results are possible with conservative management in selected cases. Emergency surgery provides better visual outcomes and a tumor vertical diameter >35 mm should tip the balance in favor of surgical management in presence of visual deficit. [43]
Consultations
Consultations to consider include the following:
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Neurosurgery for potential surgical therapy
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Medicine for general medical management
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Endocrinology for hormonal management
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Ophthalmology for documentation of visual acuity, perimetry, and motility
Complications
In a prospective study in 152 consecutive patients undergoing transsphenoidal removal of pituitary tumors, not necessarily apoplexy, various immediate postoperative complications were noted including CSF leaks, meningitis, diabetes insipidus, dyselectrolytemia, deterioration of visual acuity of field ot new cranial nerve deficit or palsy, postoperative intracranial bleeding/hematoma at operation site, and hydrocephalus. [44]
Long-Term Monitoring
Most patients experience improvement in their visual exam varying from partial improvement to complete recovery, with no difference between the conservative and surgically treated group. [2, 45]
There is a small risk for recurrent apoplexy in patients with residual tumors, and there is also a small risk for tumor recurrence following apoplexy; thus all patients should undergo surveillance examinations and repeat neuroimaging. [2]
Further Inpatient Care
Monitor metabolic status, visual acuity, visual fields, and ocular motility.
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Enhanced coronal CT showing large pituitary tumor with a "snowman" configuration and heterogeneous density (mixed signal) within the tumor indicative of pituitary apoplexy. Hemorrhage was confirmed at surgery.
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Enhanced axial and coronal T1-weighted MRI of a typical large pituitary tumor with a "snowman" configuration (coronal) and marked enhancement with contrast. This tumor has not undergone apoplexy.
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Enhanced T1-weighted axial and coronal MRI showing a large pituitary tumor that has recently undergone ischemic apoplexy showing a necrotic (hypointense) center and ring of gadolinium enhancement (hyperintense), ie, the "pituitary ring sign." There is a small area of hemorrhagic blush in the center of the necrosis.
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Automated visual field showing a bitemporal field defect due to compression of the optic chiasm from below.
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Post-contrast sagittal T1-weighted scan shows sphenoid sinus roof mucosal thickening. The yellow arrow shows the “pituitary ring sign,” while the white arrow shows sphenoid sinus roof mucosal thickening. Courtesy of Taylor & Francis (Vaphiades MS. Pituitary Ring Sign Plus Sphenoid Sinus Mucosal Thickening: Neuroimaging Signs of Pituitary Apoplexy. Neuroophthalmology. 2017 Dec. 41 (6):306-309. Online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764063/.).
