The impact of surgical timing on visual outcome in pituitary apoplexy: Literature review and case illustration
- Department of Neurosciences, Division of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
- Alfaisal University, College of Medicine, Riyadh 11533, Saudi Arabia
Department of Neurosciences, Division of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
Alfaisal University, College of Medicine, Riyadh 11533, Saudi Arabia
DOI:10.4103/2152-7806.199557Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Arif Abdulbaki, Imad Kanaan. The impact of surgical timing on visual outcome in pituitary apoplexy: Literature review and case illustration. 06-Feb-2017;8:16
How to cite this URL: Arif Abdulbaki, Imad Kanaan. The impact of surgical timing on visual outcome in pituitary apoplexy: Literature review and case illustration. 06-Feb-2017;8:16. Available from: http://surgicalneurologyint.com/surgicalint_articles/the-impact-of-surgical-timing-on-visual-outcome-in-pituitary-apoplexy-literature-review-and-case-illustration/
Background:Neuro-ophthalmologic signs are common clinical manifestations of pituitary apoplexy. Managing sudden visual loss is critical for achieving a good outcome. The timing of pituitary surgery remains controversial. In fact, various points of view have been reported in the literature.
Methods:We reviewed the impact of surgical intervention timing on visual outcome. The surgical intervention time was classified as urgent, early, intermediate, and late interventions based on the literature review. We report a case of a 40-year-old male patient who presented with headache and sudden visual loss for 3 days. He was diagnosed with pituitary apoplexy and had transnasal-transsphenoidal resection. Three days later, he achieved a complete recovery of his vision.
Results:This paper is an addition to several studies that favor early surgical decompression of pituitary fossa for apoplexy cases with severe neuro-ophthalmologic involvement. There is an increasing trend for early surgical intervention for pituitary apoplexy in the literature, especially for severe visual deterioration.
Conclusion:The visual outcome appears to be better in early intervention as compared to late. Nevertheless, good visual recovery is also seen in late surgical intervention.
Keywords: Pituitary apoplexy, transsphenoidal surgery, visual outcome
Pituitary apoplexy is a clinical syndrome characterized by sudden onset of headache, visual disturbances, altered mental status, vomiting, and hormonal dysfunction. It results from rapid expansion of a preexisting pituitary adenoma due to hemorrhage or infarction.[
A literature review was conducted through PubMed. The published articles were classified based on the timing of surgical intervention. Urgent surgical intervention was classified for all interventions within the first 24 hours of acute visual deterioration, and early intervention was done within 72 hours (after 24 hours), intermediate intervention during the first week after the first 72 hours, and late intervention after 1 week of visual deterioration. The degree and duration of visual recovery were considered as the main factors to measure the impact of intervention timing.
A 40-year-old male patient presented to the emergency room of our hospital with a history of left frontal headache, which was severe in intensity and pressure-like in quality and associated with significant acute decrease in visual acuity and vomiting for 3 days. He was seen at a local hospital before being referred to us as they lacked the facilities and expertise to perform neurosurgical intervention. At the local hospital, proper radiological surveillance was performed for him that showed a sellar-suprasellar lesion with optic chiasm compression and hemorrhagic foci. On physical examination, the patient was conscious, alert, and oriented to time, person, and place with a Glasgow coma score (GCS) of 15. He had bilateral light perception but denied any noticeable visual loss prior to the event as he was able to see and drive his own car. The visual field was difficult to be assessed, and there was no evidence of papilledema. Right third nerve palsy was also noted. These findings were confirmed by our ophthalmology team. He was also seen by our endocrinology team where he was given stress dose of hydrocortisone. Urgent magnetic resonance imaging (MRI) brain was done that showed 3 × 2.8 × 2 cm irregular lesion involving the sellar-suprasellar area, extending to the right cavernous sinus and showing irregular high signal intensity on T1 and correspondingly low signal intensity on T2, keeping with acute hemorrhage. The optic chiasm was dislocated and stretched by the lesion, and there was remolding of the roof of the sphenoid sinus [
The patient was taken to the operating room 3 days after his symptoms started and on the same day of his admission to our institution. Endoscopic transnasal-transsphenoidal resection of the pituitary lesion was performed. The lesion was heterogeneous in consistency, ranging from firm and rubbery to friable and hemorrhagic. A blood clot was exposed and removed accordingly, confirming the diagnosis of pituitary apoplexy.
The procedure went smoothly without any complications and with minimal blood loss. Postoperative MRI showed good resection of the tumor with residual [
The patient recovered well and reported progressive improvement of his vision in both the eyes few hours after the surgery. He was revaluated by the ophthalmology team 3 days after the operation. He had complete recovery of his vision and his third nerve palsy.
Pituitary apoplexy occurs in 2–7% of patients with pituitary adenoma.[
The pathophysiology of pituitary apoplexy is not fully understood. It is proposed that the adenoma outgrows its blood supply or compresses against its portal vessels resulting in necrosis of the tumor followed by hemorrhage.[
Conservative medical approach might have a role in pituitary apoplexy cases with mild neuro-ophthalmologic involvement. Ayuk et al. and Gruber et al. validated the safety of medical approach for these cases because medical management did not adversely affect the outcome.[
The timing of pituitary surgery remains controversial. Several studies with multiple results have been published in the literature. Certain authors advocated for urgent within 24 hours surgical decompression of the pituitary fossa [
Both Choudhry et al. and Zhang et al. concluded that urgent surgical decompression within 24 hours is crucial to result in better visual outcomes.[
Chen et al., Woo et al., and Chuang et al. advocated for early surgery, where the earlier the surgery, the better the outcome. The resolution of impaired visual function was higher in patients who were operated within almost 3 days compared to those operated later. There were two blind eyes in Woo's series and three blind eyes in Chuang's series that had early surgery, which resulted in partial recovery and complete recovery, respectively [
Liu et al. and Imboden et al. operated on their patients within 7 days of visual deficit and recovery was achieved in 64% and 100%, respectively. Out of the 4 blind patients in Liu's study, 3 remained blind. It could be postulated that the noted difference in the results is due to the small number of patients in Imdboden's study, and total resection rate was achieved in only 57% of Liu's cases.[
Singh et al., Gruber et al., and Sibal et al. concluded that timing of surgery did not appear to influence the outcome, and the difference between the treatment groups was not significant.[
It is crucial to understand the pathophysiology of these visual disorders. They are induced by pituitary apoplexy's compression on optic chiasm or nerve which is suspected by the displacement noted on imaging. The mechanisms of injury are categorized as reversible and irreversible. The initial axoplasmic flow disorder, conduction blockage, and demyelinization are reversible functional mechanisms. Longer and/or more intense compression leading to axonal fiber degeneration, which is seen in the fundus as optic atrophy is irreversible.[
We speculate the mechanism behind the fast complete recovery 3 days after the surgery to the release of the conduction block caused by the compression. In fact, this is the first phase of recovery identified by Kerrison at al. Recovery continuous in some patients until a couple of years postoperatively because of possible neural plasticity.[
In conclusion, there is no dominant consensus in the literature on the best timing to operate on pituitary tumor apoplexy patients. This paper is an addition to several studies that advocate early surgery for pituitary apoplexy cases with neuro-ophthalmologic involvement. The earlier to remove the compressive pathology, the better the outcome is. However, some publications reported varying degree of improvement at the delayed intervention. The final decision will be based on multidisciplinary discussion, institutional experience, and reported outcome. Prospective studies are needed to propose evidence-based guidelines.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Abouaf L, Vighetto A, Lebas M. Neuro-ophthalmologic exploration in non-functioning pituitary adenoma. Ann Endocrinol. 2015. 76: 210-9
2. Agrawal D, Mahapatra AK. Visual outcome of blind eyes in pituitary apoplexy after transsphenoidal surgery: A series of 14 eyes. Surg Neurol. 2005. 63: 42-6
3. Ayuk J, McGregor EJ, Mitchell RD, Gittoes NJ. Acute management of pituitary apoplexy--surgery or conservative management?. Clin Endocrinol. 2004. 61: 747-52
4. Bills DC, Meyer FB, Laws ER, Davis DH, Ebersold MJ, Scheithauer BW. A retrospective analysis of pituitary apoplexy. Neurosurgery. 1993. 33: 602-8
5. Bonicki W, Kasperlik-Załuska A, Koszewski W, Zgliczyński W, Wisławski J. Pituitary apoplexy: Endocrine, surgical and oncological emergency. Incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas. Acta Neurochir. 1993. 120: 118-22
6. Brougham M, Heusner AP, Adams RD. Acute degenerative changes in adenomas of the pituitary body--with special reference to pituitary apoplexy. J Neurosurg. 1950. 7: 421-39
7. Cardoso ER, Peterson EW. Pituitary apoplexy: A review. Neurosurgery. 1984. 14: 363-73
8. Chen L, White WL, Spetzler RF, Xu B. A prospective study of nonfunctioning pituitary adenomas: Presentation, management, and clinical outcome. J Neurooncol. 2011. 102: 129-38
9. Choudhry OJ, Choudhry AJ, Nunez EA, Eloy JA, Couldwell WT, Ciric IS. Pituitary tumor apoplexy in patients with Cushing's disease: Endocrinologic and visual outcomes after transsphenoidal surgery. Pituitary. 2012. 15: 428-35
10. Chuang CC, Chang CN, Wei KC, Liao CC, Hsu PW, Huang YC. Surgical treatment for severe visual compromised patients after pituitary apoplexy. J Neurooncol. 2006. 80: 39-47
11. Elsässer Imboden PN, De Tribolet N, Lobrinus A, Gaillard RC, Portmann L, Pralong F. Apoplexy in pituitary macroadenoma: Eight patients presenting in 12 months. Medicine. 2005. 84: 188-96
12. Gruber A, Clayton J, Kumar S, Robertson I, Howlett TA, Mansell P. Pituitary apoplexy: Retrospective review of 30 patients--is surgical intervention always necessary?. Br J Neurosurg. 2006. 20: 379-85
13. Jin Kim Y, Hyun Kim C, Hwan Cheong J, Min Kim J. Relationship between expression of vascular endothelial growth factor and intratumoral hemorrhage in human pituitary adenomas. Tumori. 2011. 97: 639-46
14. Kerrison JB, Lynn MJ, Baer CA, Newman SA, Biousse V, Newman NJ. Stages of improvement in visual fields after pituitary tumor resection. Am J Ophthalmol. 2000. 130: 813-20
15. Liu ZH, Chang CN, Pai PC, Wei KC, Jung SM, Chen NY. Clinical features and surgical outcome of clinical and subclinical pituitary apoplexy. J Clin Neurosci. 2010. 17: 694-9
16. McFadzean RM, Doyle D, Rampling R, Teasdale E, Teasdale G. Pituitary apoplexy and its effect on vision. Neurosurgery. 1991. 29: 669-75
17. Mohr G, Hardy J. Hemorrhage, necrosis, and apoplexy in pituitary adenomas. Surg Neurol. 1982. 18: 181-9
18. Muthukumar N, Rossette D, Soundaram M, Senthilbabu S, Badrinarayanan T. Blindness following pituitary apoplexy: Timing of surgery and neuro-ophthalmic outcome. J Clin Neurosci. 2008. 15: 873-9
19. Rajasekaran S, Vanderpump M, Baldeweg S, Drake W, Reddy N, Lanyon M. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol. 2011. 74: 9-20
20. Randeva HS, Schoebel J, Byrne J, Esiri M, Adams CB, Wass JA. Classical pituitary apoplexy: Clinical features, management and outcome. Clin Endocrinol. 1999. 51: 181-8
21. Sibal L, Ball SG, Connolly V, James RA, Kane P, Kelly WF. Pituitary apoplexy: A review of clinical presentation, management and outcome in 45 cases. Pituitary. 2004. 7: 157-63
22. Singh TD, Valizadeh N, Meyer FB, Atkinson JL, Erickson D, Rabinstein AA. Management and outcomes of pituitary apoplexy. J Neurosurg. 2015. 122: 1450-7
23. Takeda N, Fujita K, Katayama S, Akutu N, Hayashi S, Kohmura E. Effect of transsphenoidal surgery on decreased visual acuity caused by pituitary apoplexy. Pituitary. 2010. 13: 154-9
24. Woo HJ, Hwang JH, Hwang SK, Park YM. Clinical outcome of cranial neuropathy in patients with pituitary apoplexy. J Korean Neurosurg Soc. 2010. 48: 213-8
25. Zhang X, Zhang W, Fu LA, Cheng JX, Liu BL, Cao WD. Hemorrhagic pituitary macroadenoma: Characteristics, endoscopic endonasal transsphenoidal surgery, and outcomes. Ann Surg Oncol. 2011. 18: 246-52