Classical pituitary apoplexy: clinical features, management and outcome

OBJECTIVE The term classical pituitary apoplexy describes a clinical syndro me characterized by sudden headache, vomiting, Visual impairment and mening ismus caused by the rapid enlargement of a pituitary adenoma usually due to haemorrhagic infarction of the tumour. Most published reports looking at t he clinical features and management of pituitary apoplexy have not differen tiated between patients with clinical and subclinical apoplexy, the latter diagnosed at surgery. Furthermore, little is reported on the clinical outco me, in particular visual and endocrinological, and the role of radiotherapy . The purpose of this study was to observe not only the clinical presentati on but also the possible predisposing events, investigations, management, c linical outcome as well as the role of radiotherapy in patients presenting with classical pituitary apoplexy. PATIENTS AND DESIGN In a retrospective analysis 1985-96, the medical record s of 21 male and 14 female patients (mean age 49.8 years, range 30-74) with classical pituitary apoplexy were reviewed. This represents all patients s een with this condition over the stated period. MEASUREMENTS In all patients, pre- and postoperative measurements were made of FT4 FT3, TSH, PRL, LH, FSH, cortisol (0900 h), GH, oestradiol (females) and testosterone (males). Pituitary imaging was by computerized tomography (CT) scan, magnetic resonance imaging (MRI) or both. RESULTS Patients were followed for up to 11 years (mean 6.3 years: range 0. 5-11). Headache (97%) was the commonest presenting symptom, followed by nau sea (80%) and a reduction of visual fields (71%). Hypertension, defined as a systolic >160 mmHg and/ or a diastolic > 90 mmHg, was seen in 26% of pati ents. MRI correctly identified pituitary haemorrhage in 88% (n=7), but CT s canning identified haemorrhage in only 21% (n=6). By immunostaining criteri a, null-cell adenomas were the most common tumour type (61%). Transsphenoid al surgery resulted in improvement in visual acuity in 86%. Complete restor ation of visual acuity occurred in all patients operated on within 8 days b ut only in 46% of patients operated on after this time (9-34 days). Long-te rm steroid or thyroid hormone replacement was necessary in 58% and 45% of p atients, respectively. Of the male patients, 43% required testosterone repl acement, and longterm desmopressin therapy was required in 6%. Only two pat ients (6%) with tumour recurrence after transsphenoidal surgery for the ini tial apoplectic event, subsequently required radiotherapy. CONCLUSIONS In classical pituitary apoplexy, headache is the commonest pres enting symptom and hypertension may be an important predisposing factor. MR I is the imaging method of choice. Transsphenoidal surgery is safe and effe ctive. It is indicated if there are associated abnormalities of visual acui ty or visual fields because, when performed within 8 days, it resulted in s ignificantly greater improvement in visual acuity and fields than if surger y was performed after this time. Radiotherapy is not indicated immediately as the risk of tumour recurrence is small, but careful follow-up initially with annual imaging is indicated in this group.