Pituitary apoplexy

Introduction

Pituitary apoplexy is a potentially life-threatening condition due to acute ischemia or hemorrhage within the pituitary gland, and typically occurs in the setting of a pituitary adenoma. ^, The incidence of pituitary apoplexy in patients with pituitary adenomas occurs in 1% to 26% of patients in some series, and can be the primary presentation of a pituitary tumor in up to 80% of patients. ^, The most common symptoms are sudden and severe headaches in 90% to 100%, nausea and vomiting in 40% to 80%, decreased visual acuity in 45% to 90%, visual field defect in 40% to 75%, ophthalmoplegia in 50% to 80%, and altered consciousness in 5% to 40%. ^, The majority of patients (up to 80%) will have a deficiency in one or more anterior pituitary hormones, in which adrenal insufficiency occurs in 60% to 75% of patients. ^, For patients with apoplexy who present with ophthalmoplegia without visual field deficits, the management can sometimes be controversial, as there are reports with resolution of ophthalmoplegia with both conservative and surgical management. ^, In this chapter, we present a case of a patient with a pituitary apoplexy.

Example case

Chief complaint: headaches, lethargy, and double vision

History of present illness

A 70-year-old, right-handed man with a history of diabetes, hypertension, and coronary artery disease presented with acute onset of headaches, lethargy, and double vision. He was in his usual state of health until this morning when he had acute onset of the worst headache of his life, double vision with inability to move right eye in all directions, and lethargy. He was taken to the emergency room, where brain imaging was done ( Fig. 58.1 ).

Medications : Irbesartan, metformin, aspirin, clopidogrel.
Allergies : No known drug allergies.
Past medical and surgical history : Diabetes, hypertension, coronary artery disease, cataracts, carpel tunnel, right knee replacement.
Family history : No history of intracranial malignancies.
Social history: Retired veteran, remote smoking history, no alcohol.
Physical examination : Awake, lethargic, oriented to person, place, and time; Cranial nerves II to XII intact, except right cranial nerve III palsy with ptosis, visual fields full to confrontation; No drift, moves all extremities with full strength.
Pituitary labs : Prolactin 0, random cortisol 3, thyroid stimulating hormone/T4, and insulin-like growth factor-1 within normal limits.

	James J. Evans, MD, Tomas Garzon-Muvdi, MD, Thomas Jefferson University, Philadelphia, PA, United States	Paul A. Gardner, MD, Carl H. Snyderman, MD, MBA, University of Pittsburgh, Pittsburgh, PA, United States	Chae-Yong Kim, MD, PhD, Seoul National University Bundang Hospital, Seoul, South Korea	Tetsuro Sameshima, MD, PhD, Hamamatsu University, Hamamatsu, Shizuoka, Japan
Preoperative
Additional tests requested	Pituitary hormone evaluation Endocrinology evaluation Neuroophthalmology evaluation	CT angiogram Endocrinology evaluation Neuroophthalmology evaluation ENT evaluation 8 a.m. cortisol	CT maxillofacial Pituitary hormone evaluation Serum electrolytes and markers for infection Neuropsychological assessmentNeuroophthalmology evaluation	CT head Pituitary hormone evaluation
Surgical approach selected	Endoscopic endonasal transsphenoidal	Endoscopic endonasal transsphenoidal, partial transclival	Endoscopic endonasal transsphenoidal	Endoscopic endonasal transsphenoidal
Other teams involved during surgery	ENT	ENT	ENT	None
Anatomic corridor	Transnasal transsphenoidal	Transnasal transsphenoidal/transclival	Transnasal transsphenoidal	Transnasal transsphenoidal
Goal of surgery	Maximal resection	Complete resection with preservation of pituitary function	Decompression, diagnosis	Decompression (except cavernous sinus component), diagnosis
Perioperative
Positioning	Supine without pins	Supine with pins	Supine without pins	Supine with pins
Surgical equipment	Surgical navigation Endoscope	IOM (SSEP) Surgical navigation Endoscope Microdoppler	Surgical navigation Endoscope Intraoperative CT or MRI	Surgical navigation Endoscope Ultrasonic aspirator
Medications	Steroids	Steroids	Steroids Thyroid medication if low	None
Anatomic considerations	ICAs, optic nerves, diaphragma sellae, pituitary gland and stalk	Parasellar and paraclival ICAs, opticocarotid recesses, cavernous sinus walls, pituitary glands	Optic chiasm, cavernous sinus, ICA	Cavernous sinus
Complications feared with approach chosen	CSF leak, recurrent hemorrhage from residual tumor	CSF leak, hypopituitarism, vision loss	Anosmia	Cavernous sinus injury
Intraoperative
Anesthesia	General	General	General	General
Skin incision	None	None	None	None
Bone opening	Right greater than left sphenoidotomy, removal of sellar face from tuberculum to floor and cavernous to cavernous	Right middle turbinate, bottom right superior turbinate, wide sphenoidotomy, upper clivus	Wide sphenoidotomy, removal of sellar bone, posterior planum sphenoidale, subchiasmatic groove, tuberculum, medial OCR, bilateral optic canals
Brain exposure	Sella	Sella	Sella	Sella
Method of resection	Bilateral middle turbinates lateralized, identify right sphenoid ostium, wide right sphenoidotomy, preservation of mucosa, same procedure on left but limited sphenoidotomy, removal of sellar bone from tuberculum sella to sellar floor and cavernous to cavernous sinus, dura cauterized and opened in cruciate fashion, sellar mass debulked with ring curettes along floor to dorsum and then laterally to cavernous sinuses and then superiorly to decompress diaphragma, preserve normal gland, dura reconstructed with synthetic dura and sealant, middle turbinated medialized with Nasopore in middle meatus	Lateralization/resection of right middle turbinate, partial resection of right superior turbinate, lateralize left middle turbinate, disarticulate posterior septum from rostrum of sphenoid, preserve right nasoseptal flap, protect nasal corridor with sleeves, open into sphenoid, do not disrupt tumor, additional resection of posterior superior nasal septum if necessary, drill to floor and lateral recesses of sphenoid sinus, resect tumor out of lateral and clival recesses using two suckers, hemostasis before entering sella, remove remaining sella bone and expose right cavernous sinus, remove tumor with two suction tips with attention to right cavernous sinus, angled endoscope to inspect for residual, reconstruct with mucosa from right middle turbinate or nasoseptal flap if leak present	Nasal cavity packed with epinephrine soaked pledgets, bilateral middle and superior turbinates lateralized, right nasoseptal flap harvested and stored in choanae, posterior septum disarticulated, wide bilateral sphenoidotomy, septostomy, drill down of posterior planum sphenoidale/subchiasmatic groove/tuberculum/optic canals/medial OCR, expose superior intercavernous sinus, coagulate exposed dura, separate dural opening in planum and sella, tack up sutures, internal decompression, papaverine-soaked pledgets to optic nerves, nasoseptal flap if necessary for CSF leak	Right nasoseptal flap, enter sphenoid sinus, debulk as much tumor as possible using ultrasonic aspirator and curettes, spare right cavernous sinus
Complication avoidance	Nasoseptal flap, limited sphenoidotomy, debulk from floor to diaphragma	Nasoseptal flap, wide bony opening, two suction resection, attention to right cavernous sinus	Nasoseptal flap, wide bony opening, papaverine to optic nerves	Nasoseptal flap, do not compromise cavernous sinus
Postoperative
Admission	ICU or intermediate care	ICU	Intermediate care	Floor
Postoperative complications feared	CSF leak, pituitary dysfunction, rehemorrhage	CSF leak, pituitary dysfunction, rehemorrhage	Decreasing olfaction, CSF leak	CSF leak, pituitary dysfunction, worsening cranial nerve palsy
Follow-up testing	MRI 3 months after surgery Pituitary panel 3 months after surgery a.m. cortisol after surgery Sodium/SG if UOP >250 cc/hr for 2 hours	8 a.m. cortisol level 48 hours after surgery if off of steroids Prolactin level 1 day after surgery Daily electrolytes, strict fluid assessment CT immediately after surgery only if large CSF leak MRI 3 months after surgery	MRI within 48 hours after surgery Pituitary hormonal analysis ENT evaluation MRI 3 months after surgery	CT immediately after and 1 day after surgery Pituitary hormonal analysis MRI within 7 days after surgery
Follow-up visits	1 week after surgery with ENT 2 weeks after surgery with neurosurgery	1 week after surgery with ENT 1 week after surgery with neurosurgery 2 weeks after surgery with endocrinology and ophthalmology	1 month after surgery	3 months after surgery