Mehmet Turgut, Ashok Kumar Mahapatra, Michael Powell and Natarajan Muthukumar (eds.)Pituitary Apoplexy201410.1007/978-3-642-38508-7_2
© Springer-Verlag Berlin Heidelberg 2014
2. Conservative Versus Surgical Decompression for Pituitary Apoplexy
(1)
Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, Warwickshire, CV2 2DX, UK
Abstract
Pituitary haemorrhage has been recognised since 1898, with the term “pituitary apoplexy” being coined in 1950. With developments in transsphenoidal surgical techniques and the advent of corticosteroids over the last 100 years, the landscape of treatment has changed. Yet there remains much debate about surgical intervention, with multiple case series reporting favourable outcomes from a conservative approach. In this chapter we summarise the major evidence fuelling the discussion and conclude with the most recent evidence-based recommendations.
2.1 Introduction
Pituitary apoplexy is a rare condition resulting from haemorrhage or infarction of the pituitary gland and presenting with the classical clinical syndrome of headache, vomiting, neuro-ophthalmic dysfunction (abnormal acuity, field defect or ophthalmoplegia) and alterations in conscious level (Randeva et al. 1999). It is often seen complicating a known pituitary adenoma though, in 80 % of cases, it is the first presentation of a previously undiagnosed tumour. The incidence of apoplexy in patients with a pituitary adenoma is reported as between 2 and 7 % depending on diagnostic criteria (Rajasekaran et al. 2010). Haemorrhage of the pituitary without symptoms, or subclinical apoplexy, is more common and may be as high as 25 % (Ayuk et al. 2004).
Much of the clinical syndrome is the result of gland expansion, with subsequent compression of structures near to the pituitary gland. Headache is the presenting symptom in nearly 100 % of patients (Randeva et al. 1999; Ayuk et al. 2004; Sibal et al. 2004), but compression of the optic chiasm and involvement of the cavernous sinus result in visual defects and ophthalmoplegia, respectively. The incidence of these symptoms varies between case series, but up to 80–90 % can have visual symptoms (acuity and field defects combined) (Randeva et al. 1999; Ayuk et al. 2004; Sibal et al. 2004; Gruber et al. 2006) and 40–70 % have ophthalmoplegia (typically including cranial nerve III) (Sibal et al. 2004; Rajasekaran et al. 2010).
Due to the compressive nature of these symptoms, it seems logical (if simplistic) to presume that surgical decompression of the pituitary would alleviate symptoms. As with most things in medicine, things are not so straight forward. The role and timing of surgery is a greatly contentious subject and the focus of many studies, reviews and (more recently) guidelines. Most conclude that the evidence is of low quality, being primarily case series of a small number of patients, with substantial variation in outcome seen between different centres. There remains no good, high-level evidence (such as a randomised controlled trial) to answer the debate, and it is unlikely to be forthcoming given the rarity of the condition as well as the associated diagnostic challenges.
The large majority of reported cases focus on neuro-ophthalmic symptoms, using severity at presentation, progression over time and long-term visual outcomes as evidence for and against intervention. These symptoms include reduced visual acuity, visual field defects and cranial nerve palsies. Studies have also looked at endocrine outcome in conservative versus surgical groups, though less controversy exists around the importance of early medical stabilisation and replacement of corticosteroids, even before consideration of the surgical intent.
In this chapter I will lay the groundwork for this debate, touching on the evidence for and against surgical intervention in acute pituitary apoplexy and concluding with the most recent guidelines.
2.2 A Brief History of Apoplexy and Pituitary Surgery
The term pituitary apoplexy was first coined by Brougham et al. in 1950 to describe the clinical syndrome we use today, though cases of pituitary haemorrhage had been described as far back as 1898. The diagnostic term is typically reserved for the symptomatic cases, with asymptomatic pituitary haemorrhage being referred to as subclinical apoplexy (Randeva et al. 1999).
Surgery for the pituitary gland itself has been described as early as 1889 by Sir Victor Horsley with a variety of transcranial approaches being used initially. This was associated with a high rate of morbidity prior to the advent of antibiotics and steroids in the 1950s.
The first transsphenoidal resection is reported in 1907 by Hermann Schloffer, but the technique rapidly fell out of favour, though the reasons for this remain unclear. In the 1950s Gerard Guiot utilised fluoroscopy during surgery to improve on the previous transsphenoidal techniques. Along with the introduction of the operating microscope in the 1960s, this method led to a renewed interest in a transsphenoidal approach to the pituitary gland. This technique became the standard best practice for pituitary adenomas by the 1970s (Jane et al. 2002).
Surgery for pituitary apoplexy followed a similar historical path, with transsphenoidal approach, alongside routine use of steroids, showing greatly improved levels of postoperative mortality. By the 1970s operative mortality was down to 6.7 % compared to 22 of 36 patients dying in a case review from the 1960s (Cardoso and Peterson 1984). A review of five cases published in the BMJ in 1971 concluded that “neurological sequelae arising from pituitary apoplexy […] should be regarded as a neurosurgical emergency”. This review also showed an early recognition of the importance of timescale for decompression and its relativity to the symptom severity, stating “rapid and severe loss of sight surgery has only to be postponed until the patient has been adequately resuscitated and covered by adrenocorticosteroids” (Epstein et al. 1971).
2.3 Surgical Versus Conservative Intervention
Reports discussing the management of acute pituitary apoplexy were limited greatly by cohort size and varied in their opinions, but in 1999 Randeva et al. reported the largest individual case series to that date, comprising of 35 patients presenting with clinical apoplexy over an 11-year period to Oxford, UK (Randeva et al. 1999).
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