Pituitary Apoplexy - A Short Case Series

Pituitary apoplexy is a rare neuroendocrine emergency which can occur due to infarction or hemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. Patients usually present with headache, vomiting, altered sensorium, visual deficits and/or endocrine dysfunction. Hemodynamic instability may result from adenocorticotropic dysfunction. Imaging with either CT or MRI should be performed in suspected cases. We did a single center retrospective analysis of 62 patients who underwent surgery in our neurosurgical unit for pituitary lesions, out of which 6 were pituitary apoplexy that underwent transnasal endoscopic decompression immediately after the diagnosis of pituitary apoplexy with either deteriorating consciousness or progressing visual impairment. These 6 patients' data was further analyzed. Mean age was 56.3 years (24 - 78 years range), with male preponderance with male to female ratio of 2:1. All 6 patients had headache (100%), progressing visual disturbance in 4 patients (66%), 2 (33%) had diminished consciousness. Radiologically evidence of hemorrhage was seen in MRI in 4 patients (66%), sphenoid sinus invasion seen in 1 patient. Most common endocrinological abnormality was cortisol deficiency that was seen in 5 out of 6 patients (83%). All 6 patients underwent transnasal endoscopic surgery and postoperative period was uneventful in 4 patients, 1 developed CSF leak which was managed conservatively and 1 developed recurrent lower respiratory tract infections later developed sepsis and expired. Postoperatively 2 patients (33%) achieved normal endocrine profile, remaining 4 developed hypothyroidism among which 1 had associated cortisol deficiency and is on steroid replacement and 1 had transient diabetes insipidus. Clinical outcome is good in 5 patients (83%, GOS 4,5) and 1 patient expired. To conclude early surgical decompression for pituitary apoplexy appears to be a preferred modality of treatment in selected cases of pituitary apoplexy. Transnasal endoscopic approach has the added advantage of minimal invasiveness with short postoperative stay.