Management and outcomes of pituitary apoplexy

OBJECT This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes. METHODS The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale). RESULTS Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15–91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3–10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups. CONCLUSIONS The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.

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Optical Coherent Tomography Predicts Long-Term Visual Outcome of Pituitary Adenoma Surgery: New Perspectives From a 5-Year Follow-up Study

Neurosurgery ◽

10.1093/neuros/nyaa318 ◽

2020 ◽

Vol 88 (1) ◽

pp. 106-112 ◽

Cited By ~ 1

Author(s):

Young Soo Chung ◽

Minkyun Na ◽

Jihwan Yoo ◽

Woohyun Kim ◽

In-Ho Jung ◽

...

Keyword(s):

Pituitary Adenoma ◽

Visual Field ◽

Assessment Tool ◽

Visual Fields ◽

Visual Field Defects ◽

Mean Deviation ◽

Rnfl Thickness ◽

Long Term Follow Up

Abstract BACKGROUND Compressive optic neuropathy is the most common indication for transsphenoidal surgery for pituitary adenomas. Optical coherence tomography (OCT) is a useful visual assessment tool for predicting postoperative visual field recovery. OBJECTIVE To analyze visual parameters and their association based on long-term follow-up. METHODS Only pituitary adenoma patients with abnormal visual field defects were selected. A total of 188 eyes from 113 patients assessed by visual field index (VFI) and 262 eyes from 155 patients assessed by mean deviation (MD) were enrolled in this study. Postoperative VFI, MD, and retinal nerve fiber layer (RNFL) thickness were evaluated and followed up. After classifying the patients into normal (>5%) and thin (<5%) RNFL groups, we investigated whether preoperative RNFL could predict visual field outcomes. We also observed how RNFL changes after surgery on a long-term basis. RESULTS Both preoperative VFI and MD had a linear proportional relationship with preoperative RNFL thickness. Sustained improvement of the visual field was observed after surgery in both groups, and the degree of improvement over time in each group was similar. RNFL thickness continued to decrease until 36 mo after surgery (80.2 ± 13.3 μm to 66.6 ± 11.9 μm) while visual field continued to improve (VFI, 61.8 ± 24.5 to 84.3 ± 15.4; MD, −12.9 ± 7.3 dB to −6.3 ± 5.9 dB). CONCLUSION Patients with thin preoperative RNFL may experience visual recovery similar to those with normal preoperative RNFL; however, the probability of normalized visual fields was not comparable. RNFL thickness showed a strong correlation with preoperative visual field defect. Long-term follow-up observation revealed a discrepancy between anatomic and functional recovery.

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Pituitary apoplexy in acromegaly during bromocriptine therapy

Acta Endocrinologica ◽

10.1530/acta.0.0980171 ◽

1981 ◽

Vol 98 (2) ◽

pp. 171-177 ◽

Cited By ~ 32

Author(s):

Tohru Yamaji ◽

Miyuki Ishibashi ◽

Kinori Kosaka ◽

Takanori Fukushima ◽

Tomokatsu Hori ◽

...

Keyword(s):

Growth Hormone ◽

Pituitary Adenoma ◽

Pituitary Apoplexy ◽

Term Treatment ◽

Serum Growth Hormone ◽

Long Term Treatment ◽

Active Acromegaly

Abstract. Two cases of pituitary apoplexy occurring in the course of long-term bromocriptine therapy for active acromegaly are described. Although bromocriptine was effective in lowering serum growth hormone levels and concomitant clinical improvement was achieved, both patients developed an acute episode suggesting pituitary apoplexy when the therapy was continued for 6 and 24 months, respectively. Surgery verified marked haemorrhage and necrosis of an eosinophilic pituitary adenoma in each case. Bromocriptine may have suppressed the growth of these pituitary adenomas resulting in necrosis of the tumour, followed by haemorrhage into the adenoma. Pituitary apoplexy has not been documented as a complication of bromocriptine therapy. This report points out a possible role of bromocriptine in the development of this catastrophe and that careful follow-up is required when long-term treatment with bromocriptine is attempted.

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The natural history of pituitary apoplexy: long term follow-up study

Endocrine Abstracts ◽

10.1530/endoabs.65.p301 ◽

2019 ◽

Author(s):

Ayesha Shaikh ◽

Natasha Shrikrishnapalasuriyar ◽

Giselle Sharaf ◽

David Price ◽

Maneesh Udiawar ◽

...

Keyword(s):

Natural History ◽

Pituitary Apoplexy ◽

Follow Up Study ◽

Long Term Follow Up ◽

History Of

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Long-term outcomes of lumbar microdiscectomy in the pediatric population: a large single-institution case series

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.6.peds18716 ◽

2019 ◽

Vol 24 (5) ◽

pp. 549-557

Author(s):

Malia McAvoy ◽

Heather J. McCrea ◽

Vamsidhar Chavakula ◽

Hoon Choi ◽

Wenya Linda Bi ◽

...

Keyword(s):

Conservative Management ◽

Functional Outcomes ◽

Pediatric Patients ◽

Clinical Presentation ◽

Case Series ◽

Csf Leak ◽

Single Institution ◽

The Mean

OBJECTIVEFew studies describe long-term functional outcomes of pediatric patients who have undergone lumbar microdiscectomy (LMD) because of the rarity of pediatric disc herniation and the short follow-up periods. The authors analyzed risk factors, clinical presentation, complications, and functional outcomes of a single-institution series of LMD patients over a 19-year period.METHODSA retrospective case series was conducted of pediatric LMD patients at a large pediatric academic hospital from 1998 to 2017. The authors examined premorbid risk factors, clinical presentation, physical examination findings, type and duration of conservative management, indications for surgical intervention, complications, and postoperative outcomes.RESULTSOver the 19-year study period, 199 patients underwent LMD at the authors’ institution. The mean age at presentation was 16.0 years (range 12–18 years), and 55.8% were female. Of these patients, 70.9% participated in competitive sports, and among those who did not play sports, 65.0% had a body mass index greater than 25 kg/m2. Prior to surgery, conservative management had failed in 98.0% of the patients. Only 3 patients (1.5%) presented with cauda equina syndrome requiring emergent microdiscectomy. Complications included 4 cases of postoperative CSF leak (2.0%), 1 case of a noted intraoperative CSF leak, and 3 cases of wound infection (1.5%). At the first postoperative follow-up appointment, minimal or no pain was reported by 93.3% of patients. The mean time to return to sports was 9.8 weeks. During a mean follow-up duration of 8.2 years, 72.9% of patients did not present again after routine postoperative appointments. The total risk of reoperation was a rate of 7.5% (3.5% of patients underwent reoperation for the same level; 4.5% underwent adjacent-level decompression, and one patient [0.5%] ultimately underwent a fusion).CONCLUSIONSMicrodiscectomy is a safe and effective treatment for long-term relief of pain and return to daily activities among pediatric patients with symptomatic lumbar disc disease in whom conservative management has failed.

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Recovery of Visuospatial Neglect Subtypes and Relationship to Functional Outcome Six Months After Stroke

Neurorehabilitation and Neural Repair ◽

10.1177/15459683211032977 ◽

2021 ◽

pp. 154596832110329

Author(s):

Margaret J. Moore ◽

Kathleen Vancleef ◽

M. Jane Riddoch ◽

Celine R. Gillebert ◽

Nele Demeyere

Keyword(s):

Functional Outcomes ◽

Stroke Severity ◽

Visuospatial Neglect ◽

Recovery Pattern ◽

Stroke Impact Scale ◽

Impact Scale ◽

Significant Difference ◽

Initial Severity

Background/Objective. This study aims to investigate how complex visuospatial neglect behavioural phenotypes predict long-term outcomes, both in terms of neglect recovery and broader functional outcomes after 6 months post-stroke. Methods. This study presents a secondary cohort study of acute and 6-month follow-up data from 400 stroke survivors who completed the Oxford Cognitive Screen’s Cancellation Task. At follow-up, patients also completed the Stroke Impact Scale questionnaire. These data were analysed to identify whether any specific combination of neglect symptoms is more likely to result in long-lasting neglect or higher levels of functional impairment, therefore warranting more targeted rehabilitation. Results. Overall, 98/142 (69%) neglect cases recovered by follow-up, and there was no significant difference in the persistence of egocentric/allocentric (X2 [1] = .66 and P = .418) or left/right neglect (X2 [2] = .781 and P = .677). Egocentric neglect was found to follow a proportional recovery pattern with all patients demonstrating a similar level of improvement over time. Conversely, allocentric neglect followed a non-proportional recovery pattern with chronic neglect patients exhibiting a slower rate of improvement than those who recovered. A multiple regression analysis revealed that the initial severity of acute allocentric, but not egocentric, neglect impairment acted as a significant predictor of poor long-term functional outcomes (F [9,300] = 4.742, P < .001 and adjusted R2 = .098). Conclusions. Our findings call for systematic neuropsychological assessment of both egocentric and allocentric neglect following stroke, as the occurrence and severity of these conditions may help predict recovery outcomes over and above stroke severity alone.

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Pituitary Apoplexy and Its Effect on Vision

Neurosurgery ◽

10.1227/00006123-199111000-00005 ◽

1991 ◽

Vol 29 (5) ◽

pp. 669-675 ◽

Cited By ~ 74

Author(s):

Robert M. McFadzean ◽

David Doyle ◽

Roy Rampling ◽

Evelyn Teasdale ◽

Graham Teasdale

Keyword(s):

Pituitary Adenoma ◽

Clinical Diagnosis ◽

Clinical Features ◽

Visual Function ◽

Pituitary Apoplexy ◽

Diagnostic Errors ◽

Large Series ◽

Ocular Motility ◽

Pathological Findings ◽

Results Of Treatment

Abstract A series of 15 patients with a clinical diagnosis of pituitary apoplexy is reviewed. Clinical features are highlighted, with stress on the defects of visual function and ocular motility, and the associated endocrine abnormalities are described. Potential diagnostic errors and their significance are considered. The incidence of this complication in a large series of pituitary adenoma patients is measured, and the radiological and pathological findings are recorded. The results of treatment by surgery and/or radiotherapy and/or bromocriptine are assessed, particularly in relation to visual consequences, and compared with previous reports in the literature, which are reviewed.

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Long-term visual outcome after microsurgical removal of occipital lobe cavernomas

Journal of Neurosurgery ◽

10.3171/2012.5.jns112102 ◽

2012 ◽

Vol 117 (2) ◽

pp. 295-301 ◽

Cited By ~ 10

Author(s):

Juri Kivelev ◽

Elina Koskela ◽

Kirsi Setälä ◽

Mika Niemelä ◽

Juha Hernesniemi

Keyword(s):

Visual Field ◽

Visual Fields ◽

Visual Field Loss ◽

Occipital Lobe ◽

Visual Outcome ◽

Surgical Removal ◽

Long Term Outcome ◽

Visual Field Deficit

Object Cavernomas in the occipital lobe are relatively rare. Because of the proximity to the visual cortex and incoming subcortical tracts, microsurgical removal of occipital cavernomas may be associated with a risk of visual field defects. The goal of the study was to analyze long-term outcome after operative treatment of occipital cavernomas with special emphasis on visual outcome. Methods Of the 390 consecutive patients with cavernomas who were treated at Helsinki University Central Hospital between 1980 and 2011, 19 (5%) had occipital cavernomas. Sixteen patients (4%) were surgically treated and are included in this study. The median age was 39 years (range 3–59 years). Seven patients (56%) suffered from hemorrhage preoperatively, 5 (31%) presented with visual field deficits, 11 (69%) suffered from seizures, and 4 (25%) had multiple cavernomas. Surgery was indicated for progressive neurological deterioration. The median follow-up after surgery was 5.25 years (range 0.5–14 years). Results All patients underwent thorough neuroophthalmological assessment to determine visual outcome after surgery. Visual fields were classified as normal, mild homonymous visual field loss (not disturbing the patient, driving allowed), moderate homonymous visual field loss (disturbing the patient, driving prohibited), and severe visual field loss (total homonymous hemianopia or total homonymous quadrantanopia). At the last follow-up, 4 patients (25%) had normal visual fields, 6 (38%) had a mild visual field deficit, 1 (6%) complained of moderate visual field impairment, and 5 (31%) had severe homonymous visual field loss. Cavernomas seated deeper than 2 cm from the pial surface carried a 4.4-fold risk of postoperative visual field deficit relative to superficial ones (p = 0.034). Six (55%) of the 11 patients presenting with seizures were seizure-free postoperatively. Eleven (69%) of 16 patients had no disability during the long-term follow-up. Conclusions Surgical removal of occipital cavernomas may carry a significant risk of postoperative visual field deficit, and the risk is even higher for deeper lesions. Seizure outcome after removal of these cavernomas appeared to be worse than that after removal in other supratentorial locations. This should be taken into account during preoperative planning.

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Five-Year Prospective Roentgen Stereophotogrammetric and Clinical Outcomes of the BioPro MTP-1 Hemiarthroplasty

Foot & Ankle International ◽

10.1177/10711007211061366 ◽

2021 ◽

pp. 107110072110613

Author(s):

Vinay V. Balesar ◽

Lennard A. Koster ◽

Bart L. Kaptein ◽

Stefan B. Keizer

Keyword(s):

Prospective Study ◽

Clinical Outcomes ◽

Condition Number ◽

Clinical Assessment ◽

Functional Outcomes ◽

Metatarsal Bone ◽

Migration Patterns ◽

Patient Questionnaires

Background: Mixed results for functional outcomes and long-term fixation have been reported for first metatarsophalangeal arthroplasty. This prospective study was designed to evaluate the migration of the BioPro metatarsophalangeal-1 (MTP-1) joint hemiprosthesis with Roentgen stereophotogrammetric analysis (RSA). Migration patterns of the prosthesis, prosthesis-induced erosion of the metatarsal bone, and clinical outcomes were evaluated sequentially to 5 years postoperation (PO). Methods: Eleven female patients received the BioPro-1 hemiprosthesis. Prosthesis translation and metatarsal erosion were measured with RSA at immediately PO, 6 weeks, and 3, 6, 12, 36, and 60 months postoperatively. Clinical assessment was done by patient questionnaires. Results: RSA data of 9 patients were available for analysis. Median (range) number of markers used in RSA analysis, condition number, and mean error of markers around the prosthesis were 4 (3-7), 320 (208-862), and 0.13 (0.02-0.28), respectively. Progressive subsidence was seen up to 3 years PO (mean 2.1 mm, SE 0.32). Progressive metatarsal erosion was found from 1 year PO (mean 0.49 mm, SE 0.15). Pain, function, and quality scores improved after surgery and did not deteriorate at later follow-up moments. Conclusion: Model-based RSA of the BioPro-1 prosthesis shows nonstabilizing medial and distal translation and metatarsal erosion. Despite the measured migration and erosion, clinical outcomes improved and remained similar up to 5 years postoperation.

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Optical Coherent Tomography Predicts Long-Term Visual Outcome of Pituitary Adenoma Surgery: New Perspectives From a 5-Year Follow-up Study

Neurosurgery ◽

10.1093/neuros/nyaa318_s064 ◽

2021 ◽

Vol 89 (Supplement_2) ◽

pp. S64-S64

Author(s):

Young Soo Chung ◽

Minkyun Na ◽

Jihwan Yoo ◽

Woohyun Kim ◽

In-Ho Jung ◽

...

Keyword(s):

Pituitary Adenoma ◽

Visual Outcome ◽

Optical Coherent Tomography ◽

Follow Up Study

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Long-Term Outcomes of Patients with Acromegaly - A Report from the Swedish Pituitary Register

Acta Endocrinologica ◽

10.1530/eje-21-0729 ◽

2022 ◽

Author(s):

Steinunn Arnardóttir ◽

Jacob Järås ◽

Pia Burman ◽

Katarina Berinder ◽

Per Dahlqvist ◽

...

Keyword(s):

High Rate ◽

Hormone Deficiency ◽

Visual Field Defects ◽

Mortality Data ◽

Pituitary Hormone ◽

Biochemical Control ◽

Long Term Outcomes ◽

Over Time

Objective: To describe treatment and long-term outcomes of patients with acromegaly from all health-care regions in Sweden. Design and Methods: Analysis of prospectively reported data from the Swedish Pituitary Register of 698 patients (51% females) with acromegaly diagnosed from 1991-2011. The latest clinical follow-up date was December, 2012, while mortality data were collected for 28.5 years until June, 2019. Results: The annual incidence was 3.7/million; 71% of patients had a macroadenoma, 18% had visual field defects, and 25% had at least one pituitary hormone deficiency. Eighty-two percent had pituitary surgery, 10% radiotherapy and 39% medical treatment. At the 5- and 10-year follow-ups, IGF-I levels were within the reference range in 69% and 78% of patients, respectively. In linear regression the proportion of patients with biochemical control including adjuvant therapy at 10 year follow-up increased over time with 1.23 % per year. The SMR (95% CI) for all patients was 1.29 (1.11-1.49). For patients with biochemical control at the latest follow-up, SMR was not increased, neither among patients diagnosed 1991-2000, SMR 1.06 (0.85-1.33) or 2001-2011, SMR 0.87 (0.61-1.24). In contrast, non- controlled patients at the latest follow up from both decades had elevated SMR, 1.90 (1.33-2.72) and 1.98 (1.24-3.14), respectively. Conclusions: The proportion of patients with biochemical control increased over time. Patients with biochemically controlled acromegaly have normal life expectancy while non-controlled patients still have increased mortality. The high rate of macroadenomas and unchanged age at diagnosis illustrates the need for improvements in the management of patients with acromegaly.

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