Conservative Management of Pituitary Apoplexy

Abstract

Pituitary apoplexy is a rare clinical syndrome caused by sudden hemorrhaging or infarction of the pituitary gland, generally within a pituitary adenoma. Headache of sudden and severe onset is the main symptom, associated with visual disturbances or ocular palsy. Signs of meningeal irritation or altered consciousness may complicate the diagnosis. Corticotropic deficiency (secondary adrenal failure) may be life-threatening if untreated. Owing to the highly variable course of this syndrome, and the limited individual experience, the optimal management of acute pituitary apoplexy is controversial. Historically, being considered a neurosurgical emergency in the past, pituitary apoplexy was always treated surgically. However, a conservative approach is increasingly used in selected patients, as publications provide converging evidence that a wait-and-see approach is associated with similar outcomes in terms of oculomotor palsy, pituitary function, and subsequent tumor growth. Even visual acuity and visual field defects show similarly improvements with the two approaches. Owing to the uncontrolled design of retrospective studies comparing the two approaches, and the probable selection bias, the optimal management of acute pituitary apoplexy, conservative or surgery, still remains controversial. Unfortunately, visual outcome is poor in patients with monocular or binocular blindness, irrespective of the mode of management, conservative or surgery. Whatever strategy is chosen, steroid therapy must always be initiated immediately, at a dose of 50 mg hydrocortisone every 6 h, to treat the possible adrenal insufficiency and its potentially life-threatening cardiovascular complications. Patients with reduced visual acuity and/or visual field defects must be closely monitored if a conservative approach is chosen, and surgery should be considered secondarily if no clear improvement is seen after a week or if the patient deteriorates. Long-term clinical and imaging follow-up is necessary to detect the recurrence of the adenoma or growth of a tumor remnant, which will require surgery or radiation therapy.