Introduction: Pituitary apoplexy (PA) most commonly manifests as a spontaneous hemorrhage or infarct of a pituitary adenoma and can present with visual and endocrine defects.(1) The literature lacks strong support for either surgical or conservative management on symptomatic improvement of these deficits.(2) This meta-analysis compares the visual and endocrine outcomes in conservative versus surgical treatment of PA.
Methods: A systematic literature search was performed in PubMed for articles published between January 1988 and November 2018. Of the resulting 490 articles, only those describing both surgical and conservative treatments’ outcomes were included. Recovery outcomes were binarized, such that complete and partial improvements were both grouped as “improvement”. The primary outcome variables evaluated via a binary random-effects model were improvements in endocrine deficit, visual field deficit, visual acuity deficit, and ophthalmoplegia or ocular nerve palsy (O/ONP).
Results: After careful review of the published articles, 14 studies of a collective 457 subjects (259 surgical and 198 conservative) were included.(1-14) Overall, 267 initially presented with endocrine dysfunction, 167 with visual acuity deficit, 162 with visual field deficit, and 216 with O/ONP. In surgical compared to conservative management of these patients, collective odds ratio for improvement in endocrine dysfunction, visual acuity dysfunction, visual field dysfunction, and ONP/O were 1.13 (95% CI 0.51-2.49; p-value = 0.76), 0.83 (95% CI 0.33-2.01; p-value = 0.69) 0.86 (95% CI 0.32-2.32; p-value = 0.77), and 0.64 (95% CI 0.27-1.52; p-value = 0.31), respectively.
Conclusions: This meta-analysis demonstrates no significant difference in visual and endocrine outcomes in surgical versus conservative management of PA. The treatment of PA can be multi-faceted and dependent on the individual case. As such, further investigation into the appropriate intervention for PA based on the clinical presentation and longitudinal outcome data is warranted.
Patient Care: With the possible equally obtainable visual and endocrine improvements in both surgical and conservative treatment of pituitary apoplexy, physicians and patients can be open to discussing both invasive and non-invasive forms of symptom management.
Learning Objectives: By the conclusion of this session, participants should be able to 1) Describe the various possible presenting symptoms of pituitary apoplexy, 2) Discuss, in small groups, pros and cons of surgery versus conservative management in light of the presenting results, and 3) Identify an effective approach towards a case-by-case treatment decision.
References: 1. Teixeira JC, Lavrador J, Simão D, Miguéns J. Pituitary Apoplexy: Should Endoscopic Surgery Be the Gold Standard? World Neurosurg. 2018;111:e495-e499.
2. Giritharan S, Gnanalingham K, Kearney T. Pituitary apoplexy - bespoke patient management allows good clinical outcome. Clin Endocrinol (Oxf). 2016;85(3):415-22.
3. Culpin E, Crank M, Igra M, et al. Pituitary tumour apoplexy within prolactinomas in children?: a more aggressive condition?? Pituitary. 2018;21(5):474-479.
4. Seo Y, Kim YH, Dho Y, et al. The Outcomes of Pituitary Apoplexy with Conservative Treatment: Experiences at a Single Institution. World Neurosurg. 2018;115:e703-e710.
5. Singh TD, Valizadeh N, Meyer FB, Atkinson JL, Erickson D, Rabinstein AA. Management and outcomes of pituitary apoplexy. Journal of neurosurgery. 2015 Jun;122(6):1450-7.
6. Bujawansa S, Thondam SK, Steele C, et al. Presentation , management and outcomes in acute pituitary apoplexy?: a large single-centre experience from the United Kingdom for those managed conservatively or with delayed surgery was. 2014;44:419-424.
7. Simon S, Torpy D, Brophy B, Blumbergs P, Selva D, Crompton JL. Neuro-ophthalmic manifestations and outcomes of pituitary apoplexy--a life and sight-threatening emergency. N Z Med J. 2011;124(1335):52-9.
8. Leyer C, Castinetti F, Morange I, et al. A conservative management is preferable in milder forms of pituitary tumor apoplexy. 2011:502-509.
9. Gruber A, Clayton J, Kumar S, et al. Pituitary apoplexy?: retrospective review of 30 patients — is surgical intervention always necessary?? 2009;8697.
10. Sibal L, Ball SG, Connolly V, et al. Pituitary Apoplexy?: A Review of Clinical Presentation , Management and Outcome in 45 Cases. 2005:157-163.
11. Ayuk J, Mcgregor EJ, Rosalind D, Gittoes NJL. Acute management of pituitary apoplexy – surgery or conservative management?? 2004:747-752.
12. Carral san laureano F, Gavilán villarejo I, Olveira fuster G, Ortego rojo J, Aguilar diosdado M. [Pituitary apoplexy: retrospective study of 9 patients with hypophyseal adenoma]. An Med Interna. 2001;18(11):582-6.
13. McFadzean RM, Doyle D, Rampling R, Teasdale E, Teasdale G. Pituitary apoplexy and its effect on vision. Neurosurgery. 1991 Nov 1;29(5):669-75.
14. Maccagnan PA, Macedo CL, Kayath MJ, Nogueira RG, Abucham J. Conservative management of pituitary apoplexy: a prospective study. The Journal of Clinical Endocrinology & Metabolism. 1995 Jul 1;80(7):2190-7.