Pituitary apoplexy can represent a challenging diagnostic and management dilemma. Yet its serious nature demands immediate recognition, careful assessment and treatment by a multidisciplinary team.
A panel of physicians recently sat down with other healthcare professionals and medical students internationally to present two complex cases that highlight the critical decision-making processes. The webinar, hosted by Baptist Health, attracted attendees from El Salvador, Nicaragua, Ecuador, Peru, Colombia, the Bahamas, the Cayman Islands, Panama, Jamaica and the United Kingdom, in addition to the U.S.
Evan Bander, M.D.
Neurosurgeon Evan Bander, M.D., director of endoscopic skull base surgery and co-director of the Pituitary Tumor Program at Baptist Health Miami Neuroscience Institute, was joined by head and neck surgeon Alissa Kanaan, M.D., a rhinology specialist with South Florida ENT, and endocrinologist Michael Fili, M.D., with Baptist Health.
More than 10,000 people in the U.S. are diagnosed with pituitary tumors each year, although the number of cases is projected to be much higher because many patients are unaware that they have the condition. Most of the tumors are benign pituitary adenomas, which can be slow-growing and discovered incidentally.
Symptoms of pituitary apoplexy
Patients who have symptoms of pituitary apoplexy often experience:
- A sudden-onset headache
- Visual disturbances such as double vision or loss of peripheral vision
- Photophobia
- Hormone insufficiency, including life-threatening adrenal insufficiency
- Electrolyte abnormalities
- Altered mental status
Case 1
Case number one was a 62-year-old male with diabetes and hypertension who developed confusion and double vision while hospitalized post aortic valve replacement. “He was noted to have bitemporal hemianopsia, abducens nerve palsy and was mildly confused and forgetful,” Dr. Bander said.
Upon workup, the patient’s TSH was 0.408, free T4 was 0.7 ng/dL and total cortisol was 6.1. The patient’s prolactin was 6.0 and testosterone was 8. There was evidence of panhypopituitarism.
“His presentation was very suggestive of pituitary insufficiency, but whether chronic or acute was the question,” Dr. Fili said. “We believe that this particular patient certainly had an acute event that aggravated a more chronic condition.”
Dr. Bander discussed and presented the evolving data and clinical literature regarding conservative medical management versus surgical intervention and the timing of surgical intervention on outcomes in pituitary apoplexy. Although traditionally, patients with pituitary apoplexy would have been treated as neurosurgical emergencies, more contemporary data suggests that some patients can be managed conservatively, and surgical intervention can achieve optimal outcomes when performed within a week of presentation.
This patient went to the OR one-week post-bleed, in order to stabilize medical comorbidities. During the immediate post-op period, he had improvement in his CN3 palsy, although still exhibited persistent CNVI palsy. Dr. Bander reported that by his three-month follow-up, all of his cranial nerve palsies and visual deficits had resolved.
Case 2
Case number two was a 76-year-old male with a history of hypertension, coronary artery disease, AFib, DM2 and a known history of a pituitary macroadenoma. At the ER, he presented with progressive weakness, confusion, headache, vision loss, ptosis and complete left CN3 palsy.
The patient’s workup showed a TSH of 0.39, free T4 of 0.9, total cortisol of 7.1, prolactin of 1.8 and testosterone of 11, ACTH 8.3, hGH 0.2, IGF-1 16, FSH 1.1 and LH <0.3.
“It’s important to gather appropriate lab tests on these patients. Unfortunately, he received steroids before we could confirm his diagnosis,” Dr. Fili said. “However, this was more indicative of an acute episode of adrenal axis insufficiency.”
The patient also had a strong meningeal inflammatory reaction and sinusitis could be seen on pre-operative imaging. The patient was taken to the OR within 24 hours. A gross total resection was obtained and an intraoperative CSF leak was encountered and closed with an abdominal fat graft and vascularized nasoseptal flap. “This is the workhorse for fixing a CSF leak in the nose. To get good coverage, you want a vascularized flap,” explained Dr. Kanaan. ”We also placed a temporary lumbar drain to divert the CSF.”
After discharge home, he returned for his three-month follow-up visit with no residual tumor and complete resolution of his 3rd nerve palsy and a full range of extraocular movement.
Advances in technology have made it possible for surgeons to access most pituitary masses through the nose with no facial cuts, scars or bruising. “With today’s endoscopes and improved instruments, we have more magnification and a wider field of view and with angled scopes blind spots are eliminated,” Dr. Kanaan said. “These surgeries used to be massive and much more dangerous when they weren’t going through the nose. Today, patients recover faster, go home faster and have little pain. They may have some nasal congestion, and their sense of smell could be affected temporarily. But the endoscope has revolutionized treatment.”
Not every pituitary tumor needs surgery. Watchful waiting, medications and/or radiation therapy are other options physicians may consider when clinically appropriate.
