Endocrine Abstracts

Background: There is lack of consensus in the management of pituitary apoplexy. Following the 11th Clinicopathological Pituitary Conference at the RCP (2009), a multidisciplinary group produced evidence-based guidelines for management of apoplexy. A patient with apoplexy and significant neuro-ophthalmic signs or reduced level of consciousness will usually undergo surgical decompression. It is unclear what defines a significant neuro-ophthalmic deficit. There is no objective tool to monitor conservatively managed patients. A pituitary apoplexy scoring system (PAGGS) has been designed to quantify the neuro-ophthalmic deficits and serve as a monitoring tool. This study evaluates the validity of PAGGS in apoplexy.

Methods: Retrospective analysis of case records of 46 patients with classical pituitary apoplexy treated in two centres from 1979 to 2009. Level of consciousness and neuro-ophthalmic signs (visual acuity, visual fields and ocular paresis) were assessed. PAGGS was internally validated by six clinicians and was retrospectively applied to 46 patients to assess usability.

Results: Fifty-four percentage of patients had surgery within 8 days of presentation (mean PAGGS 3.16); 11% had surgery within 9–14 days (mean PAGGS 3.80) and 35% of patients were managed conservatively (mean PAGGS 1.43). Mortality rate was 0%. No patient had any deterioration in visual symptoms after surgery. Final visual and endocrine outcomes were similar to published observational studies.

Conclusion: The PAGGS has been demonstrated to be usable in a large series of patients. In addition to being a uniform monitoring tool, the score quantifies the severity of neuro-ophthalmic deficits of apoplexy. Based upon the clinical criteria in PAGGS, the current management of patients with pituitary apoplexy appears arbitrary. We suggest that this score should be validated in prospective studies comparing the outcome in conservatively and surgically managed patients. This would help in formulating an effective clinical assessment tool to optimize the management of this rare neuroendocrine emergency.