Endocrine Abstracts

Introduction

Pituitary apoplexy (PA) is a rare medical emergency caused by acute haemorrhage and/or infarction within a pituitary or usually pituitary tumour. Typically, PA is characterised by severe headache, visual fields defects, decreased visual acuity, cranial nerve palsies and hypopituitarism. However, many patients present with mild or ambiguous signs and symptoms or even PA is an incidental radiological finding.

Aim

To evaluate clinical presentations, pituitary function and management of patients diagnosed with PA. Patients and methods: We conducted a retrospective analysis of medical records of patients diagnosed with PA between 2015 and 2020 at the Department of Endocrinology of the Bielanski Hospital. Diagnosis of PA was based on clinical presentation, hormonal and imaging results.

Results

Forty-three patients were identified, with women predominance (56% female), and mean age of patients 42 yrs. (SD 17.2, range 16–79). Precipitating factors such as pregnancy/labour, surgery, dopamine agonist treatment were identified in 44% of cases. Diagnosis of pituitary tumour was established prior to PA in 11 cases (26%), during PA in more than half of cases (53%), but in as many as 21% of patients, the tumours were discovered with a suggestion of past apoplexy. Majority of PA cases (81.4%) underwent conservative management (75% of symptomatic patients) and only 18.6% required surgical intervention (due to severe headache and visual defect). Most of the pituitary lesions (63%) were identified as non-functioning pituitary adenomas. The remaining tumours were: prolactinomas (16%), Rathke cleft cysts (12%), GH- secreting adenomas (5%). There were 2 cases of Sheehan’s syndrome. Fifteen patients (35%) were asymptomatic but their imaging results strongly suggested PA. In symptomatic patients, the most common symptoms at presentation were headaches (79%), visual field defects (32%) and decreased visual acuity (50%). Other symptoms included: diplopia, isolated acute cranial nerve palsies, dizziness and impaired consciousness. The most common anterior pituitary dysfunction was gonadotroph deficiency (57%), followed by ACTH, TSH and GH deficiencies (in 46%, 46% and 36% respectively). Panhypopituitarism was present in 1 case (4%). Two patients had a second incident of PA apoplexy during follow up and 2 patients were diagnosed with encephalitis or meningitis simultaneously. Regrowth of pituitary tumour was observed in four patients (9.3%).

Conclusions

Although PA can be life-threatening and sometimes requires neurosurgery, most cases can be managed conservatively. We found less proportion of patients with anterior pituitary deficiency. The risk of tumour progression after PA makes long-term follow-up necessary.