Endocrine Abstracts

Purpose: The condition of pituitary apoplexy contains the clinical spectre from life-threatening emergency to a condition with chronic symptoms and self-limiting course, which partly determines diagnostic delay and management. Outcome evaluation of course and management of pituitary apoplexy is hampered by the diverse presentation of this condition and requires appraisal. This study aimed to describe the patient journey, clinical presentation and management of various types of pituitary apoplexy in a new classification to facilitate future outcome evaluation and identify unmet needs in the current care process.

Methods: A single-center retrospective patient chart study was conducted between 2005-2021 (n=98). Outcome measures were clinical symptoms at first presentation in hospital, being headache, consciousness, visual acuity, visual field defects (VFD), ophthalmoplegia, nausea, vomiting, fever and hypopituitarism and care process characteristics. We described their patient journey and identified three different types, differing in clinical presentation, in-hospital route and final treatment.

Results: Mean age was 47.6±16.6 years, and 51.0% was male. Most patients belonged to the acute apoplexy subtype (type A, 52%), followed by the subacute (type B, 22.5%) and non-acute subtype (type C, 25.5%). Type A generally presents with acute onset headaches, VFD or ophthalmoplegia emergency setting, with lowest mean visual acuity of both eyes and frequent hypocortisolism. Type B presents both with acute onset and chronic headaches, with VFD or ophthalmoplegia that sometimes require acute surgery. Type C usually presents with chronic headaches without acute onset and no urgent ophthalmologic complaints that require acute surgery. Next to differences in clinical presentation at hospital entry, we also showed that patients of different apoplexy subtypes go through a different type of care process with different initial working diagnosis, different attending medical specialties, and eventually different treatments.

Conclusion: Pituitary apoplexy can be approached as a spectrum of disease with 3 main subtypes, being acute, subacute and non-acute, with a different initial presentation, different in-hospital route resulting in different management. The most important unmet needs in the care process of pituitary apoplexy patients are: 1) delay in referral to a Pituitary Tumors Center of Excellence (PTCOE), 2) underdiagnosis of apoplexy subtypes B and C, since subacute and non-acute complaints are not recognized as pituitary apoplexy; 3) lack of long-term outcome evaluation of different treatment modalities within subtypes. Acknowledging subtypes will serve improvements in patient care, and outcome evaluations.