The Role of Conservative Management in Pituitary Apoplexy, MOHAMED H. EL SISSY
Abstract
Background: Pituitary apoplexy is a life threatening condition, with an incidence 0,65-27,7% of all cases with pituitary adenomas, caused by hemorrhage or infarction in macroadenomas. It is manifested clinically by sudden severe headache, neuro-ophthalmic and sometimes endocrinal abnor-malities. The optimal treatment of such condition is contro-versial.
Aim: To evaluate the role of conservative treatment in addition to the surgical treatment.
Methods: Fifteen patients (eleven males and four females) with age range from 23 to 76 years with clinical pituitary apoplexy were analyzed; nine cases were managed surgically by endoscopic assisted microscopic transsphenoid surgery and six cases were managed conservatively in about ten years duration. Surgical indications in our study were visual acuity less than 6/60 or 20/200, deteriorated visual acuity while on conservative treatment or patients presenting with disturbed conscious level, consolidated with magnetic resonance imaging revealing the apoplexy.
Results: The analysed cases were subdivided into prola-cinomas: Seven cases (46,6%), non functional adenomas: Four cases (26,6%), somatotrophic adenomas: Three cases (20%) and singe case (6,6%) with corticotrophic adenomas. Clinical picture analysis revealed; severe headache in all cases (100%), visual acuity defects in thirteen cases (86,6%), visual field defects in eleven cases (73,3%), eight cases of which had bitemporal hemianopia and ten cases (66,6%) had ocular motility abnormality. Regarding the visual acuity outcome, all cases managed surgically (nine cases) had visual acuity defects; seven of them came in the first week of the insult showed improvement; five cases (55,5%) of them had complete improvement and two cases (22,2%) had partial improvement in addition to two cases (22,2%) coming late had stationary course, while for the conservatively managed patients having visual acuity defects (four cases), one case (25%) had complete recovery, one case (25%) had partial recovery and two cases refused surgery; one of them (25%) had stationary course and the other case (25%) worsened. For cases with visual field defect (eleven cases), six cases of them were managed surgi-cally analyzed as follow; three cases (50%) had complete recovery, one case (16,6%) had partial recovery and two cases (33,3%) had stationary course, while for the conservatively managed cases with visual field defects (five cases), two cases (40%) had complete improvement, one case (20%) had partial improvement one case (20%) had stationary course and the last case (20%) deteriorated and regarding the ocular motility abnormality (ten cases); five cases were managed surgically, analyzed as follow: One case (20%) had complete improve-ment, another case (20%) had partial improvement and the other three cases (60%) had stationary course two cases of which coming after the first week, while for the conservatively managed cases (five cases); three cases (60%) had complete improvement and two cases (40%) had stationary course.
Conclusion: Conservative treatment is an acceptable alternative for management of pituitary apoplexy in cases with less severe neuro-ophthalmic manifestations, otherwise early surgery should be performed.