Endoscopic Endonasal Transsphenoidal Treatment of Pituitary Apoplexy: Outcomes in a Series of 20 Patients

Purpose: Pituitary apoplexy is a rare clinical entity, and few cases treated with an endonasal endoscopic approach (EEA) have been reported. We report our experience of treating pituitary apoplexy using an EEA approach.

Methods: We performed a retrospective chart review on all patients who underwent EEA skull base and pituitary surgery between December 2003 and March 2012 performed by the senior authors (THS and VKA) and identified patients with pituitary apoplexy. Extent of resection was determined volumetrically, and visual and endocrine outcomes were evaluated.

Results: From a total of 488 skull base surgeries, there were 241 pituitary cases, of which 20 had apoplexy. The most common presenting symptoms included headaches (80%), endocrinopathy (95%), and visual symptoms (60%). Surgery was performed within 24 hours in 15% of patients, and more than 1 month after ictus in 40% due to late referral. Gross-total resection (GTR) was achieved in 18 (90%) patients. There was one (5%) postoperative cerebrospinal fluid (CSF) leak, which was treated with lumbar drainage. Of 12 patients with preoperative visual disturbances, 7 had improvements and 5 had no change, but only 33.3% of field cuts improved. There was no postoperative visual deterioration. Two patients developed new transient postoperative diabetes insipidus (DI), and there was no new permanent DI. The median duration of follow-up was 10 months (6 days-72 months).

Conclusions: The endoscopic endonasal transsphenoidal approach is an effective modality to treat pituitary apoplexy with high rate of GTR and minimal risk. Delayed surgery may result in lower rates of visual field defect improvement.