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J Neurol Surg B Skull Base 2022; 83(S 02): e152-e159
DOI: 10.1055/s-0041-1722993
Original Article

Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

John T. Butterfield 
1   Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
,
Takako Araki
2   Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, Minnesota, United States
4   Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
,
Daniel Guillaume
1   Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
4   Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
,
Ramachandra Tummala
1   Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
4   Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
,
Emiro Caicedo-Granados
3   Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, United States
4   Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
,
Matthew A. Tyler
3   Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, United States
4   Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
,
Andrew S. Venteicher
1   Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
4   Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
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Abstract

Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined.

Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy.

Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared.

Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions.

Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

Keywords

pituitary adenoma - giant pituitary adenoma - pituitary apoplexy - skull base surgery - endoscopic endonasal approach

Supplementary Material



Publication History

Received: 29 June 2020

Accepted: 03 December 2020

Article published online:
22 February 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Han S, Gao W, Jing Z, Wang Y, Wu A. How to deal with giant pituitary adenomas: transsphenoidal or transcranial, simultaneous or two-staged?. J Neurooncol 2017; 132 (02) 313-321
    CrossrefPubMedSearch in Google Scholar
  • 2 Sinha S, Sharma BS. Giant pituitary adenomas--an enigma revisited. Microsurgical treatment strategies and outcome in a series of 250 patients. Br J Neurosurg 2010; 24 (01) 31-39
    CrossrefPubMedSearch in Google Scholar
  • 3 Karki M, Sun J, Yadav CP, Zhao B. Large and giant pituitary adenoma resection by microscopic trans-sphenoidal surgery: surgical outcomes and complications in 123 consecutive patients. J Clin Neurosci 2017; 44: 310-314
    CrossrefPubMedSearch in Google Scholar
  • 4 Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary 2012; 15 (02) 150-159
    CrossrefPubMedSearch in Google Scholar
  • 5 Hofstetter CP, Nanaszko MJ, Mubita LL, Tsiouris J, Anand VK, Schwartz TH. Volumetric classification of pituitary macroadenomas predicts outcome and morbidity following endoscopic endonasal transsphenoidal surgery. Pituitary 2012; 15 (03) 450-463
    CrossrefPubMedSearch in Google Scholar
  • 6 Chabot JD, Chakraborty S, Imbarrato G, Dehdashti AR. Evaluation of outcomes after endoscopic endonasal surgery for large and giant pituitary macroadenoma: a retrospective review of 39 consecutive patients. World Neurosurg 2015; 84 (04) 978-988
    CrossrefPubMedSearch in Google Scholar
  • 7 Goel A, Nadkarni T, Muzumdar D, Desai K, Phalke U, Sharma P. Giant pituitary tumors: a study based on surgical treatment of 118 cases. Surg Neurol 2004; 61 (05) 436-445 , discussion 445–446
    CrossrefPubMedSearch in Google Scholar
  • 8 Goel A, Deogaonkar M, Desai K. Fatal postoperative ‘pituitary apoplexy’: its cause and management. Br J Neurosurg 1995; 9 (01) 37-40
    CrossrefPubMedSearch in Google Scholar
  • 9 Mortini P, Barzaghi R, Losa M, Boari N, Giovanelli M. Surgical treatment of giant pituitary adenomas: strategies and results in a series of 95 consecutive patients. Neurosurgery 2007; 60 (06) 993-1002 , discussion 1003–1004
    CrossrefPubMedSearch in Google Scholar
  • 10 Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 2005; 56 (06) 1222-1233 , discussion 1233
    CrossrefPubMedSearch in Google Scholar
  • 11 Kurwale NS, Ahmad F, Suri A. et al. Postoperative pituitary apoplexy: preoperative considerations toward preventing nightmare. Br J Neurosurg 2012; 26 (01) 59-63
    CrossrefPubMedSearch in Google Scholar
  • 12 Mohr G, Hardy J, Comtois R, Beauregard H. Surgical management of giant pituitary adenomas. Can J Neurol Sci 1990; 17 (01) 62-66
    CrossrefPubMedSearch in Google Scholar
  • 13 Xue-Fei S, Yong-Fei W, Shi-Qi L. et al. Microsurgical treatment for giant and irregular pituitary adenomas in a series of 54 consecutive patients. Br J Neurosurg 2008; 22 (05) 636-648
    CrossrefPubMedSearch in Google Scholar
  • 14 D'Ambrosio AL, Syed ON, Grobelny BT, Freda PU, Wardlaw S, Bruce JN. Simultaneous above and below approach to giant pituitary adenomas: surgical strategies and long-term follow-up. Pituitary 2009; 12 (03) 217-225
    CrossrefPubMedSearch in Google Scholar
  • 15 Zhao B, Wei YK, Li GL. et al. Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases. J Neurosurg 2010; 112 (01) 108-117
    CrossrefPubMedSearch in Google Scholar
  • 16 de Paiva Neto MA, Vandergrift A, Fatemi N. et al. Endonasal transsphenoidal surgery and multimodality treatment for giant pituitary adenomas. Clin Endocrinol (Oxf) 2010; 72 (04) 512-519
    CrossrefPubMedSearch in Google Scholar
  • 17 Nakao N, Itakura T. Surgical outcome of the endoscopic endonasal approach for non-functioning giant pituitary adenoma. J Clin Neurosci 2011; 18 (01) 71-75
    CrossrefPubMedSearch in Google Scholar
  • 18 Guo F, Song L, Bai J. et al. Successful treatment for giant pituitary adenomas through diverse transcranial approaches in a series of 15 consecutive patients. Clin Neurol Neurosurg 2012; 114 (07) 885-890
    CrossrefPubMedSearch in Google Scholar
  • 19 Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg 2013; 118 (03) 621-631
    CrossrefPubMedSearch in Google Scholar
  • 20 Gondim JA, Almeida JP, Albuquerque LA, Gomes EF, Schops M. Giant pituitary adenomas: surgical outcomes of 50 cases operated on by the endonasal endoscopic approach. World Neurosurg 2014; 82 (1-2): e281-e290
    CrossrefPubMedSearch in Google Scholar
  • 21 Constantino ER, Leal R, Ferreira CC, Acioly MA, Landeiro JA. Surgical outcomes of the endoscopic endonasal transsphenoidal approach for large and giant pituitary adenomas: institutional experience with special attention to approach-related complications. Arq Neuropsiquiatr 2016; 74 (05) 388-395
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 Yano S, Hide T, Shinojima N. Efficacy and complications of endoscopic skull base surgery for giant pituitary adenomas. World Neurosurg 2017; 99: 533-542
    CrossrefPubMedSearch in Google Scholar
  • 23 Elshazly K, Kshettry VR, Farrell CJ, Nyquist G, Rosen M, Evans JJ. Clinical outcomes after endoscopic endonasal resection of giant pituitary adenomas. World Neurosurg 2018; 114: e447-e456
    CrossrefPubMedSearch in Google Scholar
  • 24 Fallah N, Taghvaei M, Sadaghiani S, Sadrhosseini SM, Esfahanian F, Zeinalizadeh M. Surgical outcome of endoscopic endonasal surgery of large and giant pituitary adenomas: an institutional experience from the Middle East. World Neurosurg 2019; 132: e802-e811
    CrossrefPubMedSearch in Google Scholar
  • 25 Azab WA, Nasim K, Abdelnabi EA. et al. Endoscopic endonasal excision of large and giant pituitary adenomas: radiological and intraoperative correlates of the extent of resection. World Neurosurg 2019; 126: e793-e802
    CrossrefPubMedSearch in Google Scholar
  • 26 Iglesias P, Rodríguez Berrocal V, Díez JJ. Giant pituitary adenoma: histological types, clinical features and therapeutic approaches. Endocrine 2018; 61 (03) 407-421
    CrossrefPubMedSearch in Google Scholar
  • 27 Soneru CP, Riley CA, Hoffman K, Tabaee A, Schwartz TH. Intra-operative MRI vs endoscopy in achieving gross total resection of pituitary adenomas: a systematic review. Acta Neurochir (Wien) 2019; 161 (08) 1683-1698
    CrossrefPubMedSearch in Google Scholar
  • 28 Wang SS, Wei L, Jing JJ, Zhang SM. Three-dimensional reconstruction and morphological characterization of pituitary macroadenomas. Arch Med Sci 2016; 12 (03) 576-586
    CrossrefPubMedSearch in Google Scholar