gms | German Medical Science

Objective: Sudden-onset intense headache, diplopia and visual field defects are the classic clinical features of pituitary apoplexy. Since this illness entity is deemed a medical emergency requiring neurosurgical intervention, referral to a neurosurgical unit is oftentimes effected after intracranial imaging confirms the clinical suspicion without prior endocrinological work-up. Against this background, we retrospectively assessed our own series of 31 patients with pituitary apoplexy, referred to our neurosurgical unit between 1998 and 2014 for initial presenting symptoms, histology and outcome.

Method: From our clinical information system available since 2006, we identified 29 patients treated in the neurosurgical department since then. 2 further patients were identified from our outpatient clinic at follow-up appointments. Chart records were reviewed for clinical, neuropathological and endocrinological findings.

Results: The most frequent presenting symptoms were (multiple answers possible) sudden headache (n = 17), loss of vision/visual field defects (n = 11), IIIrd nerve palsy (n = 6) and manifest Addisonian crisis (n = 3). Symptoms of Addisonian crisis were present in an additional 8 patients. Histopathology revealed 8 gonadotropinomas, 4 ACTH-immunostaining tumors, 3 prolactinomas, 3 null cell adenomas, 2 plurihormonal tumors and 1 hypophysitis. Hemorrhage/necrosis was found in 8 cases (2 histologies unavailable). In 2 patients Cushing's disease (CD) was diagnosed before the apoplexy. In one of them CD resolved afterwards, the other had a tumor recurrence years later. In 3 patients CD symptoms could be retrospectively inquired before apoplexy. 2 had anterior hypopituitarism after the apoplexy/surgery and one patient became clinically manifest with CD years later. In a further patient, prior acromegalic symptoms remitted with the apoplexy and anterior panhypopituitarism evolved instead.

Conclusions: In concordance with the literature, most patients in our study also exhibited the classic clinical symptoms of pituitary apoplexy. Addisonian crisis was present in 10% patients and must be recognized by the clinician in order to avoid potentially lethal complications. Moreover, hormonal hypersecretion of endocrine active tumors may initially cease after pituitary apoplexy, but return in the long-term. This implies that patients with pituitary apoplexy need long-term neurosurgical and endocrinological follow-ups.

Note: Oliver Müller and Ilonka Kreitschmann-Andermahr contributed equally.