Management-specific outcome evaluation of pituitary apoplexy; conservative and surgical approach

PURPOSE: Pituitary apoplexy can be managed by early surgery or a conservative approach, if necessary, followed by later elective surgery. Choice of management is related to correct diagnosis, symptom severity at presentation and symptom development prior to contacting the pituitary center of excellence (PTCOE). Specific circumstances may dictate a specific choice, in others shared decision-making is key. This retrospective cohort study aimed to describe clinical decision-making and outcomes of pituitary apoplexy treatment. METHODS: Outcome measures were factors relevant to treatment choice, visual acuity (VA), visual field defects (VFD), cranial nerve palsies, pituitary function, measured at three time points (baseline, 6 months after diagnosis, last follow-up). RESULTS: We studied 98 patients with clinical apoplexy diagnosed between 2005 and 2021. After the first clinical evaluation, 45 patients underwent early surgery and 53 initial conservative management. Main indications for early surgery were lowered VA and/or severe VFD. Postoperatively, mean VA improved from 0.63 (SD = 0.36) to 1.03 (SD = 0.3). VFD improved in 72.2% of patients. During continued follow-up, 21 initially conservatively treated patients had later elective surgery. VFD improved in 85.7% of these patients. Mean follow-up was > 38 months for each group. CONCLUSION: The choice for surgery is mainly driven by ophthalmological symptoms, in which severity determines its timing. Although ophthalmological recovery rates are reasonable, (endocrine) outcomes of apoplexy are unfavorable, irrespective of trajectory. Prospective studies are needed to assess optimal (timing of) treatment, in particular in those patients without an obvious reason for early surgery, taking into account the heterogeneity and variable course of this condition.