2025 Poster Presentations
P246: PITUITARY APOPLEXY: NAVIGATING THE ONGOING DILEMMA OF SURGICAL VS. CONSERVATIVE MANAGEMENT
Rajesh Chhabra, Professor; Apinderpreet Singh, MD; PGIMER
Introduction: Pituitary apoplexy is a rare but life-threatening condition caused by the sudden expansion of a pituitary adenoma due to hemorrhage or infarction within the tumor. This can present with symptoms such as a sudden, severe headache, visual disturbances, ocular paresis, or altered mental status, among other combinations. While historically considered a surgical emergency, increasing evidence supports initial conservative management in many cases. A significant number of patients experience improvement without surgery, but there remains a lack of well-defined criteria to predict which patients will require surgery. Additionally, the outcomes of surgical intervention in pituitary apoplexy are underreported. This study examines our experience with surgical indications and outcomes in pituitary apoplexy.
Materials and Methods: This retrospective study included all patients admitted to the emergency department with clinical and radiological evidence of pituitary apoplexy from January 2020 to December 2023. Data on clinical presentation, radiological findings, biochemical and hormonal parameters were collected. Patients who did not show improvement or experienced worsening symptoms within 48 hours of conservative management were considered for urgent surgical intervention.
Observations and Results: A total of 99 patients with pituitary apoplexy were included in the study. Of these, 29 patients underwent surgery via the trans-sphenoidal approach. Among the surgical group, 28 patients had non-functional pituitary adenomas, while one patient had acromegaly. No other functional lesions required surgery. The tumors in 15 patients were firm in consistency. Arachnoid breach occurred in 7 patients, 4 of whom developed cerebrospinal fluid (CSF) rhinorrhea. Postoperatively, 10 patients experienced new hormonal deficits. Transient diabetes insipidus (DI) occurred in 15 patients, with 3 experiencing prolonged DI. Four patients had residual tumor, but none showed disease progression during follow-up.
Discussion: The majority of patients with pituitary apoplexy can initially be managed conservatively. However, surgical intervention is necessary in select cases where patients do not improve or worsen. Tumors requiring surgery tend to be firmer and more adherent to the arachnoid, leading to a higher risk of arachnoid breach and subsequent CSF leak. Postoperative complications, including new hormonal deficits and diabetes insipidus, are also more common in surgically treated cases. Surgery for pituitary apoplexy is technically challenging and associated with a higher complication rate, underscoring the need for careful surgical planning and vigilant postoperative management.
Clear criteria for surgical intervention and a tailored approach to each case are essential to optimize outcomes for patients with pituitary apoplexy.