Clinical relevance of precipitating factors in pituitary apoplexy

OBJECTIVE: The pathogenesis of pituitary apoplexy and the role of precipitating factors in pituitary apoplexy are poorly understood. Most of the published cases are in the form of case reports. We assessed the presumed precipitating factors in a series of patients treated surgically for pituitary apoplexy and reviewed the contemporary published literature. METHOD: Thirty-eight consecutive patients with pituitary apoplexy were treated surgically by the Department of Neurosurgery at the University of Virginia, Charlottesville, VA, between January 1996 and March 2006. Their medical records were retrospectively reviewed. Contemporary published cases from 1990 to 2006 were also reviewed. RESULTS: Nine patients (24%) were identified as having precipitating factors for pituitary apoplexy. The factors identified were coronary artery surgery (two patients), other major surgery (two patients), pregnancy (two patients), gamma knife irradiation, anticoagulant therapy, and coagulopathy secondary to liver failure. The presentation, histology, and outcome were compared between those patients with a precipitating factor and those in whom none was identified. A review of the published literature showed that coronary artery surgery, pituitary stimulation, and coagulopathy were the most common precipitating factors. CONCLUSION: A minority of patients with pituitary apoplexy will have precipitating factors. The majority of patients with precipitating factors will have histopathology showing hemorrhagic infarction or hemorrhage. The most common precipitating factors are pituitary stimulation, surgery, particularly coronary artery surgery, and coagulopathy. Caution in doing endocrine investigation, surgery, or anticoagulation in patients with a known pituitary tumor is advised. Patients with no diagnosed pituitary tumor but with a known precipitating factor who have neuro-ophthalmological deterioration or endocrine failure should undergo prompt magnetic resonance image scans and endocrine investigation and endocrine replacement as indicated.