Post operative pituitary apoplexy: preoperative considerations toward preventing nightmare

Introduction. Post operative pituitary apoplexy after partial resection of a giant pituitary adenoma is mostly fatal, despite early and best management. Pathophysiology, clinical presentation and preoperative consideration toward prevention of apoplexy are discussed. Material and methods. Patients with post operative pituitary apoplexy were critically reviewed for clinical presentation, endocrine status, preoperative imaging and post operative course with outcome. Operative findings and histopathology were correlated. Results. Thirteen patients over 11 years with a mean age of 36 years were reviewed. All patients had giant pituitary adenomas. Four patients had functional adenomas. All patients were optimized for endocrine status before surgery. Twelve patients underwent transsphenoidal excision of the tumor. Only partial excision could be achieved in all cases. Deterioration of consciousness (9), visual deterioration (3), delayed reversal and excessive bleeding (1) were the primary indicators toward apoplexy. Ten patients were reexplored within 24 h of first surgery. All except one were explored transcranially a second time. Twelve patients died with variable post operative course. Hypothalamic dysfunction and dyselectolytemia (9) were leading causes of death, followed by meningitis and raised intracranial pressure. Conclusions. Post operative pituitary apoplexy is associated with high mortality, despite early and best management. Partial resection of the giant pituitary adenoma is directly responsible for post operative apoplexy. Maximum possible resection of the tumor by suitable exposure should be the optimal goal of surgery. Surgical exposure, either transcranial or transsphenoidal, should be dictated by tumor configuration on preoperative imaging. Endocrine status, histology of the tumor and clinical presentation do not appear to contribute to post operative pituitary apoplexy.