Preventing Postoperative Apoplexy in Giant Pituitary Adenomas using Combined Trans-Sphenoidal and Cranial Surgery.

Background: Combined surgery consisting of endoscopic trans-sphenoidal surgery (ETSS) and transcranial (TC) surgery for giant pituitary adenomas (GPAs) has been recommended to prevent lethal postoperative apoplexy. Based on our experience, we attempt to rationalize the indications for such surgery. Materials and Methods: We report the magnetic resonance (MR) characteristics of the tumor and the outcomes in patients with GPAs who underwent ETSS only and combined surgery. Total tumor volume (TTV), tumor extension volume (TEV), and suprasellar extension of tumor (SET) were calculated based on the lines drawn on MR images and compared between those who underwent ETSS only and those who underwent combined surgery. Results: Of 80 patients with GPAs, eight (10%) underwent combined surgery (seven in the same sitting and one had staged surgery). All eight patients (100%) who underwent combined surgery had tumors with multilobulations, extensions, and encasement of the vessels in the circle of Willis (COW). Of 72 patients who underwent ETSS alone, 21 (29.1%) had a multilobulated tumor, 26 (36.2%) tumors had anterior/lateral extensions, and 12 (16.6%) had encasement of the COW. The mean TTV, TEV, and SET for the combined surgery group were significantly higher than those in the ETSS group. None of the patients who underwent combined surgery suffered postoperative residual tumor apoplexy. Conclusion: Patients with GPAs in whom there are significant lateral intradural or subfrontal tumor extensions should be considered for combined surgery at the same sitting to avoid devastating postoperative apoplexy in the residual tumor, which can occur when ETSS alone is performed.

Surgical anatomy and nuances of the extended endoscopic endonasal transtuberculum sellae approach: pearls and pitfalls for complications avoidance.

BACKGROUND: Using the expanded endoscopic transtuberculum approach (EETA), the nuances of this technique have rendered a safe, direct, and feasible ventral corridor for the treatment of extending suprasellar pathologies. This study illustrates surgical landmarks and strategies of paramount importance for complications avoidance. METHODS: This study presents the surgical anatomy and nuances of EETA, which can be used to remove large pituitary adenomas with suprasellar extension. Special references to cadaveric dissections highlight anatomical landmarks and surgical key points for complications avoidance. CONCLUSION: The EETA represents a versatile route for the treatment of sellar/suprasellar pathologies. Although, sizeable extrasellar pituitary tumors still pose a threat due to displacement/encasement of surrounding structures, necessitating accurate knowledge of correlative operative anatomy with traditional landmarks. Complete resection of extrasellar components is essential to avoid postoperative apoplexy.

Coronary artery bypass grafting in a patient with pituitary adenoma: can alertness prevent tragedy?

Pituitary apoplexy is a rare, life-threatening complication that may occur after coronary artery bypass graft surgery for patients with pituitary adenomas. The dynamics of cardiopulmonary bypass may contribute to a sudden expansion of silent pituitary adenomas and result in the compression of surrounding structures. A range of clinical features have been described, and the condition requires prompt diagnosis and treatment to prevent further complications. Herein, we present an uncomplicated case highlighting the importance of diagnosing pituitary apoplexy, ensuring high alertness to the condition, so as to prevent life-threatening tragedy due to missed diagnosis.

[Anesthesia for open reduction of ankle fracture in a patient with giant pituitary adenoma].

A few cases of the pituitary apoplexy have been reported after spinal anesthesia in patients with pituitary tumor. A patient with giant pituitary adenoma underwent open reduction of the ankle fracture. This 69-year-old man had no symptoms related to pituitary adenoma. Femoral and sciatic nerve blocks were chosen to avoid pituitary apoplexy, cerebral herniation and other complications related to spinal anesthesia. The surgery was successfully done without any complications and the patient was discharged uneventfully 25 days after surgery. When patient has a giant pituitary tumor, peripheral nerve block might be a good choice for anesthesia.

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.

Pituitary apoplexy: re-evaluation of risk factors for bleeding into pituitary adenomas and impact on outcome.

OBJECTIVE: To assess frequency, symptoms and outcome of pituitary apoplexy (PA) among pituitary adenoma patients, to gain better insight into risk factors for bleeding into pituitary adenoma and to estimate the sequelae of PA by means of a matched control group. METHOD: By reviewing charts of 574 patients with pituitary adenoma, we analysed incidence, symptoms and outcome of PA and potential risk factors for developing PA by means of a control group (patients with pituitary adenoma without PA). RESULTS: In total, 42 suffered from PA, all had macroadenomas; 30/217 male (14%) and 12/179 female (7%) macroadenoma patients, 32/194 patients with clinically non-functioning (16.5%) and 10/202 with clinically active (5.0%) macroadenoma were affected. Antithrombotic therapy predisposed patients to PA (P=0.026), diabetes mellitus and hypertension did not (P=1.00). Patients with PA and pituitary adenoma patients without PA had similar frequencies of hypopituitarism (45 vs 48%, P>0.05) and visual field defects (38 vs 55%, P>0.05), but ophthalmoplegia was significantly more common (76 vs 5%, P<0.001) in patients with PA. Nearly all patients were treated by surgery; most recovered from ophthalmoplegia, whereas visual function improved only moderately. Endocrine outcome was worse in patients with PA than in patients without PA. CONCLUSIONS: Male sex and characteristics of the adenoma itself (especially tumour size and tumour type) rather than patient's cardiovascular risk factors such as diabetes and hypertension seem to predispose to PA; antithrombotic therapy may also be important.

Pituitary apoplexy and CABG: should we change our strategy?

Patients with pituitary adenoma that had coronary artery bypass grafting with cardiopulmonary bypass had pituitary apoplexy develop with neurologic deficits and even death. Four patients with pituitary adenoma underwent coronary artery bypass grafting operations (3 patients had coronary artery bypass grafting on bypass, 1 of them with known pituitary adenoma. All of them had pituitary apoplexy develop with neurologic deficits). One patient with known pituitary adenoma who had a coronary artery bypass grafting operation off pump was neurologically intact. Our recommendation is to consider operating on patients with pituitary adenoma who need coronary artery bypass grafting operation off pump, and to prevent pituitary apoplexy that cardiopulmonary bypass may cause.

Pituitary apoplexy following cardiopulmonary bypass: considerations for a staged cardiac and neurosurgical procedure.

Pituitary apoplexy in a pre-existing pituitary tumor can result in serious and permanent neurologic deficits following cardiac surgical procedures. Several factors related to the altered physiology of cardiopulmonary bypass (CPB) contribute separately or in combination to the development of this syndrome. Over the last year we have encountered two such cases in whom emergency and prompt decompression of the adenoma resulted in an improvement of the initial clinical presentation but nevertheless persistence of residual and devastating ocular manifestations. In the literature six similar cases have been reported following cardiac surgical procedures, with similar outcomes. In this report we describe our experience and management of these two patients, and that published in the literature. We propose a possible role for a staged cardiac and neurosurgical procedure as a prophylactic measure in patients with known pituitary tumor. The role of cerebral monitoring is also discussed.