Conservative Versus Surgical Decompression for Pituitary Apoplexy
Pituitary haemorrhage has been recognised since 1898, with the term “pituitary apoplexy” being coined in 1950. With developments in transsphenoidal surgical techniques and the advent of corticosteroids over the last 100 years, the landscape of treatment h
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Conservative Versus Surgical Decompression for Pituitary Apoplexy Christopher Harrold and Harpal Randeva
Contents
2.1
2.1
Introduction ................................................
2.2
A Brief History of Apoplexy and Pituitary Surgery ................................
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Surgical Versus Conservative Intervention ................................................
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2.4
Sooner or Later? ........................................
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2.5
Evidence-Based Guidance .........................
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References .................................................................
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2.3
C. Harrold, BM, MRCP H. Randeva, FRCP, PhD (*) Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, Warwickshire CV2 2DX, UK e-mail: [email protected]; [email protected]
Introduction
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Pituitary apoplexy is a rare condition resulting from haemorrhage or infarction of the pituitary gland and presenting with the classical clinical syndrome of headache, vomiting, neuroophthalmic dysfunction (abnormal acuity, field defect or ophthalmoplegia) and alterations in conscious level (Randeva et al. 1999). It is often seen complicating a known pituitary adenoma though, in 80 % of cases, it is the first presentation of a previously undiagnosed tumour. The incidence of apoplexy in patients with a pituitary adenoma is reported as between 2 and 7 % depending on diagnostic criteria (Rajasekaran et al. 2010). Haemorrhage of the pituitary without symptoms, or subclinical apoplexy, is more common and may be as high as 25 % (Ayuk et al. 2004). Much of the clinical syndrome is the result of gland expansion, with subsequent compression of structures near to the pituitary gland. Headache is the presenting symptom in nearly 100 % of patients (Randeva et al. 1999; Ayuk et al. 2004; Sibal et al. 2004), but compression of the optic chiasm and involvement of the cavernous sinus result in visual defects and ophthalmoplegia, respectively. The incidence of these symptoms varies between case series, but up to 80–90 % can have visual symptoms (acuity and field defects combined) (Randeva et al. 1999; Ayuk et al. 2004; Sibal et al. 2004; Gruber et al. 2006) and 40–70 % have ophthalmoplegia (typically including cranial nerve III) (Sibal et al. 2004; Rajasekaran et al. 2010).
M. Turgut et al. (eds.), Pituitary Apoplexy, DOI 10.1007/978-3-642-38508-7_2, © Springer-Verlag Berlin Heidelberg 2014
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C. Harrold and H. Randeva
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Due to the compressive nature of these symptoms, it seems logical (if simplistic) to presume that surgical decompression of the pituitary would alleviate symptoms. As with most things in medicine, things are not so straight forward. The role and timing of surgery is a greatly contentious subject and the focus of many studies, reviews and (more recently) guidelines. Most conclude that the evidence is of low quality, being primarily case series of a small number of patients, with substantial variation in
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