Multiple Pituitary Apoplexy-Cavernous Sinus Invasion as Major Risk Factor for Recurrent Hemorrhage.
OBJECTIVE
Pituitary apoplexy is a rare but potentially life-threatening disorder that occurs in up to 10% of adenomas. Whereas risk factors for the initial hemorrhagic event are well described, there is minor knowledge on clinical symptomatic recurrent pituitary apoplexies.


METHODS
At the Medical University of Vienna, 76 patients were surgically treated for clinical symptomatic pituitary apoplexy between 1990 and 2017. Four patients (5.3%) suffered multiple pituitary apoplexies after initial surgery. In this retrospective study, neuroradiologic images, clinical data, and intraoperative findings were reviewed for potential risk factors of multiple apoplexies in pituitary adenomas.


RESULTS
Patients with multiple apoplexies had significantly higher Knosp grading on preoperative imaging (median grade 4), and more frequently observed cavernous sinus invasion intraoperatively (P = 0.01). Consequently, all cases with multiple pituitary apoplexies remained with residual adenoma postoperatively. In cases of residual tumor within the cavernous sinus, recurrent apoplexy occurred in 23.5% of patients. A tumor recurrence/residual was resected significantly earlier in patients with single apoplexy (median 2.2 years) than in patients with multiple apoplexies (median 5.4 years; P = 0.05). Multiple pituitary apoplexies caused significantly greater rates of ophthalmoplegia (75% vs. 14.1%; P = 0.01) and long-term hormone-replacement therapy was necessary in all cases.


CONCLUSIONS
Cavernous sinus invasion and subtotal resection are high risk factors for multiple apoplexies in pituitary adenomas. Early treatment is recommended for residual tumor in the cavernous sinus to minimize the risk of recurrent apoplexy with subsequent worse clinical outcome.
['Hosmann|Arthur|A|', 'Micko|Alexander|A|', 'Frischer|Josa M|JM|', 'Roetzer|Thomas|T|', 'Vila|Greisa|G|', 'Wolfsberger|Stefan|S|', 'Knosp|Engelbert|E|']
D000236:Adenoma D000328:Adult D000368:Aged D002426:Cavernous Sinus D005260:Female D006470:Hemorrhage D006801:Humans D008297:Male D008875:Middle Aged D019635:Neurosurgical Procedures D010899:Pituitary Apoplexy D010911:Pituitary Neoplasms D012008:Recurrence D012307:Risk Factors D016896:Treatment Outcome
Pituitary apoplexy Pituitary adenoma Cavernous sinus Transsphenoidal