Abstract
INTRODUCTION: Pituitary apoplexy is a serious, emergent, and potentially dangerous condition of the pituitary in which the gland is affected by hemorrhage and/or ischemia typically in the setting of an underlying adenoma. In the present study, we investigate whether early versus delayed surgical intervention (in terms of three categories: before versus after 48 hours, 72 hours, and 7 days, respectively) resulted in any differences in vision outcomes for patients experiencing pituitary apoplexy. Furthermore, we compare the efficacy of surgical decompression versus conservative management as treatments for pituitary apoplexy. METHODS: Accordingly, we queried three databases in adherence to PRISMA guidelines. Quantitative meta‐analysis was performed according to the Mantel‐Haenszel method using Review Manager v5.4. P‐values < 0.05 were considered statistically significant. RESULTS: Twenty‐nine studies remained eligible for review of vision outcomes follow pituitary apoplexy, including 16 studies for timing of intervention and 15 studies comparing intervention modality. For the cohort of patients featured in the studies describing intervention timing, there was a total of 322 patients, of which 269 (83.6%) identified as male. Most patients (56%‐100%) presented with a visual deficit, and all patients underwent surgery – most commonly via an EEA approach – before or shortly after the 2‐day, 3‐day, or 7‐day cutoff points. 220 patients were included in the sub‐analysis comparing patients who underwent surgery short of 7 days to those receiving treatment after 7 days following the onset of pituitary apoplexy. Furthermore, 81 patients underwent surgical decompression of the sella prior to 48 hours, whereas 32 patients underwent surgical decompression after 48 hours. Rutkowski’s 2017 study was the only to assess outcomes prior to versus after intervention at the 72 hours timepoint. Almost all patients in this study exhibited improved vision post‐decompression, including 19/19 (100%) in the post‐72‐hour cohort. On meta‐analysis using the Mantel‐Haenszel method, there was a significant difference in favor of patients who underwent surgical decompression before 7 days as compared to after seven days (OR 5.88 [1.77, 19.60], I^2=0%, P=0.004). Furthermore, there was a total of 288 patients across the 15 studies comparing surgical versus conservative management of pituitary apoplexy – which proved equivocal in select patient upon meta‐analysis. CONCLUSION: In the present study, timing of surgical intervention for pituitary apoplexy was only found to be predictive of visual function recovery at the 7‐day timepoint, as has been reported by previous studies. Ultimately, this suggests that timeliness of intervention may have a significant impact on one of the most significant and potentially devastating implications of PA: vision loss. However, it does not appear that the optimal outcome is obtained by taking the PA patient to surgery “as soon as possible”. It is possible that timing of surgical intervention is a minimally critical or non‐critical factor in management of PA, and this should be taken into consideration when developing guidelines for treatment of PA. With regard to intervention modality, both surgery and conservative management appear to afford similar outcomes in most cases.