Singh Tarun D, Valizadeh Navid, Meyer Fredric B, Atkinson John L D, Erickson Dana, Rabinstein Alejandro A
Departments of 1Neurology.
2Neurosurgery, and.
J Neurosurg. 2015 Jun;122(6):1450-7. doi: 10.3171/2014.10.JNS141204. Epub 2015 Apr 10.
This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes.
The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale).
Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15-91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3-10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups.
The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.
本研究旨在分析垂体卒中患者的诱发因素、临床表现、治疗管理及临床恢复情况，重点关注长期视觉、内分泌及功能结局。
作者对1992年至2013年在梅奥诊所接受治疗的连续病例进行了回顾性分析。仅当患者满足以下条件时才纳入研究：1）在垂体腺瘤存在的情况下突然出现严重头痛或视觉障碍；2）垂体肿块的影像学或手术确诊。分析的主要终点为视觉（眼球运动、视野和视力）、内分泌及功能结局（使用改良Rankin量表）。
共确定87例患者（57例男性，30例女性，平均年龄50.9岁，范围15 - 91岁）。22例患者（25.3%）有已知的垂体腺瘤。高血压是最常见的相关因素（39%）。头痛是最常见的首发症状（89.7%），其次是视觉异常（47.1%）。39%的患者存在颅神经麻痹，34.1%的患者存在视野缺损。MRI检测到89%的患者有出血，而CT扫描检测到42%。61例患者（70.1%）在急性住院期间接受了手术（垂体卒中后中位时间5天，四分位间距3 - 10天），8例（9.2%）进行了延迟手术，18例（20.7%）接受了保守治疗。组织病理学检查显示，18例（30%）为单纯坏死性腺瘤，4例（6.7%）为单纯出血性腺瘤，6例（10%）为两者皆有的腺瘤。4例患者在住院期间死亡。平均随访时间为44.2±43.8个月。所有幸存者均为独立个体，在最后一次随访时眼球运动和视野完全恢复或有显著改善。许多患者需要长期使用左甲状腺素（62.7%）和皮质醇（60%）进行激素替代治疗。23%的手术患者在3个月时需要每日使用去氨加压素（而药物治疗患者均无需使用），且随着时间推移这一需求略有下降。7例患者（8.6%）出现垂体腺瘤复发。各治疗组在任何结局指标上均无统计学显著差异。
大多数垂体卒中患者的结局良好。部分患者可进行保守治疗，早期手术治疗的严重神经眼科功能缺损患者可实现良好恢复。
