title: Pituitary apoplexy: large surgical series with grading system.
abstract: BACKGROUND
  Pituitary apoplexy is an infrequent occurrence that can require timely treatment. The term "pituitary apoplexy" as used in the literature describes a heterogeneous spectrum. There is controversy about which subsets require urgent as opposed to elective surgical treatment or even medical treatment alone. We present a retrospective series of 109 consecutive cases of pituitary apoplexy from a single institution from 1992-2012 and develop a comprehensive classification system to analyze outcome.
  
  
  METHODS
  Surgical and endocrine consult databases were reviewed to analyze patterns of presentation, imaging, treatment, and outcomes.
  
  
  RESULTS
  Most of the patients in this series presented clinically with "classic" pituitary apoplexy (97%), had magnetic resonance imaging for evaluation (99%), underwent transsphenoidal surgery as their primary treatment (93%), and were found to have pituitary adenomas on histopathology (90%). We categorized patients into 5 grades based on clinical presentation. Tumor volume, cavernous sinus involvement, suprasellar extension, and need for ongoing endocrine replacement correlated with grade. Long-term endocrine replacement at follow-up was required in 62%-68% of patients with a higher grade compared with 0-23% of patients with a lower grade. Higher grade patients tended to undergo earlier surgery after symptom onset. Symptoms resolved or improved with treatment in 92%-100% of patients across all grades with good general outcomes for visual deficits and ocular motility problems, validating management decisions overall.
  
  
  CONCLUSIONS
  We offer a simple yet comprehensive grading system to classify the clinical spectrum of pituitary apoplexy, which has implications for management, outcomes, and categorization for future studies.
authors.affiliation: Neurosurgery and Neuroendoscopy Departments, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
authors.forename: David H
authors.initials: DH
authors.lastname: Jho
authors.affiliation: Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Beverly M K
authors.initials: BM
authors.lastname: Biller
authors.affiliation: Neurosurgery Service, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Pankaj K
authors.initials: PK
authors.lastname: Agarwalla
authors.affiliation: Neurosurgery Service, Massachusetts General Hospital, Boston, Massachusetts, USA. Electronic address: bswearingen@partners.org.
authors.forename: Brooke
authors.initials: B
authors.lastname: Swearingen
mesh_terms: D000236:Adenoma / Q000145:classification / Q000473:pathology / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D017558:Elective Surgical Procedures / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D017567:Karnofsky Performance Status; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D019635:Neurosurgical Procedures / Q000379:methods*; D010899:Pituitary Apoplexy / Q000145:classification / Q000473:pathology / Q000601:surgery; D010911:Pituitary Neoplasms / Q000145:classification / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies; D013100:Sphenoid Bone / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
keywords: Hemorrhagic macroadenoma; Pituitary adenoma; Pituitary apoplexy; Transsphenoidal surgery