Hemorrhagic and Non-hemorrhagic Pituitary Apoplexy: Clinical Analysis.

Objective: The diagnosis of hemorrhagic versus non-hemorrhagic pituitary apoplexy can be difficult as both the clinical presentation and radiographic appearance can be variable. Early identification and treatment of these patients is essential to prevent poor outcomes. This study identifies clinical characteristics of hemorrhagic and non-hemorrhagic pituitary apoplexy. Methods: 311 consecutive patients admitted with pituitary tumors were reviewed for clinical and radiographic evidence of pituitary apoplexy. Patient demographics, comorbidities, clinical presentation, tumor characteristics, surgical therapy, complications, and outcomes were analyzed for both groups. A cohort statistical analysis was performed using Chi square, Fisher exact test, and t-test. Results: Patients with hemorrhagic (n = 23, 57.5%) and non-hemorrhagic (n=17, 42.5%) pituitary apoplexy were similar except the hemorrhagic cohort was older (mean age 51.5 versus 40.6, p=0.03) and more hypertensive (n=16, p=0.03). Thirty-seven patients underwent surgical decompression for their pituitary apoplexy symptoms either through transcranial or endoscopic approach. There was no statistically significant difference between hemorrhagic (n=16, 43.2% endoscopic; n=4, 10.8% transcranial) and non-hemorrhagic (n=16, 43.2%, endoscopic; n=1, 2.7%, transcranial; p=0.22) apoplexy cohorts. Risks of post-operative complications were similar in both hemorrhagic (n=5: RR 1.13, 95% CI 0.59-2.1) and non-hemorrhagic cohorts (n=3: RR 0.84, 95% CI 0.31-2.3). Achievement of a good functional outcome as measured by modified Rankin scale better than 4 at last follow-up was not statistically different among cohorts (p = 0.74). Conclusions: Hemorrhagic and non-hemorrhagic pituitary apoplexy are similar clinical entities that require prompt surgical decompression of the optic apparatus and medical therapy aimed at treating acute adrenal insufficiency.

Hemorrhagic and Non-hemorrhagic Pituitary Apoplexy: Imaging Cohort Analysis.

Introduction: Patients suffering from pituitary apoplexy present with variable clinical symptoms and imaging findings. Imaging findings may differ between hemorrhagic and non-hemorrhagic apoplexy. Our study aimed to better define imaging findings in both hemorrhagic and non-hemorrhagic apoplexy and is the first cohort study to report a comparison of imaging findings in these two groups. Materials and Methods: 311 consecutive patients admitted with pituitary tumors were retrospectively reviewed for clinical and imaging evidence of pituitary apoplexy. 37 operative cases were included in this cohort. A cohort statistical analysis was performed between the two groups using Chi Square, Fisher exact test, logistic regression, ANOVA, and t-test. Results: Imaging analysis demonstrated a significant difference in the hemorrhagic cohort’s Computed Tomography (CT) finding of hyperdensity within the sella (n = 17, 48.5%, p = 0.02) and sellar Hounsfield units (mean 45 versus 38.1, p=0.05). Sellar HU were higher in the hemorrhagic pituitary apoplexy cohort. Similarly, hyperintensity on magnetic resonance imaging was more indicative of patients with hemorrhagic apoplexy according to T1 (p = 0.004), T2 (p = 0.004), and FLAIR (p = 0.04) imaging sequences. No difference was found in patterns of enhancement (p = 0.69) or restriction based on diffusion-weighted imaging (p = 0.54). Gradient echo (n=4) and susceptibility weighted imaging (n=1), while not performed in all patients, demonstrated hemorrhage within a pituitary adenoma in patients where this technique was used. Conclusions: Our study did not demonstrate a unifying imaging feature in non-hemorrhagic apoplexy cases. Hemorrhagic apoplexy was more likely associated with hyperdensity on CT and hyperintensity on T1, T2 and FLAIR MRI sequences. Because of the variation of imaging findings in hemorrhagic and especially non-hemorrhagic apoplexy, imaging appearance inconsistent with hemorrhage should not be used to exclude the diagnosis of apoplexy.

Patient Experience Following Kyphoplasty: Safety, Efficacy, and Patient Satisfaction.

Aims: Kyphoplasty is a minimally invasive treatment used to reduce pain, restore vertebral height and improve mobility in patients with painful spinal VCF. Pain from vertebral compression fractures (VCF) comprises an important health issue with significant social and economic impact, particularly in elderly patients with osteoporosis where treatment options are limited. We assessed outcomes in patients with VCF who failed conservative management and underwent kyphoplasty. Study Design: Prospective and retrospective case series. Place and Duration of Study: At a single neurosurgical practice February 2003 and September 2012. Methodology: A total of 203 patients with 288 treated vertebral body fractures treated with kyphoplasty were enrolled. The Visual Analog Scale (VAS) was used to prospectively measure back pain before and after surgery. Pre and post operative disability and quality of life were retrospectively measured with the Roland Morris Disability Index (RMDI) and EuroQol 5-Domain scale (EQ5D), respectively, via patient survey. Pre and post-operative narcotic analgesic usage and incidence of subsequent fractures were recorded. Results: There was a statistically significant improvement (P < .001) in each of the assessed measures following surgery. The post-operative rate of narcotic use was reduced from 63% to 17%. Eight patients (4.2%) developed and underwent repair of an adjacent fracture with a mean time between surgeries of 461 days. Conclusion: Following kyphoplasty, patients experienced significant, rapid, and sustained reduction of back pain, improved quality of life, and reduced disability with a low complication rate. Timely repair of VCF is indicated, not only to prevent complications associated with prolonged inactivity but also for effective treatment of severe pain in the acute setting.