Pituitary apoplexy in the magnetic resonance imaging era: clinical significance of sphenoid sinus mucosal thickening

Object. The authors report their experience with pituitary apoplexy and evaluate the clinical significance of sphenoid sinus mucosal thickening found on magnetic resonance (MR) imaging. Methods. The cases of 28 patients (19 males and nine females) with pituitary apoplexy were reviewed retrospectively. The mean age of the patients was 50 years (range 16-83 years), and the mean follow-up duration was 32 months (range 1-104 months). Admission MR imaging demonstrated hemorrhage or infarction in a pituitary tumor in each patient. A clinical grading scale for apoplexy was devised as follows: Grade I, presence of acute headache and/or endocrine abnormality (12 patients); Grade II, presence of the foregoing symptoms as well as cranial nerve deficit (visual and/or oculomotor; 15 patients); and Grade III, presence of all of these symptoms and a decreased level of consciousness (one patient). Twenty-five patients (89%) underwent early transsphenoidal resection within 9 days (80% within 72 hours) of diagnosis. Headaches and oculomotor paresis resolved completely in 100%, visual function resolved completely in 44% and partially in 56%, and hypopituitarism was reversed in 25%. Twelve patients (43%) required long-term hormone replacement therapy. Two of the three patients who were treated conservatively had prolactin-secreting adenomas, which were treated with dopamine agonist therapy. Thickening of sphenoid sinus mucosa was present in 22 patients (79%). Fifty percent of patients in Grade I and 100% of those in Grades II and III, including all those with persistent hypopituitarism and residual visual deficits, had thickened sphenoid sinus mucosa on MR imaging. Patients with thickened sphenoid sinus mucosa had larger tumors that compressed the optic chiasm or cavernous sinus, and these individuals also had a higher rate of cranial nerve deficits at presentation than those without mucosal thickening (73% compared with 0%). Patients with thickened mucosa had a higher rate of hypopituitarism and subsequent long-term hormone replacement therapy than those without thickened mucosa (55% compared with 17%). Conclusions. Thickened sphenoid sinus mucosa may correlate with higher grades of pituitary apoplexy and worse neurological and endocrinological outcomes.