Overcoming Age Barriers: Endoscopic Endonasal Management of Pituitary Apoplexy in Elderly Patients - A Single Center Experience and Literature Review.

Abstract

Pituitary apoplexy (PA) is an acute hemorrhagic event within the pituitary gland, most often occurring in pre-existing adenomas. In elderly patients, management is challenging due to frailty, comorbidities, and variable presentation. This study aimed to evaluate clinical features, management, and outcomes of PA in the elderly. We performed a retrospective analysis of elderly patients (≥65 years) treated for PA at a tertiary referral center in Italy between 2011 and 2022. Data included demographics, clinical presentation, endocrine status, tumor characteristics, frailty (mFI-5), management, and outcomes. Twenty-eight patients (median age 71 years; 79% male) were included. Visual disturbances occurred in 61%, cranial nerve palsy in 71%, and hypopituitarism in 43%. Median mFI-5 was 1. Steroids were administered in 61% of cases. At follow-up, pituitary function did not recover in patients with preoperative hypopituitarism and worsened in 11%, with 10% developing panhypopituitarism. Postoperative hypothyroidism occurred in 54%. Higher frailty showed a non-significant trend toward worse cranial nerve and endocrine outcomes. Steroid therapy was significantly associated with visual improvement (OR 47.1, p = 0.04). PA in the elderly shows heterogeneous presentation and significant endocrine morbidity. Early diagnosis and prompt steroid therapy are crucial. The endoscopic endonasal approach is safe and effective, but careful patient selection remains essential.