Early surgery is associated with improved postoperative visual outcomes in apoplectic pituitary neuroendocrine tumors with acute visual deterioration

Background Pituitary apoplexy is a neurosurgical emergency that often manifests visual deterioration and cranial nerve palsies, presenting a need for urgent surgical decompression. However, the timing of surgery remains controversial, and the impact of perioperative characteristics of patients with apoplexy on visual recovery following surgery remains nebulous. Methods We retrospectively analyzed all cases of pituitary apoplexy with acute visual deterioration operated between 2013 and 2023, recording details of clinical presentation, surgery, and the postoperative period. Visual acuity (VA) and visual field defects at presentation were recorded, as was their evolution following surgery. Perioperative characteristics of patients were compared among cases where VA improved and those that did not. Results The cohort comprised 55 patients, 29 males and 26 females. VA was negative for perception of light (PL-) in 13 cases. Forty-four patients (80%) underwent endoscopic transsphenoidal surgery, 4 patients (7.3%) underwent transcranial surgery, and 6 patients (10.9%) underwent microscopic transsphenoidal surgery. VA improved in 39 patients (75%), while significant improvement in VA occurred in 26 of 41 patients (63.4%). Multivariate analysis revealed that PL- vision, visual deterioration > 168 h, and cranial nerve palsy predicted non-improvement of VA. Conclusions Visual deterioration is the most frequent presentation of pituitary apoplexy. Following surgical decompression, improvement in VA occurs in most cases, with significant improvement in more than half of cases. Improvement in VA is superior in patients operated within 96 h to a week of onset of visual deterioration, but not earlier, and less frequently occurs in patients who present with blindness (46.2%).