Largest case series to date.....Probably still worth to try RT.....

Journal of Veterinary Internal Medicine, 2023

Christian W. Woelfel, Christopher L. Mariani, Michael W. Nolan, Erin K. Keenihan, Sophia P. Topulos, Peter J. Early, Karen R. Muñana, Sarah E. Musulin, Natasha J. Olby

Background
Pituitary apoplexy is an acute neurological syndrome resulting from hemorrhage or infarction within the pituitary gland. While well-documented in humans, the condition remains poorly described in veterinary medicine. Previous case reports and small case series suggest that affected dogs can present with acute neurological deficits, altered mentation, and signs of endocrine dysfunction. This study aimed to characterize the clinical presentation, MRI findings, treatment approaches, and outcomes of dogs diagnosed with pituitary apoplexy.

Methods
Study Design: Retrospective case series

Subjects: 26 client-owned dogs diagnosed with pituitary apoplexy based on MRI or histopathology

Inclusion Criteria:
-Acute onset of neurological dysfunction (e.g., seizures, altered consciousness, circling)
-MRI or postmortem evidence of a pituitary mass with hemorrhage or infarction

Data Collected:
-Clinical history, examination findings, laboratory results, MRI characteristics
-Treatments, including medical management and radiation therapy
-Survival outcomes

Results
Clinical Signs:
-Altered mentation (62%) and gastrointestinal signs (54%) were common presenting complaints.
-Gait or posture abnormalities (85%), cranial neuropathies (65%), and hyperthermia (31%) were frequently noted.
-38% of dogs did not have a preexisting endocrinopathy.

MRI Findings:
-Most cases exhibited T1-weighted hypo- to isointensity in the hemorrhagic region (84%).
-Peripheral enhancement of the pituitary mass was observed in 60% of cases.
-Brain herniation (56%) and obstructive hydrocephalus (52%) were frequent complications.

Treatment and Outcomes:
-15 of 26 dogs (58%) survived to hospital discharge.
-Among survivors, those treated with medical management alone had a median survival of 143 days (range: 7–641 days).
-Dogs receiving both medical therapy and radiation treatment had significantly longer survival (median: 973 days; range: 41–1719 days).

Limitations
-Retrospective design with variable diagnostic workups and treatment approaches.
-Selection bias may exist, as dogs chosen for radiation therapy may have had better prognostic factors.
-Lack of standardized endocrine testing limits the ability to fully assess hormonal dysfunction.
-Only two dogs had histopathological confirmation, relying primarily on MRI diagnosis.

Conclusions
Pituitary apoplexy should be suspected in dogs with acute neurological signs and pituitary masses on MRI.
Many affected dogs lack preexisting endocrinopathies, making endocrine dysfunction an inconsistent diagnostic feature.
MRI is essential for diagnosis, with hemorrhagic pituitary masses frequently causing secondary hydrocephalus and brain herniation.
Dogs that survive to hospital discharge can have favorable long-term outcomes, particularly with radiation therapy.
Future studies should explore standardized diagnostic protocols and prospective treatment strategies to optimize management.

Magnetic resonance imaging of pituitary apoplexy in the same dog. (A) Transverse susceptibility-weighted imaging (SWI) reveals a large suprasellar blooming artifact (marked with white asterisk). (B) Transverse T2-weighted (T2W) image revealing an ovoid suprasellar mass which is heterogeneously T2 hypointense with internal T2 hyperintense foci relative to surrounding gray matter. Obstructive hydrocephalus of the left lateral ventricle is marked with the black arrow, with deviation of the septum pellucidum (black arrowhead), consistent with a falcine shift. (C) Transverse T1-weighted (T1W) image heterogeneously T1 hypointense with internal T1 hyperintense foci relative to surrounding gray matter. (D-F) Respectively, transverse, sagittal, and dorsal T1W images after contrast administration, showing strong contrast-enhancement with some areas of ring-enhancement (white arrows). There is flattening of the rostral cerebellum and compression of the rostral colliculi, consistent with transtentorial herniation.

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