Comparing Neuroendocrine Recovery Between Surgical and Conservative Management in Pituitary Apoplexy Patients: A Propensity Score-Matched Analysis

Comparing Neuroendocrine Recovery Between Surgical and Conservative Management in Pituitary Apoplexy Patients: A Propensity Score-Matched Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparing Neuroendocrine Recovery Between Surgical and Conservative Management in Pituitary Apoplexy Patients: A Propensity Score-Matched Analysis Krittithee Saktiwarawat, Thara Tunthanathip, Thakul Oearsakul, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4160609/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Pituitary apoplexy is a rare and potentially life-threatening clinical syndrome. Patients may present with severe neuro-ophthalmologic or endocrine symptoms. Current evidence is unclear whether conservative or surgical management leads to the best neuroendocrine outcomes. This study aimed to compare neuroendocrine outcomes between surgical and conservative treatments in a single center. Methods: Cases of patients with pituitary apoplexy who received transsphenoidal surgery or conservative management in Songklanagarind Hospital between January 1, 2005 and December 31, 2022 were retrospectively reviewed. A propensity score matching method was used to adjust bias from treatment selection (surgery or conservative treatment). Differences in visual acuity, visual field, cranial nerve, and endocrine outcomes between the surgical and conservative treatment groups were analyzed using logistic regression analysis. Results: This study included 127 patients, with 98 and 29 patients in the surgical and the conservative treatment group, respectively. The optimal matching method was used for propensity score matching. Compared to the conservative group, the surgically treated patients had a significantly higher rate of visual field recovery (odds ratio (OR): 12.89, P = 0.007). However, there were no statistical differences in the recovery rate of preoperative visual acuity, cranial nerve, and endocrine deficits between the groups. Conclusions: Transsphenoidal surgery was associated with a higher rate of visual field recovery when compared to the conservative treatment for pituitary apoplexy patients. Careful selection of appropriate treatment based on the patient’s presentation and neuroendocrine status will result in the best outcomes while avoiding unnecessary surgical intervention. Conservative treatment Cranial nerve recovery Endocrine recovery Pituitary apoplexy Transsphenoidal surgery Visual recovery Figures Figure 1 INTRODUCTION Pituitary apoplexy is a rare clinical syndrome resulting from rapid expansion within the sellar turcica due to either hemorrhage or infarction [ 4 ]. This clinical syndrome is characterized by headache, visual deficits, ophthalmoplegia, and alteration in mental status [ 2 ]. Depending on the patient’s symptoms and neuro-ophthalmologic and endocrine status, surgical or conservative treatment is chosen. Currently, there is no clear surgical indication for these patients. The outcomes of surgical and conservative treatment strategies for patients with pituitary apoplexy have been reported in several studies [ 1 , 3 , 5 , 7 , 10 – 12 , 14 ]. However, there is no clear evidence whether surgical or conservative treatment will provide the best visual, cranial nerve (CN), and hormonal outcomes. The interpretation of previous results is limited by small study size, difference in patient characteristics between the two treatment groups, and bias from treatment selection. This study aimed to compare neuroendocrine recovery outcomes between surgically and conservatively treated patients by using the propensity score matching method to adjust for bias from treatment selection. Four major outcomes were evaluated in this study: visual acuity (VA), visual field (VF), CN, and endocrine recovery from preoperative deficits. MATERIALS AND METHODS Study Design and Patients This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Prince of Songkla University (17 February 2023/No. REC.66-038-10-4). We retrospectively reviewed the records of consecutive patients with pituitary apoplexy who received conservative treatment or underwent transsphenoidal surgery for tumor removal at Songklanagarind Hospital, a tertiary care center and medical school in southern Thailand, between 1st January 2005 and 31st December 2022. Participants were recruited from our database of patients with pituitary tumors who received treatment in Songklanagarind Hospital. Patients who had radiographic evidence of pituitary apoplexy together with neuro-endocrine symptoms (VA and/or VF defect, CN III-VI palsy, or hypopituitarism) were included in this study. Up until August 2014, a microsurgical approach was used for transsphenoidal surgery in our hospital. After that date, we only used an endoscopic approach owing to the advantage of wider operative exposure offered by this technique. Each patient was evaluated and treated by the endocrinologist, ophthalmologist, and neurosurgeon. All transsphenoidal operations were performed by either or both authors (T.O. and C.T.). Intraoperative computed tomography-guided neuronavigation was used in all endoscopic endonasal operations. Measurements Medical records were reviewed and data regarding patient demographics, comorbidities, preoperative use of antithrombotic medication, clinical presentation, VA, VF, CN III-VI deficits, pituitary hormonal status before and after treatment, imaging studies, adjuvant treatment, complications, and duration of follow-up were collected and analyzed. Recovery of VA after treatment was defined as a logMAR improvement of at least 0.1 between pre- and post-treatment status measured at the last follow-up evaluation. Recovery of VF after treatment was defined as any improvement of visual field defects following treatment. Recovery from a CN deficit and hypopituitarism (hypoadrenalism, hypothyroidism, or hypogonadism) was evaluated at the last follow-up evaluation (at least 6 months after surgery) and documented. The superior, lateral, and inferior extensions of the lesion were evaluated using the Knosp and Wilson–Hardy classification systems [ 9 , 16 , 17 ]. Lateral extensions were evaluated using the Knosp classification system and then classified into two groups: grades 0–2 and 3–4. Superior extension was evaluated using the Wilson–Hardy suprasellar extension stage and then classified into two groups: stages 0–A and stages B–C. Inferior extension was evaluated using the Wilson–Hardy invasion grading system and then classified into no (grades 1–2) or present (grades 3–4) sphenoid extension. The height of any suprasellar extensions was measured in millimeters to quantify the suprasellar extension of the lesion. An imaginary line was drawn from the tuberculum sellae to the dorsum sellae, and the suprasellar extension was measured by using a perpendicular line from the imaginary line to the superior part of the lesion [ 13 ]. The visual impairment score (VIS) developed by Fahlbusch and Schott [ 6 ] was used to quantify the amount of visual impairment prior to treatment. The degrees of VA and VF defects in each patient were translated into scores using specific tables. Afterward, the sum of the VA and VF defect scores in each patient was calculated, providing a VIS ranging from 0 (best) to 100 (worst) [ 6 ]. Statistical Analysis Sex, age, comorbid conditions (diabetes, hypertension, underlying bleeding tendency), current antithrombotic medication, clinical presentation, pre-treatment VA, VF, CN, and pituitary hormonal status, imaging studies, and adjuvant treatments were analyzed and compared between surgically and conservatively treated patients. Logistic regression analysis was used to identify factors associated with treatment selection (surgical or conservative treatment). Then, the propensity score was calculated based on these factors. The patient populations of the two groups were matched using various propensity score matching techniques. The matching technique that could optimally balance the covariates was chosen for comparing the outcomes between surgical and conservative treatment. The population after matching was then further analyzed. Baseline characteristics of patients were analyzed and compared between the two treatment groups. The neuroendocrine outcomes (VA, VF, CN, and pituitary hormone recovery) were compared between the groups. Logistic regression analysis was used to evaluate the association between treatment approach (surgery or conservative) and each neuroendocrine outcome. The multivariate analysis model with the lowest Akaike information criterion value was chosen to identify the factors associated with each neuroendocrine outcome. The statistical analyses were performed with the R Program version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). A P value < 0.05 was considered statistically significant. RESULTS Baseline Characteristics before Matching The study included 127 patients. Ninety-eight patients underwent transsphenoidal surgery, while 29 patients received conservative treatment. Table 1 shows the baseline characteristics of the patients before propensity score matching. Thirteen (45%) and 47 (48%) patients in the conservative and the surgery group, respectively, were male. The mean age of the patients in the conservative group was significantly older than that in the surgery group (58.7 vs. 51.6 years, P = 0.019). There were no differences in underlying comorbidities between the groups. Seven (24%) and 10 (10%) patients in the conservative and the surgery group, respectively, had been using antithrombotic medication before the onset of pituitary apoplexy. Patients in the conservative group presented with headache more frequently (P < 0.001), while patients in the surgery group had a higher incidence of preoperative VF deficit on both sides (P = 0.005). The lower incidence of VF deficit (compared to VA deficit) might have resulted from an inability to accurately measure VF in patients with poor VA. Preoperative VIS and cranial nerve deficits showed no significant differences between the two groups. Patients in the surgery group had the higher incidence of preoperative hypothyroidism (52% vs. 28%, P = 0.035) and hypogonadism (63% vs. 31%, P = 0.006). The preoperative median serum prolactin level was significantly higher in the surgery group (22.4 vs. 10 ng/mL, P = 0.019). The median tumor size was larger in the surgery group (33.5 vs 18.1 mm, P < 0.001). Table 1 Baseline Characteristics of Patients Before Propensity Score Matching Characteristic Conservative (n = 29) Surgery (n = 98) P value Sex, male 13 (45) 47 (48) 0.932 Age, years, mean ± SD 58.7 ± 17 51.6 ± 13.1 0.019 Comorbidity Diabetes mellitus 2 (7) 15 (15) 0.356 Hypertension 7 (24) 29 (30) 0.735 Antithrombotic medication 7 (24) 10 (10) 0.066 Clinical presentation Headache 26 (90) 50 (51) < 0.001 Visual impairment 24 (83) 83 (87) 0.763 Cranial nerve III-VI palsy 2 (7) 18 (18) 0.16 Alteration of consciousness 1 (3) 8 (8) 0.683 Preoperative right VA deficit 23 (82) 83 (88) 0.523 Preoperative left VA deficit 23 (82) 86 (91) 0.306 Preoperative right VF deficit 15 (54) 78 (82) 0.005 Preoperative left VF deficit 15 (54) 78 (82) 0.005 Visual Impairment Score, median (IQR) 33 (8, 59.5) 53 (26, 92) 0.074 Preoperative cranial nerve III deficit 4 (14) 13 (13) 1 Preoperative cranial nerve IV deficit 0 5 (5) 0.589 Preoperative cranial nerve V deficit 1 (3) 5 (5) 1 Preoperative cranial nerve VI deficit 0 10 (10) 0.115 Preoperative hormonal deficit Hypoadrenalism 11 (38) 56 (59) 0.076 Hypothyroidism 8 (28) 51 (52) 0.035 Hypogonadism 9 (31) 57 (63) 0.006 Preoperative serum prolactin level, ng/mL, median (IQR) 10 (5, 20.8) 22.4 (9.2, 54.4) 0.019 Tumor size, mm, median (IQR) 18.1 (13, 21) 33.5 (25, 39.8) < 0.001 Knosp classification < 0.001 0–2 27 (96) 59 (61) 3–4 1 (4) 38 (39) Wilson–Hardy classification for suprasellar extension < 0.001 0–A 27 (96) 51 (53) B–C 1 (4) 46 (47) Wilson–Hardy classification for invasion 0.014 1–2 27 (96) 70 (72) 3–4 1 (4) 27 (28) Suprasellar extension of lesion, mm, median (IQR) 3.9 (0, 5.6) 16.7 (11.3, 22.4) < 0.001 Tumor recurrence or enlargement 1 (3) 13 (13) 0.187 Adjuvant treatments < .001 None 29 (100) 61 (62) Reoperation for tumor removal 0 4 (4) Radiation 0 26 (27) Combined adjuvant treatments 0 7 (7) Duration of follow-up, months, median (IQR) 28 (14.5, 51) 42 (19.5, 76.5) 0.231 Data are presented as n (%) unless indicated otherwise. IQR, interquartile range; SD, standard deviation; VA, visual acuity; VF, visual field. Classification of the patients using the Knosp, Wilson–Hardy suprasellar extension, and Wilson-Hardy invasion classification systems showed significantly higher grades in the surgery group than in the conservative group (P < 0.001, P < 0.001, and P = 0.014, respectively). The median suprasellar extension of the lesion was higher in the surgery group (16.7 vs. 3.9 mm, P < 0.001). The incidence of tumor recurrence or enlargement following treatment showed no difference between the groups. Patients in the surgery group received adjuvant treatments more often than those in the conservative group (P < .001). Baseline Characteristics after Matching Logistic regression analysis was used to identify factors associated with surgical intervention in all patients. Then, these factors (headache symptom, VIS, Knosp classification grade, and suprasellar extension grade) were used to calculate the propensity score (Fig. 1 ). Subsequently, various propensity score-matching methods, including the nearest neighbor matching with the ratios 1:1 and 2:1, Caliper matching, optimal matching, optimal full matching, and Mahalanobis metric matching were used for matching the populations of both groups. The optimal matching technique was chosen as the optimal method to balance the covariates before further analysis. Table 2 shows the baseline characteristics of the patients after propensity score matching with the optimal matching technique. There were 28 patients in each group, and the mean age, headache symptom, preoperative VF deficit on both sides, median serum prolactin level, and imaging classification grade showed no significant differences between the groups after matching. However, patients in the surgery group still had a significantly higher incidence of preoperative hypothyroidism and hypogonadism, larger median tumor size, and higher suprasellar extension (P = 0.03, P = 0.011, P < 0.001, and P < 0.001, respectively). Table 2 Baseline Characteristics of Patients After Propensity Score Matching with Optimal Matching Technique Characteristic Conservative (n = 28) Surgery (n = 28) P value Sex, male 13 (46) 13 (46) 1 Age, years, mean ± SD 59 ± 17.2 51.1 ± 14.6 0.071 Comorbidity Diabetes mellitus 2 (7) 4 (14) 0.669 Hypertension 7 (25) 7 (25) 1 Antithrombotic medication 7 (25) 3 (11) 0.295 Clinical presentation Headache 25 (89) 22 (79) 0.469 Visual impairment 24 (86) 21 (75) 0.501 Cranial nerve III-VI palsy 2 (7) 6 (21) 0.252 Alteration of consciousness 0 1 (4) 1 Preoperative right VA deficit 23 (82) 25 (89) 0.705 Preoperative left VA deficit 23 (82) 24 (86) 1 Preoperative right VF deficit 15 (54) 19 (68) 0.412 Preoperative left VF deficit 15 (54) 18 (64) 0.587 Visual Impairment Score, median (IQR) 33 (8, 59.5) 36 (6.2, 64.8) 0.987 Preoperative cranial nerve III deficit 4 (14) 4 (14) 1 Preoperative cranial nerve IV deficit 0 2 (7) 0.491 Preoperative cranial nerve V deficit 1 (4) 1 (4) 1 Preoperative cranial nerve VI deficit 0 5 (18) 0.051 Preoperative hormonal deficit Hypoadrenalism 10 (36) 18 (64) 0.061 Hypothyroidism 7 (25) 16 (57) 0.03 Hypogonadism 8 (29) 15 (54) 0.011 Preoperative serum prolactin level, ng/mL, median (IQR) 10.5 (5, 21.1) 22.4 (6.6, 54) 0.359 Tumor size, mm, median (IQR) 18.5 (13, 21) 22.5 (20.8, 29) < 0.001 Knosp classification 0.352 0–2 27 (96) 24 (86) 3–4 1 (4) 4 (14) Wilson-Hardy classification for suprasellar extension 0.352 0–A 27 (96) 24 (86) B–C 1 (4) 4 (14) Wilson-Hardy classification for invasion 0.193 1–2 27 (96) 23 (82) 3–4 1 (4) 5 (18) Suprasellar extension of lesion, mm, median (IQR) 3.9 (0, 5.6) 9.8 (7.1, 14.8) < 0.001 Tumor recurrence or enlargement 1 (4) 6 (21) 0.101 Adjuvant treatments 0.002 None 28 (100) 19 (68) Reoperation for tumor removal 0 2 (7) Radiation 0 5 (18) Combined adjuvant treatments 0 2 (7) Duration of follow up, months, median (IQR) 30 (14, 54) 47.5 (31.5, 83.5) 0.152 Data are presented as n (%) unless indicated otherwise. IQR, interquartile range; SD, standard deviation; VA, visual acuity; VF, visual field. Neuroendocrine Outcomes Table 3 shows the neuroendocrine recovery after conservative and surgical treatments in patients who had preoperative deficits. VA recovery showed no significant difference between the surgery and conservative groups. Nevertheless, patients in the surgery group had significantly better VF recovery in at least one eye after treatment (85% vs. 50%, P = 0.034). Recovery of CN III palsy showed no difference between the groups. The incidences of preoperative CN IV, V, and VI palsy were too low to allow comparison of the outcomes between the groups. Recovery from hypoadrenalism, hypothyroidism, and hypogonadism showed no difference between the groups. Table 3 Neuroendocrine Recovery After Conservative and Surgical Treatment in Patients with Preoperative Deficits Outcome Conservative, N (%) Surgery, N (%) P value Right VA recovery 15 (65) 16 (64) 1 Left VA recovery 15 (65) 18 (78) 0.513 Recovery of VA in at least one eye 16 (70) 22 (85) 0.359 Right VF recovery 8 (50) 15 (83) 0.088 Left VF recovery 8 (50) 15 (79) 0.15 Recovery of VF in at least one eye 8 (50) 17 (85) 0.034 Recovery of CN III palsy 4 (100) 3 (75) 1 CN IV palsy - 2 (100) - CN V palsy 1 (100) 1 (100) - CN VI palsy - 4 (80) - Hypopituitarism Hypoadrenalism 1 (10) 3 (17) 1 Hypothyroidism 1 (14) 3 (19) 1 Hypogonadism 1 (13) 3 (21) 1 Data are presented as n (%). VA, visual acuity; VF, visual field; CN, cranial nerve. Factors Associated with Neuroendocrine Recovery Logistic regression analysis was used to identify factors associated with VA recovery in at least one eye after treatment. Table 4 shows the multivariate analysis of factors associated with recovery from preoperative VA deficits. Older age was significantly associated with no recovery from a preoperative VA deficit (P = 0.029). Surgery was not associated with better VA recovery (P = 0.529). Table 4 Multivariate Analysis of Factors Associated with Visual Acuity Recovery in One or Both Eyes After Treatment Factors aOR (95% CI) P (Wald Test) P (LR Test) Age 0.95 (0.9, 1) 0.05 0.029 Surgery vs. conservative treatment 1.62 (0.36, 7.31) 0.529 0.529 aOR, adjusted odds ratio; CI, confidence interval; LR, likelihood ratio. Table 5 shows the multivariate analysis of factors associated with recovery from a preoperative VF defect. Absence of underlying hypertension and surgical treatment were significantly associated with better VF recovery (P = 0.013 and P = 0.007, respectively). Table 5 Multivariate Analysis of Factors Associated with Visual Field Recovery in One or Both Eyes After Treatment Factors aOR (95% CI) P (Wald Test) P (LR Test) Hypertension 0.07 (0.01, 0.81) 0.033 0.013 Knosp classification grades 3–4 (vs. grades 0–2) 18946784.19 (0, Inf) 0.993 0.13 Surgery vs. conservative treatment 12.89 (1.37, 121.4) 0.025 0.007 aOR, adjusted odds ratio; CI, confidence interval; LR, likelihood ratio. Results from the logistic regression analysis showed that surgical treatment was not associated with better recovery from preoperative hypoadrenalism, hypothyroidism, and hypogonadism. Owing to the low incidences of preoperative CN III-VI deficits and the very high incidence of CN recovery following treatment, the association between surgical treatment and CN recovery outcome could not be analyzed. DISCUSSION Before propensity score matching, patients in the conservative group were older and presented more frequently with headache, while patients in the surgery group had a higher incidence of preoperative VF deficit, hypopituitarism, larger tumor size, and greater tumor extension in all directions. We used propensity score matching analysis to balance these covariates between the conservative and the surgery group. Following propensity score matching with the optimal matching method, the mean age, headache symptom, and preoperative VF deficit were not significantly different between the two groups. However, patients in the surgery group still had a significantly higher incidence of preoperative hypothyroidism and hypogonadism, larger median tumor size, and higher suprasellar extension. Therefore, we used a multivariate analysis to control the remaining possible confounding factors and evaluate the association between surgical (vs. conservative) treatment and neuroendocrine recovery. Our study found that compared with conservative treatment, surgical treatment was significantly associated with better improvement of preoperative visual field deficit in at least one eye. Nevertheless, surgical treatment was not associated with better recovery of VA, CN III, and hypopituitarism deficit. Previous studies found no significant differences in VA and VF recovery between surgically and conservatively treated patients [ 1 , 3 , 5 , 10 – 12 , 14 ]. A meta-analysis study by Goshtasbi et al. [ 8 ] also found no difference in visual outcomes between surgically and conservatively treated patients. However, a meta-analysis study by Tu et al. [ 15 ] found that surgically treated patients had a significantly higher rate of recovery of visual field (P < 0.05), while there was no significant difference in VA recovery between the surgical and the conservative group. In all of these studies [ 1 , 3 , 5 , 10 – 12 , 14 ], compared to the conservative treatment group, the patients in the surgery group had more severe visual symptoms. Furthermore, the tumor in the surgical group was larger and showed greater extension than that in the conservative treatment group [ 1 , 3 , 5 , 10 – 12 , 14 ]. This potential bias might interfere with outcomes comparison between the surgery and conservative groups. In our study, we used propensity score-matched analysis to balance the covariates and then used a multivariate analysis to assess the association between surgical (vs. conservative) treatment and various neuroendocrine outcomes. Our study found no difference in CN III recovery between the surgery and the conservative group. Most previous studies found no difference in CN recovery between the surgery and the conservative group [ 1 , 3 , 5 , 8 , 10 , 12 ]. A study by Shepard et al. [ 11 ] found better cranial neuropathy improvement in the conservatively managed patients (p < 0.01). On the contrary, a meta-analysis study by Tu et al. [ 15 ] found a significantly better recovery of ocular palsy in the surgically treated patients (P < 0.05). Recovery from hypoadrenalism, hypothyroidism, and hypogonadism showed no differences between the groups in this study. Likewise, studies by Giritharan et al. [ 7 ], Singh et al. [ 12 ], and Bujawansa et al. [ 3 ] found no differences in endocrine outcomes between the surgery and the conservative group. A meta-analysis by Goshtasbi et al. [ 8 ] and Tu et al. [ 15 ] also found no differences in improvements of endocrine dysfunction between surgically and conservatively treated patients. A study by Teixeira et al. [ 14 ] however found better endocrine outcomes in the surgical group (P = 0.027), while a study by Marx et al. [ 10 ] found more endocrine deficits at 1 year in the surgical group (p = 0.029). This study also found that older age and underlying hypertension were significantly associated with poor recovery from a preoperative VA and VF deficit, respectively. These findings were consistent with our findings in a previous study [ 13 ]. There are some limitations in this study. First, the retrospective study design potentially introduces bias and confounding factors. However, we used a propensity score-matched analysis to balance the covariates between the surgery and the conservative group. We also used a multivariate analysis to determine the association between surgery (vs. conservative treatment) and various neuroendocrine outcomes in the matched population. Second, we included patients with pituitary apoplexy in our institute between 2005 and 2022, and the evolution of medical care and operative treatment during this period might affect the treatment outcomes. Third, the baseline characteristics of patients in the conservative and surgery groups were different. Even after propensity score matching, some confounding factors remained. Therefore, we used a multivariate analysis to clarify the effect of surgery (vs. conservative treatment) on various neuroendocrine outcomes. In terms of strengths, the population in this study was relatively large, even after propensity score matching, compared with that in previous studies. Second, the propensity score-matched analysis potentially eliminates the bias from treatment selection (surgery or conservative treatment) for each patient with pituitary apoplexy in our study. Third, the better VF recovery in the surgery group, compared with that in the conservative treatment group, has not been identified in the previous studies, excepted the meta-analysis study by Tu et al. [ 15 ]. This finding supports the benefit of surgery in patients with pituitary apoplexy who present with VF deficit. CONCLUSIONS Patients with pituitary apoplexy usually present with headache or visual impairment. Most of these patients recovered from visual deficit and CN palsy but still had endocrine deficit following treatment. Our study found that patients with pituitary apoplexy who present with VF deficit and undergo surgery have better VF recovery than patients who receive conservative treatment. Based on our findings, we recommend surgical over conservative treatment in patients who have VF deficit owing to the better visual recovery following surgical treatment. Preoperative VF deficit, patient characteristics, and radiographic findings are important factors to consider when determining the choice of surgical treatment in each patient. Abbreviations aOR: adjusted odds ratio CI: confidence interval CN: cranial nerve IQR: interquartile range LR: likelihood ratio OR: odds ratio SD: standard deviation VA: visual acuity VF: visual field VIS: visual impairment score Declarations ACKNOWLEDGMENTS None. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Prince of Songkla University (17 February 2023/No. REC.66-038-10-4). Data Availability declaration All data supporting the findings of this study are available within the paper and its supplementary information. FUNDING The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. COMPETING INTERESTS The authors have no relevant financial or non-financial interests to disclose. Author Contribution Conceptualization: Thakul Oearsakul, Chin Taweesomboonyat; Methodology: Krittithee Saktiwarawat, Thara Tunthanathip, Thakul Oearsakul, Chin Taweesomboonyat; Formal analysis and investigation: Krittithee Saktiwarawat, Thara Tunthanathip, Chin Taweesomboonyat; Validation: Thara Tunthanathip, Chin Taweesomboonyat; Writing - original draft preparation: Krittithee Saktiwarawat, Chin Taweesomboonyat; Writing - review and editing: Thakul Oearsakul, Chin Taweesomboonyat; Resources: Thakul Oearsakul, Chin Taweesomboonyat; Supervision: Thakul Oearsakul. References Almeida JP, Sanchez MM, Karekezi C et al (2019) Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature. 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World Neurosurg 111:e495–e499. https://doi.org/10.1016/j.wneu.2017.12.103 Tu M, Lu Q, Zhu P, Zheng W (2016) Surgical versus non-surgical treatment for pituitary apoplexy: A systematic review and meta-analysis. J Neurol Sci 370:258–262. https://doi.org/10.1016/j.jns.2016.09.047 Wilson C, Tindall G, Collins W (1979) Neurosurgical Management of Large and Invasive Pituitary Tumors. Clinical Management of Pituitary Disorders. Raven, New York, pp 335–342 Wilson CB (1984) A decade of pituitary microsurgery: The Herbert Olivecrona Lecture. J Neurosurg 61:814–833. https://doi.org/10.3171/jns.1984.61.5.0814 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4160609","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":284179703,"identity":"7ebc58d9-459a-4824-a6d8-23e25013a437","order_by":0,"name":"Krittithee Saktiwarawat","email":"","orcid":"","institution":"Songklanagarind Hospital, Prince of Songkla University","correspondingAuthor":false,"prefix":"","firstName":"Krittithee","middleName":"","lastName":"Saktiwarawat","suffix":""},{"id":284179704,"identity":"abcb7be9-117a-48d3-b244-7f09bbaf575c","order_by":1,"name":"Thara Tunthanathip","email":"","orcid":"","institution":"Songklanagarind Hospital, Prince of Songkla University","correspondingAuthor":false,"prefix":"","firstName":"Thara","middleName":"","lastName":"Tunthanathip","suffix":""},{"id":284179705,"identity":"3583a5eb-2843-44ae-a196-e47c6cb28a0d","order_by":2,"name":"Thakul Oearsakul","email":"","orcid":"","institution":"Songklanagarind Hospital, Prince of Songkla University","correspondingAuthor":false,"prefix":"","firstName":"Thakul","middleName":"","lastName":"Oearsakul","suffix":""},{"id":284179708,"identity":"05008806-c76c-4031-ae0f-ec4b711d6686","order_by":3,"name":"Chin Taweesomboonyat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYDACCcYGBoYfDAn8EhCuDHFaGHsYEiRnMIA0S/AQoQVEsDEkGNwAa2EgrIV/dnPbAwYeuzzj283HH92oseBhYD98dANeS+4cbDdgsEguNrtzLLE55xjQYTxpaTfwaTGQSGyTYOA5kLjtRo5hcw4bUIsEjxkRWtgOJG6eAdLyjxQtGySAWnLbiNAicQOoJbEnOXHGjbTE2bl9EjxshPzCPyP9mcSHH3aJ/TOSD3zO+VYnx89++BheLWCQgMxhI6h8FIyCUTAKRgFBAAAymUXo3wrFgQAAAABJRU5ErkJggg==","orcid":"","institution":"Songklanagarind Hospital, Prince of Songkla University","correspondingAuthor":true,"prefix":"","firstName":"Chin","middleName":"","lastName":"Taweesomboonyat","suffix":""}],"badges":[],"createdAt":"2024-03-25 04:16:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4160609/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4160609/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53753787,"identity":"c1f6dbf6-7cc0-4fab-a01e-064c5cc4a557","added_by":"auto","created_at":"2024-03-29 18:55:04","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":198921,"visible":true,"origin":"","legend":"\u003cp\u003ePropensity score of the patients in conservative (blue) and surgery (yellow) groups. The horizontal axis represents the propensity score (psvalue) range from 0 to1, and the vertical axis represents the number of patients. The conservative group is depicted in blue and the surgery group in yellow. This image was created by R Program version 4.3.2.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4160609/v1/bcc960eecfbc0e10f4196e66.jpeg"},{"id":53794002,"identity":"8d3dda22-d5bf-4610-90f7-078be88c47a1","added_by":"auto","created_at":"2024-03-30 22:07:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":420713,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4160609/v1/11204c7a-b3c1-4c43-9cbe-998f587eb44a.pdf"},{"id":53753785,"identity":"5e4e0172-0e6d-44b4-83cd-ad46e368ac3f","added_by":"auto","created_at":"2024-03-29 18:55:04","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":55521,"visible":true,"origin":"","legend":"","description":"","filename":"Rawdataforpropensityscorematchinganalysis.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4160609/v1/075e65889081fcf367a0548c.xlsx"},{"id":53753786,"identity":"01361c96-4333-4570-bbd2-65909044cb5d","added_by":"auto","created_at":"2024-03-29 18:55:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":28803,"visible":true,"origin":"","legend":"","description":"","filename":"Caserecordform.docx","url":"https://assets-eu.researchsquare.com/files/rs-4160609/v1/e1508fe8ca960e92528df4af.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparing Neuroendocrine Recovery Between Surgical and Conservative Management in Pituitary Apoplexy Patients: A Propensity Score-Matched Analysis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePituitary apoplexy is a rare clinical syndrome resulting from rapid expansion within the sellar turcica due to either hemorrhage or infarction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This clinical syndrome is characterized by headache, visual deficits, ophthalmoplegia, and alteration in mental status [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDepending on the patient\u0026rsquo;s symptoms and neuro-ophthalmologic and endocrine status, surgical or conservative treatment is chosen. Currently, there is no clear surgical indication for these patients. The outcomes of surgical and conservative treatment strategies for patients with pituitary apoplexy have been reported in several studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, there is no clear evidence whether surgical or conservative treatment will provide the best visual, cranial nerve (CN), and hormonal outcomes. The interpretation of previous results is limited by small study size, difference in patient characteristics between the two treatment groups, and bias from treatment selection.\u003c/p\u003e \u003cp\u003eThis study aimed to compare neuroendocrine recovery outcomes between surgically and conservatively treated patients by using the propensity score matching method to adjust for bias from treatment selection. Four major outcomes were evaluated in this study: visual acuity (VA), visual field (VF), CN, and endocrine recovery from preoperative deficits.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Patients\u003c/h2\u003e \u003cp\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Prince of Songkla University (17 February 2023/No. REC.66-038-10-4). We retrospectively reviewed the records of consecutive patients with pituitary apoplexy who received conservative treatment or underwent transsphenoidal surgery for tumor removal at Songklanagarind Hospital, a tertiary care center and medical school in southern Thailand, between 1st January 2005 and 31st December 2022. Participants were recruited from our database of patients with pituitary tumors who received treatment in Songklanagarind Hospital. Patients who had radiographic evidence of pituitary apoplexy together with neuro-endocrine symptoms (VA and/or VF defect, CN III-VI palsy, or hypopituitarism) were included in this study. Up until August 2014, a microsurgical approach was used for transsphenoidal surgery in our hospital. After that date, we only used an endoscopic approach owing to the advantage of wider operative exposure offered by this technique. Each patient was evaluated and treated by the endocrinologist, ophthalmologist, and neurosurgeon. All transsphenoidal operations were performed by either or both authors (T.O. and C.T.). Intraoperative computed tomography-guided neuronavigation was used in all endoscopic endonasal operations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cp\u003eMedical records were reviewed and data regarding patient demographics, comorbidities, preoperative use of antithrombotic medication, clinical presentation, VA, VF, CN III-VI deficits, pituitary hormonal status before and after treatment, imaging studies, adjuvant treatment, complications, and duration of follow-up were collected and analyzed. Recovery of VA after treatment was defined as a logMAR improvement of at least 0.1 between pre- and post-treatment status measured at the last follow-up evaluation. Recovery of VF after treatment was defined as any improvement of visual field defects following treatment. Recovery from a CN deficit and hypopituitarism (hypoadrenalism, hypothyroidism, or hypogonadism) was evaluated at the last follow-up evaluation (at least 6 months after surgery) and documented.\u003c/p\u003e \u003cp\u003eThe superior, lateral, and inferior extensions of the lesion were evaluated using the Knosp and Wilson\u0026ndash;Hardy classification systems [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Lateral extensions were evaluated using the Knosp classification system and then classified into two groups: grades 0\u0026ndash;2 and 3\u0026ndash;4. Superior extension was evaluated using the Wilson\u0026ndash;Hardy suprasellar extension stage and then classified into two groups: stages 0\u0026ndash;A and stages B\u0026ndash;C. Inferior extension was evaluated using the Wilson\u0026ndash;Hardy invasion grading system and then classified into no (grades 1\u0026ndash;2) or present (grades 3\u0026ndash;4) sphenoid extension. The height of any suprasellar extensions was measured in millimeters to quantify the suprasellar extension of the lesion. An imaginary line was drawn from the tuberculum sellae to the dorsum sellae, and the suprasellar extension was measured by using a perpendicular line from the imaginary line to the superior part of the lesion [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe visual impairment score (VIS) developed by Fahlbusch and Schott [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] was used to quantify the amount of visual impairment prior to treatment. The degrees of VA and VF defects in each patient were translated into scores using specific tables. Afterward, the sum of the VA and VF defect scores in each patient was calculated, providing a VIS ranging from 0 (best) to 100 (worst) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eSex, age, comorbid conditions (diabetes, hypertension, underlying bleeding tendency), current antithrombotic medication, clinical presentation, pre-treatment VA, VF, CN, and pituitary hormonal status, imaging studies, and adjuvant treatments were analyzed and compared between surgically and conservatively treated patients. Logistic regression analysis was used to identify factors associated with treatment selection (surgical or conservative treatment). Then, the propensity score was calculated based on these factors. The patient populations of the two groups were matched using various propensity score matching techniques. The matching technique that could optimally balance the covariates was chosen for comparing the outcomes between surgical and conservative treatment.\u003c/p\u003e \u003cp\u003eThe population after matching was then further analyzed. Baseline characteristics of patients were analyzed and compared between the two treatment groups. The neuroendocrine outcomes (VA, VF, CN, and pituitary hormone recovery) were compared between the groups. Logistic regression analysis was used to evaluate the association between treatment approach (surgery or conservative) and each neuroendocrine outcome. The multivariate analysis model with the lowest Akaike information criterion value was chosen to identify the factors associated with each neuroendocrine outcome. The statistical analyses were performed with the R Program version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). A P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Characteristics before Matching\u003c/h2\u003e \u003cp\u003eThe study included 127 patients. Ninety-eight patients underwent transsphenoidal surgery, while 29 patients received conservative treatment. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the baseline characteristics of the patients before propensity score matching. Thirteen (45%) and 47 (48%) patients in the conservative and the surgery group, respectively, were male. The mean age of the patients in the conservative group was significantly older than that in the surgery group (58.7 vs. 51.6 years, P\u0026thinsp;=\u0026thinsp;0.019). There were no differences in underlying comorbidities between the groups. Seven (24%) and 10 (10%) patients in the conservative and the surgery group, respectively, had been using antithrombotic medication before the onset of pituitary apoplexy. Patients in the conservative group presented with headache more frequently (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while patients in the surgery group had a higher incidence of preoperative VF deficit on both sides (P\u0026thinsp;=\u0026thinsp;0.005). The lower incidence of VF deficit (compared to VA deficit) might have resulted from an inability to accurately measure VF in patients with poor VA. Preoperative VIS and cranial nerve deficits showed no significant differences between the two groups. Patients in the surgery group had the higher incidence of preoperative hypothyroidism (52% vs. 28%, P\u0026thinsp;=\u0026thinsp;0.035) and hypogonadism (63% vs. 31%, P\u0026thinsp;=\u0026thinsp;0.006). The preoperative median serum prolactin level was significantly higher in the surgery group (22.4 vs. 10 ng/mL, P\u0026thinsp;=\u0026thinsp;0.019). The median tumor size was larger in the surgery group (33.5 vs 18.1 mm, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics of Patients Before Propensity Score Matching\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;98)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.7\u0026thinsp;\u0026plusmn;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntithrombotic medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCranial nerve III-VI palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlteration of consciousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.683\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative right VA deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.523\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative left VA deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative right VF deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative left VF deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual Impairment Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (8, 59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (26, 92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve III deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve IV deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.589\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve V deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve VI deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative hormonal deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoadrenalism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypogonadism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative serum prolactin level, ng/mL, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (5, 20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.4 (9.2, 54.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size, mm, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.1 (13, 21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.5 (25, 39.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnosp classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWilson\u0026ndash;Hardy classification for suprasellar extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u0026ndash;C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilson\u0026ndash;Hardy classification for invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuprasellar extension of lesion, mm, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (0, 5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7 (11.3, 22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor recurrence or enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation for tumor removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined adjuvant treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of follow-up, months, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (14.5, 51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (19.5, 76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as n (%) unless indicated otherwise.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIQR, interquartile range; SD, standard deviation; VA, visual acuity; VF, visual field.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eClassification of the patients using the Knosp, Wilson\u0026ndash;Hardy suprasellar extension, and Wilson-Hardy invasion classification systems showed significantly higher grades in the surgery group than in the conservative group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and P\u0026thinsp;=\u0026thinsp;0.014, respectively). The median suprasellar extension of the lesion was higher in the surgery group (16.7 vs. 3.9 mm, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The incidence of tumor recurrence or enlargement following treatment showed no difference between the groups. Patients in the surgery group received adjuvant treatments more often than those in the conservative group (P\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Characteristics after Matching\u003c/h2\u003e \u003cp\u003eLogistic regression analysis was used to identify factors associated with surgical intervention in all patients. Then, these factors (headache symptom, VIS, Knosp classification grade, and suprasellar extension grade) were used to calculate the propensity score (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Subsequently, various propensity score-matching methods, including the nearest neighbor matching with the ratios 1:1 and 2:1, Caliper matching, optimal matching, optimal full matching, and Mahalanobis metric matching were used for matching the populations of both groups. The optimal matching technique was chosen as the optimal method to balance the covariates before further analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the baseline characteristics of the patients after propensity score matching with the optimal matching technique. There were 28 patients in each group, and the mean age, headache symptom, preoperative VF deficit on both sides, median serum prolactin level, and imaging classification grade showed no significant differences between the groups after matching. However, patients in the surgery group still had a significantly higher incidence of preoperative hypothyroidism and hypogonadism, larger median tumor size, and higher suprasellar extension (P\u0026thinsp;=\u0026thinsp;0.03, P\u0026thinsp;=\u0026thinsp;0.011, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics of Patients After Propensity Score Matching with Optimal Matching Technique\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.669\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntithrombotic medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.469\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.501\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCranial nerve III-VI palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlteration of consciousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative right VA deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.705\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative left VA deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative right VF deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative left VF deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.587\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual Impairment Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (8, 59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (6.2, 64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve III deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve IV deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve V deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative cranial nerve VI deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative hormonal deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoadrenalism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypogonadism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative serum prolactin level, ng/mL, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.5 (5, 21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.4 (6.6, 54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size, mm, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.5 (13, 21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5 (20.8, 29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnosp classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWilson-Hardy classification for suprasellar extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u0026ndash;C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilson-Hardy classification for invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuprasellar extension of lesion, mm, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (0, 5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.8 (7.1, 14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor recurrence or enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation for tumor removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined adjuvant treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of follow up, months, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (14, 54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5 (31.5, 83.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as n (%) unless indicated otherwise.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIQR, interquartile range; SD, standard deviation; VA, visual acuity; VF, visual field.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eNeuroendocrine Outcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the neuroendocrine recovery after conservative and surgical treatments in patients who had preoperative deficits. VA recovery showed no significant difference between the surgery and conservative groups. Nevertheless, patients in the surgery group had significantly better VF recovery in at least one eye after treatment (85% vs. 50%, P\u0026thinsp;=\u0026thinsp;0.034). Recovery of CN III palsy showed no difference between the groups. The incidences of preoperative CN IV, V, and VI palsy were too low to allow comparison of the outcomes between the groups. Recovery from hypoadrenalism, hypothyroidism, and hypogonadism showed no difference between the groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeuroendocrine Recovery After Conservative and Surgical Treatment in Patients with Preoperative Deficits\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative,\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery,\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight VA recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft VA recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecovery of VA in at least one eye\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight VF recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft VF recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecovery of VF in at least one eye\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecovery of CN III palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCN IV palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCN V palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCN VI palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypopituitarism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoadrenalism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypogonadism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eVA, visual acuity; VF, visual field; CN, cranial nerve.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFactors Associated with Neuroendocrine Recovery\u003c/h2\u003e \u003cp\u003eLogistic regression analysis was used to identify factors associated with VA recovery in at least one eye after treatment. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the multivariate analysis of factors associated with recovery from preoperative VA deficits. Older age was significantly associated with no recovery from a preoperative VA deficit (P\u0026thinsp;=\u0026thinsp;0.029). Surgery was not associated with better VA recovery (P\u0026thinsp;=\u0026thinsp;0.529).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Analysis of Factors Associated with Visual Acuity Recovery in One or Both Eyes After Treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e (Wald Test)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e (LR Test)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.95 (0.9, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery vs. conservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.62 (0.36, 7.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eaOR, adjusted odds ratio; CI, confidence interval; LR, likelihood ratio.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the multivariate analysis of factors associated with recovery from a preoperative VF defect. Absence of underlying hypertension and surgical treatment were significantly associated with better VF recovery (P\u0026thinsp;=\u0026thinsp;0.013 and P\u0026thinsp;=\u0026thinsp;0.007, respectively).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Analysis of Factors Associated with Visual Field Recovery in One or Both Eyes After Treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e (Wald Test)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e (LR Test)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.07 (0.01, 0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnosp classification grades 3\u0026ndash;4 (vs. grades 0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18946784.19 (0, Inf)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery vs. conservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.89 (1.37, 121.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eaOR, adjusted odds ratio; CI, confidence interval; LR, likelihood ratio.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults from the logistic regression analysis showed that surgical treatment was not associated with better recovery from preoperative hypoadrenalism, hypothyroidism, and hypogonadism.\u003c/p\u003e \u003cp\u003eOwing to the low incidences of preoperative CN III-VI deficits and the very high incidence of CN recovery following treatment, the association between surgical treatment and CN recovery outcome could not be analyzed.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eBefore propensity score matching, patients in the conservative group were older and presented more frequently with headache, while patients in the surgery group had a higher incidence of preoperative VF deficit, hypopituitarism, larger tumor size, and greater tumor extension in all directions. We used propensity score matching analysis to balance these covariates between the conservative and the surgery group. Following propensity score matching with the optimal matching method, the mean age, headache symptom, and preoperative VF deficit were not significantly different between the two groups. However, patients in the surgery group still had a significantly higher incidence of preoperative hypothyroidism and hypogonadism, larger median tumor size, and higher suprasellar extension. Therefore, we used a multivariate analysis to control the remaining possible confounding factors and evaluate the association between surgical (vs. conservative) treatment and neuroendocrine recovery.\u003c/p\u003e \u003cp\u003eOur study found that compared with conservative treatment, surgical treatment was significantly associated with better improvement of preoperative visual field deficit in at least one eye. Nevertheless, surgical treatment was not associated with better recovery of VA, CN III, and hypopituitarism deficit.\u003c/p\u003e \u003cp\u003ePrevious studies found no significant differences in VA and VF recovery between surgically and conservatively treated patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A meta-analysis study by Goshtasbi et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] also found no difference in visual outcomes between surgically and conservatively treated patients. However, a meta-analysis study by Tu et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] found that surgically treated patients had a significantly higher rate of recovery of visual field (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while there was no significant difference in VA recovery between the surgical and the conservative group.\u003c/p\u003e \u003cp\u003eIn all of these studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], compared to the conservative treatment group, the patients in the surgery group had more severe visual symptoms. Furthermore, the tumor in the surgical group was larger and showed greater extension than that in the conservative treatment group [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This potential bias might interfere with outcomes comparison between the surgery and conservative groups. In our study, we used propensity score-matched analysis to balance the covariates and then used a multivariate analysis to assess the association between surgical (vs. conservative) treatment and various neuroendocrine outcomes.\u003c/p\u003e \u003cp\u003eOur study found no difference in CN III recovery between the surgery and the conservative group. Most previous studies found no difference in CN recovery between the surgery and the conservative group [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A study by Shepard et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] found better cranial neuropathy improvement in the conservatively managed patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). On the contrary, a meta-analysis study by Tu et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] found a significantly better recovery of ocular palsy in the surgically treated patients (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eRecovery from hypoadrenalism, hypothyroidism, and hypogonadism showed no differences between the groups in this study. Likewise, studies by Giritharan et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Singh et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and Bujawansa et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] found no differences in endocrine outcomes between the surgery and the conservative group. A meta-analysis by Goshtasbi et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and Tu et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] also found no differences in improvements of endocrine dysfunction between surgically and conservatively treated patients. A study by Teixeira et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] however found better endocrine outcomes in the surgical group (P\u0026thinsp;=\u0026thinsp;0.027), while a study by Marx et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] found more endocrine deficits at 1 year in the surgical group (p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e \u003cp\u003eThis study also found that older age and underlying hypertension were significantly associated with poor recovery from a preoperative VA and VF deficit, respectively. These findings were consistent with our findings in a previous study [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are some limitations in this study. First, the retrospective study design potentially introduces bias and confounding factors. However, we used a propensity score-matched analysis to balance the covariates between the surgery and the conservative group. We also used a multivariate analysis to determine the association between surgery (vs. conservative treatment) and various neuroendocrine outcomes in the matched population. Second, we included patients with pituitary apoplexy in our institute between 2005 and 2022, and the evolution of medical care and operative treatment during this period might affect the treatment outcomes. Third, the baseline characteristics of patients in the conservative and surgery groups were different. Even after propensity score matching, some confounding factors remained. Therefore, we used a multivariate analysis to clarify the effect of surgery (vs. conservative treatment) on various neuroendocrine outcomes.\u003c/p\u003e \u003cp\u003eIn terms of strengths, the population in this study was relatively large, even after propensity score matching, compared with that in previous studies. Second, the propensity score-matched analysis potentially eliminates the bias from treatment selection (surgery or conservative treatment) for each patient with pituitary apoplexy in our study. Third, the better VF recovery in the surgery group, compared with that in the conservative treatment group, has not been identified in the previous studies, excepted the meta-analysis study by Tu et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This finding supports the benefit of surgery in patients with pituitary apoplexy who present with VF deficit.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003ePatients with pituitary apoplexy usually present with headache or visual impairment. Most of these patients recovered from visual deficit and CN palsy but still had endocrine deficit following treatment. Our study found that patients with pituitary apoplexy who present with VF deficit and undergo surgery have better VF recovery than patients who receive conservative treatment. Based on our findings, we recommend surgical over conservative treatment in patients who have VF deficit owing to the better visual recovery following surgical treatment. Preoperative VF deficit, patient characteristics, and radiographic findings are important factors to consider when determining the choice of surgical treatment in each patient.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eaOR: adjusted odds ratio\u003c/p\u003e\n\u003cp\u003eCI: confidence interval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCN: cranial nerve\u003c/p\u003e\n\u003cp\u003eIQR: interquartile range\u003c/p\u003e\n\u003cp\u003eLR: likelihood ratio\u003c/p\u003e\n\u003cp\u003eOR: odds ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSD: standard deviation\u003c/p\u003e\n\u003cp\u003eVA:\u0026nbsp;visual acuity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVF: visual field\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVIS: visual impairment score\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eACKNOWLEDGMENTS\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003eEthics approval\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Prince of Songkla University (17 February 2023/No. REC.66-038-10-4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Availability declaration\u003c/p\u003e\n\u003cp\u003eAll data supporting the findings of this study are available within the paper and its supplementary information.\u003c/p\u003e\n\u003cp\u003eFUNDING\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOMPETING INTERESTS\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: Thakul Oearsakul, Chin Taweesomboonyat; Methodology: Krittithee Saktiwarawat, Thara Tunthanathip, Thakul Oearsakul, Chin Taweesomboonyat; Formal analysis and investigation: Krittithee Saktiwarawat, Thara Tunthanathip, Chin Taweesomboonyat; Validation: Thara Tunthanathip, Chin Taweesomboonyat; Writing - original draft preparation: Krittithee Saktiwarawat, Chin Taweesomboonyat; Writing - review and editing: Thakul Oearsakul, Chin Taweesomboonyat; Resources: Thakul Oearsakul, Chin Taweesomboonyat; Supervision: Thakul Oearsakul.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlmeida JP, Sanchez MM, Karekezi C et al (2019) Pituitary Apoplexy: Results of Surgical and Conservative Management Clinical Series and Review of the Literature. 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Clinical Management of Pituitary Disorders. Raven, New York, pp 335\u0026ndash;342\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson CB (1984) A decade of pituitary microsurgery: The Herbert Olivecrona Lecture. J Neurosurg 61:814\u0026ndash;833. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3171/jns.1984.61.5.0814\u003c/span\u003e\u003cspan address=\"10.3171/jns.1984.61.5.0814\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Conservative treatment, Cranial nerve recovery, Endocrine recovery, Pituitary apoplexy, Transsphenoidal surgery, Visual recovery","lastPublishedDoi":"10.21203/rs.3.rs-4160609/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4160609/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Pituitary apoplexy is a rare and potentially life-threatening clinical syndrome. Patients may present with severe neuro-ophthalmologic or endocrine symptoms. Current evidence is unclear whether conservative or surgical management leads to the best neuroendocrine outcomes. This study aimed to compare neuroendocrine outcomes between surgical and conservative treatments in a single center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Cases of patients with pituitary apoplexy who received transsphenoidal surgery or conservative management in Songklanagarind Hospital between January 1, 2005 and December 31, 2022 were retrospectively reviewed. A propensity score matching method was used to adjust bias from treatment selection (surgery or conservative treatment). Differences in visual acuity, visual field, cranial nerve, and endocrine outcomes between the surgical and conservative treatment groups were analyzed using logistic regression analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e This study included 127 patients, with 98 and 29 patients in the surgical and the conservative treatment group, respectively. The optimal matching method was used for propensity score matching. Compared to the conservative group, the surgically treated patients had a significantly higher rate of visual field recovery (odds ratio (OR): 12.89, P = 0.007). However, there were no statistical differences in the recovery rate of preoperative visual acuity, cranial nerve, and endocrine deficits between the groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Transsphenoidal surgery was associated with a higher rate of visual field recovery when compared to the conservative treatment for pituitary apoplexy patients. Careful selection of appropriate treatment based on the patient’s presentation and neuroendocrine status will result in the best outcomes while avoiding unnecessary surgical intervention.\u003c/p\u003e","manuscriptTitle":"Comparing Neuroendocrine Recovery Between Surgical and Conservative Management in Pituitary Apoplexy Patients: A Propensity Score-Matched Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-29 18:54:59","doi":"10.21203/rs.3.rs-4160609/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7afbb99-52db-488a-87fd-b6c0b94e283f","owner":[],"postedDate":"March 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-30T21:59:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-29 18:54:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4160609","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4160609","identity":"rs-4160609","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}