Predictors of conversion to surgery in pituitary apoplexy : Insights from a Spanish multicenter observational study

Background: Pituitary apoplexy (PA) is a rare but potentially life-threatening condition. While conservative management is an option in selected cases, predictors of conversion to surgery after initial conservative management remain unclear. Objective: To identify predictors of transitioning to surgery in PA who were initially managed conservatively, and to assess the timing and impact of surgical conversion. Methods: This multicenter observational study included 134 patients with PA initially managed conservatively. Patients were categorized into successful conservative management (no surgery or surgery scheduled after 30 days) and conversion to surgery (surgery within 8-30 days). Logistic and Cox regression analyses were performed to identify predictors of conversion to surgery and time to transition, respectively. Results: Among the 134 patients enrolled, the median age was 61.4 years (interquartile range: 16.0) years and 93 (69.4 %) men], 69 (51.5 %) ultimately required surgery, with most transitions occurring within the first two weeks. In logistic regression analysis, larger tumor size (OR: 1.09, 95 % CI: 1.02-1.16) and higher BMI (OR: 1.11, 95 % CI: 1.01-1.22) were independently associated with conversion to surgery. However, Cox regression did not identify any variables predicting time to transition. Additionally, patients who converted to surgery had a significantly longer hospital stay (21.0 vs. 7.5 days, p < 0.01). Conclusion: Half of the patients initially managed conservatively required convertion to surgery. Tumor size and BMI were associated with an increased likelihood of surgery, but no factors predicted when surgery would occur, suggesting that the decision to conversion to surgery may be influenced by multiple clinical factors rather than a single determinant.