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Online ISSN : 1687-8329
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Postoperative Clinical Outcome of Visual Acuity of Fifty Patients with Sellar and Suprasellar Tumors
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Ahmed
M. Ali
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Department of
Neurosurgery, Cairo
University; Egypt
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ABSTRACT
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Background: The sellar, parasellar and suprasellar regions is an
anatomically complex areas, A wide range of neoplastic, inflammatory, and many
other lesions may embroil vital structures. Objectives: This is a prospective study for postoperative clinical
outcome of visual acuity (VA) in patients with sellar and suprasellar tumors. Patients
and Methods: Fifty cases were included in this
study (28 females and 22 males). The age ranged from 31 y to 55 y. All cases
were operated at Kasr Al Aini Neurosurgical Department from June 2011 to
February 2014. All patients had history, clinical examination, hormonal profile
and radiological investigations in the form of CT scan, MRI and 4 vessels or
CT angiography if needed. All cases had
post-operative CT brain, hormonal profile and visual assessment 2 days and 4
months after surgery by Lamdolt broken ring,30 patients were operated by
microscopic assisted endoscopic endonasal transsphenoid approach and 20 cases
operated by transcranial approach. Results: Thirty-two cases showed visual improvement by two lines in
Lamdolt broken ring chart 48hrs after surgery. 16 cases had same preoperative
VA. 10 cases of 16 showed gradually improvement within 4 months. The VA was
hand movement in two cases in Rt. eye and became no PL postoperative. Total
improvement of cases, after 4 months, were 42 case (84%) ,6 cases still had
same pre and postoperative visual acuity (12%) and only 2 cases (4%) had post
operative visual acuity deterioration. Conclusion: Safe, careful surgery of tumors in sellar and suprasellar
regions with good instruments and anesthesia can help improving visual acuity. [Egypt J Neurol Psychiat
Neurosurg. 2015; 52(2) : 119-122]
Key Words: Suprasellar,
Visual acuity, Lamdolt broken ring.
Correspondence to Ahmed Mohamed Ali,
Neurosurgery Department, Faculty of Medicine,
Egypt.
Tel.: +201001813369
E-mail: prof_ali2000@yahoo.com
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INTRODUCTION
Sellar and parasellar
regions with its suprasellar extension
are very important areas within the intra cranial cavity that has many
important structures1, such structures like pituitary adenoma, pituitary
stalk, hypothalamus, both optic nerves, optic chiasm and many vascular
structures like anterior circulation and
cavernous sinus2, contents of cavernous sinus such as intracavernous
portion of carotid artery, venous network, and cranial nerves III, IV, VI that
mainly controlling eye movments3, it extend inferiorly to base of
sphenoid sinus laterally to cavernous sinus and superiorly to ventricular walls4,
many lesions can affect these areas such as pituitary adenoma, meningioma,
craniopharyngioma, and epidermoid, arachnoid cysts and vascular lesions like
aneurysms of anterior circulation2. Symptoms and signs of patients
with these lesions varying from accidentally discovered, headache, hormonal
imbalance, visual affection, proptosis and cranial nerve affection with
intracavernous extension.1
Many
diagnostic investigations are very crucial to reach proper diagnosis for proper
management such radiological investigations in form of CAT scan (CT) of brain, magnetic
resonance imaging (MRI) and 4 vessels angiography or CT angiography to rule out
relations of such lesions and vascular tree, hormonal profile is very important
for replacement therapy pre and post operative5, visual impairment
should be carefully investigated by clinical assessment, perimetry and fluorescein
retinal angiography1, deterioration of visual acuity is one of
serious complications for these lesions that has to be treated rapidly to
preserve visual function5, many surgical approaches are available
for surgical decompression of lesions in these areas like transcranial,
microscopic and or endoscopic transsphenoid corridor3
This
study aims to outlines postoperative visual acuity in cases of sellar and
suprasellar tumors and impact of safe surgical resection on the patients visual
prognosis.
PATIENTS
AND METHODS
Fifty cases with sellar
and suprasellar tumors were included in this study. There were 28 females and
22 males. The age ranged from 31y to 55 years. All cases operated at Kasr El
Aini Neurosurgical department from June 2011 to February 2014.
All patients had
history, clinical examination, hormonal profile and radiological investigations
in the form of CT scan, MRI and four vessels angiography, when needed, to
outline relation between tumors and vascular tree, the cases suffered from any
local eye disease were excluded from this study. All patients had visual acuity
assessment using visual Lamdolt broken ring chart pre-operatively (Table 1) and
48 hrs and four months after surgery (Table 2).
Thirty
patients were operated by microscopic assisted endoscopic endonasal
transsphenoid approach for better visualization of optic apparatus
postoperatively and20 cases operated by transcranial approach (12 cases by
pterional approach and 8 cases by subfrontal approach). All cases had CT scan
with sellar cuts and pituitary hormonal assessment on the second postoperative
day. The visual acuity was assessed and recorded 48 hours and 4 months after
surgery.
Forty cases were discharged within 5 days post operative. Seven
cases were discharged 10 days after surgery due to postoperative Diabetes
insipidus. The last 3 cases were discharged after 2 weeks due to chest
infection.
RESULTS
Forty-three cases were operated by near total excision and seven cases
were operated by subtotal excision being adherent to vital structure. Twenty-five
cases were pituitary adenoma, 17 cases were craniopharyngioma (Figure 1), and eight
cases were Meningioma. Postoperative results were obtained by visual assessment
using Lamdolt broken ring chart 48hrs after operation and 4months later. 30
patients were operated by microscopic endonasal transsphenoid approach and 20
cases operated by transcranial approach.
Of the seven cases
subtotal excision, three cases were craniopharyngioma, two cases were pituitary
adenoma and two cases were meningioma. In the two meningioma cases subtotally
excised, the visual acuity improved. In the three craniopharyngioma cases, two
cases showed deterioration (no PL) in Rt. eye only and third had VA
improvement. Two cases of pituitary adenoma, with subtotal resection, had same
pre and postoperative visual acuity.
Thirty-two
cases showed visual improvement by two lines in the Lamdolt broken ring chart
48hrs after surgery (8 meningioma, 18 pituitary adenoma, and 6 craniopharyngioma).
Sixteen cases had same preoperative VA (10 cases of them improved gradually
within 4 m (4 pituitary and 6 craniopharyngioma) and six cases were HM pre and post-operative
(three pituitary adenoma and three craniopharyngioma). The VA was hand movement
in two cases in right eye only and
became no PL postoperative. These two cases were pathologically proven to have
craniopharyngioma. After 4 months, 42 case showed improvement (84%),6 cases
still had same pre and postoperative VA (12%) and only 2 cases (4%) had post
operative visual acuity deterioration (Tables 1 and 2).
Forty-eight
patients had an uneventful surgery. These cases have their vision improved or
remained as pre-operative. In the last two cases (craniopharyngioma), the tumor
was large and adherent to the surrounding. It compressed the optic pathway thus
affecting the visual acuity preoperative to HM, an attempt was made to separate
the tumor from the optic apparatus. This attempt ended in injury of the optic
pathway and deterioration of vision.
Figure 1. A case of 48yrs old male with suprasellar
craniopharyngioma showing pre (a) and post (b) operative images.
Table 1. Showing pre operative visual acuity in both
eyes
Visual
acuity
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Rt
.
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Lt.
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6/18
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30
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25
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6/36
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0
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5
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6/60
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12
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20
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HM
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8
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0
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Table 2. Showing postoperative visual acuity in both
eyes4 months after surgery.
Visual
acuity
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Rt.
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Lt.
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6/6
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5
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5
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6/9
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20
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20
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6/18
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17
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22
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6/36
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0
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3
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HM
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6
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0
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No PL
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2
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0
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DISCUSSION
Sellar and suprasellar
region has an intimate relation to many vital structures like vessels,
hypothalamus, Pituitary gland and stalk, cranial nerves, cavernous sinus and
optic apparatus. Such delicate structures make surgery in this area difficult
and very challenging. Good anesthesia, proper instruments and safe careful
surgery without severely damaged optic apparatus had a good impact on postoperative
results especially on VA. Data from cancer registries suggest that prevalence
of primary central nervous system (CNS) tumors is 130–230 cases per 100,000 of
the population6. Lesions of the sellar and suprasellar region are
very common, accounting for 10–15% of intracranial masses7.
In this series of fifty
cases of suprasellar tumors, 84% had postoperative improvement of VA, 12% had
same pre and postoperative VA, and finally 4% had postoperative deterioration
of VA (no PL). In the deteriorated cases, the tumor was large craniopharyngioma
adherent to the surrounding. It compressed the optic pathway thus affecting the
visual acuity to HM. An attempt was made to separate the tumor from the optic apparatus,
this attempt ended in injury of the optic pathway and deterioration of vision.
This results correlates
with Koutourousiou et
al.8. In their series in 2014, they documented good postoperative VA
in 75 cases of suprasellar meningioma treated by endoscopic endonasal surgery.
They had only two cases of visual acuity deterioration. However, their tumor
pathology differs from this study where craniopharyngioma and pituitary adenoma
were also included. The eight cases of meningioma, in this study, were operated
upon transcranially. The all improved. This may be attributed to better
visualization of optic nerve during the transcranial approach. However eight
cases is a small number and further study should be done to draw a conclusion.
The
result, in this study, is quiet similar with Sinha et
al.9. They reported 70% improvement of VA of intrancranially treated
48 cases of suprasellar tumors. This study reported 20 cases of sellar, suprasellar
tumors operated transcranially with 75%improvement in visual acuity. This
slight difference may be attributed to the difference in tumor pathology. Han et
al.10, also reported 82% improvement of postoperative VA in 29
patients with large suprasellar craniopharyngioma treated transcranially. This
study reported 17 cases of craniopharyngioma (12 cases treated transcranial and
5 cases transsphenoid) with 70% postoperative improvement.
Conclusion
Safe, careful surgery of
tumor in sellar and suprasellar regions with good instruments and anesthesia
and without severely affected optic nerve can improve visual acuity.
[Disclosure:
Authors report no conflict of interest]
REFERENCES
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2. Smith JK. : Parasellar Tumors. Suprasellar
and Cavernous Sinuses. Top Magnetic Resonance Imaging.2005; 16: 307-15.
3. Melded S.: Medical progress: Acromegaly. New England Journal of Medicine, .2006; 355: 2558-73.
4. Freda PU, Post KD. Differential diagnosis
of sellar masses. Endocrinology and Metabolism Clinics of North America.1999;
28: 81-117.
5. Bonneville J.F, Bonneville F, Cattin F.
Magnetic resonance imaging of pituitary adenomas. European Radiology.2005; 15: 543-8.
6. Davis FG, Kupelian V, FreelsS,McCarthy B,
Surawicz T. Prevalence estimates for primary brain tumors in the United States
by behavior and major histology groups. Neuro-oncology 3. 2001; 3: 152-8.
7. Terada T, Kovacs K, Stefaneanu L ,Horvath
E. Incidence, pathology, and recurrence of pituitary adenomas: study of 647
unselected surgical cases. Endocrine Pathology.1995; 6: 301-10.
8. Koutourousiou M, Fernandez-Miranda JC,Stefko ST, Wang EW, Snyderman CH, Gardner PA . Endoscopic endonasal surgery for suprasellar meningiomas:
experience with 75 patients. J Neurosurg.
2014; 120(6): 1326-39.
9. Sinha S, Kumar A, Sharma BS. Bifrontal basal interhemispheric
approach for midline suprasellar tumors. our experience with forty-eight
patients. Neurol India.2013;
61(6): 581-6.
10. Han S, Tie X, Qin X, Wang Y, Wu A. Frontobasalinterhemispheric approach for large superasellar craniopharyngiomas.
do the benefits outweigh the risks?, ActaNeurochir (Wien).2014;
156(1): 123-30.
الملخص
العربي
إن منطقة
السرج وما فوق السرج من أهم المناطق داخل المخ وذلك لقربها من الأوعية الرئيسية
للمخ وكذلك قربها من الجهاز البصري وأيضا قربها من البطين الثالث وتحت المهاد. من أكثر
الأورام انتشارا فى تلك المنطقة ورم الغدة النخامية وأورام القحف البلعومي وكذا أورام
المخ السحائية, من أهم تأثيرات تلك الأورام التأثير على الرؤية العصبية وهو مجال
البحث, أجرى هذا البحث على خمسين مريض ,ثمانية وعشرون انثى واثنين وعشرون ذكر
تتراوح أعمارهم من واحد وثلاثين إلى خمس وخمسين عاما, تم فحص جميع الحالات إكلينيكيا
وتم عمل أشعة مقطعية ورنين مغناطيسى وكذا عمل أشعة بالصبغة على شرايين المخ إذا اقتضت
الحاجة, خمس وعشرون حالة كانوا يعانون من ورم بالغدة النخامية وسبعة عشرة حالة من
ورم القحف البلعومي وثمانية من أورام سحائية, تم إجراء ثلاثون حالة عن طريق الوتدي
بالأنف بالميكروسكوب ومساعدة المنظار وعشرون حالة عن طريق المخ,تم استئصال الورم
كليا فى ثلاث وأربعين حالة وجزئيا فى سبع حالات اثنين وثلاثون حالة تحسنت قوة الإبصار
لديهم بعد الجراحة بيومين وستة عشرة حالة كان لديهم نفس قوة أبصار ما قبل الجراحة
تحسن منهم عشرة حالات بعد مرور أربعة اشهر وستة لم يتحسنوا, وبذلك يكون عدد المرضى
الذين تحسنوا اثنين وأربعين حالة بمعدل أربعة وثمانين بالمئة وحالتين تدهور النظر
بعد الجراحة الى عدم رؤية كاملة بمعدل أربعة بالمئة. وقد تبين من ذلك البحث أن
الجراحة الناجحة وكذلك حالة العصب البصري قبل الجراحة من أهم العوامل التى تؤد
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