Ophthalmoplegic complications in transsphenoidal pituitary surgery

2020 ◽  
Vol 133 (3) ◽  
pp. 693-701
Author(s):  
Simona Mihaela Florea ◽  
Thomas Graillon ◽  
Thomas Cuny ◽  
Regis Gras ◽  
Thierry Brue ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Transsphenoidal Surgery ◽  
Rare Complication ◽  
Pituitary Surgery ◽  
The Other ◽  
Nerve Lesion ◽  
Incomplete Resection ◽  
Transsphenoidal Pituitary Surgery ◽  
Important Extension ◽  
Grade 3

OBJECTIVEOphthalmoplegia is a rare complication of transsphenoidal surgery, only noted in a few studies. The purpose of this study was to analyze the complications of cranial nerve III, IV, or VI palsy after transsphenoidal surgery for pituitary adenoma and understand its physiopathology and outcome.METHODSThe authors retrospectively analyzed 24 cases of postoperative ophthalmoplegia selected from the 1694 patients operated via a transsphenoidal route in their department.RESULTSTwo patients were operated on via microscopy and 22 via endoscopy. Patients operated on endoscopically had a greater risk of presenting with an extraocular nerve deficit postoperatively (p = 0.0115). It was found that an extension into or an invasion of the cavernous sinus (Knosp grade 3 or 4 on MRI, 18/24 patients) was correlated with a higher risk of postoperative ophthalmoplegia (p < 0.0001). The deficit was apparent immediately after surgery in 2 patients. For these 2 patients, the mechanisms of ophthalmoplegia were compression or intraoperative nerve lesion. The other 22 patients became symptomatic in the 12–72 hours following the surgery. The mechanisms implied in these cases were intrasellar compressive hematoma (4/22 cases), intracavernous hemorrhagic suffusion, or incomplete resection of the intracavernous portion of the tumor. All patients who did not present with oculomotor palsy immediately after surgery completely recovered their deficits in the 3 months that followed, while the other 2 experienced permanent damage.CONCLUSIONSExtraocular nerve dysfunction after transsphenoidal pituitary surgery is a rare complication that occurs more frequently in the case of the invasion or an important extension into the cavernous sinus. In this series, it also appears to be significantly more frequent in patients operated on via an endoscopic approach. Most patients have deficits that appear with a delay of 12–72 hours postoperatively and they are most likely to completely recover.

scholarly journals Increased oxytocin release precedes hyponatremia after pituitary surgery

Pituitary ◽  
2021 ◽  
Author(s):  
Paul Eugène Constanthin ◽  
Nathalie Isidor ◽  
Sophie de Seigneux ◽  
Shahan Momjian
Keyword(s):  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
Sodium Balance ◽  
Posterior Pituitary ◽  
Axon Terminals ◽  
Early Marker ◽  
Inappropriate Secretion ◽  
Oxytocin Release ◽  
Transsphenoidal Pituitary Surgery ◽  
First Time

Abstract Purpose The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a well-known complication of transsphenoidal pituitary surgery, related to inappropriate secretion of arginine vasopressin (AVP). Its diagnosis is based on hyponatremia, with a peak of occurrence around day 7 after surgery and, to date, no early marker has been reported. In particular, copeptin levels are not predictive of hyponatremia in this case. Oxytocin (OXT) is secreted into the peripheral blood by axon terminals adjacent to those of AVP neurons in the posterior pituitary. Besides its role in childbirth and lactation, recent evidences suggested a role for OXT in sodium balance. The contribution of this hormone in the dysnatremias observed after pituitary surgery has however never been investigated. Methods We analyzed the urinary output of OXT in patients subjected to transsphenoidal pituitary surgery. Results While OXT excretion remained stable in patients who presented a normonatremic postoperative course, patients who were later diagnosed with SIADH-related hyponatremia presented with a significantly increased urinary secretion of OXT 4 days after surgery. Conclusion Taken together, these results show for the first time that urinary OXT output remains normally stable after transsphenoidal pituitary surgery. OXT excretion however becomes abnormally high on or around 4 days after surgery in patients later developing hyponatremia, suggesting that this abnormal dynamics of OXT secretion might serve as an early marker for transsphenoidal surgery-related hyponatremia attributed to SIADH.

THREE‐DIMENSIONAL ENDOSCOPIC PITUITARY SURGERY

2009 ◽  
Vol 64 (suppl_5) ◽  
pp. ons288-ons295 ◽  
Author(s):  
Abtin Tabaee ◽  
Vijay K. Anand ◽  
Justin F. Fraser ◽  
Seth M. Brown ◽  
Ameet Singh ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Depth Perception ◽  
Operative Time ◽  
Compound Eye ◽  
Intraoperative Complications ◽  
Three Dimensional ◽  
Pituitary Surgery ◽  
Extent Of Resection ◽  
3 Dimensional ◽  
Transsphenoidal Pituitary Surgery

Abstract OBJECTIVE We describe a novel 3-dimensional (3-D) stereoendoscope and discuss our early experience using it to provide improved depth perception during transsphenoidal pituitary surgery. METHODS Thirteen patients underwent endonasal endoscopic transsphenoidal surgery. A 6.5-, 4.9-, or 4.0-mm, 0- and 30-degree rigid 3-D stereoendoscope (Visionsense, Ltd., Petach Tikva, Israel) was used in all cases. The endoscope is based on “compound eye” technology, incorporating a microarray of lenses. Patients were followed prospectively and compared with a matched group of patients who underwent endoscopic surgery with a 2-dimensional (2-D) endoscope. Surgeon comfort and/or complaints regarding the endoscope were recorded. RESULTS The 3-D endoscope was used as the sole method of visualization to remove 10 pituitary adenomas, 1 cystic xanthogranuloma, 1 metastasis, and 1 cavernous sinus hemangioma. Improved depth perception without eye strain or headache was noted by the surgeons. There were no intraoperative complications. All patients without cavernous sinus extension (7of 9 patients) had gross tumor removal. There were no significant differences in operative time, length of stay, or extent of resection compared with cases in which a 2-D endoscope was used. Subjective depth perception was improved compared with standard 2-D scopes. CONCLUSION In this first reported series of purely 3-D endoscopic transsphenoidal pituitary surgery, we demonstrate subjectively improved depth perception and excellent outcomes with no increase in operative time. Three-dimensional endoscopes may become the standard tool for minimal access neurosurgery.

A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

2011 ◽  
Vol 114 (5) ◽  
pp. 1380-1385 ◽  
Author(s):  
Richard A. Chole ◽  
Chris Lim ◽  
Brian Dunham ◽  
Michael R. Chicoine ◽  
Ralph G. Dacey
Keyword(s):  
Transsphenoidal Surgery ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Surgical Approaches ◽  
Surgical Experience ◽  
Endoscopic Techniques ◽  
Minimally Invasive Surgical ◽  
Transsphenoidal Pituitary Surgery ◽  
Microscopic Techniques

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.

Recognition and management of delayed hyponatremia following transsphenoidal pituitary surgery

2007 ◽  
Vol 106 (1) ◽  
pp. 66-71 ◽  
Author(s):  
Gabriel Zada ◽  
Charles Y. Liu ◽  
Dawn Fishback ◽  
Peter A. Singer ◽  
Martin H. Weiss
Keyword(s):  
Serum Sodium ◽  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
University Hospital ◽  
Outpatient Basis ◽  
Tumor Type ◽  
University Of Southern California ◽  
Female Patients ◽  
Transsphenoidal Pituitary Surgery ◽  
The University

Object The goal of this study was to assess the incidence of symptomatic and occult hyponatremia in patients who had undergone transsphenoidal pituitary surgery. Methods Patients who underwent transsphenoidal surgery at the University of Southern California University Hospital between 1997 and 2004 had serum sodium levels drawn on an outpatient basis on postoperative Day 7. Patient records were retrospectively reviewed to determine the incidence of, and risk factors for, symptomatic and asymptomatic hyponatremia. Two hundred forty-one patients had routine serum sodium levels drawn as outpatients on postoperative Day 7. Twenty-three percent of these patients were found to be hyponatremic (Na ≤ 135 mEq/L). The overall incidence rate of symptomatic hyponatremia in the 241 patients was 5%. The majority of hyponatremic patients (80%) remained asymptomatic, whereas 20% became symptomatic. In patients with symptomatic hyponatremia, the mean sodium level at diagnosis was 120.5 mEq/L, compared with 128.4 mEq/L in asymptomatic, hyponatremic patients (p < 0.0001). Female patients were more likely to develop hyponatremia than male patients (33% compared with 22%, p < 0.03). Fifty-two percent of patients who had transient diabetes insipidus (DI) early in their postoperative course subsequently developed hyponatremia, compared with 21% of those who did not have DI (p < 0.001). Patient age, tumor type, and tumor size did not correlate with development of delayed hyponatremia. Outpatients with moderately and severely low sodium levels were 5 and 12.5 times more likely, respectively, to be symptomatic than were patients with mild hyponatremia. Conclusions Delayed hyponatremia occurs more frequently than was previously suspected in patients who have undergone transsphenoidal surgery, especially in female patients and those who have previously had transient DI. The majority of hyponatremic patients remain asymptomatic. Obtaining a serum sodium value on an outpatient basis 1 week after pituitary surgery is helpful in recognition, risk stratification, and subsequent intervention, and may prevent potentially serious complications.

Hermann Schloffer and the origin of transsphenoidal pituitary surgery

2012 ◽  
Vol 33 (2) ◽  
pp. E5 ◽  
Author(s):  
Richard F. Schmidt ◽  
Osamah J. Choudhry ◽  
Ramya Takkellapati ◽  
Jean Anderson Eloy ◽  
William T. Couldwell ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Skull Base Surgery ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Harvey Cushing ◽  
Transsphenoidal Pituitary Surgery ◽  
Transsphenoidal Operation ◽  
Technological Limitations ◽  
The University

A little over a century ago, in 1907, at the University of Innsbruck, Hermann Schloffer performed the first transsphenoidal surgery on a living patient harboring a pituitary adenoma. Schloffer used a superior nasal route via a transfacial lateral rhinotomy incision. This was perhaps his greatest academic contribution to neurosurgery. Despite the technological limitations of that time, Schloffer's operation was groundbreaking in that it laid the foundation for future development and refinement of transsphenoidal pituitary surgery, influencing prominent surgeons such as Oskar Hirsch and Harvey Cushing. Even after undergoing multiple modifications and a brief fall into obscurity, the transsphenoidal approach has endured through generations of surgeons and remains the preferred approach for lesions of the sella turcica to this day. Although Schloffer performed primarily abdominal surgery in his practice, his contributions to the transsphenoidal approach have had a lasting impact in the field of pituitary and skull base surgery. The authors review the life and career of Hermann Schloffer, the surgical details of his transsphenoidal operation, and the legacy that it has left on the field of pituitary surgery.

scholarly journals Carotid Artery Injury during Transsphenoidal Pituitary Surgery: Lessons from a 15-Year Modern Microsurgery Cohort

2019 ◽  
Vol 81 (05) ◽  
pp. 594-602 ◽  
Author(s):  
Jenna Meyer ◽  
Avital Perry ◽  
Christopher S. Graffeo ◽  
Lucas P. Carlstrom ◽  
Christopher R. Marcellino ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Rare Complication ◽  
Case Series ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Senior Author ◽  
Retrospective Case ◽  
Endoscopic Endonasal ◽  
Neurologic Outcomes ◽  
Transsphenoidal Pituitary Surgery

Background Internal carotid artery (ICA) injury is a rare but potentially catastrophic complication of transsphenoidal resection (TSR) of pituitary tumors, potentially resulting in a host of deficits due to the risk of hemorrhage, ischemia, or even death. The endoscopic endonasal approach (EEA) has gained considerable popularity in the modern era, with few busy neurosurgeons remaining committed to practicing transnasal pituitary microsurgery. Our objective was therefore to characterize the overall incidence of ICA injury in a large, longitudinal, single-surgeon microscopic TSR series conducted during the modern EEA era. Methods Retrospective case series. Results Overall TSR volume by the senior author (F.B.M.) was 817 pituitary tumors during the study period, 2002 to 2017. Within that cohort, two instances of ICA injury were identified (0.2%), including one each with Cushing's disease and acromegaly, both of whom ultimately recovered without residual neurologic deficit. No pediatric injuries were identified. Conclusion Vascular injury is an exceedingly rare complication of transsphenoidal pituitary surgery. Adjuncts to prevent this complication include careful review of the coronal magnetic resonance imaging, identification of the midline, as needed use of the Doppler, and initial caudal opening of the sellar dura. Although potentially disastrous, good neurologic outcomes may be obtained, with immediate judicious packing followed by immediate digital subtraction angiography to assess vessel patency and secondary complications such as pseudoaneurysm.

scholarly journals Endonasal Arteriovenous Fistula Following Transsphenoidal Resection of Pituitary Adenoma Treated with N-Butyl-2-Cyanoacrylate

2019 ◽  
Vol 08 (03) ◽  
pp. 196-198
Author(s):  
Giancarlo Saal-Zapata ◽  
Walter Durand Castro ◽  
Rodolfo Rodriguez Varela
Keyword(s):  
Pituitary Adenoma ◽  
Carotid Artery ◽  
Arteriovenous Fistula ◽  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
Endovascular Embolization ◽  
External Carotid Artery ◽  
Vascular Lesions ◽  
External Carotid ◽  
Transsphenoidal Pituitary Surgery

AbstractVascular lesions of the external carotid artery after transsphenoidal pituitary surgery are rare. Immediate diagnosis must be done and endovascular embolization is the treatment of choice.We report the case of a 53-year-old woman with visual complaints who underwent transsphenoidal surgery of a pituitary adenoma with good clinical and radiological evolution. Five days after surgery nasal tampons were removed and suddenly the patient started to bleed: nasal packing and air way protection were required. Digital subtraction angiography revealed an endonasal arteriovenous fistula with a feeder from the sphenopalatine artery and drainage to sphenopalatine veins. Embolization with N-butyl-2-cyanoacrylate was performed with total obliteration of the arteriovenous fistula. We suggest that endovascular treatment of external carotid artery lesions after transsphenoidal surgery is the best alternative in cases of active bleeding.

159 Factors Associated with Postoperative Complications Following Transsphenoidal Surgery for Pituitary Tumor resection from the national Surgical Quality Improvement Program (NSQIP)

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 239-240
Author(s):  
Andrew Karl Rock ◽  
Charles Frederick Opalak ◽  
Kathryn Workman ◽  
Matthew Carr ◽  
William C Broaddus
Keyword(s):  
Postoperative Complications ◽  
Transsphenoidal Surgery ◽  
Tumor Resection ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Improvement Program ◽  
Surgical Quality ◽  
Duration Of Surgery ◽  
Transsphenoidal Pituitary Surgery ◽  
Complications And Mortality

Abstract INTRODUCTION Pituitary tumors are the second most common brain tumor (15.9%) in the United States. Transsphenoidal surgery is commonly indicated for pituitary tumors and few studies have investigated postoperative complications following this procedure. Our objective was to utilize the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to estimate the prevalence of and risk factors for complications following transsphenoidal pituitary surgery. METHODS Patients undergoing transsphenoidal surgery for pituitary tumor resection (CPT codes: 61 548, 62 165) from 2005 to 2015 were extracted from the ACS-NSQIP. The prevalence of postoperative complications was determined. Multivariable logistic regression was used to identify demographic, comorbid, and perioperative characteristics associated with any morbidity, severe (Clavien IV) complications, and mortality. RESULTS >Within 1177 transsphenoidal surgeries, there were 105 (8.92%) cases with at least one non-fatal complication, 29 (2.46%) cases with a severe complication, and 11 (0.93%) cases of mortality. The three most common complications were: reoperation (3.40%), transfusion (2.04%), and unplanned intubation (2.70%). In multivariable logistic regression analysis, the only significant predictors for postoperative complications were: 1) duration of surgery in hours for any morbidity (Odds Ratio [OR]: 1.30; 95% Confidence Interval [CI]: 1.15-1.46; P < 0.001), severe complications (OR: 1.38; 95% CI; 1.18-1.61; P < 0.001), and mortality (OR: 1.36; 95% CI: 1.11-1.67; P < 0.01); and 2) American Society of Anesthesiologists (ASA) class III-V for any morbidity (OR: 1.99; 95% CI: 1.23-3.21; P < 0.05) and severe complications (OR: 2.99; 95% CI: 1.13-7.94; P < 0.05). The area under the curve for any morbidity, severe complications, and mortality were 0.67, 0.74, and 0.77, respectively. CONCLUSION Transsphenoidal pituitary surgery is a relatively safe procedure with any morbidity occurring in approximately 1 in 10 patients and mortality occurring in approximately 1 in 100 patients. Our findings demonstrate duration of surgery and higher ASA classification is associated with increased risk for postoperative complications following transsphenoidal pituitary surgery.

scholarly journals Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery

2020 ◽  
pp. 1-10 ◽  
Author(s):  
Lea M. Alhilali ◽  
Andrew S. Little ◽  
Kevin C. J. Yuen ◽  
Jae Lee ◽  
Timothy K. Ho ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Residual Tumor ◽  
Pituitary Surgery ◽  
Intraoperative Assessment ◽  
Postoperative Mri ◽  
Transsphenoidal Pituitary Surgery

OBJECTIVECurrent practice guidelines recommend delayed (≥ 3 months after operation) postoperative MRI after transsphenoidal surgery for pituitary adenomas, although this practice defers obtaining important information, such as the presence of a residual adenoma, that might influence patient management during the perioperative period. In this study, the authors compared detection of residual adenomas by means of early postoperative (EPO) MRI (< 48 hours postsurgery) with both surgeon intraoperative assessment and late postoperative (LPO) MRI at 3 months.METHODSAdult patients who underwent microscopic transsphenoidal surgery for pituitary adenomas with MRI preoperatively, < 48 hours after the operation, 3 months postoperatively, and yearly for 4 years were included. The presence or absence of residual tumor was assessed intraoperatively by a single surgeon and postoperatively by 2 neuroradiologists blinded to the intraoperative assessment and other postoperative imaging studies. The presence of residual tumor was confirmed by reresection, tumor growth on imaging, or hormonal evidence. Interreader reliability was calculated at each imaging time point. Specificity, sensitivity, positive predictive value, and negative predictive value for EPO and LPO imaging and intraoperative assessment were determined.RESULTSIn total, 102 consecutive patients who underwent microscopic transsphenoidal resection of a pituitary adenoma were included. Eighteen patients (18%) had confirmed residual tumors (12 confirmed by tumor growth, 5 by surgery, and 1 by biochemical evidence of persistent disease). Interreader reliability for detecting residual tumor on EPO MRI was almost perfect (κ = 0.88) and significantly higher than that for LPO MRI (κ = 0.69, p = 0.03). EPO MRI was highly specific for residual tumor (98%), a finding similar to that for intraoperative assessment (99%, p = 0.60) and significantly higher than that for LPO MRI (81%, p < 0.001). Notably, EPO MRI was significantly more sensitive for residual tumor (100%) than both intraoperative assessment (78%, p = 0.04) and LPO MRI (78%, p = 0.04). EPO MRI had a 100% negative predictive value and was used to find 4 residual tumors that were not identified intraoperatively. Residual tumors found on EPO MRI allowed for reresection during the same hospitalization for 3 patients.CONCLUSIONSEPO MRI after transsphenoidal pituitary surgery can be reliably interpreted and has greater sensitivity for detecting residual tumor than intraoperative assessment and LPO MRI. This result challenges current guidelines stating that delayed postoperative imaging is preferable to early imaging. Pituitary surgeons should consider performing EPO MRI either in addition to or instead of delayed imaging.

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