Ophthalmoplegic complications in transsphenoidal pituitary surgery

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OBJECTIVE

Ophthalmoplegia 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.

METHODS

The authors retrospectively analyzed 24 cases of postoperative ophthalmoplegia selected from the 1694 patients operated via a transsphenoidal route in their department.

RESULTS

Two 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.

CONCLUSIONS

Extraocular 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.

ABBREVIATIONS CI = confidence interval; CN = cranial nerve; GTR = gross-total resection; ICA = internal carotid artery; OR = odds ratio; PR = partial resection; STR = subtotal resection.

Article Information

Correspondence Simona Mihaela Florea: University Hospital of La Timone, Assistance Publique–Hôpitaux de Marseille, Université Aix-Marseille, Marseille, France. sm.floreamd@gmail.com.

INCLUDE WHEN CITING Published online July 26, 2019; DOI: 10.3171/2019.5.JNS19782.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Axial and coronal CT scans obtained in a 60-year-old woman who underwent an operation for a Knosp grade 2 gonadotrophic adenoma (left). The patient presented with left CN III palsy 24 hours after surgery. The postoperative CT scan shows a hematoma (right). The patient underwent reoperation, with a complete recovery 3 days after the decompression.

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    Left: Preoperative T2-weighted coronal MR image from a 42-year-old woman who was operated on for a microadenoma (acromegaly), located in the left anterior pituitary. The patient developed a left CN VI palsy approximately 36 hours postoperatively. Right: The postoperative CT scan shows a left cavernous sinus that is slightly hyperdense compared to the right side, suggesting a minimal hemorrhagic suffusion into the cavernous sinus. The patient did not undergo reoperation. The deficit recovered over the following 3 months.

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    Preoperative MRI (left) and postoperative CT scan (right) in a 34-year-old man with a Knosp grade 4 nonfunctioning adenoma, showing residual tumor in the left cavernous sinus. He presented with left palpebral ptosis and mydriasis approximately 48 hours after surgery. No reoperation was indicated; the deficit completely recovered by his first check-up (3 months postoperatively).

  • View in gallery

    Temporal disposition of patients presenting with postoperative oculomotor nerve palsy at our institution. Figure is available in color online only.

References

  • 1

    Agam MSWedemeyer MAWrobel BWeiss MHCarmichael JDZada G: Complications associated with microscopic and endoscopic transsphenoidal pituitary surgery: experience of 1153 consecutive cases treated at a single tertiary care pituitary center. J Neurosurg 130:140917882019

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Barker FG IIKlibanski ASwearingen B: Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 88:470947192003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Barzaghi LRLosa MGiovanelli MMortini P: Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre. Acta Neurochir (Wien) 149:8778862007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Berker MHazer DBYücel TGürlek ACila AAldur M: Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary 15:2883002012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Buchfelder MFahlbusch R: Komplicationen bei Operationen von Hypophysenadenomen in Bock WJ (ed): Komplikationen bei neurochirurgischen Eingriffen. Munich: Zuckschwerdt1988

    • Search Google Scholar
    • Export Citation
  • 6

    Cappabianca PCavallo LMColao Ade Divitiis E: Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:2932982002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Catapano DSloffer CAFrank GPasquini ED’Angelo VALanzino G: Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. J Neurosurg 104:4194252006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Cebula HKurbanov AZimmer LAPoczos PLeach JLDe Battista JC: Endoscopic, endonasal variability in the anatomy of the internal carotid artery. World Neurosurg 82:e759e7642014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Ceylan SCabuk BKoc KAnik IVural C: Endoscopic distinction between capsule and pseudocapsule of pituitary adenomas. Acta Neurochir (Wien) 155:161116192013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Charalampaki PReisch RAyad AConrad JWelschehold SPerneczky A: Endoscopic endonasal pituitary surgery: surgical and outcome analysis of 50 cases. J Clin Neurosci 14:4104152007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Ciric IRagin ABaumgartner CPierce D: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:2252371997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    de Divitiis ECappabianca PCarvallo M: Endoscopic endonasal transsphenoidal approach to the sellar region in de Divitiis ECappabianca P (eds): Endoscopic Endonasal Transsphenoidal Surgery. Vienna: Springer Vienna2003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Frank GPasquini E: Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas in Laws ER JrSheehan JP (eds): Pituitary Surgery—A Modern Approach. Basel: Karger2006 Vol 34 pp 6482

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Gondim JAAlmeida JPCAlbuquerque LAFSchops MGomes EFerraz T: Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 14:1741832011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Halvorsen HRamm-Pettersen JJosefsen RRønning PReinlie SMeling T: Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir (Wien) 156:4414492014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Hardy J: Transphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 16:1852171969

  • 17

    Hardy J: Transsphenoidal surgery of hypersecreting pituitary tumors in Kohler PORoss GT (eds): Diagnosis and Treatment of Pituitary Tumors. Amsterdam: Excerpta Medica1973 pp 179194

    • Search Google Scholar
    • Export Citation
  • 18

    Hardy JMohr G: [Prolactinoma: surgical aspects.] Neurochirurgie 27 (Suppl 1):41601981 (French)

  • 19

    Jane JA JrThapar KLaws ER Jr: Pituitary tumors: functioning and nonfunctioning in Youmans JRWinn HR (eds): Youmans Neurological Surgery ed 6. Philadelphia: Elsevier/Saunders2011 Vol. 2 pp 14761510

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Jho HDCarrau RL: Endoscopy assisted transsphenoidal surgery for pituitary adenoma. Technical note. Acta Neurochir (Wien) 138:141614251996

  • 21

    Kassam ABPrevedello DMCarrau RLSnyderman CHThomas AGardner P: Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 114:154415682011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    King JAJKaye AH: The history of trans-sphenoidal surgery for pituitary tumours in Laws Jr ERCohen-Gadol AASchwartz THSheehan JP (eds): Transsphenoidal Surgery. Cham: Springer International Publishing2017 pp 1126

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Knosp ESteiner EKitz KMatula C: Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33:6106181993

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Krings JGKallogjeri DWineland ANepple KGPiccirillo JFGetz AE: Complications following primary and revision transsphenoidal surgeries for pituitary tumors. Laryngoscope 125:3113172015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Laws ER: Complications of transsphenoidal microsurgery for pituitary adenomas in Brock M (ed): Modern Neurosurgery. Berlin: Springer Verlag1982 Vol 1 pp 181186

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Leyer CCastinetti FMorange IGueydan MOliver CConte-Devolx B: A conservative management is preferable in milder forms of pituitary tumor apoplexy. J Endocrinol Invest 34:5025092011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Magro EGraillon TLassave JCastinetti FBoissonneau STabouret E: Complications related to the endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary macroadenomas in 300 consecutive patients. World Neurosurg 89:4424532016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Messerer MDe Battista JCRaverot GKassis SDubourg JLapras V: Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus 30(4):E112011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Mortini PLosa MBarzaghi RBoari NGiovanelli M: Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 56:122212332005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Oldfield EHVortmeyer AO: Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 104:7192006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Persky MSBrunner ECooper PRCohen NL: Perioperative complications of transseptosphenoidal excision for pituitary adenomas. Skull Base Surg 6:2312351996

  • 32

    Prevedello DMEbner FHde Lara DDitzel Filho LOtto BACarrau RL: Extracapsular dissection technique with the cotton swab for pituitary adenomas through an endoscopic endonasal approach—how I do it. Acta Neurochir (Wien) 155:162916322013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Qu XYang JSun JDMou CZWang GDHan T: Transsphenoidal pseudocapsule-based extracapsular resection for pituitary adenomas. Acta Neurochir (Wien) 153:7998062011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Semple PLLaws ER Jr: Complications in a contemporary series of patients who underwent transsphenoidal surgery for Cushing’s disease. J Neurosurg 91:1751791999

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Smith TRHulou MMHuang KTNery Bde Moura SMCote DJ: Complications after transsphenoidal surgery for patients with Cushing’s disease and silent corticotroph adenomas. Neurosurg Focus 38(2):E122015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Wang FZhou TWei SMeng XZhang JHou Y: Endoscopic endonasal transsphenoidal surgery of 1,166 pituitary adenomas. Surg Endosc 29:127012802015

  • 37

    Wilson CBDempsey LC: Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 48:13221978

  • 38

    Zhou TWei SBMeng XHXu BN: [Pure endoscopic endonasal transsphenoidal approach for 375 pituitary adenomas.] Zhonghua Wai Ke Za Zhi 48:144314462010 (Chinese)

    • PubMed
    • Search Google Scholar
    • Export Citation

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