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.
The authors retrospectively analyzed 24 cases of postoperative ophthalmoplegia selected from the 1694 patients operated via a transsphenoidal route in their department.
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.
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.
AgamMSWedemeyerMAWrobelBWeissMHCarmichaelJDZadaG: Complications associated with microscopic and endoscopic transsphenoidal pituitary surgery: experience of 1153 consecutive cases treated at a single tertiary care pituitary center. J Neurosurg130:1409–17882019
AgamMS, WedemeyerMA, WrobelB, WeissMH, CarmichaelJD, ZadaG: Complications associated with microscopic and endoscopic transsphenoidal pituitary surgery: experience of 1153 consecutive cases treated at a single tertiary care pituitary center. 130:1409–1788, 201910.3171/2017.12.JNS172318)| false
BarkerFGIIKlibanskiASwearingenB: Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab88:4709–47192003
BarkerFGII, KlibanskiA, SwearingenB: Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. 88:4709–4719, 200310.1210/jc.2003-03046114557445)| false
BerkerM, HazerDB, YücelT, GürlekA, CilaA, AldurM, : Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. 15:288–300, 20122216154310.1007/s11102-011-0368-2)| false
CappabiancaP, CavalloLM, ColaoA, de DivitiisE: Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. 97:293–298, 20021218645610.3171/jns.2002.97.2.0293)| false
CatapanoDSlofferCAFrankGPasquiniED’AngeloVALanzinoG: Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. J Neurosurg104:419–4252006
CatapanoD, SlofferCA, FrankG, PasquiniE, D’AngeloVA, LanzinoG: Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. 104:419–425, 20061657265510.3171/jns.2006.104.3.419)| false
CiricI, RaginA, BaumgartnerC, PierceD: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. 40:225–237, 199710.1097/00006123-199702000-000019007854)| false
de DivitiisECappabiancaPCarvalloM: Endoscopic endonasal transsphenoidal approach to the sellar region in de DivitiisECappabiancaP (eds): Endoscopic Endonasal Transsphenoidal Surgery. Vienna: Springer Vienna2003
de DivitiisE, CappabiancaP, CarvalloM: Endoscopic endonasal transsphenoidal approach to the sellar region, in de DivitiisE, CappabiancaP (eds): . Vienna: Springer Vienna, 200310.1007/978-3-7091-6084-8_7)| false
FrankGPasquiniE: Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas in LawsERJrSheehanJP (eds): Pituitary Surgery—A Modern Approach. Basel: Karger2006 Vol 34 pp 64–82
HalvorsenHRamm-PettersenJJosefsenRRønningPReinlieSMelingT: Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir (Wien)156:441–4492014
HalvorsenH, Ramm-PettersenJ, JosefsenR, RønningP, ReinlieS, MelingT, : Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. 156:441–449, 20142434322710.1007/s00701-013-1959-7)| false
KingJAJKayeAH: The history of trans-sphenoidal surgery for pituitary tumours in Laws JrERCohen-GadolAASchwartzTHSheehanJP (eds): Transsphenoidal Surgery. Cham: Springer International Publishing2017 pp 11–26
KingJAJ, KayeAH: The history of trans-sphenoidal surgery for pituitary tumours, in Laws, JrER, Cohen-GadolAA, SchwartzTH, SheehanJP (eds): . Cham: Springer International Publishing, 2017, pp 11–2610.1007/978-3-319-56691-7_2)| false
KnospE, SteinerE, KitzK, MatulaC: Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. 33:610–618, 19938232800)| false
MagroEGraillonTLassaveJCastinettiFBoissonneauSTabouretE: Complications related to the endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary macroadenomas in 300 consecutive patients. World Neurosurg89:442–4532016
PrevedelloDMEbnerFHde LaraDDitzel FilhoLOttoBACarrauRL: Extracapsular dissection technique with the cotton swab for pituitary adenomas through an endoscopic endonasal approach—how I do it. Acta Neurochir (Wien)155:1629–16322013
PrevedelloDM, EbnerFH, de LaraD, Ditzel FilhoL, OttoBA, CarrauRL: Extracapsular dissection technique with the cotton swab for pituitary adenomas through an endoscopic endonasal approach—how I do it. 155:1629–1632, 201310.1007/s00701-013-1766-1)| false
SmithTR, HulouMM, HuangKT, NeryB, de MouraSM, CoteDJ, : Complications after transsphenoidal surgery for patients with Cushing’s disease and silent corticotroph adenomas. 38(2):E12, 201510.3171/2014.10.FOCUS1470525639314)| false