Ophthalmoplegic complications in transsphenoidal pituitary surgery

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  • 1 Department of Neurosurgery, La Timone University Hospital, and
  • 2 Department of Endocrinology, La Conception University Hospital, Assistance Publique–Hôpitaux de Marseille, Université Aix-Marseille, Marseille, France
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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.

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Contributor Notes

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.

  • 1

    Agam MS, Wedemeyer MA, Wrobel B, Weiss MH, Carmichael JD, Zada 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 130:14091788, 2019

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Barker FG II, Klibanski A, Swearingen 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 88:47094719, 2003

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

    Barzaghi LR, Losa M, Giovanelli M, Mortini P: Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre. Acta Neurochir (Wien) 149:877886, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Berker M, Hazer DB, Yücel T, Gürlek A, Cila A, Aldur M, : Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary 15:288300, 2012

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

    Buchfelder M, Fahlbusch R: Komplicationen bei Operationen von Hypophysenadenomen, in Bock WJ (ed): Komplikationen bei neurochirurgischen Eingriffen. Munich: Zuckschwerdt, 1988

    • Search Google Scholar
    • Export Citation
  • 6

    Cappabianca P, Cavallo LM, Colao A, de Divitiis E: Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:293298, 2002

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

    Catapano D, Sloffer CA, Frank G, Pasquini E, D’Angelo VA, Lanzino G: Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. J Neurosurg 104:419425, 2006

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

    Cebula H, Kurbanov A, Zimmer LA, Poczos P, Leach JL, De Battista JC, : Endoscopic, endonasal variability in the anatomy of the internal carotid artery. World Neurosurg 82:e759e764, 2014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Ceylan S, Cabuk B, Koc K, Anik I, Vural C: Endoscopic distinction between capsule and pseudocapsule of pituitary adenomas. Acta Neurochir (Wien) 155:16111619, 2013

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

    Charalampaki P, Reisch R, Ayad A, Conrad J, Welschehold S, Perneczky A, : Endoscopic endonasal pituitary surgery: surgical and outcome analysis of 50 cases. J Clin Neurosci 14:410415, 2007

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

    Ciric I, Ragin A, Baumgartner C, Pierce D: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225237, 1997

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

    de Divitiis E, Cappabianca P, Carvallo M: Endoscopic endonasal transsphenoidal approach to the sellar region, in de Divitiis E, Cappabianca P (eds): Endoscopic Endonasal Transsphenoidal Surgery. Vienna: Springer Vienna, 2003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Frank G, Pasquini E: Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas, in Laws ER Jr, Sheehan JP (eds): Pituitary Surgery—A Modern Approach. Basel: Karger, 2006, Vol 34, pp 6482

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Gondim JA, Almeida JPC, Albuquerque LAF, Schops M, Gomes E, Ferraz T, : Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 14:174183, 2011

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

    Halvorsen H, Ramm-Pettersen J, Josefsen R, Rønning P, Reinlie S, Meling T, : Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir (Wien) 156:441449, 2014

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

    Hardy J: Transphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 16:185217, 1969

  • 17

    Hardy J: Transsphenoidal surgery of hypersecreting pituitary tumors, in Kohler PO, Ross GT (eds): Diagnosis and Treatment of Pituitary Tumors. Amsterdam: Excerpta Medica, 1973, pp 179194

    • Search Google Scholar
    • Export Citation
  • 18

    Hardy J, Mohr G: [Prolactinoma: surgical aspects.] Neurochirurgie 27 (Suppl 1):4160, 1981 (French)

  • 19

    Jane JA Jr, Thapar K, Laws ER Jr: Pituitary tumors: functioning and nonfunctioning, in Youmans JR, Winn HR (eds): Youmans Neurological Surgery, ed 6. Philadelphia: Elsevier/Saunders, 2011, Vol. 2, pp 14761510

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Jho HD, Carrau RL: Endoscopy assisted transsphenoidal surgery for pituitary adenoma. Technical note. Acta Neurochir (Wien) 138:14161425, 1996

  • 21

    Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, : Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 114:15441568, 2011

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

    King JAJ, Kaye AH: The history of trans-sphenoidal surgery for pituitary tumours, in Laws, Jr ER, Cohen-Gadol AA, Schwartz TH, Sheehan JP (eds): Transsphenoidal Surgery. Cham: Springer International Publishing, 2017, pp 1126

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Knosp E, Steiner E, Kitz K, Matula C: Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33:610618, 1993

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Krings JG, Kallogjeri D, Wineland A, Nepple KG, Piccirillo JF, Getz AE: Complications following primary and revision transsphenoidal surgeries for pituitary tumors. Laryngoscope 125:311317, 2015

    • 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 Verlag, 1982, Vol 1, pp 181186

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Leyer C, Castinetti F, Morange I, Gueydan M, Oliver C, Conte-Devolx B, : A conservative management is preferable in milder forms of pituitary tumor apoplexy. J Endocrinol Invest 34:502509, 2011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Magro E, Graillon T, Lassave J, Castinetti F, Boissonneau S, Tabouret E, : Complications related to the endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary macroadenomas in 300 consecutive patients. World Neurosurg 89:442453, 2016

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

    Messerer M, De Battista JC, Raverot G, Kassis S, Dubourg J, Lapras V, : Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus 30(4):E11, 2011

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

    Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M: Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 56:12221233, 2005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Oldfield EH, Vortmeyer AO: Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 104:719, 2006

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

    Persky MS, Brunner E, Cooper PR, Cohen NL: Perioperative complications of transseptosphenoidal excision for pituitary adenomas. Skull Base Surg 6:231235, 1996

  • 32

    Prevedello DM, Ebner FH, de Lara D, Ditzel Filho L, Otto BA, Carrau RL: Extracapsular dissection technique with the cotton swab for pituitary adenomas through an endoscopic endonasal approach—how I do it. Acta Neurochir (Wien) 155:16291632, 2013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Qu X, Yang J, Sun JD, Mou CZ, Wang GD, Han T, : Transsphenoidal pseudocapsule-based extracapsular resection for pituitary adenomas. Acta Neurochir (Wien) 153:799806, 2011

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

    Semple PL, Laws ER Jr: Complications in a contemporary series of patients who underwent transsphenoidal surgery for Cushing’s disease. J Neurosurg 91:175179, 1999

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Smith TR, Hulou MM, Huang KT, Nery B, de Moura SM, Cote DJ, : Complications after transsphenoidal surgery for patients with Cushing’s disease and silent corticotroph adenomas. Neurosurg Focus 38(2):E12, 2015

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

    Wang F, Zhou T, Wei S, Meng X, Zhang J, Hou Y, : Endoscopic endonasal transsphenoidal surgery of 1,166 pituitary adenomas. Surg Endosc 29:12701280, 2015

  • 37

    Wilson CB, Dempsey LC: Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 48:1322, 1978

  • 38

    Zhou T, Wei SB, Meng XH, Xu BN: [Pure endoscopic endonasal transsphenoidal approach for 375 pituitary adenomas.] Zhonghua Wai Ke Za Zhi 48:14431446, 2010 (Chinese)

    • PubMed
    • Search Google Scholar
    • Export Citation

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