RESUMO
OBJECTIVE Endoscopic resection of pituitary adenomas has been reported to improve vision function in up to 80%-90% of patients with visual impairment due to these adenomas. It is unclear how these reported rates translate into improvement in visual outcomes and general health as perceived by the patients. The authors evaluated self-assessed health-related quality of life (HR-QOL) and vision-related QOL (VR-QOL) in patients before and after endoscopic resection of pituitary adenomas. METHODS The authors prospectively collected data from 50 patients who underwent endoscopic resection of pituitary adenomas. This cohort included 32 patients (64%) with visual impairment preoperatively. Twenty-seven patients (54%) had pituitary dysfunction, including 17 (34%) with hormone-producing tumors. Patients completed the National Eye Institute Visual Functioning Questionnaire and the 36-Item Short Form Health Survey preoperatively and 6 weeks and 6 months after surgery. RESULTS Patients with preoperative visual impairment reported a significant impact of this condition on VR-QOL preoperatively, including general vision, near activities, and peripheral vision; they also noted vision-specific impacts on mental health, role difficulties, dependency, and driving. After endoscopic resection of adenomas, patients reported improvement across all these categories 6 weeks postoperatively, and this improvement was maintained by 6 months postoperatively. Patients with preoperative pituitary dysfunction, including hormone-producing tumors, perceived their general health and physical function as poorer, with some of these patients reporting improvement in perceived general health after the endoscopic surgery. All patients noted that their ability to work or perform activities of daily living was transiently reduced 6 weeks postoperatively, followed by significant improvement by 6 months after the surgery. CONCLUSIONS Both VR-QOL and patient's perceptions of their ability to do work and perform other daily activities as a result of their physical health significantly improved by 6 months after endoscopic resection of pituitary adenoma. The use of multidimensional QOL questionnaires provides a precise assessment of perceived outcomes after endoscopic surgery.
Assuntos
Adenoma/cirurgia , Autoavaliação Diagnóstica , Neuroendoscopia/métodos , Neoplasias Hipofisárias/cirurgia , Qualidade de Vida , Visão Ocular , Adenoma/complicações , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/complicações , Estudos Prospectivos , Osso Esfenoide , Resultado do Tratamento , Transtornos da Visão/etiologiaRESUMO
OBJECT: The authors report their results in a series of large or giant carotid ophthalmic segment aneurysms clipped using retrograde suction decompression. METHODS: A retrospective review of clinical data and treatment summaries was performed for 18 patients with large or giant carotid artery ophthalmic segment aneurysms managed operatively via retrograde suction decompression. Visual outcomes, Glasgow Outcome Scale (GOS) scores, and operative complications were determined. Postoperative angiography was assessed. RESULTS: During a 17-year period, 18 patients underwent surgery performed using retrograde suction decompression. The mean aneurysm size was 26 mm. Three patients presented with subarachnoid hemorrhage. Fourteen of 18 patients presented with visual symptoms. Eleven (79%) of these 14 patients experienced visual improvement and the remaining 3 (21%) experienced worsened vision after surgery. Of 3 patients without visual symptoms and a complete visual examination before and after surgery, 1 had visual worsening postoperatively. One aneurysm required trapping and bypass, and all others could be clipped. Postoperative angiography demonstrated complete occlusion in 9 of 17 clipped aneurysms and neck remnants in the other 8 clipped aneurysms. One (5.5%) of 18 patients experienced a stroke. Eighteen patients had a GOS score of 5 (good outcome), and 1 patient had a GOS score of 4 (moderately disabled). There were no deaths. There was no morbidity related to the second incision or decompression procedure. Prolonged improvement did occur, and even in some cases of visual worsening in 1 eye, the overall vision did improve enough to allow driving. CONCLUSIONS: Retrograde suction decompression greatly facilitates surgical clipping for large and giant aneurysms of the ophthalmic segment. Visual preservation and improvement occur in the majority of these cases and is an important outcome measure. Developing endovascular technology must show equivalence or superiority to surgery for this specific outcome.
Assuntos
Aneurisma/cirurgia , Doenças das Artérias Carótidas/cirurgia , Cirurgia de Descompressão Microvascular/métodos , Artéria Oftálmica/cirurgia , Visão Ocular/fisiologia , Adulto , Idoso , Aneurisma/complicações , Angiografia , Feminino , Escala de Resultado de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Oftálmica/diagnóstico por imagem , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Resultado do Tratamento , Transtornos da Visão/etiologia , Transtornos da Visão/fisiopatologiaRESUMO
A 34-year-old woman presented with brainstem compression from a large third nerve schwannoma although third nerve function was intact. At surgery, preservation of the proximal third nerve was not possible. Because of preexisting amblyopia of the contralateral eye, an attempt was made to surgically reinnervate the affected third nerve. The fourth nerve was divided at its entry into the tentorium and anastomosed to the distal stump of the third nerve. Partial recovery of third function occurred over several months and is still present 6 years later. Successful long-term reinnervation of the third nerve by direct anastomosis with the fourth nerve may be useful when third repair is not possible.
Assuntos
Neoplasias dos Nervos Cranianos/cirurgia , Movimentos Oculares/fisiologia , Pálpebras/fisiopatologia , Neurilemoma/cirurgia , Doenças do Nervo Oculomotor/cirurgia , Nervo Troclear/cirurgia , Adulto , Anastomose Cirúrgica , Neoplasias dos Nervos Cranianos/patologia , Neoplasias dos Nervos Cranianos/fisiopatologia , Descompressão Cirúrgica , Feminino , Humanos , Neurilemoma/patologia , Neurilemoma/fisiopatologia , Doenças do Nervo Oculomotor/patologia , Doenças do Nervo Oculomotor/fisiopatologia , Recuperação de Função Fisiológica/fisiologia , Resultado do TratamentoRESUMO
Compression induced by a pituitary tumor on the optic chiasm can generate visual field deficits, yet it is unknown how this compression affects the retinotopic organization of the visual cortex. It is also not known how the effect of the tumor on the retinotopic organization of the visual cortex changes after decompression. The authors used functional MRI (fMRI) to map the retinotopic organization of the visual cortex in a 68-year-old right-handed woman before and 3 months after surgery for a recurrent pituitary macroadenoma. The authors demonstrated that longitudinal changes in visual field perimetry, as assessed by the automated Humphrey visual field test, correlated with longitudinal changes in fMRI activation in a retinotopic manner. In other words, after decompression of the optic chiasm, fMRI charted the recruitment of the visual cortex in a way that matched gains in visual field perimetry. On the basis of this case, the authors propose that fMRI can chart neural plasticity of the visual cortex on an individual basis and that it can also serve as a complementary tool in decision making with respect to management of patients with chiasmal compression.
Assuntos
Adenoma/cirurgia , Descompressão Cirúrgica , Recidiva Local de Neoplasia/cirurgia , Síndromes de Compressão Nervosa/cirurgia , Quiasma Óptico/cirurgia , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Retina/fisiopatologia , Córtex Visual/fisiopatologia , Campos Visuais/fisiologia , Adenoma/fisiopatologia , Idoso , Mapeamento Encefálico , Endoscopia , Feminino , Seguimentos , Humanos , Interpretação de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Recidiva Local de Neoplasia/fisiopatologia , Síndromes de Compressão Nervosa/fisiopatologia , Plasticidade Neuronal/fisiologia , Quiasma Óptico/fisiopatologia , Neoplasias Hipofisárias/fisiopatologiaRESUMO
BACKGROUND AND IMPORTANCE: Dural arteriovenous fistulas (dAVFs) represent 10% to 15% of all intracranial arteriovenous malformations. Most often, embolization is accomplished with transfemoral catheter techniques. We present a case in which embolization of a cavernous sinus dAVF was made possible through transcranial cannulation of a cortical draining vein. CLINICAL PRESENTATION: An 82-year-old woman presented with diplopia, left sixth cranial nerve palsy, intraocular hypertension, and bilateral chemosis. Angiography revealed a complex cavernous dAVF with cortical venous reflux, supplied by both external carotid arteries and the left meningohypophyseal trunk. Percutaneous transvenous access failed, and only partial occlusion was achieved by transarterial embolization. A frontotemporal craniotomy was performed to access the superficial middle cerebral vein in the left sylvian fissure. Under fluoroscopic guidance, a microcatheter was advanced through this vein to the floor of the middle cranial fossa and into the dAVF, permitting coil occlusion. CONCLUSION: This transcranial vein technique may be a useful adjunct in dAVF therapy when percutaneous transarterial or transvenous approaches fail or are not possible.
Assuntos
Trombose do Corpo Cavernoso/terapia , Malformações Vasculares do Sistema Nervoso Central/terapia , Veias Cerebrais/cirurgia , Embolização Terapêutica/métodos , Idoso de 80 Anos ou mais , Cateterismo/instrumentação , Cateterismo/métodos , Trombose do Corpo Cavernoso/diagnóstico por imagem , Trombose do Corpo Cavernoso/patologia , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Malformações Vasculares do Sistema Nervoso Central/patologia , Embolização Terapêutica/instrumentação , Feminino , Humanos , Radiografia , Reoperação/métodosRESUMO
OBJECTIVES: To describe the tumor characteristics and visual function in conservatively managed patients with non-functioning pituitary macroadenoma (NFMA) that contacted/compressed the visual pathway. DESIGN: Retrospective case-series. SETTING: Tertiary-care academic institution. PARTICIPANTS: Six patients with diagnosis of NFMA. MAIN OUTCOME: Visual function and radiological characteristics of the optic apparatus and pituitary tumor. RESULTS: All patients had radiological evidence of optic apparatus compression but only one had visual field defect at the initial presentation. While two of the six patients developed visual field changes during followup (41±34.8 months), the patient with visual field defect at the time of diagnosis improved to normal vision. CONCLUSIONS: Select NFMAs that contact the optic apparatus, without visual dysfunction, may be managed with close ophthalmological and radiographic monitoring, depending on tumor and imaging characteristics. This may be of particular relevance in patients considered to have a high peri-operative risk, such as advanced age or significant co-morbidities.
Assuntos
Adenoma/complicações , Neoplasias Hipofisárias/complicações , Transtornos da Visão/etiologia , Campos Visuais/fisiologia , Adenoma/diagnóstico , Idoso , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/diagnóstico , Estudos Retrospectivos , Transtornos da Visão/diagnóstico , Vias Visuais/fisiopatologiaRESUMO
PURPOSE: The aim of this study was to assess the incidence of mild (