Inefficiency of the anticoagulant therapy in the regression of the radiation-induced optic neuropathy in Cushing’s disease

Abstract

Radiation-induced optic neuropathy is a rare complication (prevalence less than 1%) following radiotherapy of the sellar region. However, the vasculopathy in Cushing's disease predisposes to radiation-induced injury. We report the case of a 24-year-old man with Cushing's disease since he was 16. The hormonal study including bilateral inferior petrosal sinus catheterization diagnosed a pituitary right lesion, but imagiology was always negative. He underwent a transsphenoidal microadenomectomy and the pathological study showed the presence of corticotrophic hyperplasia but no adenoma. Secondary hypothyroidism and hypogonadism as well as permanent diabetes insipidus were diagnosed and because the patient was not cured he underwent a second transsphenoidal total hypophysectomy. After that and because he was still hypercortisolemic, pituitary external irradiation was given in a total dose of 6000 rad. Six months later he developed progressive bilateral visual loss. Cerebral MR revealed focal enhancement of the enlarged optic nerves and chiasm, associated with demyelination areas of the posterior visual pathways. Treatment was tried first with high doses of corticosteroids and later with anticoagulants-heparin EV. 1000 U/h during 7 days followed by warfarin, but unsuccessfully, probably because the patient was already amaurotic at the beginning of the last treatment.

Radiation-induced optic neuropathy

“…However, the success has been limited in patients with radiation injury to the visual pathway. 49 Moreover, RION has been documented to occur in patients receiving anticoagulation therapy for cardiac disease. 50 …”

Radiation‐induced optic neuropathy: still no treatment

“…I have tried both with poor results. Indeed, like Landau and Killer 22 , I have seen a patient who developed RON while taking warfarin for cardiac disease.…”

“…Treatment for RON, as emphasized in the two articles in this issue of the Journal 1,2 , is disappointing to say the least. Neither systemic corticosteroids nor anticoagulation, both of which seem to be somewhat effective in treating generalized radionecrosis in the CNS 19,20 , are effective in the treatment of RON 11,21,22 . I have tried both with poor results.…”

Optic Neuropathy Following Orbital Irradiation for Graves’ Ophthalmopathy: A Case Report and Literature Review

“…A similar beneficial effect, however, has not been demonstrated in patients with RON. 14 Kim et al 15 demonstrated in a rat model that ramipril (an angiotensin-converting enzyme inhibitor) significantly modified radiation-induced injury.…”