Visual deterioration after endonasal endoscopic skull base surgery: causes, treatments, and outcomes

Abstract

OBJECTIVE Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood. METHODS The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods. RESULTS Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits. CONCLUSIONS Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.

Risk Factors for Significant Postoperative Hemorrhage After Pituitary Neuroendocrine Tumor Resection: A Case-Control Study of 1066 Surgeries

“…This study is limited by its retrospective nature. Although this data set's prevalence of apoplexy and SPH are concordant with the existing literature, [5][6][7][8][20][21][22] the small number of cases makes assessment of long-term outcomes more challenging. Specifically, although there were no mortalities in our cohort, other recent studies have found that up to 42% of SPH cases may be fatal.…”

“…[2][3][4] The rate of SPH after endonasal resection of pituitary neuroendocrine tumor ranges between 0.1% and 1.5, and composes 7.4% of 30-day readmissions for PitNET surgery. [5][6][7][8][9][10][11] Although this is similar to the rate in the broader neurosurgical population, 12 the specific risk factors for developing SPH after pituitary surgery are unknown and potentially unique. This topic has not been investigated thoroughly because of the low incidence of SPH, 13 and as a result, recommendations for prevention and surveillance are lacking.…”

Visual Outcomes and Surgical Approach Selection Focusing on Active Optic Canal Decompression and Maximum Safe Resection for Suprasellar Meningiomas

“…Carnevale et al reported that visual deterioration caused by optic nerve compression or ischemia after EEA is rare but treatable. 52 ) We encountered two cases of delayed postoperative visual deterioration (one after EEA and the other after SFA). Although the etiology is unclear, vasospasm of small arteries, such as the SHAs or other chiasmatic branches of the circle of Willis, may be responsible.…”