Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 1751  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,006 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
   References
   Article Figures

 Article Access Statistics
    Viewed1796    
    Printed23    
    Emailed1    
    PDF Downloaded49    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 2  |  Page : 274-276

Postoperative arachnoid cyst causing visual deterioration following transsphenoidal excision of a pituitary adenoma


Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication5-May-2015

Correspondence Address:
Mazda K Turel
Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.156309

Rights and Permissions



How to cite this article:
Turel MK, Chacko AG. Postoperative arachnoid cyst causing visual deterioration following transsphenoidal excision of a pituitary adenoma. Neurol India 2015;63:274-6

How to cite this URL:
Turel MK, Chacko AG. Postoperative arachnoid cyst causing visual deterioration following transsphenoidal excision of a pituitary adenoma. Neurol India [serial online] 2015 [cited 2019 Aug 23];63:274-6. Available from: http://www.neurologyindia.com/text.asp?2015/63/2/274/156309


Sir,

Acute visual deterioration following endoscopic trans-sphenoidal surgery for a pituitary adenoma could be due to a postoperative hematoma, over-packing of the sella turcica with a fat graft, direct operative trauma to the optic apparatus or due to a vascular compromise. Delayed visual dysfunction is commonly due to tumor recurrence, and rarely due to either chiasmal herniation into a secondary empty sella or a radiation-induced optic neuropathy (if postoperative radiation therapy has been administered). [1],[2],[3],[4],[5] In our two patients, visual compromise occurred due to the formation of a suprasellar cystic collection; in one patient, in the immediate postoperative period, and in the other, 4 years after surgery. We discuss the possible mechanisms responsible for the development of these cysts and discuss the methods of diagnosing as well as preventing this postoperative complication.

Our first patient was a 37-year-old man who presented with progressive diminution of vision in both eyes for 6 months. He was able to count fingers at 4 feet in the left eye and at 10 feet in the right with a bitemporal hemianopia. The magnetic resonance imaging (MRI) scan showed a 3 cm Hardy's grade C cystic pituitary adenoma with an enhancing periphery [Figure 1]. An endoscopic transsphenoidal surgery was performed, the tumor was radically excised and the sella was packed with fat since there was an intraoperative cerebrospinal fluid (CSF) leak. His vision remained unchanged in the immediate postoperative period. When he woke up the next morning, he complained of inability to perceive light with both eyes. His Glasgow Coma Scale (GCS) and extraocular movements were normal. A cranial computed tomography (CT) showed a large cystic collection between the fat graft and the optic chiasm with a peripheral rim of blood [Figure 2]. He underwent an emergency resurgery. As soon as the fat graft was removed, the CSF gushed out under pressure. There was no hematoma seen. Following this, the suprasellar arachnoid was seen pulsating well. The optic chiasma was clearly visualized through the arachnoidal membrane. Postoperatively, his vision improved to finger counting at 10 feet with both eyes.
Figure 1: (a-c) Axial, sagittal and coronal gadolinium enhanced preoperative MRI of a 37-year-old man showing a 3 cm Hardy's grade C cystic pituitary adenoma with an enhancing periphery. There is compression of the optic chiasm and the floor of the third ventricle superiorly but no invasion into the cavernous sinus

Click here to view
Figure 2: (a-d) Postoperative axial sellar suprasellar sections of a plain CT scan showing the sellar fat packing with a cystic collection above it and a rim of peripheral blood. There is no evidence of a tumor bed hematoma

Click here to view


The second patient was a 29-year-old man who underwent a transsphenoidal radical excision of a Hardy's grade C pituitary adenoma at our hospital 4 years ago [Figure 3]a-c. He had an intraoperative CSF leak requiring sellar repair with fat. Regular postoperative MRI scans showed no residual tumor [Figure 3]d-f. He presented to us with diminution of vision (6/12 in the right eye and 6/60 in the left eye with a bitemporal hemianopia) for 6 months. The MRI showed a 3 cm sellar-suprasellar cystic lesion with a cyst wall that was enhancing in some areas [Figure 4]a-c.
Figure 3: (a-c) Axial, sagittal and coronal, gadolinium-enhanced preoperative MRI of a 29-year-old man showing a 3 cm Hardy's grade C solid and cystic pituitary adenoma. (d-f) a 2-year postoperative axial, sagittal and coronal gadolinium enhanced MRI showing the postoperative changes but no recurrence of tumor. There is a small cystic collection in the sella

Click here to view
Figure 4: (a-c) A 4-year postoperative axial, sagittal and coronal gadolinium enhanced MRI showing a 3 cm cystic collection in the sella, extending into the sphenoid sinus below and the suprasellar cistern above with chiasmal compression. There is a scanty and patchy enhancement of the cyst. (d-f) A repeat enhanced MRI performed 3 months following the re-surgery in axial, sagittal and coronal planes showing no residual lesion

Click here to view


At surgery, the sellar floor had ballooned into the sphenoid sinus and on opening the dura, it was discovered that the cyst wall had reached the sellar floor. After drainage of the loculated CSF, we found that the suprasellar arachnoid had receded superiorly and had a small tear in it. There was no tumor in the sella. The compressed adenohypophysis and neurohypophysis had been displaced to the periphery and were probably being represented on the MRI as the enhancing wall of the cyst. We packed the sella with fat, and layered it with fibrin glue. Postoperatively, his vision improved to 6/6 in the right eye and 6/12 in the left. At a follow-up visit after 3-months, the MRI showed no residual lesion or cyst [Figure 4]d-f.

The incidence of immediate postoperative visual deterioration following transsphenoidal surgery for pituitary adenomas is about 0.5-2%, the causes being either an intraoperative manipulation of the optic apparatus or a postoperative hematoma. [1],[2],[3],[6] The visual decline in our two patients was due to a trapped cystic collection between the fat graft and the optic chiasma. The rapidity of CSF collection was different in the two cases resulting in an acute deterioration in one patient and a more delayed collection in the other. It is likely that following repair of the sella with the fat graft, CSF continued to leak from the small arachnoidal tear and was trapped above the fat ultimately compressing the optic chiasm. Over packing of the sella with fat was not the cause of the visual problems since the onset of deterioration of the visual acuity occurred only the next day in our first patient and was significantly delayed in our second patient.

In order to prevent this complication, it is probably best to directly plug the tear in the arachnoid particularly when the defect is small. The bath-plug technique [7] has now been routinely employed for closure of these defects. In this technique, a fat plug with a vicryl suture is introduced into the intradural space. This snug fit of the graft prevents the increased pressure due to CSF leakage from pushing away the graft from the defect. Occasionally, a Valsalva maneuver during surgery helps to determine the stability of the graft.

This report describes a rare complication of transsphenoidal surgery and emphasizes the importance of prompt intervention in reversing the deteriorating vision, both in the acute and the chronic setting.

 
  References Top

1.
Berker M, Hazer DB, Yücel T, Gürlek A, Cila A, Aldur M, et al. Complications of endoscopic surgery of the pituitary adenomas: Analysis of 570 patients and review of the literature. Pituitary 2012;15:288-300.  Back to cited text no. 1
    
2.
Halvorsen H, Ramm-Pettersen J, Josefsen R, Rønning P, Reinlie S, Meling T, et al. Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: A consecutive series of 506 procedures. Acta Neurochir (Wien) 2014;156:441-9.  Back to cited text no. 2
    
3.
Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: A series of 555 patients. Pituitary 2014;17:307-19.  Back to cited text no. 3
    
4.
Chubb D, Johnson RD, Kaye AH. Visual loss two years after pituitary adenoma resection. J Clin Neurosci 2011;18:386, 450.  Back to cited text no. 4
    
5.
Czech T, Wolfsberger S, Reitner A, Görzer H. Delayed visual deterioration after surgery for pituitary adenoma. Acta Neurochir (Wien) 1999;141:45-51.  Back to cited text no. 5
    
6.
Chacko AG, Chandy MJ. Complications of trans-sphenoidal pituitary surgery. Neurol India 1997;45:224-30.  Back to cited text no. 6
    
7.
Wormald PJ, McDonogh M. The bath-plug closure of anterior skull base cerebrospinal fluid leaks. Am J Rhinol 2003;17:299-305.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow