J.ophthalmol.(Ukraine).2021;5:35-40.

http://doi.org/10.31288/oftalmolzh202153540

Received: 20 May 2021; Published on-line: 23 October 2021


Visual disturbances before and after transnasal endoscopic surgery  for craniopharyngiomas

K. S. Iegorova, A. A. Chukov; M. O. Guk, O. Ie. Skobska, L. V. Zadoianyi, M. R. Kostiuk

The State Institution"Romodanov Neurosurgery Institute, National Academy of Medical Sciences of Ukraine"; Kyiv (Ukraine)

TO CITE THIS ARTICLE: Iegorova KS, Chukov AA, Guk MO, Skobska OIe, Zadoianyi LV, Kostiuk MR. Visual disturbances before and after transnasal endoscopic surgery for craniopharyngiomas. J.ophthalmol.(Ukraine).2021;5:35-40.  http://doi.org/10.31288/oftalmolzh202153540

 

Background: Craniopharyngiomas (CP) are benign epithelial tumors of the chiasmal and sellar region and/or the third ventricle region which arise from embryonic remnants of Rathke’s pouch. They are in close proximity to the surrounding nervous, endocrine and vascular structures of the brain such as the chiasm, optic nerves and tracts, hypothalamus, pituitary stalk, major vessels and their branches, including perforating branches of the anterior cerebral, posterior communicating, and posterior cerebral arteries. Tumor relation to the optic tracts is an important aspect of surgery for CP. The blood supply to the optic nerve/chiasm complex is usually not affected, which allows maintaining it perioperatively; however, sometimes in radical surgery for CP there is elimination of some perforating arteries from the blood supply and devascularization of the chiasm, causing ischemic abnormalities in the chiasm.

Purpose: To determine the features of visual disturbances before and after surgery for craniopharyngioma.

Material and Methods: We examined the medical records of a cohort of 61 patients who underwent treatment including transnasal endoscopic surgery for suprasellar craniopharyngioma at the Transsphenoidal Neurosurgery Department, Romodanov Neurosurgery Institute, during the period from 2017 through 2020. The main group included 48 patients (96 eyes). Of these, 46 patients had presented with visual disturbances (reduced visual acuity and/or visual field defects), and 2 patients exhibited them after, but not before surgery. Patients underwent clinical and neurological, eye, and otoneurological examination.

Results: Visual disturbances in the presence of suprasellar craniopharyngiomas were found in 46 patients (75%), and their amount and severity substantially varied, which was associated with mechanical compression of the chiasm, growth of the tumor into the optic nerve and chiasm, as well as impaired chiasmal blood supply. The pupillomacular bundle and optic tracts are involved in exerting an effect on the posterior chiasm in suprasellar CP, which was reflected by the predominance of the symmetric chiasmal syndrome (39.1%) with bilateral optic atrophy, and accompanied by reduced visual acuity (78.3%), visual field defects (96.7%), bitemporal heteronymous hemianopia with central scotoma (27.2%), bitemporal paracentral scotoma (22.8%) and homonymous hemianopia (6.5%). The surgical treatment resulted in improvement or restoration of visual functions in 58.3% of patients. Postoperative worsening of visual functions was observed not only in patients who did exhibit visual disturbances preoperative (16.6%) but also in those who did not (4.2%), which was due to devascularization of the chiasm in radical surgery for CP.

Conclusion: Transnasal endoscopic surgery for CP enables direct visualization and surgical control of the vessels supplying the chiasm. In addition, this approach allows performing a rather radical surgery with as low as 20.8% postoperative frequency of visual loss or appearance of visual disturbances.

Keywords: skull-base tumors, craniopharyngioma, chiasmal syndrome, compressive optic neuropathy, chiasmal blood supply, devascularization of the chiasm, transnasal endoscopic surgery

 

References

1.Cavallo LM, Frank G, Cappabianca P, Solari D, Mazzatenta D, Villa A, et al. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg. 2014;121(1):100-13.

Crossref  PubMed

2.Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg. 2011;114(6):1544–68.

Crossref  PubMed

3.Yasargil MG. Microsurgery Applied to Neurosurgery. Stuttgart: Thieme, 1969. 

4.Louis DN, Ohgaki H, Wiestler OD, Webster KC, Burger PC, Jouvet A, et al. The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol. 2007;114(2):97–109.

Crossref  PubMed

5.Mortini P, Gagliardi F, Boari N, Losa M. Surgical strategies and modern therapeutic options in the treatment of craniopharyngiomas. Crit Rev Oncol Hematol. 2013 Dec;88(3):514-29.

Crossref  PubMed

6.Karavitaki N, Brufani C, Warner JT, Adams C, Richards P, Ansorge O, et al. Craniopharyngiomas in children and adults: systematic analysis of 121 cases with long-term follow-up. Clin Endocrinol (Oxf). 2005 Apr;62(4):397-409.

Crossref  PubMed

7.Wall M, George D. Visual loss in pseudotumor cerebri: incidence and defects related to visual field strategy. Arch Neurol. 1987 Feb;44(2):170-5.

Crossref  PubMed

8.Gibo H, Lenkey C, Rhoton AL. Microsurgical anatomy of the supraclinoid portion of the internal carotid artery. J Neurosurg. 1981 Oct;55(4):560-74.

Crossref  PubMed

9.Repka MX, Miller NR, Miller M. Visual outcome after surgical removal of craniopharyngiomas. Ophthalmology. 1989 Feb;96(2):195-9.

Crossref 

10.10. GrkovićD, Barisić S. Postoperative visual recovery following surgical treatment of craniopharygiomas. Med Pregl. Mar-Apr 2016;69(3-4):79-84.

Crossref  PubMed

11.Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Elizabeth C, Tyler-Kabara, Wang EW, et al. Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients. J Neurosurg. 2013;119(5):1194–207. 

Crossref  PubMed

12.Jacobsen MF, Thomsen AS, Bach-Holm D, Doroudian G, Nissen KR, Fugleholm K, et al. Predictors of visual outcome in patients operated for craniopharyngioma - a Danish national study. Acta Ophthalmol. 2018 Feb;96(1):39-45.

Crossref  PubMed

13.Pereira AM, Schmid EM, Schutte PJ, Voormolen JH, Biermasz NR, Sjoerd W, et al. High prevalence of long-term cardiovascular, neurological and psychosocial morbidity after treatment for craniopharyngioma. Clin Endocrinol (Oxf). 2005 Feb;62(2):197-204. 

Crossref  PubMed

14.Kim SM, Kim SH, Seo DW, Lee KW. Intraoperative Neurophysiologic Monitoring: Basic Principles and Recent Update. J Korean Med Sci. 2013; 28(9):1261–1269.

Crossref  PubMed

 

Conflict of Interest: 

The authors declare that there is no real or potential conflict of interest (financial, personal, professional or other interests) that could influence their opinion on the subject matter or materials described and discussed in this manuscript.    

Disclaimer: 

The views expressed in this article are those of the authors and not of the institution.