Factors Affecting the Visual Outcome of Pituitary Adenoma Patients Treated with Endoscopic Transsphenoidal Surgery

Radiomics using multiparametric magnetic resonance imaging to predict postoperative visual outcomes of patients with pituitary adenoma

BACKGROUND

Preoperative prediction of visual outcomes following pituitary adenoma surgery is challenging yet crucial for clinical decision-making. We aimed to develop models using radiomics from multiparametric MRI to predict postoperative visual outcomes.

METHODS

A cohort of 152 patients with pituitary adenoma was retrospectively enrolled and divided into recovery and non-recovery groups based on visual examinations performed six months after surgery. Radiomic features of the optic chiasm were extracted from preoperative T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and contrast-enhanced T1-weighted imaging (T1CE). Predictive models were constructed using the least absolute shrinkage and selection operator wrapped with a support vector machine through five-fold cross-validation in the development cohort and evaluated in an independent test cohort. Model performance was evaluated using the area under the curve (AUC), accuracy, sensitivity, and specificity.

RESULTS

Four models were established based on radiomic features selected from individual or combined sequences. The AUC values of the models based on T1WI, T2WI and T1CE were 0.784, 0.724, 0.822 in the development cohort, and 0.767, 0.763, 0.794 in the independent test cohort. The multiparametric model demonstrated superior performance among the four models, with AUC of 0.851, accuracy of 0.832. sensitivity of 0.700, specificity of 0.910 in the development cohort, and AUC of 0.847, accuracy of 0.800, sensitivity of 0.882 and specificity of 0.750 in the independent test cohort.

CONCLUSION

The multiparametric model utilizing radiomics of optic chiasm outperformed single-sequence models in predicting postoperative visual recovery in patients with pituitary adenoma, serving as a novel approach for enhancing personalized treatment strategies.

Insights into Visual Outcomes and Determinants in Pituitary Adenoma Surgery: A 5-Year Retrospective Cohort Study

Purpose

To investigate the long-term visual outcome and their determinants after an operation in Thai pituitary adenoma (PA).

Patients and Methods

A retrospective cohort study was conducted on PA patients who underwent surgery at Rajavithi Hospital. Baseline characteristics and visual parameters, including visual acuity (VA) and visual field (VF), were analyzed in relation to the visual prognosis outcome. The outcome was defined as VA improvement at 1-year postoperatively. Visual parameters were measured at each follow-up visit and compared. Factors for improved visual prognosis were evaluated using logistic regression analysis.

Results

A total cohort of 87 patients (64.37% female), 62.07% showed improvement in visual outcome. Most improvement occurred immediately after surgery, evident at the 1-month visit. The mean follow-up time was 47.45 months (±28.49 SD), mean difference in VA improvement at 1-year was -0.56 logMAR (95% CI -0.73, -0.47). In multivariable logistic regression model, prolonged onset duration was associated with a reduced odds of improved visual outcome, with an odds ratio (OR) of 0.946 (95% CI 0.899-0.996, p = 0.034). Baseline characteristics, tumor volume, Hardy and Knops classification, and surgical approaches were not identified as significant predictors.

Conclusion

Both TSS and transcranial approaches are effective for pituitary adenoma. A prompt operation is recommended for patients with prolonged onset duration, with thorough discussion on poor postoperative visual outcomes.

Treatment outcomes of neuroendoscopic and microscopic trans-sphenoidal pituitary adenomectomies and the effects on hormone levels

BACKGROUND

We aimed to compare the treatment outcomes of neuroendoscopic and microscopic trans-sphenoidal pituitary adenomectomies, as well as the effects on hormone levels and clinical symptoms.

METHODS

A total of 82 patients with pituitary adenomas that were surgically resected from June 2018 to March 2021 were selected and divided into a group receiving neuroendoscopic trans-sphenoidal pituitary adenomectomy (group A, N.=40), and the other group receiving microscopic surgery (group B, N.=42). Surgery-related indices, hormone levels before discharge and alleviation of symptoms 24 weeks after surgery were compared.

RESULTS

Both groups had significantly different degrees of tumor resection (P<0.05). The proportion of cases receiving total adenomectomy in group A significantly exceeded that of group B (P<0.05). The surgical time of group A was significantly longer than that of group B (P<0.05). Group A had significantly shorter mean hospitalization stay than that of group B (P<0.05). The postoperative hormone levels of both groups decreased significantly differently (P<0.05). Before discharge, the hormone recovery rate of group A significantly surpassed that of group B (P<0.05). The hormone levels of cases with prolactinoma, adrenocorticotropic hormone adenoma and growth hormone adenoma in group A dropped more significantly than those of group B did (P<0.05).

CONCLUSIONS

Compared with microscopic surgery, neuroendoscopic trans-sphenoidal pituitary adenomectomy worked more effectively, induced fewer postoperative complications and better promoted the postoperative recovery of hormone levels.

Preoperative volume of the optic chiasm is an easily obtained predictor for visual recovery of pituitary adenoma patients following endoscopic endonasal transsphenoidal surgery: a cohort study

BACKGROUND

Predicting the postoperative visual outcome of pituitary adenoma patients is important but remains challenging. This study aimed to identify a novel prognostic predictor which can be automatically obtained from routine MRI using a deep learning approach.

MATERIALS AND METHODS

A total of 220 pituitary adenoma patients were prospectively enrolled and stratified into the recovery and nonrecovery groups according to the visual outcome at 6 months after endoscopic endonasal transsphenoidal surgery. The optic chiasm was manually segmented on preoperative coronal T2WI, and its morphometric parameters were measured, including suprasellar extension distance, chiasmal thickness, and chiasmal volume. Univariate and multivariate analyses were conducted on clinical and morphometric parameters to identify predictors for visual recovery. Additionally, a deep learning model for automated segmentation and volumetric measurement of optic chiasm was developed with nnU-Net architecture and evaluated in a multicenter data set covering 1026 pituitary adenoma patients from four institutions.

RESULTS

Larger preoperative chiasmal volume was significantly associated with better visual outcomes ( P =0.001). Multivariate logistic regression suggested it could be taken as the independent predictor for visual recovery (odds ratio=2.838, P <0.001). The auto-segmentation model represented good performances and generalizability in internal (Dice=0.813) and three independent external test sets (Dice=0.786, 0.818, and 0.808, respectively). Moreover, the model achieved accurate volumetric evaluation of the optic chiasm with an intraclass correlation coefficient of more than 0.83 in both internal and external test sets.

CONCLUSION

The preoperative volume of the optic chiasm could be utilized as the prognostic predictor for visual recovery of pituitary adenoma patients after surgery. Moreover, the proposed deep learning-based model allowed for automated segmentation and volumetric measurement of the optic chiasm on routine MRI.

Can Preoperative Diffusion Tensor Imaging Tractography Predict the Visual Outcomes of Patients with Pituitary Macroadenomas? A Prospective Pilot Study

OBJECTIVE

Visual impairment has been reported as the most common clinical manifestation of pituitary adenoma (PA) due to the compressive effect of the tumor. This prospective study aimed to evaluate the predictive role of diffusion tensor imaging (DTI) in the visual improvement of patients with PA, who were candidates for endoscopic endonasal surgery.

METHODS

A total of 13 patients (male, 8; female, 5) with visual impairment due to pituitary macroadenoma were enrolled in this study. The DTI findings and visual parameters, including visual acuity (VA), visual field (VF), and visual evoked potential (VEP), were recorded for all participants before and 3 months after surgery.

RESULTS

Significant recovery was reported in both VA and VF following PA surgery (P < 0.001). The results of perimetry indicated recovery in all quadrants, except for the lower nasal quadrant of the right eye. The tumor volume showed no significant association with the preoperative optic nerve, optic tract, and chiasm fractional anisotropy (FA) or mean diffusivity (MD). The VA and VF recoveries were more likely in patients with a lower preoperative optic nerve MD. Besides, increased preoperative FA of the optic nerve was associated with a higher probability of VA recovery. No significant correlation was found between the optic tract MD and FA values and visual improvement. Overall, MD values below 0.0021 and FA values above 0.1689 could predict a good prognosis of VA recovery after surgery.

CONCLUSIONS

DTI may have a predictive value in estimating visual improvement in patients with PA preoperatively.

Sinonasal Outcome After Endoscopic Transnasal Surgery-A Prospective Rhinological Study

BACKGROUND

The sinonasal outcome after transnasal skull base surgery has often been neglected aside from major outcome criteria as extent of tumor resection, ophthalmological, and endocrinological parameters.

OBJECTIVE

To analyze rhinological outcome after endoscopic transnasal neurosurgery.

METHODS

Patients were treated using a middle turbinate-preserving transnasal endoscopic approach for sellar/parasellar lesions. As major variables, olfactory function and nose breathing ability were assessed. The study participants were investigated by odor testing ("Sniffin' sticks"), rhinomanometry, and endoscopic inspection of the nasal cavity before and 6 months after surgery. Furthermore, sinonasal-associated quality of life was measured before, immediately and 6 months after surgery with a standardized questionnaire (SNOT-20-GAV).

RESULTS

Eighty-two patients (47 male, 35 female, median age 55 years) matched the inclusion criteria. Before surgery, the average odor was found to be 30.75 (≥31 = normosmia); in the postinterventional examination at 6 months, the average increased to 33.08 (n.s.). Rhinomanometric examination of binostril nasal airflow showed an average of 590.42 mL/s on inspiration before and an increase to 729.78 mL/s at 6 months after surgery. SNOT-20 symptom scores had a maximum score right after and no difference at 6 months after surgery (scores 23.76 and 14.91 vs 15.53 before surgery).

CONCLUSION

Based on the study, the endoscopic transnasal technique preserving the middle turbinate has no significant negative effects on the rhinological outcome.

Visual field improvement after endoscopic transsphenoidal surgery in patients with pituitary adenoma

Purpose

To analyze and predict the possibility of visual field (VF) recovery after endoscopic transsphenoidal surgery (ETSS) in patients with pituitary adenoma, we investigated the factors affecting the improvement of the visual field defect (VFD) and built a nomogram predictive model based on these risk factors. We further investigated specific recovery regions of VF associated with the improvement of VFD.

Methods

The clinical data of patients who underwent ETSS for pituitary adenomas at a single center between the January 2021 and April 2022 were retrospectively analyzed. Univariate and multivariate analyses were used to determine the predictive factors affecting the improvement in the VF defect and specific recovery regions in patients with pituitary adenomas after ETSS.

Results

We enrolled 28 patients (56 eyes) who were hospitalized at our institution. Four clinical features, including compression of the optic chiasm, preoperative mean defect (MD), diffuse defect, and duration of the visual symptom, were chosen from the least absolute shrinkage and selection operator regression analysis to establish the predictive nomogram. The nomogram's area under the curve (AUC) was 0.912, indicating a good degree of differentiation. A calibration plot was used to evaluate the predictive model's calibration, and a decision curve was used to evaluate its clinical application value. The VF defects were improved in the 270-300° range (270-300: RR = 361.00, 95% CI: 21.01-6,202.41).

Conclusion

We developed a predictive nomogram model based on significant visual field improvement-associated factors after ETSS in patients with pituitary adenoma. Postoperative visual field improvement is likely to begin at 270-300° in the inferior temporal quadrant. This improvement would enable personalized counselling for individual patients by precisely predicting the visual field recovery after surgery.

A retrospective cohort study assessing geometrical parameters related to visual deterioration in pituitary macroadenoma

PURPOSE

We aim to identify specific parameters that will allow identification of those patients at greater risk of vision loss, specifically variables such as geometry, volume and size of the pituitary tumour.

METHODOLOGY

Volume measurements were made with both manual (using the formula width × height × length × 0.5) and video size, sub-voxel interpolation using Brainlab software. The shape of the tumour was divided into four categories, ovoid, dumbbell, pyramidal and other. Chiasmal compression was divided into central and lateral compression and the chiasm location was classified based on pre/post and normal fixed chiasm in relation to the tuberculum sella. We used a visual impairment score ranging from (0-100), which was then further subdivided in to four grades: Grade I - 0-25 (mild); Grade II - 26-50 (moderate); Grade III - 51-75 (severe); Grade IV - 76-100 (subtotal or complete).

RESULTS

Univariate analysis of variables related to vision loss found tumour volume, suprasellar growth and lateral chiasmal compression related to pre-operative vision loss. On multivariate regression analysis tumour volume and lateral chiasmal compression remained significant (p < 0.008). In relation to post-operative vision, univariate analysis indicated that variables such as giant macroadenoma, pre-operative visual impairment score and suprasellar growth were significant. Multivariate analysis showed pre-operative visual impairment and suprasellar growth as the only statistically significant variables.

CONCLUSION

Our ROC analysis suggests tumours with suprasellar extension 16 mm (sensitivity 85 %, specificity 67 %) in sagittal plane are more likely to result in moderate to severe grade vision loss (VIS grade ≥ 2).

Analysis of visual field disturbance in patients with sellar and suprasellar lesions: relationship with magnetic resonance imaging findings and sagittal bending of the optic nerve

PURPOSE

Visual dysfunction due to sellar and suprasellar lesions is thought to be caused by chiasmatic compression and bending of the optic nerve at the entrance of the optic canal. We examined the relationship between visual field impairment and magnetic resonance (MR) imaging.

METHODS

This study reviewed 122 consecutive patients with sellar and suprasellar tumors. We have newly devised a simple visual field impairment score (SVFIS) that was divided into 12 areas. SVFIS is classified into four grades as mild (0-3 points), moderate (4-6 points), severe (7-9 points), and most severe (10-12 points) for each eye. We investigated the relationship between SVFIS grades and MR imaging, including the recently reported optic nerve-canal bending angle (ONCBA) and visual acuity.

RESULTS

Ipsilateral visual acuity tended to deteriorate with increased SVFIS grade. Larger ONCBA was associated with increased SVFIS grades. Bitemporal hemianopia occurred in the early stage (mild case), but the central visual field within 30° was particularly likely to be impaired. The visual field disturbance progressed clockwise (counterclockwise on the left side) from the upper temporal side. Disorders of the central visual field within 5° were associated with ipsilateral large ONCBA.

CONCLUSIONS

The newly developed SVFIS grades are closely associated with indicators of visual pathway impairment on MR imaging, and are useful as indicators of the severity and progression of visual field impairment due to sellar and suprasellar lesions. Disorders of the central visual field within 5° were found to be associated with ipsilateral large ONCBA.

A Factorial Analysis on Visual Outcomes of Transsphenoidal Surgery for Pituitary Macroadenoma

Objective  Sellar lesions are possible reversible causes of vision loss. This study is to provide quantitative objective measurement of efficacy of surgery for non-functioning pituitary adenoma and discuss different factors that could affect visual outcome of non-functioning pituitary adenoma.

Method  This is a single centre, retrospective study conducted at a tertiary neurosurgery referral centre. 108 cases of sellar tumors which underwent surgery during the 3-year period from early June 2015 to late May 2018 were reviewed. Pituitary adenoma that were non-functioning and without apoplexy at initial presentation were selected for the study. We have analyzed the correlation of different factors with the visual outcome, including the extent of vertical decompression in terms of change in tumor height post operation and the extent of lateral decompression in terms of change in Knosp grading. Visual outcome was represented by the visual impairment score (VIS), an integrated measurement of visual acuity and visual field deficit.

Results  Preoperative absolute tumor height and supracarotid height correlated with preoperative VIS scale ( p  ≤ 0.01). Absolute Knosp grading correlates significantly with VA ( p  = 0.001) and VF ( p  ≤ 0.001) of that particular eye. Although most patients had an objective improvement in visual acuity (VA) (88%) and visual field (VF) (99%) after operation, a larger reduction in tumor height and successful Knosp downgrading after surgery is associated with better VIS improvement. ( p  = 0.025) Change in supracarotid height shows trend in correlating with change in VIS ( p  = 0.084).

Conclusion  Height of tumor measured from genu of cavernous ICA correlates better with visual outcome than absolute tumor height. The extent of both vertical and lateral decompression of non-functioning pituitary adenoma are important determinants that lead to better visual outcome. As endoscopic approach is able to achieve a greater degree of lateral decompression, it is a preferred approach in pituitary surgery to achieve a better visual outcome.

3D Virtual Modeling for Morphological Characterization of Pituitary Tumors: Preliminary Results on Its Predictive Role in Tumor Resection Rate

Among potential factors affecting the surgical resection in pituitary tumors, the role of tumor three-dimensional (3D) features is still unexplored. The aim of this study is to introduce the use of 3D virtual modeling for geometrical and morphological characterization of pituitary tumors and to evaluate its role as a predictor of total tumor removal. A total of 75 patients operated for a pituitary tumor have been retrospectively reviewed. Starting from patient imaging, a 3D tumor model was reconstructed, and 3D characterization based on tumor volume (Vol), area, sphericity (Spher), and convexity (Conv) was provided. The extent of tumor removal was then evaluated at post-operative imaging. Mean values were obtained for Vol (9117 ± 8423 mm3), area (2352 ± 1571 mm2), Spher (0.86 ± 0.08), and Conv (0.88 ± 0.08). Total tumor removal was achieved in 57 (75%) cases. The standard prognostic Knosp grade, Vol, and Conv were found to be independent factors, significantly predicting the extent of tumor removal. Total tumor resection correlated with lower Knosp grades (p = 0.032) and smaller Vol (p = 0.015). Conversely, tumors with a more irregular shape (low Conv) have an increased chance of incomplete tumor removal (p = 0.022). 3D geometrical and morphological features represent significant independent prognostic factors for pituitary tumor resection, and they should be considered in pre-operative planning to allow a more accurate decision-making process.

Machine Learning Prediction of Visual Outcome after Surgical Decompression of Sellar Region Tumors

Introduction: This study aims to develop a machine learning-based model integrating clinical and ophthalmic features to predict visual outcomes after transsphenoidal resection of sellar region tumors. Methods: Adult patients with optic chiasm compression by a sellar region tumor were examined to develop a model, and an independent retrospective cohort and a prospective cohort were used to validate our model. Predictors included demographic information, and ophthalmic and laboratory test results. We defined “recovery” as more than 5% for a p-value in mean deviation compared with the general population in the follow-up. Seven machine learning classifiers were employed, and the best-performing algorithm was selected. A decision curve analysis was used to assess the clinical usefulness of our model by estimating net benefit. We developed a nomogram based on essential features ranked by the SHAP score. Results: We included 159 patients (57.2% male), and the mean age was 42.3 years old. Among them, 96 patients were craniopharyngiomas and 63 patients were pituitary adenomas. Larger tumors (3.3 cm vs. 2.8 cm in tumor height) and craniopharyngiomas (73.6%) were associated with a worse prognosis (p < 0.001). Eyes with better outcomes were those with better visual field and thicker ganglion cell layer before operation. The ensemble model yielded the highest AUC of 0.911 [95% CI, 0.885–0.938], and the corresponding accuracy was 84.3%, with 0.863 in sensitivity and 0.820 in specificity. The model yielded AUCs of 0.861 and 0.843 in the two validation cohorts. Our model provided greater net benefit than the competing extremes of intervening in all or no patients in the decision curve analysis. A model explanation using SHAP score demonstrated that visual field, ganglion cell layer, tumor height, total thyroxine, and diagnosis were the most important features in predicting visual outcome. Conclusion: SHAP score can be a valuable resource for healthcare professionals in identifying patients with a higher risk of persistent visual deficit. The large-scale and prospective application of the proposed model would strengthen its clinical utility and universal applicability in practice.

Predictive value of OCT and MRI for postoperative visual recovery in patients with chiasmal compressive lesions

PURPOSE

We aimed to investigate the predictive value of retinal thickness measured by optical coherence tomography (OCT) and mass biometrics measured using magnetic resonance image (MRI) for visual recovery after surgery for removal of a mass compressing the optic chiasm.

METHODS

Consecutive patients who showed typical temporal visual field defect (VFD) with respect to the vertical meridian due to a chiasmal compressive mass and who underwent mass removal surgery were recruited. Ophthalmic examination was performed preoperatively and postoperatively. Retinal thickness was measured by the Cirrus OCT. The height and size of the mass and suprasellar extension (SSE) in both the sagittal and coronal planes were evaluated. Patients were divided into two groups based on the improvement in VFD (mean deviation [MD] change ≥ 5 dB: group R; others: group NR) and clinical characteristics were compared.

RESULTS

Fifteen patients were included in the study. Eight (53.3%) patients were allocated into group R and others (7 patients, 46.7%) into group NR. Age, sex, initial visual acuity, initial MD was not different between the two groups. The retinal thicknesses were not different while tumor height, volume, and both sagittal and coronal SSE were significantly different between the two groups. (p = 0.029, 0.014, <0.001, and <0.001, respectively) All MRI parameters showed significant predictive value for the degree of MD recovery.

CONCLUSION

MRI showed better predictive value than OCT in predicting postoperative VFD recovery in patients with temporal VFDs due to chiasmal compressive disorder.

Analysis of factors affecting visual field recovery following surgery for pituitary adenoma

PURPOSE

To analyze the factors influencing visual field recovery in patients with pituitary adenoma following surgical treatment.

METHODS

We retrospectively reviewed 144 eyes of 72 patients with pituitary adenoma who had been followed up for more than 6 months following surgery between January 2016 and December 2019. Pre and postoperative visual acuity, visual field test and retinal nerve fiber layer (RNFL) thickness were investigated. We defined recovery of visual field defects as being an improvement in mean deviation (MD) of 2 dB or more.

RESULT

The average age of the 72 patients (144 eyes) was 51.94 ± 14.69 years, making for 37 patients in the recovery group and 35 patients in the non-recovery group. Preoperative MD, pattern standard deviation (PSD), and visual field indexes (VFI) were negatively correlated to postoperative MD, PSD and VFI changes and positively correlated to postoperative MD, PSD, and VFI values. Using multiple regression analysis, a shorter duration of symptoms (Odds ratio [OR], 0.990; p = 0.033), higher preoperative MD values (OR, 0.871; p = 0.025), and thicker temporal RNFL (OR, 1.068; p = 0.048) were associated with a visual field recovery following surgery.

CONCLUSIONS

The prognosis for visual field recovery is favorable for patients who have a short period from symptom onset to surgery, a higher MD value of preoperative VF, and a thicker peripapillary temporal RNFL thickness. Therefore, the preoperative MD, temporal RNFL thickness, and the symptom period can be predictive variables affecting postoperative visual field recovery.

Predictors of Postoperative Visual Outcome After Surgical Intervention for Craniopharyngiomas

BACKGROUND

Because of involvement of the optic apparatus, craniopharyngiomas frequently present with visual deterioration. Although visual improvement is a primary goal of surgical intervention, prediction models are lacking.

METHODS

We retrospectively reviewed all patients undergoing craniopharyngioma surgery at a single institution (2014-2019). Preoperative, intraoperative, and postoperative variables of interest were collected. Visual acuity and visual fields (VFs) were standardized into Visual Impairment Scores (VISs), defined by the German Ophthalmological Society. VIS ranged from 0 (normal vision) to 100 (complete bilateral blindness). Visual improvement/deterioration was defined as a postsurgical decrease/increase of ≥5 VIS points, respectively.

RESULTS

Complete ophthalmologic assessments were available for 61 operations, corresponding to 41 patients (age, 4-73 years). Vision improved after 28 operations (46%), remained stable after 27 (44%), and deteriorated after 6 (10%). In bivariate analysis, significant predictors of visual improvement included worse preoperative VIS (odds ratio [OR], 1.058; P < 0.001), worse preoperative VF mean deviation (OR, 1.107; P = 0.032), preoperative vision deficits presenting for longer than 1 month (OR, 6.050; P = 0.010), radiographic involvement of the anterior cerebral arteries (OR, 3.555; P = 0.019), and gross total resection (OR, 4.529; P = 0.022). The translaminar surgical approach was associated with visual deterioration (OR, 6.857; P = 0.035). In multivariate analysis, worse preoperative VIS remained significantly associated with postoperative visual improvement (OR, 1.060; P = 0.011). Simple linear correlation (R²=0.398; P < 0.001) suggests prediction of postoperative VIS improvement via preoperative VIS.

CONCLUSIONS

Patients with reduced preoperative vision, specific radiographic vascular involvement, and gross total resection showed increased odds of visual improvement, whereas the translaminar approach was associated with visual deterioration. Such characteristics may facilitate patient-surgeon counseling and surgical decision making.

Sagittal bending of the optic nerve at the entrance from the intracranial to the optic canal and ipsilateral visual acuity in patients with sellar and suprasellar lesions

OBJECTIVE

Visual acuity impairment due to sellar and suprasellar tumors is not fully understood. The relationship between these tumors and disturbance of visual function was examined using preoperative MRI.

METHODS

This study reviewed 93 consecutive patients with sellar and suprasellar tumors. Best-corrected visual acuity (BCVA) and visual impairment score (VIS) were used for estimation of visual impairments. Preoperative MR images were examined to obtain several values for estimation of chiasmatic compression. Additionally, the optic nerve-canal bending angle (ONCBA) was newly defined as the external angle formed by the optic nerve in the optic canal and the optic nerve in the intracranial subarachnoid space at the junction, using preoperative sagittal T2-weighted MR images.

RESULTS

The mean ONCBA was about the same on the right (44° ± 25°) and the left (44° ± 24°). Sagittal ONCBA was defined as large (> 45°) and moderate (≤ 45°) on each side. Preoperative VIS was found to be significantly worse if the right or left ONCBA (or both) was large (right side: ONCBA large [median 20, IQR 8-30] > ONCBA moderate [median 10, IQR 3-17], p = 0.003, Mann-Whitney U-test; left side: ONCBA large [median 22, IQR 9-30] > ONCBA moderate [median 10, IQR 2-16], p = 0.001). A large ONCBA showed a significant relationship with unfavorable ipsilateral BCVA (> logMAR, 0; right side, p = 0.001, left side, p = 0.001, chi-square test). The ONCBA had a positive correlation with ipsilateral BCVA (right: r = 0.297, p = 0.031; left: r = 0.451, p = 0.000, Pearson's correlation coefficient). Preoperative BCVA was significantly lower on the same side in the large ONCBA group compared with the moderate ONCBA group (right side: large ONCBA 0.169 ± 0.333 [logMAR, mean ± standard deviation] vs moderate ONCBA 0.045 ± 0.359, p = 0.026, Student t-test; left side: large ONCBA 0.245 ± 0.346 vs moderate ONCBA 0.025 ± 0.333, p = 0.000). This visual acuity impairment improved after resection of the tumors.

CONCLUSIONS

Sagittal bending of the optic nerve at the entrance from the intracranial subarachnoid space to the optic canal may be related to ipsilateral deterioration of visual acuity in sellar and suprasellar lesions. Sagittal T2-weighted MRI is recommended for preoperative estimation of the optic nerve bending.

Ophthalmological Management of Patients with Pituitary Adenomas

Pituitary tumours are a common cause of functional impairment and degeneration of the anterior visual pathway. Depending on localization and size, they clinically manifest as initially reversible visual field defects. As part of interdisciplinary tumour management, ophthalmologic examinations are of particular importance concerning diagnostics, indication for tumour resection and documentation of functional surgical results. Based on the relationship between clinical dysfunction and manifest atrophy, together with the patient's age and the duration of symptoms, the ophthalmologist can provide insights into the postoperative visual prognosis. Under good conditions, surgical tumour resection often results in significant improvements to visual fields and acuity. Long-term ophthalmological controls are required in cases of persistent visual loss, radiotherapy or tumour remnants abutting the visual pathway.

The suprasellar volume of nonfunctioning pituitary adenomas: a useful tool for predicting visual field deficits

PURPOSE

The aim of the present study is to assess the predictive value of the suprasellar volume (SSV) of nonfunctioning pituitary adenomas (NFPAs) for visual field (VF) impairment in order to guide clinical decision-making and improve neurosurgical management.

METHODS

Two independent samples of patients with NFPAs (exploratory population N = 50, testing population N = 98) were included in the present study. In the first phase, we determined the optimal cut-off value of the SSV correlating with VF deficits in the exploratory population. In the second phase, we then studied the accuracy of identified cut-off in predicting a VF deficit in the testing population.

RESULTS

In the exploratory population, the optimal cut-off value of the SSV to determine the presence of a VF deficit was 1.5 mL. Sensitivity and specificity of the cut-off were 81.3 and 100%, respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 100 and 75%, respectively. When we checked the identified cut-off score on the testing population, we found a sensitivity of 71% and a specificity of 100%. The PPV and NPV were 100 and 59.2%, respectively. In six cases with VF defects and SSV inferior to 1.5 mL, the displacement of optic chiasm was in superior position.

CONCLUSION

The SSV may represent an accurate method in routinely clinical practice for predicting VF deficit in patients affected by NFPA.

Visual Outcomes after Endoscopic Endonasal Transsphenoidal Resection of Pituitary Adenomas: Our Institutional Experience

Objectives  Visual dysfunction in patients with pituitary adenomas is a clear indication for endoscopic endonasal transsphenoidal surgery (EETS). However, the visual outcomes vary greatly among patients and it remains unclear what tumor, patient, and surgical characteristics contribute to postoperative visual outcomes. Methods  One hundred patients with pituitary adenomas who underwent EETS between January 2011 and June 2015 in a single institution were retrospectively reviewed. General patient characteristics, pre- and postoperative visual status, clinical presentation, tumor characteristics, hormone production, radiological features, and procedural characteristics were evaluated for association with presenting visual signs and visual outcomes postoperatively. Suprasellar tumor extension (SSE) was graded 0 to 4 following a grading system as formulated by Fujimoto et al. Results  Sixty-six (66/100) of all patients showed visual field defects (VFD) at the time of surgery, of whom 18% (12/66) were asymptomatic. VFD improved in 35 (35%) patients and worsened in 4 (4%) patients postoperatively. Mean visual acuity (VA) improved from 0.67 preoperatively to 0.84 postoperatively ( p  = 0.04). Nonfunctioning pituitary adenomas (NFPAs) and Fujimoto grade were independent predictors of preoperative VFD in the entire cohort ( p  = 0.02 and p  < 0.01 respectively). A higher grade of SSE was the only factor independently associated with postoperative improvement of VFD ( p  = 0.03). NFPA and Fujimoto grade 3 were independent predictors of VA improvement (both p  = 0.04). Conclusion  EETS significantly improved both VA and VFD for most patients, although a few patients showed deterioration of visual deficits postoperatively. Higher degrees of SSE and NFPA were independent predictors of favorable visual outcomes.

Infundibuloneurohypophysitis associated with autoimmune thrombocytopenia and chiasmal syndrome: a case report

Lymphocytic hypophysitis is an uncommon autoimmune disease. It may involve the adenohypophysis, neurohypophysis and pituitary stalk. It is most often encountered in pregnant women. Its diagnosis and management pose a significant challenge, as its clinical manifestation and appearance in imaging studies are difficult to distinguish from more common lesion of the sellar region (e.g., pituitary adenomas). We present the case of a 42-year-old man who presented with a chiasmatic syndrome, diabetes insipidus and hypopituitarism. Brain MRI documented a sellar lesion with suprasellar extension and optic chiasm dislocation. He underwent an endoscopic endonasal transsphenoidal resection of the mass. Histopathological examination revealed a lymphocytic hypophysitis. Visual symptoms improved dramatically postoperatively with permanent diabetes insipidus and panhypopituitarism. We discuss the indication for surgical resection in patients with inflammatory lesions extending to the suprasellar region associated with visual impairment.

Visual Outcomes After Pituitary Surgery

Visual signs and symptoms are a common manifestation of pituitary adenomas from compression or ischemia of the optic nerves and optic chiasm. Although bitemporal hemianopsia is a classic presenting visual field deficit, additional visual disturbances can result from these tumors. After endoscopic endonasal pituitary surgery, most patients have improvement in visual symptoms. Preoperative factors including retinal nerve fiber layer thickness, severity of preoperative deficit, duration of visual symptoms, tumor size, extent of resection, and patient age serve as possible predictors of postoperative visual outcomes.

Increased frequency of cataract surgery in patients over age 50 with pituitary macroadenomas and chiasmal compression

BACKGROUND

Patients with visual loss from macroadenomas compressing their optic apparatus may also have concomitant age-related visual pathology such as cataracts. How these two pathologies interact with each other is not well documented.

OBJECTIVE

The interaction between these two pathologies in elderly patients is the subject of this study.

METHODS

We identified a series of non-functioning macroadenoma patients over age 50 years with tumors compressing the chiasm who underwent transsphenoidal surgery at our institution between 2004 and 2018. Pre- and post-operative visual complaints, tumor size and extent of resection were analyzed. Prevalence of the diagnosis of cataract and prevalence of cataract surgery in each decade were compared with national averages.

RESULTS

We identified 200 patients who met selection criteria. 18% of these patients had a diagnosis of cataract and 12.5% had cataract surgery. Compared with the Eye Diseases Prevalence Research Group (EDPRG) study, the prevalence of cataract surgery was 2.5 times the national average of 5.1%. 32% of these patients had no improvement in their vision after cataract surgery but 76% improved after transsphenoidal surgery.

CONCLUSIONS

We reported a high prevalence of cataract surgery in patients over age 50 in patients with pituitary macroadenomas compressing the optic pathway compared with national averages in patients without adenomas. While visual loss from adenoma likely precipitated more cataract surgeries in this group of patients, some who may not have required it, those patients with cataracts who did not have their cataracts extracted were less likely to recover vision after transsphenoidal surgery. Addressing both pathologies is beneficial.

Characteristics of Preoperative Visual Disturbance and Visual Outcome After Endoscopic Endonasal Transsphenoidal Surgery for Nonfunctioning Pituitary Adenoma in Elderly Patients

BACKGROUND

Pituitary adenomas in elderly patients may become more common as the population ages. Surgical benefits, especially for visual outcome, after endoscopic endonasal transsphenoidal surgery for pituitary adenomas remain to be elucidated. This retrospective analysis investigated clinical factors affecting visual outcome.

METHODS

The study included 35 patients with nonfunctional pituitary adenomas who underwent surgery and were subdivided into elderly (≥70 years old, n = 12) and younger (<70 years old, n = 23) groups for analysis. Clinical characteristics and preoperative and postoperative visual function evaluated using visual impairment score (VIS) were compared between groups.

RESULTS

Mean age at diagnosis was 75.1 ± 1.5 years in the elderly group and 55.5 ± 2.0 years in the younger group. VIS was improved in 91% of elderly patients and 80% of younger patients, but postoperative VIS remained higher in elderly patients. Preoperative VIS and incidence of previous cataract surgery were significantly higher in elderly patients than in younger patients. Preoperative and postoperative VISs were significantly correlated with age. Preoperative VIS was significantly higher in patients with previous cataract surgery and correlated with postoperative VIS.

CONCLUSIONS

Visual disturbances were improved postoperatively in most patients in both groups at similar rates, but preoperative and postoperative visual disturbances were more severe in elderly patients because the symptoms may have been masked by the presence of lens opacity. Early diagnosis and intervention may be required in elderly patients for better visual outcome.

Increased resting-state functional connectivity in suprasellar tumor patients with postoperative visual improvement

Background and Objective: Large suprasellar tumors often compress the optic chiasm and give rise to visual impairment. Most patients have significantly improved visual function at 1 to 4 months after chiasmal decompression surgery, and only a few individuals regain normal vision at 1 week after surgery. How the recovery of visual function in these patients affects the visual cortex is not fully understood. In this study, we aimed to investigate alterations in brain functional connectivity (FC) in suprasellar tumor patients with visual improvement using resting-state functional magnetic resonance imaging (rs-fMRI). Methods: This longitudinal study was conducted on 13 suprasellar tumor patients who had ophthalmological examinations and rs-fMRI at the following time points: within 1-week preoperation (Pre-op), 1-week postoperation (Post-1w) and 1-month postoperation (Post-1m). The visual impairment score (VIS), local functional correlation (LCOR) and FC values were subjected to one-way ANOVA. Pearson correlation coefficients between changes in the LCOR and clinical factors were calculated. Results: The VIS was significantly decreased at both Post-1w and Post-1m compared to that at Pre-op. Whole-brain analysis of LCOR values showed that the left V1 (primary occipital cortex) was increased significantly at Post-1m compared to that at Pre-op (p < 0.05, FDR corrected). ROI analysis exhibited a significant negative correlation between the LCOR and VIS changes at Post-1m compared to those at Pre-op (p < 0.05, r = - 0.60). FC analysis within the visual network showed that the FC strengths were significantly increased between the left V5 and the left V4, right V3a, left V3, left V2d, and right V5 at Post-1m compared to those at Pre-op (p < 0.05, FDR corrected). Additionally, the FC strengths were significantly increased between the left V5 and the left V1, right orbital-frontal gyrus and left posterior supramarginal gyrus at the whole-brain network level at Post-1m compared to those at Pre-op (p < 0.05, FDR corrected). Conclusions: Postoperative visual improvement can be reflected by the increased FC of the visual cortex at Post-1w and Post-1m, especially at Post-1m. The LCOR value of the left V1 was associated with improved visual outcomes and may be used to objectively assess early visual recovery after chiasmal decompression at Post-1m.

Intraoperative low field MRI in transsphenoidal pituitary surgery

BACKGROUND

Intraoperative low field MRI (iMRI, 0.15 T) during transsphenoidal surgery on pituitary adenomas (PAs) may significantly improve tumor removal. However, extensive surgery can lead to pituitary hormone deficiency. Furthermore, introduction of iMRI will prolong duration of surgery, which may elevate risk of postoperative infections.

METHODS

Overall, 180 transsphenoidal surgeries for PAs from 2007 to 2015 were included. IMRI was available from 2011 to 2015, during this period 67/78 (86%) surgeries were with iMRI (iMRI, n = 67). A total of 113 surgeries were performed without iMRI (controls). All surgical procedures were performed by microscopic technique. Tumor size, hormonal status and vision were assessed before surgery and 3-5 months postoperatively.

RESULTS

Gross total resection (GTR), mean tumor remnant volume and ∆-volumes were comparable between iMRI and controls: 15% (10/66) vs 23% (26/109) (P = 0.17), 2.97 cm³ (0.9-5) vs 2.1 cm³ (1.6-2.6) (P = 0.3) and 4.5 cm³ (3.6-5.5) vs 5.1 cm³ (4.2-6) (P = 0.4), respectively. Duration of surgery was significantly longer during iMRI vs controls: 126 min (117-135) vs 98 min (92-103) (P < 0.001). New pituitary-adrenal deficiency in iMRI vs controls was seen in 35% (17/48) and 35% (23/66) of surgeries, respectively (P = 0.95). New thyroid deficiency was found in 33% (13/29) and 41% (28/69) and visual field deficiencies improved in 44% (19/43) and 38% (23/60) in iMRI vs controls, respectively (P > 0.1).

CONCLUSION

Tumor remnant after pituitary surgery was not significantly reduced using intraoperative low field MRI. Duration of surgery was increased in iMRI, but was not associated with increased infection rate. Pituitary hormonal function and vision were comparable between iMRI and controls.