title: Cranial nerve dysfunction following Gamma Knife surgery for pituitary adenomas: long-term incidence and risk factors.
abstract: OBJECTIVE
  Gamma Knife surgery (GKS) has become a significant component of neurosurgical treatment for recurrent secretory and nonsecretory pituitary adenomas. Although the long-term risks of visual dysfunction following microsurgical resection of pituitary adenomas has been well studied, the comparable risk following radiosurgery is not well defined. This study evaluates the long-term risks of ophthalmological dysfunction following GKS for recurrent pituitary adenomas.
  
  
  METHODS
  An analysis of 217 patients with recurrent secretory (n = 131) and nonsecretory (n = 86) pituitary adenomas was performed to determine the incidence of and risk factors for subsequent development of visual dysfunction. Patients underwent ophthalmological evaluation as part of post-GKS follow-up to assess for new or worsened cranial nerve II, III, IV, or VI palsies. The median follow-up duration was 32 months. The median maximal dose was 50 Gy, and the median peripheral dose was 23 Gy. A univariate analysis was performed to assess for risk factors of visual dysfunction post-GKS.
  
  
  RESULTS
  Nine patients (4%) developed new visual dysfunctions, and these occurred within 6 hours to 34 months following radiosurgery. None of these 9 patients had tumor growth on post-GKS neuroimaging studies. Three of these patients had permanent deficits whereas in 6 the deficits resolved. Five of the 9 patients had prior GKS or radiotherapy, which resulted in a significant increase in the incidence of cranial nerve dysfunction (p = 0.0008). An increased number of isocenters (7.1 vs 5.0, p = 0.048) was statistically related to the development of visual dysfunction. Maximal dose, margin dose, optic apparatus dose, tumor volume, cavernous sinus involvement, and suprasellar extension were not significantly related to visual dysfunction (p >0.05).
  
  
  CONCLUSIONS
  Neurological and ophthalmological assessment in addition to routine neuroimaging and endocrinological follow-up are important to perform following GKS. Patients with a history of radiosurgery or radiation therapy are at higher risk of cranial nerve deficits. Also, a reduction in the number of isocenters delivered, along with volume treated, particularly in the patients with secretory tumors, appears to be the most reasonable strategy to minimize the risk to the visual system when treating recurrent pituitary adenomas with stereotactic radiosurgery.
authors.affiliation: Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-0212, USA.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Cifarelli
authors.forename: David J
authors.initials: DJ
authors.lastname: Schlesinger
authors.forename: Jason P
authors.initials: JP
authors.lastname: Sheehan
mesh_terms: D000236:Adenoma / Q000601:surgery*; D003389:Cranial Nerve Diseases / Q000175:diagnosis* / Q000453:epidemiology*; D020209:Cranial Nerve Injuries / Q000175:diagnosis* / Q000453:epidemiology*; D003430:Cross-Sectional Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis* / Q000453:epidemiology*; D016634:Radiosurgery / Q000009:adverse effects*; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D014786:Vision Disorders / Q000175:diagnosis* / Q000453:epidemiology*