title: Decision Making for Patients With Concomitant Pituitary Macroadenoma and Ophthalmologic Comorbidity: A Clinical Controversy.
abstract: BACKGROUND
  Coexisting complex visual field defects and serious ophthalmologic comorbidities make the management of the pituitary macroadenomas more challenging. Diffusion tensor imaging (DTI) magnetic resonance imaging that tracks neural fibers in the white matter has been used recently to visualize the impact of different pathologies on cranial nerves. This study explains application of anterior optic pathway tractography for patients with ophthalmologic comorbidities and pituitary adenoma.
  
  
  METHODS
  Two patients with atypical visual field defects caused by nonfunctional pituitary macroadenoma and simultaneous ophthalmologic morbidities (one glaucoma and the other giant cell arteritis) were selected for surgical decompression of the anterior optic apparatus. Standard perimetry and optic pathway DTI were done preoperatively, intraoperatively, and 3 months after surgery.
  
  
  RESULTS
  The nontypical pattern of visual field defect could not differentiate between the ophthalmologic disease and the chiasmatic compression attributable to pituitary macroadenoma as the main cause. Preoperative visual pathway DTI tractography showed lack of decussating chiasmatic fibers in both of the patients. DTI tractography revealed the reappearance of these fibers intraoperatively in one and postoperatively in the other one. Three months after surgery, the visual field and acuity improved and DTI tractography confirmed presence of crossing chiasmatic fibers.
  
  
  CONCLUSIONS
  Visual pathway DTI tractography is a promising adjunct to the standard perimetry in preoperative assessment of pituitary macroadenoma with serious ophthalmologic comorbidities. It also may be useful in the intraoperative determination of the optic pathway decompression and for following the visual outcome of these patients after surgery.
authors.affiliation: International Neuroscience Institute, Hannover, Germany; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Iranian International Neuroscience Institute, Tehran University of Medical Sciences (TUMS), Tehran, Iran. Electronic address: dr.m.haji55@gmail.com.
authors.forename: Mohamadreza
authors.initials: M
authors.lastname: Hajiabadi
authors.affiliation: International Neuroscience Institute, Hannover, Germany; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Iranian International Neuroscience Institute, Tehran University of Medical Sciences (TUMS), Tehran, Iran.
authors.forename: Maysam
authors.initials: M
authors.lastname: Alimohamadi
authors.affiliation: International Neuroscience Institute, Hannover, Germany.
authors.forename: Rudolf
authors.initials: R
authors.lastname: Fahlbusch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D003657:Decision Making; D019299:Decompression, Surgical; D056324:Diffusion Tensor Imaging; D013700:Giant Cell Arteritis / Q000150:complications / Q000503:physiopathology; D005901:Glaucoma / Q000150:complications / Q000503:physiopathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods*; D009897:Optic Chiasm / Q000473:pathology / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D014792:Visual Acuity; D058609:Visual Field Tests; D014794:Visual Fields; D014795:Visual Pathways / Q000473:pathology / Q000503:physiopathology
keywords: Diffusion tensor imaging; Giant cell arteritis; Glaucoma; Optic pathway; Pituitary adenoma; Tractography