Endonasal endoscopic transsphenoidal chiasmapexy using a clival cranial base cranioplasty for visual loss from massive empty sella following macroprolactinoma treatment with bromocriptine: case report.
Visual deterioration after dopamine-agonist treatment of prolactinomas associated with empty sella syndrome and secondary optic apparatus traction is a rare event. Chiasmapexy has been described as a viable treatment option, although few cases exist in the literature. Here, a novel endonasal endoscopic approach to chiasmapexy is described and its efficacy is demonstrated in a case report. A 55-year-old female patient with a history of a giant prolactinoma and 14 years of treatment using dopaminergic agonist therapy presented to our institution with a 1-month history of visual changes. Neuroophthalmological examination confirmed severe bitemporal field defects, and MRI revealed a large empty sella with downward optic chiasmal herniation. Endoscopic endonasal chiasmapexy was performed by elevating the chiasm with lumbar drainage and filling the clival and sellar defect with an extradural liquid (HydroSet; a cranioplasty bone cement), and a piece of AlloDerm was used to cover and cushion the chiasm. Postoperative imaging demonstrated successful anatomical elevation of the optic apparatus, and the patient showed functional improvement in the visual field at 3 months postoperatively. Although rare, massive empty sellar and chiasmal descent from macroadenoma treatment can result in progressive visual loss. Here, a novel technique of endonasal endoscopic extradural cranioplasty aided by lumbar drainage is reported, which appears to be an effective technique for stabilizing and possibly reversing anatomical and visual deterioration.
Departments of 1 Neurosurgery.
G Rene
GR
Alvarez Berastegui
Departments of 1 Neurosurgery.
Shaan M
SM
Raza
Otolaryngology, and.
Vijay K
VK
Anand
Departments of 1 Neurosurgery.|Otolaryngology, and.|Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York.
Theodore H
TH
Schwartz
D001971:Bromocriptine / Q000627:therapeutic use; D003399:Craniotomy / Q000379:methods*; D004652:Empty Sella Syndrome / Q000209:etiology / Q000601:surgery*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006727:Hormone Antagonists / Q000627:therapeutic use; D006801:Humans; D008875:Middle Aged; D009296:Nasal Cavity / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods*; D009897:Optic Chiasm / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000150:complications* / Q000188:drug therapy; D015175:Prolactinoma / Q000150:complications* / Q000188:drug therapy; D019291:Skull Base / Q000033:anatomy & histology / Q000601:surgery; D013100:Sphenoid Bone / Q000601:surgery*; D016896:Treatment Outcome; D014786:Vision Disorders / Q000209:etiology* / Q000601:surgery*
D006727:Hormone Antagonists; D001971:Bromocriptine
ACoA = anterior communicating artery; CTA = CT angiography; bromocriptine; chiasmapexy; empty sella; endonasal; endoscopic; pituitary surgery; plasty; prolactinoma; transsphenoidal