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Visual deterioration during pregnancy due to skull base tumors compressing the optic apparatus

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Abstract

Intracranial tumors may rapidly enlarge during pregnancy. When the tumor abuts the optic apparatus, tumor growth may cause visual deterioration. The decisions regarding the management of these tumors should take into consideration visual function, fetal and maternal safety, and the ability for total resection of the tumor. The objective of the study was to describe our experience and to establish principles for management of intracranial tumors compressing the optic apparatus that present during pregnancy or in the early post partum period. A retrospective case-series review was conducted. Women who presented with visual deterioration either during pregnancy or in the early post partum period due to an intracranial tumor were included. Neurosurgical and obstetrical data were collected from the patients’ hospital files and outpatient clinic records. Between 2005 and 2011, nine pregnant women with visual deterioration were diagnosed and treated. Of them, four underwent a neurosurgical procedure during pregnancy. Of the five patients who underwent surgery for tumor resection after delivery, three required urgent cesarean section either due to acute visual deterioration or obstetrical reasons. There was no maternal or fetal mortality and a good overall neonatal outcome was achieved. Improvement in visual acuity and visual fields was achieved in all patients. Postoperative complications included two cases of CSF leak, which resolved after treatment. Visual deterioration during pregnancy due to tumors that compress the optic apparatus requires treatment by a multi-disciplinary team. Surgery is well tolerated by mother and fetus during early and midpregnancy; thus, in cases where visual deterioration is detected, delay of surgery is not justified.

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No funding has been received for this study.

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    Authors and Affiliations

    1. Department of Neurosurgery, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel Aviv, Israel

      Erez Nossek, Gal Barkay, Tal Shahar, Lior Gonen & Nevo Margalit

    2. Department of Anesthesiology and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

      Margaret Ekstein

    3. Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

      Eli Rimon

    4. Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

      Anat Kesler

    Authors
    1. Erez Nossek
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    2. Margaret Ekstein
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    3. Gal Barkay
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    4. Tal Shahar
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    5. Lior Gonen
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    6. Eli Rimon
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    7. Anat Kesler
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    8. Nevo Margalit
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    Corresponding author

    Correspondence to Nevo Margalit.

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    Comments

    Isabel Cuervo-Arango Herreros, Asturias, Spain, and Álvaro Campero, Tucumán, Argentina

    This is a comprehensive retrospective report about nine pregnant women with visual deterioration who were diagnosed and treated between 2005 and 2011 in Tel Aviv Medical Center, Israel. The study group comprises six meningiomas, two pituitary non-functioning adenomas, and one chondrosarcoma, so it is important to differentiate the natural history of the tumor type. Since meningiomas are known to become larger during pregnancy and during the luteal phase of the menstrual cycle, suggesting that growth may be dependent on female hormones, they return after delivery and recur during a subsequent pregnancy in relation to progesterone receptor concentration. Conversely, the increased levels of estrogens during pregnancy have been associated with hypertrophic and hyperplastic changes in lactotroph cells, so pregnancy may affect the evolution of a pituitary adenoma and that effect is more pronounced in the second and third trimesters.

    Moreover the clinic to determine the therapeutic approach in skull base tumors in pregnant women depends on compression of surrounding structures by the pituitary gland, the pituitary stalk, or the optic pathways. In this series, the therapeutic approach was associated exclusively with the deterioration of visual function. Because of that, four patients underwent tumor resection between 29 and 33 weeks of gestation and five between 2 days and 6 months after delivery. Surgery during pregnancy often increases the risk for a first- or second-trimester spontaneous abortion, but it does not seem to increase the incidence of congenital abnormalities. The risk that exists at the time or shortly after delivery is due to the transient known coagulopathy that can develop frequently during the immediate postpartum. However, deterioration in the results of neuro-ophthalmic examination indicates the need for therapeutic intervention with multi-disciplinary approach, as the authors recommend.

    Erez Nossek and Margaret Ekstein contributed equally to this work.

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    Nossek, E., Ekstein, M., Barkay, G. et al. Visual deterioration during pregnancy due to skull base tumors compressing the optic apparatus. Neurosurg Rev 38, 473–479 (2015). https://doi.org/10.1007/s10143-015-0608-4

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    • DOI: https://doi.org/10.1007/s10143-015-0608-4

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