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Evaluation of early visual recovery in pituitary macroadenomas after endoscopic endonasal transphenoidal surgery: Quantitative assessment with diffusion tensor imaging (DTI)

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Abstract

Background

Visual field analyses reflect the degree of the compression to the optic nerve that results the structural damage of the nerve. These structural damages can be evaluated by diffusion tensor imaging (DTI), which assesses the structural integrity of white matter tracts. Thus, we evaluated the quantitative assessment of early visual recovery in patients with pituitary macroadenomas, corresponding DTI with visual field analyses.

Methods

Seventy-two patients who had pituitary macroadenomas with visual field defects were included in the study retrospectively. All patients were operated on by pure endoscopic transphenoidal approach. Visual field assessment using Humphrey field analyzer and DTI with 3T magnet were performed in the preoperative and postoperative second day and sixth month.

Findings

Mean symptom duration was 14.7 ± 10.5 weeks in the full recovery group patients, 50.1 ± 29.1 weeks in partial recovery patients, and 92.4 ± 15.4 weeks in the ones with no recovery. There was a significant difference at p < 0.001 among the groups. On visual field analysis, the visual lost was mostly recognized at upper temporal levels preoperatively. Visual field findings of both eyes were improved in 80% of the patients. Among these, 25% revealed full recovery, 55.6% partial recovery, and 19.4% did not demonstrate significant changes. DTI assessments of affected sides revealed preoperative fractional anisotropy (FA) values below 0.400 and mean diffusivity (MD) values over 1,400 × 10-6 mm2 s-1 were related with no visual improvement in the postoperative 6 months period. The percentage increase of mean FA values of the affected areas postoperatively were found to be 21.9% in totally responded patients, 20.6% in partial responded patients, and 9.8% in patients that did not respond.

Conclusions

There is a correlation between DTI-derived FA values of the optic nerves and visual parameters. DTI assessments of the affected sides with FA and MD values may help to estimate the response of visual improvement to the surgical therapy in the early postoperative period.

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Authors and Affiliations

  1. Department of Neurosurgery, School of Medicine, Kocaeli University, Umuttepe, 41380, Kocaeli, Turkey

    Ihsan Anik, Kenan Koc, Savas Ceylan & Hamza Genc

  2. Department of Radiology, School of Medicine, Kocaeli University, Umuttepe, 41380, Kocaeli, Turkey

    Yonca Anik

  3. Department of Ophthalmology, School of Medicine, Kocaeli University, Umuttepe, 41380, Kocaeli, Turkey

    Ozgul Altintas

  4. Department of Anesthesiology and Reanimation, School of Medicine, Kocaeli University, Umuttepe, Turkey

    Dilek Ozdamar

  5. Department of Anesthesiology and Reanimation, Erzincan State Hospital, Erzincan, Turkey

    Duygu Baykal Ceylan

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  1. Ihsan Anik
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  3. Kenan Koc
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  4. Savas Ceylan
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  6. Ozgul Altintas
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  8. Duygu Baykal Ceylan
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Corresponding author

Correspondence to Ihsan Anik.

Additional information

Comment

This is a nice study of a transsphenoidal series related to visual recovery. It is interesting for three reasons.

First it is the first that sets out to look at recovery following endoscopic resection. There is a lot in the literature on this with microscope but little of quality on the endoscope for which much has been offered in terms of improved extent of resection. Here, it is interesting that recovery overall (80%)is very much as one has come to expect over the last twenty years, so no real improvement with the endoscope. Perhaps more puzzling is that the recovery to normal is lower than what we would expect to see overall; here only 25% and for ourselves 51%. Perhaps it is a selected patient group, but their exclusions are fine and no different from our own.

Second, this is the first series that sees an inverse statistically shown relationship between recovery and length of history. We have all tried to link the two, as it seems logical that the longer that one leaves the loss, less likely is the recovery. However, we found that even elderly patients with optic atrophy on occasions returned to normal. Perhaps their patients are better at reporting visual loss than ours who may have been harbouring theirs for a good time (because they already had atrophy) before they noticed they were losing vision.

Finally, the authors use DTI to analyse the results. This elegant technique has seemed to offer a lot but has largely been rejected in our institution as too expensive and not offering anything over the careful study using the Humphrey and other methods. Despite these comments, the authors find it offers something of value, although in my heart of hearts, I think it will be like the hemi field VER's that were explored in the late eighties and are now rightfully abandoned. This they have clarified, and conclude that where patients vision is too poor it may become the investigation of choice. It certainly restricts the use of Humphrey computerised field assessment, so this could be valuable.

Michael Powell

London, UK

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Anik, I., Anik, Y., Koc, K. et al. Evaluation of early visual recovery in pituitary macroadenomas after endoscopic endonasal transphenoidal surgery: Quantitative assessment with diffusion tensor imaging (DTI). Acta Neurochir 153, 831–842 (2011). https://doi.org/10.1007/s00701-011-0942-4

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