Is Reconstruction of the Sella Necessary to Prevent Optic Chiasm Prolapse and Cerebrospinal Fluid Leakage Following Endoscopic Resection of Pituitary Macroadenomas?

摘要

Visual compromise is a common presentation of pituitary macroadenomas and is related to direct optic nerve and chiasm compression. Although the extent of visual recovery following treatment depends on the duration and severity of the visual compromise, the majority of patients experience gradual improvement in their vision. Delayed visual deterioration following treatment is typically related to either tumor recurrence or radiation-induced optic neuropathy, although visual worsening due to prolapse of the optic apparatus into a secondary empty sella has rarely been reported. In 1968, Guiot reported the first a case of reversible visual deterioration associated with optic chiasm prolapse following resection of a large pituitary macroadenoma (Guiot). Based on their observations, Guiot and collaborators recommended that a “prop” be placed in the sella at the time of transsphenoidal pituitary adenoma resection to prevent progressive herniation of the optic structures. Similarly, Hardy coined the term “preventive chiasmopexy” to describe filling of the sella cavity with autologous tissue such as muscle or fat following resection of large tumors to prevent this herniation phenomenon. While optic chiasm prolapse with associated visual deterioration appears to represent a rare occurrence, its true incidence and pathophysiological basis remain uncertain. Reconstruction of the sella with autologous tissues is also widely employed as a means to prevent postoperative cerebrospinal fluid leakage with these tissues typically harvested from a secondary operative site such as the abdomen. Although not frequently reported in the pituitary literature, complications of abdominal fat graft harvest include hematoma and seroma formation as well as infection with an incidence ranging from 1-7%. At our institution, we do not routinely perform dural reconstruction following transsphenoidal resection of pituitary macroadenomas using adipose tissue to prevent cerebrospinal fluid leakage or optic chiasm prolapse. In this study, we sought to determine the incidence of optic chiasm prolapse into the sellar defect by determining the radiographic position of the optic chiasm following surgery and incidence of delayed visual deterioration.Pages: 13-15