Endonasal endoscopic transsphenoidal chiasmapexy using a clival cranial base cranioplasty for visual loss from massive empty sella following macroprolactinoma treatment with bromocriptine: case report

Abstract

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.

Chiasmal herniation following treatment of pituitary macroadenoma

“…Most patients developed a herniation between 6 months and 10 years after treatment. This time frame was similar to previously reported moment of onset of herniation with 45 published cases, in which patients developed herniations between 1 day and 14 years after treatment [2,9,10,[13][14][15][16][17][18][19][20][21][22][24][25][26][27][28][29][30]. There was no significant difference in the VFs before and after herniation of the optic chiasm.…”

“…The incidence of visual deterioration and herniation of the optic chiasm varied from 0.8 to 10% (4 out of 501 and 3 out of 28) [9,13]. Patients were aged between 20 and 71 years, 55% had an endocrine active adenoma, 43% had a nonfunctioning pituitary adenoma (NFA) and 2% a Rathke's Cleft Cyst (RCC) [2,9,10,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]. Furthermore, in 8 patients with secondary empty sella, chiasmal herniation and the severity of visual symptoms were not related [10].…”

3D printing and intraoperative neuronavigation tailoring for skull base reconstruction after extended endoscopic endonasal surgery: proof of concept

“…17,18,39 In addition to postoperative defect reconstruction, this 3D printing technique might also be helpful in noniatrogenic CSF leak repairs and other situations, such as empty sella syndrome, where techniques for remodeling bony anatomy are limited. 2,6,32…”

Empty sella syndrome as a window into the neuroprotective effects of prolactin

“…A syndrome characterized by both downward herniation of the optic chiasm into an empty sella turcica (the bony cave that houses the pituitary gland) and delayed secondary vision loss. Only 21 cases are known to be reported in the literature, a large majority of them treated with either reduction or cessation of dopamine agonist therapy (22)(23)(24)(25)(26)(27), or with surgical management to untether or elevate the optic apparatus (28)(29)(30)(31)(32)(33)(34).…”