Postoperative Cerebrospinal Fluid Leak Negatively Impacts Long-Term Visual Recovery after Endoscopic Pituitary Adenoma Resection

Introduction: Endoscopic transsphenoidal surgery (ETS) is a frequently used approach to resect sellar and parasellar skull base lesions, including pituitary adenomas (PA). PAs frequently present with visual dysfunction secondary to optic chiasm compression. While surgical decompression aids in recovery of vision, a significant population continues to experience visual deficits or even worsened vision after resection. Presently, no consensus exists regarding factors that drive differential vision recovery after endoscopic surgery. In this study, we sought to elucidate prognostic factors which affect the likelihood of vision recovery after ETS.

Methods: A single-center retrospective review identified 433 adult patients who received nonemergent ETS for management of PA from March 2009 to May 2020. All patients within this cohort who presented preoperatively with vision loss were included for analysis. Patients were excluded if data regarding preoperative or postoperative ophthalmological testing was incomplete. The cohort was then stratified by improvement in vision on postoperative follow-up or no change/worsening of vision. Preoperative frailty was assessed using the modified frailty index (mFI-5) and the risk analysis index (RAI-C). Tumors were measured on T1-weighted contrast-enhanced magnetic resonance imaging (MRI). Functional status was assessed on discharge and at 90-day follow-up using the modified Rankin’s scale (mRS). Clinical and demographic characteristics were analyzed using χ ² and Student’s t-tests. For factors with p-value < 0.1, a multivariate logistic regression model was constructed to estimate the adjusted odds of vision recovery across predictive factors.

Results: Of 433 patients, 107 (24.7%) patients with preoperative vision loss and complete ophthalmological testing were identified. On univariate analysis, comorbid psychiatric disease (p = 0.044), increased RAI-C (p = 0.084), postoperative cerebrospinal fluid (CSF) leak (p = 0.027), new-onset postoperative cranial nerve palsies (p = 0.027), and worsened mRS on discharge (p = 0.066), and at 90-day follow-up (p = 0.01) were associated with decreased odds of vision recovery. On multivariate analysis, the presence of a postoperative CSF leak was associated with 2856% increased odds of unchanged or worsening visual deficits (OR: 29.56 [2.57–956.52], p = 0.016). A mRS score of 1 on 90-day follow-up trended toward but did not significantly affect odds of long-term postoperative vision recovery (p = 0.083).

Conclusion: The development of a postoperative CSF leak led to significantly increased odds of long-term persistent visual deficit after ETS. Other factors such as tumor size or apoplexy incidence did not significantly affect odds of visual recovery. Close postoperative monitoring is necessary to prevent CSF leaks and maximize a patient’s likelihood of postoperative visual improvement after ETS.

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Artikel online veröffentlicht:
07. Februar 2025