Neuro-ophthalmological Deficits Research Articles

ODP331 Management and Long Term Outcomes in a Patient with Pituitary Apoplexy in Pregnancy

Abstract Background Pituitary apoplexy is caused by hemorrhage or infarction of the pituitary gland. This diagnosis is rare in pregnancy, with little data to guide management in this population. Case A 30-year-old previously healthy pregnant female G4P3002 at 31 weeks gestation, presented with three days of severe headaches, dizziness, polyuria, polydipsia, and photophobia without vision loss. Her last pregnancy two years prior was uncomplicated. Pituitary MRI showed a 1.5 cm lesion with internal blood products, possibly indicating recent hemorrhage within an adenoma or cyst. The pituitary gland extended into the suprasellar cistern without compressing the optic chiasm. She was empirically started on stress dose steroids. Labs showed an ACTH of 32.9 pg/mL [9. 0-50. 0], cortisol 27.13 mcg/dL [3. 09-22.40], TSH 1.404 uIU/mL [0.550-4.780], with free T4 0.94 ng/dL [0.93-1.76] and total T4 of 11. 0 mcg/dL [4.5-10.9]. Glucocorticoids were continued given the inability to verify adrenal insufficiency after steroid initiation. Central hypothyroidism was diagnosed based on total T4 being less than 1.5 times the upper limit of the pre-pregnancy normal range, and she was started on levothyroxine. Prolactin was 93. 0 ng/mL [9.7-208.5] without hook effect on dilutional testing; this value was considered lower than expected for the third trimester. IGF-1 was normal at 296 ng/mL [117-329]. FSH was <0.3 mIU/mL [<0.3], LH <0.7 mIU/mL [<0.1-1.5], and estradiol >4000 pg/mL [reference range unavailable], all normal values for pregnancy. She had a normal serum sodium, however had polyuria at 266 mL/hour during a six hour water restriction test, with persistently dilute urine studies. Urine output and concentration improved after giving desmopressin. She was diagnosed with partial central diabetes insipidus and started on maintenance desmopressin. Per her obstetric team's recommendation, she underwent an uncomplicated Caesarean section at 38 weeks and was able to breastfeed shortly after delivery . Due to refractory headaches, 8 weeks after delivery she underwent transsphenoidal resection of an intrasellar cystic lesion with old blood products. No adenoma was identified. She was able to taper off hydrocortisone, desmopressin, and levothyroxine over one year after surgery. Follow up FSH, LH, estradiol, and prolactin levels normalized, and she resumed regular menses. Annual MRI's over five years have shown no evidence of lesion recurrence. Conclusion Studies have shown successful treatment of pituitary apoplexy with both surgical and non-surgical management, with surgery favored in patients with severe and/or progressive neuro-ophthalmologic deficits (1). However, there is a lack of data to guide treatment in pregnant patients. We present a case of pituitary apoplexy in pregnancy in which symptoms and hormonal function fully recovered after surgery, and imaging has been stable. Further research is needed to compare surgical and non-surgical treatment in this population, as well as the risk of tumor recurrence. (1) Marx et al. Endocrine, 2021. Presentation: No date and time listed

A key role for conservative treatment in the management of pituitary apoplexy.

The management of pituitary apoplexy, a rare emergency neuroendocrine condition, is controversial. The aim of the present study is to compare the outcomes of patients with pituitary apoplexy managed either by a conservative or surgical approach. A retrospective cohort study including patients diagnosed between 2007 and 2018 in a tertiary French university hospital. Pituitary Apoplexy Score (PAS) was retrospectively applied in the perspective of therapeutic decision support. Forty-six patients were treated for pituitary apoplexy either with conservative management (n = 27) or surgery (n = 19). At initial evaluation, visual field defects (VFD) and visual acuity impairment were more frequent in patients from the surgery group. At 1 year there were no statistical differences in the rates of complete/near-complete resolution of VFD (100 vs. 91.7%), visual acuity impairment (100 vs. 87.5%), and cranial nerve palsies (83.3 vs. 100%), between conservative and surgical treatment groups. There were more endocrine deficits at 1 year in the surgical group (p = 0.029). PAS (n = 41) was 3.4 on average in the early surgery group and 1.3 in the conservative treatment/delayed surgery group. Among patients with a score < 4, 31.3% were operated at first line and did not present better outcomes than patients managed conservatively. In all, 88.9% of patients with a score ≥ 4 underwent surgery. PAS may be a reliable parameter for defining therapeutic strategy. Patients with non-severe and nonprogressive neuro-ophthalmological deficits can be managed conservatively without negative impact on outcomes, thus surgery should be reserved only for those patients with a PAS ≥ 4.

Endovascular Treatment of 147 Cases of Cavernous Carotid Aneurysms: A Single-Center Experience

Cavernous carotid aneurysms (CCAs) are characterized by pain and neuro-ophthalmologic deficits. The optimal treatment remains unclear, especially for asymptomatic CCAs. This study investigated the efficacy of endovascular treatment for CCAs in our center. Data obtained from patients who underwent endovascular treatment for CCAs from July 2011 to July 2014 were reviewed. A retrospective analysis was conducted regarding the general condition, clinical presentation, aneurysm characteristics, therapeutic strategy, and prognosis of CCA patients. One hundred forty-seven patients who exhibited 155 CCAs were included, which comprised 46 asymptomatic and 101 symptomatic CCA cases. Forty-eight cases presented with headache, 5 cases presented with subarachnoid hemorrhage, 20 cases presented with diplopia, 38 cases presented with cranial nerve palsy, and 27 cases presented with ischemic stroke. The mean aneurysm sizes were 15.3 ± 12.2 and 8.1 ± 7.1 mm in the symptomatic and asymptomatic groups, respectively. Different treatments were administered: coil occlusion (n = 15), stent/balloon-assisted coil occlusion (n = 123), and parent artery occlusion (PAO) (n = 17). The PAO-treated group exhibited the highest aneurysm occlusion rate. Follow-up data were available for 131 cases, which included 86 symptomatic and 45 asymptomatic cases. There were no deaths. Among the symptomatic patients, 40.7% improved, 58.1% remained stable, and 1.2% worsened; 12 patients exhibited regrowth and 6 patients had repeated endovascular treatment. The asymptomatic patients remained stable, including 5 patients who exhibited regrowth and 2 patients who had repeated endovascular treatment. Endovascular treatment is safe and effective for CCAs and should be considered in patients with minimal complications, as well as in asymptomatic patients with stable symptoms.

Management and outcomes of pituitary apoplexy

This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes. The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale). Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15-91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3-10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups. The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.

Cavernous carotid aneurysms in the era of flow diversion: a need to revisit treatment paradigms.

Recent techniques of endoluminal reconstruction with flow-diverting stents have not been incorporated into treatment algorithms for cavernous carotid aneurysms. This study examines the authors' institutional experience and a systematic review of the literature for outcomes and complications using the Pipeline Embolization Device in unruptured cavernous carotid aneurysms. A retrospective search for cavernous carotid aneurysms from a prospectively collected data base of aneurysms treated with the Pipeline Embolization Device at our institution was performed. Baseline demographic, clinical, and laboratory values; intrainterventional data; and data at all follow-up visits were collected. A systematic review of the literature for complication data was performed with inquiries sent when clarification of data was needed. Forty-three cavernous carotid aneurysms were included in the study. Our mean radiographic follow-up was 2.05 years. On last follow-up, 88.4% of the aneurysms treated had complete or near-complete occlusion. Aneurysm complete or near-complete occlusion rates at 6 months, 12 months, and 36 months were 81.4%, 89.7%, and 100%, respectively. Of patients with neuro-ophthalmologic deficits on presentation, 84.2% had improvement in their visual symptoms. Overall, we had a 0% mortality rate and a 2.3% major neurologic complication rate. Our systematic review of the literature yielded 227 cavernous carotid aneurysms treated with the Pipeline Embolization Device with mortality and morbidity rates of 0.4% and 3.1%, respectively. Endoluminal reconstruction with flow diversion for large unruptured cavernous carotid aneurysms can yield high efficacy with low complications. Further long-term data will be helpful in assessing the durability of the cure; however, we advocate a revisiting of current management paradigms for cavernous carotid aneurysms.

P-003 Endovascular Concurrent Use of Coils and Pipeline Embolization Device for Intracranial Aneurysms: Clinical and Angiographic Results

BackgroundThe utility of the pipeline embolization device (PED) has been described as the sole device for treatment of brain aneurysms. The benefit using concurrent coils with limited number of PEDs...

Presentation and treatment of carotid cavernous aneurysms

We analyzed a group of patients with the diagnosis of internal carotid aneurysms in its intracavernous segment, with emphasis in prevalence, clinical features, treatments, evolution and neurological prognosis. Neurological signs and symptoms at initial presentation were registered and compared with final outcome. Patients were divided into two stratified groups, one with 19 patients which underwent interventionist treatment, and another with 21 patients who were conservatively treated. The present study demonstrated that intervention is significantly correlated with a better prognosis considering evolution of pain symptoms secondary to neurovascular compression (p=0,002). Regarding neurological deficits, an interventionist approach was also significantly correlated with better outcome in comparison with initial presentation (p=0,008). These results indicate that interventionist treatment determines improvement or resolution of pain symptoms in comparison with patients conservatively treated, as well as stabilization or partial improvement of neuro-ophthalmological deficits.

Short-Wavelength Automated Perimetry in Neuro-Ophthalmologic Disorders

Objective: To evaluate the efficacy of short-wavelength automated perimetry (SWAP) in the assessment of patients with neuro-ophthalmologic disorders, especially optic neuropathies. Methods: A modified Humphrey field analyzer was used to perform standard automated perimetry and SWAP, a technique that isolates the activity of short-wavelength-sensitive (blue) mechanisms. Forty patients (80 eyes) were evaluated by SWAP and standard automated perimetry. Thirteen patients (26 eyes) had recovered from optic neuritis and/or multiple sclerosis, 15 (30 eyes) were in various stages of treatment for pseudotumor cerebri, and 12 (24 eyes) had other miscellaneous neuro-ophthalmologic conditions. Six additional patients (12 eyes) with neuro-ophthalmologic conditions were tested twice on different days during a 2-week period, with the order of SWAP and standard perimetric testing being reversed on the second day. Results: Of the 80 eyes tested, 38 (48%) had SWAP visual fields that were worse than standard automated perimetry results; 29 (36%) showed no difference between standard and SWAP visual fields; and 13 (16%) had standard automated perimetry results that were worse than SWAP visual fields. Of the 26 eyes in patients with optic neuritis and/or multiple sclerosis, 15 (58%) had SWAP results that were worse than standard visual fields. Ten (33%) of the 30 eyes with pseudotumor cerebri had SWAP results worse than standard automated perimetry results, and 13 (54%) of 24 eyes with miscellaneous neuro-ophthalmologic conditions had SWAP results worse than standard automated perimetry results. For the 12 eyes undergoing repeated testing, SWAP visual fields were worse when they were performed last, perhaps indicating that some fatigue effect was present. This was observed for standard visual fields as well, but to a smaller extent. Conclusions: Preliminary findings suggest that SWAP may be useful in detecting certain neuro-ophthalmologic deficits more readily than standard automated visual field testing, especially for optic neuritis and multiple sclerosis. Further evaluations will be necessary to define the effects of fatigue for SWAP visual fields in neuro-ophthalmologic disorders.

Short-wavelength automated perimetry in neuro-ophthalmologic disorders.

To evaluate the efficacy of short-wavelength automated perimetry (SWAP) in the assessment of patients with neuro-ophthalmologic disorders, especially optic neuropathies. A modified Humphrey field analyzer was used to perform standard automated perimetry and SWAP, a technique that isolates the activity of short-wavelength-sensitive ("blue") mechanisms. Forty patients (80 eyes) were evaluated by SWAP and standard automated perimetry. Thirteen patients (26 eyes) had recovered from optic neuritis and/or multiple sclerosis, 15 (30 eyes) were in various stages of treatment for pseudotumor cerebri, and 12 (24 eyes) had other miscellaneous neuro-ophthalmologic conditions. Six additional patients (12 eyes) with neuro-ophthalmologic conditions were tested twice on different days during a 2-week period, with the order of SWAP and standard perimetric testing being reversed on the second day. Of the 80 eyes tested, 38 (48%) had SWAP visual fields that were worse than standard automated perimetry results; 29 (36%) showed no difference between standard and SWAP visual fields; and 13 (16%) had standard automated perimetry results that were worse than SWAP visual fields. Of the 26 eyes in patients with optic neuritis and/or multiple sclerosis, 15 (58%) had SWAP results that were worse than standard visual fields. Ten (33%) of the 30 eyes with pseudotumor cerebri had SWAP results worse than standard automated perimetry results, and 13 (54%) of 24 eyes with miscellaneous neuro-ophthalmologic conditions had SWAP results worse than standard automated perimetry results. For the 12 eyes undergoing repeated testing, SWAP visual fields were worse when they were performed last, perhaps indicating that some fatigue effect was present. This was observed for standard visual fields as well, but to a smaller extent. Preliminary findings suggest that SWAP may be useful in detecting certain neuro-ophthalmologic deficits more readily than standard automated visual field testing, especially for optic neuritis and multiple sclerosis. Further evaluations will be necessary to define the effects of fatigue for SWAP visual fields in neuro-ophthalmologic disorders.

The brain and cardiac surgery: Design and implementation of a research program

Cerebrovascular complications are one of the primary sources of morbidity and disability following cardiac surgery (1-3). Rapid improvements in myocardial preservation and continuing refinements in surgical technique have markedly reduced postoperative cardiovascular morbidity and mortality. As a result, surgery is offered to an increasing proportion of elderly patients, resulting in an increased incidence of postoperative cerebrovascular complications (4). Because more than 250,000 cardiac surgical procedures are performed each year, as many as 10,000 frank strokes and at least 50-100,000 less severe, but clinically evident, neurologic, neuropsychologic, and neuro-ophthalmologic deficits result from these procedures. The significant incidence of postoperative neurologic deficits is recorded in the literature (Table 1). If subtle cognitive deficits and biochemical evidence of neuronal injury are included, the incidence of cerebrovascular sequelae exceeds 75%. Following valvular surgery, the incidence of major cerebrovascular complications is even greater. Although some of these deficits resolve with time, others persist as sources of substantial disability for otherwise functional patients. We intend to measure different types of neurologic deficit. The variables include: the type of surgery, the age of the patient, whether the study is done on a prospective or retrospective basis, how and when are the patients examined, how sensitive is the testing, such as the neuropsychologic testing, and then one always has to consider the preconceived bias of the investigators. Ifwe are looking at neurologic outcome after bypass surgery, what should we look at? Frank stroke, whether there is presence or absence of acute or sustained diffuse encephalopathy, more subtle neuro-

Automated kinetic perimetry: an efficient method of evaluating peripheral visual field loss

This paper describes a technique for performing automated kinetic perimetry of the peripheral visual field. The test algorithm incorporates optimal stimulus parameters for kinetic perimetry, a priori information about age-related normal visual field properties, exploratory data sampling procedures, and real-time decision-making processes designed to make the test adaptive, efficient, and interactive. Preliminary testing in 100 eyes (twenty normal eyes, forty eyes with glaucomatous visual field loss, and forty eyes with neuro-ophthalmologic deficits) revealed good qualitative correspondence between automated and manual kinetic perimetry in about 77% of the cases. Another 15% of the automated kinetic perimetry results were very difficult to interpret and 8% revealed findings of no clinical value. Our results suggest that automated kinetic perimetry can provide an efficient means of testing the peripheral visual field, although current test procedures must be refined before they can be regarded as useful reliable clinical tools.