Perspectives Commentary on: Optic Chiasm Distortions Caused by Craniopharyngiomas: Clinical and Magnetic Resonance Imaging Correlation and Influence on Visual Outcome by Prieto et al. pp. 500-529.
Craniopharyngiomas and Visual Dysfunction: How to Predict the Visual Outcome Teresa Somma, Alberto Di Somma, Paolo Cappabianca
W
ith their article in this issue of WORLD NEUROSURGERY, Prieto et al. analyze the correlation between the anatomical deformation of the optic chiasm caused by craniopharyngiomas and the presence of visual disturbances, according to the data obtained from large series of these tumors already reported in literature. Six patterns of chiasm distortion are identified: nondistorted or normal, compressed downward, compressed forward, stretched forward, stretched upward, and stretched backward. Furthermore, beside Hoffman et al.’s (6), Yasargil et al.’s (11), Samii and Tatagiba’s (10), Ciric and Cozzens’s (3), and Kassam et al.’s (8) classifications of craniopharyngiomas, the authors give their own one with the recognition of 5 different topographical categories: 1) strictly intraventricular, 2) infundibulotuberal or not strictly intraventricular, 3) suprasellar-secondarily intraventricular, 4) suprasellar-pseudointraventricular, and 5) sellar-suprasellar. Finally, according to their shape, craniopharyngiomas are also divided into the following: 1) spherical, 2) rounded, 3) elliptical, 4) pear-like, and 5) multilobulated. With their, paper the authors provide information useful to define and predict the pre- and postoperative visual status according to the chiasm deformation that has been identified as a valuable neuroradiologic finding. As a matter of fact, Prieto et al. highlight how the suprasellar-secondarily intraventricular and pseudointraventricular types, pear-like or multilobulated shaped, are strictly associated with a forward chiasm compression or to a stretched chiasm, thus resulting into a greater rate of pre- and postoperative visual impairment if compared with other types and shapes. Given the peculiar location of these tumors, they
Key words Craniopharyngioma - Optic chiasm - Visual acuity - Visual field - Visual outcome -
WORLD NEUROSURGERY 83 [4]: 455-456, APRIL 2015
typically give rise to 3 main clinical syndromes: hypothalamicpituitary axis alteration, visual dysfunction, and elevation of the intracranial pressure that may lead to hydrocephalus. Approximately 30%e50% of patients harboring a craniopharyngioma complain of blurring vision, even at the time of presentation, and a formal ophthalmologic testing may highlight decreased visual acuity, eye field defects, and fundoscopy alterations from 65% up to 95% of these cases (1, 2, 7). Nowadays, thanks to the recent improvements in neuroimaging, including image-guided surgical methods, the intricate relationship between craniopharyngiomas, hypothalamus, pituitary stalk, and optic apparatus has gained a clearer way to be studied. When caused by craniopharyngiomas, visual loss often is progressive and may result in permanent blindness; for such reason, the presence of visual disturbances has been considered a leading indication for prompt surgical treatment of such neoplasm. Currently, preserving and/or improving patient’s quality of life is a key aspect in the general management of craniopharyngiomas and visual dysfunction is not the only issue to be considered. As a matter of fact, symptoms of hypothalamic involvement, such as unexplained high body temperature, obesity, impaired sexual function, somnolence, inappropriate emotional responses, and/or defective memory and neurocognitive functions, have to be clearly evaluated in the pre- and postoperative care (9). The visual recovery after surgery has a wide range of variability so that it is impossible to predict the postoperative visual outcome of a single patient. Knowledge of prognostic factors enables the
Department of Neurosciences & Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy To whom correspondence should be addressed: Paolo Cappabianca, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 4:455-456. http://dx.doi.org/10.1016/j.wneu.2014.11.009
www.WORLDNEUROSURGERY.org
455
PERSPECTIVES
surgeon to provide specific data about postoperative outcome during the counseling with patients. A wide range of variables such as patient age, duration of compression, preoperative visual field, visual acuity at the time of surgery, and presence of optic disc atrophy may implicate the visual prognosis after chiasmatic decompression surgery (4). None of these factors, however, enables the surgeon to evaluate the postoperative outcome for each case. In particular, the preoperative visual field examination provides information only on visual dysfunction, not on whether the impairment is associated with permanent axonal loss.
REFERENCES 1. Cappabianca P, Cavallo LM, Solari D, Di Somma A, Del Basso De Caro ML: Introduction and Outcome. In: Kenning TJ, Evans JJ, eds. Craniopharyngiomas: a comprehensive guide to diagnosis, treatment, and outcome. San Diego: Academic Press; 2015. 2. Cavallo LM, Frank G, Cappabianca P, Solari D, Mazzatenta D, Villa A, Zoli M, D’Enza AI, Esposito F, Pasquini E: The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg 121:100-113, 2014. 3. Ciric IS, Cozzens JW: Craniopharyngiomas: transsphenoidal method of approachefor the virtuoso only? Clin Neurosurg 27:169-187, 1980. 4. Galal A, Faisal A, Al-Werdany M, El Shehaby A, Lotfy T, Moharram H: Determinants of postoperative visual recovery in suprasellar meningiomas. Acta Neurochir (Wien) 152:69-77, 2010.
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www.SCIENCEDIRECT.com
According to recent studies, optical coherence tomography may predict visual outcome by measurement of ganglion cell axons or retinal nerve fiber layer. In particular, the retinal nerve fiber layer thickness has to be taken into account to indirectly determine an objective quantification of axonal loss (5). Hence, we believe that the preoperative visual assessment should be focused not only on the anatomical correlation between the optic chiasm and the lesion, as seen through the magnetic resonance imaging, but also via functional studies, i.e., optical coherence tomography, that may implement and complete preoperative evaluation of the visual status of each patient.
5. Garcia T, Sanchez S, Litre CF, Radoi C, Delemer B, Rousseaux P, Ducasse A, Arndt C: Prognostic value of retinal nerve fiber layer thickness for postoperative peripheral visual field recovery in optic chiasm compression. J Neurosurg 121:165-169, 2014. 6. Hoffman HJ, De Silva M, Humphreys RP, Drake JM, Smith ML, Blaser SI: Aggressive surgical management of craniopharyngiomas in children. J Neurosurg 76:47-52, 1992.
intracranial approaches for craniopharyngiomas: an analysis of the first 160 historical procedures. Neurosurg Focus 36:E13, 2014. 10. Samii M, Tatagiba M: Surgical management of craniopharyngiomas: a review. Neurol Med Chir (Tokyo) 37:141-149, 1997. 11. Yasargil MG, Curcic M, Kis M, Siegenthaler G, Teddy PJ, Roth P: Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg 73:3-11, 1990.
7. Jane JA Jr, Laws ER: Craniopharyngioma. Pituitary 9:323-326, 2006. 8. Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM: Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg 108:715-728, 2008. 9. Pascual JM, Prieto R, Castro-Dufourny I, Carrasco R, Strauss S, Barrios L: Development of
Citation: World Neurosurg. (2015) 83, 4:455-456. http://dx.doi.org/10.1016/j.wneu.2014.11.009 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.11.009
Craniopharyngiomas and Visual Dysfunction: How to Predict the Visual Outcome Teresa Somma, Alberto Di Somma, Paolo Cappabianca
W
ith their article in this issue of WORLD NEUROSURGERY, Prieto et al. analyze the correlation between the anatomical deformation of the optic chiasm caused by craniopharyngiomas and the presence of visual disturbances, according to the data obtained from large series of these tumors already reported in literature. Six patterns of chiasm distortion are identified: nondistorted or normal, compressed downward, compressed forward, stretched forward, stretched upward, and stretched backward. Furthermore, beside Hoffman et al.’s (6), Yasargil et al.’s (11), Samii and Tatagiba’s (10), Ciric and Cozzens’s (3), and Kassam et al.’s (8) classifications of craniopharyngiomas, the authors give their own one with the recognition of 5 different topographical categories: 1) strictly intraventricular, 2) infundibulotuberal or not strictly intraventricular, 3) suprasellar-secondarily intraventricular, 4) suprasellar-pseudointraventricular, and 5) sellar-suprasellar. Finally, according to their shape, craniopharyngiomas are also divided into the following: 1) spherical, 2) rounded, 3) elliptical, 4) pear-like, and 5) multilobulated. With their, paper the authors provide information useful to define and predict the pre- and postoperative visual status according to the chiasm deformation that has been identified as a valuable neuroradiologic finding. As a matter of fact, Prieto et al. highlight how the suprasellar-secondarily intraventricular and pseudointraventricular types, pear-like or multilobulated shaped, are strictly associated with a forward chiasm compression or to a stretched chiasm, thus resulting into a greater rate of pre- and postoperative visual impairment if compared with other types and shapes. Given the peculiar location of these tumors, they
Key words Craniopharyngioma - Optic chiasm - Visual acuity - Visual field - Visual outcome -
WORLD NEUROSURGERY 83 [4]: 455-456, APRIL 2015
typically give rise to 3 main clinical syndromes: hypothalamicpituitary axis alteration, visual dysfunction, and elevation of the intracranial pressure that may lead to hydrocephalus. Approximately 30%e50% of patients harboring a craniopharyngioma complain of blurring vision, even at the time of presentation, and a formal ophthalmologic testing may highlight decreased visual acuity, eye field defects, and fundoscopy alterations from 65% up to 95% of these cases (1, 2, 7). Nowadays, thanks to the recent improvements in neuroimaging, including image-guided surgical methods, the intricate relationship between craniopharyngiomas, hypothalamus, pituitary stalk, and optic apparatus has gained a clearer way to be studied. When caused by craniopharyngiomas, visual loss often is progressive and may result in permanent blindness; for such reason, the presence of visual disturbances has been considered a leading indication for prompt surgical treatment of such neoplasm. Currently, preserving and/or improving patient’s quality of life is a key aspect in the general management of craniopharyngiomas and visual dysfunction is not the only issue to be considered. As a matter of fact, symptoms of hypothalamic involvement, such as unexplained high body temperature, obesity, impaired sexual function, somnolence, inappropriate emotional responses, and/or defective memory and neurocognitive functions, have to be clearly evaluated in the pre- and postoperative care (9). The visual recovery after surgery has a wide range of variability so that it is impossible to predict the postoperative visual outcome of a single patient. Knowledge of prognostic factors enables the
Department of Neurosciences & Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy To whom correspondence should be addressed: Paolo Cappabianca, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 4:455-456. http://dx.doi.org/10.1016/j.wneu.2014.11.009
www.WORLDNEUROSURGERY.org
455
PERSPECTIVES
surgeon to provide specific data about postoperative outcome during the counseling with patients. A wide range of variables such as patient age, duration of compression, preoperative visual field, visual acuity at the time of surgery, and presence of optic disc atrophy may implicate the visual prognosis after chiasmatic decompression surgery (4). None of these factors, however, enables the surgeon to evaluate the postoperative outcome for each case. In particular, the preoperative visual field examination provides information only on visual dysfunction, not on whether the impairment is associated with permanent axonal loss.
REFERENCES 1. Cappabianca P, Cavallo LM, Solari D, Di Somma A, Del Basso De Caro ML: Introduction and Outcome. In: Kenning TJ, Evans JJ, eds. Craniopharyngiomas: a comprehensive guide to diagnosis, treatment, and outcome. San Diego: Academic Press; 2015. 2. Cavallo LM, Frank G, Cappabianca P, Solari D, Mazzatenta D, Villa A, Zoli M, D’Enza AI, Esposito F, Pasquini E: The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg 121:100-113, 2014. 3. Ciric IS, Cozzens JW: Craniopharyngiomas: transsphenoidal method of approachefor the virtuoso only? Clin Neurosurg 27:169-187, 1980. 4. Galal A, Faisal A, Al-Werdany M, El Shehaby A, Lotfy T, Moharram H: Determinants of postoperative visual recovery in suprasellar meningiomas. Acta Neurochir (Wien) 152:69-77, 2010.
456
www.SCIENCEDIRECT.com
According to recent studies, optical coherence tomography may predict visual outcome by measurement of ganglion cell axons or retinal nerve fiber layer. In particular, the retinal nerve fiber layer thickness has to be taken into account to indirectly determine an objective quantification of axonal loss (5). Hence, we believe that the preoperative visual assessment should be focused not only on the anatomical correlation between the optic chiasm and the lesion, as seen through the magnetic resonance imaging, but also via functional studies, i.e., optical coherence tomography, that may implement and complete preoperative evaluation of the visual status of each patient.
5. Garcia T, Sanchez S, Litre CF, Radoi C, Delemer B, Rousseaux P, Ducasse A, Arndt C: Prognostic value of retinal nerve fiber layer thickness for postoperative peripheral visual field recovery in optic chiasm compression. J Neurosurg 121:165-169, 2014. 6. Hoffman HJ, De Silva M, Humphreys RP, Drake JM, Smith ML, Blaser SI: Aggressive surgical management of craniopharyngiomas in children. J Neurosurg 76:47-52, 1992.
intracranial approaches for craniopharyngiomas: an analysis of the first 160 historical procedures. Neurosurg Focus 36:E13, 2014. 10. Samii M, Tatagiba M: Surgical management of craniopharyngiomas: a review. Neurol Med Chir (Tokyo) 37:141-149, 1997. 11. Yasargil MG, Curcic M, Kis M, Siegenthaler G, Teddy PJ, Roth P: Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg 73:3-11, 1990.
7. Jane JA Jr, Laws ER: Craniopharyngioma. Pituitary 9:323-326, 2006. 8. Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM: Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg 108:715-728, 2008. 9. Pascual JM, Prieto R, Castro-Dufourny I, Carrasco R, Strauss S, Barrios L: Development of
Citation: World Neurosurg. (2015) 83, 4:455-456. http://dx.doi.org/10.1016/j.wneu.2014.11.009 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.11.009
