A 39yrs old male presented with headache for 1yr and loss of vision for 8 months...

1. Preop Case Presentation
On Behalf of NSU- Pink
PRESENTED BY
DR. MD. ATIQUL ISLAM
MS PHASE- B
DEPARTMENT OF NEUROSURGERY, DMCH

2. Particulars of the patient.
 Name – Shahin Rahman
 Age – 39 years
 Sex –Male
 Handed – Right
 Address –Veramara, Kustia
 Date of Admission – 07/12/2022

3. Chief complaint
 Headache for 1yr
 Loss of vision for 8 months

4. History of present illness
According to the statement of patient , he was apparently well 1 year
back.
 Then he developed headache over the vertex, which was insidious in
onset mild to moderate in intensity, intermittent and dull aching in
nature. There was no aggravating factor but relieved by taking some
medication and sleep. Headache was not associated with nausea and
vomiting

5.  He also complained progressive visual disturbance, in the form of
difficulty in distant vision on left side for last 8 months. He also
complained of occasional bumping into objects, placed on lateral
aspect of his eyesight both eye
 He denies truncal obesity, moon facies or development of
hypertension or diabetes in recent times
 No history of intolerance to heat or cold, hyper-activity or
pronounced lethargy, nervousness, palpitation or tremor

6.  No history of enlargement of hands or feet in recent months,
change in shoe size, enlargement of front/back of the head or
jaw, history of loss of libido
 No history of anorexia, weight loss, fever, cough, chest pain,
haemoptysis and bowel bladder disturbance

7. Past medical/surgical History:
 Nothing significant.
Drug history:
 Paracetamol, other NSAID.
Personal history:
 Non-smoker, non-alcoholic.

8. Family history
 He has 2 son 1 daughter. None of his family member
has similar type of illness
Socio-economic history
 He belongs to middle class family

9. Allergy History
 Not allergic to known drugs or food
Immunization history
 Patient was immunized as per EPI Schedule

10. GENERAL EXAMINATION
 Appearance- anxious, ill looking
 Body built- Average
 Cooperative
 Decubitus- Mostly lying
 Nutritional status- Good
 Anaemia, Jaundice, Cyanosis-absent
 Clubbing-absent

11.  Dehydration, Oedema-absent
 Lymph node-not palpable
 Thyroid gland-not enlarged
 Pulse-76b/min
 BP-90/60mmhg
 Temperature-98oF
 Respiratory rate-18/min
GENERAL EXAMINATION

12. Nervous System Examination
 Higher psychic function including speech- Intact
 GCS- 15
 Gait- Normal
Systemic examination

13. CN-II, reveals
 Visual Acuity-
 Right- 6/6
 Left- 6/24
 Visual Field-
 Bitemporal hemianopia
 Color vision- Intact
 Fundoscopy- Normal.
Cranial nerve examination

14.  Examination of other cranial nerves reveals normal
 Sensory examination-
All modalities of sensation like pain, touch, temperature,
vibration & joint position are normal.

15. Fundal Photography

16. Visual Field Perimetry

17. Motor examination-
Upper limb Right Left
Bulk Normal Normal
Tone Normal Normal
Power (MRC grade) Root Value
Elbow flexors C5 5 5
Wrist extensors C6 5 5
Elbow extensors C7 5 5
Finger flexors C8 5 5
Finger extensors T1 5 5
Deep tendon reflexes
Biceps jerk C5,6 Normal Normal
Triceps jerk C7 Normal Normal
Supinator jerk C5,6 Normal Normal
Special tests
Hoffman’s sign Absent Absent

18. Lower limb Right Left
Bulk Normal Normal
Tone Normal Increased
Power (MRC grade) Root Value
Hip flexors L2 5 5
Knee extensors L3 5 5
Ankle dorsiflexors L4 5 5
Great toe extensors L5 5 5
Ankle planter flexors S1 5 5
Deep tendon reflexes
Knee jerk L3,4 Normal Normal
Ankle jerk S1,2 Normal Normal
Clonus
Knee clonus Absent Absent
Ankle clonus Absent Absent
Special tests
Plantar response Normal Normal

19.  Cerebellar sign- Absent.
 No Sign of meningeal irritation
 Examination of other systems reveal normal

21.  Sellar Suprasellar Space Occupying Lesion
Provisional Diagnosis

22. Investigations

23. MRI T1

24. MRI T1

25. MRI T2

26. MRI T2

27. Contrast MRI

28. Contrast MRI

29. FLAIR

30. DWI

31. Knosp classification

32. Hormone and Serum Profile
Investigation Patient Value Normal Range
Cortisol 10 μg/m ND to 46 pg/ml
GH 0.11 ng/ml 0.06 to 5 ng/ml
TSH 4.87 μIU/ml 0.35 to 5.50 μIU/ml
Prolactin 17.87 ng/ml 1.9 to 25 ng/ml
RBS 5.5 mmol/l 4.4 to 7.8 mmol/l

34. Non functioning Pituitry macroadenoma
Clinico-Radiological diagnosis

35. Operative Plan
Endoscopic endonasal transsphenoidal resection of
pituitary macroadenoma

36. Principles of endonasal Pituitary
Surgery
 Capitalize on Experience
 Develop a Comprehensive Understanding of the Surgical Anatomy
 Don’t: Rely on Tools Such as Neuronavigation
 Employ the Four-Handed, Binostril Technique
 Select the Anatomical Corridor Required for Complete Access
 Plan the Reconstruction Prior to the Approach and Resection
 Ensure Adequate Exposure
 Dissect Carefully with Great Respect for the Tissues

37. Important measures
 The endotracheal tube will be brought out from the left side
of the mouth.
 Oropharyngeal pack
 Prophylactic antibiotic
 Catheterization: per-operative monitoring
of urine output
 Hypotensive anaesthesia

38. Positioning
 Supine position with torso elevated 15 -20˚
 Forehead and chin lies horizontally.
 Level of head higher than chest (to improve venous return)
 Head flex 15 ̊ and rotated 10-15 ̊ towards the surgeon

39. Stages of surgery
 Nasal phase
 Sphenoidal phase
 Sellar phase
 Reconstruction

40. Nasal cavity architecture

41. Nasal phase

42.  Lateralization of Inferior turbinate
 Partial Resection of middle turbinate – Turbinectomy scissors

43.  Identification and lateralization of superior terbinate
 Exposure of sphenoid osteum and choana

44. Hadad flap

45.  The posterior nasal septum is disarticutlated from the rostrum of the sphenoid bone;
its posterior edge is resected with a backbiting forceps. Save this bone for later sellar
reconstruction following tumor resection.
 Bilateral instrumentation without deviation of the septum into the path of the endoscope and
increase lateral angulation and range of motion of the instruments.
Removal of posterior part of nasal septum

46. Sphenoid phase

47. Sphenoid phase

48. Sellar phase

49. (a)Bone of the sella has been removed.
(b) The blue hue seen of the cavernous and intercavernous sinuses.

50. (a) The dural incisions are made to avoid the intercavernous
sinus.
(b) The dural flap is reflected upward to expose the tumor.

51. (a) The pituitary tumor is dissected inferiorly first.
(b) Inspection for residual tumor is carried out after descent of
the diaphragma.

52. (a) Fibrous bands and the tumor capsule are dissected.
(b) Exposure for suprasellar tumor extension involves exposure of the
opticocarotid recess. Removal of the planum sphenoidale will increase exposure
superiorly.

53. (a) Doppler probes assist in determining the course of the carotid artery.
(b) The completed dissection with removal of the lateral extension of the
tumor reveals the cavernous sinus, internal carotid artery, and diaphragma
sellae.

54. Fascia lata graft and Fat

55. Reconstruction

56. The flap is placed over the entire closure with its vascular pedicle.

57. Closure
 Irrigate the nasal cavity & repositioning of the nasal
septum in the midline.
 The nasal cavity is packed with an expandable foam
sponge (Merocel) .

58. Complications

59. Peroperative
 Vascular injury: Cavernous sinus, ICA
 DI
 CSF leak
 Nerve injury: Optic nerve, optic chiasm, cavernous cranial
nerves (III, IV, VI)
 Pituitary injury
 Hypothalamic injury
 Stalk injury

60. Postoperative
 DI & electrolyte imbalance
 CSF rhinorrhoea
 Visual deterioration
 Infections

61. THANK YOU