Intracranial tumors

窑Clinical Research窑

Visual findings as primary manifestations in patients

with intracranial tumors

Department of Ophthalmology, Izmir Ataturk Education and · KEYWORDS: intracranial tumors; neuro-ophthalmologic
Research Hospital, Izmir 35360, Turkey
examination; optic neuropathy
Correspondence to: Nazife Sefi-Yurdakul. Halk Sokak, No: DOI:10.3980/j.issn.2222-3959.2015.04.28
26 Sahilevleri, Narlidere-Izmir 35320, Turkey. nsefi@
yahoo.com Sefi-Yurdakul N. Visual findings as primary manifestations in patients
Received: 2014-01-31 Accepted: 2014-03-07 with intracranial tumors. 2015;8(4):800-803

Abstract INTRODUCTION
· AIM: To evaluate the visual findings as primary
manifestations in patients with intracranial tumors.
I ntracranial tumors may cause serious ocular signs and
symptoms in addition to neurological complications due
to increased intracranial pressure, cranial nerve impairment
· METHODS: The medical charts of the patients with
or brain compression. Therefore, prompt diagnosis of
intracranial tumors who initially admitted to the Neuro - intracranial tumors can allow early treatment and avoidance
ophthalmology and Strabismus Department with ocular of complications. Usually, the diagnosis of an intracranial
complaints between August 1999 and December 2012
tumor can only be established in the presence of usual
were reviewed retrospectively. The detailed clinical
symptoms or signs and sometimes these may lead to
history and the findings of neuro -ophthalmologic
misinterpretation and misdiagnosis [1-3]. Typical initial ocular
examination were recorded. Ocular symptoms and signs,
symptoms are progressive loss of vision with or without optic
the types and locations of intracranial tumors, and the
nerve atrophy, visual field defects, and extraocular nerve
duration of symptoms before the diagnosis were
evaluated.
palsies [4-7]. Instead of progressive visual defects, occasionally,
some of these lesions may cause acute visual loss as the
·RESULTS: The mean age of 11 women (61.1%) and 7
presenting manifestation of intracranial tumors[5,8-10].
men (38.9%) was 42.2依11.0 (range 20-66y) at the time of In this study, we aimed to draw attention to careful
intracranial tumor diagnosis. Initial symptoms were
evaluation of the findings in patients with intracranial tumors
transient visual obscurations, visual loss or visual field
who were referred to the Neuro-ophthalmology and
defect in 16 cases (88.9% ), and diplopia in 2 cases
Strabismus Department with ocular complaints.
(11.1% ). Neuro -ophthalmologic examination revealed
SUBJECTS AND METHODS
normal optic discs in both eyes of 6 patients (33.3% ),
Subjects We retrospectively reviewed the medical charts of
paleness, atrophy or edema of optic disc in 12 patients
(66.7% ), and sixth cranial nerve palsy in 2 patients
patients who were referred to the Neuro-ophthalmology and
(11.1%). Visual acuity ranged between normal vision and Strabismus Department of our hospital between August 1999
loss of light perception. Cranial imaging demonstrated and December 2012 with ocular symptoms, and those who
craniopharyngioma ( =1), plasmacytoma ( =1), were subsequently diagnosed with intracranial tumors in the
meningioma ( =6; olfactory groove and tuberculum Neurology Department were included in the present study.
sellae, pontocerebellar angle, anterior cranial fossa, Written informed consent was obtained from the patients in
frontal vertex, suprasellar region), and pituitary accordance with the Declaration of Helsinki. The study used
macroadenoma ( =10). The mean duration between the routine data, which were collected in a standard manner on
onset of visual disturbances and the diagnosis of all cases.
intracranial tumor was 9.8依18mo (range 3d-6y). Methods The diagnosis of intracranial tumors had been
· CONCLUSION: The ophthalmologist is frequently the made on the basis of characteristic clinical and radiological
first physician to encounter a patient with clinical findings. The detailed clinical history and the findings of a
manifestations of intracranial tumors that may cause full ophthalmologic and neuro-ophthalmologic examination,
neurological and ocular complications. Neuro - including visual acuity, visual field, pupillary reactions, color
ophthalmologic findings should be carefully evaluated to vision, ocular motility, biomicroscopy of anterior segment,
avoid a delay in the diagnosis of intracranial tumors. intraocular pressure measurement, and dilated fundus
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examinations, were recorded. Additionally, the initial

symptoms, signs prior to diagnosis of the tumor, and
neurological, biochemical and hematological findings at
diagnosis were recorded. Ocular manifestations, the types
and locations of intracranial tumors were evaluated. The
estimated duration of symptoms described by the patients
was investigated.
RESULTS
This study included 18 patients of whom 61.1% ( =11) were
woman and 38.9% ( =7) were man. The mean age at Figure 1 Incomplete homonymous hemianopsia and enlargement
presentation was 42.2依11.0 (range 20-66y). Decreased visual of blind spot (case 18).

acuity, transient visual obscurations or visual field defect

were the most common presenting symptoms ( =16, 88.9%),
followed by diplopia ( =2, 11.1%). Eleven patients (61.1%)
complained of progressive blurred vision. The remaining
patients presented with acute visual deterioration for a period
of less than one month. Visual acuity ranged between normal
vision and loss of light perception. Visual field pattern
differed from normal visual field to total loss of visual field. Figure 2 Bilateral optic disc edema (case 18).

Incomplete right homonymous hemianopsia and enlargement

of blind spot are shown in Figure 1 (case 18). The mean
duration between the onset of visual disturbances and the
diagnosis of intracranial tumor was 9.8依18mo (range 3d-6y).
Dilated fundus examination showed normal optic discs in
both eyes of 6 patients (33.3% ), and paleness, atrophy or
edema of optic disc in 12 patients (66.7%). Bilateral optic
disc edema is disclosed in Figure 2 (case 18). Sixth nerve
palsy was detected in 2 patients (11.1% ). Non-specific
headache was described by 22.2% of the patients. All
extensive laboratory tests were within normal limits.
Before radiological investigations, one case (case 1) had
pre-diagnosis of toxic optic neuropathy, one case (case 17)
Leber's hereditary optic neuropathy, one case (case 6) Figure 3 Anterior cranial fossa meningioma (case 1).
ischemic optic neuropathy, and 2 cases (cases 3, 15)
retrobulbar neuritis. After neuro-ophthalmologic examination, misinterpreted both by the patients and physicians, and
the patients were consulted by a neurologist. The definitive appropriate investigations are consequently delayed. The
diagnosis of an intracranial tumor was made based on the
duration of symptoms may be as long as 13y before the
characteristic clinical and radiological findings. Neurological
diagnosis [3-5,14]. In the present study, the estimated duration of
examination and cranial imaging demonstrated
symptoms described by the patients before the diagnosis
craniopharyngioma ( =1), plasmacytoma ( =1),
ranged from 3d to 6y, with a mean of 9.8mo.
meningioma ( =6), and pituitary macroadenoma ( =10).
The three most common types of intracranial tumors in adults
The locations of the meningiomas were olfactory groove and
are pituitary adenoma, meningioma, and craniopharyngioma,
tuberculum sellae ( =1), pontocerebellar angle ( =1),
in decreasing order of frequency [4-6,12]. Pituitary adenoma
anterior cranial fossa ( =1), frontal vertex ( =1), and
suprasellar region ( =2). A large anterior cranial fossa frequently manifests with bitemporal hemianopia, but is
meningioma is demonstrated in Figure 3 (case 1). The size of usually asymmetrical and unpredictable in its evolution [6].
the tumors ranged between 1 and 7 cm. Descriptive features Clinical presentation is related with anatomic location of the
of the patients are presented in Table 1. chiasm. Cranial nerve paralysis and diplopia can develop
DISCUSSION because of parasellar extension of the tumor[15-17]. In this study,
Intracranial tumors generally cause progressive visual deficits neuro-ophthalmologic examination and cranial imaging
and visual field loss (up to 95% ) over weeks to months demonstrated pituitary macroadenomas in 10 patients; all
before the diagnosis [11-13]. Initial symptoms and signs are often cases, except one with diplopia (case 14), were admitted due
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Intracranial tumors

Table 1 Descriptive features of the patients with intracranial tumors who were initially admitted to ophthalmology outpatient
clinic with ocular symptoms
Case Age Visual Diagnosis Duration
Sex Visual field defects Other findings Optic disc
No. (a) acuity (localization) (D)
RE: P- RE: Not done Headache RE: Edema Meningioma
1 55 M 3d
LE: P - LE: Not done Anosmia LE: Edema (anterior cranial fossa)
RE: P+ RE: Not done Headache RE: Atrophy Meningioma
2 66 F 6y
LE: 20/50 LE: Hemianopsia Cortical cataract LE: Atrophy (suprasellar)
RE: 20/20 RE: Normal RE: Normal Meningioma
3 26 F Headache 7d
LE: 1m CF LE: Not done LE: Normal (suprasellar)
RE: 20/20 RE: BSE Transient visual RE: Edema Meningioma
4 37 F 3mo
LE: 20/20 LE: BSE obscuration LE: Edema (pontocerebellar angle)
Transient visual
RE: 20/20 RE: BSE RE: Edema Meningioma
5 44 F obscurations 20d
LE: 20/20 LE: BSE LE: Edema (frontal verteks)
(right eye)
Meningioma
RE: 20/20 RE: Normal RE: Normal (olfactory
6 51 F - 3y
LE: 2m CF LE: Total loss LE: Pale groove-tuberculum
sellae)
RE: 20/30 RE: Hemianopsia RE: Normal
7 46 F - Pituitary macroadenoma 1y
LE: 20/200 LE: Hemianopsia LE: Normal
RE: 20/200 RE: Hemianopsia RE: Atrophy
8 43 M - Pituitary macroadenoma 1y
LE: 20/200 LE: Hemianopsia LE: Atrophy
RE: HM RE: Not done RE: Atrophy
9 50 M - Pituitary macroadenoma 1y
LE: 3m CF LE: Diffuse loss LE: Atrophy
RE: 20/30 RE: Hemianopsia RE: Normal
10 41 F - Pituitary macroadenoma 9mo
LE: 20/40 LE: Hemianopsia LE: Normal
RE: 20/40 RE: Total loss RE: Atrophy
11 44 M - Pituitary macroadenoma 2mo
LE: 20/20 LE: Hemianopsia LE: Edema
RE: 2m CF RE: Concentric narrowing RE: Pale
12 42 F - Pituitary macroadenoma 30d
LE: 20/20 LE: Normal LE: Normal
RE: 20/30 RE: Hemianopsia Transient visual RE: Normal
13 51 F Pituitary macroadenoma 1y
LE: 20/30 LE: Hemianopsia obscuration LE: Normal
RE: 20/20 RE: Normal RE: Normal
14 26 F Diplopia Pituitary macroadenoma 15d
LE: 20/20 LE: Normal LE: Normal
RE: 20/20 RE: Normal RE: Normal
15 36 F - Pituitary macroadenoma 20d
LE: 20/25 LE: Normal LE: Normal
RE: 20/40 RE: Diffuse loss RE: Edema
16 42 M - Pituitary macroadenoma 10d
LE: 20/20 LE: Diffuse loss LE: Pale
RE: P+ RE: Diffuse loss RE: Atrophy Craniopharyngioma
17 20 M - 15-30d
LE: 3m CF LE: Diffuse loss LE: Pale (suprasellar)
RE: 20/20 RE: Hemianopsia Diplopia RE: Edema Plasmacytoma
18 39 M 30d
LE: 20/20 LE: Hemianopsia Headache LE: Edema (posterior fossa)
RE: Right eye; LE: Left eye; P: Light perception; HM: Hand motions; CF: Count fingers; BSE: Blind spot enlargement; D: Time from
onset of symptoms to diagnosis.

to visual or visual field defects. No patient primarily huge size without showing any symptom and be easily
presented with endocrinologic symptoms. Before confused with toxic optic neuropathy, especially in patients
confirmation of the diagnosis with cranial imaging, one who present with bilateral vision loss and visual field defects.
patient (case 15) was pre-diagnosed as retrobulbar neuritis. Jung [18]
reported a case with bilateral visual loss for over
Besides the cases with pituitary macroadenoma, three cases 2y due to a giant olfactory meningioma encompassing the
with meningioma were pre-diagnosed as toxic optic entire frontal lobe and compressing the optic nerves. Bouyon
neuropathy (case 1), retrobulbar neuritis (case 3), and [3]
reported 5 patients with an initial presentation of
ischemic optic neuropathy (case 6). The most dramatic case retrobulbar optic neuropathy and in radiological imaging, that
(case 1) among our patients had anterior cranial fossa had to be repeated to make the diagnosis of meningioma,
meningioma, and he developed bilateral visual loss in three which was noted to be delayed from 18mo to 4y. Puchner
days. This patient described nonspecific headache and [20]
suggested that the commonly very late diagnosis of
anosmia from time to time. He was initially referred to our meningiomas as a cause of visual loss may be attributed to
clinic and pre-diagnosed as toxic optic neuropathy, and then the low incidence of the tumor.
eventually a large olfactory groove meningioma, 5.5× 6.7× Although benign in nature, craniopharyngiomas can
8.5-cm3 in size, invading the anterior cranial fossa was contribute to significant morbidity. Karavitaki [21]
and
determined. Olfactory groove meningiomas most commonly Overly [22]
found visual field defects and an initial decrease in
present with symptoms of headache, anosmia, and visual acuity in their patients with suprasellar
personality changes [18,19]. Furthermore, they can reach to a craniopharyngioma. Chen [23]
reported that change from
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39-year old man presented to our clinic with the complaint of 12 Aui-aree N, Phruanchroen C, Oearsakul T, Hirunpat S, Sangthong R.
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Conflicts of Interest: Sefi-Yurdakul N, None. olfactory meningioma. 2012;6:339-342
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