Genda Lal Soni is a 43-year-old shopkeeper from Bihar, who visited our screening OPD on 30-Jun-22 with a 3-year history of blurring of vision. He was evaluated for the same at a local centre and found to have a tumour in the pituitary gland, which had grown significantly, causing compression of the optic chiasma, causing visual blurring. 

We evaluated him for any disturbances in the hormonal balance, which is common in these tumours. The ophthalmologist examined him in detail for his visual status and concluded to have peripheral field restriction of the vision, which is characteristic of tumours in this region. 

He underwent an endoscopic trans-nasal trans-sphenoidal approach and excision under general anaesthesia on 17-Jun-22. In this, we reach the pituitary gland through the nose and take out the tumour. Surgery was uneventful and he was in the ICU. The patient did well post-operatively and he was shifted to the ward. 

On the second post-operative day, Genda Lal complained that he was not seeing anything in his right eye. The MRI found an operative cavity blood clot was compressing his right-sided optic nerve. He was rushed to the operative room on Sunday morning and an emergency evacuation of the hematoma was done. He regained his right eve vision to 

the same level as the preoperative state. 

He was doing well in the ward, when suddenly he started having a watery leak from the nose CSF rhinorrhoea. Insertion of a lumbar drain to divert CSF was attempted. but the drain could not be inserted in the ICU because of his unusual anatomical variation. He was taken to the OT and a lumbar drain was inserted by removing part of the bone of lumbar vertebra at L3 level. 

This did help transiently, but the leak recurred. He was taken up again for endoscopic repair of the leak followed by the peritoneal shunt a thin tube that drains CSF from lumbar subarachnoid space into the abdominal cavity. He was doing well transiently, then again leakage recurred from the nose. 

We decided to seal the leak from the inside portion of the skull itself and he underwent Bifrontal craniotomy and intradural repair of a defect in Sella with vascularised pericranium under GA on 9-Jul-22. 

At last, his CSF leak stopped and a much larger problem was waiting for giving him more trouble. After a period of doing well, he became dull and the sensorium went down. He started having a fever, CT brain showed enlarged ventricles with hydrocephalus. Extra ventricular drain (EVD) was inserted and CSF showed infection and appropriate antibiotic were started both intravenous and intrathecal route. 

EVD tube kept on blocking and it was replaced once. He was on antibiotics, as he fought a deadly condition known as ventriculitis. Our attempts and timely interventions every time he had an issue saved his vision and life multiple times. During all these, he had a turbulent course concerning his sodium levels. With the background of pituitary tumour, infection and hydrocephalus, his electrolyte imbalance was challenging to manage but it was done successfully. 

Once his infection was confirmed to be negative, we did a permanent ventriculoperitoneal shunt and the patient was discharged successfully to be followed up with the endocrinologist for his hormonal imbalance. 

The entire team of neurosurgeons put in their best effort every time to get him out of the turbulence he faced. In spite of three months of struggle, multiple surgeries and distressed family members, it was rewarding to see that at the end, Genda Lal Soni is healthy and is coming for his regular follow-ups. 

                                                      Author -Dr. Prashanth Alle