Use of the Neurological Pupil Index to Predict Postoperative Visual Function After Resection of a Tuberculum Sellae Meningioma: A Case Report

The Neurological Pupil index (NPi) is a standardized method for evaluating pupil reactivity that removes inter-examiner variability. Changes in the NPi can predict clinical deterioration in patients with traumatic brain injury (TBI); however, its use to predict visual impairment after the resection of parasellar meningiomas has not been described. A 71-year-old female underwent a modified expanded bifrontal craniotomy for resection of a 3.1 cm tuberculum sella meningioma that caused compression of the optic chiasm and resulted in left temporal and right superior temporal visual field deficits. Postoperatively, she lost vision in the right eye. Pupillometer measurements demonstrated an asymmetrically low NPi at that time, which improved to normal prior to partial vision recovery. The average NPi in the right pupil was 1.67 during the time of vision loss compared to 3.47 in the left pupil (p=1.7x10(-10)). Statistical analysis was performed with the Student’s t-test and the significance level was set at p-value < 0.01. Resection of parasellar meningiomas is challenging because of the proximity of the optic apparatus. We report a case of unilateral vision loss after resection of a tuberculum sella meningioma in which the impaired eye’s NPi value correlated closely with visual function. NPi values that decrease below 3 predict spikes in intracranial pressure in TBI patients; similarly, increases in the NPi value above 2.5-3 predict improvement in vision in the case reported here. By monitoring the proximal portion of the oculomotor reflex, the NPi can be a marker of visual impairment after surgery.