NANOS 2018 Kona, Hawaii Literature Review: Neurosurgery Neil R. Miller, MD FACS Frank B. Walsh Professor of Neuro-Ophthalmology Professor of Ophthalmology, Neurology & Neurosurgery Johns Hopkins University School of Medicine Baltimore, Maryland USA
Journals Reviewed Classification of Articles • Acta Neurochirurgica • Clinical trials • Prospective • British Journal of • Retrospective Neurosurgery • Original research • Child’s Nervous System • Prospective • Journal of Neurosurgery • Retrospective • Journal of Neurosurgery • Review articles Pediatrics • Case reports • Neuroradiology • Single • Neurosurgery • Small series • World Neurosurgery
Surgical Approaches to Compressive Lesions Involving the Anterior Visual Pathway • The optimum approach to pituitary adenomas and other lesions that compress the optic nerves and/or chiasm continues to evolve • Numerous articles, all retrospective reviews, discuss the pros and cons of endoscopic vs microscopic approaches • Most favor endoscopic approaches because of improved quality of vision and health associated with shorter operative times and lengths of hospital stays despite a significant learning curve on the part of the surgeon • CI Eseonu et al. World Neurosurg 2017;97:317-325 • M Koutourousiou et al. World Neurosurg 2017;103:713-732 • T Luomaranta et al. World Neurosurg 2017;105:422-431 • A Li et al. World Neurosurg 2017;101:236-246 • VS Patel et al. World Neurosurg 2017;108:6-14 • A Wolf et al. J Neurosurg 2017;127:409-416
Surgical Approaches to Compressive Lesions Involving the Anterior Visual Pathway • The optimum approach to suprasellar lesions (eg, meningiomas and aneurysms) that compress the optic nerves and/or chiasm continues to evolve • Numerous articles, all retrospective reviews, discuss the pros and cons of the transciliary “keyhole” approach compared with open craniotomy • Most favor the keyhole approach because of improved esthetic and comparable outcomes despite reduced exposure • H Singh et al. J Neurosurg 2017;126:940-944 • DW Zumofen et al. World Neurosurg 2017;98:614-624
Venous Sinus Stenting for Primary Pseudotumor Cerebri (aka IIH) • 10 patients with medically refractory PTC and venous sinus stenosis • Elevated gradient across region of stenosis (30.0+13.2 mm Hg) • Elevated ICP (42.2+15.9 mm Hg) • Following stent placement, all patients had resolution of the stenosis and gradient (1+1 mm Hg) • ICP monitored throughout the procedure: Immediate decrease in ICP occurred following placement of the stent (17.0+8.3 mm Hg) with a further decrease overnight • Reduced ICP maintained over long-term follow-up • KC Liu et al. J Neurosurg 2017;127:1126-1133
Venous Sinus Stenting for Primary PTC • 10 patients with PTC, venous sinus stenosis, increased gradient across area of stenosis, and increased ICP confirmed by 24-hour monitoring • Monitoring performed during stenting • Immediate lowering of ICP confirmed in 9 patient s • One patient with no effect had bilateral stenosis • Low ICP persisted for 24 hours of post-procedure monitoring • Change in mean ICP statistically significant: p=0.00393 • SA Matloob et al. Acta Neurochir 2017;159:1429-1437
Visual Effects of Ophthalmic Segment Aneurysm Endovascular Treatment • 127 consecutive patients with 160 OSAs • All patients treated with flow diversion • Complete occlusion in 90 of 101 (89%) aneurysms with mean f/u of 18 months • No mortality but 2 pts developed hemiplegia • Of 10 patients with pre-procedure visual symptoms, one had immediate improvement in visual function • Of 117 patients without visual symptoms, 2 (1.6%) experienced permanent post-procedure visual impairment • The authors conclude that treatment of OSAs with flow diversion is a safe and effective procedure • CG Griessenauer et al. Neurosurgery 2017;80:726- 732
Visual Effects of OSA Treatment • Two-center retrospective cohort comparison of stent- assisted coiling vs Pipeline (flow diversion) device • 172 patients • 62 treated with stent-assisted coiling • 106 treated with Pipeline • Stent-coiling and flow diversion equally effective in treating OSAs • No significant differences in procedural complications or in angiographic, functional, or visual outcomes • No patient with stent-coiling had a permanent visual complication whereas only one patient in the flow diversion series had permanent visual loss • N Adeeb et al. World Neurosurg 2017;105:206-212
Oculomotor Effects of Ruptured Internal Carotid-Posterior Communicating Artery Aneurysm Endovascular Treatment • 34 patients with third nerve palsy associated with a ruptured PCom aneurysm treated with endovascular coiling • Conventional in 23 pts • Stent-assisted in 11 pts • All aneurysms successfully occluded • At 6-month follow-up, 21 (61.8%) had experienced complete recovery of their palsy whereas 8 (23.5%) had incomplete recovery • Mean time to resolution: 24.5 days • Trend toward complete recovery among patients with initially incomplete palsy • No patient had post-operative worsening of an incomplete palsy • Q-Q Zu et al. Neuroradiology 2017;59:1165-1170
Oculomotor Effects of Unruptured Internal Carotid-Posterior Communicating Artery Aneurysm Endovascular Treatment • 15 patients + narrative review of 179 patients from 31 case reports or cohort studies • In the 15-pt series, no difference in recovery of complete palsy between clipping and coiling (p = 0.08) • In cohort study, surgical clipping associated with higher rate of recovery than was endovascular treatment • Complete palsy • 70% recovery with clipping • 46.5% recovery with coiling • Patients with complete palsy had lower rate of recovery than those with partial palsy • S Hall et al. World Neurosurg 2017:107:581-587
Results of Microvascular Decompression for Hemifacial Spasm • 1548 patients treated with MVD and followed for at least 2 years • 92.5% had complete disappearance of their spasms and 4.2% had marked improvement • No MVD-related mortality • Postoperative complications in 16% (n=249) • Facial nerve palsy in 150 pts (almost 10%) • 134 (94%) experienced complete recovery in 10-92 days • At 2-year follow-up, 6 patients still had a palsy • Hearing impairment in 55 pts (3.5%) • One became completely deaf; 11 had permanent impairment • Ipsilateral sixth nerve palsy • All recovered completely within 2 months • Authors conclude that MVD is a “safe” treatment for HFS • H Zhao et al. World Neurosurg 2017;107:559-564
Molecular Genetics of Anterior Skull Base Meningiomas • SMO and AKT1 mutations occur in some skull base meningiomas • Targeted sequencing of SMO and AKT1 performed in 62 patients with anterior skull base meningiomas • SMO mutations in 7 (11%) • AKT1 mutations in 12 (19%) • Although percentages relatively small, targeted therapy for these and other mutations may one day obviate the need for more invasive treatment of these tumors • MR Strickland et al. J Neurosurg 2017;127:438-444, 2017
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