Neurosurgery Neil R. Miller, MD FACS Frank B. Walsh Professor of - - PowerPoint PPT Presentation

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

NANOS 2018 Kona, Hawaii

Journals Reviewed Classification of Articles

• Acta Neurochirurgica
• British Journal of

Neurosurgery

• Child’s Nervous System
• Journal of Neurosurgery
• Journal of Neurosurgery

Pediatrics

• Neuroradiology
• Neurosurgery
• World Neurosurgery
• Clinical trials
• Prospective
• Retrospective
• Original research
• Prospective
• Retrospective
• Review articles
• Case reports
• Single
• Small series

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
• f 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
• f improved esthetic and comparable
• utcomes 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 patients
• 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
• r 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
• f 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
• f 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

• ther mutations may one day
• bviate the need for more invasive

treatment of these tumors

• MR Strickland et al. J Neurosurg

2017;127:438-444, 2017