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 2018Kona, 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 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 suprasellarlesions (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 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 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 Neurosurg2017:107:581-587

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 Neurosurg2017;127:438-444, 2017