Literature Review: Neurosurgery

Transcription

1 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

2 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

3 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: M Koutourousiou et al. World Neurosurg 2017;103: T Luomaranta et al. World Neurosurg 2017;105: A Li et al. World Neurosurg 2017;101: VS Patel et al. World Neurosurg 2017;108:6-14 A Wolf et al. J Neurosurg 2017;127:

4 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: DW Zumofen et al. World Neurosurg 2017;98:

5 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 ( mm Hg) Elevated ICP ( 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 ( mm Hg) with a further decrease overnight Reduced ICP maintained over long-term follow-up KC Liu et al. J Neurosurg 2017;127:

6 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= SA Matloob et al. Acta Neurochir 2017;159:

7 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:

8 Visual Effects of OSA Treatment Two-center retrospective cohort comparison of stentassisted 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:

9 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:

10 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:

11 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 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:

12 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: , 2017