Dural Attachment Research Articles

The Management of the Venous Sinuses During Surgery for Posterior Fossa Meningiomas

To define, from a series of surgically treated meningiomas of the posterior fossa with dural attachment above the dural sinuses, the best management of the sinus invasion according to the pattern of venous circulation. Seventy-five patients with posterior fossa meningioma whose dural attachment involved the major venous sinuses were included in the study. We considered tumor location and dural attachment, pattern of venous sinus circulation, degree of sinus involvement and its management, entity of surgical resection, complications, and recurrences. The resection of the involved sinus segment (Simpson I) was performed in 15 patients (20%) (10 with complete occlusion and pattern of circulation of types A and B and 5 with narrowed sinus and type B circulation); 42 cases (56%, all of type 1) were treated by coagulation and/or removal of the outer dural layer (Simpson II). In 14 (19%) the intrasinusal fragment was left (Simpson III), and in 4 (5%) the resection was partial, with residual intradural tumor (Simpson IV). No postoperative complications secondary to venous obstruction occurred. Eleven patients (15%) experienced tumor recurrence and were reoperated on. Only 4 of them with extensive dural invasion had further recurrence. In patients with posterior fossa meningiomas, we suggest to safety resect the involved sinus segment only when completely occluded. If the sinus lumen is not invaded or the tumor lies on the side of the unique or dominant transverse sinus, it should be preserved. This results in no or negligible risk of venous infarction and rather low recurrence rate.

Distraction Osteogenesis for Unicoronal Craniosynostosis: Rotational Flap Technique and Case Series.

The limitations of the soft-tissue envelope, devascularized bone grafts, and relapse of the deformity are important considerations in the surgical treatment of unicoronal craniosynostosis. The authors report their technique evolution of distraction osteogenesis for treatment of patients with unicoronal craniosynostosis. Open anterior cranial vault reconstruction combined with internal distraction was used, with the aid of virtual surgical planning. Technique evolution included maximizing bone flap perfusion by means of limited rotational flap osteotomies, and preservation of dural attachments. Clinical and procedural characteristics including distraction protocol, intracranial volume change, efficiency of distraction, transfusion, operative time, length of hospitalization, complications, and postoperative outcomes were analyzed. Sixteen patients with nonsyndromic unicoronal craniosynostosis underwent repair between August of 2013 and December of 2016. Mean age was 9.0 months. Distractors were advanced a mean of 27.1 mm and achieved a cranial volume change of 29.5 percent, with a mean efficiency of 1.3 percent increase per millimeter of distraction. Mean operating time was 169.3 minutes. Complications were predominately related to infections at the distractor site. At most recent follow-up, all patients had a Whitaker grade I result. Distraction osteogenesis can be a safe and effective method of achieving satisfactory aesthetic outcomes and volume expansion for patients with unicoronal craniosynostosis. The technique presented is proposed to maximize bone flap viability and limit relapse of deformity. Further long-term follow-up is needed for definitive comparison with traditional anterior cranial vault reconstruction. Therapeutic, IV.

THE PTERIONAL APPROACH IN A CASE OF PLANUM SPHENOIDALE MENINGIOMA

Meningiomas represent almost 15 percent of primary brain tumors and are the most common non-glial primary brain tumor. Parasellar meningiomas represent 5–10 percent of all intracranial meningiomas. They may arise from the diaphragma sella, tuberculum sellae, planum sphenoidale, medial lesser wing of sphenoid, anterior clinoid, clivus, and cavernous sinus (Smith 2005). Planum sphenoidale meningiomas are located anterior to and in proximity to the olfactory groove. For an optimal postoperative outcome planum, sphenoidale meningiomas must be diagnosed early, and the operative procedures performed promptly and with utmost care. Ideally, management is intended to preserve and improve vision and consists of total resection with no injury to the neighboring vital structures. We report the case of a 64-year-old woman who presented with progressive visual disturbance, impairment of visual acuity, visual field defects and diffuse headache. Gadolinium-enhanced T1-weighted MR images showed a well-defined, suprasellar solid mass, measuring 30/35/40 mm. The lesion was hyperintense on T1-weighted imaging with homogenous enhancement and a broad dural attachment to the planum sphenoidale. The planum sphenoidale meningioma was successfully resected using a left pterional approach. The intraoperative and postoperative courses were uneventful with a total recovery. Improvement of visual acuity was noted and the postoperative computer-tomography investigation showed total surgical removal with no residual tumor.

Suboccipital Lateral Approach for Resection of Cerebellopontine Angle Meningioma: Operative Video and Technical Nuances.

We present the case of a 34-year-old woman, who presented to our department with a 4 months history of dizziness, hearing loss, and tinnitus on the right side. MRI (magnetic resonance imaging) scan demonstrated a large extra-axial lesion, suggestive of a meningioma, with dural attachments to the petrosal bone surface and tentorium, closely related with the trigeminal, abducens, facial, vestibulocochlear, and lower cranial nerves in the right side. Treatment options were discussed with the patient, and surgical resection was selected to remove the lesion, and decompress the cranial nerves and brainstem. The surgery was performed with a patient in a semi-seated position with head placed in a flexed, nonrotated position. A right lateral suboccipital approach was performed, exposing the right transverse and sigmoid sinuses. After dura opening, microsurgical dissection was used to open the cisterna magna, and obtain cerebellum relaxation. That was followed by identification of cranial nerves VII–XII and then identification of the tumor itself. Tumor debulking was then performed with use of suction and ultrasonic aspirator. After extensive resection, the tumor margins were dissected away from brainstem, cerebellum, and cranial nerves. Finally, the tumor attachment to the tentorium was coagulated and cut and the tumor was completely removed. Postoperative MRI confirmed complete resection of the tumor. The patient was discharged on the 1st week after surgery, with no additional postoperative deficits or complications. The link to the video can be found at: https://youtu.be/aZ3jhZTAeAA .

Surgical Strategy for and Anatomic Locations of Petroapex and Petroclival Meningiomas Based on Evaluation of the Feeding Artery

The anterior transpetrosal (ATP) approach is the most appropriate approach for petroclival meningiomas (PCMs), which are typically located from the dorsum sellae to the upper border of the internal auditory meatus (IAM). Although neurosurgeons can resect over this area if the tumor is detached from the dura, tumors within the indication area for PCMs are not appropriate for the ATP approach, because it can be difficult to evaluate whether the tumor is attached to or onlytouching the dura. In this study, we investigated the tumorextension area based on an evaluation of the feeding artery to achieve a more accurate assessment of the dural attachment area. Using various angiography techniques, we studied 51 feeding arteries from 24 patients who had undergone surgical treatment of primary petroapex meningiomas and PCMs via the ATP approach. We measured the lower and posterior extension distances, the extension rate of the cavernous sinus and Meckel's cave, and the midline extension rate of the tumors. The ascending pharyngeal artery (AphA) was the predominant feeding artery for tumors with lower extension. We determined that tumors extending over the lower border of IAM in cases in which the feeding artery was not the AphA can be resected using the ATP approach. This study shows an association between the predominant feeding artery and tumor extension area and demonstrates that an evaluation of the dural attachment area based on the feeding artery can aid selection of the appropriate surgical approach.

The Importance of Flexion MRI in Hirayama Disease with Special Reference to Laminodural Space Measurements

Hirayama disease is a benign focal amyotrophy of the distal upper limbs involving C7, C8, and T1 segmental myotomes with sparing of the brachioradialis and proximal muscles of the upper limb innervated by C5-6 myotomes. The objective of the present study was to study the utility of MR imaging in young patients presenting with weakness and wasting of the distal upper extremity and to evaluate the importance of the laminodural space during flexion cervical MR imaging. This was a prospective cross-sectional study conducted from January 2014 to July 2017 in a tertiary care center from Northeast India. Forty-five patients with clinically definite Hirayama disease underwent electrophysiologic evaluation followed by MR imaging of the cervical spine. The mean age at recruitment was 22.8 ± 5.5 years. Forty patients (88.9%) had unilateral and 5 (11.1%) had bilateral upper extremity involvement. Cervical cord T2-weighted hyperintensities were demonstrated in 16 patients (35.6%), of which 15 (33.3%) had anterior horn cell hyperintensities. Flexion MR imaging showed loss of the posterior dural attachment, forward shifting of the posterior dural sac with postcontrast enhancement, and prominent posterior epidural venous plexus in all patients. The laminodural space at maximum forward shifting of the posterior dural sac ranged from 3 to 9.8 mm, with a mean distance of 5.99 mm (95% confidence interval, 5.42-6.57 mm). Flexion cervical MR imaging is a very useful investigation in diagnosing Hirayama disease. The increase in the laminodural space and the presence of cervical cord flattening during flexion are essential for diagnosis.

Tratamento cirúrgico dos meningeomas da goteira olfatória

Objetivos: O artigo revisa as manifestações clínicas e radiológicas dos meningeomas da goteira olfatória e discute a abordagem cirúrgica destas lesões. Métodos: Foi realizada revisão da literatura com especial atenção nos acessos frontorbitários unilateral e bilateral, além de utilizados casos clínicos ilustrativos do manejo cirúrgico destas lesões. Conclusões: Os meningeomas da goteira olfatória são lesões que envolvem uma região de importantes estruturas neurovasculares e,portanto, representam um formidável desafio neurocirúrgico. A ressecção microcirúrgica radical deve ser sempre o objetivo inicial do tratamento, independentemente do volume da lesão. A ressecção óssea e dural da implantação tumoral diminui o risco de recidiva. A reconstituição da dura-máter da base do crânio deve ser rigorosamente efetuada para prevenção da fístula de liquor.

Atypical Recurrence Presentation of Pre-Transplant Period Multiple Myeloma: Multiple Intracranial Plasmacytomas With Intratumoral Hemorrhage

Multiple Myeloma may have extraosseous manifestations in the cranial region. It may be a solitary intracranial tumor (extramedullary plasmacytomas without any other signs of multiple myeloma) or intracranial disease may be a part of generalized disease. We report herein a 65-year-old multiple myeloma patient with the involvement of different regions of brain parancyhma with spontaneous intratumoral hemorrhages. It is an unusual recurrence presentation and unusual situation that intracranial involvements are both with and without dural attachment and all of them have intratumoral hemorrhages.

Primary Intramedullary Diffuse Large B cell Lymphoma Mimicking a Spinal Meningioma: A Case Report and Review of the Literature

Non-Hodgkin lymphomas account for only 0.3 to 1.5% of all central nervous neoplasms and are mainly subdivided in B-cell and T-cell lymphomas. Primary spinal involvement of PNCLS is a very rare disease, most being metastatic. We report a rare case of a 62-yearold male with a short history of progressive paraparesis. MRI of the spine showed a homogeneous contrast enhanced tumor mass with dural attachment, assuming a spinal meningioma. During surgery the tumor appeared diffusely grown into the spinal cord without detectable margins. Histological work-up brought up the diagnosis of a diffuse large B-cell-lymphoma (DLBCL). We illustrate the diagnostic steps and pitfalls and highlight the multimodal therapy and oncological features of this rare disease.

Surgical Treatment of Spinal Synovial Cysts in Elderly Patients: Symptoms, Treatment Course, and Outcome in Patients >75 Years of Age.

With the aging of our society comes a rising number of elderly patients with progressive degeneration of the spine associated with synovial cysts. Surgical treatment may be particularly challenging in elderly patients because of comorbidities. Patients treated in our department between 1999 and 2014 for spinal synovial cysts were screened. The 28 patients ≥75 years old were classified as elderly and were compared with 96 patients 50-74 years old. No patient underwent fusion as part of cyst resection. Despite a significantly higher frequency of muscle reflex changes in elderly patients at presentation, symptoms, cyst levels, rate of complications, and surgical method were not different between groups. Cyst adherence to the dura and subtotal resection were observed significantly more often in the elderly group (18% vs. 3%; P < 0.05). Outcome according to the Oswestry Disability Index was classified as no disability or minimal disability in 85% of the elderly group and in 82% of the control group. Recurrent cyst and delayed fusion rates were lower in the elderly group (4% and 4%) compared with the control group (7% and 8%). The clinical course of elderly patients with surgical treatment of spinal synovial cysts did not differ compared with younger patients. Good or excellent results could be achieved and persisted for a long time in most cases. Fusion should be performed only in cases of severe instability. Nonaggressive cyst removal in cases of dural attachment enables low cerebrospinal fluid fistula rates without increasing cyst recurrence rates.

Meningioma in Lateral Cerebellomedullary Cistern without Dural Attachment

AbstractIntracranial meningiomas without dural attachment are rare and posterior cranial fossa meningiomas without dural attachment are rarer. Such meningiomas are thought to arise from arachnoid cap cells in pial membrane, tela choroidea, or choroid plexus. MRI is the best imaging modality for the diagnosis of meningiomas and typically shows an enhancing, dural based, extra-axial soft tissue mass with a characteristic dural tail. Meningioma without dural attachment should be suspected if the MRI shows a space-occupying lesion having features of a meningioma but without a dural base and dural tail. We report a case of meningioma in the lateral cerebellomedullary cistern without dural attachment.

Parasagittal meningiomas – literature review and a case report

Meningiomas are tumors that can develop anywhere along the neuraxis, but with increased concentration in some specific areas. Parasagittal meningiomas have the dural attachment on the external layer of the superior sagittal sinus (SSS) and invade the parasagittal angle displacing brain away from its normal position. Among meningiomas, the parasagittal location is the most common (22%). Taking into account their anatomic insertion along SSS, parasagittal meningiomas can have their dural attachment in the anterior, the middle or the posterior third of the SSS. Most frequently parasagittal meningiomas are located in the middle third of the superior sagittal sinus (between coronal suture and lambdoid suture). The clinical picture of parasagittal meningiomas depends on the tumor location along the SSS and so is the attitude towards ligation and reconstruction of the sinus. Controversial issues regarding surgical management of parasagittal meningiomas concerning leaving a tumor remnant that invades the SSS instead attempting total resection, or the attitude in the case of totally occluded segment of a sinus are summarized in this paper. The special care for the venous system is emphasized. The recurrence matter is also approached underlining the importance of adjuvant radiosurgery for the management of residual tumors. Results described in the main papers of the literature are reviewed. Conclusions are referring to the historical evolution regarding the surgical management of parasagittal meningiomas: aggressiveness of resection, sinus reconstruction, importance of adjuvant techniques: radiosurgery, endovascular surgery and to the importance of microsurgery and careful and meticulous planning of the approach in order to avoid interference with venous collaterals. A suggestive clinical case from the authors experience is presented.

Endoscopic Transnasal Coagulation of Anterior and Posterior Ethmoidal Arteries before Open Resection of Large Anterior Skull Base Meningiomas: A Novel Combined Approach and Review of Two Illustrative Cases

Introduction: Large anterior skull base (ASB) meningiomas are occasionally highly vascular, and are supplied predominantly by the anterior and posterior ethmoidal arteries which are branches of the ophthalmic artery. Effective preoperative embolization of these lesions is thwarted by concerns of retrograde embolization of the ophthalmic artery with visual loss or blindness. The standard goal of early intraoperative devascularization of these meningiomas at the basal dural attachment is often difficult until there has been substantial tumor decompression. As such, resection of these lesions is often coupled with lengthy operative times and significant blood loss. Endoscopic transnasal approaches provide direct access to the ethmoidal arteries, and ASB meningiomas are largely devascularized early on in the course of surgical resection. However, endoscopic resection of larger ASB meningiomas has been associated with lengthy resection times, subtotal resection, and increased rate of postoperative CSF leak. In an effort to decrease operative time and blood loss we have adopted a surgical strategy that incorporates endoscopic transnasal devascularization of the tumor as a means to complement the strengths of an open surgical approach. We present our institutional experience with two cases in which we treated large (>4 cm) ASB meningiomas with a combined approach—endoscopic transnasal sacrifice of the anterior and posterior ethmoidal arteries followed by open subfrontal resection.

Correction of Sagittal Craniosynostosis Using Distraction Osteogenesis Based on Strategic Categorization.

Distraction osteogenesis has been used to correct sagittal craniosynostosis in various ways. The purpose of this study was to introduce three distraction osteogenesis procedures by describing four objective measurements. Fifty-four patients with sagittal synostosis were recruited and assigned to one of three therapeutic groups: group 1, anteroposterior compression with bitemporal expansion (n = 35); group 2, bitemporal expansion (n = 9); and group 3, anteroposterior expansion with bitemporal expansion (n = 10). Distraction procedures were performed while maintaining dural attachment. Four indices-namely cranial index, head circumference, intracranial volume, and neurodevelopmental index (using the Bayley Scales of Infant Development II), were analyzed. The preoperative cranial index of group 1 (68.51 ± 4.73) differed significantly from those of groups 2 (76.75 ± 2.4; p < 0.05) and 3 (86.8 ± 3.99; p < 0.05). Postoperative cranial index in all groups converged to the mesocephalic cranial index. Preoperative intracranial volume determinations were within the normal range for the majority of participants in groups 1 and 2; however, most fell below -1 SD in group 3 [n = 8 (80 percent)]. Postoperatively, 90 percent of group 3 participants had intracranial volume values within the normal range. The preoperative mental and psychomotor developmental indices of group 3 were significantly lower than those in the other two groups. The postoperative analysis showed significant improvement in these indices in groups 1 and 3 or when all patients were analyzed. Symmetric sagittal synostosis can be effectively treated with distraction osteogenesis reformation guided by strategic categorization. Therapeutic, IV.

Deep Sylvian Meningioma: A Case Report and Review of the Literature

Introduction Meningiomas are extra-axial tumors. They usually display a dural attachment, although meningiomas without dural attachment are extremely rare and reported only occasionally in the literature. In this article, the authors present a new case of a deep sylvian meningioma and briefly review the relevant literature. Case Report We present the case of a 39-year-old man presented with 1- month history of headache associated with an episode of generalized tonic–clonic seizure. Neurological examination showed no abnormality. Magnetic resonance imaging (MRI) demonstrated a lesion located in the right temporo-frontal region which was isointense on T1 and hypointense on T2 with homogeneous enhancement after gadolinium administration. Coronal, axial, and sagittal MRI revealed no dural attachment and the mass appeared to be completely surrounded by brain parenchyma. Intraoperatively, the lesion was presented as a subcortical mass and was mainly in the posterior part of right sylvian fissure. The histological diagnosis showed a World Health Organization grade I meningioma, transitional type. Conclusion Deep sylvian meningiomas are a rare entity. Preoperative diagnosis is difficult. Nevertheless, neurosurgeons and neuropathologists should be aware of this possibility and should include this hypothesis in the differential diagnosis of an intraparenchymal tumor.

Role of Surgical Resection in Patients with Single Large Brain Metastases: Feasibility, Morbidity, and Local Control Evaluation

The aim of this study was to evaluate the safety and the feasibility of surgery for single large brain metastases. This retrospective study included 69 patients. All received a "supramarginal resection" according to functional boundaries, defined as a microsurgical excision with an extension larger at least 5 mm greater than the enhancing T1-weighted magnetic resonance imaging (MRI) sequence borders with dural attachment radicalization. Hypofractionated stereotactic radiosurgery on the tumor bed, using 30 Gy in 3 fractions, was performed within 1 month after surgery. Clinical outcome was evaluated at 30 days postoperative and by MRI performed every 3 months. The appearance of postoperative neurologic deficits, local control (LC), brain distant progression (BDP), and overall survival were evaluated. Clinical remission of symptomatology was obtained in 90.5% of patients. None of them had new neurologic deficits or worsening of preoperative functional status. No major complications or cerebrospinal fluid leakage occurred. No residual tumor was detected on postoperative MRI. The median follow-up was 24 months (range 4-33 months). The 1- to 2-year LC was 100%. Twenty-four (29% of) patients had new BDP, and 75% had extracranial progression. The median 1- to 2-year overall survival was 24 months, 91.3% and 73%. At the last observation time, 15 patients (21.7%) were dead and 54 patients (78.3%) were alive. Supramarginal resection along with dural attachment radicalization have proved to be safe and effective for selected patients with single large brain metastases.

Hemilaminectomy for spinal meningioma: A case series of 20 patients with a focus on ventral- and ventrolateral lesions

ObjectiveTo demonstrate the effectiveness and safety of hemilaminectomy in spinal-meningioma surgery, with special attention to ventral lesions. We also describe technical tips to enhance surgical-corridor width. Patients and methodsA total of 20 patients (14 female and 6 male) underwent hemilaminectomy for resection of a spinal meningioma between January 2005 and December 2015. Preoperative magnetic resonance imaging defined the tumor location (16 thoracic, 3 cervical, 1 lumbar) and the dural-attachment site (4 ventral, 11 ventrolateral, 3 lateral, 2 posterior). Pre- and postprocedural functional status was evaluated according to McCormick’s classification. Intraoperative neurophysiological monitoring was employed in all patients. ResultsThe unilateral approach allowed for complete resection (Simpson grade I–II resection) in 18 patients (90%), including tumors with a ventral dural attachment. In most patients (n=13), monosegmental hemilaminectomy was performed, a single patient required hemilaminectomy of 3 levels, while the remaining 6 patients underwent hemilaminectomy of 2 levels. No patients experienced either worsening of neurological status or procedure-related complications. All patients who had preoperative pain reported postoperative improvement. ConclusionsThe goal of surgery for spinal tumors is to achieve gross tumor removal while minimizing morbidity. In our experience, hemilaminectomy is an effective surgical approach, even in patients with ventral- and ventrolateral spinal meningiomas. The procedure offers several advantages in terms of early patient mobilization and rehabilitation, management of postoperative pain, and preservation of spinal stability while achieving positive functional outcomes.

Disposal of Occipital Condyle in Far Lateral Approach for Ventrolateral Foramen Magnum Meningiomas

To investigate the necessity of drilling the occipital condyle in a tailored far lateral approach for resection of ventrolateral foramen magnum meningiomas (FMMs). Clinical data of 15 patients with ventrolateral FMMs who underwent surgery during a 6-year period were reviewed retrospectively. A retrocondylar approach was performed in 8 cases (6 above the vertebral artery [VA] and 2 below the VA) in which the dural attachment was surgically accessible with no restriction of the initial part of the V4 segment of the VA, and a partial transcondylar approach was performed in 7 cases on both sides of the VA where the dural attachment associated with the VA auxiliary space was reached by superolateral displacement of the VA by drilling of the condyle. Exposure of the V3 segment of the VA was performed in all patients, but no circumcision of the dural ring along with transposition of the VA was needed. Simpson grade II resection was achieved in all patients. Postoperative complications were encountered in 20% of patients, predominantly associated with cranial nerve impairment. No tumor recurrence was demonstrated during follow-up lasting 7-68 months (mean 29.2 months). The surgical approach for ventrolateral FMMs varies depending on the location of dural attachment with reference to VA dural entry. Bone removal is warranted in FMMs arising from both sides of the VA to allow superolateral displacement of the VA to some extent, improving surgical accessibility to the hidden VA auxiliary space and achieving a more radical tumor resection. It should be a reasonable alternative to the conventional aggressive VA transposition in cases of ventrolateral FMMs.

Foramen magnum meningiomas: surgical results and risks predicting poor outcomes based on a modified classification.

OBJECTIVE This study aimed to evaluate neurological function and progression/recurrence (P/R) outcome of foramen magnum meningioma (FMM) based on a modified classification. METHODS This study included 185 consecutive patients harboring FMMs (mean age 49.4 years; 124 females). The authors classified the FMMs into 4 types according to the previous classification of Bruneau and George as follows: Type A (n = 49, 26.5%), the dural attachment of the lesion grows below the vertebral artery (VA); Type B (n = 39, 21.1%), the dural attachment of the lesion grows above the VA; Type C1 (n = 84, 45.4%), the VA courses across the lesion with or without VA encasement or large lesions grow both above and below the bilateral VA; and Type C2 (n = 13, 7.0%), Type C1 plus partial/total encasement of the VA and extradural growth. RESULTS The median preoperative Karnofsky Performance Scale (KPS) score was 80. Gross-total resection (GTR) was achieved in 154 patients (83.2%). Lower cranial nerve morbidity was lowest in Type A lesions (16.3%). Type C2 lesions were inherently larger (p = 0.001), had a greater percentage of ventrolateral location (p = 0.009) and VA encasement (p < 0.001), lower GTR rate (p < 0.001), longer surgical duration (p = 0.015), higher morbidity (38.5%), higher P/R rate (30.8%, p = 0.009), and poorer recent KPS score compared with other types. After a mean follow-up duration of 110.3 months, the most recent follow-up data were obtained in 163 patients (88.1%). P/R was observed in 13 patients (7.2%). The median follow-up KPS score was 90. Compared with preoperative status, recent neurological status was improved in 91 (49.2%), stabilized in 76 (41.1%), and worsened in 18 (9.7%) patients. The multivariate Cox proportional hazard regression model demonstrated Type C2 (HR 3.94, 95% CI 1.04-15.0, p = 0.044), nontotal resection (HR 6.30, 95% CI 1.91-20.8, p = 0.003), and pathological mitosis (HR 7.11, 95% CI 1.96-25.8, p = 0.003) as independent adverse predictors for tumor P/R. Multivariate logistic regression analysis identified nontotal resection (OR 4.06, 95% CI 1.16-14.2, p = 0.029) and pathological mitosis (OR 6.29, 95% CI 1.47-27.0, p = 0.013) as independent risks for poor outcome (KPS score < 80). CONCLUSIONS The modified classification helped to predict surgical outcome and P/R in addition to the position of the lower cranial nerves. Preoperative imaging studies and neurological function should be reviewed carefully to establish an individualized management strategy to improve long-term outcome.

Advances of optical coherence tomography in myopia and pathologic myopia.

The natural course of high-axial myopia is variable and the development of pathologic myopia is not fully understood. Advancements in optical coherence tomography (OCT) technology have revealed peculiar intraocular structures in highly myopic eyes and unprecedented pathologies that cause visual impairment. New OCT findings include posterior precortical vitreous pocket and precursor stages of posterior vitreous detachment; peripapillary intrachoroidal cavitation; morphological patterns of scleral inner curvature and dome-shaped macula. Swept source OCT is capable of imaging deeper layers in the posterior pole for investigation of optic nerve pits, stretched and thinned lamina cribrosa, elongated dural attachment at posterior scleral canal, and enlargement of retrobulbar subarachnoid spaces. This has therefore enabled further evaluation of various visual field defects in high myopia and the pathogenesis of glaucomatous optic neuropathy. OCT has many potential clinical uses in managing visual impairing conditions in pathologic myopia. Understanding how retinal nerve fibers are redistributed in axial elongation will allow the development of auto-segmentation software for diagnosis and monitoring progression of glaucoma. OCT is indispensable in the diagnosis of various conditions associated with myopic traction maculopathy and monitoring of post-surgical outcomes. In addition, OCT is commonly used in the multimodal imaging assessment of myopic choroidal neovascularization. Biometry and topography of the retinal layers and choroid will soon be validated for the classification of myopic maculopathy for utilization in epidemiological studies as well as clinical trials.