Optic Nerve Compression Research Articles

Meningioma de la vaina del nervio óptico y tratamiento con radioterapia conformacional. Reporte de un caso clínico tratado con largo seguimiento

Introducción: Los meningiomas de la vaina del nervio óptico (MVNO) son tumores inusuales de la vía visual anterior. Sin tratamiento, el crecimiento del tumor lleva a pérdida visual progresiva hasta la ceguera debido a la compresión que ejerce sobre el nervio óptico. Presentación del caso: Paciente, sexo femenino, 42 años, sin antecedentes mórbidos, que en 1992, inicia cuadro de disminución de la agudeza visual del ojo izquierdo. La resonancia magnética (RM) cerebral informa una lesión expansiva fusiforme en relación a la vaina del nervio óptico izquierdo que lo engloba, altamente sugerente de MVNO. En esa ocasión se realiza exploración de órbita la cual resulta frustra, por lo que se decide observación con controles clínicos e imagenológicos anuales, permaneciendo estable. Aproximadamente diez años más tarde, en el lapso de un año, inicia agravación progresiva de la agudeza y campo visual, ptosis palpebral y alteraciones de la oculo-motilidad del ojo izquierdo, objetivadas por examen neuro-oftalmológico, por lo que se sospecha progresión de MVNO. Se solicita nueva RM que confirma crecimiento significativo del tumor. Se descarta nuevo abordaje quirúrgico por riesgo de mayor deterioro visual y se efectúa radioterapia conformacional con una dosis de 54 Gy. Actualmente, a la edad de 65 años, se cumplen 24 años de evolución, 13 post radioterapia, confirmándose estabilidad clínica y radiológica de MVNO. Discusión: La radioterapia, cuando se observaprogresión de la enfermedad, ha demostrado ser una terapia eficaz para los MVNO, con menos complicaciones y con mejores resultados en la preservación de la función visual a largo plazo.

P14.104 The outcomes of conservatively observed asymptomatic nonfunctioning pituitary adenomas with optic nerve compression

Abstract BACKGROUND We investigated the natural history of asymptomatic nonfunctioning pituitary adenomas (NFPAs) abutting on optic nerve. MATERIAL AND METHODS Eighty-three patients with asymptomatic NFPAs with documented optic nerve compression on magnetic resonance imaging (MRI) at the time of detection between 2000 and 2016 were included in this study. Patients were evaluated with a hormone test, visual acuity test, visual field test and MRI at the time of diagnosis, and then, yearly, without any treatment (including surgery and radiation). RESULTS The mean age was 57.7±13.6 (range, 15 - 81) years. The mean follow-up duration was 66.6±39.0 (range, 12 - 184) months. Tumor volume growth ≥ 20% was observed in 64 (77.1%) patients. Ten (12.2%) patients experienced any kind of hormonal dysfunction, and gonadotropin deficiency was the most common type of hormonal deficiency [n=9 (10.8%)]. Visual deterioration quantified by Visual Impairment Scale was seen 27 (32.5%) patients. There was no statistically significant factor for tumor growth or visual aggravation. Fourteen (16.9%) patients eventually underwent tumor resection. From multivariate analysis, the significant predictors for eventual surgical intervention were cavernous sinus invasion (OR=20.95; 95% CI, 2.754–159.3; p=0.003) and last follow-up visual field defect score (OR=1.170; 95% CI, 1.049–1.305; p=0.005). All patients who underwent surgery did not experience any neurologic or endocrinological deficits postoperatively. CONCLUSION The clinical outcomes of conservatively observed NFPAs with optic nerve compression can be acceptable. The decision for surgical intervention should be made by balancing the risk and benefits.

Monocular Vision Loss: A Rare Cause.

A 62-year-old woman with a history of metastatic breast cancer and known meningioma presented with unilateral vision loss associated with anisocoria and an afferent pupillary defect. On magnetic resonance imaging we found the cause to be optic nerve compression by a right frontal meningioma. Monocular vision-loss etiologies are anatomically localized to structures anterior to the optic chiasm. This case serves as a reminder that cerebral structures in this location must not be forgotten in the differential.

A Female Patient with Intraorbital Varix: A Case Report

: The present study reported the case of a 23-year-old female patient with right-sided enophthalmos. After several episodes of spontaneous periorbital ecchymosis, she developed positional proptosis. The ophthalmologic examination was normal, except a 3-mm enophthalmos measured using the Naugle exophthalmometer, which improved significantly by the Valsalva maneuvers. The diagnostic imaging tests in orbital disease consisting of orbital computed tomography and orbital magnetic resonance imaging showed a retro-orbital vascular lesion. The most likely diagnosis was orbital varix, which is a rare orbital vascular lesion. It was decided to manage the patient conservatively, in the absence of complications such as proptosis with corneal exposure, optic nerve compression, or unacceptable appearance.

The case of sinogenic subperiosteal abscess without symptoms of sinusitis

Orbital infection occurs when pathogens pass from an infected sinus into the orbit. The inflammation is spreading onto the orbital structures from the surrounding tissues mainly from ethmoidal sinuses due to its specific anatomical conditions. The orbital complications are preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and intracranial infections. The diagnosis of subperiosteal orbital abscess is based mainly on clinical presentation. The symptoms depends on which sinus is affected. Orbital symptoms include periorbital swelling, proptosis, ophthalmoplegia, chemosis, and optic nerve compression. Computer tomography is mandatory. Early diagnosis and appropriate treatment can prevent from permanent vision loss and intracranial complication. The study discusses the course of the disease of a 25-year-old woman who was admitted to the Emergency Department due to inflammatory eyelid oedema and proptosis for 3 days. No symptoms of sinusitis were noted. The CT scans established diagnosis - subperiosteal orbital abscess. The patient was treated with broad-spectrum antibiotics and functional endoscopic sinus surgery. Her treatment and recovery were uneventful. In follow-up nighter ophthalmological nor otorhinolaryngological complains were noted.

Tension pneumo-orbit secondary to minor blunt force trauma

IntroductionTension pneumo-orbit is a rare but eye-threatening sequelae of orbital trauma. Minimal trauma to the lamina papyracea can result in a valve effect leading to rapid-onset proptosis and optic nerve compression in the absence of a haematoma. Case reportWe describe a case of medial orbital wall fracture in a 35-year-old lady following a minor fall at home. She presented with severe proptosis of the left eye. Imaging showed marked pneumo-orbit, which was managed definitively by endoscopic orbital decompression. DiscussionTension pneumo-orbit requires prompt recognition and surgical decompression. An endonasal approach may be used to decompress the orbit via the medial wall.

Visual field and orbital computed tomography correlation in dysthyroid optic neuropathy due to thyroid eye disease

ABSTRACTPurpose: The pathogenesis of dysthyroid optic neuropathy (DON) in thyroid eye disease (TED) is thought to be compression of the apical optic nerve by hypertrophied extraocular muscles. We correlated worsening DON to the area occupied by extraocular muscles.Methods: Records of adults with TED DON evaluated from 1/1/2013 to 1/1/2018 were retrospectively reviewed. Each patient’s visual field with the worst mean deviation (MD) was selected. Orbit CT scans were reviewed. Reformatted oblique coronal images were created perpendicular to the optic nerve. The cross-sectional area (CSA) of the orbit and each muscle group was measured and expressed as ratios of the CSA of the orbital apex. Univariate and multivariate analysis was performed for predictors of HVF MD.Results: 34 orbits with TED DON were analyzed. On orbital CT, the superior muscle complex occupied 15% of the apex (range 6–26%), inferior 18% (range 6–33%), lateral 10% (range 4–18%), medial 17% (range 8–27%), and all combined 61% (range 28–80%). Increasing total muscle area and superior complex area correlated with worsening MD. In multivariate linear regression, the superior muscle complex remained a significant predictor of MD (p = 0.01) over total muscle area (p = 0.25).Conclusions: Enlargement of extraocular muscles is common in TED, but DON occurs in only 6%. Our findings demonstrate that as DON worsens, as quantified by visual field MD, the superior muscle complex crowds the apex. This is consistent with the typical inferior visual field findings seen in TED DON. Hypertrophy of the superior rectus and levator palpabrae superioris complex may be predictive of worsening DON.

SAT-LB075 Pituitary Function after Surgery for Non-Functioning Macroadenoma: A Tertiary Single Center Retrospective Cohort

Introduction: Non-functional pituitary adenomas (NFPA) represent the second most frequent cause of pituitary tumors after prolactinomas. For those patients that harbor a macroadenoma, surgery is indicated in case of visual function disturbances, risk for future optic nerve or chiasm compression, and tumor progression during follow-up. Hypopituitarism, in this context, is only a relative indication for surgery and the available data regarding postoperative hormonal outcomes are inconsistent. The aim of this study was to evaluate the impact of transphenoidal surgery on pituitary function. Methods: We retrospectively analyzed data from 350 patients having had pituitary surgery in a tertiary center, from March 2004 to January 2018, and included 137 non-functioning or gonadotroph adenomas, on the basis of histology reports. There were 40.9% males and 59.1% females, with a mean age of 60 years old at the time of surgery. For 89.9% of patients, indication for surgery was based on visual impact or risk. Mean tumor diameter was 24.8 mm. Patients were operated on with a microscopic trans-septal transsphenoidal approach, by the same experienced surgeon. Hormonal evaluation data were retrieved and patients were classified as normal or deficient, by axis. Pituitary magnetic resonance imaging, before and after surgery, was also analyzed, and the average of the three diameters was calculated. Results: In our cohort, new insufficiencies were observed in 5.1% of patients for the GH axis, 9.2% of patients for the ACTH axis, 8.3% for the FSH/LH axis, and 1.6% for the TSH axis. Among patients with hyperprolactinemia prior to surgery, 71.4% normalized prolactin values postoperatively. Recovery of preoperative insufficiencies was observed in 45.5%, 15.4%, 35.7% and 30.4% for the GH, ACTH, FSH/LH and TSH axis respectively. Logistic regression analysis showed that patients with the smallest decrease in tumor size where at higher risk for developing new insufficiencies after surgery (odds ratio: 11.37, 95% CI: 1.13-114,96) and that male sex was associated with a higher chance of postoperative hormonal recovery (odds ratio: 2.74, 95% CI: 1.11-6.78). Conclusion: Pituitary insufficiency is restored in more than one third of patients after surgery for NFPAs, whereas, new deficiencies appear in less than 10% of patients with previously normal function, with ACTH axis being the most fragile and TSH axis being the most resistant to damage. Poor postoperative results, in terms of volume decrease, are associated with higher risk of new deficiencies. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

SUN-619 Thyroid Carcinoma Masquerading as Pituitary Tumor: A Rare Diagnosis Not to Miss in the Evaluation of a Sellar Mass

Background Metastatic disease constitutes 1-2% of sellar masses. The majority of pituitary metastases are secondary to lung or breast cancer. Rarely thyroid cancer metastasizes to the pituitary gland setting off diagnostic and therapeutic challenges. We present such a case in a patient with no known history of thyroid cancer. Clinical case A 73 year old woman with history of right breast ductal carcinoma in situ, presented with headaches and left sided vision loss. MRI scan showed a large 6.5 x 3.5 x 4.6 cm sellar mass extending into the clivus, nasal cavity and maxillary, sphenoid and cavernous sinuses with bilateral optic nerve compression. Biopsy of the nasal mass revealed malignant clusters of follicles with scattered intranuclear pseudoinclusions and grooves and immunostaining was positive for thyroid transcription factor 1 and thyroglobulin, consistent with metastatic thyroid carcinoma. PET scan showed a hypermetabolic left hemithyroid mass, the large hypermetabolic destructive skull base mass and a few suspicious right sided cervical lymph nodes. She had a palpable left sided thyroid nodule, seen on ultrasound as 2.9 cm lobulated, rim calcified nodule that was positive for papillary thyroid cancer on fine needle aspiration biopsy. Preoperative thyroglobulin level was >30,000 ng/ml (normal 1.6-55 ng/ml). She underwent a combined endonasal transsphenoidal partial resection of the large sellar mass and total thyroidectomy. Postoperative thyroid pathology was consistent with angioinvasive follicular thyroid cancer (FTC), and surrounding lymph nodes were negative for malignancy. She has recovering vision in both eyes. The residual sellar tumor was treated with fractionated external beam radiation therapy. This was followed by adjuvant radioactive iodine ablation for stage IVc FTC. Conclusion In patients found to have an extensive sellar mass, prompt workup should be done to identify etiology, keeping an open mind to rare pathologies. Pituitary metastases more commonly present with symptoms related to mass effect in the sella than hormone deficiencies. Usually patients with thyroid cancer pituitary metastases already have known thyroid cancer, often with additional metastases. This case is unique in that the patient presented with signs and symptoms of mass effect from an extensive sellar mass. In scenarios with coexisting sellar mass and thyroid nodule it is very important not to miss the possibility of thyroid cancer with metastases to the pituitary gland.

SAT-579 A Rare Presentation of Ophthalmopathy in a Patient with Hashimoto's Hypothyroidism

Ophthalmopathy is a known disorder that consists of inflammation of the orbits and periorbital tissues that can be commonly seen in systemic autoimmune diseases such as Graves. On the other hand, ophthalmopathy associated with Hashimoto's thyroiditis is a rare presentation that is under-reported in the literature. A 58-year-old female was admitted to the hospital for sudden onset of double vision with subsequent progression of vision loss in her left eye. Prior to admission, she had a known history of hypothyroidism for several years with non-compliance to replacement therapy. On admission, patient's thyroid function tests (TFTs) showed a TSH of 37.95 and a Free T4 of 0.6 along with elevated thyroid peroxidase (TPO) antibodies at 58.3, thus confirming the diagnosis of Hashimoto's hypothyroidism. Upon Ophthalmology consultation, she was noted to have orbitopathy, namely left eye rectus lateralis paralysis, that was attributed to the TPO antibodies. The patient was started on appropriate thyroid hormone replacement with improvement of TFT values within a few days. However, the patient continued to have persistent diplopia despite therapy. At this time, the patient was started on prednisone 20 mg daily for a total of 2 weeks. At the end of the steroid therapy, complete resolution of the orbitopathy with vision improvement was noted. Hashimoto's ophthalmopathy is a rare form of orbitopathy especially when compared to the well-known version in Graves' Disease. In the literature, there has been some case studies that looked at the association of Hashimoto's thyroiditis with diplopia. In one study, the authors noted that both Graves' and Hashimoto's diseases accounted for 6% of thyroid associated eye disease while Graves' disease accounted for the majority of cases. The authors also noted that patients with Hashimoto's thyroid-associated eye disease were: older, had a longer duration of Hashimoto's diagnosis, were less likely to have co-existent other autoimmune disease, had a positive history of tobacco usage, and had elevated values of thyroid stimulating antibodies (TSAb). The authors also established a positive correlation between the occurrence and severity of thyroid associated eye disease in relation to increasing TSAb levels.1 Although Hashimoto's associated ophthalmopathy is a rare presentation of this autoimmune thyroid disorder, it is prudent to have a high index of suspicion in order to institute appropriate anti-inflammatory therapy such as steroid therapy for early resolution of eye symptoms. Early identification and treatment can stop the disease progression and prevent complications such as blindness due to optic nerve compression. 1. Kan E, Kan EK, Ecemis G, Colak R. Presence of thyroid-associated ophthalmopathy in Hashimoto's thyroiditis. International Journal of Ophthalmology. 2014;7(4):644-647. doi:10.3980/j.issn.2222-3959.2014.04.10.

Clipping of a giant partially thrombosed ophthalmic segment aneurysm

Abstract Ophthalmic segment aneurysms (OSA) originate from the paraclinoid portion of the internal carotid artery (ICA) usually at the origin of the ophthalmic artery. OSAs represent 1.5–10% of intracranial aneurysms, and although often asymptomatic, may lead to optic nerve (ON) compression and/or subarachnoid hemorrhage. When the dome is partially or completely thrombosed, microsurgical clipping can provide vascular exclusion and ON decompression through thrombectomy. Nevertheless, high expertise and knowledge of the regional anatomy are required to manage this complex surgical field. In this operative video, we show the management of a giant thrombosed OSA. The 52-year-old male patient presented with a recent history of worsening headache and progressive right visual loss. Neuroimaging revealed a 3 cm partially thrombosed right OSA, with mass effect on the ON and surrounding edema. An incidental 5 mm right middle cerebral artery (MCA) bifurcation aneurysm was also identified. Endovascular occlusion was not feasible, and the patient agreed to microsurgical treatment. A right pterional craniotomy was performed and the sylvian fissure was split, exposing both lesions. Parent vessel control was achieved with temporary clipping of the cervical ICA, and distal to the origin of the aneurysm. After debulking of the thrombosed and calcified dome with ultrasonic aspiration, the aneurysm was secured with combined clipping inside and outside the dome. The MCA aneurysm was subsequently exposed and clipped. Indocyanine green video-angiography confirmed exclusion of both aneurysms and flow patency of the rest of the circulation. The patient was discharged without complications and post-operative angiography showed complete occlusion of both aneurysms.

Incidence and outcomes of retrobulbar hematoma diagnosed by computed tomography in cases of orbital fracture

ObjectiveRetrobulbar hemorrhage (RBH) is a potentially sight-threatening complication of orbital fractures causing an orbital compartment syndrome (OCS). RBH causing OCS is regarded as a clinical diagnosis when evidence of optic nerve compression is found. Nonetheless, many patients with facial trauma will have received imaging by computed tomography (CT) on which there is documented RBH, with or without signs of OCS. The aim of this study was to identify the incidence and describe the outcomes of these CT-diagnosed RBH. MethodsThis is a retrospective chart review of patients with orbital fractures for which ophthalmology was consulted. Confirmation of orbital fracture and presence of an RBH on facial-bones CT was recorded. Patient demographics, proptosis, visual acuity, intraocular pressure and interventions received at initial visit and follow-up were recorded. Results292 orbits with wall fractures were identified. 94 (32.2%) were documented by CT to have RBH. Of these orbits, only one (1.1%) was diagnosed with OCS receiving canthotomy and cantholysis. 53 orbits with initial CT-diagnosed retrobulbar hematoma were seen in follow-up a week or more later, none of which had developed signs of OCS or needed medical or surgical intervention for OCS. ConclusionsRBH is a frequently reported finding on CT in cases of orbital fractures. In this study, almost all of these CT-diagnosed RBH did not develop OCS initially or by the time of follow-up. CT presence of RBH is not an accurate predictor for OCS, and the diagnosis and treatment of OCS should be directed clinically.

Troubles visuels aigus associés aux méningiomes sphénoïdaux

Meningiomas represent about 20% of intracranial tumors. Involvement of the medial sphenoid wing includes anterior clinoid, cavernous sinus and superior orbital fissure meningiomas. Due to the proximity of these tumors to the optic nerve, typically progressive unilateral vision loss, over several months to years, is the classic clinical presentation. We report three cases of acute monocular vision loss, two transient and one permanent, ipsilateral to a sphenoid meningioma. Ophthalmological involvement with sphenoid meningiomas is most often chronic, due to interruption of axoplasmic flow and demyelination of the optic nerve by local compression. However, vascular involvement with ischemia of the optic nerve or transient low blood flow secondary to compression of the carotid branches vascularizing these structures is another possible mechanism. In our series, two patients had amaurosis fugax, and one patient had sudden, persistent visual loss in relation to acute anterior ischemic optic neuropathy on the side of the meningioma. The mean age of patients with acute visual manifestations was 62 years. These ischemic and non-compressive visual symptoms, ipsilateral to sphenoid meningiomas, are difficult to interpret. Whether these temporary visual disturbances of vascular origin should be considered an early sign of future severe or permanent visual impairment when no optic nerve compression is observed is not certain. The place of these acute visual disturbances in the therapeutic decision, particularly surgical, remains to be defined. Larger multicentric prospective studies are needed to better understand the role of local circulatory factors attributable to meningioma in the occurrence of these acute visual signs.

Case on Pituitary Macroadenoma

Pituitary adenomas are slowly progressive and usually benign type of tumors which may induce a poor quality of life of patients due to progressive loss of vision over time by compression of optic nerves, cavernous sinus, optic chiasm. Its therapy generally involves differential diagnosis with an MRI of Brain and surgical option with radiation therapy. Here with we present a case of 48 year old women who had undergone microscopic transnasal transphenorbital excision of tumor two years ago of pituitary macroadenoma. She was not on any chemotherapy which led to a recurrence of her tumor. Presently her MRI scan and histopathologic reports confirms the diagnosis of Pituitary macroadenoma which was effectively treated surgically and put up on Dihydroartemisnin, a derivative of Artemether which has similar cytotoxic properties as that of artemether.

Intracranial Arterial Compression of the Anterior Visual Pathway

ABSTRACTCompression of anterior visual pathway (AVP) structures by intracranial arteries is observed not infrequently on neuroimaging. Whether or not such compression results in damage to these structures, however, remains unclear. This information is important to define as AVP compression by intracranial arteries may be a causative factor in patients with otherwise unexplained visual dysfunction. In a single centre, 37 patients with evidence of intracranial artery AVP compression demonstrated on magnetic resonance imaging were identified by retrospective review of case records over the period 2011–2017. Variables were collected, including patient demographics, visual acuity, visual fields, pupillary reactions and optic disc appearance for patients in the case series. Visual field deficits correlated with compression sites in the 37 patients examined. Internal carotid artery-optic nerve compression was the most frequent (unilateral compression n = 9, bilateral compression n = 14), followed by chiasmal compression by the anterior cerebral artery (n = 8) and a combination of optic nerve and chiasmal compression (n = 5). Visual acuity and visual fields were stable on follow-up (mean 4 years) in 24 of 26 cases (93%). We conclude that AVP compression by intracranial arteries may be a causative factor in unexplained visual dysfunction. The visual defects are largely non-progressive.

Interruption of autoimmunity for thyroid eye disease: B-cell and T-cell strategy.

Recent new insights into the molecular basis of thyroid eye disease have led to the use of more specific therapies such as monoclonal antibodies This review explores the traditional immunosuppressant therapy for TED, highlighting the basis for emergent recent medications, possible treatment options and, eventually possible new general recommendation for management of TED. Data has been retrieved from the literature searching on Pubmed. Steroid therapy remains the first line therapy for moderate/severe and severe vision threatening TED The use of some traditional nonspecific immunosuppressant such as mycophenolate, cyclosporine and azathioprine seems useful in combination with steroid therapy to achieve stable results in the long term; methotrexate is useful as steroid-sparing medications and in steroid resistant or intolerant patients. In recent years, many scientific reports have showed the effectiveness of biological immunosuppressive agents in the management of TED. Etanercept, adalimumab, and tocilizumab have shown to be effective in reduction of the inflammatory signs with the possible advantage to prevent relapse of the disease. Particularly Tociliuzumab seems very effective as second line therapy, after steroid failure. Teprotumumab may control the disease activity and it seems to be very effective in preventing severity disease progression. Infliximab might be useful in severe TED with optic nerve compression resistant to steroid and decompression. Indeed, the actual incidence of adverse effects is not well assessed yet, therefore the use should be limited at those cases that really need an alternative therapy to steroid, handled by an expert multidisciplinary team.

A comparative analysis of piezosurgery and oscillating saw for balanced orbital decompression

ABSTRACTIntroduction: Different minimally invasive surgical approaches to the orbit allow individualized bone resection to reduce proptosis and decompress the optic nerve in patients with Graves’ orbitopathy (GO). This study aims to compare piezosurgery to an oscillating saw used to resect bone from the lateral orbital wall.Methods: In a retrospective study, we analyzed balanced orbital decompressions performed on 174 patients (318 cases) with GO. An oscillating saw was used in 165 cases (saw group) and piezosurgery in 153 cases (piezo group). Peri- and postoperative complications, reduction of proptosis, new onset of diplopia and improvement of visual acuity in cases of pre-operative optic nerve compression were analyzed.Results: We observed no significant differences in the surgical outcome between the two groups. Proptosis reduction was 4.6 mm in the saw group (p < 0.01) and 5.3 mm in the piezo group (p < 0.01). Intraoperative handling of the piezosurgery device was judged superior to the oscillating saw, due to soft tissue conservation and favourable cutting properties. Duration of the surgery did not differ between the groups. No serious adverse events were recorded in both groups.Conclusion: The application of piezosurgery in orbital decompression is more suitable than an oscillation saw due to superior cutting properties such as less damage to surrounding soft tissue or a thinner cutting grove.

Microsurgical clipping of ophthalmic artery aneurysms: surgical results and visual outcomes with 208 aneurysms.

OBJECTIVEWhile most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms.METHODSResults from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed.RESULTSDespite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0-2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits.CONCLUSIONSThe most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially decrease the incidence of delayed visual deficits. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.

Giant Frontal Sinus Osteomas: Demographic, Clinical Presentation, and Management of 10 Cases

Osteomas are rare benign and slow-growing osteogenic tumors mainly involving frontal and ethmoid sinuses. The primary objective of our study is to present the management of cases of giant frontal sinus osteomas. Secondarily, we describe our modified unilateral osteoplastic flap approach without obliteration to remove these osteomas. Retrospective chart review at a tertiary academic center ("Hôpital de l'Enfant-Jésus") from July 2006 to October 2016. Demographics characteristics, tumor characteristics, presenting symptoms, frontal sinus surgery technique (osteoplastic flap, endoscopic surgery, or a combination of both), and outcomes of giant frontal sinus osteomas (≥30 mm) were recorded. For laterally placed osteomas, tumors with posterior wall involvement, orbital roof involvement, or intracranial extension, the modified unilateral osteoplastic flap approach was used. A decision-making algorithm is proposed for the choice of surgical approach. Ten giant frontal osteomas were analyzed (7 men and 3 women). The mean age at diagnosis was 38 years old (range, 24-55 years; median, 39 years; standard deviation, 11 years). The most common presenting symptom was headache (43% of symptomatic patients). Five patients had complications preoperatively due to tumoral extension (sinusitis, cellulitis, mucocele, optic nerve compression, and convulsions). One patient was treated endoscopically, 3 patients had an open approach and 6 patients had a combined technique. One patient experienced a postoperative complication (local infection treated with oral antibiotics). Six patients had minimal residual tumor with one patient needing reoperation. Osteomas are rare paranasal sinus tumors. Due to the proximity to noble structures, a giant frontal osteoma should be managed surgically. The modified unilateral osteoplastic flap without obliteration offers good long-term surgical and aesthetic results. Osteomas are not known for malignant transformation and recurrences are rare; thus, subtotal resection is warranted and safe when a cleavage plan is not found.

Complications Associated With Transsphenoidal Pituitary Surgery: Review of the Literature.

Complications Associated With Transsphenoidal Pituitary Surgery: Review of the Literature.