Tag: visual outcome.

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Anterior clinoid meningiomas: surgical results and proposed scoring system to predict visual outcomes

J Neurosurg 140:1295–1304, 2024

The authors report a single-surgeon experience with anterior clinoid meningiomas (ACMs) and propose a novel scoring system to predict visual outcomes based on preoperative risk factors.

METHODS A cohort study of all ACMs that were surgically treated by a single surgeon between 2003 and 2021 was performed. Visual function was assessed by an ophthalmologist pre- and postoperatively. Based on the combination of visual fields and visual acuity, 4 visual grades were described. Favorable visual outcomes were defined as mild visual deficit or intact vision postoperatively. Unfavorable visual outcomes were defined as a severe or moderate visual deficit. Predictors of unfavorable visual outcomes were identified using multivariable logistic regression analysis. A scoring system was then created using the resulting β coefficient. A receiver operating characteristic curve analysis was performed to identify a cutoff point on the grading score for stratifying patients at risk for unfavorable visual outcomes.

RESULTS Fifty-two patients met all inclusion criteria. Twenty-five (48%) patients presented with intact vision, and 27 (51%) presented with some visual dysfunction. Postoperative favorable visual outcomes were achieved in 39 patients (75%). Among the 27 patients presenting with visual dysfunction, 14 (52%) experienced improvement after surgery. No new visual deficits were observed among the 25 patients with intact vision at baseline. Nine patients (17%) had a reversible complication. Multivariable analysis showed that severe preoperative visual deficit (OR 13.03, 95% CI 2.64–64.39; p = 0.002), radiographic evidence of optic nerve (ON) encasement (OR 4.20, 95% CI 1.06–16.61; p = 0.04), intraoperative evidence of ON invasion (OR 17.31, 95% CI 2.91–102.86; p = 0.002), an average ganglion cell layer thickness of ≤ 70 µm (OR 21.54, 95% CI 2.94–159.04; p = 0.003), and an average retinal nerve fiber layer thickness of ≤ 80 µm (OR 13.68, 95% CI 1.91–98.00; p = 0.009) were associated with unfavorable visual outcome. The predictive score included the following factors: abnormal optical coherence tomography (OCT) findings, radiographic evidence of ON encasement by the tumor, and severe preoperative visual deficit. A score ≥ 4 of 6 points was demonstrated to be the cutoff associated with unfavorable visual outcome, with a sensitivity of 80%, specificity of 88%, positive predictive value of 80%, negative predictive value of 88%, and area under the curve of 0.847 (95% CI 0.674–1.0; p = 0.003).

CONCLUSIONS The authors have designed a practical and novel scoring system to predict visual outcomes in patients with ACMs. This scoring system may guide preoperative discussions with patients and timely surgical intervention to yield optimal visual function outcomes. Although most patients have excellent neurosurgical outcomes, severe baseline visual deficits, ON encasement, and characteristic OCT abnormalities are associated with unfavorable visual function after ACM resection.

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Contralateral subfrontal approach for tuberculum sellae meningioma

J Neurosurg 138:598–609, 2023

Tuberculum sellae meningiomas (TSMs) present a burdensome surgical challenge because of their adjacency to vital neurovascular structures. The contralateral subfrontal approach provides an outstanding corridor for removing a TSM with an excellent visual outcome and limited complications. The authors present their long-term surgical experience in treating TSMs via the contralateral subfrontal approach and discuss patient selection, surgical techniques, and clinical outcomes.

METHODS Between 2005 and 2021, the authors used the contralateral subfrontal approach in 74 consecutive patients presenting with TSMs. The surgical decision-making process and surgical techniques are described, and the clinical outcomes were retrospectively analyzed.

RESULTS The mean patient age was 54.4 years, with a female predominance (n = 61, 82%). Preoperatively, 61 patients (82%) had vision symptoms and 73 (99%) had optic canal invasion by tumor. Gross-total resection was achieved in almost all patients (n = 70, 95%). The visual function improvement and stabilization rate was 91% (67/74). Eight patients (11%) showed a worsening of visual function on the less-compromised (approach-side) optic nerve. There was no occurrence of cerebrospinal fluid leakage. Four patients (5%) experienced recurrences after the initial operation (mean follow-up duration 63 months). There were no deaths in this study.

CONCLUSIONS The contralateral subfrontal approach provides a high chance of complete tumor removal and visual improvement with limited complications and recurrences, especially when the tumor is in a unilateral or midline location causing unilateral visual symptoms or bilateral asymmetrical visual symptoms, regardless of tumor size or encasement of major vessels. With the appropriate patient selection, surgical technique, and familiarity with surrounding neurovascular structures, this approach is reliable for TSM surgery.

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Surgical management of Tuberculum sellae Meningiomas: Myths, facts, and controversies

Acta Neurochirurgica (2020) 162:631–640

The optimal management of tuberculum sellae (TS) meningiomas, especially the surgical strategy, continues to be debated along with several controversies that persist.

Methods A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumors on a European perspective. To achieve this, the task force also reviewed in detail the literature in this field and had formal discussions within the group.

Results The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological and endocrinological assessments, optimal surgical strategies, and follow-up management.

Conclusion This article represents the consensually derived opinion of the task force with respect to the surgical treatment of tuberculum sellae meningiomas. Areas of uncertainty where further clinical research is required were identified.

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Management of tuberculum and diaphragma sellae meningiomas

TSM, DSM

Neurosurg Focus 35 (6):E7, 2013

Tuberculum sellae meningiomas (TSMs) and diaphragma sellae meningiomas (DSMs) are challenging lesions to treat due to their proximity to neurovascular structures.

Methods. The authors reviewed the medical records of patients who underwent surgical excision of TSMs and DSMs from 1990 to 2013. They also describe the technical strategies used to minimize injury to the optic apparatus, vascular structures, and pituitary stalk.

Results. Twenty-four patients with TSM and 6 patients with DSM were included in the study. Seventy percent of the tumors were large (≥ 5 cm). The pterional approach was employed in most cases. Optic canal involvement was observed in 4 patients. Twenty-one patients (70%) had visual dysfunction before surgery. At follow-up (median 18 months), visual improvement was noted in 10 (47.6%) of 21 patients. Gross-total excision was achieved in 22 patients (91.6%) with TSM and 5 (83.3%) with DSM. At last follow-up, 28 patients (93.3%) had a Glasgow Outcome Scale score of 5. There were no deaths in this series.

Conclusions. Tuberculum and diaphragma sellae meningiomas present a unique subset of tumors due to their location. They can be safely excised with minimal morbidity and mortality using microsurgical techniques. Attention to technical details during surgery leads to greater respectability and superior visual outcome.

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Visual outcomes for surgical treatment of large and giant carotid ophthalmic segment aneurysms

Vision after aneurysm clipping with suction decompression

J Neurosurg 118:937–946, 2013

The authors report their results in a series of large or giant carotid ophthalmic segment aneurysms clipped using retrograde suction decompression.

Methods. A retrospective review of clinical data and treatment summaries was performed for 18 patients with large or giant carotid artery ophthalmic segment aneurysms managed operatively via retrograde suction decompression. Visual outcomes, Glasgow Outcome Scale (GOS) scores, and operative complications were determined. Postoperative angiography was assessed.

Results. During a 17-year period, 18 patients underwent surgery performed using retrograde suction decompression. The mean aneurysm size was 26 mm. Three patients presented with subarachnoid hemorrhage. Fourteen of 18 patients presented with visual symptoms. Eleven (79%) of these 14 patients experienced visual improvement and the remaining 3 (21%) experienced worsened vision after surgery. Of 3 patients without visual symptoms and a complete visual examination before and after surgery, 1 had visual worsening postoperatively. One aneurysm required trapping and bypass, and all others could be clipped. Postoperative angiography demonstrated complete occlusion in 9 of 17 clipped aneurysms and neck remnants in the other 8 clipped aneurysms. One (5.5%) of 18 patients experienced a stroke. Eighteen patients had a GOS score of 5 (good outcome), and 1 patient had a GOS score of 4 (moderately disabled). There were no deaths. There was no morbidity related to the second incision or decompression procedure. Prolonged improvement did occur, and even in some cases of visual worsening in 1 eye, the overall vision did improve enough to allow driving.

Conclusions. Retrograde suction decompression greatly facilitates surgical clipping for large and giant aneurysms of the ophthalmic segment. Visual preservation and improvement occur in the majority of these cases and is an important outcome measure. Developing endovascular technology must show equivalence or superiority to surgery for this specific outcome.

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Lateral Supraorbital Approach Applied to Tuberculum Sellae Meningiomas

Neurosurgery 70:1504–1519, 2012 DOI: 10.1227/NEU.0b013e31824a36e8

Various surgical approaches for the removal of tuberculum sellae meningiomas (TSMs) have previously been described.

OBJECTIVE: To assess the reliability and safety of the lateral supraorbital (LSO) approach to remove TSMs.

METHODS: We identified all TSM patients operated on at the Department of Neurosurgery at Helsinki University Central Hospital, Finland, by the senior author (J.H.) using the LSO approach between September 1997 and August 2010. We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients and discuss the operative technique.

RESULTS: Apparent complete tumor removal was achieved in 45 patients (87%). Of 42 patients, preexisting visual deficit improved in 22, remained the same in 13, and worsened in 7, and de novo visual deficit occurred in 1 patient. At 3 months postdischarge, 47 patients (90%) had a good recovery, 4 (8%) were moderately disabled, and 1 (2%) died 40 days after surgery of unexplained cardiac arrest. Seven patients (13%) had minimal residual tumors, 2 of which required reoperation. During the median follow-up of 59 months (range, 1-133 months), tumor recurred in 1 of the patients who had undergone a second operation.

CONCLUSION: TSMs of all sizes can be removed via the LSO approach with minimal morbidity and mortality. Low-power or no coagulation is recommended near the optic nerves and the optic chiasm to preserve their vascular support from the internal carotid artery perforators. Our results are comparable to those obtained using more extensive and time-consuming approaches. We recommend the LSO approach to remove TSMs.

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Fronto-basal interhemispheric approach for tuberculum sellae meningiomas; long-term visual outcome

Ganna, Ahmed, Dehdashti, Amir R., Karabatsou, Konstantina and Gentili, Fred. British Journal of Neurosurgery,23:4,422-430, (2009).

URL: http://dx.doi.org/10.1080/02688690902968836

We report our experience with the treatment of tuberculum sellae meningiomas using the fronto-basal interhemispheric approach. A retrospective analysis was performed on a series of 24 patients with tuberculum sellae meningiomas who were operated between March 2000 and January 2007. Patients’ presenting symptoms, radiological images, operative reports, and clinical follow-up data were reviewed with special consideration for visual outcome. Visual deterioration was the presenting symptom in all patients, followed by headache in 9 patients (37.5%). The average duration of visual symptoms was 17.6 months. The average tumor diameter was 2.63 cm; encasement of the carotid artery was identified in 7 patients (29%). Complete tumor removal was achieved in 21 patients (87.5%). Mean follow-up period was 52 months. Vision improved in 19 patients (79%), remained stable in 4 (17%) and deteriorated in 1 patient (4%). The degree of tumor removal or visual outcome were both unrelated to the tumor size (p=0.2 and p=0.6 respectively). While the degree of preoperative visual deficit did not affect the visual improvement rate in the whole group (p=0.9), those patients with improvement to good functional vision (>20/40) after the surgery, had a less severe preoperative deficit (p<0.001). The most common complication was anosmia (29.1%) and there was no mortality. The frontobasal interhemispheric approach is safe and provides a direct anatomical approach to tuberculum sellae meningiomas with relatively low incidence of complications. Patients with improved vision to good functional level had a better preoperative visual status.

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