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World Neurosurgery Sep 2019Pediatric oculomotor nerve schwannomas are rare and challenging lesions due to the high morbidity associated with surgical intervention and their proximity to critical...
OBJECTIVE
Pediatric oculomotor nerve schwannomas are rare and challenging lesions due to the high morbidity associated with surgical intervention and their proximity to critical structures limiting the opportunity for stereotactic radiosurgery. We aim to report and review the novel use of fractionated Cyberknife (Accuray, Inc., Sunnyvale, California, USA) stereotactic radiotherapy in pediatric patients with oculomotor schwannomas.
METHODS
A systematic review of PubMed, Embase, and Cochrane was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two patients, ages 8 and 10 years, with tumor volumes of 0.1 cm and 0.2 cm, respectively, were treated with fractionated Cyberknife radiotherapy at our institution. A total dose of 45-50 Gy was administered over 25 fractions (1.8-2.0 Gy per fraction) to the 82%-84% isodose line. Serial magnetic resonance imaging was obtained for long-term follow-up (56-58 months).
RESULTS
We found 14 articles published between 1982 and 2018 that reported a total of 18 pediatric patients with intracranial oculomotor schwannomas. No previously described cases of pediatric intracranial oculomotor schwannomas were treated with radiation therapy. In both of our patients, radiographic tumor control was achieved at a mean follow-up of 57 months, with 1 patient displaying a decrease in tumor volume. Neither patient exhibited any worsening of their presenting symptoms, nor did either patient develop any new neurocognitive deficits following treatment.
CONCLUSIONS
Fractionated Cyberknife radiotherapy is an effective and well-tolerated treatment option for intracranial oculomotor nerve schwannomas with excellent tumor control rates, similar to surgical and radiosurgical techniques, while sparing critical surrounding structures.
Topics: Child; Cranial Nerve Neoplasms; Dose Fractionation, Radiation; Female; Humans; Male; Neurilemmoma; Oculomotor Nerve Diseases; Radiosurgery
PubMed: 31125775
DOI: 10.1016/j.wneu.2019.05.114 -
Clinical Interventions in Aging 2018Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of...
Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature.
BACKGROUND
Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA.
CASE DESCRIPTION
We describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient's poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family's wishes, we continued the conservative treatment and watched closely for any changes in the patient's condition. After 6 months of conservative treatment, the patient's symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient's hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone.
CONCLUSION
In older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients' condition closely and continue conservative treatment, which may yield good results.
Topics: Aged; Conservative Treatment; Humans; Hydrocortisone; Incidental Findings; Male; Nerve Compression Syndromes; Ophthalmoplegia; Optic Nerve; Pituitary Apoplexy; Pituitary Neoplasms; Vision Disorders
PubMed: 30349217
DOI: 10.2147/CIA.S181109 -
Frontiers in Neurology 2023For the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations...
OBJECTIVES
For the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations are essential to distinguish peripheral from central causes. Here we assessed patterns of spontaneous nystagmus (SN) observed in AVS and its diagnostic accuracy at the bedside.
METHODS
MEDLINE and Embase were searched for studies (1980-2022) reporting on the bedside diagnostic accuracy of SN-patterns in AVS patients. Two independent reviewers determined inclusion. We identified 4,186 unique citations, examined 219 full manuscripts, and analyzed 39 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted and SN beating-direction patterns were correlated with lesion locations and lateralization.
RESULTS
Included studies reported on 1,599 patients, with ischemic strokes ( = 747) and acute unilateral vestibulopathy ( = 743) being most frequent. While a horizontal or horizontal-torsional SN was significantly more often found in peripheral AVS (pAVS) than in central AVS (cAVS) patients (672/709 [94.8%] vs. 294/677 [43.4%], < 0.001), torsional and/or vertical SN-patterns were more prevalent in cAVS than in pAVS (15.1 vs. 2.6%, < 0.001). For an (isolated) vertical/vertical-torsional SN or an isolated torsional SN specificity (97.7% [95% CI = 95.1-100.0%]) for a central origin etiology was high, whereas sensitivity (19.1% [10.5-27.7%]) was low. Absence of any horizontal SN was more frequently observed in cAVS than in pAVS (55.2 vs. 7.0%, < 0.001). Ipsilesional and contralesional beating directions of horizontal SN in cAVS were found at similar frequency (28.0 vs. 21.7%, = 0.052), whereas for pAVS a contralesional SN was significantly more frequent (95.2 vs. 2.5%, < 0.001). For PICA strokes presenting with horizontal SN, beating direction was ipsilesional more often than contralesional (23.9 vs. 6.4%, = 0.006), while the opposite was observed for AICA strokes (2.2 vs. 63.0%, < 0.001).
CONCLUSIONS
(Isolated) vertical and/or torsional SN is found in a minority (15.1%) of cAVS patients only. When present, it is highly predictive for a central cause. A combined torsional-downbeating SN-pattern may be observed in pAVS also in cases with isolated lesions of the inferior branch of the vestibular nerve. Furthermore, in cAVS patients the SN beating direction itself does not allow a prediction on the lesion side.
PubMed: 37396773
DOI: 10.3389/fneur.2023.1208902 -
Frontiers in Oncology 2021Intraorbital tumor could be approached by numerous surgical methods. The neuroendoscopic endonasal approach could provide a feasible corridor for indicated tumors....
Intraorbital tumor could be approached by numerous surgical methods. The neuroendoscopic endonasal approach could provide a feasible corridor for indicated tumors. Herein we present a series of 6 consecutive intraorbital tumors from April 2018 to October 2020, which received endonasal endoscopic resection. Cadaveric dissection was performed for the intraconal approach, and the literature was also reviewed. Five tumors were located intraconally, while one extraconally. The pathology revealed 1 angioleiomyoma, 1 cavernous hemangioma, 1 pilocytic astrocytoma, 1 meningioma, and 2 schwannomas. Five of the six achieved gross total resection, including 3 tumors with lateral extension beyond the optic nerve. Preoperative visual deterioration was observed in 4 of the 6 patients, and all got improvement postoperatively. Transient oculomotor nerve palsy was presented in one patient postoperatively. No cerebrospinal fluid leakage, enophthalmos, or strabismus was observed. The median follow-up time is 27 months (11~41 months). At the 6-month follow-up, the visual acuity remained unchanged compared with that at discharge. Proptosis was resolved in 2 of the 3 patients; diplopia was improved in one patient. In conclusion, endoscopic endonasal intraconal approach could be suitable for selected pathological conditions, and for both medial or beyond medial extraconal and intraconal orbital tumors.
PubMed: 35047399
DOI: 10.3389/fonc.2021.780551 -
World Neurosurgery Sep 2019We report the first case of oculomotor nerve (ON) schwannoma treatment through an endonasal endoscopic approach. We also review the literature to determine prognosis...
BACKGROUND
We report the first case of oculomotor nerve (ON) schwannoma treatment through an endonasal endoscopic approach. We also review the literature to determine prognosis factors of ON function after treatment.
METHODS
A complete MEDLINE search was undertaken for all articles reporting data for oculomotor schwannoma. We divided the patient population into 2 groups; Group I: patients who conserved or recovered good ON function and Group II: patients with either new, worsening, or unchanged third-nerve palsy at the last available follow-up. We conducted a comparative statistical analysis of data between the 2 groups.
RESULTS
We identified 55 reported cases of ON schwannoma, all of whom were treated with open transcranial surgery, stereotactic radiosurgery, or observation. There were 22 patients in group I and 33 in group II. At admission, 29 patients had complete oculomotor nerve palsy (34.7% in group I and 67.7% in group II; P = 0.02). Surgical treatment was performed in 36 cases. Radiosurgery was performed in 3 cases. Among patients with good preoperative ON function, 34.6% worsened at last follow-up (26.6% after surgery and 50% with observation; P = 0.03). In total, 31% of patients with total or near-total palsy at admission had an improvement of their ON function (all after surgical resection; P = 0.05).
CONCLUSIONS
ON function at admission and surgical resection of schwannoma appears to be a predictive factor of favorable prognosis regardless of location and tumor size. The endonasal endoscopic approach can be used to biopsy tumors in cases in which open surgery is considered too risky, such as cavernous sinus schwannomas.
Topics: Adolescent; Adult; Aged; Child; Child, Preschool; Cranial Nerve Neoplasms; Female; Humans; Infant; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurilemmoma; Neuroendoscopy; Neurosurgical Procedures; Oculomotor Nerve Diseases; Treatment Outcome
PubMed: 31150851
DOI: 10.1016/j.wneu.2019.05.170 -
Journal of Neuro-oncology May 2024Clival metastatic cancer is rare and has limited literature to guide management. We describe management of clival metastasis with Gamma Knife radiosurgery (GKRS). We...
PURPOSE
Clival metastatic cancer is rare and has limited literature to guide management. We describe management of clival metastasis with Gamma Knife radiosurgery (GKRS). We augment our findings with a systematic review of all forms of radiation therapy for clival metastasis.
METHODS
Records of 14 patients with clival metastasis who underwent GKRS at the University of Pittsburgh Medical Center from 2002 to 2023 were reviewed. Treatment parameters and clinical outcomes were assessed. A systematic review was conducted using evidence-based guidelines.
RESULTS
The average age was 61 years with male predominance (n = 10) and average follow-up of 12.4 months. The most common primary cancers were prostate (n = 3) and lung (n = 3). The average time from cancer diagnosis to clival metastasis was 34 months. The most common presenting symptoms were headache (n = 9) and diplopia (n = 7). Five patients presented with abducens nerve palsies, and two presented with oculomotor nerve palsies. The median tumor volume was 9.3 cc, and the median margin dose was 15 Gy. Eleven patients achieved tumor control after one procedure, and three with progression obtained tumor control after repeat GKRS. One patient recovered abducens nerve function. The median survival from cancer diagnosis and GKRS were 49.7 and 15.3 months, respectively. The cause of death was progression of systemic cancer in six patients, clival metastasis in one, and unknown in four. The systematic review included 31 studies with heterogeneous descriptions of treatment and outcomes.
CONCLUSION
Clival metastasis is rare and associated with poor prognosis. GKRS is a safe, effective treatment for clival metastasis.
Topics: Humans; Radiosurgery; Middle Aged; Male; Female; Cranial Fossa, Posterior; Aged; Skull Base Neoplasms; Adult
PubMed: 38598088
DOI: 10.1007/s11060-024-04648-9 -
Medicine Dec 2022Covid-19 has serious sequelae that may be poorly understood, underreported, and, as a result, not diagnosed promptly, such as variations in clinical manifestations of...
BACKGROUND
Covid-19 has serious sequelae that may be poorly understood, underreported, and, as a result, not diagnosed promptly, such as variations in clinical manifestations of hyperinflammation among people infected with SARS-CoV-2. ophthalmoplegia can be one of these manifestations.
METHODS
We are reporting a 55-year-old male patient with unilateral diplopia considering it as a case of multisystem inflammatory syndrome in adults. We also reviewed the literature systematically for the previously reported studies/cases with third, fourth and sixth cranial nerve palsies due to or after Covid-19.
RESULTS
The literature search yielded 17 studies reporting 29 patients. 71.4% of the patients were males with a mean age of 42.23 years. Ophthalmological symptoms took 9.7 days to appear after the respiratory involvement. All patients had diplopia as part of their visual symptoms. 41.4% of the patients had unilateral sixth nerve palsy, 24% had bilateral sixth nerve involvement, 17% had fourth nerve involvement, and 27.6% had third nerve involvement.
CONCLUSION
Ophthalmoplegia is considered presenting symptom of Covid-19. Further research is needed to detect all neuro-ophthalmological manifestations of Covid-19.
Topics: Adult; Female; Humans; Male; Middle Aged; Abducens Nerve Diseases; COVID-19; Cranial Nerve Diseases; Diplopia; Oculomotor Nerve Diseases; Ophthalmoplegia; SARS-CoV-2
PubMed: 36626529
DOI: 10.1097/MD.0000000000032023 -
Clinical Neurology and Neurosurgery Aug 2020The Oculomotor nerve (OCN) lies in a close relationship with large arteries inside the basal cisterns. Therefore, it may be compressed by vascular malformations or...
BACKGROUND
The Oculomotor nerve (OCN) lies in a close relationship with large arteries inside the basal cisterns. Therefore, it may be compressed by vascular malformations or aneurysms. Nevertheless, the compression is not always related to pathologic conditions. Indeed, some cases of neurovascular conflicts of the OCN have been described in the literature.
METHODS
A case of neurovascular conflict of the OCN resolved after steroid treatment is reported. Additionally, a systematic literature review of those cases was performed.
RESULTS
OCN palsy due to a neurovascular conflict has been described as acute or chronic persistent palsy, or with an intermittent presentation. Symptoms result from compression, although asymptomatic compression is not uncommon. Surgical treatment, pharmacological treatment, and observation have been reported as options in the literature. Microvascular decompression was employed effectively in some cases of OCN neurovascular conflict. Nevertheless, other cases were treated successfully with steroids (persistent presentation) and carbamazepine (intermittent presentation). A management algorithm based on the results of the literature review is proposed.
CONCLUSIONS
Treatment options for OCN neurovascular conflicts and their results are heterogeneous. Based on the literature review, the pharmacological treatment seems to be the most appropriate first-line approach, reserving surgery for refractory cases. Collecting clinical information about new cases will allow defining treatment standards for this rare condition.
Topics: Algorithms; Disease Management; Humans; Male; Microvascular Decompression Surgery; Middle Aged; Nerve Compression Syndromes; Oculomotor Nerve Diseases; Ophthalmoplegia; Steroids
PubMed: 32474258
DOI: 10.1016/j.clineuro.2020.105920 -
Indian Journal of Ophthalmology Nov 2019Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear....
Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy," "vertical rectus transposition for abducens palsy," "superior rectus transposition," "inferior rectus transposition," and "Hummelsheim procedure." References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.
Topics: Abducens Nerve Diseases; Esotropia; Eye Movements; Humans; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Vision, Binocular
PubMed: 31638036
DOI: 10.4103/ijo.IJO_1841_18 -
Ophthalmic Plastic and Reconstructive... 2018To review the level of standardization of frontalis-orbicularis muscle advancement to correct severe blepharoptosis and the degree of scientific evidence supporting the...
PURPOSE
To review the level of standardization of frontalis-orbicularis muscle advancement to correct severe blepharoptosis and the degree of scientific evidence supporting the procedure as a useful modality of blepharoptosis repair.
METHODS
The authors searched the Medline, Lilacs, and Scopus databases for all articles in English, Spanish, and French that used as keywords the terms "frontalis muscle flap," "orbicularis muscle flap," and "ptosis." Data retrieved included authorship specialty, geographic region where the surgeries were performed, characteristics of the samples reported, type and dimensions of the flaps used, time of follow-up, rate of undercorrection, and complications.
RESULTS
Thirty-eight articles were retrieved and analyzed. Most studies originated from Asian countries, especially China, Taiwan, and Korea. Many variations of the procedure were encountered, including location of incisions and frontalis flap design. There were 23 case series with more than 10 patients. None compared the procedure to conventional frontalis suspension surgery. The samples were not homogeneous, including patients with different type of ptosis, variable degrees of levator function, and using distinct methods of evaluating eyelid position. Undercorrection rates ranged from 1.8% to 38% with a median value of 12.2%. The rate of complications (eyelid crease abnormalities, entropion, hematoma, and supraorbital nerve injury) was low.
CONCLUSIONS
The direct frontalis-orbicularis muscle advancement has been judged positively in all reports analyzed. However, the level of standardization of the surgery is low, and the reported series are not homogeneous. Further studies are needed to better evaluate this operation.
Topics: Blepharoplasty; Blepharoptosis; Eyelids; Facial Muscles; Humans; Oculomotor Muscles; Surgical Flaps
PubMed: 29958196
DOI: 10.1097/IOP.0000000000001145