Endoscopic Endonasal Transsphenoidal Approach for the Removal of Optochiasmatic Cavernoma: Case Report and Literature Review

Endoscopic Endonasal Resection of a Cavernous Malformation of the Third Ventricle: Case Report and Literature Review

BACKGROUND

 Suprasellar and third ventricle cavernous malformations (CMs) are uncommon. Conventional approaches such as interhemispheric and translamina terminalis approaches are often used to resect these lesions. Here we demonstrate the use of the endoscopic endonasal approach for a third ventricle CM.

CASE DESCRIPTION

 A 31-year-old man presented with progressive symptoms of headache and visual disturbance as well as short-term memory deficit over a 6-month period. Neurologic examination revealed bitemporal hemianopsia. Radiologic images showed a suprasellar lesion extending into the third ventricle as well as obstructive hydrocephalus. The patient was operated on using an endoscopic endonasal approach and histopathology revealed a diagnosis of CM. Transient diabetes insipidus and adrenal insufficiency were reported postoperatively.

CONCLUSION

 This report demonstrates safe resection of a third ventricle CM via the endonasal route.

Optochiasmatic Cavernomas: Updated systematic review and proposal of a novel classification with surgical approaches

Cavernomas are histologically benign vascular malformations found at different sites in the brain. A rare site for such cavernomas, however, is the anterior optic pathway, comprising the optic nerve, chiasma, and optic tract-called optochiasmatic cavernomas (OCC). These lesions usually present with sudden onset or progressive vision loss, headache, and features mimicking pituitary apoplexy. In this paper, we describe a case of OCC operated at our center. We carry out an updated review of literature depicting cases of OCC, their clinical presentation, management, and postoperative complications. We also propose a novel classification system based on lesion location and further analyze these cavernoma types with respect to the surgical approach used and visual outcome. A 30-year-old lady had presented with a 3-week history of progressive bilateral vision loss and headache. Based on imaging, she was suspected to have a cavernous angioma of the chiasma and left optic tract. Due to progressive vision deterioration, the lesion was surgically excised using pterional craniotomy. Postoperatively, her visual symptoms improved, but she developed diabetes insipidus. Clinical and radiological follow-up has been done for 18 months after surgery. A total of 81 cases have been described in the literature, including the present case. Chiasmal apoplexy is the most common presentation. Surgical excision is the standard of care. Our analysis based on lesion location shows the most appropriate surgical approach to be used for each cavernoma type. Visual outcome correlates with the preoperative visual status. Visual outcome is good in patients presenting with acute chiasmal apoplexy, and when complete surgical excision is performed. The endonasal endoscopic approach was found to provide the best visual outcome. In addition to preoperative visual status, complete surgical excision predicts favorable visual outcomes in OCC. Our proposed classification system guides the appropriate surgical approach required for a particular location of the cavernoma.

Diagnosis and treatment status of suprasellar optic pathway cavernous malformations

Cerebral cavernous malformations constitute a subtype of cerebral vascular malformation typically located in the cerebral cortex. However, their occurrence in the suprasellar optic pathway is relatively rare. There is some uncertainty surrounding the clinical diagnostic methods and optimal treatment strategies specific to suprasellar optic pathway cavernous malformations. In this narrative review, we retrospectively analyzed relevant literature related to suprasellar visual pathway cavernous malformations. We conducted a study involving 90 patients who were postoperatively diagnosed with cavernous malformations, including the 16-year-old male patient mentioned in this article. We have summarized crucial clinical data, including the patient age distribution, sex ratio, lesion locations, primary symptoms, and surgical approaches. The comprehensive analysis of this clinical information underscores the critical importance of timely intervention in relieving symptoms and improving neurological deficits in affected patients. These findings provide valuable guidance and insight for clinical practitioners and researchers dealing with this specific medical condition.

Optochiasmatic cavernoma: Surgical treatment and outcomes

OBJECTIVE

Optochiasmatic cavernoma is an extremely rare cerebral lesion. They account for approximately 1% of all cavernomas of the central nervous system. Reports on this pathology are limited. Abrupt visual deterioration is a common symptom of the disease. Treatment strategy and visual outcomes after different treatment approaches remain a subject for discussion.

METHODS

Patients operated in a period 2005-2021 were analyzed in this study. All patients preoperatively underwent computed tomography (CT) scan, CT-angiography, and magnetic resonance imaging (MRI). Visual function of the patients was assessed pre-op, post-op and at the follow-up. Duration of visual dysfunction was noted as well. Surgical details were also extracted from medical notes. All patients were followed up, and control MRI was performed one month after operation. We assessed surgical series of optochiasmatic cavernomas published for last 10 years. Further comparative analysis with our data was performed.

RESULTS

Five patients were included into this study. There were four men and one woman. Mean age comprised 33.8 years (range 20-48 years). Most patients were admitted to our hospital due to visual disturbances (80%). Visual function improved in four patients. Visual function was unchanged in one patient, lacking visual disturbancies pre-op. Complication developed in one patient.

CONCLUSIONS

Optochiasmatic cavernomas are encountered extremely rare. Despite the use of contemporary diagnostic options, differential diagnosis remains challenging. Full diagnostic work-up is mandatory. After the diagnosis is made, surgical treatment should be considered first. Total microsurgical or endoscopic transsphenoidal removal of the optochiasmatic cavernoma is a relatively safe and effective treatment method facilitating improvement of visual function.

An isolated cavernous malformation of the sixth cranial nerve: A case report and review of literature

Background

Isolated cavernous malformation (CM) of the abducens nerve has not been reported in the literature. Herein, the authors address the clinical importance of these lesions and review the reported cases of CM from 2014 to 2020.

Case Description

A 21-year-old man presented with binocular diplopia and headache from 2 months before his admission. The neurological examination revealed right-sided abducens nerve palsy. The brain MRI revealed an extra-axial pontomedullary lesion suggestive of a CM. The lesion was surgically removed. During the operation, the abducens nerve was resected considering the lesion could not be separated from the nerve and an anastomosis was performed using an interposition nerve graft and fibrin glue. Pathological examination of the resected lesion revealed that it was originated from within the nerve. The patient's condition improved in postoperative follow-ups.

Conclusion

Surgical resection of the cranial nerves CMs is appropriate when progressive neurological deficits are present. If the lesion is originated from within the nerve, we suggest resection of the involved nerve and performing anastomosis. Novel MRI sequences might help surgeons to be prepared for such cases and fibrin glue can serve as an appropriate tool to perform anastomosis when end-to-end sutures are impossible to perform.

Cavernous Malformations of the Optic Nerve and Optic Pathway: A Case Series and Systematic Review of the Literature

BACKGROUND

Although rare, cavernous malformations (CMs) of the optic nerve and anterior optic pathway (optic pathway cavernous malformations [OPCMs]) can occur, as described in several single case reports in the literature.

OBJECTIVE

To describe the technical aspects of microsurgical management of CMs of the optic pathway on the basis of an extensive single-center experience and review of the literature.

METHODS

A systematic literature review was performed to augment an earlier review, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In addition, an institutional database was searched for all patients undergoing surgical resection of OPCMs. Patient information, surgical technique, and clinical and radiographic outcomes were assessed.

RESULTS

Since the previous report, 14 CMs were resected at this institution or by the senior author at another institution. In addition, 34 cases were identified in the literature since the systematic review in 2015, including some earlier cases that were not discussed in the previous report. Most OPCMs were resected via pterional, orbital-pterional, and orbitozygomatic craniotomies. Visual outcomes were similar to those in earlier reports, with 70% of patients reporting stable to normal vision postoperatively.

CONCLUSION

OPCMs can occur throughout the anterior visual pathway and may cause significant symptoms. Surgery is feasible and should be considered for OPCMs presenting to a surface of the nerve. Favorable results can be obtained with resection, although optimal results are obtained with patients who present with milder symptoms without longstanding damage to the optic apparatus.

Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report

BACKGROUND AND IMPORTANCE

Cavernous malformations (CMs) are angiographically occult low-flow vascular malformations that infrequently involve the optic pathway and the hypothalamus (OPH).

CLINICAL PRESENTATION

A 23-yr-old male presented with bitemporal hemianopia due to chaismal apoplexy. Imaging revealed a CM involving the OPH. The CM was resected by an extended endonasal approach. The patient had improvement in his visual field defects, and postoperative magnetic resonance imaging (MRI) revealed a gross total resection of the CM.

CONCLUSION

This case demonstrates the surgical technique of endoscopic endonasal resection of a CM involving the optic pathway.

Opto-chiasmatic apoplexy as a compartment syndrome? Anatomical and surgical considerations on two bleeding cavernous malformations

OBJECTIVE

Opto-chiasmatic (OC) cavernous malformations are sporadic lesions that are often misdiagnosed clinically and radiologically. Presenting symptoms range from incidental findings to the more frequent and dramatic "chiasmal apoplexy." The present study aims to evaluate the potential role of arachnoidal membranes of the basal cisterns in the onset of OC apoplexy. A possible mechanism resembling a compartment syndrome is discussed through the description of two cases of bleeding cavernomas.

METHODS

We describe clinical, radiological, intraoperative findings in two cases of young patients presenting with OC apoplexy from bleeding cavernoma. The first was a 38-year-old man diagnosed with optic neuritis at the first episode of visual acuity deterioration. The second patient was a 22 -year-old woman who suffered two OC apoplexy episodes from a recurrence, which also presented with bleeding.

RESULTS

Both patients were operated on via pterional craniotomy and presented a postoperative improvement of visual symptoms. The second patient experienced deterioration 30 months after surgical resection due to rebleeding from a recurrence and required a second operation. Follow-up revealed a good recovery of visual disturbances; MRI at 6 and 3 years showed in both patients an apparent complete removal of the cavernous malformations.

CONCLUSION

The cisternal environment where OC cavernous malformations develop and the paradigm of a compartment syndrome could explain the clinical presentation variability. This very rare subset of cavernomas would benefit from a classification system using ad hoc neuroimaging protocols and consistent indications.

Multimaterial and multicolor 3D-printed model in training of transnasal endoscopic surgery for pituitary adenoma

OBJECTIVE

The aim of the present study was to investigate the practical value of a multimaterial and multicolor 3D-printed model in anatomical teaching, surgical training, and preoperative planning of transnasal endoscopic surgery for pituitary adenoma.

METHODS

Multimodality neuroimaging data were obtained in a 42-year-old healthy male volunteer and a 40-year-old female patient with an invasive nonfunctional pituitary adenoma. Three 3D-printed models were produced: a monomaterial and monocolor model, a monomaterial and multicolor model, and a multimaterial and multicolor model. The effects on anatomical teaching and surgical training for exposing the vidian nerve were assessed by 12 residents, and the training effect was validated on cadavers. The practical values for preoperative planning were evaluated by 6 experienced neurosurgeons. All evaluations were based on 5-point Likert questionnaires.

RESULTS

The multimaterial and multicolor model was superior to the monomaterial models in surgical training for exposing the vidian nerve (Fisher test; p < 0.05). In addition, the multimaterial and multicolor model was superior to the monomaterial models in anatomical teaching and preoperative planning (Friedman test; p < 0.05).

CONCLUSIONS

Multimaterial and multicolor 3D printing technology makes it convenient and efficient to produce a practical model for simulating individualized and complex anatomical structures in the sellar region. Furthermore, the multimaterial model can provide a more realistic manipulative experience for surgical training and facilitate the preoperative planning.

Transnasal endoscopic removal of a retrochiasmatic cavernoma: A case report and review of literature

Background:

Cavernomas arising in the region of the optic apparatus are extremely rare, accounting for <1% of all the central nervous system cavernomas. Most patients are affected by acute visual disturbances related to hemorrhagic events. A prompt resection of the lesion together with a decompression of the optic apparatus may lead to a functional improvement. Almost all patients reported in literature were treated by means of a craniotomy, whereas only few papers described the use of a transnasal approach.

Case Description:

We report the case of a 53-year-old woman with a hemorrhagic, cavernous malformation of the optic chiasm region and we discuss the technical nuances of the endoscopic transnasal approach we employed. We also review literature for patients with cavernomas treated with a transsphenoidal approach. In our case, the patient underwent the gross-total resection of the lesion through a fully endoscopic transnasal route and the visual disturbances improved immediately after the operation. The ventral access allowed an adequate exposure of the chiasm/anterior circulation complex, thus avoiding an excessive dissection and retraction of neurovascular structures. Moreover, with the aid of angled scopes, we were able to identify the frail vascular supply of the chiasm by employing the suprachiasmatic corridor as well as the infrachiasmatic one. We stress the need for a careful reconstruction of the skull base to avoid a postoperative cerebrospinal fluid leak.

Conclusions:

With the evolution and spreading of the neuroendoscopic techniques, in selected cases, we advocate the use of the transnasal route for the removal of cavernomas arising in the region of the anterior optic pathways.

Postoperative Management of Anterior Visual Pathway Cavernoma, a Unique Perspective: Case Report

Cavernous malformations (CMs) are low-flow vascular lesions with an incidence of 0.1% to 0.7% in the general population. Less than 1% are found in the anterior visual pathway. The most common presenting symptoms are visual disturbances due to hemorrhage and the current standard of treatment is gross total resection.

The authors report a case of a 42-year-old male with visual disturbance and findings on T1-weighted magnetic resonance imaging (MRI) suggesting CM of the right optic nerve and right optic chiasm. The patient underwent right pterional craniotomy for gross total resection of the lesion. One year postoperatively, the patient demonstrated improvement in visual deficits with no signs of recurrence on MRI. Thirty-two months postresection, MRI showed a small slightly lobulated area of T1 hyperintense material within the postoperative cavity along the right aspect of the optic chiasm. MRI at 39 months postresection showed previously seen small amounts of T1 hyperintensity in the central and right aspect of the optic chiasm, with significantly decreased conspicuity. These findings suggest a trace amount of recurrence in the 32-month postoperative imaging despite overall stable visual field testing.

There is a paucity of literature concerning the retreatment of resected CM in the anterior visual pathway. The authors suggest serial imaging as an integral component of CM management. Although repeated visual field testing and clinical follow-up are important aspects of CM management, they are no substitute for the gold standard of MRI.

Three-Dimensional Printed Skull Base Simulation for Transnasal Endoscopic Surgical Training

OBJECTIVE

Transnasal endoscopic skull base surgery (SBS) presents a major challenge for inexperienced neurosurgeons because of the complicated anatomic structures, 2-dimensional endoscopic view, limited operative field, and required skills. We designed a personalized multimaterial and multicolor three-dimensional (3D)-printed SBS simulation to reproduce the complex anatomy of the skull base. The fidelity and feasibility for anatomic education and surgical training were assessed.

METHODS

Two-dimensional computer tomography and magnetic resonance images were collected from a 42-year-old healthy male volunteer. After 3D modeling and spatial alignment, personalized SBS simulations were produced using a multimaterial 3D printer. The fidelity of the models was assessed by 3 experienced neurosurgeons, and the effects for anatomic education and surgical training were evaluated by 10 resident trainees. Both evaluations were based on 5-point Likert questionnaires.

RESULTS

The mean scores for fidelity of tissue structure ranged from 3.7 to 4.7, and scores for aid in anatomic education and surgical training ranged from 3.5 to 4.9.

CONCLUSION

The 3D-printed SBS simulation is a practical, economical, high-fidelity model. It has great potential for anatomic education and operative training in transnasal endoscopic surgery.