Non-functioning pituitary adenoma may lead to blindness and causes visual impairment in 58% of cases and, more rarely, ocular motor disorder. Patients are slow to become aware of their visual dysfunction, vision in one eye compensating the deficit in the other. Assessment of visual function, comprising visual acuity and visual field evaluation and fundus examination, should be performed regularly according to the severity of impairment. Optic nerve optical coherence tomography (OCT) can quantify optic atrophy reproducibly, and is of prognostic value for postoperative visual recovery. Diplopia most often involves decompensation of heterophoria, visual field fusion being hampered by the visual field defect; such diplopia without ocular motor deficit is known as "hemifield slide". Diplopia associated with ocular motor palsy is caused by tumoral invasion of the cavernous sinus (IIIrd, IVth or VIth nerve palsy); in large impairment, restricted eye movement is easily observed; milder palsies require neuro-ophthalmologic assessment and/or Lancaster test. Pituitary apoplexy induces ocular motor impairment in 70% of cases, strongly guiding diagnosis. Visual impairment is associated in 75% of cases. The degree of neuro-ophthalmologic (visual and ocular motor) impairment is one of the main criteria guiding treatment of pituitary apoplexy (conservative medical and/or surgical treatment) and follow-up.

Neuro-ophthalmologic exploration in non-functioning pituitary adenoma

Object For oculomotor nerve palsy (ONP) induced by unruptured posterior communicating artery (PCoA) aneurysms, the authors performed surgical clipping via a superciliary keyhole approach as an optimal treatment modality with high efficiency and low invasiveness. In this study, they then evaluated the technical feasibility, safety, clinical outcomes, including recovery from ONP as well as cosmetic results, and durability of the procedure. Methods Thirteen patients presenting with complete (7 patients) or incomplete (6 patients) ONP underwent surgery via a superciliary approach. The operative video record was used to evaluate the technical feasibility, neurological examinations and CT were performed to analyze the safety of the treatment, and neuroophthalmological examinations and 3D CT angiography were undertaken to determine the effectiveness and durability of the treatment. Results In all cases, the aneurysms were successfully clipped using a 3.5-cm eyebrow incision and supraorbital minicraniotomy. The m...

Superciliary keyhole surgery for unruptured posterior communicating artery aneurysms with oculomotor nerve palsy: maximizing symptomatic resolution and minimizing surgical invasiveness

Introduction Posterior circulation perforator artery aneurysms are sparsely reported in the literature. The natural history of these rare lesions remains unclear and their diagnosis and management are not well-defined. Methods We reviewed our institution9s medical records and performed a comprehensive literature search for cases of posterior circulation perforator aneurysms. Diagnostic imaging, management and clinical outcomes were the primary components of interest. Results Our first case was a 58-year-old patient who developed an infarct after attempted endovascular treatment of a basilar perforator artery aneurysm, the second case was a 55-year-old patient with a posterior cerebral artery perforator aneurysm who did well with conservative management and the third case was a 68-year-old patient who suffered an infarct after successful Onyx embolization of a superior cerebellar artery perforator aneurysm. From the literature we identified four case reports and four case series, all describing aneurysmal lesions of the basilar perforator arteries, giving a total of 17 cases including those from our institution. All cases presented with subarachnoid hemorrhage although 47% of initial vascular imaging studies failed to reveal the aneurysm. Cumulatively, 41% of patients were treated with microsurgery, 35% were treated with endovascular therapy and 24% were managed conservatively with subsequent spontaneous aneurysm resolution at a mean interval of 10 months after rupture. Conclusions Perforator aneurysms of the posterior circulation are diagnostic and therapeutic challenges. Both microsurgical and endovascular treatment of posterior circulation perforator aneurysms are technically difficult, necessitating comprehensive management by an experienced cerebrovascular team.

Perforator aneurysms of the posterior circulation: case series and review of the literature

Objective Basilar trunk perforator (BTP) aneurysms are rare. Treatment options traditionally considered for these uncommon lesions have included direct surgery, endovascular therapy, or conservative management. Flow diverters represent a newer therapeutic option for BTP aneurysms but pitfalls and complications are unknown. We describe three patients with BTP aneurysms treated with flow diverter stents. Methods All three patients had ruptured BTP aneurysms and, after loading doses of dual antiplatelet agents, underwent treatment with a flow diverter alone (two patients) or in combination with an intracranial stent (one patient). Results Complications directly (two thromboembolic events) or indirectly (one hemorrhage at the external ventricular drain site, probably facilitated by the dual antiplatelet therapy) occurred in all three patients and resulted in permanent morbidity in one case. Imaging follow-up confirmed obliteration in all three patients, and no episodes of rebleeding from the aneurysms were observed at follow-up. Conclusions Flow diverters are effective in obliterating BTP aneurysms. However, given the challenges and complications encountered, especially in patients with ruptured lesions, their use must be carefully weighed against other available therapeutic modalities, including observation.

https://jnis.bmj.com/content/neurintsurg/8/2/190.full.pdf

Flow diverter stent treatment for ruptured basilar trunk perforator aneurysms

The authors present the cases of 3 patients with ruptured perforator aneurysms of the posterior circulation Patients were 39, 55, and 59 years old None of the patients had relevant past medical or family history All presented with World Federation of Neurosurgical Societies Grade I and Fisher Grade 2 or 3 subarachnoid hemorrhage Initial angiography results were normal A second cerebral angiogram in each case revealed a small (< 3 mm) aneurysm of perforator arteries of the posterior circulation Patients were successfully managed conservatively None of the patients developed symptomatic vasospasm, rebleeding, or hydrocephaly Control angiograms at 3 months showed spontaneous resolution of the aneurysm in all cases Rupture of perforator aneurysms of the posterior circulation is a rare condition and it may be underdiagnosed because of limitations of imaging techniques Treatments can lead to complications in highly functional territories and should be considered wisely, especially due to the fact that

Spontaneous resolution of perforator aneurysms of the posterior circulation

A prospective study was underway to evaluate the outcome of eyebrow keyhole approach for ruptured anterior circulation aneurysms on early stage. In the past 4 years, 88 patients with ruptured anterior circulation aneurysms, were operated on early stage by an experienced neurosurgical team through eyebrow craniotomy. The clinical data were analyzed. Patients with Hunt and Hess Grade I–II (85.2%) or III (14.8%) were selected for eyebrow approach on early stage. All aneurysms were small (20.5%) or middle (79.5%) in size. All but seven (92.0%) aneurysms were clipped successfully. The opening of frontal sinus occurred in 11(12.5%) cases through eyebrow approach. Of all, 78 (88.6%) patients achieved favorable outcomes. Eyebrow keyhole approach for ruptured anterior circulation aneurysms on early stage might be in particular selected according to the Hunt and Hess Scale, the projection of aneurysm, the length of M1 segment, the location of cerebral hematoma, the size and complexity of aneurysm, as well as the preference and experience of the neurosurgical team.

Is eyebrow approach suitable for ruptured anterior circulation aneurysms on early stage: a prospective study at a single institute

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Is eyebrow approach suitable for ruptured anterior circulation aneurysms on early stage: a prospective study at a single institute