Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling.
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Humans↗
Biomedical subjects
Hadas Stiebel-Kalish
Publications and source records attributed to Hadas Stiebel-Kalish.
Puberty as a risk factor for less favorable visual outcome in idiopathic intracranial hypertension.
PURPOSE: To test the hypothesis that puberty is a risk factor for poorer visual outcome in idiopathic intracranial hypertension (IIH). DESIGN: Retrospective chart review case series. METHODS SETTING: Tertiary referral center, neuro-ophthalmology unit. PATIENT POPULATION: Ninety-six patients with IIH followed for a minimum of one year. OBSERVATION: Age (grouped into prepubertal, pubertal, teenage, or adult), obesity, initial intracranial pressure (ICP), measurements and presence of hypertension, anemia, or renal failure were correlated with final visual outcome using chi(2), stepwise logistic regression, and model-selection log linear analyses. MAIN OUTCOME MEASURES: Visual outcome was graded into "excellent" -- no evidence of an optic neuropathy or any permanent visual field defect in either eye, "moderate"-- evidence of an optic neuropathy and/or a mild (nasal constriction) visual field defect, or "poor outcome" (peripheral constriction) -- permanent visual field defect. RESULTS: Outcome data were complete for 96 patients. Moderate to poor visual outcome, as opposed to excellent, was significantly associated with puberty (P = .007 using the gender-specific definition of puberty, .0002 using the broad definition). Moderate-poor visual outcome occurred in none of seven IIH patients of prepubertal age (<9 years), in 15 of 26 patients presenting between nine to 16 years, in two of six patients aged 17 to 22 years, and in seven of 57 adult patients over the age of 23 years. CONCLUSIONS: In this series of 96 patients with IIH, visual outcome was less favorable in pubertal patients than in prepubertal, teenage, and adult patients. We recommend that clinicians maintain a high index of awareness when caring for pubescent children with IIH.
Acetazolamide↗
CSF pressure measurement during anesthesia: an unreliable technique.
BACKGROUND: The measurement of cerebrospinal fluid (CSF) pressure is necessary for many clinical indications. Its accuracy may be compromised in frightened or uncooperative children who find it difficult to relax sufficiently. The aim of the present study was to evaluate possible effects of general anesthesia on CSF pressure values. METHODS: Lumbar puncture was performed under general anesthesia in 15 patients aged 4.5-20 years for the evaluation of headaches associated with a swollen optic nerve. Cerebrospinal fluid pressure was measured with a manometer when the patient was fully anesthetized (opening pressure) and then continuously recorded until the patient regained consciousness. The opening pressure was compared with the lowest pressure measured at the termination of the procedure (end-measurement pressure). RESULTS: Seventeen pressure measurements were performed in 15 patients. In all but two measurements, differences were noted between the opening and end pressure, ranging from 5 to 13 cmH(2)O. The opening pressure was abnormally high in 16 measurements, and the end pressure was abnormally high in seven. The difference between the two measurements was highly significant (P < 0.001). CONCLUSIONS: Lumbar puncture performed under general anesthesia may yield two pressure measurements. Many factors, such as hypercarbia and the anesthetic agent used, may influence the results. Owing to the dynamic changes in CSF pressure, measurements made under anesthesia may be unreliable.
Adolescent↗
Presentation, natural history, and management of carotid cavernous aneurysms.
OBJECTIVE: We present the largest reported cohort of carotid cavernous aneurysms (CCA), comparing the neuro-ophthalmic presentation, complications, and outcome with and without endovascular treatment. METHODS: Retrospective review of 185 patients with 206 CCAs examined between 1980 and 2001 at a tertiary neuro-ophthalmology and neurovascular service. Patients' symptoms and findings at presentation were recorded and compared with those at outcome. The effect of treatment on outcome and on complication rate was analyzed using the chi test, multivariate analysis of covariance, model-selection log-linear analysis, and multinomial logistic regression. RESULTS: Long-term follow-up was available for 189 of 206 CCAs. Seventy-four CCAs underwent treatment (endovascular, 67 [91%]; surgical treatment, 6 [9%]), and 115 were followed for an average of 4 years, two of which required later treatment. Treatment reduced the incidence and severity of pain, even after adjusting for the severity of initial pain (F(1,192 = 9.59, P = 0.002). Treatment did not significantly affect the patient's final diplopia after adjusting for their initial diplopia (F(1, 182 = 2.01, P = 0.158). Statistical examination revealed that the treated group had a higher proportion of neurological and visual complications than people who were not treated (2(2). = 25.26, P = 0.0003). CONCLUSION: Endovascular treatment of carotid cavernous aneurysms leads to a significantly higher rate of pain resolution compared with untreated patients, even after adjusting for initial pain severity. Diplopia may not resolve after treatment. The results of this study underscore our approach indicating treatment only in cases of debilitating pain, visual loss from compression, or diplopia in primary gaze or in patients with risk factors for major complications such as pre-existing coagulopathy or sphenoid sinus erosion.
Adolescent↗
Swedish interactive thresholding algorithm fast for following visual fields in prepubertal idiopathic intracranial hypertension.
OBJECTIVE: To examine the reliability of Swedish Interactive Thresholding Algorithm Fast (SITA Fast) visual fields (VFs) in prepubertal idiopathic intracranial hypertension (IIH) and to compare whether age, gender, or severity of visual outcome influenced the reliability of VF tests. DESIGN: Prospective, longitudinal cohort study. PARTICIPANTS: Twenty-six prepubertal children (<11 years of age; mean age, 7.2 years) with IIH. TESTING: Children were prospectively followed up using a child-oriented program, which included SITA Fast VF tests. Age, gender, and severity of visual outcome were correlated with reliability of performance on SITA Fast VFs using a 1-way analysis of variance, point-biserial correlation, and the chi-square test for independence of observation. MAIN OUTCOME MEASURES: Statistical analyses results that correlated the reliability of SITA Fast VFs with age, gender, and visual outcome. RESULTS: Three children were treated at the age of 2 years and were unable to perform automated VF tests. Four children were treated at the age of 4 years, 3 of whom were able to perform repeatable reliable SITA Fast VF tests. Forty-two eyes of 21 children had an average SITA Fast test time of 4.5 minutes for each eye, compared with 8 minutes using the Fastpac strategy. Age was not associated with reliability scores of SITA Fast tests (F = 0.971, not significant [ns]). Gender did not influence the reliability of SITA Fast VF tests (chi-square((1)) = 0.669, ns), nor did severity of visual outcome (chi-square((2)) = 3.348, ns). Visual deficits were observed in 55% of patients at presentation and in 27% of patients after resolution of papilledema. CONCLUSIONS: The SITA Fast VF tests can be performed from age 4 years and offer a reliable method for shortening test time. A child-oriented follow-up program, which entails a shortened testing time, may improve outcome in prepubertal IIH.
Algorithms↗
The natural history of nontraumatic subarachnoid hemorrhage-related intraocular hemorrhages.
PURPOSE: To describe the natural history of intraocular hemorrhages related to subarachnoid hemorrhage (SAH) as a result of ruptured intracranial aneurysms. METHODS: Retrospective review of patients with cerebral aneurysms examined by a referral neuro-ophthalmology service between 1980 and 1998. Patients with intraocular hemorrhages associated with SAH as a result of ruptured aneurysms were followed up without vitrectomy, unless bilateral vitreous hemorrhage occurred. RESULTS: Seventy of 450 patients with cerebral aneurysms had an SAH. Of these, 30 eyes of 19 patients had intraocular hemorrhages. Fourteen eyes had a vitreous hemorrhage; 12 had subhyaloid blood without a vitreous hemorrhage; and four had retinal hemorrhages alone. Two patients died shortly after presentation. Twenty-eight eyes were followed up for a mean of 4.8 years. Initial visual acuity was 20/100 to light perception in eyes with a vitreous hemorrhage, 20/20 to 20/400 in eyes with subhyaloid blood, and 20/20 to 20/40 in eyes with retinal hemorrhages. Three of the 12 eyes with a vitreous hemorrhage underwent vitrectomy. Of the nonoperated eyes, final visual acuity was at least 20/30 in 19 (76%) eyes, 20/40 to 20/60 in four (16%) eyes, and 20/100 in both eyes of one patient with premacular subhyaloid blood. None of the nonoperated eyes developed cataract formation or progression, retinal tears, or retinal detachment. Epiretinal membrane developed in one eye and pigmentary maculopathy developed in five. CONCLUSIONS: Except for patients with bilateral vitreous hemorrhages, early vitrectomy may not be necessary in most cases of intraocular hemorrhages associated with nontraumatic SAH.
Adult↗
Evolution of oculomotor nerve paresis after endovascular coiling of posterior communicating artery aneurysms: a neuro-ophthalmological perspective.
OBJECTIVE: Guglielmi detachable coil treatment is becoming an accepted alternative to microsurgical clipping for select intracerebral aneurysms. Resolution of oculomotor nerve paresis (ONP) after endovascular packing was claimed to be complete in two prior series, with three and six cases. We describe the evolution of ONP after Guglielmi detachable coil treatment of posterior communicating artery aneurysms, and we search for endovascular and patient factors correlated with the degree of functional nerve recovery. METHODS: Twelve cases of ONP attributable to posterior communicating artery aneurysms were treated with Guglielmi detachable coils between 1999 and 2002. Eleven patients were available for follow-up monitoring. The degree of ONP was recorded at admission, at discharge, after 3 months, and at yearly intervals thereafter. The size of the aneurysm, the duration of ONP before coiling, the degree of coiling, age, and the presence of other microvascular risk factors were correlated with the degree of nerve recovery. RESULTS: Complete resolution of ONP did not occur in any of the 11 cases in this series. However, residual oculomotor nerve deficits did not cause diplopia with primary gaze for 10 of 11 patients. Clinically significant ptosis did not persist for any of the patients. The pupil remained minimally affected in all cases. CONCLUSION: Although mass effect remains after endovascular packing, oculomotor nerve dysfunction improves comparably to the recovery observed after surgical clipping. Contrary to previous reports, typical residual oculomotor nerve deficits persist. Older age and the presence of microvascular risk factors seem to be detrimental to ONP recovery.
Adult↗
Cavernous sinus dural arteriovenous malformations: patterns of venous drainage are related to clinical signs and symptoms.
OBJECTIVE: To provide evidence that venous congestion and drainage patterns are responsible for the manifestations of cavernous sinus area dural arteriovenous malformations (CSdAVMs). DESIGN: Retrospective observational case series. PARTICIPANTS: Records of 85 patients with complete clinical and angiographic evaluations of CSdAVMs were evaluated for the clinical features of the disorder. A neuroradiologist analyzed patterns of venous drainage to and from the cavernous sinus without knowledge of the clinical features. Four venous drainage patterns (reversal of flow from the CSdAVMs into the anterior cavernous sinus, ophthalmic vein thrombosis, drainage into the inferior petrosal sinus or drainage into the superior petrosal sinus) were statistically tested for their predictive value of signs and symptoms using logistic regression. MAIN OUTCOME MEASURES: The power of prediction of orbital congestion, elevated IOP, extraocular muscle dysfunction, optic neuropathy, venous-stasis retinopathy, choroidal effusion, anterior chamber shallowing, bruits, cranial nerve paresis, and central nervous system dysfunction from four patterns of venous drainage. RESULTS: Reversal of drainage into the anterior cavernous sinus and ophthalmic veins was highly predictive (P = 0) of orbital congestion, which was seen in 77 (91%) patients. In contrast, eight (9%) patients without orbital congestion had shunts that did not drain into the anterior cavernous sinus and ophthalmic veins. Cavernous sinus dural arteriovenous malformation drainage into the anterior cavernous sinus and ophthalmic veins also predicted elevated IOP (P = 0.0023) and optic neuropathy (P = 0.047). Ophthalmic vein thrombosis significantly predicted cases with choroidal effusion (P = 0.002) and anterior chamber shallowing (P = 0.01). Third nerve paresis could be predicted from flow toward the inferior petrosal sinuses (P = 0.017). Central nervous system symptoms or dysfunction, occurring in 7 (8%) patients, was predicted by venous drainage into the superior petrosal sinus (P = 0.0008). CONCLUSIONS: The clinical features found in patients with CSdVAMs are related to the abnormal venous drainage and can be predicted by these venous drainage patterns. Venous congestion and hypertension seem to cause the clinical dysfunction in this disorder.
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