Neurosurgery of the visual

pathway

Dr Muthoka Mativo
Facilitator: Prof Ilako
Objectives
• Review of the visual pathway
• Diagnosis of Lesions
• Approaches to Management
• Examples
• Summary
Visual pathway
Cont..
• Extensive intraorbital and intracranial course leads to high frequency
of interference by pathology

• Anterior and posterior segment lesions exhibit trans-synaptic

degeneration both retro- and anterograde

• Interdisciplinary approach in management

• Inextricable link between Ophthalmologist and Neurosurgeon

Jindahra P, Petrie A, Plant GT. The time course of retrogradetrans-synaptic degeneration following occipital lobe damage in
humans. Brain. 2012;135(Pt 2):534–541.
Diagnosis of lesions
• Thorough history

• Detailed physical examination- RAPD

• Investigations- Imaging, OCT, Visual field maps, Electrophysiology

Differentiates Intra-orbital from Intracranial lesions

Concerns for the neurosurgeon
• Symptomatology and relief e.g RICP

• Life expectancy and age of patient

• Probability of resection-intra vs extra axial, discrete or infiltrative, size,

threat to life, biological behaviour

• Minimization of morbidity and mortality- maximal safe resection

Michael et al Tumors of the anterior skull base, Expert Rev. Neurother. 14(4), (2014)
Location of lesions
Anterior skull base
• Commonest tumors: Osteomas, Meningiomas, Pituitary adenomas,
craniopharyngiomas and sinonasal malignancies

• Maybe non neoplastic; Vascular, congenital, infectious, inflammatory and

traumatic

• Commonest presentation; Visual loss, diplopia and anosmia

• May even present with numbness, hemiparesis and CN palsies

Michael et al Tumors of the anterior skull base, Expert Rev. Neurother. 14(4), (2014)
Approaches
Decisions are made on a case by case basis based on concerns

• Approaches can be
• Transcranial-Frontotemporal, Pterional, Supraorbital
• Transfacial- lateral rhinotomy, Weber-Fergusson etc
• Craniofacial combine the above
• Endonasal

Michael et al Tumors of the anterior skull base, Expert Rev. Neurother. 14(4), (2014)
Some Endonasal entry points
(1) Transfrontal
(2) Transcribriform
(3) Transtuberculum/transplanum
(4) Transsellar
(5) Transclival.
Sellar and Parasellar Regions
• Commonest; pituitary adenomas (15-20%), Meningiomas (25%),
craniopharyngiomas (1%). Also Gliomas may present

• Compression of the optic Chiasm with visual field defects

• Decompression leads to improvement of acuity in about 80%

• OCT correlates with Perimetry and is predictive of visual recovery

Pramit et al Assessment of Optic Pathway Structure and Function in patients with compression of the Optic Chiasm.
Invest Ophthalmol Vis Sci. 2016;57:3884–3890.
• Functional adenomas are often diagnosed by symptoms due to
hormonal hypersecretion.

• Visual symptoms prevail in non-functioning adenomas

• Carvenous sinus involvement adds a predictable constellation.

• Usually gradual except in Pituitary apoplexy

Ruben, R & Sadun A. Optic Chiasm, Parasellar Region, and Pituitary Fossa. In: Yanoff M, Duker A, eds. Ophthalmology. 2nd
Edition. St. Louis. Mosby, 2003.
• Chiasmal syndromes?

• Lateral chiasmal lesions due to; distended 3rd ventricle, artheroma of

carotids and posterior communicating arteries

• Characterised by binasal hemianopia

Foroozan, Rod (2003). "Chiasmal syndromes". Current Opinion in Ophthalmology. 14 (6): 325–331. doi:10.1097/00055735-
200312000-00002.
Approaches
• Trans-sphenoidal surgery has favorable visual outcomes

• Carvenous sinus infiltration, massive intracranial extension and suprasellar

extension favor transcranial approaches (frontolateral or pterional)

• Post-op Fractionated radiotherapy follows- detrimental to vision though

• Adjuvant chemo carboplatin and Paclitaxel-Craniopharyngiomas

Sofela et al; Malignant transformation in craniopharyngiomas Neurosurgery. 75 (3): 306-314.

Hemispheric lesions
• Gliomas, metastases, and ventricular tumors like ependymomas. May
also be Abscesses, AVMs etc

• Varied presentation according to degree of displacement or

infiltration.

• Temporal lobe vs Parietal Vs Occipital

• Other features of disturbed cortical function according to

representation
Approaches
• According to ease of access- trans-sulcal vs interhemispheric

• Avoidance of critical eloquent areas with/without unilateral

representation

• Utilization of Image guided neuronavigation, tractography, awake

surgery with electrophysiological stimulation to avoid inadvertent
injury
Technology
• Microscope- Improved operating times and outcomes (NS first in 1957)
Diffusion tensor imaging-tractography
• Non-invasive portrayal of white matter tracts in the human brain.

• Reduces risk of harming eloquent areas

• Added to neuro-navigational protocols

Hana et al, DTI of the Visual Pathway -White Matter Tracts and Cerebral Lesions. J. Vis. Exp. (90), e51946, doi:10.3791/51946
(2014).
Neuronavigation
• Neuronavigation systems have been developed for image-guided
neurosurgery to aid in the accurate resection of brain tumors

• Safe navigating of the critical anatomy is of prime importance in skull

base and eloquent brain surgeries.

• Still being improved

• https://www.youtube.com/watch?v=LstGpKhvtmk

Alireza et al Neuronavigation: Principles, Clinical Applications and Potential Pitfalls, Iran J Psychiatry. 2012 Spring; 7(2): 97–103
Awake craniotomy
• Important technique for increased lesion removal and minimizing
damage to eloquent cortex.

• Cortical mapping and clinical monitoring aim to localize eloquent

brain areas.

• Dexmedetomidine is central

Cally Burnand and Joseph Sebastian Anaesthesia for awake craniotomy, Continuing Education in Anaesthesia, Critical
Care & Pain | Volume 14 Number 1 2014
Case
• A 28-year-old woman presented to the ED on Friday afternoon at 5:00
PM with the ‘‘worst headache of her life’’ and visual loss in both eyes.
A noncontrast head CT is interpreted as ‘‘normal.’’
• A lumbar puncture to ‘‘rule out meningitis’’ or ‘‘subarachnoid
hemorrhage’’ is normal. She is given analgesic therapy in the ED and
her headache resolves. She is told to make a follow-up appointment
with her neurologist for ‘‘migraine’’ the following Monday.
• The patient has worsening visual loss over the next 2 days, however.
An ophthalmologist notes 6/60 acuity in the right eye and 6/6 acuity
in the left eye. There is a right relative afferent papillary defect and a
right sixth nerve palsy
• The patient is admitted to the hospital and laboratory testing reveals
panhypopituitarism. She undergoes hormone replacement therapy
and an urgent trans-sphenoidal resection of the lesion is performed.

• The final pathology is infarcted pituitary adenoma with associated

hemorrhage.

• The vision improves to 20/20 in both eyes, but there is residual visual
field loss in the right eye and bilateral optic atrophy.
Summary
• Neurosurgical conditions present with Opthalmologic manifestations

• Keen Evaluation is key

• Management on a case by case basis

• Utilization of technology has greatly advanced management