Visual Mapping for Tumor Resection: A Proof of Concept of a New Intraoperative Task and A Systematic Review of the Literature.

Homonymous hemianopia has been reported after brain tumor resection with a significant effect on quality of life. Nevertheless, no standardized methods exist for intraoperative optical radiation mapping. The purpose of this article is to describe a new intraoperative task for visual mapping and to review the existing literature. A Central and Peripheral Image task was used to map optic radiations during brain tumor resection in 3 patients. A systematic review was performed following PRISMA 2020 guidelines, with 25 of 449 articles included. Optic radiations were identified in all patients and preserved in all but one, in whom the extent of resection prevailed. The literature review exposed 2 methods to assess visual function: visual evoked potentials (VEP) and direct electric stimulation (DES), with 13 and 12 articles and 341 and 63 patients, respectively. Hemianopia was developed in 13.49% of patients with VEP versus 1.59% of patients with DES. The use of DES might be associated with a better outcome (level IV evidence). However, standardization of intraoperative tasks during DES could be improved. In this context, the Central and Peripheral Image task might be an adequate tool for the resection of tumors affecting the optic radiations.

Partial Balint's syndrome and left homonymous hemianopsia presenting after resection of a right occipito-parietal glioblastoma.

A 66-year-old left-handed male was admitted to our acute inpatient rehabilitation (AIR) unit following a resection of the right occipito-parietal glioblastoma. He presented with symptoms of horizontal oculomotor apraxia, contralateral optic ataxia and left homonymous hemianopsia. We diagnosed this patient with partial Bálint's syndrome (BS)- oculomotor apraxia, optic ataxia but not simultanagnosia. BS is typically caused by bilateral posterior parietal lesions, but we here describe a unique case due toresection of a right intracranial tumor. A short AIR stay allowed our patient to learn how to compensate for visuomotor and visuospatial deficits, and improved his quality of life significantly.

Forensic implications of pituitary macroadenoma: An autopsy case report.

Pituitary adenomas are the most common tumours of the sellar region. Functional pituitary adenomas are related with immense assorted variety in their endocrine manifestations secondary to hypo or hyperfunction of the pituitary gland and mass impact. They can have a slow but severe impact on vision due to compression of the optic nerves, optic chiasm and cavernous sinus. Hereby, we discuss a case of a 29-year-old female patient who presented to the emergency with an alleged history of chest pain after ingestion of rat poison (zinc phosphide) in an attempt to commit suicide. Autopsy finding revealed a large mass that was present in the pituitary fossa impinging onto the optic chiasma. On further inquiry of the law enforcing agencies, it was found that the patient was undergoing treatment for psychiatric illness, and she had also complained of vision loss for the past few months. The parents of the deceased lodged a case of homicide by the husband. This case demonstrates the psycho-social and forensic implications of a pituitary tumour. The role of collaborative efforts of the autopsy team and the law enforcing agencies are emphasised.

Uncovering homonymous visual field defects in candidates for pediatric epilepsy surgery.

OBJECTIVES: Perimetry in children can be challenging due to low cooperation and short attention span. Especially during the pre-surgical work-up of children with pharmaco-refractory epilepsies, however, diagnosing homonymous visual field defects (HVFDs) can be crucial for planning surgical strategies. Here, we evaluated "campimetry" for visual field testing in children. Furthermore, we analyzed strabismus and anomalous head posture as clinical signs for HVFDs. METHODS: Campimetry and a standard orthoptic examination were performed in 18 patients (age range: 3 y 2 m-18 y) who underwent epilepsy surgeries in our center during the study period, and in 11 additional patients (age range: 2 y 10 m-22 y 10 m) with suspected or confirmed HVFDs. RESULTS: In 16/18 patients of our unselected surgery cohort, pre- and postoperative campimetry was successfully completed. Of these, only 7/16 patients had intact visual fields pre- and postoperatively, while 5/16 patients already showed preoperative HVFDs and 4/16 patients suffered newly acquired HVFDs as calculated consequences of the surgery. Regarding clinical signs, strabismus (mostly esotropia) and anomalous head posture were specific indicators of HVFDs (strabismus: 6/12 with HVFDs vs 1/18 without; anomalous head posture: 8/12 with HVFDs vs 0/18 without). CONCLUSIONS: For perimetry in children with limited cooperation, we suggest campimetry as it allows early detection and fast delineation of HVFDs. This is particularly important in pediatric epilepsy surgery patients, who display a surprisingly high proportion of HVFDs (9/16). Both, strabismus and anomalous head posture can indicate such HVFDs. Therefore, clinicians should pay attention to these clinical signs, especially in the context of epilepsy surgery.

Supracerebellar Transtentorial Approach for Occipital Meningioma to Maximize Visual Preservation: Technical Note.

BACKGROUND AND IMPORTANCE: Surgery for resection of tentorial meningiomas compressing primary visual cortex carries a significant risk of worsening vision. This concern is especially acute in patients with a preexisting visual deficit. Approaches that involve mechanical retraction of the occipital lobe further threaten visual function. The supracerebellar transtentorial (SCTT) approach, which does not carry a risk of occipital retraction injury, should be considered for patients with occipital tentorial meningiomas to maximize functional visual outcomes. CLINICAL PRESENTATION: A 54-yr-old woman underwent 2 resections and radiation therapy for a right occipital oligodendroglioma as a teenager. She was left with a complete left homonymous hemianopsia. The patient now presented with progressive vision loss in her remaining right visual field. Imaging revealed a left occipital superiorly projecting tentorial meningioma. To preserve her remaining visual function the SCTT approach was chosen for resection. A Simpson grade 1 removal was achieved without disrupting the occipital lobe pia or requiring mechanical cerebellar retraction. A diagnosis of a WHO grade II meningioma (presumably radiation induced) was made. The patient's vision returned to premorbid baseline 1 wk after surgery. CONCLUSION: The SCTT approach should be considered for the surgical management of patients with occipital tentorial meningiomas when visual preservation is at risk. This approach avoids transgression of visual cortex and minimizes the risk of venous infarction or contusions from retraction injury.

Increased adenosine A1 receptor levels in hemianopia patients after cerebral injury: an application of PET using 11C-8-dicyclopropylmethyl-1-methyl-3-propylxanthine.

PURPOSE: The aim of this study was to apply positron emission tomography (PET) with C-8-dicyclopropylmethyl-1-methyl-3-propylxanthine (MPDX), a radioligand for adenosine A1 receptor (A1R), to patients with hemianopia caused by brain injury to study neurorepair mechanisms in the brain. PATIENTS AND METHODS: Four patients with homonymous hemianopia and 15 healthy subjects were examined using PET to measure cerebral glucose metabolism, C-flumazenil (FMZ) binding to the central benzodiazepine receptor, and MPDX binding to A1R. Left and right regions of interest (ROIs) were selected, and semiquantitative data on the 3 kinds of PET examinations were obtained. The ROIs were referenced using the data for homologous regions in the contralateral hemisphere [ipsilateral/contralateral (I/C) ratio]. RESULTS: The I/C ratios for cerebral glucose metabolism and FMZ binding were low in the primary visual cortex (PVC) and visual association cortex in all the patients, whereas MPDX binding increased in the PVC in patients 1 and 2. Patients 1 and 2 experienced improvement in their visual field after 1 year. However, the other 2 patients showed no changes. We observed an increase in MPDX binding to A1R in the injured portion of the PVC in the patients who recovered. CONCLUSIONS: Evaluation of A1R by MPDX-PET may be useful for predicting prognosis and understanding the compensatory and reorganization processes in hemianopia caused by organic brain damage.

A congruous superior quadrantanopsia following a junctional scotoma induced by asperogillosis.

A 69-year old man presented to us with decreased vision in his right eye and a relative afferent pupillary defect. Under the presumption that he was suffering from retrobulbar optic neuritis or ischemic optic neuropathy, visual field tests were performed, revealing the presence of a junctional scotoma. Imaging studies revealed tumorous lesions extending from the sphenoid sinus at the right superior orbital fissure, with erosion of the right medial orbital wall and optic canal. Right optic nerve decompression was performed via an endoscopic sphenoidectomy, and histopathologic examination confirmed the presence of aspergillosis. The patient did not receive any postoperative antifungal treatment; however, his vision improved to 20 / 40, and his visual field developed a left congruous superior quadrantanopsia 18 months postoperatively. A junctional scotoma can be caused by aspergillosis, demonstrating the importance of examining the asymptomatic eye when a patient is experiencing a loss of vision in one eye. Furthermore, damage to the distal optic nerve adjacent to the proximal optic chiasm can induce unusual congruous superior quadrantanopsia.

A case of multiple sclerosis presenting with inflammatory cortical demyelination.

OBJECTIVE: To describe a patient presenting with a clinically silent, incidentally found, and pathologically confirmed active demyelinating solitary cortical lesion showing MRI gadolinium contrast enhancement, in whom biopsy was performed before the radiographic appearance of disseminated white matter lesions. METHODS: Neurologic examination, MRI, CSF and serologic analyses, and brain biopsy were performed. Sections of formalin-fixed paraffin-embedded biopsied brain tissue were stained with histologic and immunohistochemical stains. RESULTS: Biopsy revealed an inflammatory subpial lesion containing lymphocytes and myelin-laden macrophages. Recurrent relapses with dissemination of MRI-typical white matter lesions characterized the subsequent course. CONCLUSIONS: Our findings highlight that cortical demyelination occurs on a background of inflammation and suggest that the noninflammatory character of chronic cortical demyelination may relate to long intervals between lesion formation and autopsy. This case provides pathologic evidence of relapsing-remitting MS presenting with inflammatory cortical demyelination and emphasizes the importance of considering demyelinating disease in the differential diagnosis of patients presenting with a solitary cortical enhancing lesion.

Prolonged left homonymous hemianopsia associated with migraine-like attacks in a child with Sturge-Weber syndrome.

We report a patient with Sturge-Weber Syndrome (SWS) who developed migraine-like headaches followed by cerebral infarction. SWS without facial nevus was diagnosed based on calcification detected by CT and pial angioma detected by enhanced MRI. His migraine-like headaches were preceded by left homonymous hemianopsia, which persisted for more than 60 min. Although homonymous hemianopsia disappeared with cessation of the headache until 13 years of age, from age 14 years onward, this homonymous hemianopsia persisted after the headaches ended. Moreover, reduced cerebral blood flow was seen in the right occipital area on SPECT. At first, his left homonymous hemianopsia persisted for several months after the headache disappeared, but it had recovered completely. However, the durations of episodes of left homonymous hemianopsia, which persisted after headache disappearance, gradually became longer. At last one year after his first admission, the visual defect had become permanent. SWS is well known to be associated with migraine attacks and hemianopsia. However, the course of our present patient, i.e. recurrent homonymous hemianopsia, associated with migraine-like headaches becoming permanent, is rare. The pathophysiological mechanism underlying this clinical course is uncertain. The efficacy of valproate and propranolol as preventive therapy has been inadequate, to date.

Bilateral, symmetric and simultaneous rhegmatogenous retinal detachment. Predisposition or coincidence? A case report.

The following is a case report of a 65-year-old patient who had previously been diagnosed with primary open-angle glaucoma and who was experiencing a sudden loss of both visual acuity and of superior visual field in both eyes. In the ophthalmological examination, a bilateral, symmetric rhegmatogenous retinal detachment that affected the inferior quadrants of both eyes was detected. The retinal detachment was caused by a retinal horseshoe break located at the equator of 6 h in each eye. The factors that could determine the predisposition for and/or the coincidence of bilateral and symmetric rhegmatogenous retinal detachment will be discussed.

Charles Bonnet syndrome in hemianopia, following antero-mesial temporal lobectomy for drug-resistant epilepsy.

Charles Bonnet syndrome (CBS) is a disorder characterized by the occurrence of complex visual hallucinations in patients with acquired impairment of vision and without psychiatric disorders. In spite of the high incidence of visual field defects following antero-mesial temporal lobectomy for refractory temporal lobe epilepsy, reports of CBS in patients who underwent this surgical procedure are surprisingly rare. We describe a patient operated on for drug-resistant epilepsy. As a result of left antero-mesial temporal resection, she presented right homonymous hemianopia. A few days after surgery, she started complaining of visual hallucinations, such as static or moving "Lilliputian" human figures, or countryside scenes, restricted to the hemianopic field. The patient was fully aware of their fictitious nature. These disturbances disappeared progressively over a few weeks. The incidence of CBS associated with visual field defects following epilepsy surgery might be underestimated. Patients with post-surgical CBS should be reassured that it is not an epileptic phenomenon, and that it has a benign, self-limiting, course which does not usually require treatment.

Monocular temporal hemianopia with septo-optic dysplasia.

A 26-year-old woman displayed a monocular temporal hemianopic defect together with an ipsilateral afferent pupillary defect and bowtie optic nerve hypoplasia. MRI revealed a thin right optic nerve, an asymmetrically thinned chiasm, and an absent septum pellucidum. Monocular temporal visual field loss from organic lesions is quite rare but has been reported in conjunction with compressive lesions at the optic nerve-optic chiasm junction. This is the first report to demonstrate this visual field defect together with bowtie optic nerve hypoplasia.

When the patient says no. Management of exotropia with hemianopic visual field defects.

BACKGROUND: A homonymous hemianopia can be compensated for by an exotropia in the direction of the visual field defect. CASE REPORTS (AND LITERATURE REVIEW): Two young males with visual field defects and exotropia are reported. Both refused surgery when they were advised of the risk of reduction of their binocular visual field with the alignment of their eyes. CONCLUSION: Mapping of the binocular visual field is mandatory in patients with exotropia and neurological involvement to search for this rare combination which could produce a disappointing surgical outcome.

Craniopharyngioma: a review of long-term visual outcome.

PURPOSE: To assess the clinical presentation and long-term visual outcome in a series of patients with craniopharyn-gioma. METHODS: Retrospective case review. RESULTS: Thirty-six patients were reviewed, comprising 19 female patients and 17 male patients. The age range was 2-77 years with a bimodal distribution of 17 children (mean age 10 years) and 19 adults (mean age 47 years). Blurred vision was the most common visual complaint (23 cases, 64%) and headache the most frequent systemic complaint (19 cases, 53%). The average duration of systemic symptoms was 45 weeks compared to 10 weeks for visual symptoms. Deficits in visual acuity occurred in 13 patients (36%) and showed no significant change from initial presentation to final review. Sixteen patients (44%) had bitemporal hemianopia on presentation and pleomorphism (change from one type of visual field defect to another) occurred in 11 patients. Recurrence of tumour occurred in 15 patients (42%) and was more likely in children (59%) than adults (26%). The mean time period to recurrence was 7 years. The average follow-up period for all cases was 10 years. CONCLUSION: Patients with craniopharyngioma generally present late, and the visual symptoms are often preceded by a long history of systemic symptoms. Children are more likely to present with systemic symptoms than adults. Visual field pleomorphism is a feature of craniopharyngioma and occurred in one-third of the patients. Local recurrence is common. Although magnetic resonance imaging is the recommended means of follow up, regular neuro-ophthalmic review is useful in the early detection of anterior visual pathway compression by recurrent tumour.