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Kim JW, Kim SK. The role of surgery for optic pathway gliomas in the era of precision medicine. Childs Nerv Syst 2024:10.1007/s00381-024-06450-4. [PMID: 38743267 DOI: 10.1007/s00381-024-06450-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/16/2024]
Abstract
Optic pathway gliomas (OPGs) represent a unique subset of brain tumours that primarily affect the paediatric population. Traditionally, these tumours are managed conservatively due to their location to and association with vital structures. This article explores the evolving role of surgery in the management of OPGs, particularly in the context of advancements in precision medicine. The advent of targeted therapy, especially for tumours with specific genetic alterations, such as BRAF V600E mutations, has revolutionized the treatment landscape, offering new avenues for patient-specific therapy. However, surgery still plays a crucial role, especially for debulking in cases of hydrocephalus or when standard therapies are ineffective. Advances in surgical techniques, including neuronavigation, endoscopic approaches, and intraoperative neurophysiological monitoring, have enhanced the safety and efficacy of operative interventions. Despite these developments, the complexity of OPGs necessitates a multidisciplinary approach, focusing on long-term outcomes and quality of life. Future research is needed to further elucidate the role of surgery in an era increasingly dominated by molecular genetics and targeted therapies.
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Affiliation(s)
- Joo Whan Kim
- Division of Paediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Seung-Ki Kim
- Division of Paediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
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Liu ZM, Liao CH, An X, Zhou WT, Ma ZY, Liu W, Tian YJ. The role of imaging features and resection status in the survival outcome of sporadic optic pathway glioma children receiving different adjuvant treatments. Neurosurg Rev 2022; 45:2277-2287. [PMID: 35106677 DOI: 10.1007/s10143-022-01743-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/30/2022]
Abstract
Optic pathway glioma (OPG) is a rare brain tumor affecting children, with no standard treatment strategy. This study described the sporadic OPG survival outcomes after surgical treatment and analyzed the role of imaging features and resection status in children receiving different adjuvant treatments. This retrospective study included 165 OPG patients whose clinical information were obtained from the hospital record system. Tumor volume and residual tumor volume were calculated by delineating the lesion area. Kaplan-Meier method and Cox proportional hazards model were conducted to analyze the independent prognosis factor. A total of 165 patients were included in this study. Respectively, the 5-year overall survival (OS) and progression-free survival (PFS) were 87.58% and 77.87%. Residual tumor size and first adjuvant treatment (AT) after surgery were both associated with PFS. In patients with small-size residual tumors, there was no significant difference in PFS between the AT treatment groups. Moreover, age, exophytic cystic components, leptomeningeal metastases, and AT were associated with OS. In patients with exophytic cystic components and those with leptomeningeal metastases, there was no significant difference in OS. Our results revealed that OPG patients could avoid or defer AT by maximized resection. Age ≤ 2 years was a disadvantageous factor for OS. Patients with exophytic cystic components were more likely to benefit from primary surgery, and CT or RT was not beneficial for these patients. Patients with leptomeningeal metastases had a poor prognosis regardless of the treatment they received. Future prospective clinical studies are needed to develop more effective treatment regimens.
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Affiliation(s)
- Zhi-Ming Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Chi-Hyi Liao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Xu An
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Wen-Tao Zhou
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Zhen-Yu Ma
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Wei Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Yong-Ji Tian
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China.
- Laboratory of Neural Reconstruction, Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, No. 119, South 4th Ring Road, Fengtai District, Beijing, 100070, China.
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Yang P, Liu HC, Qiu E, Wang W, Zhang JL, Jiang LB, Kang J. Comparison of two surgical methods for the treatment of optic pathway gliomas in the intraorbital segment: an analysis of long-term clinical follow-up, which evaluates the surgical outcomes. Transl Pediatr 2021; 10:1586-1597. [PMID: 34295773 PMCID: PMC8261595 DOI: 10.21037/tp-20-451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/16/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND This study analyzes two kinds of surgical methods for the treatment of optic pathway gliomas (OPGs) in the intraorbital segment, as well as the surgical outcomes of OPGs. METHODS The clinical data of 86 patients with OPGs treated in our center was analyzed retrospectively, and the clinical symptoms, treatment methods, and follow-up results were recorded. RESULTS For OPGs in the intraorbital segment, the optic nerve sheath incision was performed to remove a tumor while retaining the optic nerve sheath in Group 1 (n=36). The optic nerve sheath and the tumor were simultaneously removed without retaining the optic nerve sheath in group 2 (n=50). The effects of the design of the surgical methods on the post-surgical outcome are: One patient (1/36, 2.8%) had recurrence in Group 1 and one patient (1/50, 2.0%) had recurrence in group 2. The differences in the surgical outcomes of the two groups regarding exophthalmos, conjunctiva swelling, eye movement disorder, and ptosis were found to be statistically significant (P<0.05). Compared with group 2, the surgical outcomes in the postoperative phase of Group 1 were more satisfactory. CONCLUSIONS The two surgical methods do not increase the recurrence rate of tumors. The resection of OPGs through an optic nerve sheath incision was found to be an ideal surgical method for reducing complications in the postoperative phase and for providing better surgical outcomes.
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Affiliation(s)
- Peng Yang
- Department of Neurosurgery, Tongren Hospital of China Capital Medical University, Beijing, China
| | - Hao-Cheng Liu
- Department of Neurosurgery, Tongren Hospital of China Capital Medical University, Beijing, China
| | - E Qiu
- Department of Neurosurgery, Tongren Hospital of China Capital Medical University, Beijing, China
| | - Wei Wang
- Department of Neurosurgery, Tongren Hospital of China Capital Medical University, Beijing, China
| | - Jia-Liang Zhang
- Department of Neurosurgery, Tongren Hospital of China Capital Medical University, Beijing, China
| | - Li-Bin Jiang
- Department of Ophthalmology, Tongren Hospital of China Capital Medical University, Beijing, China
| | - Jun Kang
- Department of Neurosurgery, Tongren Hospital of China Capital Medical University, Beijing, China
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Liao C, Zhang H, Liu Z, Han Z, Li C, Gong J, Liu W, Ma Z, Tian Y. The Visual Acuity Outcome and Relevant Factors Affecting Visual Improvement in Pediatric Sporadic Chiasmatic-Hypothalamic Glioma Patients Who Received Surgery. Front Neurol 2020; 11:766. [PMID: 32973646 PMCID: PMC7466562 DOI: 10.3389/fneur.2020.00766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/22/2020] [Indexed: 11/29/2022] Open
Abstract
Background: The role and effectiveness of primary surgical treatment for sporadic chiasmatic–hypothalamic glioma (CHG) are not clear. The present study was to describe sporadic CHG visual acuity (VA) outcomes after surgery and to analyze the relevant factors affecting VA improvement. Methods: Forty-five pediatric sporadic CHG patients who met the inclusion criteria were included in a retrospective study. All patients received primary intratumor partial resection. Disease characteristics, treatment strategies, complications, and VA outcome were analyzed. Univariate and multivariate analyses were performed to identify relevant factors of VA improvement. Receiver operating characteristic (ROC) analysis was performed to evaluate the predictive accuracy of measurement indexes. Results: There were 77 eyes of 45 children suffering from various levels of VA impairment before surgical treatment, and only 13 eyes had normal vision. Patients with resection extents >70, 50–70, and <50% accounted for 26.67, 24.44, and 48.89%, respectively. The percentages of VA maintained and deteriorated in normal vision eyes were 61.54 and 38.46%. The percentages of VA improved, maintained, and deteriorated in visually impaired eyes after surgery were 29.87, 45.45, and 24.68%, respectively. There was a positive correlation between the IVA level and VA improvement. There was no significant difference in VA improvement between the different resection extents. Blindness occurred in ~4.4%. Approximately 11.1% of the children had complications that affected quality of life, which correlated with resection extent. IVA and tumor size were correlated with VA improvement. The AUC for IVA + tumor size predicting VA improvement was 0.831. The cutoff points for IVA level and tumor volume were 4.5 and 43.50 cm3, respectively. Conclusions: IVA and tumor size were correlated with VA improvement after primary intratumor partial resection. Children with IVA ≥ level 5 were more likely to achieve visual improvement after decompression surgery, but decompression had limited effectiveness on vision improvement in patients with tumor volumes ≥ 43.50 cm3. Performing resections < 50% was safe and did not reduce the effect of decompression to improve VA.
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Affiliation(s)
- Chihyi Liao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Heng Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Zhiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Zhe Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Chunde Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Jian Gong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Wei Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Zhenyu Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
| | - Yongji Tian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Brain Tumor, China National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China
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Aquilina K, Daniels DJ, Spoudeas H, Phipps K, Gan HW, Boop FA. Optic pathway glioma in children: does visual deficit correlate with radiology in focal exophytic lesions? Childs Nerv Syst 2015; 31:2041-9. [PMID: 26277358 DOI: 10.1007/s00381-015-2855-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 07/28/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Unlike pilocytic astrocytomas in other parts of the brain, optic pathway gliomas (OPG) are usually diffuse lesions involving the anterior optic pathways and hypothalamus. Their infiltrative nature often precludes complete surgical resection. We sought to determine whether careful magnetic resonance (MR) analysis, correlated with visual deficits, could be sufficient to identify those focal lesions that may be amenable to more aggressive surgical resection at presentation. METHODS We retrospectively reviewed the medical records of patients from two sites: children under 20 years of age treated for OPG between 1985 and 2009 at St Jude's Children's Research Hospital and children under 16 years of age treated at Great Ormond Street Hospital, London, UK, between 1984 and 2011. Patients with isolated optic nerve tumors were excluded. Visual acuity and visual field data at presentation were reviewed and correlated with MR characteristics, including extent of optic pathway involvement, symmetry, and lateral extension. RESULTS Two hundred and one children were treated for OPG between 1984 and 2011 in the two institutions; 74 had neurofibromatosis 1 (NF1). At presentation, visual loss was symmetrical in 132 patients and asymmetrical in 69. Potential correlation between pattern of visual loss and tumor characteristics on routine MRI was found in only 13 patients with asymmetrical vision. There was no difference between patients with and without NF1. CONCLUSION The decision for aggressive surgical resection for optic pathway gliomas should be based on clinical criteria, particularly in children with good vision in one eye and poor vision in the other, as current MRI results do not reliably predict visual field deficits.
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Affiliation(s)
- Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | - David J Daniels
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Pediatric Neurosurgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Helen Spoudeas
- Developmental Endocrinology Research Group, Clinical & Molecular Genetics Unit, University College London Institute of Child Health, London, UK
| | - Kim Phipps
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | - Hoong-Wei Gan
- Developmental Endocrinology Research Group, Clinical & Molecular Genetics Unit, University College London Institute of Child Health, London, UK
| | - Frederick A Boop
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA. .,Division of Pediatric Neurosurgery, St Jude Children's Research Hospital, Memphis, TN, USA. .,Semmes Murphey Clinic, 6325 Humphreys Blvd., Memphis, TN, 38120, USA.
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Massimi L, Tufo T, Di Rocco C. Management of optic-hypothalamic gliomas in children: still a challenging problem. Expert Rev Anticancer Ther 2008; 7:1591-610. [PMID: 18020927 DOI: 10.1586/14737140.7.11.1591] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Optic pathway-hypothalamic gliomas (OPHGs) are rare, often unresectable tumors that mostly occur in childhood. Their biological behavior is unpredictable, although they tend to follow an aggressive clinical course in infants and a benign course in children with neurofibromatosis type 1. Optimal management is still controversial. Nonprogressing OPHGs are usually followed by surveillance alone. Surgery is advocated for progressing tumors to decompress the optic pathways, obtain a quick relief from intracranial hypertension and allow histologic examination (when needed). The current trend is in favor of conservative surgical behavior, except for resectable tumors. Chemotherapy is increasingly used in the management of OPHGs, especially in infants, to delay radiotherapy. Carboplatin and vincristine are the most frequently used drugs, although several chemotherapeutic agents in different combinations are currently employed with good results. Radiotherapy is utilized in children over 5 years of age as an adjuvant or as an alternative to surgery. The prognosis of OPHGs is quite good, with regard to the overall survival rate (70-100% at 5 years), but less favorable in terms of late morbidity.
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Affiliation(s)
- Luca Massimi
- Catholic University Medical School, Pediatric Neurosurgery, Institute of Neurosurgery, Largo A Gemelli 8, 00168, Rome, Italy.
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Ahn Y, Cho BK, Kim SK, Chung YN, Lee CS, Kim IH, Yang SW, Kim HS, Kim HJ, Jung HW, Wang KC. Optic pathway glioma: outcome and prognostic factors in a surgical series. Childs Nerv Syst 2006; 22:1136-42. [PMID: 16628460 DOI: 10.1007/s00381-006-0086-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Indexed: 10/24/2022]
Abstract
OBJECTS The goals of this study were to evaluate the surgical outcomes of optic pathway glioma (OPG) and to analyze the prognostic factors related to the progression-free survival. MATERIALS AND METHODS A retrospective review was conducted on 33 patients who underwent surgery for OPG; these included 15 male and 18 female patients with a mean age of 8.3 years. The mean duration of follow-up was 52 months. RESULTS AND CONCLUSIONS The preservation rate of ipsilateral vision was 25%, while that of contralateral vision was 83% (P<0.001). There was no remarkable endocrine improvement after surgery. The overall and progression-free survival rates at 5 years were 93.6 and 52.4%, respectively. In our study, the predictors for tumor progression were children younger than 5 years of age (p=0.023) and of female gender (p=0.022). Because of the variable course of OPG, treatment policy should be optimized individually according to patient's status.
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Affiliation(s)
- Yong Ahn
- Department of Neurosurgery, Seoul National University Children's Hospital, Seoul, South Korea
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Tong Z, Wanibuchi M, Uede T, Tanabe S, Hashi K. Significant Improvement of Visual Functions after Removal of an Intracranial Giant Optic Nerve Glioma Revealing Exophytic Growth: Case Report. Neurosurgery 2006; 58:E792; discussion E792. [PMID: 16575300 DOI: 10.1227/01.neu.0000204308.59999.60] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE:
Intracranial giant optic nerve gliomas, usually presumed as optic chiasmatic gliomas, are much less common. The architectural tumor form of optic nerve glioma without neurofibromatosis type 1 is usually the expansile-intraneural pattern. The exophytic optic nerve gliomas without neurofibromatosis type 1 are relatively uncommon. Surgical decompression for intracranial optic gliomas frequently leads to clinical improvement, but obvious improvement of vision is rare. We report a case that demonstrated significant recovery of visual function after removal of the intracranial giant optic nerve glioma, revealing exophytic growth.
CLINICAL PRESENTATION:
A 13-year-old boy presented with visual impairment in both eyes. Magnetic resonance images (MRI) disclosed a 6 cm diameter mass in the suprasellar area. On heavily T2-reversed MRIs, it was obvious that the intracranial portion of right optic nerve was enlarged, and optic tracts were shifted to the left by the tumor. The relationship of the tumor to the chiasma could not be affirmed on MRIs.
INTERVENTION:
A right frontotemporal craniotomy for decompression of the optic apparatus was performed. After the majority of the tumor was resected, it became clear that the tumor originated in the right optic nerve. The tumor exophytically grew and dislocated the optic chiasma and optic tracts. Significant improvement of visual functions began from the first week after surgery and continued gradually thereafter. The histological diagnosis was pilocytic astrocytoma. A follow-up MRI taken 4 years after surgery showed no regrowth of the residual tumor.
CONCLUSION:
Giant exophytic gliomas without neurofibromatosis type 1 may arise from the intracranial portion of an isolated optic nerve. Direct visualization of optic component by heavily T2-reversed MRI could more precisely delineate the relationship of the intracranial optic nerve glioma to the optic apparatus. Surgery may be indicated in giant exophytic intracranial optic nerve gliomas and preoperative postulated optic chiasmatic gliomas. Microsurgical resection can induce postoperative visual improvement without regrowth of the residual tumor.
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Affiliation(s)
- Zhiyong Tong
- Department of Neurosurgery, Affiliated First Hospital, China Medical University, Shenyang, China.
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Chernov MF, Ivanov PI, Zhinzhina IV, Getmanova OY, Zabrodskaya JM, Tigliev GS. Complete Recovery of Visual Functions After Multimodality Treatment for Intrinsic Chiasmatic-Hypothalamic Astrocytoma-Case Report-. Neurol Med Chir (Tokyo) 2004; 44:129-32. [PMID: 15095966 DOI: 10.2176/nmc.44.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 21-year-old female was admitted with complaints of severe impairment of vision. The visual acuity was 0.02 in both eyes along with residual visual fields and central scotomas. Neuroimaging disclosed a chiasmatic-hypothalamic glioma. Surgery was performed with partial removal of the intrachiasmatic part of the intrinsic tumor. The histological diagnosis was fibrillary astrocytoma. Progressive recovery of vision began in the first week after surgery. Adjuvant treatment included one course of fractionated radiation therapy and six courses of chemotherapy. Complete recovery of visual acuity occurred after 10 months, and the visual fields were restored after an additional 6 months. Her vision has been stable during 2 years of follow up. The prognosis for recovery of vision after treatment of optic pathway gliomas mainly depends on the severity of visual loss at admission and is negatively influenced by intrinsic tumor growth, symmetrical extension, and involvement of the chiasm. Despite the presence of all these factors in the present case, multimodality management resulted in the complete recovery of visual functions. Surgery may be indicated in cases of intrinsic chiasmatic gliomas complicated by severe visual loss.
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Affiliation(s)
- Mikhail F Chernov
- Department of Surgical Neurooncology, Russian A. L. Polenov Neurosurgical Institute, St. Petersburg, Russia.
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Affiliation(s)
- V V Dolenc
- Department of Neurosurgery, University Hospital Centre, Ljubljana, Slovenia
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