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Steven A. Newman

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Eric D. Weber and Steven A. Newman

✓Aberrant regeneration of cranial nerve III, otherwise known as oculomotor synkinesis, is an uncommon but well-described phenomenon most frequently resulting from trauma, tumors, and aneurysms. Its appearance usually follows an oculomotor palsy, but it can also occur primarily without any preceding nerve dysfunction. It is vital that neurosurgeons recognize this disorder because it may be the only sign of an underlying cavernous tumor or PCoA aneurysm. The tumor most often implicated is a cavernous or parasellar meningioma, but any tumor that causes compression or disruption along the course of the oculomotor nerve may cause primary or secondary misdirection. The most common clinical signs of oculomotor synkinesis consist of elevation of the upper eyelid on attempted downward gaze or adduction, adduction of the eye on attempted upward or downward gaze, and constriction of the pupil on attempted adduction. The authors present the largest series of patients with oculomotor synkinesis, including those in whom it developed after neurosurgical intervention, to illustrate various presentations. In addition, the various mechanisms that contribute to synkinesis are reviewed. Last, the treatment strategies for both oculomotor palsies and synkinesis are discussed.

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Tim E. Darsaut, Giuseppe Lanzino, M. Beatriz Lopes and Steven Newman

The term “orbital tumors” comprises a wide variety of lesions that often share the same cardinal clinical finding (exophthalmos) and clinical history. Age at presentation, associated ophthalmological findings, and radiological features, however, provide invaluable information as to the possible histological type of tumor. The present article serves as an introductory overview regarding the pathological characteristics, clinical features, radiological characteristics, and principles of treatment of orbital tumors.

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Austin R. T. Colohan, John A. Jane, Steven A. Newman and William W. Maggio

✓ The authors have previously advocated a supraorbital approach to tumors of the orbit. In this paper, they describe a technique in which they take advantage of a large frontal sinus as a means of entering the orbit without the necessity of intracranial exposure, as required by the more conventional supraorbital approach. This is achieved without frontal burr holes, allowing for a superior cosmetic result. The anterior wall of the frontal sinus is removed, and with it the roof of the orbit as a single bone flap. A case in which this technique was used is described.

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Kenneth C. Liu, Robert M. Starke, Christopher R. Durst, Tony R. Wang, Dale Ding, R. Webster Crowley and Steven A. Newman

OBJECTIVE

Idiopathic intracranial hypertension (IIH) may cause blindness due to elevated intracranial pressure (ICP). Venous sinus stenosis has been identified in select patients, leading to stenting as a potential treatment, but its effects on global ICP have not been completely defined. The purpose of this pilot study was to assess the effects of venous sinus stenting on ICP in a small group of patients with IIH.

METHODS

Ten patients for whom medical therapy had failed were prospectively followed. Ophthalmological examinations were assessed, and patients with venous sinus stenosis on MR angiography proceeded to catheter angiography, venography with assessment of pressure gradient, and ICP monitoring. Patients with elevated ICP measurements and an elevated pressure gradient across the stenosis were treated with stent placement.

RESULTS

All patients had elevated venous pressure (mean 39.5 ± 14.9 mm Hg), an elevated gradient across the venous sinus stenosis (30.0 ± 13.2 mm Hg), and elevated ICP (42.2 ± 15.9 mm Hg). Following stent placement, all patients had resolution of the stenosis and gradient (1 ± 1 mm Hg). The ICP values showed an immediate decrease (to a mean of 17.0 ± 8.3 mm Hg), and further decreased overnight (to a mean of 8 ± 4.2 mm Hg). All patients had subjective and objective improvement, and all but one improved during follow-up (median 23.4 months; range 15.7–31.6 months). Two patients developed stent-adjacent stenosis; retreatment abolished the stenosis and gradient in both cases. Patients presenting with papilledema had resolution on follow-up funduscopic imaging and optical coherence tomography (OCT) and improvement on visual field testing. Patients presenting with optic atrophy had optic nerve thinning on follow-up OCT, but improved visual fields.

CONCLUSIONS

For selected patients with IIH and venous sinus stenosis with an elevated pressure gradient and elevated ICP, venous sinus stenting results in resolution of the venous pressure gradient, reduction in ICP, and functional, neurological, and ophthalmological improvement. As patients are at risk for stent-adjacent stenosis, further follow-up is necessary to determine long-term outcomes and gain an understanding of venous sinus stenosis as a primary or secondary pathological process behind elevated ICP.

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Aaron S. Dumont, Paul T. Boulos, John A. Jane Jr., Dilantha B. Ellegala, Steven A. Newman and John A. Jane Sr.

Fibrous dysplasia is a benign but slowly progressive disorder of bone in which normal cancellous bone is replaced by immature woven bone and fibrous tissue. Significant deformity and both acute and chronic visual impairment can result. A contemporary understanding of fibrous dysplasia, emphasizing the origins of visual impairment, indications for decompressive surgery, and the techniques for correction of the cosmetic deformity are presented.

In their experience and review of the literature, the authors found the most frequent clinical presentations to be exophthalmos, displacement of the globe, abnormalities of extraocular motility, cosmetic deformity, and visual impairment. Although traditionally the cause of visual impairment has been ascribed to impingement of the optic canal on the optic nerve, the authors' experience is that the most common cause of visual loss is cystic degeneration of the tumor, particularly with those involving the anterior clinoid process. Exophthalmos and optic canal stenosis are less common causes of visual impairment. Indications for surgical intervention include acute and/or serially radiographically documented and relentless visual impairment and significant cosmetic deformity. Individualized management strategies are also discussed.