2026 Proffered Presentations
S288: SURGICAL MANAGEMENT OF OPTIC PATHWAY-HYPOTHALAMIC GLIOMAS: INSTITUTIONAL EXPERIENCE AND SYSTEMATIC REVIEW
Julian D Brown1; Diwas Gautam1; Farshad Nassiri, MD, PhD2; Robert C Rennert, MD1; William T Couldwell1; 1University of Utah; 2University of Toronto
Introduction: Optic pathway–hypothalamic gliomas (OPHGs) are rare, challenging lesions due to their deep location and proximity to critical visual, endocrine, and vascular structures. Treatment is multifactorial, and the role of surgical resection is still debated. This study presents our institutional surgical experience and a systematic review of the literature surrounding resection of OPHG, with an emphasis on surgical approach.
Methods: We retrospectively reviewed all patients with OPHGs who underwent surgical resection at our institution between 2011 and 2025. Demographics, presentation, pathology, operative approach, extent of resection, complications, and outcomes were analyzed. A systematic review of surgically treated OPHGs was conducted per PRISMA guidelines (PubMed/EMBASE, 1946–2024). Pooled data were used to compare adult (≥18 years) and pediatric (<18 years) patients.
Results: In our local series, nine patients underwent surgery at our institution (mean age 32.3±17.3 years; 56% female). Presenting symptoms included visual disturbance (56%), endocrine dysfunction (33%), headache (33%), and hydrocephalus (33%). Pilocytic astrocytoma was most common (67%). Approaches included pterional transsylvian (56%), endoscopic transsphenoidal (33%), and interhemispheric trans–third ventricular (11%), selected based on tumor extent relative to the optic apparatus, hypothalamus, and carotid arteries. Gross total resection (GTR) was achieved in 33%. Complications included diabetes insipidus (22%), anterior choroidal infarct (11%), and transient ptosis (11%). Tumor recurrence occurred in 33% at a mean of 27 months.
From 15 studies, 50 additional surgically treated patients were identified (mean age 14.4±11.2 years; 48% female). Visual disturbance (76%) and hydrocephalus (36%) were the most common presenting symptoms. GTR was achieved in 12%. Postoperative complications included endocrine dysfunction (28%) and new visual disturbance (16%). Recurrence occurred in 22% at a mean of 56 months.
In combined analysis (n=59), pediatric patients more frequently presented with hydrocephalus (46% vs. 21%, p=0.05) and hypothalamic involvement (97% vs. 79%, p=0.02). Adults more often underwent endoscopic approaches (38% vs. 14%, p=0.04) and had lower rates of new postoperative visual decline (0% vs. 20%, p=0.01).
Conclusions: OPHGs demand a flexible surgical strategy, with approach selection dictated by tumor location and relationship to critical neurovascular structures. Pterional, transsphenoidal, and trans-third ventricular corridors each provide safe access for distinct anatomic patterns. In experienced hands, surgery can achieve durable control with acceptable morbidity, particularly in adults who appear less prone to postoperative visual decline. Resection remains an important tool within a multidisciplinary treatment paradigm for carefully selected OPHG patients.