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Background The Mount Fuji sign (MFS) is a radiological sign on computed tomographic scans depicting air between the frontal lobes. Air in this location indicates tension pneumocephalus (TP), considered a neurosurgical emergency.We evaluate the correlation between the MFS and perioperative mortality attributed to TP in nonagenarians who have undergone evacuation of chronic subdural hemorrhage (cSDH). Materials and methods We retrospectively reviewed the records of nonagenarians who had cSDH evacuation between 2006 and 2015. Postoperative computed tomographic images were evaluated for findings consistent with the MFS. Results Of 45 patients, 15 patients (33%) had radiological MFS, and 3 patients (20%) with MFS required reoperation because of new blood collection. No patient required reoperation because of TP. Perioperative (30-day) mortality in patients demonstrating the MFS was 6.67% caused by cardiac arrhythmia versus 13.33% mortality in patients with no evidence of the MFS. Conclusion Mount Fuji sign in nonagenarians after cSDH evacuation is not a specific sign of TP.

We review our experience with four patients who presented to our Medical Center from 2005-2015 with adult idiopathic occlusion of the foramen of Monro (FM). All patients underwent CT scanning and MRI. Standard MRI was performed in each patient to rule out a secondary cause of obstruction (T1-weighted without- and with gadolinium, T2-weighted, fluid-attenuated inversion recovery [FLAIR] and diffusion-weighted imaging [DWI] protocols). When occlusion of the FM appeared to be idiopathic, further high-resolution MRI with multiplanar reconstructions for evaluation of stenosis or an occluding membrane at the level of the FM was performed (T1-weighted without- and with gadolinium, T2-weighted 3D turbo spin-echo). Occlusion of the FM was due to unilateral stenosis and septum pellucidum deviation in two patients, to an occluding membrane in one, and to bilateral stenosis in one patient. Urgent surgical intervention is mandatory when there are signs of increased intracranial pressure while asymptomatic patients may be managed conservatively. In this patient series, truly bilateral stenotic obstruction of the FM was best managed with ventriculoperitoneal shunt and patients with membranous obstruction or unilateral stenosis with septum deviation were treated endoscopically.

Ventriculoperitoneal (VP) shunt placement is the mainstay of treatment for hydrocephalus, yet shunts remain vulnerable to a variety of complications. Although fat droplet migration into the subarachnoid space and cerebrospinal fluid pathways following craniotomy has been observed, a VP shunt obstruction with fat droplets has never been reported to our knowledge. We present the first reported case of VP shunt catheter obstruction by migratory fat droplets in a 55-year-old woman who underwent suboccipital craniotomy for removal of a metastatic tumor of the left medullocerebellar region, without fat harvesting. A VP shunt was inserted 1month later due to communicating hydrocephalus. The patient presented with gait disturbance, intermittent confusion, and pseudomeningocele 21days after shunt insertion. MRI revealed retrograde fat deposition in the ventricular system and VP shunt catheter, apparently following migration of fat droplets from the fatty soft tissue of the craniotomy site. Spinal tap revealed signs of aseptic meningitis. Steroid treatment for aseptic "lipoid" meningitis provided symptom relief. MRI 2months later revealed partial fat resorption and resolution of the pseudomeningocele. VP shunt malfunction caused by fat obstruction of the ventricular catheter should be acknowledged as a possible complication in VP shunts after craniotomy, even in the absence of fat harvesting.

Skull base drilling is a necessary and important element of skull base surgery; however, drilling around vulnerable neurovascular structures has certain risks. We aimed to assess the frequency of complications related to drilling the anterior skull base in the area of the optic nerve (ON) and internal carotid artery (ICA), in a large series of patients. We included anterior skull base surgeries performed from 2000 to 2012 that demanded unroofing of the optic canal, with extra- or intradural clinoidectomy and/or drilling of the clinoidal process and lateral aspect of the tuberculum sella. Data was retrieved from a prospective database and supplementary retrospective file review. Our IRB waived the requirement for informed consent. The nature and location of pathology, clinical presentation, surgical techniques, surgical morbidity and mortality, pre- and postoperative vision, and neurological outcomes were reviewed. There were 205 surgeries, including 22 procedures with bilateral optic canal unroofing (227 optic canals unroofed). There was no mortality, drilling-related vascular damage, or brain trauma. Complications possibly related to drilling included CSF leak (6 patients, 2.9 %), new ipsilateral blindness (3 patients, 1.5 %), visual deterioration (3 patients, 1.5 %), and transient oculomotor palsy (5 patients, 2.4 %). In all patients with new neuropathies, the optic and oculomotor nerves were manipulated during tumor removal; thus, new deficits could have resulted from drilling, or tumor dissection, or both. Drilling of the clinoid process and tuberculum sella, and optic canal unroofing are important surgical techniques, which may be performed relatively safely by a skilled neurosurgeon.

Background. Optic nerve vascular compression in patients with suprasellar tumor is a known entity but is rarely described in the literature.Case Description. We present a unique, well-documented case of optic nerve strangulation by the A1 segment of the anterior cerebral artery in a patient with a tuberculum sellae meningioma. The patient presented with pronounced progressive visual deterioration. Following surgery, there was immediate resolution of her visual deficit.Conclusion. Vascular strangulation of the optic nerve should be considered when facing progressive and/or severe visual field deterioration in patients with tumors proximal to the optic apparatus.

Pterional craniotomy is one of the most widely used approaches in neurosurgery. The MacCarty keyhole has remained the preferred means of beginning the craniotomy to achieve a low access point; however, the bone opening may result in a residual defect and an aesthetically unpleasant depression in the periorbital area. We present our modification of the traditional technique. Instead of drilling the keyhole in the frontoperiorbital area, the classical location, we perform a 5 × 15 mm strip craniectomy at the lowest accessible point in the infratemporal fossa, corresponding to the projection of the most lateral point of the sphenoid ridge. The anterior half of this opening exposes the basal frontal dura, while the posterior half brings the temporal dura into view. This modified technique was applied in 48 pterional craniotomies performed for removal of a variety of neoplasms during 2014-2015. There were no approach-related complications. Aesthetic outcomes and patient acceptance have been good; no patient developed skin depression in the periorbital area. In our experience, craniotomy for a pterional approach with the lowest possible access to the frontotemporal skull base may be performed by drilling a narrow oblong opening, without the use of any keyhole or burr hole, to create a smaller skull defect and achieve optimal aesthetic outcomes.