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Background: Cavernomas arising in the region of the optic apparatus are extremely rare, accounting for <1% of all the central nervous system cavernomas. Most patients are affected by acute visual disturbances related to hemorrhagic events. A prompt resection of the lesion together with a decompression of the optic apparatus may lead to a functional improvement. Almost all patients reported in literature were treated by means of a craniotomy, whereas only few papers described the use of a transnasal approach. Case Description: We report the case of a 53-year-old woman with a hemorrhagic, cavernous malformation of the optic chiasm region and we discuss the technical nuances of the endoscopic transnasal approach we employed. We also review literature for patients with cavernomas treated with a transsphenoidal approach. In our case, the patient underwent the gross-total resection of the lesion through a fully endoscopic transnasal route and the visual disturbances improved immediately after the operation. The ventral access allowed an adequate exposure of the chiasm/anterior circulation complex, thus avoiding an excessive dissection and retraction of neurovascular structures. Moreover, with the aid of angled scopes, we were able to identify the frail vascular supply of the chiasm by employing the suprachiasmatic corridor as well as the infrachiasmatic one. We stress the need for a careful reconstruction of the skull base to avoid a postoperative cerebrospinal fluid leak. Conclusions: With the evolution and spreading of the neuroendoscopic techniques, in selected cases, we advocate the use of the transnasal route for the removal of cavernomas arising in the region of the anterior optic pathways. [ABSTRACT FROM AUTHOR]

Objective: Even though advances in surgical techniques have improved facial nerve outcomes, functional preservation is still an issue because injury to the facial nerve has significant physical and psychological consequences for the patient. We retrospectively review our data in VS surgery to compare the facial outcome in intraoperative facial monitored versus not-monitored patients. Materials and Methods: 51 consecutive patients with unilateral vestibular schwannoma in the period from 2005 to 2010 were treated in our Institution. In according to the type of neurophysiological tool used during surgical procedures, two patients groups were identified: Group 1 (facial stimulator only) and Group 2 (stimulator and facial monitoring). Statistical comparison of the two groups was made with the t-test, and facial function results were evaluated with the Fisher's exact test. Results: In the Group 1, of the 22 patients with anatomically preserved facial nerves, 3 (13.6%) showed excellent facial nerve function, 14 (63.6%) showed intermediate function, and 5 (22.7%) showed poor function. In the Group 2, all the 27 patients got anatomically preserved facial nerves, and 18 (66.7%) showed excellent facial nerve function, 9 (33.3%) showed intermediate function, and no one showed poor function. Conclusions: We found that retrosigmoid approach associated with continuous EMG facial monitoring combined with the use of bipolar stimulation is a safe and effective treatment for vestibular schwannomas. [ABSTRACT FROM AUTHOR]

Introduction Aneurysms in the vertebrobasilar system are rare and in the distal segment of the posterior inferior cerebellar artery they are even less frequent. Giant aneurysms are also rare in the posterior cranial fossa. Giant aneurysms of the distal posterior inferior cerebellar artery generally can have mainly compressive effects on the adjacent structures and they can be mistaken for tumors. Case presentation We report the case of a 74-year-old Italian woman who presented with a complaint of dizziness. Her dizziness was found to be a result of aneurysmal dilatation arising from the distal segment of the right posterior inferior cerebellar artery. A mid-line suboccipital craniotomy was performed, and the aneurysm was clipped without post-operative deficits and with improvement in the patient's dizziness. In our present report, we also review the literature and discuss our case with regard to the clinical and radiological features and surgical procedure performed. Conclusion To the best of our knowledge, few cases of this type of aneurysm have been described in the literature. Our patient had a good outcome after surgical treatment. [ABSTRACT FROM AUTHOR]

Introduction Cavernous hemangiomas are rare benign bone tumors and those at the level of the cranial bones are even rarer. Case presentation A 50-year-old woman of Italian ethnicity presented with a frontal mass. A computed tomography scan showed an osteolytic lesion and a magnetic resonance imaging scan revealed a hypointense lesion on the T1-weighted image and a hyperintense lesion on the T2-weighted image. We performed a tailored craniectomy and cranioplasty. Histological examination revealed a cavernous hemangioma. Conclusions These benign tumors do not have classic radiographic features and so can be misinterpreted as lesions like multiple myeloma or osteosarcoma. Consequently, the diagnosis is most often made during surgical resection. [ABSTRACT FROM AUTHOR]

Background:The endovascular techniques has widely changed the treatment of intracranial aneurysms. However surgery still represent the best therapeutic option in case of broad-based and complex lesions.The combined use of endoscopic and microsurgical techniques (EAM) may improve surgical results. Objective: The purpose of our study is to evaluate the advantages and limits of EAM for intracranial aneurysms. Methods: Between January 2002 and December 2012, 173 patients, harboring 206 aneurysms were surgically treated in our department with the EAM technique. One hun-dred and fifty-seven aneurysms were located in the anterior circulation and 49 were in the posterior circulation. Standard tailored approaches, based on skull base surgery principles, were chosen.The use of the endoscope included three steps: initial inspection, true opera-tive time, and final inspection. For each procedure, an intraoperative video and an evaluation schedule were prepared, to report surgeons' opinions about the technique itself. In the first cases, we always used the endoscope during surgical procedures in order to get an ade-quate surgical training. Afterwards we became aware in selecting cases in which to apply the endoscopy, as we started to become familiar with its advantages and limits. Results: After clipping, all patients were undergone postoperative cerebral angiography. No surgical mortality related to EAM were observed. Complications directly related to endoscopic procedures were rare. Conclusion: Our retrospective study suggests that endoscopic efficacy for aneurysms is only scarcely influenced by the preoperative clinical condition (Hunt-Hess grade), surgical timing, presence of blood in the cisterns (Fisher grade) and/or hydrocephalus. However the most important factors contributing to the efficacy of EAM are determined by the anatom-ical locations and sizes of the lesions. Furthermore, the advantages are especially evident using dedicated scopes and holders, after an adequate surgical training to increase the learning curve. [ABSTRACT FROM AUTHOR]

Background: The objective of our study was to determine the safety and usefulness of performing surgery via occipital transtentorial approach to treat posterior cranial fossa tumors, which is well known as an approach to the pineal region (Poppen's approach). Methods: Fourteen patients with posterior cranial fossa tumors were successfully treated using occipital transtentorial approach between 2007 and 2012. The lesions included five meningiomas, three astrocytomas, two metastases, two hemangioblastomas, one cavernoma, and one dysgerminoma. Results: Lesions were <3 cm in 12 cases and ≥3 cm in two cases. Average Karnofsky Performance Status (KPS) scoring at admission was 88.5. Eleven patients scored ≥70 and seven patients <70. Average age was 43.1 years. All patients underwent surgical treatment by the same surgical team. All tumors were completely removed surgically without any injury to the venous complex and the adjoining structures. There was no incidence of mortality or morbidity in all patients, and all functional outcomes were good to excellent postoperatively. Postoperative computed tomography (CT) imaging revealed that none of the patients had suffered brain damage or infarction around the cerebellum, brainstem, or occipital lobe. Conclusions: We found that the use of occipital transtentorial approach is strongly supported by the successful removal of posterior cranial fossa tumors without serious complications. Open microneurosurgery is probably still the most effective therapy in improving survival and KPS in patients with posterior cranial fossa tumors, given that the proper surgical technique is used and complications do not occur. This case study has strongly suggested that this approach is very useful, safe, and accurate for removing the tumors of posterior fossa and evaluating the surrounding anatomy, as well as for determining operative strategy. [ABSTRACT FROM AUTHOR]

We report our preliminary clinical experience with microscope-integrated intraoperative indocyanine green (ICG) videoangiography in the treatment of arteriovenous malformations (AVMs). Nine patients underwent surgical procedures for AVMs. All patients had preoperative and early postoperative digital subtraction angiography (DSA). In all the procedures, ICG was injected intravenously during AVM occlusion and the removal of the nidus were directly analized into the microscope-integrated video, and they were compared with early postoperative angiography images. A total of 16 intraoperative ICG angiographies were performed. In all the patients the image quality was excellent, allowing intraoperative real-time evaluation of the completeness of the removal of the nidus. ICG videoangiography is easily performed during surgery for AVM and can confirm the completeness of the removal and may detect residual nidus, thus improving outcomes. [ABSTRACT FROM AUTHOR]

Background: The authors describe a case of endovascular stenting of an extracranial–intracranial saphenous vein high-flow bypass graft in the management of a complex bilateral carotid aneurysm case. Case Description: A 43-year-old woman was admitted with progressive visual field restriction and headache. Imaging studies revealed bilateral supraclinoid carotid aneurysms. The right carotid aneurysm was clipped and the left one was treated by an endovascular procedure, after performing an internal carotid artery–middle cerebral artery (ICA-MCA) saphenous vein bypass graft. A few months following the bypass procedure, a 70–80% stenosis of the graft was discovered and treated endovascularly with a stenting procedure. Follow-up at 36 months after the first operation showed the patency of the venous graft and no neurological deficits. Conclusions: Endovascular stenting of the extracranial–intracranial saphenous vein high-flow bypass graft is technically feasible when postoperative graft occlusion is discovered. [ABSTRACT FROM AUTHOR]

Background: Facial nerve schwannomas include only 0.8% of all intrapetrous mass lesions, and schwannomas originating exclusively from the greater petrosal nerve (GPN) are extremely rare. To date, only 13 reports have been described. In this case, the tumor was thought to originate from the GPN on the basis of clinical, radiological, and operative findings. Case Description: A 23-year-old girl presented an acute left facial palsy, a disturbance in tear secretion of the ipsilateral eye, and a left-sided conductive hypoacusia. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed an extradural mass in the left middle fossa. A subtemporal approach was performed and the lesion, originating from the proximal portion of the GPN, was excised. The post-operative course was satisfactory, except for a xerophtalmia, which was treated with artificial teardrops. Conclusion: GPN schwannomas can originate anywhere alongside the course of the nerve, from its proximal segment near the facial hiatus to its distal segment near the foramen lacerum. For these reasons, it requires differential diagnosis with trigeminal nerve schwannomas or with injuries arising from the geniculate ganglion, because it can be easily confused with those lesions. However, in less severe cases, an early diagnosis can be able to preserve the function of the facial nerve by reducing iatrogenic injuries caused by surgical maneuvers. [ABSTRACT FROM AUTHOR]

The author discusses the case report of meningioma with implant base in the right posterior clinoid process (PCP) which was treated using frontotemporo-orbito-zygomatic (FTOZ) approach. Topics discussed include the claim of report's authors that the definition of PCP meningiomas refer to lessions which eccentrically originate at the level of dorsum sellae, the use of FTOZ craniotomy combined with silvian fissure opening, and significance of the use of endoscopic assistance.

Background: The authors reported the first documented case of intracranial extraaxial nonneurofibromatosis type 1-related nontriton malignant peripheral nerve sheath tumor (MPNST) originating from the falx cerebri., Observations: A 34-year-old man with headache, short-term memory deficit, postural instability, and blurred vision presented with a large heterogenous contrast-enhanced intraventricular cystic lesion originating from the free margin of the falx cerebri. The patient received surgery using the right posterior interhemispheric approach. Gross total resection was performed, and the inferior border of the falx cerebri was resected. The postoperative course was uneventful. Histological examination revealed hypercellular foci of neoplastic spindle cells with hyperchromatic and wavy nuclei. Hence, a diagnosis of MPNST was made based on concomitant immunochemistry findings, including mouse double minute 2 homolog focal positivity and geographic loss of H3K27me3. The patient received adjuvant radiotherapy, and recurrence was not observed., Lessons: Intracranial MPNSTs are extremely rare tumors, typically originating from the cranial nerves in the posterior cranial fossa. An even rarer variant of these tumors, referred to as malignant intracerebral nerve sheath tumors, may directly arise from the brain parenchyma. The authors reported the first case of an intracranial MPNST originating from the dura mater of the falx cerebri, acting as an extraaxial lesion with prevalent expansion in the right ventricle.

Peripheral nerves can be affected by a variety of benign and malignant tumour and tumour-like lesions. Besides clinical evaluation and electrophysiologic studies, MRI is the imaging modality of choice for the assessment of these soft tissue tumours. Conventional MR sequences, however, can fail to assess the histologic features of the lesions. Moreover, the precise topographical relationship between the peripheral nerve and the tumor must be delineated preoperatively for complete tumour resection minimizing nerve damage. Using Diffusion tensor imaging (DTI) and tractography, it is possible to obtain functional information on tumour and nerve structures, allowing the assess anatomy, function and biological features. In this article, we review the technical aspects and clinical application of DTI for the evaluation of peripheral nerve tumours.

Background: Various materials have been proposed to obliterate dead spaces and to reconstruct dural defects during a neurosurgical approach. This study describes our technique of using the abdominal autologous fat graft and evaluates the complications and characteristics related to the use of this tissue during cranial procedures., Methods: Autologous fat grafts were used in 296 patients with basicranial and convexity extraaxial tumors from April 2005 to January 2015. The adipose tissue was removed from the paraumbilical abdominal region and was transformed into a thin foil. When possible, a watertight suture was made between the dural or bone edge with a fat graft. We always used fibrin glue to reinforce the dural closure., Results: Complications occurred between 2 days and 1 year following procedure. Cerebrospinal fluid leaks were found in 11 cases. No case of mortality, pseudomeningoceles, fistula, infections, bacterial meningitides, or lipoid meningitides was reported. No patient required removal of the graft. No adhesion was observed between the brain and the autologous fat. Other fat-related complications observed were 2 cases of fat necrosis in the abdomen and 2 cases of abdominal hemorrhage., Conclusion: The technique of harvesting and applying fat grafts is fairly simple, although it must be performed meticulously to be effective. Our experience has led us to believe that the use of fat grafts presents low morbidity and mortality. However, a neurosurgeon should never forget the possible late or early complications related to the use of fat grafts.

With modern technology, intraoperative computed tomography scans are being used in neurosurgical operative rooms. A case of severe head trauma is reported to underline how intraoperative computed tomography can improve the treatment of traumatic lesions, without changing the operative setup, with safety for patients and surgeons. The ability to perform an intraoperative computed tomography scan rapidly, at any surgical step, and with no need of any change in the operative room set or of moving the patient from the operative table improves safety both for the patient and surgeon. Intraoperative computed tomography is a very helpful tool during surgery for complex cases when a rapid evaluation of surgical manoeuvres is required.