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Pineal cysts are typically detected in around 1.3% to 4.3% of patients during routine magnetic resonance imaging (MRI) scans. 1 , 2 The vast majority of pineal cysts are benign, asymptomatic, and typically do not necessitate surgical intervention. Large pineal cysts are known to cause hydrocephalus with its associated symptoms and thus can require in rare cases surgical resection. Even in the absence of hydrocephalus, selected patients with large pineal cysts causing headaches and visual disturbances can find relief after surgical resection. 3 , 4 The supracerebellar infratentorial (SCIT) approach is widely used and represents an extraparenchymatous approach through a natural corridor to the pineal region. 5 Performing this approach in a semisitting position allows for an optimal retraction of the cerebellum by gravity. We employ a minimally invasive paramedian SCIT approach for the resection of pineal cysts. In our experience, the paramedian SCIT approach allows for a less steep operating angle and a smaller craniotomy compared with the midline SCIT approach. We present a 24-year-old female complaining of headache. The initial MRI was conducted 2 years before surgery. Following the initial evaluation, the patient experienced progressive headaches without neurologic deficits. A subsequent MRI revealed enlargement of the pineal cyst, leading to the indication for surgical resection. The surgery was performed mainly under the operating microscope with endoscopic visualization in suitable situations as our small approach restricts bimanual dissection with an endoscope. In our experience, this approach provides a versatile and minimally invasive access to the pineal region, making it optimally suitable for pineal cysts requiring surgical resection., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Crooke cell adenomas (CCAs) are a rare, aggressive subset of secretory pituitary corticotroph adenomas (sCTAs) found in 5%-10% of patients with Cushing disease. Multiple studies support worse outcomes in CCAs but are limited by small sample size and single-institution databases. We compared outcomes in CCA and sCTA using a multicenter, international retrospective database of high-volume skull base centers., Methods: Patients surgically treated for pituitary adenoma from January 2017 through December 2020 were included., Results: Among 2826 patients from 12 international centers, 20 patients with CCA and 480 patients with sCTA were identified. No difference in baseline demographics, tumor characteristics, or postoperative complications was seen. Microsurgical approaches (60% CCA vs. 62.3% sCTA) were most common. Gross total resection was higher in CCA patients (100% vs. 83%, P = 0.05). Among patients with gross total resection according to intraoperative findings, fewer CCA patients had postoperative hormone normalization of pituitary function (50% vs. 77.8%, P < 0.01) and remission of hypersecretion by 3-6 months (75% vs. 84.3%, P < 0.01). This was the case despite CCA having better local control rates (100% vs. 96%, P < 0.01) and fewer patients with remnant on magnetic resonance imaging (0% vs. 7.2%, P < 0.01). A systematic literature review of 35 studies reporting on various treatment strategies reiterated the high rate of residual tumor, persistent hypercortisolism, and tumor-related mortality in CCA patients., Conclusions: This modern, multicenter series of patients with CCA reflects their poor prognosis and reduced postsurgical hormonal normalization. Further work is necessary to better understand the pathophysiology of CCA to devise more targeted treatment approaches., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Resection of vestibular schwannomas with good functional outcome remains a neurosurgical challenge. In this study, we report on our initial experience with a suction spatula, which allows free bimanual dissection of small tumors in a clear, bloodless surgical field in supine position., Methods: Forty-one patients underwent vestibular schwannoma surgery in supine position, using a suction spatula. To analyze its feasibility, 11 aspects of the device were compared with the regular retractor., Results: The suction spatula was successfully applied in all surgeries. Compared with a common spatula, the suction spatula showed superior performance during meatotomy, microsurgical and endoscopic tumor dissection, and management of bleedings. We noted no difference in ergonomics, compatibility, instrumental conflict, costs, reusability, and sterilization issues. Minor performance was related to its thickness/size. There were no significant disadvantages according to our data. There were no surgical complications related to this device., Conclusions: The main advantage of the suction spatula is in the treatment of small, mainly intrameatal vestibular schwannomas in supine patient position. It gives the surgeon a "third hand" while enabling a continuous bimanual dissection with 2 microinstruments without the use of a regular suction tip., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Surgical indications for patients with pineal cysts are controversial. There are absolute indications such as hydrocephalus or tectal compression; otherwise, it is difficult to decide whether surgery would be beneficial when symptoms are not distinct., Objective: We tried to clarify the indications and clinical course of patients after resection of pineal cysts without ventriculomegaly., Methods: We reviewed our database for all patients operated on for pineal cyst without ventriculomegaly from 2003 to 2018. We studied the presenting symptoms, cyst size, surgical approach, extent of resection, and clinical and radiologic follow-up. Follow-up ranged from 3 months to 14 years (mean 3.74 years)., Results: Forty-three patients underwent surgery for pineal cyst in absence of ventriculomegaly; 36 female patients, 7 male patients, mean age 25.63 years (±10.62 years, range 4-52 years). Presenting symptoms included headache (41/43), nausea and vomiting (31/43), dizziness (19/43), visual disturbances (10/43), and sleep disturbances (8/43). Mean cyst size was 15.7 mm (±4.9 mm, range 9-27 mm). In total, 41 of 43 patients reported a good outcome, represented by a Chicago Chiari Outcome Scale score of 11 or greater and only 2 of 43 patients reported a bad outcome, defined by Chicago Chiari Outcome Scale score of 10 or less., Conclusions: We suggest that pineal cysts without ventriculomegaly are an indication for surgery when patients present with headache and/or visual disturbances and other causes have been excluded. Resolution of symptoms and quality of life in our cohort may denote a good indication for resection. However, we must admit that there is still no evidence to recommend this technique as a treatment of headache in these patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Primary leptomeningeal melanocytic tumors of the central nervous system are rare and, especially in the spine, less frequent compared with other entities. There is no consensus regarding the best care of these tumors., Case Description: We report 2 cases of primary leptomeningeal melanocytic tumors, 1 primary leptomeningeal melanoma (PLM) and 1 primary leptomeningeal melanocytoma (PLMC) of the upper cervical spine, and emphasize different surgical findings and clinical courses of these patients. A review of the literature according to primary leptomeningeal melanocytic tumors of the spine was done, especially to compare different treatment modalities in the younger history., Conclusions: Primary melanocytic tumors of the spine are exceedingly rare. Before surgery it is difficult to make a correct diagnosis. Usually an unexpected intraoperative finding with consecutive histopathologic analyses leads to the final diagnosis. An accurate search for melanocytic tumors outside the central nervous system as a primary source is mandatory. PLMC has a better prognosis than PLM. There is no consensus regarding the adjuvant therapy, but patients with PLM should be given radiotherapy, chemotherapy, and immunotherapeutic approaches as immune checkpoint blockade after surgery. Communicating hydrocephalus is highly associated with PLM, but may occur in PLMC as well., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Endoscopic resection of colloid cysts is a widely accepted treatment option instead of microsurgery. However, there is still a debate about a potentially higher rate of incomplete resections and recurrence., Objective: The aim of this retrospective study was to evaluate long-term results after endoscopic removal of colloid cysts., Methods: Twenty patients underwent endoscopic treatment in our department. Eighteen patients agreed to follow-up examinations. In 17 patients, magnetic resonance images were obtained., Results: Total cyst resection was achieved in 16 procedures. In 1 patient, only plexus coagulation and widening of the ipsilateral foramen of Monro were performed. In 3 patients, small remnants of the cyst membrane were left behind. Conversion to microsurgery became necessary in 1 patient. Mild temporary complications occurred in 6 patients. Preoperative symptoms were completely relieved in 16 patients and improved in 2 patients. The average follow-up period was 188 months. In the patient with plexus coagulation, the cyst did not change. Recurrence occurred in 2 of 3 patients with cyst remnants. To date, no cyst remnant or recurrence has caused any symptoms or required surgical treatment., Conclusions: Our results indicate that endoscopic treatment of colloid cysts is a safe and effective treatment option that provides excellent long-term results. However, we determined that a significant risk for recurrence exists when even small parts of the cyst capsule were left behind. Therefore, we advocate an attempt at total endoscopic cyst resection., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Vertebrobasilar dolichoectasia (VBD) is a rare cause of hemifacial spasm. The ectatic vessel hinders microscopic visualization of the root exit zone. The aim of this study was to evaluate the benefit of endoscopic visualization during microvascular decompression (MVD) in managing this type of neurovascular compression., Methods: Retrospective evaluation of patients with VBD treated by endoscope-assisted MVD for hemifacial spasm between 2007 and 2016 was performed. A prospectively maintained database of all patients treated by MVD for hemifacial spasm was screened for vascular compression. Magnetic resonance imaging was evaluated to detect patients who had VBD according to defined criteria. The value of endoscopic inspection to detect offending vessels was analyzed, and clinical outcome was evaluated., Results: VBD was detected in 11 of 290 patients (incidence 3.8%). In these patients, 12 MVD procedures were performed. The endoscope was useful in identifying the offending vessels and adjacent perforators without any brain retraction in all patients. At last clinical follow-up, all patients had almost complete to complete resolution of clinical symptoms. The interposing technique alone was effective with excellent results in 8 patients. Three patients required an additional transposition-fixation technique to achieve sufficient decompression., Conclusions: VBD is a rare cause of hemifacial spasm. Because of the large diameter of the offending vessel, MVD is technically more demanding. Endoscopic inspection with a 45° endoscope enables accurate visualization of the root exit zone, offending vessels, and perforating arteries. Furthermore, accurate placement of the Teflon pledgets can be confirmed leading to a favorable outcome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: We analyzed our results using Hemopatch ® as a new dural sealant after durotomy in cranial and spinal neurosurgical procedures., Patients and Methods: In our prospective single center study, we analyzed all patients who received Hemopatch ® used as a dural sealant between October 2016 and May 2017. 34 patients received Hemopatch ® used as a dural sealant in the study period. We included 23 (67.6%) female and 11 (32.3%) male patients. The mean age was 56 years (4-83 years). We included emergency and elective surgical procedures as well as spinal and cranial intradural surgery. We did not exclude any type of underlying pathology. We took note of the general patient data, the size of Hemopatch ® used, the type of dural closure, and the postoperative stay. Additionally, we recorded the type of dural closure (watertight/ watertight with additional muscle patch/ not watertight with small or large defect (>1 cm) remaining) and of preoperative hydrocephalus as well as intraoperative ventricular opening., Results: Hemopatch ® was used in addition to the following dural closures: 11 (32.4%) watertight suture, 23 (67.6%) non-watertight suture. Three (8.8%) surgeries were emergency procedures. The site of surgery was as follows: 18 (52.9%) supratentorial, 16 (47.1%) infratentorial. A ventricular opening was performed in 13 (38.2%) cases. A hydrocephalus was present in 2 (5.9%) cases. A revision surgery after use of Hemopatch ® was performed in 2 (5.9%) patients. Postoperative CSF fistulas and infections were observed in 2 patients each., Conclusion: We could demonstrate the safety and efficiency of Hemopatch ® used as dural sealant after durotomy in microneurosurgical procedures. To confirm our promising results a larger prospective randomized controlled trial will be needed., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Ventriculoperitoneal (VP) shunting is the most commonly performed procedure in the treatment of hydrocephalus. VP shunt migration can occur at different sites. The aim of the study was to present different sites of abnormal distal shunt location, pathophysiology, and the management in each situation., Methods: Between 2014 and 2017, all patients with hydrocephalus in the Department of Neurosurgery, Cairo University, were gathered prospectively. All pediatric patients below the age of 12 years with shunt migration of the distal end of the VP shunt were identified., Results: Of 1092 patients operated on by the VP shunt between 2014 and 2017, 15 presented with shunt dysfunction because of distal shunt migration (6 anal, 3 scrotal, 1 colon, 1 peroral, 1 upper lumbar extrusion, 1 paraspinal, 1 penile, and 1 umbilical). Especially upper lumbar extrusion and paraspinal shunt location are extremely rare. All the 15 patients were treated successfully with VP shunts and prospectively followed until they presented with complications on different occasions., Conclusions: Peritoneal complications are among the most common causes of VP failure. We present a rare complication where the shunt migrates outside the peritoneal cavity elsewhere with ambiguous pathogenesis. Special considerations have to be appointed during the shunt revision surgeries of these cases., (Copyright © 2018 Elsevier Inc. All rights reserved.)

In this case report we present an immunocompetent 64-year-old patient presenting with an orbitofrontal invasive aspergillosis treated successfully with voriconazole monotherapy following biopsy and orbital decompression., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: The main objective of the present prospective, randomized, single-blinded controlled study was to measure heat during bony decompression of lumbar spinal stenosis with high-speed drills and an ultrasonic bone-cutting knife., Methods: Ninety patients diagnosed with lumbar spinal stenosis were included in this study and randomized for lumbar spinal canal decompression using either a high-speed drill with automatic irrigation, high-speed drill with manual irrigation, or an ultrasonic bone-cutting knife with automatic irrigation (USBCD). For evaluation of group homogeneity, a visual analog scale pain score and neurologic findings were measured preoperatively and postoperatively. Temperatures during bony decompression were measured using a forward-looking infrared camera system., Results: Clinical results among the 3 groups did not differ in pain reduction, improvement of neurologic findings, or the rate of complications. However, significantly lower values were found for absolute and mean maximal temperatures during bony decompression in the USBCD group compared with the groups of patients who received the high-speed drill with automatic irrigation and the high-speed drill with manual irrigation, indicating this technique to be less aggressive in terms of thermal induction of bone necrosis. USBCD allows more precise bone removal compared with high-speed drills, and despite increased device time, no significant difference in the overall decompression time was observed., Conclusions: All methods examined produced short temperature peaks with possible, at least temporary, damage to bone and neural tissue. Automatic irrigation was associated with lower heat development compared with manual irrigation. Despite evidence of critical temperatures, no clinical correlation (e.g., neurologic deficits) was encountered in this study. Clinically, all 3 methods presented equally good results., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Gross total resection is often avoided in posterior fossa ependymoma surgery because of the fear of permanent neurologic deficits after operation. However, the extent of resection is a major prognostic factor for progression-free and overall survival. This study evaluates the outcome of posterior fossa ependymoma gross total resection in adult patients using a 4-hand suction-irrigation technique at the floor of the fourth ventricle., Methods: All surgical procedures for posterior fossa ependymomas performed since 2001 in the Department of Neurosurgery, University Medicine Greifswald were analyzed., Results: Eight patients (2 women and 6 men; mean age, 41.9 years; range, 29-56 years) underwent surgery for posterior fossa ependymoma. All tumors were World Health Organization grade II. Tumor adherence was found to be in the caudal rhomboid fossa (between the obex and striae medullare, but below the facial colliculus) in all patients. The 4-hand suction-irrigation technique led to gross total resection in all patients (100%), without significant permanent neurologic deficits after surgery. None of the patients got further treatment (chemotherapy, radiation therapy, or second surgery). In none of these patients, tumor recurrence was seen on magnetic resonance imaging after a mean follow-up of 102 months (range, 14-181 months)., Conclusions: Long-term progression-free survival in adult patients suffering from posterior fossa ependymoma is possible by gross total resection without adjuvant radio- or chemotherapy. By careful bimanual microsurgical dissection using the 4-hand suction-irrigation technique and avoidance of bipolar coagulation on the floor of the fourth ventricle, the risk for permanent neurologic deficits is low., (Copyright © 2017 Elsevier Inc. All rights reserved.)