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Background: Cavernous hemangioma are the most common benign lesions of the orbit. Their surgical resection is still challenging and several surgical approaches have been proposed. Case description: We present the case of a 59-year-old woman with a cavernous hemangioma of the orbital apex, which was diagnosed incidentally. The hemangioma was extraconal and involved mainly the medial orbital apex; it also extended to the pterygoid fossa, to the middle fossa, to the maxillary and sphenoid sinuses. The surgical resection was performed by a pure endoscopic transphenoidal, transmaxillary, transethmoidal approach, achieving a total removal. The patient had a transient and incomplete paresis of the VI cranial nerve on the left side and did not experience other postoperative complications. Conclusion: The endoscopic endonasal approach proved successful in the management of this case and it should be considered in the surgical management of extraconal orbital apex lesions with medial or inferior extension.

Low-grade gliomas are slow growing intrinsic lesions that induces a progressive functional reshaping of the brain. Surgical removal of these lesions requires the combined efforts of a multidiscipinary team of neurosurgeon, neuroradiologist, neuropsychologist, neurophysiologist, and neurooncologists that all together contribute in the definition of the location, extension, and extent of functional involvement that a specific lesion has induced in a particular patient. Each tumor has induced particular and specific changes of the functional network, that varies among patients. This requires that each treatment plan should be tailored to the tumor and to the patient. When this is reached, surgery should be accomplished according to functional and anatomical boundaries, and has to aim to the maximal resection with the maximal patient functional preservation. This can be reached at the time of the initial surgery, depending on the functional organization of the brain, or may require additional surgeries, eventually intermingled with adjuvant treatments. The use of so called brain mapping techniques extend surgical indications, improve extent of resection with greater oncological impact, minimization of morbidity and increase in quality of life. To achieve the goal of a satisfactory tumor resection associated with the full preservation of the patients abilities, a series of neuropsychological, neurophysiological, neuroradiological and intraoperative investigations have to be performed. In this chapter, we will describe the rationale, the indications and the modality for performing a safe and rewarding surgical removal of low-grade gliomas by using these techniques, as well as the functional and oncological results.

Objectives: To investigate the hospital length of stay (LOS) and total direct costs of management of patients with intracranial aneurysm in Italy. To test whether treatment choices impact LOS and total direct costs. Design: Data were collected in a prospective, incidence-based, observational multicentre study. Patients were enrolled in a consecutive manner in 27 hospitals stratified according to macro-areas (North, Centre and South) and volume of activity (number of aneurysm patients treated annually). The costs were evaluated through a bottom-up, microcosting approach. The associations between demographic characteristics, clinical variables, modality of treatment and LOS/total costs were examined in two multiple regression models. Results: A total of 473 patients with single aneurysm were enrolled from October 1st 2005 to November 30th 2006 across the country. The average length of stay was 19.8 days while the total direct costs per patient were €21,810. The overheads represented the most important cost category (€15,867), followed by supplies used during treatment procedure (€3026), personnel (€1042) and diagnostic imaging (€591). Fifty four % of patients were treated with endovascular (coiling) approach while the rest was submitted to surgical intervention (clipping). After adjusting for covariates, three significant predictors of hospital LOS were identified: Hunt & Hess (H&H) level, geographical area and choice of treatment, while the type of admitting organizational unit represented one additional predictor of total costs. One additional point on H&H scale resulted in increasing LOS by 14% (p<0.001) and total costs by 16% (p<0.001), holding other variables constant. The choice of treatment also predicts the outcome: endovascular approach decreases LOS by 39% (p=0.001) without significant reduction of total costs (p=0.4). Conclusions: The intracranial aneurysm treatment poses significant economic burden on hospitals. The current analysis indic