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Background: Extra-axial cerebral cavernous hemangiomas particularly those found in the sellar region, are extremely rare. Their clinical manifestations and imaging characteristics can mimic those of a pituitary adenoma thus making preoperative diagnosis difficult. Few cases are reported in the literature. We present a case, along with a comprehensive review of the literature regarding specific aspects of diagnosis and management of all similarly reported rare cases. Case Description: We present the clinical, radiological, and operative data of a rare case of a large intrasellar cavernous hemangioma in a 49-year-old female patient presented with headache and diminution of vision, which was diagnosed intraoperatively during an endonasal endoscopic transsphenoidal approach. Subtotal debulking was performed with immediate postoperative clinical improvement. The patient was then referred for radiotherapy and maintained her clinical improvement since then. Conclusion: Neurosurgeons should consider this rare pathology in the preoperative differential diagnosis of sellar tumors. Bright hyperintense T2 signal with or without signal voids associated with centripetal delayed contrast enhancement in magnetic resonance imaging images might raise the suspicion which can be further confirmed intraoperatively with frozen sections. Due the reported high vascularity and intraoperative profuse bleeding leading to high operative morbidities, piecemeal subtotal resection followed by radiosurgery may be considered today as the safest and most effective strategy.

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Highlights Only 15 cases of clinically diagnosed hemorrhagic colloid cysts were reported in the literature and 5 more cases on autopsy. The benefits of excellent visualization and minimally invasive access through the dilated ventricular system are offered by the endoscopic approach. Open microsurgical technique is the best choice for hemorrhagic colloid cysts.

Background: Pineal tumors are uncommon tumors that affect <1% of adults, with 50% of them being germinomas. A combination of endoscopic third ventriculostomy (ETV) and tumor biopsy is usually used. Cerebral vasospasm in association with aneurysmal subarachnoid hemorrhage (aSAH) has been extensively studied. However, at least according to the research, this is not the case in intraventricular hemorrhage (IVH) cases. We present a case with two distinct findings: (1) an unexpected large IVH following the removal of an external ventricular drain (EVD) in a patient who had undergone ETV and tumor biopsy, resulting in severe clinical vasospasm and (2) incidental pineal region germinoma regression on follow-up magnetic resonance imaging (MRI) without any prior adjuvant chemoradiation to explain such regression. Case Description: The authors describe an 18-year-old male patient who had a routine, uneventful combined ETV and tumor biopsy, as well as the placement of an EVD. Histopathological examination revealed germinoma. His postoperative course was complicated by IVH after EVD removal, which resulted in clinical vasospasm. Without any prior adjuvant chemoradiation, follow-up MRI of the b rain revealed a significant reduction in the size of the germinoma as well as reconstitution of the patency of the previously obstructed aqueduct of Sylvius. Conclusion: The take-home message from this case is that in the case of postoperative clinical deterioration in a patient with concurrent IVH and ETV, a high index of suspicion for vasospasm is required, as this may allow a significant amount of blood to pass down to the basal cisterns. Early detection and management of clinical vasospasm are critical for a better neurological outcome. Furthermore, unexpected tumor size changes can occur due to a variety of factors, so recent preoperative MRI of the brain should be obtained in the lead-up to surgery, and postoperative computed tomography should be used sparingly to avoid radiation-related tumor changes.

Lumboperitoneal (LP) shunt had been in use as an internal cerebrospinal fluid (CSF) diversion for a variety of different indications, namely benign intracranial hypertension, communicating hydrocephalus, slit ventricle syndrome and CSF fistulas.Generally, considered to be a simple surgical procedure, butcertain potential complications are associated with this technique, including chronic subdural hematoma, subarachnoid hemorrhage, acquired Chiari malformations and migration of the shunt tubing. 1,2 Proximal intrathecal migration of LP shunt catheter tip, high up in the cervical spine is a rare reported complication. [3][4][5][6][7][8] If doubtful on X-rays, Computed Topography (CT) scan confirms the diagnosis. Although, the multi factorial's proximal migration is usually because of a faulty technique when anchoring sutures are loosened or cut. The measures employed to avoid this potential complication include appropriate techniques for securing the LP shunt tube at the proximal lumbar and the distal peritoneal insertion sites with suture collars, thus enabling fixation of the tube. We report a case of an obese middle age female who developed proximal migration of the lumbar tube up to the cervical spine, after having undergone LP shunt for pseudotumor cerebri.

Background The goal of this study is to show the feasibility and benefits of using the simultaneous biportal endoscopic procedure to treat pineal tumors in patients with obstructive hydrocephalus. Methods We retrospectively reviewed three patients with pineal tumors and acute obstructive hydrocephalus who were treated in one session with a frameless stereotactic guided simultaneous biportal endoscopic third ventriculostomy and endoscopic tumor biopsy performed through two separate ports using one rigid ventriculoscope. Results In the three patients, ventriculostomy and endoscopic biopsies were conducted. There was no death or morbidity throughout the 45-min procedure. All of the patients’ histological findings were confirmed. Germinoma was diagnosed in two patients who recieved postoperative radiotherapy, and the third patient diagnosed with a pineocytoma. Magnetic resonance imaging with flow-sensitive sequences was used to confirm ventriculostomy patency in all patients 6 months after the surgery. Conclusion Biportal endoscopic approach enables better visual control of both procedures. Furthermore, it allows the surgeon to safely pass the ventriculoscope via the foramen of monro, even if it is narrow. Moreover, during endoscopic tumor biopsy and third ventriculostomy, the intracranial pressure can be smoothly managed using the outlet tubes accessible. This treatment may be an alternative to traditional uniportal endoscopic operations in certain patients.