Meningiomas rarely occur in the pineal region, but they can reach huge diameters. We presented the case of a patient with a very large meningioma of the pineal region (6x5x4 cm). The tumor, developed from the falcotentorial junction, was totally removed via an occipital interhemispheric transtentorial approach with minimal postoperative neurological deficits. The postoperative course was complicated with an acute internal hydrocephalus that needed temporary placement of an external ventricular drainage. The supratentorial surgical corridors allow for increased exposure and are best suited for falcotentorial meningiomas.

The operative management of giant pituitary prolactinoma represents a significant challenge for neurosurgeons, due to the degree of local tumor infiltration into adjacent structures such as cavernous sinus. The degree of parasellar tumor extension can be classified according to the Knosp grading system’ while suprasellar extension is qualified in accordance with the modified Hardys classification system. This report describes the case of a male patient with a giant pituitary prolactinoma in which a partial tumor resection via a subfrontal approach was achieved. Typically, resection rates of less than 50% have been reported following surgery on giant pituitary adenomas. Prolactin levels were very high, consistent with invasive giant prolactinoma. Our patient was treated with Cabergoline which eventually normalized the prolactin level and significantly reduced the size of the residual tumor. This case serves to illustrate that in the presence of significant suprasellar and parasellar extension, multi-modal treatment strategies with surgery and dopamine agonist, is the gold standard in the management of locally aggressive pituitary prolactinomas.

Background. Paraclinoid aneurysm is a nonspecific term that includes ophthalmic segment aneurysms and distal cavernous internal carotid artery (ICA) aneurysms. The literature mostly described the frequency to be in the range of 1.3-5%. and a high incidence of being multiple or having a large size. Methods. A retrospective review of 18 consecutive patients surgically treated for paraclinoid aneurysm was performed. The data of all our consecutive patients were searched to obtain patient and aneurysm characteristics, treatment details, complications and follow up. Clinical outcome was graded according to the modified Rankin scale. The follow-up period varied widely from 3 to 62 months (mean 26 months). Results. Surgical clipping was performed for 15 ruptured paraclinoid aneurysms; only in 3 cases the aneurysm was unruptured. Post-operative control angiography was performed in 10 patients (55.56%), from which we reported a full occlusion of the aneurysm in 9 patients (90%). Best results were obtained in patients who preoperatively were included in 1st and 2nd grade of Hunt & Hess scale. Two months postoperative follow-up was complete for all but one patient who died 12 days after surgery, from cerebral ischemia resulting from severe cerebral vasospasm. There were excellent and good results (mRS 0–2) in 88% of the cases (15 out of 17 patients) at two months follow-up, and 94% (16 out of 17 patients) at six months follow-up. Three patients with slight disabilities, ranked mRS 1-2 at two months follow-up, improved to mRS 0, with no symptoms at all, at 6 months postoperative control. All 3 patients with a surgically treated non-ruptured paraclinoid aneurysm had an excellent outcome (mRS 0). Conclusions. Most appropriate treatment is to occlude aneurysms without compromising patency of the parent artery. Anterior clinoidectomy and microsurgical clipping can still be a standard treatment despite of recent development of endovascular coiling procedures.

Petroclival meningiomas represent only 10% of all meningiomas located in the posterior fossa, but are some of the most formidable challenges in skull base surgery. We described our recent experience (2005 regarding the surgery of these tumors. We retrospectively analyzed surgical results and outcome in 11 cases of petroclival meningiomas. Most common symptoms in our series were headache and gait disturbance, while cranial nerves palsies represented the most common presenting signs. There were 8 females and 3 males, and the mean age was 52 years. Surgical approaches chosen for petroclival meningiomas in our series were retrosigmoid (9 patients) and subtemporal transtentorial (2 patients). We achieved total tumor resection in 5 cases (45%) and subtotal resection in 6 cases (55%). Overall outcome (total/subtotal resection) was good in 6 cases, fair in 3 cases and poor in one case. One postoperative death occurred due to hemorrhagic midbrain infarction (9%). Complications were usually related to cranial nerve deficits: loss of hearing (2 patients), paresis of trochlear nerve (1 patient), trigeminal nerve (3 patients) and facial nerve (1 patient). In 4 patients these cranial nerves deficits were transient. In one case, a patient developed postoperative hydrocephalus and needed shunt placement. Despite the fact that complications can be disastrous, we considered that an appropriate approach, combined with microsurgical techniques and a better understanding of the anatomy, greatly decrease the incidence and severity of complications and make feasible a total tumor resection.

Background: Cerebral vasospasm that occurs after subarachnoid hemorrhage (SAH) can be an important cause of mortality and morbidity for patients successfully operated for a cerebral aneurysm. Methods: Five cases of prompt diagnostic and surgical treatment of a cerebral aneurysm, with important SAH on cerebral computed tomography (CT) at onset, are presented. All patients were admitted in a poor neurological state and developed severe vasospasm. Both, the correct clipping of the aneurysm and the cerebral vasospasm were angiographic demonstrated in all cases. Two patients showed complete obliteration of one carotid artery. Results: Postoperatory, four of the patients were treated with intrathecally administered nimodipine (10mg/50ml). In three cases, the procedure caused the reverse of the vasospasm and clinical improvement of the patients. Their clinical outcomes were very good and were discharged with minimal neurological deficits. In one case, repeated intraarterial administration of nimodipine, showed no reduction of the vasospasm, and no improvement of patient’s clinical status. The patient was conscious, but presented focal neurological deficits (hemiplegia and aphasia). One patient did not benefit from this treatment and had a poor clinical outcome, remaining in a vegetative state. Conclusions: Cerebral vasoconstriction after SAH could be an important obstacle in obtaining very good results in aneurysm surgery. Intra-arterial administration of nimodipine is an important and useful treatment, but good results in reversal severe cerebral vasospasm are not always mandatory.

Abstract:Objectives: Metastases in Meckel's cave are a rare tumor entity, but they should be considered in patients with a known primary malignancy and who complain of trigeminal neuralgia. Methods: The case of a patient with a left trigeminal neuralgia caused by a metastatic tumor involving the Meckel's cave and Gasserian ganglion is reported. Preoperative symptoms included headache, trigeminal hyperesthesia and facial pain. Results: The patient underwent microsurgical resection of the tumor, obtaining a histological diagnosis and a resolution of the pain. Trigeminal motor function was preserved. Conclusion: The best treatment for tumors of Meckel's cave, including metastases, is complete microsurgical removal. Although good results have been reported with radiosurgery, this treatment should be reserved only for nonresectable and residual tumors.

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Introduction: Tumors of the lateral ventricle are rare lesions including a large variety of benign or malignant tumors. These tumors could originate in the ventricular wall or arising and expanding within the lateral ventricle from the surrounding neural structures. The purpose of this study is to discuss postoperative results and factors that affected the preference for transcallosal or transcortical approach. Material and methods : We performed a retrospective study, lasted between 2005- 2013, that comprised 26 consecutive patients who underwent operation for lateral ventricle tumors. The main clinical symptoms and signs were associated with the localization and size of the tumors. Cerebral computed tomography and magnetic resonance imaging were used to determine the location and expansion of each tumor. The transcortical approach was used in 17 patients and the transcallosal approach was used in 9 patients. Results : Total tumor resection was achieved in 73% of cases (19 patients). Most frequent histological tumor’s type was glioblastoma, choroid plexus papilloma, ependymoma and meningioma. Signs of increased intracranial pressure were most dominant. One patient died because of postoperative intraventricular hemorrhage. Additional neurological deficits were seen in 3 patients and postoperative seizure occurred in three patients. One patient with preoperative hydrocephalus required ventriculoperitoneal shunting after tumor’s resection. Two patients developed postoperative epidural hematoma and one required reoperation. 15 of 26 patients received postoperative radiotherapy and 6 of them received adjuvant chemotherapy. The mean duration of postoperative evaluation was 24,32 (range 5-92). Excepting the cases with subtotal resection, two patients were reoperated for recurrences. Conclusions : The nature, size, location and vascularization of intraventricular tumors are the most important elements influencing the choice of surgical approach. Surgeons must evaluate all these factors and prefer the short and safe way to remove the tumor.