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BACKGROUND: Different treatment options have been proposed for obstructive hydrocephalus associated with pineal lesions. We discuss the obstructive hydrocephalus management associated with pineal region tumors and cysts in Helsinki Neurosurgery. METHODS: In this article, hydrocephalus treatment by tumor-cyst removal (n = 40), shunt surgery (n = 25), and endoscopic ventriculostomies (n = 3) is evaluated in 68 patients with obstructive hydrocephalus among 136 patients with pineal region tumor and cyst. Multivariate statistical analysis was followed by univariate and multivariate regression models of last functional status, last tumor-free imaging, and disease-specific mortality of the study population. RESULTS: Preoperative hydrocephalus was linked to higher World Health Organization tumor grades, poor functional status, higher mortality, and incomplete resection of pineal region cysts and tumors. Preoperative hydrocephalus remained a predictor of poor last functional status after multivariate regression. Pineal lesion removal with the posterior third ventricle opening as primary hydrocephalus treatment resulted in better last functional status, fewer postoperative shunts, fewer hydrocephalus related procedures, and fewer postoperative infections than in the shunt-treatment group. Multivariate regression analysis linked higher World Health Organization tumor & nbsp;grade, poor immediate functional status, postoperative complications, and incomplete surgical resection as independent predictors of disease mortality in patients with hydrocephalus. Same variables (except immediate modified Rankin Scale score) and higher number of shunt surgeries became independent predictors of poor last functional status at multivariate analysis. Incomplete resection was the only independent predictor of tumor-free magnetic resonance imaging at the last evaluation. CONCLUSIONS: Direct removal of pineal lesions with the opening of the posterior third ventricle could represent effective and reliable management of the associated obstructive hydrocephalus. Further research is required to generalize our inferences.

OBJECTIVE: The midline supracerebellar infratentorial (SCIT) approach and its paramedian development are commonly used for dealing with pineal lesions. Comparative clinical studies are lacking, however. We aim to establish the better performance of the paramedian SCIT approach in terms of clinical safety in surgically treated pineal cysts and pineal region tumors. Procedural functionality and effectiveness have been also analyzed. METHODS: A comparative analysis of clinical, radiologic, pathologic, and surgical features, and outcome was performed between 55 midline and 57 paramedian SCIT approaches that were exclusively performed in 112 patients (57 pineal cysts and 55 tumors of the pineal region) operated in sitting position by a single surgeon. Information was retrieved from hospital records and microsurgical videos. RESULTS: The paramedian SCIT approach linked with fewer postoperative complications (odds ratio [OR]: 0.40) and fewer approach-related complications (OR: 0.28) than the midline SCIT approach. The SCIT paramedian approach was achieved in a shorter time, by a smaller bone flap, and with fewer complex procedural steps than the midline approach. The SCIT paramedian approach did not require the opening of the falx cerebelli, midline cerebellar retraction, section of the midline cerebellar draining veins, nor wide opening of the dura. Gross total resection, size of the lesion, microsurgical time for removal, histopathological diagnosis and postoperative outcome were statistically similar in both groups. CONCLUSIONS: The SCIT approach represents a safer and more functional approach for the removal of cysts and tumors of the pineal region than the classic midline approach, while maintaining the same effectiveness.

Objective Surgical treatment of ventrally located intradural cysts is difficult and controversial. Laminectomy with division of the denticulate ligaments and gentle cord mobilization remains the standard approach but risks further neurologic deterioration secondary to cord manipulation. Our purpose is to evaluate the safety and effectiveness of a midline cord-splitting approach as an alternative for treating ventral thoracic intradural cysts. Methods We describe 2 patients who were treated for ventral intradural cysts causing progressive and severe myelopathy. Under general anesthesia and continuous neurophysiologic monitoring, laminectomy, durotomy, and cord splitting through a midline approach gave direct access to both lesions. Cyst drainage was supplemented by a cystopleural shunt in 1 case. Results Cyst collapse and cord reexpansion were documented in both patients with a magnetic resonance imaging scan 1 week after surgery. In both cases there was a significant neurologic improvement, which was maintained 2 years postoperatively. Intraoperative monitoring recorded no loss of somatosensory or motor potentials during surgery. Follow-up magnetic resonance imaging scans 2 years postoperatively showed no evidence of cyst recurrence, and both patients remained neurologically improved and stable. Conclusions We have been able to drain 2 ventral intradural cysts using a cord-splitting technique. This has allowed safe access to purely ventrally located lesions, which were inaccessible dorsally or dorsolaterally. By using this method we have been able to avoid a more invasive ventral transthoracic approach necessitating vertebrectomy and reconstruction and risking serious complications.

BACKGROUND: Vascular pineal malformations are rare and technically demanding lesions. Because the locations of these lesions, endovascular techniques and radiosurgery have been increasingly used in the recent decades to accomplish safe occlusion. Nevertheless, microsurgical treatment may be required sometimes. METHODS: We present a retrospective review of the vascular pineal malformations operated by the senior author. Moreover, we report illustrative cases for the various types of vascular lesions with a careful analysis of the different microsurgical stages. RESULTS: Eighteen patients with pineal vascular lesions were operated on between 1980 and 2015: 6 patients had vein of Galen malformations, 5 plexiform arteriovenous malformations, 6 cavernous malformations, and 1 patient had a ruptured medial posterior choroidal artery aneurysm. A complete resection and occlusion was possible in all vascular malformations. CONCLUSIONS: The pineal region is an infrequent but challenging location for vascular lesions. A careful and step-wise operative strategy for the different types of vascular lesion is paramount to accomplish an effective and safe microsurgical treatment when other alternatives fail or are not available.

Objective We present our experience with a modification of the conventional techniques for the removal of large spinal epidural hematomas (SEHs), based on multilevel “skip hemilaminectomies.” Methods Eleven patients with SEHs extending over 5 or more spinal segments were treated at our institution via a modified hemilaminectomy technique from 2008 to 2014. This procedure, that we called “skip hemilaminectomy,” consists in performing consecutive, alternating, unilateral laminar decompressions at 2–3 levels, followed by sublaminar undercutting, ipsi- and contralateral flavectomy, plus hematoma removal. Results Complete clot evacuation and full neurologic recovery were always achieved. A short hospital stay, fast postoperative mobilization, a minimized need of analgesic drugs, and no complications were recorded. Conclusions In our preliminary experience, skip hemilaminectomy seems to be as safe as more conventional techniques (laminectomy, extended hemilaminectomy) for the removal of large multilevel SEHs, granting full neurologic improvement, short surgical times—even for very large lesions—and no complications at follow-up.

BACKGROUND: Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors. CASE DESCRIPTION: Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patient's motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru. CONCLUSIONS: The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.

Objective The supracerebellar infratentorial (SCIT) paramedian approach in sitting position represents one of the most used surgical routes for dealing with pineal region lesions. The purpose of this study is to determine the cornerstones to perform this approach in a simple, safe, and effective way, so that it could be easily reproduced in other neurosurgical centers, particularly in those with modest resources. Methods We reviewed and analyzed the surgical videos of 24 pineal region lesions that were operated on through an SCIT approach between June 2012 and October 2015. The SCIT approach may be divided into 3 main steps: 1) skin-muscle incision; 2) craniotomy; and 3) dura opening and access to the pineal region. Results Complete lesion removal was accomplished in 23 cases, and subtotal removal was accomplished in 1 case. The pineal region was effectively and safely reached through the SCIT approach in the sitting position with a mean time of 14 minutes, using a basic set of microsurgical instruments. Cornerstones and potential delaying events were carefully recorded for each of the 3 main steps of the approach. Moreover, we present in a short video a step-by-step guide to perform the SCIT approach in a fast and safe way. Conclusions A correct application of microsurgical principles may allow to safely and rapidly perform the SCIT approach, therefore offering an effective and relatively atraumatic route for dealing with pineal region lesions.

BACKGROUND: Economic, cultural, and geographical reasons usually limit the access to specialized health centers in developing countries, especially in rural areas. Peruvian health system indicators still highlight significant unmet clinical need for neurosurgical patients. Our project is to develop the first highly specialized neurosurgical center in the EsSalud hospital of Trujillo, with the goal to improve the treatment of neurosurgical diseases in that region, thus optimizing their outcomes while decreasing expensive and risky patients transfer to the neurosurgical departments in the capital district. METHODS: After an initial center evaluation, 2 neurosurgeons and 2 nurses from the Helsinki University Central Hospital provided the microneurosurgical training for the local team. Moreover, our team worked closely with the local staff to develop standardized protocols for surgical procedures and postoperative management. RESULTS: From February to May 2016, 59 surgeries were performed in the new Neurosurgical Center, including cerebrovascular and skull-base cases that were never performed before in Trujillo. Moreover, the first "Cerebral Bypass and Vascular Microsurgery Live Course" was held in Trujillo in May 2016. After we left, the local team continued to work following the same protocols we introduced, and built up together. CONCLUSIONS: An effective and adequate operative skill transfer to the local staff may be accomplished in a reasonable amount of time, thus guaranteeing a longlasting improvement of neurosurgical care, while minimizing expenditures on personnel and capital. We believe that this is possible following a general microsurgical philosophy that can be simplified as follows: "simple, clean, fast, and preserving normal anatomy."

Objective Complex skull base approaches are often used to treat lesions within the middle incisural space; yet the well-known retrosigmoid route may provide an effective avenue to this difficult-to-reach region. The purpose of this study was to quantify the exposure advantages on the middle incisural space provided by cutting of the tentorium cerebelli via a standard suboccipital retrosigmoid approach (i.e., via the cerebellopontine cistern route). Also, 2 illustrative cases are presented. Methods A suboccipital retrosigmoid approach to the middle incisural space was performed bilaterally in 3 specimens in the semisitting position. A quantitative analysis of the brainstem surface exposed above the origin of the trigeminal nerve was performed before and after tentorial incision. Results Tentorial cutting significantly improved the exposure of the middle incisural space cisternal structures such as the oculomotor and trochlear nerves and the superior cerebellar and posterior cerebral arteries. The mean brainstem surface exposed more than doubled (2.13-fold increase) after tentorial incision with an average increase from 73.18 mm 2 to 155.76 mm 2 . When the endoscope was used, it was possible to follow the entire course of the cisternal, infratentorial trochlear nerve segment during the opening of the tentorial free edge, facilitating its preservation. In the illustrative cases, 2 cerebellopontine angle meningiomas with supratentorial and infratentorial extension were removed without any postoperative complication. Conclusions Tentorial incision may be useful to extend the rostral exposure of the middle incisural space via a simple retrosigmoid approach, avoiding the need for more complex skull base routes.