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Pineal region tumors remain challenging lesions to safely resect because of their central location.1 Patients frequently present with symptoms associated with hydrocephalus and brainstem compression.2 Local anatomy, primarily the tentorium angle and venous anatomy, plays a central role in the selection of the approach.3 The paramedian supracerebellar approach pioneered by Yaşargil in 19844 allows to access the pineal region through a less steep angle while avoiding the central thickened arachnoid and midline cerebellar and vermian veins.3 Although the author strongly prefers the advantageous three-quarter concord position, this early case was performed in a sitting position, which requires a bubble test to rule out the presence of a persistent foramen ovale. The preoperative pineal differential diagnosis should be exhaustive, including blood and cerebrospinal fluid (CSF) tumor markers in suitable cases. Hemangioblastomas are seldom found or expected in the pineal area, and the surgeon must be alarmed by their typical "cherry nodule" appearance.2,5 Their recognition prior to resection is paramount in avoiding excessive blood loss from tumor entry. Similar to arteriovenous malformations, hemangioblastoma surgical tenets include en bloc resection and preservation of the main draining veins until the last steps of the resection. Von Hippel-Lindau (VHL) syndrome genetic workup is necessary is similar patients, as more than 25% of hemangioblastomas are associated with VHL tumor suppressor gene mutations in chromosome 3.2 The patient consented to the surgery and use of her photography. Image at 2:41 from Ueyama et al, Bridging veins on the tentorial surface of the cerebellum: a microsurgical anatomic study and operative considerations, Neurosurgery, 1998, 43(5),3 used with permission from the Congress of Neurological Surgeons., (© Congress of Neurological Surgeons 2021.)

Background: Dissection of brain surface adhesions during recurrent glioma surgery carries a risk of injury to cortical vessels and important surface vessels. We present our experience with the use of BioD film, a biocompatible amniotic membrane implant, to help prevent postoperative adhesions. We describe a novel method for preventing postoperative adhesions after high-grade glioma surgery using BioD film., Methods: Amniotic sac implants were laid on the brain surface after resection of gliomas located near major surface arteries (sylvian fissure) and major veins (parasagittal convexity). Seven cases involved reoperation for tumor recurrence., Results: In all 7 of the cases requiring reoperation, a new arachnoid-like surface layer was formed without any dural adhesions. The newly formed layer allowed for easy and simple dissection and mobilization of surface vessels while avoiding any trauma to the cortex., Conclusions: Amniotic sac implants have a promising role in preventing most surgical brain adhesions associated with recurrent glioma surgery, reducing the risks of cortical vessel and tissue injury., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Object: Epidermoid tumors arise from misplaced squamous epithelium and enlarge through the accumulation of desquamated cell debris. Optimal treatment consists of total removal of the capsule; therefore, giant and multicompartmental tumors are particularly challenging. A conservative attitude in handling the tumor capsule is common given concerns about capsule adherence to neurovascular structures, and thus the possibility of recurrence is accepted with the intent of minimizing complications. This study focuses on the outcome of surgery in patients with giant epidermoid tumors for which total capsule removal was the aim., Methods: The authors conducted a retrospective analysis of all patients with giant epidermoid tumors treated by the senior author (O.A.), who pursued total removal of the capsule through skull base approaches. Patients were divided into 2 groups: one including patients with de novo tumors and the other consisting of patients who presented with recurrent tumors., Results: Thirty-four patients had undergone 46 operations, and the senior author performed 38 of these operations in the study period. The average tumor dimensions were 55 × 36 mm, and 25 tumors had multicompartmental extensions. Total removal of the tumor and capsule was achieved with the aid of the microscope in 73% of the 26 de novo cases but in only 17% of the 12 recurrent tumor cases. The average follow-up among all patients was 111 months (range 10-480 months), and the average postsurgical follow-up was 56.8 months (range 6-137 months). There were 4 recurrences in the de novo group, and every case had had a small piece of tumor capsule left behind. One patient died after delayed rupture of a pseudoaneurysm. In the de novo group, the average preoperative Karnofsky Performance Scale (KPS) score was 71.42%, which improved to 87.14% on long-term follow-up. In the group with recurrences, the KPS score also improved on long-term follow-up, from 64.54% to 84.54%. In the de novo group, 3 cases (11.5%) had permanent cranial nerve deficits, and 4 cases (15.4%) had a CSF leak. In the recurrence group, 3 cases (25%) had new, permanent cranial nerve deficits, and 1 (8.3%) had a CSF leak. Two patients in this group developed hydrocephalus and required a shunt., Conclusions: Total removal of the capsule of giant epidermoid tumors was achieved in 73% of patients with de novo tumors and was associated with improved function, low morbidity and mortality, and a lower risk of recurrence. Surgery in patients with recurrent tumors was associated with higher morbidity and persistence of the disease.