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Cerebrospinal fluid (CSF) leak through petrosal air cells is a known complication after drilling the posterior wall of the internal acoustic canal (IAC) for resection of vestibular schwannoma (VS). Whereas mild pneumocephalus is common after retrosigmoid craniotomy, tension pneumocephalus has been rarely documented. To testify a case of fatal tension pneumocephalus after VS resection in a patient with ventriculo-peritoneal (VP) shunt and to propose possible recommendations to limit the risk of this dramatic complication. A case of fatal tension pneumocephalus after VS resection in presence of hidden CSF fistula is illustrated with pre- and post-operative images. In the uneventful situation of concomitant post-operative CSF fistula in presence of VP shunt, tension pneumocephalus may occur. The negative pressure created by the shunt system and the presence of osteo-dural defect allow the air to enter and, at the same time, prevent the outflow. After VS resection, tension pneumocephalus can occur as a consequence of CSF fistula from petrosal air cells in the presence of functioning VP shunt. Precautions as pre-operative increase to 'virtual-off' the pressure of the valve, subsequences CT scans after surgery and sealing of the petrous air cells are recommended to avoid such as fatal complication. [ABSTRACT FROM AUTHOR]

Byline: Paolo. di Russo, Paolo. Perrini, Nicola. Benedetto, Gabriele. Siciliano Sir, Although well-known adverse events are associated with its administration, phenytoin is a commonly used broad-spectrum antiepileptic drug.[sup][1] Collateral effects [...]

Objective  This study was aimed to present the complete removal of a large recurrent Meckel's cave meningioma. Design  This study is a case report. Setting  The study was conducted at Department of Neurosurgery and Skull Base Laboratory at Lariboisiére Hospital, Paris. Participant  A 53-year-old male was presented with a severe V1, V2, and V3 hypoesthesia and pain. He was operated 7 years ago for a right Meckel's cave meningioma with postoperative V1–V2 hypoesthesia. Magnetic resonance imaging (MRI) showed a large tumor recurrence extending into the cavernous sinus (CS), posterior fossa (PF), sphenoid sinus (SS), pterygopalatine (PPF), and infratemporal fossa (ITF; Fig. 1). Main Outcome Measures  Radiological results and postoperative course were assessed for this study. Results  The previous right frontotemporal approach was used. The lateral wall of the orbit, the middle fossa floor and the anterior temporal base were drilled to expose the orbit, PPF, and ITF. Foramen ovale (FO), foramen rotondum (FR), and superior orbital fissure (SOF) were opened. The meningoorbital band was cut and the lateral wall of CS was elevated (Fig. 2). The inferior orbital fissure was opened and tumor removed into the ITF, PPF, and orbit. After entering Meckel's cave from above, tumor was removed from PF. After microsurgical tumor removal, a 45-degree endoscope was used to remove tumor remnant and mucosa into SS. A watertight dural closure with pericranium was performed, reinforced with autologous fat and fibrin glue. Postoperative MRI showed complete tumor resection (Fig. 1). The patient experienced a right-side keratitis that resolved within 10 days and a V3 hypoesthesia that improved at 2 months. Conclusion  This surgical case shows how the anatomical knowledge is mandatory in skull base surgery and how the integration of microsurgical and endoscopic-assisted techniques allows to obtain optimal results. The link to the video can be found at: https://youtu.be/qxt_389AdWU. [ABSTRACT FROM AUTHOR]

Background: Presacral schwannomas are rare benign tumors that may reach large size before becoming symptomatic. Total surgical removal has been considered the best treatment option. Tumors arising from the presacral area are commonly managed through anterior approaches, whereas posterior approaches are used for pure intrasacral tumors or large lesions with both intrasacral and presacral extension, alone or in combination with anterior approaches., Methods: We describe a quick and minimally invasive navigation-guided posterolateral approach to a right presacral L5 schwannoma. The lesion was microsurgically removed through high-speed drilling of the upper portion of the right sacral ala, under intraoperative neurophysiologic monitoring., Results: The postoperative course was unremarkable, and the patient experienced improvement in his sensory disturbance. Postoperative magnetic resonance imaging and computed tomography scan showed the complete excision of the lesion and the removal of the upper sacral ala with preservation of the right L5-S1 articular complex. The histologic examination confirmed a schwannoma (World Health Organization grade I)., Conclusions: The posterolateral transsacral ala approach may represent a minimally invasive option in the surgical management of presacral well-circumscribed benign tumors. Spinal navigation could be properly used to facilitate lesion exposure and to minimize the bone removal. The intraoperative neurophysiologic monitoring is an essential tool for the preservation of the lumbosacral nerve roots., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Perforating branches arising from the superior cerebellar artery (SCA) or anterior inferior cerebellar artery (AICA) that pierces the brainstem within 5 mm of the trigeminal root may limit offending vessel transposition during microvascular decompression for trigeminal neuralgia., Objective: To investigate the microsurgical anatomy of peritrigeminal perforators and evaluate their effect on the mobility of the SCA and AICA. Additionally, we propose strategies for mitigating the potential complications caused by the presence of short peritrigeminal perforators., Methods: Retrosigmoid approaches and exposure of the upper cerebellopontine angle were performed on 11 cadaveric heads (22 sides). The number, origin, and course of perforators were recorded and each was classified as either type I, short straight (<3 mm); type II, long straight perforators (>3 mm); or type III, long circumflex (>3 mm). Transposition of each SCA and AICA away from trigeminal nerve was performed, and degree of mobilization was evaluated and graded., Results: A total of 123 perforators were identified, of which 44 were considered peritrigeminal. Of these, 19 arose from the AICA, 18 from the SCA, and 7 from the basilar artery. Type I peritrigeminal perforators were the most common at 77.3%. Transposition or interposition of the parent vessel was not possible in 8 (47.1%) instances., Conclusion: Identification of inhibiting perforators is essential before performing microvascular decompression to avoid ischemic injury to the brainstem. The presence of type I perforators may necessitate extensive arachnoid dissection and use of an interpositioning technique with minimal repositioning of the offending vessel., (Copyright © 2018 by the Congress of Neurological Surgeons.)