The International Subarachnoid Aneurysm Trial led to a shift from clipping to endovascular coiling as the primary therapy for cerebral aneurysm particularly in the management of posterior circulation aneurysm. However, endovascular therapy is often unavailable in low-resource settings, emphasizing the importance of maintaining surgical skill sets in resource-poor countries. This article presents a detailed case report on the successful microneurosurgical management of a 65-year-old female with a history of headache and weakness with past history of hypertension and a right posterior cerebral artery territory infarct who was diagnosed with a ruptured aneurysm situated within the intracranial vertebral artery. Patient was operated with the far lateral approach and clipping of the aneurysm. This case report elucidates the intricate surgical techniques employed, and the challenges neurosurgeons encountered in treating posterior circulation intracranial aneurysms, particularly those with ruptured complications. The aneurysms\' intricate anatomy and increased rupture risk necessitate a meticulous microneurosurgical approach. The severity of subarachnoid hemorrhage from ruptured aneurysms increases morbidity and mortality rates.

Intracranial epidermoid cysts are rare, benign tumors. Nevertheless, the microsurgical removal of these cysts is challenging. This is due to their capacity to adhere to the neurovascular tissue, as well as the associated difficulties in microsurgically peeling off their capsular wall hidden in dead angles. To better understand the rate of recurrence after surgical intervention, we have performed preoperative and postoperative volumetric analysis of epidermoid cysts, allowing the estimation of their growth rate after resection.
Imaging data from 22 patients diagnosed and surgically treated for an intracranial epidermoid cyst between 2000 and 2022 were retrospectively collected from 2 European neurosurgical centers with microsurgical expertise. Volumetric analysis was performed on magnetic resonance imaging data.
Average cyst volume at diagnosis, before any surgery, measured in 12 patients was 28,877.6 ± 10,250.4 mm3 (standard error of the mean [SEM]). Estimated growth rate of incompletely resected epidermoids after surgery was 1,630.05 mm3 ± 729.95 (SEM). Assuming linear growth dynamics and normalizing to postoperative residual volume, the average postoperative growth rate corresponded to 61.5% ± 34.3% (SEM) of the postoperative residual volume per year. We observed signs of recurrence during a radiologic follow-up period of 6.0 ± 2.8 years (standard deviation) in more than 50% of our patients.
Due to their slow-growing nature, epidermoid cysts can often reach a complex multicompartmental size before resection, even in young patients, thus requiring complex approaches with challenging capsular resection, which implies a high risk of nerve and vascular injury per se. Tumor recurrence may be predicted on the basis of postoperative volumetry.

Dural arteriovenous fistulas (dAVFs) of the superior sagittal sinus (SSS) are uncommon and represent 5%-12% of all intracranial dAVFs. SSS dAVFs can be divided into two main subtypes. The first type involves direct arterialization of the SSS, whereas the second type consists of a parasagittal arteriovenous shunt draining into a cortical vein directly lateral to the SSS and has retrograde cortical venous drainage with only secondary involvement of the SSS. Descriptions of the latter type of SSS dAVF are limited. As such, the authors present a consecutive case series of parasagittal SSS dAVFs from their institution. They detail clinical presentation, treatment strategies, and clinical and radiographic outcomes.
The authors retrospectively reviewed a prospectively collected database of dAVFs that were treated between 2017 and 2023. All dAVFs characterized by an arterialized parasagittal vein directly lateral to the SSS were included in this study. Baseline demographic, clinical, radiological, treatment, and outcome-specific variables of interest were abstracted.
One hundred fifty-four dAVFs were seen at the authors\' institution over the 6-year period of interest. Eight (5.2%) were parasagittal dAVFs. At initial diagnostic imaging, 7 were Cognard grade III and 1 was grade IV. All patients initially underwent embolization of their dAVF. Three patients did not have complete obliteration of their dAVF after the first embolization. One patient underwent further treatment with repeat embolization, and 1 underwent microsurgical disconnection-both resulted in complete occlusion of the dAVF. Seven dAVFs were obliterated at final follow-up and 1 remained patent as the patient refused further treatment despite angiographic progression of dAVF. All symptomatic patients had resolution of their symptoms, and the average length of follow-up was 16.8 months.
Treatment of parasagittal dAVFs consists of occluding the proximal portion of the parasagittal arterialized draining vein. Endovascular therapy with liquid embolic agents is usually the first line of treatment. Surgical ligation is a valid option if the fistula cannot be successfully obliterated with embolization. Symptoms related to the SSS dAVF resolve after their obliteration.

Treating unruptured brain arteriovenous malformations (bAVMs) represent significant challenges, with numerous uncertainties still in debate. The ARUBA trial induced further investigation into optimal management strategies for these lesions. Here, we present a systematic-review and meta-analysis focusing on ARUBA-eligible studies, aiming to correlate patient data with outcomes and discuss key aspects of these studies.
Following PRISMA guidelines, we conducted a systematic-review. Variables analyzed included bAVM Spetzler-Martin (SM) grade, treatment modalities, and outcomes such as mortality and neurological deficits. We compared studies with a minimum of 50% cases classified as SM 1-2 lesions and those with less than 50% in this category. Similarly, a comparison between studies with at least 50% microsurgery-cases and those with less than 50% was performed. We examined correlations between mortality incidence, SM distribution, and treatment modalities.
Our analysis included 16 studies with 2.417 patients. The frequency of bAVMs SM-grade 1-2 ranged from 44% to 76%, SM-grade 3 from 19% to 48%, and SM 4-5 from 5 to 23%. Notably, studies with more than 50% cases presenting lesions SM-grade 1-2 presented significantly lower mortality rates than those with less than 50% cases of SM 1-2 lesions (P < 0.001). No significant difference in mortality rates or neurological deficits was identified between studies with more than 50% of microsurgery-cases and those with less than 50%.
The analysis revealed that studies with a higher proportion of bAVMs presenting SM 1-2 lesions were associated with lower mortality rates. Mortality did not show a significant association with treatment modalities.

UNASSIGNED: We designed a novel intraoperative malleable adjustable continuous suction tube to obtain clear surgical fields, reduce intracranial pressure, and lower the temperature of the surgical area.
UNASSIGNED: This device consists of six parts: continuous suction tube head and cotton patty, suction tube, fixed wire position, fixed clip, spiral plastic pressure regulating valve, and tail. It can continuously extract blood, cerebrospinal fluid, and rinsing solution from surgical fields, with minimal contact and trauma to tissues, nerves, and blood vessels, while also having a negligible impact on the surgeon\'s focus and procedure.
UNASSIGNED: The excellent and safe performance (simple, malleable, adjustable, space-saving, inexpensive, safe, and effective) of this device in clearing the operating field has been proven in more than 2000 neurosurgical operative procedures. We encountered no complications associated with this device, such as cerebral hematoma, postoperative low intracranial pressure, or vascular and nerve injuries.
UNASSIGNED: The newly innovated intraoperative malleable adjustable continuous suction tube is effective and safe for microneurosurgery.

Intracranial dermoid cysts are rare dysembryonic tumors of benign nature. These are uncommon in adults. If present, they are usually located in the midline or along the lines of embryonic fusion. The posterior fossa region is an infrequent site. Extradural or interdural locations are even more rare. In this case report, the authors report a laterally located large posterior fossa right cerebellar convexity interdural and extradural dermoid cyst over the sigmoid sinus. It was managed by totally extradural maximum possible safe decompression with microneurosurgical technique. The authors share their experience of addressing this rare pathology at the rarest location with unusual imaging findings.

OBJECTIVE: This retrospective study was performed to evaluate the feasibility and safety of surgically clipping intracranial aneurysms using a transcranial neuroendoscopic approach.
METHODS: A total of 229 patients with cerebral aneurysms were included in our study, all of whom were treated with clamping surgery at Wuhan University People\'s Hospital. They were divided into neuroendoscopic and microscopic groups, according to whether or not neuroendoscopy was used for the clamping surgery. We statistically analyzed the patients\' baseline data, surgical outcomes, and complications, which were then evaluated to assess the treatment effect.
RESULTS: The baseline characteristics were not statistically significant, except for gender, for which the proportions of female patients in the two groups were 69 (56.1%) and 46 (43.4%). There were no patients with incomplete aneurysm clamping or parent vessel occlusion in the neuroendoscopic group, and there were 4 (3.8%) and 2 (1.9%) in the microscopic group, respectively; however, there was no statistically significant difference in the comparison of the two groups. The mean operative times of the two groups were 181 min and 154 min, respectively, and were statistically different. However, the mRS scores of the two groups showed no significant difference in patient prognosis. The differences in complications (including limb hemiplegia, hydrocephalus, vision loss, and intracranial infection) were not statistically significant, except for cerebral ischemia, for which the proportions of patients in the two groups were 8 (6.5%) and 16 (15.1%).
CONCLUSIONS: Neuroendoscopy can provide clear visualization and multi-angle views during aneurysm clipping, which is helpful for ensuring adequate clipping and preventing complications.

In recent decades, the management of middle fossa arachnoid cysts in pediatric patients has evolved significantly through the integration of novel techniques, such as the utilization of endoscopy systems1 and implementation of minimally invasive approaches like keyhole craniotomy.2,3 These cystic formations, occurring within the arachnoid membrane, may lead to neurologic impairments and raised intracranial pressure if left untreated.4 The utilization of endoscopy to aid microsurgical techniques or as a complement to them provides a level of visualization and manipulation of the cyst walls that is significantly more precise than the isolated use of a microscope.1 The keyhole craniotomy allows for reduced surgical trauma, smaller incisions, and quicker recovery times.5 In Video 1, we present the case of a 2-year-old patient with bilateral middle fossa arachnoid cysts exerting mass effect on the adjacent parenchyma. The patient was referred to our institution due to developmental delay and cognitive issues related to language and social interactions. On the basis of imaging findings and clinical correlation, we opted for a microsurgical fenestration with endoscopic inspection using a keyhole craniotomy to minimize complications and enhance the benefits of both techniques. Throughout the surgical video, tricks and considerations that contribute to the combined procedure\'s efficiency and ease of execution are highlighted and discussed. Postoperative images showed no complications, and the patient was discharged 3 days after surgery.

Anterior communicating artery (ACoA) aneurysms are the most frequently encountered type of intracranial aneurysm. ACoA aneurysms may require treatment depending on clinical presentation, size, risk of rupture, and ruptured status. In patients where treatment is indicated, options entail endovascular securement or clipping. Under the clipping umbrella, surgical approaches traditionally entail a pterional craniotomy and its modifications such as the lateral supraorbital approach. Sidedness of this craniotomy has been a topic of debate. To discuss this we present a case and technical report with nuances of the approach wherein a 48-year-old female presented with the worst headache of her life. The patient was found to have a ruptured wide-necked 7.2 x 8.1 x 5.8 mm ACoA aneurysm more eccentric to the left and fed from the left A1 intertwined with a frontopolar branch, numerous perforators and the recurrent artery of Heubner. The patient underwent a successful clipping from a right-sided approach. As such, with appropriate skull base drilling, exposure, optimization of brain relaxation, and a generous opening of the Sylvian fissure bilateral internal carotid arteries, anterior cerebral arteries with both A1 and A2 segments, middle cerebral arteries, the ACoA, and the relevant anatomy can be appropriately visualized from a right-sided approach. Therefore, an approach is described to optimize exposure to allow for nearly all anterior communicating aneurysms to be clipped from a right-sided pterional approach.

UNASSIGNED: Colloid cysts are benign lesions of the roof of the third ventricle, often diagnosed incidentally; sometimes they can cause hydrocephalus due to obstruction of the foramina of Monroe. Symptomatic cysts could be resected either microsurgically (transcallosal or transcortical) or endoscopically. Although both strategies are effective and have advantages and disadvantages, there is no consensus on the choice of the optimal approach. Transcallosal resection, although more invasive than endoscopy, allows adequate bimanual manipulation of the cyst and is associated with high rates of complete resection, the use of neuronavigator and intraoperative ultrasound optimizes surgical trajectory and improves safety of the procedure with complication rates comparable to endoscopy. Endoscopy is less invasive but complete resection of solid cysts can be challenging.
UNASSIGNED: In Video 1, we show resection of a solid partially calcified colloid cyst using a transcallosal bilateral transforaminal approach to anterior third ventricle male, 65 years old; headache and mild memory impairment for 6 months; admitted at our emergency department because of a brief loss of consciousness. Neurologic examination was normal. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a colloid cyst at the level of anterior third of the third ventricle (1.5 cm in diameter) with hypointense appearance in T2 sequences suggesting a solid calcific component. The ventricular system was enlarged. Colloid cyst risk score 3/5 (diameter >0.7 cm, headache, risk zone I) considered an intermediate-risk subgroup according to Alford et al. On this basis, we proposed the surgical treatment. We chose a transcallosal microsurgical resection. The patient gave consent for the procedure. A preoperative planning with a computer-generated 3D model is performed to simulate the approach. Craniotomy, interhemispheric dissection, and callosotomy were planned with the neuronavigator and with the aid of intraoperative ultrasound to optimize the trajectory and perform a limited and tailored callosotomy. The 1.5 cm callosotomy allows to approach both lateral ventricles, the cyst was progressively dissected working bilaterally through both foramina of Monroe without injuries of the fornices. Resection at term is complete. Postoperative MRI and CT scan confirmed complete excision without complications; the patient was discharged after a week in good neurological condition with complete regression of headache.
UNASSIGNED: Microscopic transcallosal resection of the colloid cyst of the third ventricle allows for complete resection with low complication rates. The use of preoperative 3D planning and integrated neuronavigation with intraoperative ultrasound helps to reduce invasiveness.