Microsurgical management of aneurysms of the superior cerebellar artery - lessons learnt: An experience of 14 consecutive cases and review of the literature.

OBJECTIVE: This is a retrospective study from January 2002 to December 2012 analyzing the results of microsurgical clipping for aneurysms arising from the superior cerebellar artery (SCA). MATERIALS AND METHODS: All patients with SCA were evaluated with computerized tomography angiography and/or digital subtraction angiography (DSA) prior to surgery. All patients in our series underwent microsurgical clipping and postoperative DSA to assess the extent of aneurysm occlusion. The Glasgow outcome scale (GOS) and the modified Rankin's scale (mRS) were used to grade their postoperative neurological status at discharge and 6 months, respectively. RESULTS: Fourteen patients had SCA aneurysms (ruptured-9, unruptured-5). There were 10 females and 4 males with the mean age of 47.2 years (median - 46 years, range = 24-66 years). Subarachnoid hemorrhage (SAH) was seen in 11 patients. The mean duration of symptoms was 2.5 days (range = 1-7 days). The WFNS score at presentation was as follows: Grade 1 in 10 cases, II in 2 cases, III in 1 case and IV in 1 case. In the 9 cases with ruptured SCA aneurysm, average size of the ruptured aneurysms was 7.3 mm (range = 2.5-27 mm, median = 4.9 mm). The subtemporal approach was used in the first 7 cases. The extradural temporopolar (EDTP) approach was used in the last 5 cases. Complications include vasospasm (n = 6), third nerve palsy (n = 5) and hydrocephalus (n = 3). Two patients died following surgery. At mean follow-up 33.8 months (median - 25 months, range = 19-96 months), no patient had a rebleed. At discharge 9 (64%), had a GOS of 4 or 5 and 3 (21%) had a GOS of 3. At 6 months follow-up, 10/14 (71%) patients had mRS of 0-2, and 2 (14%) had mRS of 5. CONCLUSIONS: Aneurysms of the SCA are uncommon and tend to rupture even when the aneurysm size is small (<7 mm). They commonly present with SAH. The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.

Extradural temporopolar approach for parahypothalamic hypothalamic hamartoma and use of posterior communicating artery as resection margin pointer.

BACKGROUND: Hypothalamic hamartomas (HH) are malformations originating from the hypothalamus and are associated with seizures, hormonal and behavioral abnormalities. METHOD: Most patients, especially those with a typical syndrome characterized by gelastic seizures, precocious puberty, cognitive decline, and behavior problems, are diagnosed in childhood. Pedunculated and parahypothalamic types of hamartomas are attached to the floor by a narrow or wide peduncle in the absence of distortion of the overlying hypothalamus. This location is most commonly associated with a clinical presentation of precocious puberty, and surgical removal has proved curative in small case series. Enthusiastic resection of hypothalamic lesions are known to produce severe hypothalamic disturbance while under resection might mean inadequate response to surgery. CONCLUSIONS: In this article, the authors describe the use of extradural temporopolar approach to hypothalamic hamartoma as an improvisation to improve access with reduced morbidity and describe a surgical nuance of using posterior communicating artery to determine a safe but maximal resection margin.