Introduction. Spinal schwannomas are benign nerve sheath tumors. Completely extradural schwannomas of the lumbar spine are extremely rare lesions, accounting for only 0,7–4,2% of all spinal NSTs. Standard open approaches have been used to treat these tumors, requiring extensive muscle dissection, laminectomy, radical foraminotomy, and facetectomy. In this paper the authors present the case of a minimally invasive resection of a completely extradural schwannoma. Operative technique literature review is presented. Material & Methods. A 50-year-old woman presented with progressive complains of chronic right leg pain and paresthesia. The magnetic resonance imaging revealed a giant well-encapsulated dumbbell-shaped extradural lesion at the L3-L4 level. The patient underwent a minimally invasive gross total resection of the tumor using a tubular expandable retractor system. Results. The patient had complete resolution of radiculopathy in the immediate postoperative period and she was discharged home, neurologically intact, on the second postoperative day. Postoperative MRI demonstrated no evidence of residual tumor. At latest follow-up (18 months) the patient remains asymptomatic. Conclusion. Although challenging, this minimally invasive procedure is safe and effective, being an appropriate alternative, with many potential advantages, to the open approach.

No abstract

No abstract

The article by Le Reste et al. [7] addresses a very important topic in our current cerebrovascular practice. In order to deliver to our patients the best quality of care, a certain level of proficiency and competence needs to be attained and maintained. This is true for all areas of neurosurgery and constitutes a realistic objective in the treatment of most pathologies.The authors have looked at a particular subset of patients for whom surgery remains the recommended form of treatment. In fact, in high-grade SAH patients with intracerebral space-occupying hematomas, surgical decompression of the mass effect may be warranted, and along with it the clipping of the bleeding aneurysm. The authors suggest a correlation between cumulative surgical experience and lower intraoperative aneurysm rupture, although mortality and final outcome did not reach statistical significance. This can in fact be due to the sample size and the lower number of cases treated by surgeons with less cumulative experience. Five surgeons operated on these difficult patients on an emergency basis, one of them with minimal experience in the elective surgical treatment of aneurysms (surgeon 1 with only ten cumulative cases, nine of them within the study). There is no reference as to who was assisting these surgeons and what kind of experience these assistants had.Of course the surgical scenario in such challenging cases is far from being favorable. The brain is angry and edematous, intracranial pressure is flying high, not always with dilated ventricles enabling ventricular drainage, arachnoid spaces are collapsed with opercula overlying each other, which makes the dissection significantly more difficult than usual because the brain and veins become rather more friable. The surgeon has to constantly worry, control, and override all these difficulties, draining the hematoma, securing space and surgical conditions, which will enable him to control the circulation and deal with the ruptured aneurysm. In emergency cases like these, there is little time and room for the usual discussion regarding the size and shape of the sac and neck, the existence of calcified walls, and whether there are arteries taking off directly from the sac. In other words, all considerations that are pertinent in the context of an elective choice between a surgical or an endovascular treatment are cast away by the need to surgically decompress the hematoma, secure the aneurysm, and control ICP. As wisely pointed out by the authors, the surgeon needs to be prepared to circumvent all these difficulties, having as background the particularly adverse scenario of an urgent or emergent procedure in an unstable patient with poor medical condition. Both very important technical and also non-technical factors are at play. The technical gesture will only be perfect if the psychological condition of the surgeon and his resilience to act in severe adversity exists. The conjunction of the former and latter factors will only occur if the acting surgeon has acquired and maintained a level ...

Giant and complex intracranial aneurysms can be formidable lesions to tackle from a surgical standpoint. Their treatment has witnessed an enormous improvement in recent decades with the development of several technical refinements, both surgical and endovascular. By combining optimal cerebral protection with extended periods of circulatory control, deep hypothermic cardiac arrest (DHCA) is a useful adjunct for appropriately dealing with very select cases. In this article we discuss the rationale behind the use of DHCA and review the results of the most relevant series recently published. DHCA remains an important though exceptional way of surgically treating giant and complex intracranial aneurysms.