Central nervous system (CNS) hemangioblastoma is the most common manifestation of von Hippel-Lindau (VHL) disease. It is found in 70–80% of VHL patients. Hemangioblastoma is a rare form of benign vascular tumor of the CNS, accounting for 2.0% of CNS tumors. It can occur sporadically or as a familial syndrome. CNS hemangioblastomas are typically located in the posterior fossa and the spinal cord. VHL patients usually develop a CNS hemangioblastoma at an early age. Therefore, they require a special routine for diagnosis, treatment and follow-up. The surgical management of symptomatic tumors depend on many factors such as symptom, location, multiplicity, and progression of the tumor. The management of asymptomatic tumors in VHL patients are controversial since CNS hemangioblastomas grow with intermittent quiescent and rapid-growth phases. Preoperative embolization of large solid hemangioblastomas prevents perioperative hemorrhage but is not necessary in every case. Radiotherapy should be reserved for inoperable tumors. Because of complexities of VHL, a better understanding of the pathological and clinical features of hemangioblastoma in VHL is essential for its proper management.

A 65-year-old woman presented with basilar invagination manifesting as neck pain, dysesthesia around the lips, and truncal ataxia. The radiological findings demonstrated invagination of the odontoid process into the medulla oblongata and vertical atlantoaxial subluxation with C1 assimilation. The clivo-axial angle was 88° and the cervicomedullary angle was 115°, indicating severe basilar invagination. We planned occipitocervical fusion with atlantoaxial distraction using a cylindrical titanium cage. C2 pedicle screws were inserted, and the atlantoaxial joint was opened to translocate the odontoid process downward. A cylindrical titanium cage packed with local bone graft was inserted into the opened facet joint space. Occipital-C2 fusion was completed by fastening the occipital bone plates with pedicle screws using titanium rods. Postoperatively, the apex of the odontoid process descended by 7 mm, and the clivo-axial and cervicomedullary angles opened to 112° and 125°, respectively. Invagination of the odontoid process into the medulla oblongata was relieved. The preoperative symptoms improved, and she remained symptom-free without requiring anterior decompression over 2 years. Bone fusion of the atlantoaxial joints was completed with sustained facet distraction 12 months after the surgery, and adequate relief of the basilar invagination was maintained. The atlantoaxial distraction method using a cylindrical titanium cage can be a useful option in posterior fusion surgery for basilar invagination.

Intracranial chondroma is a rare benign tumor comprising only 0.2% of all intracranial tumors. A 27-year-old woman presented with visual dysfunction and headache. Brain computed tomography and magnetic resonance imaging revealed a suprasellar mass lesion with a calcified component. Gross total removal was achieved via a basal interhemispheric approach. Postoperatively, visual function improved to the normal range, and no recurrence was evident 4 years later. Histopathological examination confirmed the diagnosis of benign chondroma. Preoperative differentiation of chondromas from chordomas is clinically important, because of the different treatment and prognostic implications. The only effective treatment for chondroma is total surgical removal. We present a case of gross total resection of a suprasellar chondroma with reference to the literature.

We report a case of multiple intracerebral hemorrhages that immediately occurred after evacuation of a chronic subdural hematoma along with previous cases described in the literature. The complications of craniostomy for chronic subdural hematoma mostly have a good prognosis, but serious intracerebral hemorrhage after craniostomy has been reported to be rare but usually devastating. We performed evacuation and irrigation of a chronic subdural hematoma via a burr hole under local anesthesia for an 87-year-old woman with a previous history of old cerebral infarction. Immediately after the operation, the patient had a general tonic seizure, and computed tomography scan revealed multiple intracerebral hemorrhages. After the operation, moderate left hemiparesis and gait disability remained.

Summary:It is clearly important to avoid damage to the major arterial trunk during surgery.However, it is also useful to consider how to address problems associated with an unexpected arterial injury. We report a case in which a left proximal A2 occlusion and urgent A3A3 anastomosis were performed for arterial injury during surgery for an unruptured anterior communicating artery aneurysm. When an arterial injury occurs, closing of the arterial defect should first be attempted by stitching or clipping. If this is impossible, it might be necessary to occlude the artery and perform vascular reconstruction. However, there are 2 major problems in a case requiring urgent vascular reconstruction such as A3A3 anastomosis: the difficulty of suturing vessels in a deep and narrow field, and the requirement for further preparation of vascular components to make them adequate for vascular reconstruction.Good judgment and prompt performance of the procedure is required to avoid ischemic complications.