Pneumocephalus has various forms of presentations and a diverse etiology ranging from trauma to iatrogenic craniotomies and spinal surgeries. Most cases are benign and uncomplicated and resolve with minimal or no intervention. Few cases of pneumocephalus or pneumoventricles are either persistent despite treatment or present in various unique forms leading to considerable difficulty in the diagnosis and management of these patients. In this study, we analyze six cases of pneumocephalus with unusual and rare form of presentations and discuss their management strategies along with a review of relevant literature.

Background Achieving hemostasis during neurosurgical procedures within deep seated tumors is of paramount importance. Chemical methods like using ORC and gel foam are preferred to bipolar cautery as bipolar cautery causes thermal injury to the normal eloquent surrounding white matter fibers, thereby causing significant morbidities. In addition to the chemical methods, we advocate a new relatively simple mechanical method by using small size Foley catheter inflated with saline can achieve hemostasis in case of deep locating brain tumor surgery with diffuse oozing from the tumor bed and surrounding white matter tissues are of concern. The balloon tamponade effect of the inflated Foley catheter helps in achieving complete hemostasis without damaging the surrounding normal white matter parenchyma. Case presentation A 52-years-old female admitted with history of progressive drowsiness and altered sensorium. Brain MRI was done showing large right-sided trigonal meningioma. Right parieto-occipital craniotomy was done, through the superior parietal lobe, corticotomy was done, and tumor was reached. Gentle retraction was done using curved blades in between the tumor and normal brain parenchyma. During surgery, following tumor removal, there was a diffuse oozing from tumor bed and the surrounding stretched white matter fibers. Hemostasis was attempted with chemical methods like ORC and gel foam. We avoided bipolar cautery to prevent thermal injury to the normal stretched eloquent white matter, as bleeding was not settled over the period of 45 min using chemical methods. Then, we placed a 10 F size Foley catheter in the tumor cavity and inflated with 6 ml of saline over the period of 10 min. Prior to Foley placement, we coated ORC over the tumor bed and the surrounding white matter. This achieved hemostasis to a significant extent and the same was repeated for another 10 min, and finally, complete hemostasis was achieved. Postoperative period went uneventful. Patient was discharged with good neurological recovery. Conclusion Inflatable Foley catheter balloon is a simple, cost-effective technique for achieving hemostasis in deep white matter tumors in addition to the routinely available hemostatic techniques.

Background: This video highlights the standard surgical steps of retrosigmoid craniotomy and excision of a moderately sized vestibular schwannoma with facial nerve preservation, with basic technical nuances to guide young neurosurgeons. Objective: A systematic step-by-step approach to microsurgical dissection and removal of vestibular schwannoma that achieves gross total excision with good facial nerve preservation. Methods: The video starts with a note on clinical presentation of a 45-year-old male with unilateral sensorineural hearing loss and headache with MRI brain showing a 3.8 × 3.0 cm schwannoma arising from the left vestibular nerve. The surgery was performed in lateral position with neuromonitoring, using a conventional retrosigmoid craniotomy. The essential surgical steps of arachnoid opening and extra capsular dissection, identification and preservation of facial nerve, and drilling of the internal acoustic meatus (IAM) are demonstrated step by step achieving a gross total excision. Results: A systematic and meticulous approach to microsurgical excision of vestibular schwannoma is pivotal in the preservation of facial nerve and in preventing damage to surrounding neurovascular structures. Conclusion: Adopting microsurgical techniques in vestibular schwannoma with intraoperative facial nerve monitoring aids in achieving good functional outcome and tumor control.

Mirror aneurysms of the distal posterior inferior cerebellar arteries are extremely rare. We report a young female with bilateral aneurysms of the cortical segment of the posterior inferior cerebellar artery (PICA) with subarachnoid haemorrhage managed by microsurgical clipping of both the aneurysms in a single stage with excellent outcome. The management dilemmas and the risk factors of the mirror aneurysms of the distal PICA are also discussed.