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Vestibular schwanoma is the most appropriate name for 8th nerve tumours arising in cerebellopontine angle. As the tumour grows it not only causes deafness but also involves 7th and 5th nerves. Cerebellum and brainstem are severely compressed with increase in size of tumour and hydrocephalus is quite common with large tumours. Sometime although tumour may not be large but patients can have papilloedema because of increased csf proteins, resulting in decreased visual acuity. Even today blindness as a result of this tumour is not uncommon. A tumour as large as in this adult lady continues to be a challenge. Radiosurgery for such a large tumour does not solve the problem and surgery remains the primary option. For long time craniectomy has been taught to us for approaching posterior fossa tumours. Author has been routinely using craniotomy for all the posterior fossa tumours. A special trephine having adjustable dura guard is used by author for all the posterior fossa tumours and it takes very little time to make a craniotomy. Above patient is an example where total excision of acoustic has been done and no calvarial defect has been left behind.

A 14 years old boy sustained head injury as result of a brick accidently striking his head at a construction site. First NCCT head within few hours shows a small right frontal extradural haematoma. As his headache persisted NCCT head was done 2 days later showing a significant increase in size of right frontal extradural haematoma. patient came to us on 29/8/10 3 days after injury. Right frontal trephine craniotomy and evacuation of extradural haematoma was done which provided him good relief. Question is whether we can do something like temporary blockage of middle meningeal artery or administration of recombinant factor 7 to prevent this haematoma from developing after detecting it in the first scan?

Trephine craniotomy is the fastest way to open the cranium. Trephine can be made almost on any part of skull. William B Scoville was a pioneer in practicing trephine craniotomy. His visit to Vellore in India around 1964 was instrumental in introducing trephine craniotomy. Author has made trephine craniotomy very safe and cost effective with introduction of adjustable dura guard. In more than 90 percent of cases author uses trephine craniotomy. Above pictures from top to bottom- 1 and 2. Excised meningiomas 3. BrainLab Image guided system and Muller microscope. 4. MRI showing two meningiomas 5. Trephined bone in a case of left parietal meningioma operated on 27/8/10. 6. Trephined bone inside out showing bony grooves for hypertrophied meningeal vessels. 7. Meningioma in a middle aged female operated by trephine craniotomy in April 2010 in Korean Hospital, Addis Ababa. 8. Picture of Karam Chand trephine with adjustable dura guard. The trephine is available in various diameters.
Even for acoustic tumours and other posterior fossa tumours author routinely uses trephine craniotomy.

Bottom 2 images show posterior 3rd ventricular lesion with hydrocephalus. Rest of images reveal ventricular size reduction after endoscopic third ventriculostomy.

I have loaded fresh set of images of my previous blog. Thic 18 years old male underwent posterior fixation with titanium cable and iliac crest bone graft. You can appreciate large occipital condyle and signal change in the cord.

Large condyles of occipital bone resulting in cervicomedullary compression was seen in an 18 years old male. Patient had upper motor neuron quadriparesis.

British Petroleum lost billions of dollars in plugging the oil leak in Gulf of Mexico. Marine life was adversely  affected  by huge oil leak. From mid April to  mid July, 2010 BP tried many methods including harvesting the oil to  stop the largest oil leak in the history of mankind. Obama admitted his great  concerns about the the leak saying that last thing before sleeping and first thing on waking up were about this topic only. One of the leaks which needs to be plugged in human body is haemorrhage from aneurysms and arteriovenous malformations.
Since the beginning of modern neurosurgery leaks from intracranial aneurysms and arteriovenous malformations having interested many neuroscientists. When Drake, Sengupta and other neurosurgeons had almost perfected the art of clipping the neck of aneurysms, intervention procedures started taking precedence over clipping.
The debate about clipping versus coiling in the last decade ,seems to be settling in favour of coiling. Alternatives to coiling will also develop in future.
One of the substitute to coiling could be injection of material which could be wrapped around the wall of aneurysm, to strengthen it, by a deliberate puncture of aneurysm wall or the wall of artery just distal or proximal to neck of aneurysm. Same material could be delivered through a transcranial image guided route also.
Stent which preserves the normal openings of perforaters near the aneurysm could also be devised in each individual case depending upon the three dimensional anatomy  of vessel.

Top image is postoperatve CT head showing midline craniotomy and no residual cyst in septum pellucidum. Bottom image is preoperative CT head showing cyst in septum pellucidum.

Tradition of first making a burr hole and then turning a free or pedicled bone flap is deep rooted in neurosurgery. Although with speed drills you do not need multiple burr holes, still you have to make intial burr hole before we of use craniotomy blade. The burr holes made over forhead and other visible parts of scalp, leave an ugly visible calvarial defect. You can improve the cosmetic appearance by putting a burr hole cap, but that needs a foreign material and can increase cost. The burr holes can be easily replaced by making a 1.5 cm trephine. Author has added an adjustable dura guard to the trephine. By adjusting the dura guard chances of injury to underlying dura and brain are minimised. Also by using bigger size of this trephine, safe craniotomy can be done to access most of intracranial lesions. This type of craniotomy is quick and cost effective, morever it just needs a straight scalp incision. The above paper is one of my presentation of Aug 2009 at Harvard Medical school auditorium in Aug 2009. Special scalp retractor designed by author for craniotomy with straight incision is also shown in this poster.

This is in all probability a tuberculoma in posterior 3rd ventricular location. A right ventriculoperitoneal shunt has been done 5 days back. The child has been put on antitubercular drugs. Do you need to excise this lesion or wait for antitubercular drugs to resolve this?