Paramedian thalamic infarction caused by cisternal drain placement in open clipping for aneurysmal subarachnoid hemorrhage: Two case reports

Background: Some complications associated with cisternal drainage have been reported; however, there are few reports on direct vascular injury caused by cisternal drain. We experienced two rare cases of thalamic infarction caused by cisternal drain placement during open clipping for a ruptured anterior communicating artery (AcomA) aneurysm through an anterior interhemispheric approach. Case Description: Two cases of ruptured AcomA aneurysm were treated by surgical clipping through an anterior interhemispheric approach, and then a cisternal drain was inserted from opticocarotid space toward prepontine cistern. Postoperatively, the magnetic resonance imaging showed unilateral anterior-medial thalamic infarction in both two cases. By reviewing the postoperative computed tomography and digital subtraction angiography, it was suspected that the cisternal drain, which was inserted slightly deep, obstructed the P1 perforator because of an anatomical variation involving a lowered basilar bifurcation and caused postoperative unilateral paramedian thalamic infarction. Conclusion: To avoid these complications, neurosurgeons should consider the potential for P1 perforator injury related to cisternal drain placement.

Anterior Interhemispheric Approach in Craniopharyngiomas : Personal Experience of Operative Technique and Results

Introduction: Removal of intracranial supra-sellar masses continues to be a surgical challenge. Various approaches have been used by different authors with varying results. Anterior basal interhemispheric approach is most suitable with better results than other approaches for craniopharyngiomas Materials and methods: Fifteen patients with large craniopharyngiomas having third ventricular and or retro or supra-sellar extensions or reaching the interpeduncular cisterns were operated by this approach, over a period of seven years since the first use of this approach at our institute. The data of patients opearated by this approach were then retrospectively analysed. There were eleven males and four females with five patients in the pediatric age group. Follow up range was from 2 to 83 months with a mean of 21.6 months. Results: Total excision was achieved in seven (46.6%) and near total excision in another seven (46.6%), partial excision was done in only one (6.66%). Seven patients with total excision were disease free at mean follow up of 6.8 months. There was asymptomatic recurrence in two (13.33%) patient with near total excision at 11 and 63 months respectively and were given radiotherapy post-operatively. All patients were symptom free except one with diabetes insipidus (DI) and one mortality, and one with post operative visual deterioration. Conclusion: Anterior basal interhemispheric approach is a useful alternative to other transcranial approaches in the management of the craniopharyngiomas. It has the advantage of being a midline approach and displays the tumour brain interface better.