INTRODUCTION Adult hemangioblastomas are rare WHO central nervous system (CNS) Grade 1 tumors particularly affecting the posterior cranial fossa. They exhibit a gender bias, impacting men in their fifth and sixth decades of life and manifesting sporadically or as part of von Hippel Lindau (VHL) disease. Understanding the intricacies of CNS hemangioblastomas is crucial for clinical decision-making. METHODS A systematic review of 576 articles was conducted following PRISMA guidelines. Eligibility criteria included 3189 adult cases of CNS hemangioblastomas. Data on patient demographics, tumor characteristics, symptoms, treatment modalities, complications, and outcomes were systematically extracted and synthesized. RESULTS The review revealed a heterogeneous demographic distribution, with a male predominance. Median age at diagnosis was 44.7 years. Cranial hemangioblastomas were more commonly located in the infratentorial (73 %) than supratentorial (27%) compartments. Spinal hemangioblastomas were mostly located in the cervical spine (44.3 %), followed by thoracic (36.7 %) and lumbar spine (12 %). Clinical symptoms varied by location, emphasizing the importance of anatomical considerations. Surgical intervention-total resection (82% of cases)-was the preferred treatment modality, while radiotherapy was less common. Histological examination and immunohistochemistry aided in accurate diagnosis. Complications were location-specific, with intracranial complications more common in infratentorial tumors. Overall, favorable outcomes were prevalent (78% of cases), with low mortality rates. CONCLUSION Adult CNS hemangioblastomas present with diverse characteristics and clinical manifestations. Surgical intervention remains the mainstay treatment; ongoing research into genetic and molecular mechanisms may enhance our understanding of tumor pathology and lead to improved management strategies in the future.

The modern period of neurosurgery in Bosnia and Herzegovina began with the first neurosurgical procedure performed by Dr. Karl Bayer in 1891 on 3 patients with depressed skull fractures and epilepsy. In 1956 the Department of Surgery in Sarajevo designated several beds specifically for a neurosurgical unit. A significant milestone in the history of neurosurgery in Bosnia and Herzegovina was the establishment of the Division of Neurosurgery at the Clinical Center University of Sarajevo in 1970. The first neurosurgeon to complete his training in Bosnia and Herzegovina was Dr. Faruk Konjhodžić. The first female neurosurgeon was Dr. Nermina Iblizović. Presently, there are 7 neurosurgical departments in the country, located in Sarajevo, Tuzla, Zenica, Mostar, Banja Luka, Bihać, and Foča. The Association of Neurosurgeons in Bosnia and Herzegovina, founded in 2003, is a member of the European Association of Neurosurgical Societies and the World Federation of Neurosurgical Societies. The aim of this historical paper is to provide a concise chronology of important events and mention key individuals who have contributed to the development of modern neurosurgery in Bosnia and Herzegovina.

Objective. Anticoagulant therapy is a risk factor for repeated intratumoral hemorrhage and acute enlargement of a vestibular schwannoma (VS) with neurological deficits. Therefore, we describe two cases of patients on oral anticoagulant therapy with intratumoral hemorrhage in which anticoagulant therapy prior to surgical resection was discontinued. We also discuss other similar cases from the literature since this is a rare event. Case Reports. We described the two cases of intratumoral hemorrhage in acoustic neurinoma and conducted a literature review of similar cases of patients with intratumoral hemorrhage in acoustic neurinoma who were also on oral anticoagulants. Both patients presented with CN-VII palsy prior to surgery; both also fully recovered after surgery except for hearing loss on the tumor side. Our literature review found 50 cases of VS (reported as vestibular schwannomas in the literature) with intratumoral hemorrhage. From this total, 11 patients used oral anticoagulant therapy with reported poor outcomes and high mortality; 9 of these 11 cases were reported in the past 20 years. The incidence is expected to rise due to increased use of anticoagulant therapy due to onset of atrial fibrillation, atherosclerosis, and thromboembolism from longer human lifespan. Conclusion. Anticoagulant therapy represents a risk factor for intratumoral hemorrhage and acute enlargement of VS tumor mass with neurological deficits.

The beginnings of neurosurgery in Croatia date to the end of the 19th century when Teodor Wickerhauser performed the first craniotomy in the country in 1886. Exactly 60 years later, in 1946, Danko Riessner founded a separate neurosurgical ward in Zagreb and is therefore considered the founder of Croatian neurosurgery. His main scientific contribution was a paper on the shifting of brain masses, published in 1939. The Department of Neurosurgery at the University of Zagreb was founded in 1974 as one of the first institutions of its kind in Southeast Europe. Finally, the Croatian Neurosurgical Society was founded in 1992 to promote the neurosurgical profession and science at the national level. This historical vignette aimed to provide a brief chronology of the most important events and notable people in the history of Croatian neurosurgery, as well as to commemorate its founders and highlight its development from the beginning to its current state of proficiency and expertise.

Clinoidal meningiomas are meningiomas arising from or in the vicinity of the anterior clinoid process.1 Despite advanced microsurgical techniques, clinoidal meningiomas remain challenging.2 Extradural anterior clinoidectomy with optical unroofing remains an important tool in skull base surgery, which provides a safe operative corridor, facilitating greater extent of resection and enhancing overall outcome, particularly visual function.2-13 A 66-year-old female presented with history of visual disturbances. MRI revealed dural-based tumor consistent with a large left clinoidal meningioma, with tumor wrapping (encircling) around left trunk and internal carotid artery (ICA) bifurcation, elevating the left middle cerebral artery M1 segment, and invading the left optic canal. Left cranio-orbital craniotomy with pretemporal exposure was used.1,9 High-speed diamond drill with irrigation completed the extradural anterior clinoidectomy and optical canal unroofing. Use of 1mm Kerrison rongeur should be used with utmost care. The tumor was unwrapped via meticulous piecemeal removal. Final dissection and ICA unwrapping was done when the tumor was debulked enough that dissecting it off the artery was safe and under less tension. Due to its obscurity, final decompression of the left optic nerve with incision and opening of the falciform ligament was performed at the end of the procedure.10 Postoperative neuro-ophthalmologic exam showed grossly unchanged left visual field with some visual acuity improvement. Resection of tumor encircling the ICA has been described previously14; however, to the best of our knowledge, this is the first video describing removal of tumor surrounding ICA ("unwrapping") the left ICA trunk and its bifurcation. The patient consented to publication.

OBJECTIVE Diagnosis of Chiari I malformation (CM-1) is based on measurements of the inferior extension of the cerebellar tonsils into the foramen magnum on cranial or cervical spine magnetic resonance imaging (MRI). Imaging may be obtained before the patient is referred to the neurosurgical specialist. The length of time raises questions about the possibility that Body Mass Index (BMI) fluctuations could affect the measurement of ectopia length. However, previous literature on BMI and CM-1 has reported conflicting findings on BMI. METHODS We conducted a retrospective chart review of 161 patients who were referred to a single neurosurgeon for CM-1 consultation. Patients with multiple recorded BMI values (n=71) were compared to see if BMI changes correlated with changes in ectopia length. In addition, we compared and tested 154 recorded ectopia lengths from the patients (one per patient) and patient BMI values with Pearson's Correlation and Welch's t-tests to determine if BMI changes either influenced or were associated with ectopia changes. RESULTS For the 71 patients with multiple BMI values, change in ectopia length ranged from -4.6-9.8 mm but was not statistically significant (r = 0.019; p = 0.88). For the 154 measured ectopia lengths, changes in BMI did not correlate with ectopia length (p > 0.05). Likewise, differences in ectopia length between patients in normal, overweight, and obese categories were not statistically significant (|tstat| < |tcrit|, p > 0.05). CONCLUSION In individual patients, we found that BMI and changes in BMI were not accompanied by changes in tonsil ectopia length.

Glioblastomas presenting topographically at the cerebellopontine angle (CPA) are exceedingly rare. Given the specific anatomical considerations and their rarity, overall survival (OS) and management are not discussed in detail. The authors performed an integrative survival analysis of CPA glioblastomas. A literature search of PubMed, Scopus, and Web of Science databases was performed per PRISMA guidelines. Patient data including demographics, clinical features, neuroimaging, management, follow-up, and OS were extracted. The mean age was 39 ± 26.2 years. The mean OS was 8.9 months. Kaplan–Meier log-rank test and univariate Cox proportional-hazards model identified hydrocephalus (log-rank, p = 0.034; HR 0.34; 95% CI 0.12–0.94; p = 0.038), chemotherapy (log-rank, p < 0.005; HR 5.66; 95% CI 1.53–20.88; p = 0.009), and radiotherapy (log-rank, p < 0.0001; HR 12.01; 95% CI 3.44–41.89; p < 0.001) as factors influencing OS. Hydrocephalus (HR 3.57; 95% CI 1.07–11.1; p = 0.038) and no adjuvant radiotherapy (HR 0.12; 95% CI 0.02–0.59; p < 0.01) remained prognostic on multivariable analysis with fourfold and twofold higher risk for the time-related onset of death, respectively. This should be considered when assessing the risk-to-benefit ratio for patients undergoing surgery for CPA glioblastoma.

BACKGROUND Chiari malformation type 1 (CM-1) diagnosis is based on measurement of the cerebellar tonsils on cranial or cervical spine MRI. However. imaging parameters of cranial and cervical spine MRIs could differ because spine MRIs have greater resolution. METHODS We conducted a retrospective chart review of 161 patients of a single neurosurgeon for Adult CM-I consultation between February 2006 and March 2019. Patients were selected based on receiving both cranial and cervical spine MRIs within a month of each other to determine tonsillar ectopia length for CM-1. Ectopias were measured to determine if differences in values were statistically significant. RESULTS From the 161 total patients, 81 had cranial and cervical spine MRIs for a total of 162 tonsil ectopia measurements (81 cranial and 81 spinal). Average ectopia length on a cranial MRI was 9.1 mm (±5.2 mm); average ectopia length on a spinal MRI was 8.9 mm (±5.3 mm). Average cranial and spinal MRI values were found to be less than 1 standard deviation apart. Two-tailed, non-equal variances t-test determined that differences between the cranial and spinal ectopia measurements were insignificant (P = 0.2403). CONCLUSION This study confirmed that the added resolution offered by spine MRIs did not make better or more refined measurements over cranial MRIs that could lead to measurement differences, which can instead be attributed to chance. Cranial and cervical spine MRIs can be used to determine the degree of the tonsil ectopia.

BACKGROUND Supratentorial hemangioblastomas are benign and highly vascularized neoplasms that appear most often in the spine and posterior cranial fossa. They can also be located in the supratentorial compartment of the brain. We conducted a systematic review of the literature to better understand the clinical insights of supratentorial hemangioblastoma in adults. METHODS Using PRISMA guidelines, the authors reviewed the English-language literature in the PubMed/MEDLINE database on supratentorial hemangioblastoma in adults published in the past 40 years. We analyzed the differences between sporadic hemangioblastomas and hemangioblastomas associated with von Hippel-Lindau disease. In addition, we compared the characteristics of supratentorial hemangioblastomas with infratentorial and spinal cord locations. RESULTS We reviewed 92 articles, describing 157 supratentorial hemangioblastomas in a total cohort of 148 adult patients. Most articles reporting supratentorial hemangioblastomas were published in the United States. Supratentorial hemangioblastomas occur more frequently in women than men. The median age at the time of diagnosis was 44.48 years. The sellar/parasellar region was the most commonly tumor location, while the most common morphological type was the solid type. Almost 80% of hemangioblastomas were completely resected; the outcome was favorable in more than three-quarters of patients. CONCLUSION Given their rarity, the literature on supratentorial hemangioblastomas is limited and based mostly on case reports. Complete surgical resection is the first choice of treatment and is associated with a good treatment outcome.

In this study, the authors summarize the current knowledge on epidemiology, demographics, risk factors, and prognostic factors that influence outcomes in patients with adult Chiari malformation type I (CM-I) who underwent posterior fossa decompression surgery with duraplasty. Furthermore, they describe the contribution of their research group to the field of adult CM-I treatment, including association of increased body mass index with severity of CM-I and syringomyelia, relevant surgical anatomy, and surgical technique of 270° microsurgical decompression of foramen magnum. The authors also report on common complications in the literature and describe techniques for prevention of complications.

Tuberculum sellae meningiomas represent 3% to 10% of all intracranial meningiomas and present with progressive visual deterioration secondary to optic apparatus compression. 1 Treatment options include open microsurgical or endoscopic endonasal approaches, with the size of the tumor, optic canal invasion, and the relationship to the surrounding neurovascular structures dictating the preferred approach. 2-10 Transcranial fronto-temporal skull base approaches offer excellent optic apparatus decompression, particularly when combined with anterior clinoidectomy and early sectioning of the falciform ligaments and release of the optic nerves. 2 - 4 , 11 - 14 We describe the case of a 57-year-old woman who presented to the senior author (KIA) with a large tuberculum sellae meningioma and signi fi cant optic apparatus compression causing a 2-month long worsening of vision that progressed to bilateral legal blindness for 2 weeks. The patient underwent a cranio-orbital pretemporal approach, 15 extradural anterior clinoidectomy, opening of falciform ligaments, release of optic nerve, and microsurgical resection of the tumor. To the best of our knowledge, this is the fi rst video case reporting on the reversal of bilateral preoperative blindness lasting 2 weeks preoperatively. The case presentation, surgical anatomy, operative nuances, and postoperative course with imaging are reviewed. The patient provided written informed consent for the publication of her image and PHI.

BACKGROUND: Questions remain regarding optic nerve (ON) physiology, mechanical compliance, and microvasculature, particularly surgical outcomes and atypical visual field defects associated with sellar/parasellar pathology (eg, tumors and aneurysms). OBJECTIVE: To study the microsurgical/histological anatomy of each ON segment and corresponding microvasculature, calculate area of optic-carotid space at each decompression stage, and measure ON tension before/after compression. METHODS: Five cadaveric heads (10 sides) underwent sequential dissection: (1) intradural (arachnoidal) ON dissection; (2) falciform ligament opening; (3) anterior clinoidectomy, optic canal decompression, and ON sheath release. At each step, we pulled the nerve superiorly/laterally with a force meter and measured maximal mobility/mechanical tension in each position. RESULTS: Cisternal ON microvasculature was more superficial and less dense vs the orbital segment. ON tension was significantly lower with higher mobility when manipulated superiorly vs lateromedially. Optic-carotid space significantly increased in size at each decompression stage and with ON mobilization both superiorly and laterally, but the increase was statistically significant in favor of upward mobilization. At decompression step, upward pull provided more space with less tension vs side pull. For upward pull, each step of decompression provided added space as did side pull. CONCLUSION: Opening the optic canal, falciform ligament, and arachnoid membrane decompresses the ON for safer manipulation and provided a wider optic-carotid surgical corridor to access sellar/parasellar pathology. When tailoring decompression, the ON should be manipulated superiorly rather than lateromedially, which may guide surgical technique, help prevent intraoperative visual deterioration, facilitate postoperative visual improvement, and help understand preoperative visual field deficits based on mechanical factors.