A man aged 50 years presented with subarachnoid hemorrhage from a complex left internal carotid artery aneurysm that was clipped during surgery. He recovered without deficits. A woman aged 29 years previously had an aneurysm clipped that later recurred, requiring another clipping. A woman aged 44 years had two bleedings from an anterior communicating artery aneurysm that was ultimately clipped after two coiling attempts.

1. Patient 1
A man aged 50 years had subarachnoid hemorrhage from left internal carotid artery aneurysm (preoperative
WFNS 4, GCS 7, Fisher 3, right-sided hemiparesis). The ruptured aneurysm was complex (fenestration of
artery with two different aneurysms connected with each other and with two secondary sacs). Thick left
posterior cerebral artery originated only from left internal carotid artery. Endovascular treatment was not
possible according to an experienced endovascular radiologist. There was also fenestration in basilar artery but
without an aneurysm.
During surgery both aneurysms were clipped with one 20 mm long clip and both posterior cerebral and anterior
choroidal arteries remained open. Proximal part of aneurysm complex and proximal secondary sac were point
of rupture.
Patient recovered gradually from severe bleeding to an independent state without hemiparesis or dysphasia and
he obtained a shunt. There were no ischemic lesions visible on CT scan. Next year I operated on his mirror
aneurysm on right side. His condition has been favorable after a severe bleeding and two operations.
Preoperative images:

2. Postoperative images:

3. Patient 2
A woman aged 29 years had subarachnoid hemorrhage from left middle cerebral artery aneurysm and was
previously operated on by another neurosurgeon. Fourteen year later she had a new subarachnoid hemorrhage
from a de novo aneurysm located in right middle cerebral artery which was coiled and the treatment remained
permanent.
Next year simultaneously with an angiographic control of coiled aneurysm, left carotid angiography was also
done. This revealed that fifteen years previously clipped aneurysm had recurred showing the clip on the
aneurysm edge. The complicated aneurysm had a secondary sac and endovascular treatment was not possible.
Previously ruptured and clipped thin-walled aneurysm was attached to skull base and had a fibrous scar around.
During surgery aneurysm was sharply prepared from scarred tissue and clipped finally with three additional
clips. The patient recovered well and was able to work. Postoperative CT showed no ischemic lesions.
Postoperative and follow-up carotid angiograms two years later showed that treatments remained permanent
and no further follow-up was needed.
Preoperative image (left) and postoperative ones (next two):

4. Patient 3
One and four years before the surgery, a woman aged 44 years had two subarachnoid hemorrhage episodes
from an anterior communicating artery aneurysm filled mainly from left side. After both bleeding episodes
aneurysm was coiled. After the second rupture and coiling the aneurysm started to refill and coiling was no
more possible. During the left-sided pterional surgery aneurysm was prepared from chiasma, sphenoid planum,
arteries and old scars caused by previous bleedings and clipped which was confirmed in postoperative
angiography. No ischemic lesion was visible on postoperative CT scan. The patient recovered well and was
able to work.
Preoperative images:
After the first bleeding (left) and the first coiling (right):
After the second bleeding (left) and the second coiling (right):

5. Before surgery (left) and after surgery (nest two images):

6. Image during surgery (previously coiled twice ruptured aneurysm after clipping between both optic nerves,
chiasma, sphenoid planum and anterior communicating artery):

7. Patient 4
A woman aged 47 years had headache, hyperesthesia in the region of the first and second branches of left
trigeminal nerve and dysphagia. The reason of symptoms was a tumor originating from medulla oblongata and
filling the forth ventricle (size 5*3 cm). During a craniotomy, the tumor was radically removed from medulla
oblongata and PAD was Ependymoma gr II. After surgery dysphagia and ataxia transiently worsened but the
patient returned to home in an independent state. During a three-year follow-up tumor has not recurred.
Preoperative images:

8. Postoperative images:

9. Patient 5
A woman aged 68 years had a giant (max 10 cm in diameter) destructive skull base tumor causing severe visual
deficits, cognitive disorders, and hypopituitarism. Tumor was removed to a great extent through
transsphenoidal surgery. PAD was pituitary adenoma. Tumor has partially remained in ethmoid sinus and in the
rims of tumor cavity. In the center of cavity adipose tissue graft was placed.
Preoperative image (up) and postoperative one (below):

10. Patient 6
A woman was almost blind because of tumor which had destructed clivus and penetrated through a small hole
in dura and reached the pons. pituitary adenoma was removed with transsphenoidal surgery. Dura was closed
with a suture and cavity was filled with tissue glue and fascia lata. After surgery her vision became normal.
Preoperative image (up) and postoperative one (below):

11. Patient 7
A 25-year old male cook had a rapidly progressive impairment of vision (counting of fingers, <1m distance),
hypopituitarism and disorders from hypothalamus. MRI revealed a large cystic retrochiasmatic
craniopharyngioma (diameter 4.5 cm). Tumor was subtotally removed through pterional craniotomy. A small
cystic residual in the sella was later treated by stereotactic radiosurgery. After operation his vision improved
(0.7/0.7) and he returned to his previous job. His driving license was also returned from the authorities.
Preoperative images:

12. Postoperative images:

13. Patient 8
A man aged 59 years had very severe cognitive disorders, worst being memory difficulties. He had a large
craniopharyngioma (diameter 4 cm) filling the 3th ventricle which caused hydrocephalus and hypopituitarism.
After a shunt operation the tumor was totally/subtotally removed through a transcallosal route. In a
postoperative CT no tumor was seen and cognitive disorders gradually reduced. During waiting a follow-up
MRI at 5 months after surgery he unfortunately died because of bleeding shock caused by warfarin treatment.
Preoperative images:

14. Postoperative image:

15. Patient 9
A boy aged 2 months had impaired consciousness because of an increased intracranial pressure and
ophtalmoplegia. MRI showed a giant left-sided posterior fossa tumor between foramen magnum and tentorium
aperture attached to brain stem and cerebellum. After a shunt operation tumor was removed by microsurgery.
PAD was aggressive medulloblastoma. Postoperative MRI showed that tumor was totally removed (report of
neuroradiologist) and the symptoms eased. Because of a young age postoperative radiotherapy was not possible
to use and the patients received repeated courses of cytostatic drugs and finally survived for almost 1.5 years
until received a relapse in the pons and adjacent region.
Preoperative images:

17. Postoperative images: