Meningioma is a meningothelial (arachnoidal) cell neoplasm, typically attached to the inner surface of the dura mater. Most meningiomas are benign and correspond to WHO grade I. Certain histological subtypes or meningiomas with specific combinations of morphologic parameters are associated with less favourable clinical outcomes and correspond to WHO grade II, including chordoid, clear cell, and atypical meningiomas, and grade III, including papillary, rhabdoid, and anaplastic meningiomas. The treatment strategy for meningiomas is total removal. While benign meningiomas have recurrence rates of about 7-25%, WHO grade II meningiomas recur in 29-52% of cases and grade III meningiomas at rates of 50-94%. Thus, radiotherapy for grade II and III meningiomas after tumor removal may be needed.

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  Neurofibromatosis 2 (NF2) and von Hippel-Lindau Disease (VHLD) are the two most frequently encountered familial neoplastic diseases in neurosurgery practice. Both cause multiple neoplasms in neural and extraneural systems and the patients have to undergo multiple surgeries during their lifetimes, each of which harbors the risk of incurring neurological deficits. Optimal management requires knowledge on the natural course of the disease, which is essential to determine the timing and method of intervention. In addition, an understanding of the genetic mechanism at the molecular level helps the physician make a more detailed diagnosis and create better follow-up schedules for each patient. However, genetic diagnosis can also have a profound impact on patients and their family members, and therefore, we should closely follow the guideline.

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  Hitherto, surgical resection has been the best treatment for clinically non-functioning pituitary adenoma, because an effective drug is not available. In patients with growth hormone (GH), adrenocorticotropic hormone (ACTH) or thyroid-stimulating hormone (TSH) producing pituitary adenomas, the first-line treatment is surgical intervention too. However, recent pharmacological treatment has proved effective against functioning pituitary adenomas. As certain recent dopamine agonists are very effective against prolactinoma, a pharmacological approach has become the first-line for treatment of prolactinoma. Dopamine agonists have high normalization rate of hyperprolactinemia ; however, its cure rate remains unsatisfactory.
 In acromegaly patients, a long-term surgical cure rate of ca. 70%. Therefore, a chemotherapeutic approach may play an important complementary role in achieving complete treatment of acromegaly. But the efficacy rate of somatostatin analog for acromegaly is ca. 70%. Pegvisomant can also control IGF-I levels ; however, complete cure of acromegaly has yet to be established.
 Cushing's disease, which is associated with high morbidity and mortality, is a life-threatening disease in patients where hypercortisolemia cannot be controlled. In cases where surgical treatment has failed, medical management is essential for reducing or normalizing—hypercortisolemia. Mitotane and methyrapone are effective drugs for hypercortisolemia ; however, a useful candidate for ACTH-producing pituitary adenoma has yet to be established.
 For aggressive pituitary tumors such as atypical pituitary adenoma and pituitary carcinoma, the use of temozolomide was attempted.

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  Treating skull base tumors require long-term tumor control and preservation of neurological functions. Malignant skull base tumors, such as cancers or sarcomas originating in the nasal or paranasal sinuses, are treated by en bloc resection with tumor-free margins. Five-year survival rates of en bloc resection have been 60∼70%. Analysis of long-term outcome is necessary to clarify the role of proton beam or heavy ion radiotherapies. Chordomas require surgical resection and high-dose radiation. Five-year survival rates have been 60∼80%. Radical resection including the surrounding bone is important for tumor control. Extended endonasal endoscopic surgery and proton beam or heavy ion radiotherapies could become standard treatments after confirmation of their long-term outcomes. Skull base meningiomas are currently treated using surgical resection and stereotactic radiotherapy. Precise planning of surgical procedures and the goals of tumor removal are important to obtain satisfactory surgical outcomes. Skull base meningiomas can be clinically malignant with invasive and rapid growing characteristics, quick recurrence, or malignant-transformation. Diagnosis of clinically malignant meningiomas might change surgical strategies in the future. Also, the timing of stereotactic radiotherapy (immediately after surgery vs. after confirming remnant tumor growth) has been controversial. Consequently, the analysis of long-term outcomes (more than 10 or 20 years) of stereotactic radiotherapy is mandatory to elucidate the best timing and possibility of malignant transformation or second cancer formation.

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  Particle radiation therapy using proton or carbon beams is an emerging new treatment modality for skull base tumors such as chordomas, chondrosarcomas, and meningiomas, as well as for photon-resistant malignant brain tumors. Recent advances in beam-delivery systems, research into the biological and molecular mechanism of radiation-induced bystander effect, local tumor recurrence, metastasis, and late radiation injury are all important issues for future development and clinical application of particle radiation therapy.

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  Chronic subdural hematoma is one of the most common diseases encountered in neurosurgical practice. Although the treatment method is well established, the factors associated with recurrence are not understood.
  To identify the risk factors for recurrence, we compared the clinical features of two groups of patients : patients with recurrence (recurrence) and those without recurrence (non-recurrence). The study included 662 adult patients (769 operation cases) who had undergone a burr-hole surgery between January 2000 and December 2010. The recurrence factors were retrospectively analyzed, and the primary endpoint was defined as the time at which recurrence warranted re-drainage.
  The recurrence factors were age (more than 70 years), days from trauma to operation (more than 70 days), bilateral hematoma, bilateral operation, density on preoperative computed tomography scans (niveau), volume of preoperative hematoma (more than 80 ml), and hematoma cavity reduction ratio.
  We concluded that the re-expansion of the brain postoperatively was the factor that was most closely associated with recurrence. Our results indicate that neurosurgeons may need to wash out hematomas and prevent air invasion of the subdural space during operation to reduce the possibility of recurrence.

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  A 20-year old woman suffered left facial trauma from a bicycle accident and was admitted to our hospital for observation due to persistent nausea and vomitting. Neurological examination on admission was normal. On the third hospital day she abruptly complained of severe left visual disturbances (corrected visual acuity : 0.08, constriction of visual field). The patient was diagnosed with traumatic optic neuropathy and the symptoms improved after a course of steroid pulse therapy. Cranial CT and MRI were unremarkable except for a small fracture on the left postero-lateral orbital wall with no evidence of optic canal fracture. Normal findings on fundoscopy and fluorescent angiography suggested posterior optic nerve injury. Traumatic optic neuropathy with delayed onset is very rare. A review of the literature and discussion of the mechanisms of injury are presented. It is important to bear in mind that even a small fracture near the optic canal can be a warning sign for such unexpected ophthalmological aggravations as this case.

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  We report a case of acquired tracheoinnominate artery fistula (TIF) at 6 months after tracheostomy in a 78-year-old woman. She had massive hemorrhage from the stoma when the tracheostomy tube cuff was deflated. The hemorrhage was temporarily controlled by hyperinflating the cuff. Contrast-enhanced computed tomography (CT) angiography revealed TIF. The patient died the next day because of massive rebleeding.
  TIF, a highly fatal complication of tracheostomy (incidence rate, 0.1%-4%), mostly occurs within 48 h to 4 weeks after tracheostomy. TIF usually results from erosion of the tracheal and innominate arterial walls by the tracheostomy tube cuff or tube tip. The risk factors for this condition include high intracuff pressure, mucosal trauma caused by malpositioned cannula tip, low tracheostomy, and deformity and shifting of the trachea and major blood vessels. Although the complication cannot be completely prevented, it may be avoided by creating the stoma at the second to third tracheal cartilage or appropriate management of intracuff pressure. Minor tracheal bleeding, also called “sentinel bleeding,” is an early sign of TIF ; if noted, the cause of bleeding should be immediately confirmed by bronchoscopy or CT, and suitable interventions should be initiated. Thus, TIF is a life-threatening condition and is a risk that should be considered in tracheostomy management.

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