A brain aneurysm may grow over time because of the persistent pounding of the blood and increasing pressure inside the sac. If the aneurysm sac expansion reaches a critical point where the wall becomes too thin, the aneurysm may rupture, leading to a devastating stroke, also known as subarachnoid haemorrhage. Many small unruptured brain aneurysms can be safely monitored without needing neurosurgical or endovascular treatment. However, it is well established that aneurysm growth (while being watched) is associated with an increase risk of rupture. In the current case, this 65 year old patient was initially diagnosed with a small brain aneurysm 3 years prior. With serial and close radiological follow up, we detected a significant increased in size of the aneurysm. Despite her age and overall low risk profile (non-smoker, no family history of brain aneurysm), treatment was recommended given the perceived greater rupture risk. Surgery with clip occlusion was preferred due to the wide-neck morphology of this brain aneurysm, obviating the need for endovascular stent placement and requirement for long-term anti-coagulation and the risk associated with this treatment modality.

Surgical decision-making in patients with acutely ruptured brainstem cavernomas can be difficult and requires delicate consideration between the risks and benefits of intervention. The natural risk of further bleeding with subsequent neurological deficits must be weighed against the risk of the surgery, given the highly eloquent function of the brainstem. In general, conservative management should be recommended in patients who are asymptomatic with a small bleed. Surgery may be considered for those who became symptomatic, with accessible lesions, repeated bleeding and/or neurological decline. In this video demonstration, a 32 year old man presented with recurrent bleeding of a brainstem cavernoma. This was initially managed conservatively, but the patient represented 2 weeks later with a further devastating bleed, rendering him weak on one side (hemiparesis). Surgery was, therefore, performed to relieve the pressure in the brainstem and to prevent further bleeding from the cavernoma. The patient had made an excellent clinical recovery following the surgery and was discharged home on day 3 postoperative period without neurological deficit.

Meningioma is a type of benign brain tumour that develops from the membrane that surrounds the brain and spinal cord. Most meningiomas (90%) are considered benign (or non-cancerous) and grow slowly over time. However, the word "benign" can be misleading, as some tumours arise from "tricky" locations that constrict and affect the brain, leading to disability and even life threatening symptoms. Petroclival meningiomas are one such type of lesions. These tumours arise from the base of the skull in the upper two thirds of the clivus. When they grow, they often displace the brain stem and the basilar artery to the opposite side, and can lead to slow progressive neurological problems over time. In this video demonstration, a young patient had presented with double vision due to compression of one of the cranial nerves. Surgery was performed to relieve the pressure from the nerve and the brainstem.

Metastatic brain tumours (a.k.a. secondary brain tumours) are cancers that begin somewhere else in the body then spread to the brain. The most common types of cancer that can spread to the brain are cancers of the lung, breast, skin (melanoma), colon, kidney and thyroid. In Australia, we have a very high incidence of melanoma and so there is a high rate of metastatic melanoma to the brain. In recent years, the incidence of metastatic brain cancer has increased due to a growing aging population, improved treatment for primary disease and increasing surveillance of patients with cancer. Treatment generally involves a combination of surgery, radiotherapy and drug treatment (chemotherapy, which are different for different cancers). Treatment options are complex and the decision relies on discussion among various specialists (neurosurgeons, radiation oncologists, medical oncologists) to determine the best course of action. In the current case, an elderly patient presents with significant stroke like symptoms from a large metastatic brain tumour from the lung.

A brain arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting arteries (high pressure system) to veins (low pressure system) in the brain. Rupture of a brain AVM is not common. Each year, around 1 to 3 individuals for every 100,000 Australians are affected. Bleeding may be large or small, and depending on the extent and location of the bleed, the outcome may be slight, disabling or fatal. Most bleeding occur at a young age (mean age 34 years), with no significant differences in gender predilection. Once a brain AVM has ruptured, the risk of further bleeding increases, and is estimated to be between 6.2 and 15.4% in the first 12 months. Over time, the risk gradually decline and return to baseline (2.2% risk of bleeding each year) in the following years. A bleeding AVM is a neurosurgical emergency and requires immediate medical attention. The objective of treatment is to prevent further complications by limiting bleeding, controlling raised pressure inside the head, controlling seizures, and if possible, removing the AVM. The expected outcome varies. Around 1 in 10 patients will die as a result of brain AVM rupture. For those who survived the initial bleed, the risk of developing a disabling stroke is around 60%. In this video, a middle-aged patient presents with moderate degree of bleeding in the brain from a ruptured brain AVM. We performed surgery within the same hospital admission to remove the AVM to eliminate the risk of further bleeding.

Meningioma that arise from the lining at the base of the skull is not common. They are typically non-cancerous and slow-growing, and many tumours in this location do not require treatment. Most tumours can be safely managed with regular radiological surveillance or treated with radiation therapy. Occasionally, a skull base meningioma may continue to grow despite appropriate conservative management. They can become quite large and press on nearby structures such as brain tissue, nerves or blood vessels causing neurological symptoms. In this video, a middle-aged patient has developed gradual eye symptoms on the side of the tumour due to progressive growth, causing deteriorating and double vision, and a bulging eye (proptosis). This video demonstrates a typical case of surgery to remove a large skull base meningioma located in the cavernous sinus.

Acoustic neuroma is a type of non-cancerous (benign) brain tumour that grows in the canal connecting the brain to the inner ear. It is also known as vestibular schwannoma. Without treatment, important nerves (including the hearing, facial and balance nerves) can be affected and the growing tumour may eventually affect the brainstem. Acoustic neuromas are not common. Each year, more than 300 Australians are diagnosed with acoustic neuroma. Most cases develop in individuals between the ages of 30 and 60 years. The average growth rate of this type of tumour is 1 to 2 millimeters each year, but it can vary, with periods or more or less growth. Watchful waiting can continue for years, and some people may never require treatment. Occasionally, surgery may be required to remove an acoustic neuroma if the tumour is 1) continuing to grow during surveillance, 2) diagnosed at a very large size or 3) causing significant pressure on the brainstem. This video demonstrates a standard case of acoustic neuroma surgery in a young patient with early brainstem compression after years of watchful waiting.

In Australia, around 1800 cases of malignant brain tumours are diagnosed each year. Of these, only one fifth can survive beyond 5 years from the time of diagnosis. Complete removal by surgery is not possible due to where and how these tumours infiltrate brain tissue. The current standard of treatment (surgery, chemotherapy and radiotherapy), although not perfect, has resulted in more people living beyond two, three, four years or even longer. The goal of surgery is to remove as much of the tumour as possible for tissue diagnosis, to reduce tumour burden and to help control patients symptoms. This video demonstrates a standard case of surgery for removing a malignant brain tumour.