Surgical approaches to the orbit differ depending on the surgical specialty. Neurosurgical approaches consider the posterior two-thirds of the orbit and can be summed up as the superior, lateral, and superolateral approaches. Orbital rim removal enlarges the exposure when necessary. Each neurosurgical approach is described in this chapter. Schematically, subfrontal approaches are used to reach the inner quadrant orbital tumors and the others to access external quadrant tumors. Nevertheless, the choice of the approach is discussed regarding to the presumed pathologic preoperative diagnosis.

Interdisciplinary collaboration can offer unusual approaches for the treatment of orbital pathologies. The authors report their experience with the eyelid incision in treating three children with epidural orbitary hematoma, dermoid cyst of the upper outer quadrant and a dermoid cyst of the internal inferior quadrant. For all the children, removal was complete and cosmetic results satisfying. The authors discuss the indications and complications of this surgical approach.La collaboration interdisciplinaire permet de proposer des voies d’abord inhabituelles en neurochirurgie pour traiter la pathologie orbitaire. Les auteurs rapportent leur expérience de l’abord trans-palpébral chez trois enfants présentant un hématome traumatique, un kyste dermoïde du quadrant supéro-externe et un kyste dermoïde du quadrant inféro-interne. Dans tous les cas, l’exérèse a pu être complète et le résultat esthétique très satisfaisant. Les auteurs discutent les complications et les indications de cette voie d’abord.

In this chapter, we report the results of orbital tumor management in a few neurosurgical departments and compare it to a Paris neurosurgical department that has developed a close relation with an ophthalmological department. These departments' activity is quite low, treating mainly sphenoorbital meningiomas. Other tumor groups are unequally and sporadically managed.

Vascular tumors of the orbit include capillary hemangioma, cavernous hemangioma, hemolymphangioma, hemangiopericytoma and a few rare tumors. Capillary hemangioma and hemolymphangioma, occurring mainly in children, are covered in the chapter devoted to childhood tumors. In this chapter, cavernous hemangioma and hemangiopericytoma are discussed as well as rare vascular tumors. Although orbital varix is not a tumor, it is also considered because of the diagnostic problems and the close correlation of orbital varix with a true tumor: hemolymphangioma.

Nous rapportons le cas d’une patiente de 56 ans qui vint consulter pour une masse de la glande lacrymale principale gauche avec signes inflammatoires, discrète exophtalmie et douleurs. L’imagerie au scanner montra une hyperdensité dans la loge lacrymale gauche. Une surveillance de 9 mois fut effectuée ; aucun traitement anti-inflammatoire ne put être appliqué en raison d’ulcères digestifs en évolution. Au terme de cette surveillance, une exérèse monobloc par voie antérolatérale permit l’analyse histologique de la pièce qui conclut à un adénome pléomorphe. Ce cas démontre l’intérêt d’une approche chirurgicale suffisamment large de toute masse de la glande lacrymale pour éviter toute effraction capsulaire, source potentielle de récidive tumorale. A 56-year-old female patient displayed an increased volume of her left lacrimal gland with pain and inflammation. On CT scan, a hyperdense lacrimal mass was found in the left lacrimal fossa. Observation was the first course, for no steroid therapy could be applied because of evolving digestive ulcers. After 9 months of observation, the gland was surgically removed en bloc through a wide anterolateral approach. Pathological analysis of the gland showed a pleomorphic adenoma. This case illustrates the advantage of a wide surgical approach in treating lacrimal gland tumors, in order to avoid or limit the risk of recurrence.

A 56-year-old female patient displayed an increased volume of her left lacrimal gland with pain and inflammation. On CT scan, a hyperdense lacrimal mass was found in the left lacrimal fossa. Observation was the first course, for no steroid therapy could be applied because of evolving digestive ulcers. After 9 months of observation, the gland was surgically removed en bloc through a wide anterolateral approach. Pathological analysis of the gland showed a pleomorphic adenoma. This case illustrates the advantage of a wide surgical approach in treating lacrimal gland tumors, in order to avoid or limit the risk of recurrence.

Cavernous hemangioma is the most common primary vascular orbital tumor in adults. Generally the benign tumor arises within the muscle cone, revealed by proptosis with choroidal folds, and more rarely develops in other orbital localizations. We report the case of a 42-year-old female African patient who had a cavernous hemangioma in an unusual anterior localization. Clinically, a small superficial tumor was palpated in the right superior nasal orbital angle. After complete surgical excision, the histopathological study established the diagnosis of cavernous hemangioma

A 29-year-old female patient displayed a dense and hard left orbital mass, inferiorly, 3 years after she was treated through a neurosurgical approach for a left orbital varix. The lesion was hyperdense on CT-scan and was removed through a trans-conjunctival approach, with an excellent result. The histological diagnosis was a phlebolith.

Cavernous hemangioma is the most common primary Vascular orbital tumor in adults. Generally the benign tumor arises within the muscle cone, revealed by proptosis with choroidal folds, and more rarely develops in other orbital localizations. We report the case of a 42-year-old female African patient who had a cavernous hemangioma in an unusual anterior localization. Clinically, a small superficial tumor was palpated in the right superior nasal orbital angle. After complete surgical excision, the histopathological study established the diagnosis of cavernous hemangioma

A 29-year-old female patient displayed a dense and hard left orbital mass, inferiorly, 3 years after she was treated through a neurosurgical approach for a left orbital varix. The lesion was hyperdense on CT-scan and was removed through a trans-conjunctival approach, with an excellent result. The histological diagnosis was a phlebolith.

The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. We report on a series in which both techniques were applied.From September 1992 to June 1996, 395 consecutive patients with small or large aneurysm were treated either by surgery (N = 102) or by endovascular coiling (N = 293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third.Satisfactory results with complete or subtotal obliteration and no recanalization on the following controls at 1, 6, 12 and 36 months, were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfactory results were observed after surgery in 7 cases and in 25 cases after embolization. After retreatment, it remains 3 post-surgical and 2 post-endovascular cases.In the overall series, good and excellent clinical outcome was noted in 90% for small aneurysms and in 86.5% for large ones; mortality was of 4.8%.In a series in which were applied both types of treatment, surgery in 25% and endovascular technique in 75%, good results in terms of aneurysm occlusion and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, endovascular treatment is a good alternative for treatment of the majority of saccular aneurysms.

The conventional lateral approach to the orbit (Krönlein) does not allow a satisfactory view of the superior part of the orbit and the operative field is rather narrow. Therefore, large tumors which have developed not only laterally but also superiorly are usually approached transcranially. The craniotomy and exposure of the dura may be avoided when the tumor does not extend too far posteriorly and medially, by turning a larger orbital bone flap than the Krönlein's one. This technique was described by Nakamura as “type I orbitotomy” and can be referred to as a superolateral approach. After a bicoronal skin incision, a free orbital bone flap is cut. It includes the lateral orbital rim, a large external part of the superior orbital rim, and the lateral orbital wall. From 1985 to 1990 this approach was performed on 23 patients presenting with lacrimal gland tumors in 14 cases (11 pleomorphic adenomas, 2 adenoid cystic carcinomas, 1 adenocarcinoma), schwannomas in 2 cases, dermoid cyst in 1 case, hydatic cyst in 1 case, cavernous hemangiomas in 2 cases, inflammatory Pseudotumor in 1 case, and mucoceles in 2 cases. This superolateral approach provides a wider exposure to the superolateral orbit than the classical Krönlein's approach and avoids the drawbacks of a craniotomy. A direct incision through the eyebrow can be used for bald people or for patients in poor condition.

Cavernous hemangioma is one of the commonest primary orbital tumors. Painless and progressive reducible unilateral proptosis causing a variable degree of hyperopia is the usual clinical presentation. The case of a 39-year-old-female patient is reported. The clinical presentation was unilateral left axial proptosis with acquired hyperopia. Imaging studies showed a well circumscribed mass in the orbit, a superior neuro-surgical approach allowed complete resection of the tumor, and histopathology revealed the diagnosis of cavernous hemangioma.

Cavernous hemangioma is one of the commonest primary orbital tumors. Painless and progressive reducible unilateral proptosis causing a variable degree of hyperopia is the usual clinical presentation. The case of a 39-year-old-female patient is reported. The clinical presentation was unilateral left axial proptosis with acquired hyperopia. Imaging studies showed a well circumscribed mass in the orbit, a superior neuro-surgical approach allowed complete resection of the tumor, and histopathology revealed the diagnosis of cavernous hemangioma.

Seventy-one intracranial aneurysms were treated by endovascular techniques, with the placement of minicoils inside the aneurysmal sac. Most aneurysms were manifest by hemorrhage (67 cases), and 43 of these were treated within the first 3 days after presentation. At the 1-year follow-up examination, the outcome was scored as good in 84.5% of cases, but the morbidity and mortality rates were 4.2% and 11.3%, respectively. Twenty-nine aneurysms in the anterior circulation and 42 in the posterior circulation were treated. In this series, 23 patients were classified as Hunt and Hess neurological Grade I, 27 as Grade II, 12 as Grade III, nine as Grade IV, and none as Grade V. Thirty-three aneurysms were less than 10 mm in diameter, 28 were 10 to 25 mm, and 10 were larger than 25 mm. The preliminary results from this study appear to justify the emergency treatment of aneurysms by this approach. Aneurysms in the posterior circulation are particularly well suited for this type of surgery.