Multiple intracranial aneurysms (AIM) are relatively common, occurring in approximately 23% of all patients with aneurysms. The risk factors include female gender, hypertension, smoking and family history possibly intracranial aneurysms or cerebrovascular disease. The ruptured aneurysm location can be determined with a high accuracy rate with digital angiography when used in conjunction with computed tomography (CT) and magnetic resonance (MR). The average breakdown of untreated multiple aneurysms is between 1 and 2.2%. The critical size associated with significant risk of bleeding was 7 mm. Multiple aneurysms occur most often along the internal carotid artery (ICA) and the bifurcation of the middle cerebral artery (MCA). After bleeding is of any of the aneurysms, you must diagnose what was it bled, and which should be the first to be clipped, this is important especially when all aneurysms can not be clipped with a single approach. Most multiple intracranial aneurysms of the anterior circulation can be clipped by fronto-temporo-sphenoid approach; inclusive aneurysms on the contralateral side.Also, the development of new endovascular techniques (use of hidrocoils, bioactive coils, onyx, remodeling techniques with balloon or stent aneurysm single or double), permit more satisfactory treatments, including combining both techniques.
Conclusion: Multimodal approaches combining microsurgical and endovascular treatment, have been used successfully in cases of multiple cerebral aneurysms.

We report our experience with LINAC stereotactic radiosurgery for tumors of the skull base: 32 patients (21 meningiomas and 11 acoustic neurinomas) tracked over 20 months between November 2004 and July 2010. 17 received before radiosurgery, surgical treatment with partial tumor resection. With a median of 32 months after radiosurgery, tumor control is evident in 97% of cases, including 10 cases had tumor regression and tumor necrosis 12, making 22 cases with frank tumor regression. 9 patients remain under observation with no change in tumor size but incipient necrosis. A patient with acoustic neuroma showed tumor growth at 36 months of observation for which he received a second treatment with radiosurgery. Among the functional effects of radiosurgery., 9 of the 10 patients with trigeminal neuralgia were recovered, 2 of 3 cases with oculomotor nerve paresis and 1 patient with ptosis recovered normal ocular motility. A patient with neurofibromatosis 2 deaf evolved despite its tumor regression. Benign tumors of the skull base have their personalized treatment option, either as primary therapy after subtotal resection or recurrence, radiosurgery is the best choice because it provides high rates of regression with control or low risk of complications.

Trigeminal neuralgia is classically described as one of the most severe facial pain syndromes. Usually it is defined as a paroxysmal, lancinating, electric-type pain, recurrent and usually unilateral, in the distribution of one or more divisions of the trigeminal nerve. Typical trigeminal pain is characterized by intermittent, generally with periods of exacerbation and remission. The annual incidence of this pathology varies between 4 and 13 per 100, 000 individuals. The male:female ratio is 1:1.5. Although cause of trigeminal neuralgia is idiopatic, exist cases associated to compression of the trigeminal nerve by a vascular structure or tumors. Epidermoid cysts are tumors of embryological origin that are located in cerebellopontine angle in third place after schwannomas and meningiomas. Three cases of trigeminal neuralgia in relation to epidermoid cysts of the cerebellopontine angle compressing the trigeminal
nerve are presented. Clinical presentation, diagnostic studies, surgical treatment and postoperative results are discussed. 
 

Key words: Trigeminal neuralgia, trigeminal nerve, epidermoid cyst, neuropathic pain, cerebellopontineangle.

The dysplastic giant aneurysm with wide neck is a difficult complex aneurysm surgery, the use of endovascular therapy in this pathology is promising and waffle cone technique is very useful in those in wich when we use a Stent and it is impossible to exceed the distal end of the aneurysm neck. A woman patient of 73y,  housewife with disease duration of 5 days, headache associated with neck stiffness and cranial nerve VI paresis of the left was studied. The brain CT showed subarachnoid hemorrhage in the left sylvian valley and an image suggestive of a giant aneurysm of left carotid siphon. The angiographic study concluded giant-ophthalmic aneurysm ruptured left and right paraoftálmic large aneurysm not broken.

The treatment of choice for aneurismal disease is still under discussion, but in the case of giant aneurysm endovascular techniques may achieve optimal results without major complications, endovascular technique waffle cone through the use of Stents is very useful and should extend its use in those dysplastic giant aneurysm with wide neck do not allow the stent to achieve beyond the distal aneurismal neck and both nest in the pouch is able to embed a Neuroform Stent-in the neck of the aneurysm to proceed to use coils of different dimensions to completely embolize the aneurysm. The disadvantages of this technique are the potential for drilling and higher rate of recanalization caused by changes in arterial blood flow. Waffle cone technique is particularly useful in those dysplastic giant aneurysms with wide neck in wich the structure of the aneurysm does not allow the location of the stent at the distal end of its neck.

Subarachnoid hemorrhage (SAH) is defined as the presence of blood in the subarachnoid space and cisterns of the base. The source is variable and may be due to rupture of intracranial aneurysms (80%), arteriovenous malformations (AVMs), tumors and trauma cranoencefálicos. The HSA is a relatively common disease with an incidence is 5% of cerebral vascular disease. The estimated prevalence of 10 new cases per 100,000 people each year. The proportion of HSA varies with age, being the most prevalent group between 50 and 60. It is a pathology with high morbidity and mortality, since a high percentage of patients (10-15%) did not reach the hospital and the remaining group of about 15% die. Angiography is the standard diagnostic procedure, although angiography is an important alternative. Treatment should be administered as soon as possible within 72 hours, both surgical and endovascular techniques to prevent complications such as rebleeding, vasospasm and hydrocephalus, being the most widely used surgical approach is the pterional craniotomy. The prognosis depends on careful handling and the degree of the initial hemorrhage.

          Key words:  Subarachnoid hemorrhage, Intracraneal aneurysm, Craniotomy.