World Neurosurgery

The Right Stuff

Michael L.J. Apuzzo — 2011-12-01

Many decades ago, on the occasion of my very first residency interview, Joseph Evans, the Professor and Chairman of Neurosurgery at the University of Chicago, said, “So, you want to be a neurosurgeon. Are you tough in mind and body?” To a certain extent, this remark captured the essence of our requirements of involvement.

Enhancing the Utility of Surgical Simulation: From Proficiency to Automaticity

Addason F.H. McCaslin, Salah G. Aoun, H. Hunt Batjer, Bernard R. Bendok — 2011-12-01

Over the past decade, surgical simulation has been promoted as an efficient way of acquiring and refining surgical skills. Although surgical simulation has been shown to improve technical proficiency and manual dexterity, currently available models do not guarantee the transferability of expertise to the operating room (OR) (). This fact may be related to distractions and unpredictable events within real operations, and to the fact that simulation protocols aim for “proficiency” in their evaluations. Proficiency is defined by reductions in technical error and time-related variables and does not account for the levels of concentration and physiological stress required to perform a given task (). Recognizing the impact of these factors on surgical performance, Stefanidis et al., from the Carolinas Simulation Center in Charlotte, North Carolina, have hypothesized that achieving “automaticity” may enhance the transfer of skills to the OR. Automaticity, defined as the ability to multitask during surgery, enables the operator to successfully overcome unpredictable events and emergencies that cannot be easily simulated. It allows the proficient execution of a task despite external interferences or unpredictable stimuli. The concept of going beyond proficiency toward automaticity has not yet been well studied in currently available simulation protocols. This approach could theoretically improve technical skill transferability to real surgery and potentially decrease the number of surgical errors.

Traumatic Intracerebral Hemorrhage—To Operate or Not?

Richard Francis, Elise N. Rowan, Barbara A. Gregson, A. David Mendelow — 2011-12-01

When a neurosurgeon is presented with bleeding onto the brain surface (extradural or subdural hematomas), the decision about what to do is usually clear cut; however, when a patient experiences a head injury that has caused bleeding inside the brain, the choice of action is not always straight forward. When the head injury patient has few and small bleeds and their eye, motor, and verbal abilities (as measured using the Glasgow Coma Score [GCS]) are good, it is more likely that they will be treated conservatively, with medication and observation. However, when there are multiple or large bleeds into the brain itself and GCS is poor, it is more likely that the bleed and surrounding contusion will be surgically removed (contusionectomy). When a patient's symptoms and pathology are not at either extreme, the best course of action is unclear. The Surgical Trial in Traumatic Intracerebral Haemorrhage (STITCH [Trauma] trial) is currently investigating this dilemma and has recruited its hundredth patient (on September 14, 2011), with a final target of 840 patients.

Epidermal Electronics

Nikolay Martirosyan, M. Yashar S. Kalani — 2011-12-01

The field of nanotechnology offers much promise for biomedical applications. One potential application of nano-scaled biomaterials is in monitoring of physiological processes. Monitoring of neurological function is currently limited to electrode recordings of brain waves. The recording electrodes used in neuro-monitoring date back to the 1920s. Although wire recordings have shown reliability, they are cumbersome to use, and several complications, including infection, allergic reactions, and skin irritation, have been associated with their use. In a recent issue of Science, Kim et al. () reported on a novel class of materials named “epidermal electronics” that remedies many of the shortcomings of the classic wire recording. The unique construct reported by this group allows for incorporation of electrodes, electronics, power supply, and sensor and communication module into a thin, elastic, skin-like membrane. The innovative design contains all of the necessary components of a monitoring electronic in an ultra-thin layer, roughly the thickness of a human hair. The material can be applied to skin with a soft touch and removed conveniently. One of the advantages of this electrode is its ability to contour to the skin and remain in place for an extended period without causing discomfort to the patient. This device has been successfully utilized for electroencephalography, electrocardiography, and electromyography. Epidermal electrodes enable intimate, mechanically “invisible,” tight, and reliable attachment of high-performance electronic functionality with the surface of the skin in ways that bypass the limitations of previous approaches. This new class of material promises to be a viable and low-cost alternative to classic recording wires and electrodes and will likely find clinical use in neurosurgery. ().

Luigi Maria Cavallo, Domenico Solari — 2011-12-01

With his book entitled Brains: How They Seem to Work, Dale Purves provides readers with an astonishing overview of the main aspects of neurobiology and of the main organ of this branch of science, the brain. Purves does not attempt to detail the sophisticated mechanisms that stand behind the curtain of such a perfect clockwork as the brain or the technical aspects of neurobiology as a science. What he sheds light on is the extraordinary variability of aspects that define a scientific field and the numerous routes that could lead to the final point. The main topic, the brain, is a perfect example to be considered as the focus.

Upcoming Events

2011-12-01

JANUARY 25-27, 2012, Microscopic and Endoscopic Approaches to the Skull Base, Strasbourg, France

The Visual Dimensions of Future Neurosurgical Education

Jon H. Robertson, Jeffrey M. Sorenson — 2011-12-01

In the book by the acclaimed writer and neurologist Dr. Oliver Sacks, entitled The Mind's Eye, he has written a chapter devoted to the phenomenon of stereopsis and notes that perhaps 5% to 10% of the population has little or no stereoscopic vision (). Dr. Sacks discusses the case of Susan Barry, a woman who was born with strabismus and lacked binocular vision. Because she had very poor depth perception, her visual world was two-dimensional, as if she were looking at a photograph. In her 50s, she trained herself to develop stereopsis by forcing her eyes to align through repeated exercises. Barry described her experience of acquiring binocular vision like it was an epiphany: In the past the snow would have appeared to fall as a flat sheet in one plane slightly in front of me. I would have felt like I was looking in on the snowfall. But now, I felt myself within the snowfall, among the snowflakes … as I watched, I was overcome with a deep sense of joy … I could see the space between each flake, and all the flakes together produced a beautiful three-dimensional dance … ().

Dissecting a Complex Neurosurgical Illustration: Step-by-Step Development

Ian Suk — 2011-12-01

Modern computer graphics software has enabled the medical illustrator to render very complex anatomy by composing many different layers of drawings simultaneously. This and the author's capacity to take an “editorial” approach to compress several chronological events into a single, comprehensive two-dimensional illustration are analyzed in a step-by-step process. Through a series of images, the article provides a visual synopsis of the development of an illustration for an extensive clinical case: total sacrectomy performed through an all-posterior approach. Originally given as a slide presentation at the American Association of Neurological Surgeons Theodore Kurze Lecture in April 2011, the article provides some detailed notes on the techniques the author used to develop a comprehensive neurosurgical illustration.

Ein Heldenleben: A Life in Neurosurgery

Michael L.J. Apuzzo — 2011-12-01

There are many exciting and noble professions, but the gravity and concept of a life in neurosurgery is clearly in its own category of elite status. It is a life of involvement with the dramatic events of life and death and a terrible gray area in between, where lives are disrupted and emotional pain is intense. It is, by any measure, an extraordinary calling.

Avoiding (and Reporting) Complications: When Nerves Pay a Price

Eric L. Zager — 2011-12-01

Skoro et al. are to be commended for publishing an unpopular but important type of report—a devastating surgical complication. They have performed a valuable service so that surgeons and patients are properly informed about the realistic risks of surgical procedures. It is well recognized that the surgical literature suffers from a general tendency to underreport complications, and this may be particularly true of new and exciting innovations. In general, the authors of the largest series in the literature have the greatest experience with the new techniques and often participated in their development. Most surgical series report outcomes that have been assessed by the surgeons themselves so that reporter bias may be a significant factor. Thus, the efficacy and safety data reported for a new procedure may not apply when the technique is practiced more widely by less-experienced surgeons.

Neuroethical Principles of Deep-Brain Stimulation

Morten L. Kringelbach, Tipu Z. Aziz — 2011-12-01

Results from translational neuroscience and novel neuroimaging methods have given us unprecedented insights into the fundamental mechanisms of the human brain. This new understanding has given rise to treatments and interventions for previously treatment-resistant disorders, perhaps most poignantly shown by the instant reversal of motor symptoms by deep-brain stimulation (DBS; e.g., see videos in supplementary material in Kringelbach et al. []). As such, DBS has been remarkably successful when applied to movement disorders such as Parkinson disease (), essential tremor (), and dystonia () and even to affective disorders such as chronic pain () and cluster headache ().

Shunts and Aneurysms

R. Loch Macdonald — 2011-12-01

Hoh et al. dredge the enormous patient numbers contained in the Nationwide Inpatient Sample to determine the incidence of ventricular shunt placement after neurosurgical clipping and endovascular coiling of ruptured and unruptured aneurysms. They also use this database to identify factors that are associated with shunting in these patients. Among 10,899 admissions for ruptured aneurysm, the incidence of shunting was about 10%, regardless of whether the patient underwent clipping or coiling. Shunting was more likely with increasing age, more associated medical illnesses, admission type, payor, and increasing number of patients with ruptured aneurysms treated at the hospital. Similarly, for 9686 unruptured aneurysms, the incidence of shunting was 0.5% and also not different for clipping or coiling. The only factors associated with shunting were medical illnesses and admission type.

Does Aneurysm Treatment Modality Influence the Incidence of Shunt-Dependent Hydrocephalus?

Stavropoula I. Tjoumakaris, Robert H. Rosenwasser — 2011-12-01

Hydrocephalus is one of the most common neurological disorders, with variable presentations in both adult and pediatric populations. Cerebrospinal fluid shunting is the single most common method for treatment of hydrocephalus, accounting for 70,000 hospital admissions in the United States annually (). Hydrocephalus is one of the long-term sequelae of subarachnoid hemorrhage (SAH) from a ruptured cerebral aneurysm. Bagley first suggested this concept in the 1920s by presenting the functional and organic alterations in the central nervous system caused by the presence of blood in the cerebral fluid (). The literature suggests that several factors influence the incidence of chronic hydrocephalus in SAH patients, such as age, Fisher grade, clinical presentation, aneurysm location, multiple aneurysms, meningitis, and treatment modality.

The Necessity of Preserving Brain Functions in Glioma Surgery: The Crucial Role of Intraoperative Awake Mapping

Hugues Duffau — 2011-12-01

Since several decades, the majority of series dedicated to gliomas (with the aim of studying both natural history and impact of treatments, in particular surgery) mainly focused on pure oncological considerations, especially progression-free survival and overall survival. However, the functional aspects received less attention. Recently, the quality of life (QoL) of patients with gliomas has increasingly been taken into consideration, in order to evaluate the benefit-to-risk ratio of therapeutic strategies.

Surgery for Glioblastoma Multiforme: Striking a Balance

Raymund L. Yong, Russell R. Lonser — 2011-12-01

Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults. GBM is composed of highly proliferative and infiltrative neoplastic cells that frequently invade eloquent areas of the cerebral hemispheres (), producing progressive neurological deficits and symptoms of increased intracranial pressure. When possible, surgical resection of GBMs after diagnosis is used to relieve mass effect, confirm the diagnosis pathologically, and set the stage for multimodal adjunctive therapy ().

The National Cancer Institute's SEER Registry and Primary Malignant Osseous Spine Tumors

Narendra Nathoo, Ehud Mendel — 2011-12-01

Malignant primary bone tumors of the spine are rare, accounting for less than 5% of all osseous neoplasms and less than 0.2% of all cancers (). Although significant advancements have been made on the surgical and medical management of these tumors, information to date on the pathological behavior, extent of local invasion, and survival patterns were derived from small institutional case series and controlled trials. Given that these tumors cause significant morbidity as the result of local invasion and destruction of adjacent structures with the potential to metastasize, Mukherjee et al. () used the Surveillance Epidemiology, and End Results (SEER) registry with its power of size and long follow-up to study a rare pathologic entity, i.e., common primary malignant osseous spinal tumors (osteosarcoma, chondrosarcoma, Ewing sarcoma, chordomas).

Trigeminal Neuralgia: Diagnosis and Treatment

Ronald Brisman — 2011-12-01

Trigeminal neuralgia (or tic douloureux) is a unique and severe form of face pain that neurosurgeons treat when pain is intractable to medical management. Trigeminal neuralgia is a clinical syndrome characterized by brief electric-like pains (intense, sharp, superficial, or stabbing) that may last up to two minutes. Pains are usually triggered by light touch about the mouth or face, such as with talking, eating, brushing the teeth, or washing the face. The pain is unilateral at any one time and is in the trigeminal distribution, usually the second and third divisions, either alone or in combination, or the second and first divisions and infrequently, the first division alone. Periods of spontaneous remission are characteristic.

The Putative Role of Pericytes in Tumor Angiogenesis

Jonathan J. Russin, Steven L. Giannotta — 2011-12-01

Hemangiopericytomas are rare tumors representing approximately 1% of all intracranial tumors and 2.4% of all tumors presumed to be meningiomas (). These tumors were initially classified as a vascular type of meningioma; however, subsequent investigations resulted in the World Health Organization recognizing hemangiopericytomas as a distinct clinicopathological entity in 1993 (). These tumors arise from pericytes, which are cells found at the periphery of microvessel walls and are involved in microcirculatory regulation, maintenance of the blood-brain barrier, endothelial cell regulation, and angiogenesis. Pericytes are found throughout the human body but are more frequent in the retina and brain. The pericyte-to-endothelia ratio is 1:100 in striated muscle versus 1:3 in the brain (). Pericytes are located outside of the microvasculature and are surrounded by the basal laminae, which separates them from the endothelium as well as the foot processes of astrocytes. They are most commonly found on precapillary arterioles, capillaries, and postcapillary venules ().

Deep Brain Stimulation and Ethics: Perspectives from a Multisite Qualitative Study of Canadian Neurosurgical Centers

Emily Bell, Bruce Maxwell, Mary Pat McAndrews, Abbas Sadikot, Eric Racine — 2011-12-01

Objective: Deep brain stimulation (DBS) is an approved neurosurgical intervention for motor disorders such as Parkinson disease. The emergence of psychiatric uses for DBS combined with the fact that it is an invasive and expensive procedure creates important ethical and social challenges in the delivery of care that need further examination. We endeavored to examine health care provider perspectives on ethical and social challenges encountered in DBS. Methods: Health care providers working in Canadian DBS surgery programs participated in a semistructured interview to identify and characterize ethical and social challenges of DBS. A content analysis of the interviews was conducted. Results: Several key ethical issues, such as patient screening and resource allocation, were identified by members of neurosurgical teams. Providers described challenges in selecting patients for DBS on the basis of unclear evidence-based guidance regarding behavioral issues or cognitive criteria. Varied contexts of resource allocation, including some very challenging schemas, were also reported. In addition, the management of patients in the community was highlighted as a source of ethical and clinical complexity, given the need for coordinated long-term care. Conclusions: This study provides insights into the complexity of ethical challenges that providers face in the use of DBS across different neurosurgical centers. We propose actions for health care providers for the long-term care and postoperative monitoring of patients with DBS. More data on patient perspectives in DBS would complement the understanding of key challenges, as well as contribute to best practices, for patient selection, management, and resource allocation.

Incidence of Ventricular Shunt Placement for Hydrocephalus with Clipping versus Coiling for Ruptured and Unruptured Cerebral Aneurysms in the Nationwide Inpatient Sample Database: 2002 to 2007

Brian L. Hoh, Dominic T. Kleinhenz, Yueh-Yun Chi, J. Mocco, Fred G. Barker — 2011-12-01

Background: Few studies have compared the incidence of ventricular shunt placement for hydrocephalus after clipping versus coiling of cerebral aneurysms. Objective: The Nationwide Inpatient Sample (NIS) database was used to compare, on a national level, the incidence of ventricular shunt placement after clipping versus coiling of ruptured and unruptured aneurysms. Methods: Hospitalizations for clipping and coiling of ruptured and unruptured aneurysms from 2002 to 2007 were collected from the NIS by cross-matching International Classification of Diseases–9 codes for diagnoses of subarachnoid hemorrhage or unruptured cerebral aneurysm with procedure codes for clipping or coiling. The incidence of ventricular shunt placement for hydrocephalus after clipping and coiling was compared using generalized linear models with generalized estimating equations (GEE) to adjust for patient- and hospital-specific factors and correlation between admissions. Results: Of 10,899 ruptured aneurysm patients (6593 clipping, 4306 coiling), clipping had a similar incidence of ventricular shunt placement (9.3%) compared to coiling (10.5%) (odds ratio = 0.984; 95% confidence interval = 0.85, −1.14; P value = 0.833 after adjustment for patient-specific and hospital-specific factors). Likewise, of 9686 unruptured aneurysm patients (4483 clipping, 5203 coiling), clipping had similar incidence of ventricular shunt placement (0.4%) compared to coiling (0.5%) (odds ratio = 0.763; 95% confidence interval = 0.37, −1.58; P value = 0.465 after adjustment for patient-specific and hospital-specific factors). Predictors of shunt placement in ruptured aneurysm patients were age, comorbidity score, admission type, payer, and hospital aneurysm volume. Predictors of shunt placement in unruptured aneurysm patients were comorbidity score and admission type. Conclusions: In an observational study, clipping and coiling of ruptured and unruptured cerebral aneurysms are associated with similar incidences of ventricular shunt placement for hydrocephalus.

Surgically Treated Brain Tumors: A Retrospective Case Series of 10,009 Cases at a Single Institution

2011-12-01

Objective: To evaluate the chronologic trends in brain tumor surgery at a single institution over 53 years (1957–2009). Methods: Data were collected from medical records and documents (eg, daily records, surgical notes, or electronic databases) preserved in the library of the Department of Neurosurgery, Seoul National University College of Medicine. Results: During the period 1957–2009, 10,009 brain tumors were surgically treated. Glial tumor (25.2%) was the most frequently reported histologic category. Meningioma and pituitary adenoma accounted for 17.5% and 17.1% of the histologies. In children <20 years old, astrocytoma (16.7%), embryonal tumor (16.2%), and germ cell tumor (11.9%) were the most common histologies. The chronologic trend for changes in proportions of individual brain tumor surgeries showed that cases of glioma have gradually increased since the 1980s, whereas cases of benign extra-axial tumors, including meningioma, sellar tumor, and schwannoma, have decreased. This trend implies that the presurgical diagnosis of glioma has increased owing to modern imaging technologies, and alternative treatment options, such as radiosurgery or observation, have been more frequently applied over time to benign extra-axial tumors. Simultaneously, the surgical management of lymphoma and metastatic tumor has increased gradually. Conclusions: This article describes the largest series of chronologic analysis of brain tumor surgeries conducted at a single institution and reflects the longitudinal trends by treatment option in incidences of selected brain tumors.

Long-Term 25-Year Follow-up of Surgically Treated Parasagittal Meningiomas

Jenny Pettersson-Segerlind, Abiel Orrego, Stefan Lönn, Tiit Mathiesen — 2011-12-01

Background: Parasagittal meningiomas are either treated with conservative surgery or aggressive surgery with extensive vascular reconstructions to achieve radicality. The optimal management is subject to controversy. A prerequisite for good management and for design of relevant studies is the knowledge of natural history after radical and subtotal surgery. Methods: All patients operated for parasagittal meningiomas at Karolinska Hospital between 1975 and 1979 were identified. This cohort of 51 patients was retrospectively analyzed to obtain 25-year follow-up data. Data were obtained from medical charts at all treating hospitals, the Swedish cancer registry, and the Swedish registry of causes of death. Radiology reports and images were reviewed. All patients still alive were contacted for visits, interviews, and radiologic imaging when indicated. Karnofsky index, Simpson grade, and pathologic examinations were obtained. Results: The total recurrence rate after 25 years was 47%. Ten- and 25-year recurrence rates for radically operated parasagittal meningioma (Simpson grade 1-2) were 13% and 38%, respectively. The recurrence rates increased with increasing Simpson grades; 10- and 25-year recurrence rates in the Simpson grade 4 group were 62% and 69%, respectively. The relative risk for recurrence in Simpson grade 4 patients was 1.78 compared to Simpson grade 1-3 patients. The 10- and 25-year mortality rates were 33% and 63%, respectively. Of the total mortality 50% was caused by the tumor after 10 years and 48% after 25 years. Conclusions: A 25-year follow-up was necessary to estimate the long-term outcomes of parasagittal meningiomas. It is necessary to consider long-term recurrences and morbidity as important factors when managing patients with parasagittal meningiomas whose life expectancies are not diminished by old age or co-morbidities. The long-term outcomes must also be considered when evaluating different treatment modes, as “cure” of parasagittal meningiomas cannot be evaluated without sufficient follow-up.

The Risk of Getting Worse: Surgically Acquired Deficits, Perioperative Complications, and Functional Outcomes After Primary Resection of Glioblastoma

Sasha Gulati, Asgeir S. Jakola, Ulf S. Nerland, Clemens Weber, Ole Solheim — 2011-12-01

Objective: Gross total resection (GTR) prolongs survival but is unfortunately not achievable in the majority of patients with glioblastoma multiforme (GBM). Cytoreductive debulkings may relieve symptoms of mass effect, but it is unknown how long such effects sustain and to what degree the potential benefits exceed risks. We explore the impact of surgical morbidity on functional outcome and survival in unselected GBM patients. Methods: We retrospectively included 144 consecutive adult patients operated on for primary GBM at a single institution between 2004 and 2009. Reporting of adverse events was done in compliance with Good Clinical Practice Guidelines. Results: A total of 141 (98%) operations were resections and 3 (2%) were biopsies. A decrease in Karnofsky performance status (KPS) scores was observed in 39% of patients after 6 weeks. There was a significant decrease between pre- and postoperative KPS scores (P < 0.001). Twenty-two (15.3%) patients had surgically acquired neurological deficits. Among patients who underwent surgical resection, those with surgically acquired neurological deficits were less likely to receive radiotherapy (P < 0.001), normofractioned radiotherapy (P = 0.010), and chemotherapy (P = 0.003). Twenty-eight (19.4%) patients had perioperative complications. Among patients who underwent surgical resection, those with perioperative complications were less likely to receive normofractioned radiotherapy (P = 0.010) and chemotherapy (P = 0.009). Age (P = 0.019), surgically acquired neurological deficits (P < 0.001), and surgical complications (P = 0.006) were significant predictors for worsened functional outcome after 6 weeks. GTR (P = 0.035), perioperative complications (P = 0.008), radiotherapy (P < 0.001), and chemotherapy (P = 0.045) were independent factors associated with 12-month postoperative survival. Conclusion: Patients with perioperative complications and surgically acquired deficits were less likely to receive adjuvant therapy. While cytoreductive debulking may not improve survival in GBM, it may decrease the likelihood of patients receiving adjuvant therapy that does.

Association of Extent of Local Tumor Invasion and Survival in Patients with Malignant Primary Osseous Spinal Neoplasms from the Surveillance, Epidemiology, and End Results (SEER) Database

2011-12-01

Background: Malignant osseous spinal neoplasms are aggressive tumors associated with poor outcomes despite aggressive multidisciplinary measures. It remains unknown whether increased local tumor invasion at time of treatment predicts worse survival. The surveillance, epidemiology, and end results (SEER) registry was reviewed to determine whether extent of local tumor invasion at presentation was independently associated with overall survival. Methods: The SEER registry (1973–2003) was queried to identify cases of histologically confirmed primary spinal chordoma, chondrosarcoma, osteosarcoma, or Ewing sarcoma. Extent of local invasion was defined at time of care by histology, radiology, or intraoperative assessment and classified as confined (tumor within periosteum), local invasion (extension to surrounding tissues), or distal metastasis. The association of extent of local tumor invasion with overall survival was assessed by Cox analysis. Results: One thousand eight hundred ninety-two patients were identified (414 chordoma, 579 chondrosarcoma, 430 osteosarcoma, 469 Ewing sarcoma). Overall median survival was histology specific (osteosarcoma, 11 months; Ewing sarcoma, 26 months; chondrosarcoma, 37 months; chordoma, 50 months) and correlated with extent of local tissue invasion or metastasis at presentation. Presence of metastasis was associated with marked decrease in survival (P < 0.001) for all tumor types. For patients with isolated spine tumors, neoplasms confined within the periosteum were associated with improved overall survival independent of age, radiotherapy, or surgical resection for chordoma (hazard ratio [HR], 0.50; P = 0.08), chondrosarcoma (HR, 0.62; P = 0.03), and osteosarcoma (HR, 0.68; P = 0.05), but not Ewing sarcoma (HR, 0.62; P = 0.27). Conclusions: The preoperative radiographic recognition of local tissue invasion may identify patients with a more aggressive tumor and help guide the level of aggressiveness in subsequent treatment strategies.

Long-Term Follow-up of Patients Treated with Percutaneous Balloon Compression for Trigeminal Neuralgia in Taiwan

Jyi-Feng Chen, Po-Hsun Tu, Shih-Tseng Lee — 2011-12-01

Objective: This study aimed to evaluate the outcomes and complication rates associated with percutaneous balloon compression (PBC) for trigeminal neuralgia for a 10-year follow-up period. Methods: A total of 185 patients with trigeminal neuralgia were treated with an initial PBC between July 2000 and December 2001 and were followed up until July 2010. PBC was performed under general anesthesia with endotracheal intubation. Meckel's cave was cannulated with a No. 4 Fogarty catheter, and the balloon was inflated for 70–90 seconds. Results: Treatment and long-term follow-up was completed for 130 of the 185 patients. The mean length of the follow-up period was 8.9 years. Sixty-two patients (47.7%) were 65 years of age or older. Seventy-eight patients (60%) had pain involving the ophthalmic or multiple trigeminal divisions. One hundred twenty-two patients (93.8%) experienced immediate relief from neuralgia after the procedure. No pain recurred within 3 months. Seventeen patients (14%) had recurrent symptoms within 2 years. Twenty-three patients (18.9%) had recurrent symptoms within 3 years. Thirty-six patients (29.5%) had recurrent symptoms within 5 years. A total of 46 patients (37.7%) had recurrent symptoms during the entire study period. Conclusions: PBC is a technically simple, less painful procedure carried out under brief general anesthesia and is well tolerated by patients. The operation success rate is high, and the recurrence rate is similar to that of other reports. We also found that longer compression time resulted in longer symptom-free periods.

Fenestration of Supraclinoid Internal Carotid Artery and Associated Aneurysm: Embryogenesis, Recognition, and Management

Mahua Dey, Issam A. Awad — 2011-12-01

Objective: Fenestration of internal carotid artery (ICA) is extremely rare and may be associated with aneurysms arising from the fenestrated segment. Here we report two cases with successful surgical clipping of associated saccular aneurysms, and we systematically review the 12 previously reported cases. Methods: In one case of 39-year-old female patient, the aneurysm and fenestration were found incidentally in the course of a workup for headaches and a thyroid nodule. In the second case, a 32-year-old female patient, the aneurysm was associated with subarachnoid hemorrhage in the setting of suspected postpartum eclampsia. In both instances the fenestration involved the supraclinoid ICA, and the aneurysm arose from the duplicated segment proximal to the origin of the posterior communicating artery. The aneurysms were more proximal than typical posterior communicating artery aneurysms, and fenestration was suspected by rotational three-dimensional angiography, and confirmed at surgery. Results: In both instances the aneurysm was approached via an extended pterional craniotomy. In one case, partial anterior clinoidectomy was necessary, along with decompression of the optic nerve canal for optimal exposure of the aneurysm neck. Clip reconstruction was successful, obliterating the aneurysm and preserving ICA patency. Conclusions: ICA fenestration should be considered when one analyzes ventral supraclinoid ICA aneurysms. In these and other reported cases, aneurysm is generally amenable to surgical clipping despite broad neck incorporating the fenestrated arterial segment.

Large Hemangiopericytoma Associated with Arteriovenous Malformations and Dural Arteriovenous Fistulae

2011-12-01

Background: Hemangiopericytomas are rare vascular tumors of the central nervous system. Although hemangiopericytomas have been associated with other vascular malformations, there is no report of an intracranial hemangiopericytoma found in association with multiple arteriovenous malformations and dural arteriovenous fistulae. Case Description: We present the case of an otherwise healthy 25-year-old woman who presented with a large hemangiopericytoma involving the superior sagittal sinus. The highly vascular nature of the lesion, the total occlusion of the sinus anterior to the tumor, and the presence of multiple arteriovenous malformations and dural arteriovenous fistulae complicated resection of this tumor. Conclusion: To our knowledge, no prior report has described a tumor of this magnitude in association with multiple AVMs and dAVFs.

Brainstem Tethering with Ondine's Curse

Zhan Liu, Yanyang He, Song Li, Lihua Wu, Qiangfang Jiao — 2011-12-01

Background: Brainstem tethering is a rare disease. Case Description: We report and discuss a 20-year-old patient who experienced paroxysmal apnea (a symptom of Ondine's curse) during sleeping, causing him to wake up and control his breathing consciously. A magnetic resonance imaging study revealed that his medulla oblongata was twisted and displaced posteriorly by an abnormal tissue cord. An operation was performed to detether the tethered brainstem, with a satisfying result reached. Conclusion: Brainstem tethering is a rare but late complication of occipital encephalocele with insufficient operation. The symptoms of this disease are related to the dysfunction of the medulla oblongata and their adjunctive nerves. Magnetic resonance imaging can be used to identify the abnormal region and distinguish it from other medulla oblongata diseases. Surgery in the early stage of the brainstem tethering is helpful, but ventriculoperitoneal shunting is unnecessary or cannot be performed before detethering, although these patients usually have ventricular dilation.

An Intramedullary Tuberculous Abscess of the Conus in a 5-Year-Old Child Presenting with Urinary Dysfunction

2011-12-01

Objective: To report a case of the primary presence of an intramedullary tuberculous abscess in the conus medullaris with neither a history of contact nor tuberculous infection elsewhere in the body. Case Description: A 5-year-old boy progressed from urinary hesitancy and frequency to complete urinary retention over the course of 1 month. He was seronegative for human immunodeficiency virus. Magnetic resonance imaging (MRI) showed a D11-L1, well-circumscribed, intramedullary mass within the conus, which was hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging with a thin-walled enhancing capsule. A D11-L2 laminectomy revealed a tense dura and expanded cord with no arachnoidal adhesions. A midline myelotomy and capsular fenestration released thick yellowish, creamy pus. The histology showed loose aggregates of epithelioid cells and a mixed leukocyte population including polymorphonuclear leukocytes and mononuclear cells without formed granulomas. Ziehl-Neelsen staining showed acid-fast bacilli of Mycobacterium tuberculosis. The patient showed rapid improvement of sphincteric function with four-drug antituberculous therapy (ATT). Conclusions: To the best of the authors' knowledge, an intramedullary conus tuberculous abscess in a young child presenting with urinary dysfunction has never been reported. Perhaps hematogenous spread of M. tuberculosis within the conus, encapsulated proliferation and caseating necrosis (owing to delayed-type hypersensitivity), and an osmotic increase in the fluid content were responsible for its genesis and for the lack of arachnoidal adhesions around the cord. Surgical decompression of the abscess established the diagnosis, increased penetrability of ATT, and decreased the biologic load of bacteria, achieving a good recovery.

2011-12-01

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2011-12-01

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2011-12-01

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2011-12-01

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2011-12-01

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2011-12-01

World Neurosurgery

The Right Stuff

Enhancing the Utility of Surgical Simulation: From Proficiency to Automaticity

Traumatic Intracerebral Hemorrhage—To Operate or Not?

Epidermal Electronics

Upcoming Events

The Visual Dimensions of Future Neurosurgical Education

Dissecting a Complex Neurosurgical Illustration: Step-by-Step Development

Ein Heldenleben: A Life in Neurosurgery

Avoiding (and Reporting) Complications: When Nerves Pay a Price

Neuroethical Principles of Deep-Brain Stimulation

Shunts and Aneurysms

Does Aneurysm Treatment Modality Influence the Incidence of Shunt-Dependent Hydrocephalus?

The Necessity of Preserving Brain Functions in Glioma Surgery: The Crucial Role of Intraoperative Awake Mapping

Surgery for Glioblastoma Multiforme: Striking a Balance

The National Cancer Institute's SEER Registry and Primary Malignant Osseous Spine Tumors

Trigeminal Neuralgia: Diagnosis and Treatment

The Putative Role of Pericytes in Tumor Angiogenesis

Deep Brain Stimulation and Ethics: Perspectives from a Multisite Qualitative Study of Canadian Neurosurgical Centers

Incidence of Ventricular Shunt Placement for Hydrocephalus with Clipping versus Coiling for Ruptured and Unruptured Cerebral Aneurysms in the Nationwide Inpatient Sample Database: 2002 to 2007

Surgically Treated Brain Tumors: A Retrospective Case Series of 10,009 Cases at a Single Institution

Long-Term 25-Year Follow-up of Surgically Treated Parasagittal Meningiomas

The Risk of Getting Worse: Surgically Acquired Deficits, Perioperative Complications, and Functional Outcomes After Primary Resection of Glioblastoma

Association of Extent of Local Tumor Invasion and Survival in Patients with Malignant Primary Osseous Spinal Neoplasms from the Surveillance, Epidemiology, and End Results (SEER) Database

Long-Term Follow-up of Patients Treated with Percutaneous Balloon Compression for Trigeminal Neuralgia in Taiwan

Fenestration of Supraclinoid Internal Carotid Artery and Associated Aneurysm: Embryogenesis, Recognition, and Management

Large Hemangiopericytoma Associated with Arteriovenous Malformations and Dural Arteriovenous Fistulae

Brainstem Tethering with Ondine's Curse

An Intramedullary Tuberculous Abscess of the Conus in a 5-Year-Old Child Presenting with Urinary Dysfunction

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