World Neurosurgery

A Dragon Rises

Michael L.J. Apuzzo — 2012-02-01

During the past two decades, enormous changes have been realized in the existing world order. With “flattening,” the geopolitical and economic landscape has undergone immense evolution. This climate has changed our medical and neurosurgical landscape as well. Few would deny that China has become a striking new and important factor in the world of neurosurgery. Following a period of significant austerity beginning in 1949, the emergence of relaxation of internal regulation and privatization beginning in 1970 led to significant but slow progress over the next three decades, with a brisk escalation of progress evident during the past decade. This has been paralleled by the emergence of Chinese colleagues in the global world of neurosurgery. I personally have seen this progression as Editor of both Neurosurgery and WORLD NEUROSURGERY over the past 21 years. As part of this emergence, it has become evident that many unusually gifted colleagues with unique experience and talent exist in China, many of whom have not only experienced but fueled the march to modernity in that immense country.

WORLD NEUROSURGERY Neurosurgeon of the Year 2012: Liangfu Zhou

Peter M. Black — 2012-02-03

The growth of neurosurgery in China has been one of the most important recent developments in world neurosurgery. Dr. Liangfu Zhou, Chief of Neurosurgery at Huashan Hospital of Fudan University in Shanghai, is a leading architect of that growth. He is therefore a completely appropriate choice by the WORLD NEUROSURGERY committee for Neurosurgeon of the Year.

The Neurosurgeon “Academician” in China

Charles Y. Liu — 2012-02-13

Neurosurgery exists as a complex interplay among clinical science, basic neuroscience, and technical and operative considerations, all enabled by ever advancing technological developments but modulated by social, political, and economic forces. Therefore, the unique challenges and opportunities faced by the discipline relate directly to the fluidity of these elements. Practitioners of neurosurgery engage in a wide spectrum of activities; however, in each country of the world, individuals with unique qualifications are chosen to provide leadership in guiding the successful development of neurosurgery within the context of their local circumstances. Over the past decades, China has witnessed perhaps the most dramatic social and economic developments of any country in the world, emerging as a principal voice in the global conversation. This accelerated development is clearly evident in neurosurgery, where the technology and resources available to Chinese neurosurgeons have expanded dramatically. In China, this responsibility of stewarding neurosurgery through these challenging and opportune times is carried by the neurosurgeon members of their national academies.

Liangfu Zhou: Clinical Neurosurgeon, Academician, Teacher, and Friend

Zhifeng Shi, Jianping Song, Yao Zhao, Ying Mao — 2012-01-17

In 2002, archaeologists found evidence of primitive trephination in the skeletal remains of Dawenkou aboriginal people that may be the earliest neurosurgical operation in China, dating to 5000 years ago. There is also a legend about a famous ancient doctor named Hua Tuo who intended to perform a craniotomy on Cao Cao, king of the Wei kingdom (A.D. 222-280), to cure his headache caused by brain tumor. Unfortunately, Cao Cao, who had a suspicious disposition, killed Hua Tuo. From that time on, there was no neurosurgery in Chinese traditional medicine. Before the founding of the People's Republic of China in 1949, there was little development in neurosurgery in China, with very few traumatic brain injuries and brain abscesses operated on by western-trained general surgeons, such as Song-Tao Guan of Beijing and Charlie Chang of Shenyang, the first doctors to perform neurosurgery in China. Before 1949, due to poor social conditions and an underdeveloped national economy, fewer than 60 neurosurgical procedures on simple brain tumors had been performed and only 16 articles related to neurosurgery had been published ().

Neurosurgeon of the Year

Fady T. Charbel — 2011-11-28

The Editorial Board of WORLD NEUROSURGERY has bestowed on Professor Liangfu Zhou the distinctive honor of being named Neurosurgeon of the Year 2012. It is quite fitting that such an honor and recognition from a leading world publication would have chosen Professor Liangfu Zhou, an international figure of neurosurgery. Professor Zhou is a master surgeon, educator, researcher, scientist, innovator, and a visionary leader. He has been at the helm of the Department of Neurosurgery at Huashan Hospital in Shanghai since 1984. Ever since, Professor Zhou has quickly expanded the depth and sophistication of his department, transforming it into a world-class center.

Short comment on Professor Zhou

Kyung Gi Cho — 2011-11-28

I met Professor Zhou at the American Association for Neurological Surgeons meeting in Seattle 20 years ago. My first impression of him was of gentleness and warmth. At that time, most of the neurosurgeons from China could not speak English well, but Professor Zhou's English was fluent, and that's how I remembered him. A couple of years later, I visited Huashan Hospital in Shanghai. Zhou was operating on numerous brain tumor surgeries. Consequently, many patients with brain tumors in China were anxious to see him. Many of them came to see him from all over China. As more and more brain tumor patients came to see him, they built a new hospital just for neurosurgical patients, and his department has continued to expand to comprise 100 staff members (including 8 professors, 39 associate professors, 27 assistant professors, and 15 resident physicians).

Neurosurgeon of the Year

Yong-Gu Chung — 2011-11-28

I met Professor Liangfu Zhou for the first time during an endoscopic symposium in Germany during February of 1998. At that time, it was very rare to meet Chinese neurosurgeons in an international meeting seemingly because of the political and economic situation in their country. At first glance, he seemed like a young neurosurgeon who was eager to learn new things in the field of neurosurgery. Afterward, we had so many conversations not only regarding the academic field of neurosurgery but also cultural understandings. I really appreciate the wonderful job he has done to start and continue communication with neurosurgeons in other Asian countries, including Korea. I respect him for his contribution to growing the field of the neurosurgery in China during the modernization period in 1990s. His hard work and achievements earned him academic scholarships during the 2000s. We must applaud his accomplishments not only in the development of neurosurgery in China but also in bridging relationships between neurosurgeons in China and other countries.

Neurosurgeon of the Year

Takanori Fukushima — 2012-01-27

I have known Professor Liangfu Zhou for the past 10 years. Professor Zhou is one of the top experts in microneurosurgery in China. He is a well known pioneer of cranial base surgery. I have been collaborating with him on his annual skull base dissection courses in Shanghai.

Zhou dynasty and the art of neurosurgery

Juha Hernesniemi — 2011-11-03

After the founding of the People's Republic of China in 1949, the development of neurosurgery started in Shanghai and Beijing. A frontal lobe glioma was removed successfully for the first time in 1950 in the Chung-Shan Hospital in China. A few years later, in 1953, the neurosurgical department of the Chung-Shan Hospital moved to the First Red Cross Hospital, which was the predecessor of Huashan Hospital. Similarly, our own Töölö Hospital in Helsinki was originally the First Red Cross hospital in Finland. Since 1950s, the Department of Neurosurgery in the Shanghai Huashan Hospital has grown to become one of the continent's leading and busiest neurosurgical units. In addition to high-level clinical competence, the Department of Neurosurgery at the Huashan Hospital has shown commitment to basic and clinical research, which is a prerequisite for constant progress and development.

An Academic Leader, Professor Liang-Fu Zhou

Takeshi Kawase — 2011-11-28

It may be a common feeling for all the people who ever met professor Zhou that his spirit is younger than 50 years. I became acquainted with him more than 12 years ago, but my impression of him has not changed in that time. Our first meeting was in New Orleans, at the reception of the American Association of Neurological Surgeons Congress in 1999. Speaking frankly, he was not a man of dignified appearance, which was common in a Chinese professor, but rather more relaxed. During my first meeting with him, therefore, I did not realize that he was one of the great founders of Chinese neurosurgery! He founded neurosurgery in Huashan Hospital in Shanghai in 1970 and became a professor in 1989 after having studied in the United States. In 2001, he became the Director of Neurosurgery Hospital and Institute, which is a leader in neurosurgery in Shanghai. He introduced microsurgery during its early stages to China, and the number of surgeries increased threefold in those 10 years in his hospital. His interest was always on scientific and technical points, in addition to revising microsurgical techniques.

Neurosurgeon of the Year

Peter Nakaji — 2011-11-28

Among a host of worthy candidates, the recognition of Professor Liangfu Zhou as the WORLD NEUROSURGERY Neurosurgeon of the Year can be received with warm enthusiasm. It might be too easy for an outsider to dismiss the remarkable achievements of Professor Zhou and his department, based at Huashan Hospital, in Shanghai as a mere epiphenomenon of the stunning rise of China as a whole. Yet, to do so would be disingenuous: Not all other centers have grown so quickly or so well, nor have they kept pace so admirably with the broader field of neurosurgery, which itself has undergone many transformations during the same period. From a unit of 60 beds in 1984, Huashan has become the largest center in China and one of the largest anywhere: More than 15,000 surgical cases are now treated there each year. This remarkable growth, however, reflects scope and quality as well as volume. Huashan now can hold itself with pride as an equal among the great centers of the world.

WORLD NEUROSURGERY's “Neurosurgeon of the Year” for 2012, Liang Fu Zhou

Anil Nanda — 2011-11-28

In the midst of the bustling metropolis of Shanghai is a tall lean skyscraper that would look like any building in New York City, London, or Hong Kong. Only this is one of the premiere hospitals in China, and housed within its cavernous structure is the remarkable Huashan Hospital, a branch of Fudan University. When I first went there as a guest of Professor Zhou, I was amazed at the three floors of operating rooms with 28 neurosurgical operating rooms teeming like beehives and a service with more than 100 attending neurosurgeons performing close to 9000 neurosurgical procedures. What was even more remarkable was that these cases did not include any degenerative spine or deformity surgery. Clearly Professor Zhou has built one of the great neurosurgical services in the world.

Comment of Prof. Liang-Fu Zhou

Tomio Ohta — 2011-12-15

I was so pleased to hear that my dear friend Professor Liangfu Zhou has been selected by a senior committee of the publication as a WORLD NEUROSURGERY Neurosurgeon of the Year 2012. I am quite sure that he is the best qualified person to have been selected as such an honorable neurosurgeon. I met Professor Zhou in 1989 when I visited Huashan Hospital in Shanghai for the first time. My first impression of him was that he was quiet but smart, a person with integrity and inner strength. I felt that this young professor had something special to leave such an impression in my heart.

Neurosurgeon of the year 2012: Liang-fu Zhou Commentary

Wai S. Poon — 2012-01-27

I have known Professor Liangfu Zhou since the late 1980s. A long-term relationship between the Huashan Hospital and the Prince of Wales Hospital of more than two decades has been established. As the person in charge of the largest neurosurgical service in mainland China and an elected Fellow of the prestigious Chinese Academy of Engineering, Professor Zhou's achievements in academic neurosurgery have been listed and elegantly described in articles and other commentaries in this issue of WORLD NEUROSURGERY. In this short commentary, features of his lifestyle that account for his success will be described.

Comment to professor Liangfu Zhou in China

Renzhi Wang — 2012-01-27

Professor Zhou is one of the most prestigious leading experts in the field of contemporary neurosurgery China. Since becoming the Chief of the Department of Neurosurgery at Huashan Hospital (affiliated with Fudan University) in 1984, he has dedicated his excellent clinical skills, noble medical ethics, and outstanding leadership to the pursuit of upgrading the original department to one of the largest neurosurgery centers in the world.

Professor L. F Zhou

Shuyuan Yang — 2011-11-28

Neurosurgery is undergoing an extremely rapid development in China, and Professor Liangfu Zhou is undoubtedly one of the most outstanding elites who have made great contributions to this neurosurgical advancement. I have known Professor Liangfu Zhou for 35 years. I believe that he is a gifted neurosurgeon; he even demonstrated his potential and talent in the early days when he was studying in the United States. His passion, prudence, and innovation in his work have impressed me deeply. The number of the operations in which he has participated during the 40 years since he entered the neurosurgical field has surpassed 10,000. He is particularly adept at central nervous system tumors, cerebral vascular diseases, and traumatic brain injury, which is priceless knowledge in the development of neurosurgery in China.

Comments on “Neurosurgeon of the Year” for 2012

Xiang Zhang — 2011-11-28

Born in Fujian Province, China, Prof. Liangfu Zhou is one of the most outstanding neurosurgeons in the world. After graduating from Shanghai No.1 Medical College in 1965, he worked with Prof. Yuquan Shi, the founder of the Department of Neurosurgery of Huashan Hospital for several decades. Prof. Zhou has been the Chief of Neurosurgery Service at Huashan Hospital in Shanghai since 1984. He completed his postdoctoral training under the tutelage of Prof. Shelly N. Chou at the Department of Neurosurgery, University of Minnesota Medical College in 1985.

Neurosurgeon of the year 2012, Professor Liangfu Zhou by Professor Dingbiao Zhou

Dingbiao Zhou — 2011-11-28

I am delighted to know that Professor Liangfu Zhou was elected as Neurosurgeon of the Year 2012 by WORLD NEUROSURGERY. I have known Prof. Zhou for more than three decades. As the Chairman of Chinese Neurosurgical Society, also as his old friend, it is truly my privilege to write about Prof. Zhou's accomplishments and his impact on rapidly advancing field of neurosurgery in China.

Preoperative Planning for Cerebral Aneurysms Based on In Vitro Experimentation: Are We There Yet?

L. Fernando Gonzalez, M. Haithem Babiker, David H. Frakes — 2012-01-06

Recent advances in sensing technology and computer hardware and software have led to remarkable new medical imaging capabilities. Those capabilities now allow us to detect many cerebral aneurysms before they rupture, an occurrence that still carries a high mortality rate. In the past, aneurysms were usually treated through craniotomy and clipping. Today, the range of treatment options has expanded to include endovascular techniques such as embolization with coils, embolization with liquid agents, and more recently, flow diversion with stents. The latter option is a result of the evolution of bare metal stents from primarily mechanical tools used in cardiology to flow-diversion tools used in neurosurgical aneurysm treatment. Flow diverters change the hemodynamics intrinsic to the aneurysm, from the parent vessel itself, without the need to introduce coils or embolic materials. Accordingly, they constitute pure endoluminal treatment as opposed to the traditional endosaccular approach.

What Is the Best Medical Treatment for Symptomatic Intracranial Stenosis?

Maxim Mokin, Elad I. Levy — 2012-01-06

The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) study () was a prospective randomized multicenter trial designed to compare intensive medical management alone versus intensive medical management plus angioplasty combined with stenting in patients with symptomatic high-grade (70%–99%) stenosis of a major intracranial artery. On the basis of the recommendation of the study's Data Safety Monitoring Board, the National Institute of Neurological Disorders and Stroke stopped enrollment of patients into SAMMPRIS after a significantly higher rate of stroke and death was seen in patients from the combined group. The much lower than anticipated rate of stroke in the medical management group was also unexpected and has become the topic of many discussions on what currently constitutes the best medical therapy for intracranial stenosis in patients presenting with acute ischemic stroke or transient ischemic attack. Although new devices for the treatment of intracranial stenosis are currently being tested, the neurosurgical community should also be familiar with recent randomized trials relevant to medical treatment of intracranial atherosclerotic disease. Intracranial stenosis accounts for up to 10% of ischemic strokes, and outcome improvement will likely be based on future advances in both surgical and medical treatment approaches.

Glioma Stem Cells: Their Role in Chemoresistance

Ryosuke Yamada, Ichiro Nakano — 2012-01-06

Glioblastoma multiforme (GBM) is the most commonly diagnosed primary central nervous system tumors in adults, with approximately 10,000 new cases annually in the United States. The outlook for this devastating disease still appears bleak, even with optimal intervention such as maximal surgical resection, radiotherapy, and chemotherapy, most commonly with temozolomide (TMZ). Even after the much anticipated clinical introduction of TMZ after its discovery in 1987 (), its clinical impact was limited, with the median survival improving from 12 months to 14.8 months. The exact statistics surrounding survival are somewhat variable depending on the literature, but the unequivocal opinion is that all GBMs recur and are universally fatal. Chemotherapy regimens used for recurrence are much less effective and, therefore, the speculation was that the cellular entity of recurrent tumors is distinct from that of primary GBM, and indeed recent evidence supports that notion ().

Cerebral Collateral Circulation: Integral to Defining Clinical Outcome in Acute Cerebral Ischemia

Aditya S. Pandey, B. Gregory Thompson, Joseph J. Gemmete, Neeraj Chaudhary — 2012-01-06

Cerebral ischemia represents the third and second leading cause of death and disability in the United States and the world, respectively. Nearly $75 billion dollars (the value of the 59th largest economy in the world) are spent in direct and indirect costs to care for stroke victims. While stroke prevention is the ideal method of treatment, those who are experiencing an acute cerebral ischemic attack have an approximately 50% chance of becoming ambulatory and independent once all medical and surgical interventions have been exhausted. The advent of interventional mechanical therapies is allowing for recanalization of occluded vessels; however, clinical outcomes continue to be dismal (with 36% achieving independence in the Multi Merci Trial [] and 25% achieving independence in the Penumbra trial []). Clinical outcome could be improved with better patient selection. In this article, we will briefly discuss the role of collateral cerebral circulation as it relates to the therapeutic time window, success of recanalization, risk of hemorrhagic transformation, and overall clinical outcome in patients who experience acute cerebral ischemia ().

M. Necmettin Pamir — 2011-11-09

The second edition of the seminal textbook on meningiomas by Ossama Al-Mefty appears 20 years after the first edition's publication in 1991. In 1998, seven years after the first book, professor Al-Mefty complemented his extremely well received textbook with an operative atlas, and now comes a fully updated new version. The editors of the second edition are Franco DeMonte, from MD Anderson Cancer Center, Michael W. McDermott, from University of California-San Francisco, and Ossama Al-Mefty, from Brigham & Women's Hospital-Harvard Medical School. The chapters are prepared by a cosmopolitan crew of 88 contributors from America, Europe, and Japan.

2012-02-01

APRIL 5-8, 2012, 5th ISMISS Congress on Minimal Invasive Spine Surgery and Interventional Treatments, Antalya, Turkey

Endovascular Neurosurgery in Europe and in Italy: What Is in the Future?

Simone Peschillo, Roberto Delfini — 2011-11-09

Background: The cerebrovascular discipline has undergone dramatic changes in recent years. This has been made possible by the work of pioneers in the fields of neurosurgery and neuroradiology. Methods: In this article we review the evolution and fundamental stages that led to the birth of endovascular treatment and discuss why, also in Europe, this treatment must be included in neurosurgery, encouraging the training of endovascular neurosurgeons who can collaborate with their interventional neuroradiology colleagues in order to form unbiased surgeons who understand the disease from both the endovascular as well as the surgical prospective. We examine how the new generation of European cerebrovascular specialists, including neurosurgeons, neuroradiologists, and some neurologists, will attain their requisite endovascular training. Finally, we briefly review the current state of endovascular neurosurgery in Europe and in Italy and speculate about what its role will be in the near and distant future. Conclusions: To remain at the forefront of evaluating, caring for, and treating patients with cerebrovascular disease, vascular neurosurgery must evolve toward a specialty, mastering the knife as well as the catheter. We think it is time for European neurosurgeons to start training residents in endovascular neurosurgery in the same way we train neurosurgeons in every other neurosurgical discipline. •Peer-Review Report

Neurosurgery in Siberia

Alexey L. Krivoshapkin, Vladimir L. Zelman — 2012-01-13

There is archaeological evidence that the first neurosurgical procedure in what is now known as Siberia was performed in 8005 ± 100 B.C. According to signs of bone growth, perhaps more than half of the individuals who received the ancient trepanations survived. In Siberia, the first operations on the human brain and spinal cord were performed in 1909 at Tomsk University Hospital by the outstanding Russian surgeon and professor Vladimir M. Mysh. Professor Mysh initially moved from Saint Petersburg to Tomsk and later to Novosibirsk. Nicolay N. Burdenko, the founder of Russian neurosurgery and the Moscow Neurosurgical Institution, began his medical education at the Tomsk Imperial University. In the 1950s, Professor Ksenia I. Kharitonova exerted her great influence upon the development of neurosurgery in Siberia. Since 1955, and for 30 years thereafter, Professor Kharitonova was recognized as a principal leader of Siberian neurosurgery. She applied every effort to spread neurosurgical knowledge, and she popularized best practices around Siberia and the Far East. Perestroika deconstructed and ultimately eliminated the orderly system of neurosurgical service in the Soviet Union. From another perspective, the process opened the window to the world. Fully equipped centers and clinics with state-of-the-art techniques for neuro-oncology, cerebrovascular diseases, neurotrauma, and spinal pathology management in Novosibirsk, Barnaul, Kemerovo, and Irkutsk were enabled.

Tailor the Procedure to the Patient: About Vascular and Endovascular Neurosurgeons or Both

Shady Jahshan, L. Nelson Hopkins — 2011-11-09

In 1976, a neurosurgeon (Dr. Hopkins) performed the first endovascular procedure at Millard Fillmore Gates Circle Hospital, a diagnostic cerebral angiogram with vertebral artery catheterization, which was based on patient need. At that time, the staff neuroradiologist refused to perform the procedure or to provide training on how to obtain access. An interventional cardiologist taught that neurosurgeon the method for obtaining access (cutdown technique for brachial access). Since that time, endovascular neurosurgery has become a daily routine for the neurosurgery team here, which comprises members who are well trained in both endovascular and open vascular surgical procedures. During the last two decades, more than 35 neurosurgeons who are familiar and competent with both techniques have graduated from our endovascular training program.

The Way to an Open and Structured Training for Neuroendovascular Therapy in Europe: What Is the Current Situation?

Bernd Richling — 2011-11-09

Endovascular neurosurgery, or interventional neuroradiology, or simply endovascular neurointervention, is a “particular qualification using percutaneous and endovascular procedures to treat patients with diseases of the brain, sensory organs, head and neck, spinal cord, vertebral column and adjacent structures, and the peripheral nervous system in adults and children.” This is the definition of the draft of the European Union of Medical Specialists (UEMS) recommendations for acquiring a particular qualification to treat patients by procedures often simply called embolizations.

Reflections on the Benefits and Pitfalls of Ultra-Early Aneurysm Treatment After Subarachnoid Hemorrhage

Peter A. Gooderham, Gary K. Steinberg — 2011-12-09

Until the publication of the International Cooperative Study on the Timing of Aneurysm Surgery, the prevailing wisdom regarding the timing of aneurysm treatment following subarachnoid hemorrhage was to delay surgery for at least 1 week from the time of hemorrhage to optimize surgical conditions. This delay allowed the cerebral swelling related to the hemorrhage to subside and the high risk period for vasospasm to pass. There was a phase shift in the management paradigm following the publication of the cooperative study results, which showed that the surgical risks were not significantly different with early (0–3 days) versus late (>7 days) surgery and that a significant number of patients died or had poor outcome from rebleeding or vasospasm while awaiting delayed surgery ().

Treatment of Ruptured Aneurysms: Earlier is Better

Alexander G. Weil, Ji-Zong Zhao — 2011-12-19

Rebleeding is the primary cause of early morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH) (). The efficacy of aneurysm obliteration at preventing rebleeding and improving outcome after SAH has been well established since the 1970s. However, the debate over optimal timing of aneurysm treatment after SAH has carried on for over 4 decades (). Initially, the debate centered on the risks of rebleeding encountered while awaiting late surgery (>10 days) versus the morbidity incurred by operating early (<3 days) on an acutely injured and swollen brain or during the intermediate period of cerebral vasospasm (3 to 10 days). In the early 1980s, the International Cooperative Study, a large, multicenter, prospective, observational trial, addressed the issue of optimal timing for surgery. This study found that early surgery (<3 days) was at least equivalent to delayed surgery (>10 days) in terms of mortality and morbidity for good grade patients (). Over the next decade (1980s), improvements in the overall medical management of SAH, and in particular, the prevention and treatment of vasospasm and delayed cerebral ischemia, provided a further rationale for neurosurgeons to perform early aneurysm surgery (). The vast majority of studies that ensued, including one randomized control trial and multiple observational studies, suggested that early and even intermediate surgery were associated with a better outcome and shorter hospitalization than later surgery in aneurysmal SAH patients, especially in good clinical grade patients, but also in poor-grade patients (). Early aneurysm obliteration (<72 hours), either by neurosurgical clipping or endovascular coiling, has been widely adopted by neurovascular centers worldwide for over a decade.

Transcranial Doppler: A Simple Way to Estimate the Effect of Radiosurgery in Arteriovenous Malformations

Mika Niemelä, Riku Kivisaari — 2011-11-03

Arteriovenous malformations (AVMs) of the brain are among the most complex lesions encountered by a neurosurgeon. The reason for their treatment is to prevent neurological morbidity and even mortality resulting from a hemorrhagic stroke. The annual risk of rupture in all AVMs, on average, has been 2% to 4% in most series but is known to vary widely depending on certain characteristics of the AVM (). The severity and consequences of AVM rupture are less well studied, but it is generally agreed that it is a less dangerous form of stroke than aneurysmal subarachnoid hemorrhage or hypertensive intracerebral hemorrhage (). Because the treatment is prophylactic, it should not impose a risk of morbidity and mortality on the patient that is greater than that caused by the AVM itself. This applies even more strongly for the examinations related to the evaluation and treatment of AVMs. For many years it has been known that AVMs cause changes in the flow that are recordable with transcranial Doppler (TCD), i.e., elevated mean blood flow velocity and decreased pulsatility and resistance indexes (). Relevant applications for the clinical use of TCD in the treatment of AVMs have been scarce.

Arteriovenous Malformation Radiosurgery: Now You See It, Now You Don't

Bruce E. Pollock — 2011-11-09

Stereotactic radiosurgery is an accepted management option for many patients with intracranial arteriovenous malformations (AVM). The primary goal of AVM radiosurgery is complete nidus obliteration to protect a patient from the risk of future hemorrhage. In 1988, Lindquist and Steiner defined AVM obliteration on cerebral angiography as “a normal circulation time, complete absence of pathological vessels in the former nidus of the malformation, and the disappearance or normalization of draining veins from the area” (). The histopathologic changes noted after AVM radiosurgery include damage to the endothelial cells, progressive thickening of the intimal layer secondary to proliferation of smooth muscle cells that produce an extracellular matrix containing type IV collagen, cellular degeneration, and finally hyaline transformation (). Further electron microscopic studies of AVMs resected after radiosurgery revealed spindle cell proliferation in the connective tissue stroma and in the subendothelial region of irradiated arteries (). The characteristics of the spindle cells were similar to myofibroblasts noted during wound healing, and these cells likely contribute to the occlusive process and final obliteration of AVMs after radiosurgery. Numerous studies have confirmed that AVM obliteration generally occurs between 1 and 5 years after radiosurgery. The most important factor associated with obliteration after AVM radiosurgery appears to be the margin radiation dose delivered to the nidus ().

Transcranial Ultrasound for Arteriovenous Malformations: Something Old Is New Again

Jason Sheehan — 2011-11-09

The concept of ionizing radiation to treat arteriovenous malformations was devised in 1914 (). At that time, Vilhelm Magnus, a neurosurgeon from Norway, used radium therapy to treat a patient with a large arteriovenous malformation (AVM) located in the motor cortex. Two years later, Magnus found that the patient's seizures ceased. He remarked that “In this case radiotherapy was more lenient than the knife” (). Since then, thousands of patients with cerebral arteriovenous malformations (AVM and dural arteriovenous fistulae [dAVF]) have undergone stereotactic radiosurgery. Most of the vascular malformations obliterate within 3 to 4 years after radiosurgery. In the interim, patients are typically followed with serial magnetic resonance imaging (MRI) performed at 6-month intervals. Once the vascular malformation seems to have disappeared on the MRI, a diagnostic angiogram is usually performed to confirm obliteration. The interval between radiosurgery and angiographically confirmed obliteration is filled with some degree of uncertainty and anxiety for patients and clinicians alike. The risk of hemorrhage appears unchanged until complete obliteration is achieved. However, from a clinical perspective, we know that hemodynamic changes are occurring during the timeframe between treatment and obliteration. Favorable hemodynamic changes may be accompanied by improvements in symptoms such as tinnitus for patients with dAVF or seizures in patients with AVM. Unfavorable hemodynamic changes may be accompanied by clinical worsening.

The Cost of Brain Metastasis Management

Maya A. Babu, Bruce E. Pollock — 2011-11-09

During the past several decades, it has become obvious that the unconstrained cost of health care is not compatible with the long-term economic viability of developed countries. Although all would agree that the goal is to provide the greatest quality of health care to the largest number of people at the lowest cost, the means to achieve this end are hotly debated. The measurement of quality is a relatively new science and requires a large amount of resources to develop and collect the necessary information. Fully developed and tested quality measures are only available for some of the most common conditions or processes of health care delivery. In simple terms, the concept of increasing quality in health care delivery is based on the premise of patient outcomes as a function of cost. Greater quality by this definition can be provided by improving outcomes while holding costs the same, providing similar outcomes at a reduced cost, or some combination of better outcomes and reduced cost. Participants in this debate have developed a number of methodologies to assess the relative cost-effectiveness of different interventions in the hope of making rationale choices based on the best evidence available. However, the best management strategy frequently depends on the perspective of the analysis, and for individual patients, does not take into account the emotional and economic factors that complicate medical decision making.

The Evolving Role of the Transsphenoidal Route in the Management of Craniopharyngiomas

Paolo Cappabianca, Luigi Maria Cavallo — 2011-11-09

In the interesting article by Komotar et al., the investigators performed a well-organized and wide literature review accounting for the different surgical treatment options for craniopharyngiomas of the past 15 years, transcranial and transsphenoidal microsurgical and endoscopic. The meta-analysis conducted sheds light on some results in terms of surgical removal that are very interesting, although somehow affected by the variability related to the heterogeneity of data among series. Among results reported, it has to be underlined that “the endoscopic cohort had a significantly higher rate of gross total resection (66.9% vs. 48.3%; P < 0.003) and improved visual outcome (56.2% vs. 33.1%; P < 0.003) compared with the open cohort. […] The rate of [cerebrospinal fluid] CSF leak was higher in the endoscopic (18.4%) and transsphenoidal (9.0%) than in the transcranial group (2.6%; P < 0.003), but the transcranial group had a higher rate of seizure (8.5%), which did not occur in the endonasal or transsphenoidal groups (P < 0.003).”

Treatment Options for Refractory Trigeminal Neuralgia

Bernhard Meyer, Jens Lehmberg — 2011-11-09

Over the past century, various treatment options for trigeminal neuralgia emerged. At the beginning of the 20th century, open rhizotomies were performed before anticonvulsants showed their effectiveness in tic douloureux (). Percutaneous techniques, such as radiofrequency thermocoagulation, glycerol rhizotomy, and balloon compression, were developed thereafter (). The compression of the trigeminal root by a vessel was then described as a causative role in trigeminal neuralgia. Consequently, microvascular decompression has been shown to be very effective in the treatment of tic douloureux (). During the past two decades, gamma knife surgery as a noninvasive lesioning technique has been promoted widely.

The Employment of the “Sniff Test”

Edward C. Benzel — 2011-11-09

“There are three kinds of lies—lies, damned lies, and statistics.” Variously attributed to Benjamin Disraeli, Mark Twain, and others The testing of a spinal construct by mechanical means is fraught with difficulty. Oftentimes, in the case of published studies, the data acquired and presented are found to be statistically significant. Although, on the surface, the study may appear to be methodologically sound, the actual and literal conclusions may, in fact, be irrelevant to the clinical situation at hand. The study presented herein by Daniel et al. is no exception. I am not being critical of Daniel et al. in particular; nor am I singling them out. I am, conversely, casting aspersions on the majority of biomechanical studies that assess the integrity and efficacy of spinal constructs in cadavers via quasistatic flexibility testing strategies.

Critical Evaluation of Biomechanical Stability of Craniovertebral Junction Realignment Based on an Experimental Study

Hiroshi Nakagawa, Koji Saito, Tohru Mitsugi — 2011-11-03

Posterior fixation techniques of atlantoaxial joints have greatly advanced since C1 lateral mass–C2 pedicle screw fixation was introduced by Goel and Harms (). Daniel et al. reported an excellent experimental study on biomechanical stability of posterior-alone fixation technique following three kinds of craniovertebral realignment using flesh human cadavers. The study proved reliable biomechanical stability on flexion-extension, lateral bending, and axial rotation loading in stand-alone spacers in the atlantoaxial joint, combined with C1 lateral mass screw–C2 pedicle screw fixation and again combined with midline wiring construct.

Does Ganglionectomy Still Have a Role in the Era of Neuromodulation?

Fahd R. Khan, Jaimie M. Henderson — 2011-11-09

The greater occipital nerve is a medial branch of the posterior C2 and C3 primary sensory divisions. Along with the lesser occipital nerve, which is derived mainly from the C3 root, it emerges between the posterior arch of C1 and the lamina of C2, ascending and piercing the semispinalis and trapezius muscles near their attachment on the occipital skull. Along the superficial fascia, it innervates the posterior scalp over the vertex (). The C2 nerve root and ganglion are not covered by lamina and are situated outside of the spinal canal between the posterior arch of C1 and the lamina of C2, making them particularly susceptible to entrapment by hypertrophied posterior atlantoaxial ligament or engorgement by the venous plexus ().

Lumbar Textilomas: A Neurosurgical Complication Rarely Touched

Mohamed El-Fiki — 2011-11-09

Lumbar textilomas are rare postoperative finding responsible for occasional morbidity and mortality after posterior lumbar spine surgery. Each year (), 1500 cases of retained foreign bodies are reported in the American literature with 1.5% of them as spinal textilomas. It is mainly due to foreign body reaction presenting either early or several months to several years after the primary surgery. A sterilized cottonoid patty or gauze sponge that is discolored and stained with blood will be easily missed among muscles and blood products in the operative field, especially at the corners of the incision or in a bloody field in fatty subjects. The foreign body may be difficult to distinguish from healthy tissues, especially when it is not tagged with a suture or a radiopaque marker.

The Value of Teleradiology in Neurosurgery

Lian Chen, Ying Mao — 2011-11-18

Teleradiology has been growing fast ever since its emergence in 1990s and is still a promising and effective way of remote medical service with great development potential (). Teleradiology enables radiologists immediate access of images anywhere and anytime; thus it is helpful to raise their working efficiency to provide prompt diagnosis for patients in remote rural areas. Moreover, with the establishment of international teleradiology, all CT machines and all the radiologists can be regarded as terminals of the network. Medical consultation can be served without site restriction and communication of local practitioners with remote subspecialists can be enabled.

Should a Picture Ever Replace a Thousand Words? Harnessing Technology without Compromising Neurosurgical Resident Education and Patient Care

Gabriel Zada — 2011-11-18

In the article by Min et al. featured in the current issue of WORLD NEUROSURGERY, the authors aimed to determine the ability of junior residents (both neurosurgical and non-neurosurgical) to appropriately select a representative image from the entirety of a given neuroimaging study and subsequently relay this to an attending surgeon via a multimedia messaging service (MMS). The pathology in question included a variety of primarily emergent neurosurgical diseases, such as intracerebral hemorrhage, subdural hematoma, hydrocephalus, and one spine case. The authors concluded that MMS is an efficient and reliable way of communicating visual information regarding urgent or emergent neurosurgical conditions and that these visual data can be accurately relayed by junior residents with minimal or no neurosurgical training.

The Value of Translational Models for Microvascular Anastamosis

Jonathan Russin, Steven L. Giannotta — 2011-11-09

Microvascular anastomosis is a seminal skill for modern neurosurgeons. It is technically demanding but rarely used. Failure carries dire physiologic consequences. As an advanced psychomotor exercise, its mastery requires a role model (instructor), aptitude, willingness to practice, and a learning environment outside the operating room theater. Historically, live animal models have been considered the gold standard for training resident surgeons. However, the increasing expense and restrictions on maintaining live animals has led to innovative options. Models that use artificial materials as well as harvested vessels from chicken wings or turkey necks have been used with either static or pulsatile flow (). Reproductions of clinical scenarios have included artificial skull and brain combinations for deep anastomosis as well as cadaver models (). Results assessment of these models has included open and endoscopic intraluminal inspection ().

To Clip or Not to Clip, That is the Question?

Walter A. Hall — 2011-11-18

The issue of whether or not to remove the hair of the scalp in preparation for a clean neurosurgical procedure has never been satisfactorily resolved. This question has remained unanswered for decades. The first published prospective attempt to address this technical concern reviewed the results in 638 consecutive patients where the hair was not removed and the infection rate was only 1.1%. In that series 218 patients underwent shunt placement for cerebrospinal fluid diversion (). The conclusion from this analysis was that there is no indication for hair removal before cranial neurosurgery. Another series using a similar preparative protocol and perioperative antibiotics in 346 cranial procedures found no infections in any patient or type of procedure (). In looking at larger, more recent series performed outside of the United States, one report from 2001 with 1038 patients had an infection rate of 1.25%, which was comparable to the rate seen in those where the hair was shaved (). Another group reported a 1.1% infection rate when no hair was shaved in 632 patients ().

Barber Surgeon, or Surgeon Barber?

James R. Van Dellen — 2011-11-18

The definition of a barber (Latin barba = beard) has been given as someone, most often male, whose occupation is to shave or trim the beards of men and to cut hair. Priests and medicine men in the very early periods were recorded as being barbers. In Europe during the Medieval and into the Middle Ages, the barbers often served as surgeons and dentists, performing bloodletting and leeching, fire cupping, enemas, and the extraction of teeth. In 1163, the medieval Roman Catholic church after the Council of Tours under Pope Alexander III banned clergy from the practice of surgery and, from about then, “physicians” also became clearly separated. Surgery was thereafter not generally conducted by physicians but by barbers and they were further charged with looking after soldiers or sailors during or after a battle that earned them the name barber surgeons. The barber pole (although the exact colors and configuration remain under debate), associated with the service of bloodletting, originally had a brass wash basin at the top, in which leeches were kept, and another at the bottom, to receive the blood and the pole represented the staff the patient gripped to encourage blood flow. British barbers were even recorded to have received higher pay than surgeons until surgeons were assigned to war ships. In most countries, the trade or craft guild system was increasingly put under pressure by the medical profession. For example, the Company of the Barber-Surgeons of London, formed in 1540 by the union of the Company of Barbers and the Fellowship of Surgeons, split in 1745, the surgeons from the barbers, and formed the Company of Surgeons, which, in 1800, became the Royal College of Surgeons.

Harvey Cushing and the Subject of Brain Death in 1908: An Early Neurosurgical Dilemma and Putting It All into Perspective

James Tait Goodrich — 2011-11-09

Harvey Cushing (1869–1939) () revealed a good deal about his drive and zeal in neurosurgery in an early brain surgery case done in 1908. Cushing was early on in his career when he undertook the care of a 30-year-old man with headaches and convulsions. As was common in this early period, Cushing performed a left frontal craniotomy looking for a presumed lesion or bleed, but he found no pathology, at least not identifiable on the cortical surface. Cushing proceeded to do the only treatment available at that time to reduce brain pressure—a subtemporal craniectomy, a treatment only just introduced in the first decade of the 20th century. With only ether anesthesia along with very rudimentary neurosurgical instrumentation, Cushing undertook a complex craniotomy. With blood transfusion not yet available (occasionally one could transfuse from a family member), the surgeon had to be incredibly meticulous in controlling bleeding and blood loss. In 1908, the surgeon had only a small surgical armamentarium available for hemostasis; this would have included only bone wax, muscle pledgets, and pressure applied with cotton paddies. In reviewing the clinical details of this case, Cushing made a serious error of judgment with his decision to do a spinal tap to reduce the swollen brain and brain pressure; he made this decision because he believed it would be easier for him to open the dura mater. There was a quick demise of the patient that was likely due to a downward brain herniation that knocked off the lower cranial nerves.

Harvey Cushing and Brain Death

Dirk De Ridder — 2011-11-09

Scientists have not yet come up with a unanimously accepted definition of “life,” which also makes it difficult to define “death” unequivocally. Life is most commonly defined as quality or characteristic that distinguishes a vital from a dead body (Merriam Webster), which is not much of a help, and therefore life is often defined by a list of mandatory characteristics essential for life. These seven pillars of life—Program, Improvisation, Compartmentalization, Energy, Regeneration, Adaptability, Seclusion—are the fundamental principles on which a living system is based (). Recently, with the creation of a continuously reproducing bacterial cell controlled by a chemically synthesized genome (), the first artificial creation of life has been witnessed. This is an initial step toward realizing an age-old dream of mankind to create life like the gods did, exemplified by stories such as Frankenstein. Almost universally man is created from clay, analogous to the golem in Hebrew tradition, and similar creation stories are found in Africa, New Zealand, China, in Mayan and Egyptian culture.

Cross-Circulation Techniques for Endovascular Revascularization of Acute Stroke

Matthew F. Lawson, Brian L. Hoh — 2011-11-09

There have been remarkable advances in endovascular neurosurgery over the past decade, both in endovascular management of intracranial aneurysms and endovascular stroke care. In the following case report by Liu et al., these disciplines come together as they adapt transcirculation approach techniques previously described for aneurysm coiling () and use them in a thrombectomy procedure for acute basilar thrombosis. This report is not the first of its kind, as Hui et al. () reported using a posterior-to-anterior circulation approach to treat a middle cerebral artery occlusion. Nevertheless, these reports as well as the one by Liu et al. represent an elegant use of advanced endovascular techniques for new indications.

Surgical Options for Pineal Region Tumors

Ian F. Pollack — 2011-11-09

Pineal region tumors encompass a diverse array of histologies that include germinomas, malignant germ cell tumors and teratomas, pineal parenchymal tumors, gliomas, and meningiomas, among others. Apart from teratomas, which have a characteristic appearance, the histological identity of a pineal region tumor can be difficult to predict by imaging alone. In the past, patients with pineal tumors that were thought to potentially be germinomas were often given a “test dose” of irradiation, and if a complete response was achieved, they were treated empirically with further irradiation, with biopsy reserved for nonresponding lesions.

Corpus Callosotomy: What Is New and What Is Relevant?

Karl Schaller — 2011-11-09

Van Wagenen and Herren () were the first to report on corpus callosotomy as a method for the surgical treatment of epilepsy. Surgical techniques, as well as the definition of indications, have been refined continuously ever since, and at present, corpus callosotomy is still being performed in epilepsy surgical centers throughout the world. Callosotomy is applied to treat patients who are suffering from atonic seizures (with drop attacks) or from generalized seizures, which are originating in one hemisphere and show very rapid transfer to the other, the supposedly healthy hemisphere. Lennox-Gastaut syndrome is just one form of epilepsy that responds favorably to corpus callosotomy. With rates of seizure freeness being low, corresponding to multifocal origin of the seizures in these patients, it is a procedure, that is rendered palliative by many. It is performed rarely and after extensive epileptologic work-up only, but it clearly has its place, as the potential candidates for surgery are suffering frequently from catastrophic epilepsies, with up to several hundred seizures per day, and in whom seizure reduction of 50% to 60% constitutes a clear improvement of their desolate situation. With its known potentially severe side effects, such as disconnection syndrome (sensory and/or visual), it is reserved as some sort of last resort therapy for patients in whom other less invasive palliative procedures, such as vagal nerve stimulation, have failed ().

Neuroendoscopy in Diagnosis and Treatment of Hydrocephalus by Basal Meningitis

Michael R. Gaab — 2011-11-09

The article by Rangel-Castilla et al. underlines the importance of neuroendoscopy (endoscopic neurosurgery) as a diagnostic tool, followed by or immediately combined with an effective, minimally invasive treatment. Historically, endoscopy was first introduced for diagnostics, that is, Bozzini's speculum endoscope in gynecology in 1806 () and routine clinical use of Nitze–Leiter's lens endoscope with the introduction of the incandescent Mignon lamp since 1889 (). The addition of systematically developed instruments then rapidly led to therapeutic applications, from outflow dilation to biopsies, tumor removals, and stent insertions already at the end of the 19th century: first in urology, by Desormeaux in 1865 (), followed by Nitze's first operation endoscope in 1891 (), and later on complex tumor biopsies and treatment of tumors in urology in 1896 (). Today, endoscopy continues to be a main diagnostic tool in ear, nose, and throat; bronchoscopy; gastroenterology; laparoscopy; urology; gynecology; arthroscopy; endoscopic ultrasound, etc. and is far more often used for diagnostics (including biopsies) than for definite surgical treatment.

Can the Release of Only Few Subarachnoidal and Basal Cistern Adhesions Resolve Postinfective Hydrocephalus?

Michelangelo Gangemi, Vincenzo Seneca — 2011-11-09

In their case report, Rangel-Castilla et al. underline the importance of suspecting histoplasmosis of the central nervous system in patients with a positive clinical history and/or immunocompromise. They also show the possibility of performing a neuroendoscopic procedure with diagnostic and therapeutic goals in postinfective hydrocephalus. We believe that, in case of hydrocephalus, because of an infective etiology, endoscopic third ventriculostomy (ETV) is an extremely effective procedure to manage early hypertensive symptoms and to obtain a histologic diagnosis through the biopsy of multiple samples under direct vision (). We also emphasize the possibility and the necessity of opening the Liliequist membrane (both mesencephalic and diencephalic) and basal cisterns adhesions; moreover, the observed relationship between the incremental increase of cerebrospinal fluid (CSF) flow through the stomy and the release of subarachnoid and basal cisterns adhesions raises controversial issues regarding the pathophysiology of communicating hydrocephalus (). Therefore, the main question is, in our opinion, how the release of only few subarachnoidal and basal cistern adhesions can resolve postinfective hydrocephalus.

Ultra-Early (within 24 Hours) Aneurysm Treatment After Subarachnoid Hemorrhage

2011-11-03

Background: The timing of definitive aneurysm treatment (coiling or clipping) in acute aneurysm subarachnoid hemorrhage was a subject of controversy. Although most vascular neurosurgeons agreed on early aneurysm treatment (within the first 72 hours), whether ultra-early aneurysm treatment (within the first 24 hours) was beneficial remained debatable. We aimed to investigate whether ultra-early aneurysm treatment is associated with better neurological outcome in all patients or only good-grade patients or only poor-grade patients. Methods: Two-hundred and seventy-six (84%) patients had hemorrhage onset time and aneurysm treatment time available for analysis. Values of P < 0.05 were taken as statistically significant, and P values between 0.05 and 0.10 were considered to be a trend. Results: For the 96 poor-grade (World Federation of Neurological Surgeons grading scale 4 to 5) patients, there was a significant association between Short Form-36 mental scores and ultra-early aneurysm treatment (50 ± 10 vs. 46 ± 10, P = 0.019) and a trend toward association between ultra-early surgery and favorable neurological outcome (odds ratio 2.4 [95% confidence interval 1.0 to 6.0], P = 0.062). A reduction in clinical rebleeding (12% vs. 22%, P = 0.168) was observed in patients undergoing ultra-early aneurysm treatment. Conclusions: Aneurysm treatment performed within the 24-hour window may be associated with a better outcome and halve the clinical rebleeding risk in poor-grade aneurysmal subarachnoid hemorrhage patients.

Hemodynamic Changes in Arteriovenous Malformations After Radiosurgery: Transcranial Doppler Evaluation

Kyung-Il Jo, Jong-Soo Kim, Seung-Chyul Hong, Jung-Il Lee — 2011-11-09

Objective: To monitor hemodynamic changes using transcranial Doppler (TCD) in patients with an arteriovenous malformation (AVM) after Gamma Knife surgery (GKS). Methods: The study comprised 22 patients (17 men and 6 women, mean age 42 years, range 18–69 years) with an unruptured AVM fed by only the middle cerebral artery (MCA) or its branches. Serial TCD profiles from proximal MCAs were analyzed and correlated with treatment outcome. Results: Baseline TCD measurements (presented as means ± standard deviations) revealed significantly higher mean blood flow velocity (Vm) and lower mean pulsatility index (PI) in MCAs ipsilateral to AVMs than in contralateral MCAs (Vm 102 cm/s ± 29 vs 66 cm/s ± 16, P < 0.05; PI 0.63 ± 0.10 vs 0.84 ± 0.10, P < .05). No correlation was found between AVM volumes and hemodynamic indices. Vm values in ipsilateral MCAs were lower at 6 months (88 cm/s ± 26) after GKS than at baseline (P < 0.05). At 2 years after GKS, a further decrease in mean Vm and an increase in mean PI were observed in ipsilateral MCAs, which then approximated the values of contralateral MCAs (Vm 71 cm/s ± 30 vs 61 cm/s ± 11, P = 0.16; PI 0.76 ± 0.17 vs 0.83 ± 0.14, P = 0.15). Cerebral angiography (CAG) at the same time revealed total obliteration of AVMs in 11 patients. Changes in Vm and PI values were found to be correlated with the completeness of obliteration. However, no correlation was found between baseline TCD measurements and level of obliteration. Conclusions: Normalization of hemodynamic indices measured by TCD was found to be correlated with AVM obliteration after GKS. However, significant hemodynamic improvements may develop after GKS before obvious obliteration by anatomic imaging.

The Cost-Effectiveness of Stereotactic Radiosurgery versus Surgical Resection in the Treatment of Brain Metastasis in Vietnam from the Perspective of Patients and Families

Duong Anh Vuong, Dirk Rades, Anh Ngoc Le, Reinhard Busse — 2011-11-09

Background: This study aims to evaluate the cost-effectiveness of the treatment of brain metastasis with surgical resection (SR) and stereotactic radiosurgery (SRS) in the lower-middle-income country of Vietnam from the perspective of patients and families. Methods: The treatment of 111 patients with brain metastases who underwent SR (n = 64) and SRS (n = 47) was retrospectively reviewed. Propensity score matching was used to adjust for selection bias (n = 30 each); mean and curves of survival time were defined by the Kaplan-Meier estimator; the cost analysis focused on the time period of relevant treatment. Results: The mean survival times of SRS and SR were 11.9 and 10.5 months, and the 18-month survival rates were 32% and 14%, respectively (P = 0.346). The mean number of hospital bed days was significantly higher for SR than SRS (16.5 versus 7.6 days, P < 0.05), but direct costs of SR were significantly lower (14.5 as opposed to 35.3 million Vietnamese dong [VND] per patient, P < 0.001). However, indirect costs of SR were 10 times higher (26.0 versus 2.5 million VND per patient, P < 0.001). The cost per life year gained was higher for SR than SRS (46.4 and 38.1 million VND, respectively). Conclusions: SRS is similarly effective as SR. However, in the broader context of the cost-effectiveness from the perspective of patients and their families, SRS is more cost-effective. The lower costs directly charged by the hospital for SR may prevent poorer and older patients from choosing SRS. Thus, the overall cost-effectiveness of each treatment option should be taken into consideration in deciding on the treatment.

Endoscopic Endonasal Compared with Microscopic Transsphenoidal and Open Transcranial Resection of Craniopharyngiomas

2011-11-03

Objective: Craniopharyngiomas have traditionally represented a challenge for open transcranial or transsphenoidal microscopic neurosurgery because of their anatomical location and proximity to vital neurovascular structures. The extended endoscopic endonasal transsphenoidal approach has been more recently developed as a potentially surgically aggressive, yet minimal access, alternative. To gain a more comprehensive assessment of the benefits and limitations of the various approaches to resection of craniopharyngiomas, we performed a systematic review of the available published reports after endoscope-assisted endonasal approaches and compared their results with transsphenoidal purely microscope-based or transcranial microscope-based techniques. Methods: We performed a MEDLINE search of the modern literature (1995-2010) to identify open and endoscopic surgical series for pediatric and adult craniopharyngiomas. Comparisons were made for patient and tumor characteristics as well as extent of resection, morbidity, and visual outcome. Statistical analyses of categorical variables were undertaken by the use of χ2 and Fisher exact tests with post-hoc Bonferroni analysis to compare endoscopic, microsurgical transsphenoidal, and transcranial approaches. Results: Eighty eight studies, involving 3470 patients, were included. The endoscopic cohort had a significantly greater rate of gross total resection (66.9% vs. 48.3%; P < 0.003) and improved visual outcome (56.2% vs. 33.1%; P < 0.003) compared with the open cohort. The transsphenoidal cohort had similar outcomes to the endoscopic group. The rate of cerebrospinal fluid leakage was greater in the endoscopic (18.4%) and transsphenoidal (9.0%) than in the transcranial group (2.6%; P < 0.003), but the transcranial group had a greater rate of seizure (8.5%), which did not occur in the endonasal or transsphenoidal groups (P < 0.003). Conclusions: The endoscopic endonasal approach is a safe and effective alternative for the treatment of certain craniopharyngiomas. Larger lesions with more lateral extension may be more suitable for an open approach, and further follow-up is needed to assess the long-term efficacy of this minimal access approach.

What Bone Part Is Important to Remove in Accessing the Suprachiasmatic Region with Less Frontal Lobe Retraction in Frontotemporal Craniotomies

2011-11-14

Background: The anterolateral approach is one of the main routes for accessing suprachiasmatic lesions involving the anterior communicating artery (AComA) complex. Pterional (PT) craniotomy and its alternatives, including orbitozygomatic, orbitopterional, and mini-supraorbital craniotomies, have been developed as tailored frontotemporal craniotomies. One of the main differences between PT craniotomy and its alternatives is the removal of the orbital bone along with the sphenoid wing. However, which bone part is the most important to remove has not been discussed in relation to frontal lobe retraction. We have evaluated how the removal of the supraorbital bar versus the removal of the lateral orbital wall along with the sphenoid wing affects the relationship between the levels of frontal lobe retraction and area of exposure (AOE) in the suprachiasmatic region. Methods: We performed three types of craniotomies: PT craniotomy, PT craniotomy with the removal of the supraorbital bar (PT-SO craniotomy), and PT craniotomy with the removal of the lateral orbital wall along with the sphenoid wing, i.e., the frontal process of the zygomatic bone and the orbital and cerebral faces of the greater sphenoid wing (PT-LO-SW craniotomy). For each craniotomy, the AOE around the suprachiasmatic region was measured at four different levels of frontal lobe retraction, namely, 5, 10, 15, and 20 mm, from the cranial base. Results: At 5-mm retraction, PT-LO-SW craniotomy was the only craniotomy in which the AComA complex was visible. At 10-mm retraction, PT-LO-SW craniotomy afforded the greatest AOE among the three craniotomies, and the AOE was significantly greater than that of PT craniotomy (P = 0.025). At 15- and 20-mm retraction, there were no significant differences among the three craniotomies. Conclusions: Treatment of lesions in the suprachiasmatic region via an anterolateral route involving a frontotemporal craniotomy requires sufficient removal of the lateral orbital wall along with the greater sphenoid wing so that brain retraction is minimized.

Do Grossly Identifiable Ganglia Lie Along the Spinal Accessory Nerve? A Gross and Histologic Study with Potential Neurosurgical Significance

2011-11-09

Objective: To elucidate further the anatomy of focal enlargements that have been observed along the spinal accessory nerve (SAN) as it courses within the posterior cranial fossa. Methods: Dissection of the posterior cranial fossa was performed on 27 adult cadavers with attention to the SAN and any focal enlargements associated with it. Results: Grossly, four specimens (14.8%) were found to have focal enlargements associated with the SAN within the posterior cranial fossa. These structures were in intimate contact with the dorsal aspect of the spinal portion of the SAN in all specimens and measured a mean diameter of 1.9 mm. One right-sided male specimen had two focal enlargements. All focal enlargements were found within 1 cm of the foramen magnum. Histologically, no ganglion or neuronal cells were identified within these focal enlargements in any specimen. These focal enlargements are best described as ectopic glial nests or heterotopias within the leptomeninges around the SAN. Conclusions: The focal enlargements located along the SAN should not be termed ganglia. These structures do not contain neural structures and should not be mistaken for pathology of the posterior fossa.

Repeated Percutaneous Balloon Compression for Recurrent Trigeminal Neuralgia: A Long-Term Study

Jyi-Feng Chen, Po-Hsun Tu, Shih-Tseng Lee — 2011-11-09

Background: Percutaneous balloon compression (PBC) is an alternative surgical treatment for trigeminal neuralgia refractory to carbamazepine. PBC is the preferred procedure for some patients. However, to our knowledge, the clinical results of repeat PBC have not been reported thus far. Objective: The aim of this study was to evaluate the outcomes of and the complication rates associated with repeat PBC performed for recurrent trigeminal neuralgia, over an 8-year study period. Methods: Until July 2004, we performed PBC in 272 consecutive patients with typical symptoms of unilateral trigeminal neuralgia at our hospital. PBC was successful in 43 patients, and they did not experience any pain for at least 3 months; however, symptoms recurred later. Among these 43 patients, 32 underwent a repeat (second) PBC whereas 11 received pharmacologic treatment. The repeat PBC was performed between March 2001 and December 2004, and the patients were followed up till June 2010. Results: Thirty-two patients with recurrent trigeminal neuralgia participated in this study. The follow-up period ranged from 5.08 to 8.75 years (mean, 6.43 years). After the repeat PBC, 30 patients (93.8%) experienced immediate relief from neuralgia. None of the patients developed transient diplopia or anesthesia dolorosa. Although 2 patients (6.2%) experienced severe hypoesthesia, they could tolerate it. Six patients (18.8%) showed limited mandibular activity. No major surgical or anesthetic complication was observed, and death did not occur. Pain did not recur in any patient for 3 months after the surgery. The symptoms recurred in 5 patients (16.7%) within 2 years, in 7 patients (23.3%) within 3 years, and in 12 patients (40%) within 5 years after the surgery. Over the 8-year study period, symptoms recurred in 13 patients (43.3%). Conclusions: Repeated PBC is recommended for patients with recurrent trigeminal neuralgia after the first PBC or other unsuccessful treatments. Although the recurrence rate associated with the repeat PBC was slightly higher than that associated with the first, repeated PBC was safe, less complicated, and associated with a low incidence of dysesthesia and had a high success rate.

Biomechanical Stability of a Posterior-Alone Fixation Technique After Craniovertebral Junction Realignment

2011-11-09

Objective: The aim of the current study was to investigate the biomechanical stability and fixation strength provided by a posterior approach reconstruction technique to realign the craniovertebral junction. Methods: We tested seven human cadaver occipito-cervical spines (occiput-C4) by applying pure moments of ±1.5 Nm on a spine tester. Each specimen was tested in the following modes: 1) intact; 2) injured; 3) spacers alone at C1-C2 articulation (S); 4) spacers plus C1-C2 Posterior Instrumentation (S+PI); and 5) spacers plus C1-C2 posterior instrumentation plus midline wiring (S+PI+MLW). C1-C2 range of motion for each construct was obtained in flexion-extension, lateral bending, and axial rotation. Results: In all the loading modes, S, S+PI, and S+PI+MLW constructs significantly reduced range of motion compared with the intact and injured condition (P < 0.05). There was no statistical difference between any of the three instrumentation constructs (P > 0.05). Conclusions: This study investigated the biomechanics of the posterior approach technique for realignment of the craniovertebral junction and also made comparisons with additional posterior fixations. The stand-alone spacers were stable in all three loading modes. Posterior instrumentation increased the stability as compared to stand-alone spacers. The third point of fixation, carried out by using midline wiring, increased the stability further. However, there was not much difference in the stability imparted with the midline wiring versus without. The present study highlights the biomechanics of this novel concept and reaffirms the view that distraction of the C1-C2 articular facets and direct articular joint atlantoaxial fixation would be an ideal method of management of basilar invagination.

Salvage C2 Ganglionectomy After C2 Nerve Root Decompression Provides Similar Pain Relief as a Single Surgical Procedure for Intractable Occipital Neuralgia

Jared M. Pisapia, Deb A. Bhowmick, Roger E. Farber, Eric L. Zager — 2011-11-09

Objective: To determine the effectiveness of C2 nerve root decompression and C2 dorsal root ganglionectomy for intractable occipital neuralgia (ON) and C2 ganglionectomy after pain recurrence following initial decompression. Methods: A retrospective review was performed of the medical records of patients undergoing surgery for ON. Pain relief at the time of the most recent follow-up was rated as excellent (headache relieved), good (headache improved), or poor (headache unchanged or worse). Telephone contact supplemented chart review, and patients rated their preoperative and postoperative pain on a 10-point numeric scale. Patient satisfaction and disability were also examined. Results: Of 43 patients, 29 were available for follow-up after C2 nerve root decompression (n = 11), C2 dorsal root ganglionectomy (n = 10), or decompression followed by ganglionectomy (n = 8). Overall, 19 of 29 patients (66%) experienced a good or excellent outcome at most recent follow-up. Among the 19 patients who completed the telephone questionnaire (mean follow-up 5.6 years), patients undergoing decompression, ganglionectomy, or decompression followed by ganglionectomy experienced similar outcomes, with mean pain reduction ratings of 5 ± 4.0, 4.5 ± 4.1, and 5.7 ± 3.5. Of 19 telephone responders, 13 (68%) rated overall operative results as very good or satisfactory. Conclusions: In the third largest series of surgical intervention for ON, most patients experienced favorable postoperative pain relief. For patients with pain recurrence after C2 decompression, salvage C2 ganglionectomy is a viable surgical option and should be offered with the potential for complete pain relief and improved quality of life (QOL).

Survival and Functional Outcome After Surgical Resection of Intramedullary Spinal Cord Metastases

2011-11-09

Objective: Intramedullary spinal cord metastasis (ISCM) is a rare manifestation of systemic cancer and data about the optimal management of these lesions are lacking. To clarify the role of surgery, we investigated survival and neurological outcomes after surgical resection of ISCMs. Methods: Between 2003 and 2010, we surgically treated 10 ISCMs in 9 patients. For each patient, we retrospectively collected the following data: demographic variables, history of prior cancer, site of primary cancer, extent of cancer on presentation, degree of resection, preoperative and postoperative spinal cord impairment (American Spinal Injury Association [ASIA] grade), and postoperative survival. We investigated the relationship between these variables, overall survival, and preservation of function. Results: Eight ISCMs were treated with gross total resection and two were treated with subtotal resection. Overall postoperative survival was 6.4 ± 9.4 months (mean ± standard deviation), with one patient still alive at last follow-up. Patients with a diagnosis of melanoma had higher mean survival than those with nonmelanoma histology (20.5 ± 13.4 vs. 2.4 ± 1.7 months, P < 0.01). Degree of resection, number of organ systems affected, ambulatory status, and ASIA grade pre operatively or postoperatively, were not significantly associated with survival. Of the nine patients, seven (78%) demonstrated no change in ASIA grade postoperatively, one (11%) improved, and one patient (11%) deteriorated. All patients who were ambulatory preoperatively remained ambulatory postoperatively and at last follow-up. Conclusions: Although ISCM is associated with poor prognosis, survival appears to be greater in patients with melanoma. Surgical resection does not appear to significantly lengthen survival but may be indicated to preserve ambulatory status in symptomatic patients.

Paraspinal Textiloma After Posterior Lumbar Surgery: A Wolf in Sheep's Clothing

2011-11-09

Objective: Paraspinal textiloma (ParaTex) is a well-known complication after posterior lumbar surgery. However, there are few articles on this topic, probably because of medicolegal concerns. In addition, patients with ParaTex can remain asymptomatic for months or even years unless it causes complications. The purpose of this study is to review our experience on this “undesirable” topic to increase awareness among spinal surgeons and radiologists and avoid unnecessary morbidity, which is still being encountered. Methods: This study is a retrospective case series of six patients with ParaTex who underwent posterior lumbar spinal surgery in our neurosurgical department between January 2000 and December 2010. The medical records of each patient were reviewed and demographic data, clinical characteristics, initial diagnosis, surgical procedures, time interval between operation and onset of symptoms, biological and radiologic findings, treatment, and outcome were analyzed. Results: The six patients included four women and two men with a mean age of 48 years. Four patients had a history of lumbar disc herniation, one had undergone a laminectomy for a lumbar spinal stenosis, and a Gill's procedure was performed in one patient with a lumbar spondylolisthesis. The time from the causative operation to presentation ranged from 2 months to 6 years. All patients presented with nonspecific lower back pain and/or surgical site infection without fever or neurological symptoms. Laboratory parameters showed increased blood sedimentation rates and/or C-reactive protein level in four patients. Bacteria were isolated in only one patient. Five patients were evaluated with computed tomography scan, and this showed the spongiform pattern with gas bubbles in three cases. Magnetic resonance imaging was performed in two patients. The signal intensity varies according to stage and fluid content of the lesion. The ParaTex was removed surgically in all patients with a good outcome. Conclusions: ParaTexs are more common in obese patients, after emergency surgery, and with unplanned changes in surgical procedure. On computed tomography scan, the classic spongiform appearance is highly suggestive. Magnetic resonance imaging findings are variable and less specific, but confrontation of imaging data with the surgical history helps with the preoperative diagnosis. In the early postoperative period symptoms are related to the exudative response; at later times symptoms may be linked to pseudotumor formation clinically and radiologically. Appropriate antibiotic therapy is recommended when a septic complication is present or suspected. Strict measures must be taken to prevent this complication. Surgical sponges should always be counted at least three times (preoperatively, at closure, and at the end), radiopaque markers should be used, and if there is doubt, intraoperative radiography must be performed.

Operation-Microscope-Mounted Touch Display Tablet Computer for Intraoperative Imaging Visualization

2011-11-09

Objective: The authors have developed a novel sterile draped touch display solution for convenient intraoperative access to imaging data. This study describes the technology and clinical experience of the system. Methods: We developed a flexible, mounted touch display solution (Apple iPad) that allows fixation of the display on the operation microscope and fine adjustments during surgery when the microscope is moved. We compared this setup with a conventional wall-mounted flat-panel and a mobile display stand in illustrative cases of vestibular schwannoma. Results: The surgeon was able to employ the system without the need to leave the operation field or the need for external assistance while referring to imaging data. Commanding through imaging data with sterile gloves on the touch display was more convenient, more precise, and faster compared with other modalities. Conclusion: The operation-microscope-mounted touch display provides useful assistance for intraoperative imaging visualization in neurosurgical procedures.

Use of Multimedia Messaging System (MMS) by Junior Doctors for Scan Image Transmission in Neurosurgery

Ji Min Ling, Kim Zhuan Lim, Wai Hoe Ng — 2011-11-18

Background: Multimedia Messaging Service (MMS) is used by neurosurgical residents to transmit scan images to the attending neurosurgeon in conjunction with telephone consultation. This service has been well received by the attending neurosurgeons, who felt that after viewing scan images on their phones, they felt increased confidence in clinical decision making and that it reduced the need for recall to the hospital. Objective: The use of MMS can be extended to junior doctors making referrals from regional hospitals with no neurosurgical cover. This study aims to validate the competency of non-neurosurgically trained junior doctors in selecting optimal images to transmit via MMS to the attending neurosurgeon on call. Methods: Ten junior doctors with no formal neurosurgical training and five neurosurgical residents were interviewed. They were shown the full complement of images together with relevant clinical history and assessment. They were then asked to make the radiological diagnosis and then select two images for MMS transmission to the attending neurosurgeon that they thought would best aid the neurosurgeon in clinical decision making. The attending neurosurgeon was asked to comment, on each image, whether his management plan would differ if he was shown the entire series of the images. Results: All the images chosen are deemed appropriate, and the decision made based on the MMS images would be similar if the entire series of images were available to the neurosurgeon. However, 7 of 10 junior doctors were unable to read magnetic resonance images of lumbar spine. There was no significant difference in the images chosen by the neurosurgical residents and the junior doctors. Conclusion: It is feasible and safe for junior doctors to utilize MMS to transmit computed tomographic images to a neurosurgeon while making an urgent referral. The images selected are representative of the disease pathology and facilitate clinical decision making.

A Simple Method for Evaluating the Quality of Microvascular Anastomoses Performed In Vitro

2011-11-09

Objective: The aim of this paper is to describe a simple and effective method for evaluating the quality of microvascular anastomoses performed in vitro. Methods: After the microvascular anastomosis has been performed in vitro, the vessel is cannulated at a distance of several millimeters from the anastomosis site with a catheter that is connected to a syringe filled with commercially available silicone glue. The silicone glue is slowly injected into the artery until the whole specimen is filled. Small leaks at the anastomosis site can be seen directly as the silicone glue will slowly extrude at the point of a leak. Then, the catheter is withdrawn and the specimen, filled with silicone, is left for several hours to solidify. Subsequently, the specimen is immersed in H2O2 for several hours in order to dissolve the tissue from the silicone cast. In this manner, the cast of the silicone represents the virtual lumen of the blood vessel and the print of the lumen surface. Results: Using this method, several important technical aspect of the anastomosis can be easily evaluated, such as diameter differences of the blood vessel, stricture, narrowing, irregularities of the vessel wall, leakage through the anastomotic site, and the alignment of the vessel walls. Conclusion: The silicone cast method as described in this study can be used to evaluate some technical aspect of a microvascular anastomosis performed in vitro. Moreover, it can be used to monitor the progress of the trainee and as an aid in improving and mastering vascular microsurgery.

Outpatient-Based Scalp Surgery without Shaving and Allowing Use of Shampoo

2011-11-18

Objective: To assess the authors' experience of wound management following scalp mass surgery after introducing a policy of leaving hair unshaved and allowing patients to use shampoo. Methods: The authors retrospectively reviewed 93 patients who underwent outpatient-based excision of a scalp or skull mass. Surgical complications, mass depth, and maximal mass size were analyzed. All of the surgeries were performed without shaving around the lesion; the hair was simply parted along the proposed incision, and the parting was maintained using adhesive plasters. Routine antiseptic scalp preparations, skin closure with staples after mass excision, and topical ointment on the day following surgery were used, and use of shampoo was allowed. The staples were removed on postoperative days 7–10. Results: The masses were located in the skin (23 cases), subcutaneously (64 cases), and subgaleally (6 cases). All patients except one had satisfactory wound healing. No infections occurred. Conclusions: Leaving hair unshaved and allowing patients to use shampoo can be applied in wound management after scalp mass surgery.

“Any Possible Restoration of Function Could Not Occur”: Harvey Cushing and the Early Description of Brain Death

2011-11-09

Objectives: To describe a case from 1908 of apparent brain death after operative intervention by Harvey Cushing at the Johns Hopkins Hospital. Methods: After institutional review board approval, which waived the requirement of informed consent from patients, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912. Results: We selected a single adult patient operated upon by Cushing, whose respirations ceased in the operating room and who was maintained by the use of artificial respiration via a tracheostomy during a 36-hour period, whereas further surgical interventions were performed in an attempt to improve his condition. The patient's condition remained unimproved; artificial respirations were discontinued and the “cessation of all cardiac activity” was observed. Conclusions: Brain death is a concept that presents unique challenges to the practicing physician. Although recent advances have allowed for better diagnosis of brain death, the topic remains fraught with controversy. The case described here documents Harvey Cushing's struggles with the ethics of maintaining vital organ function with artificial respiration, despite clear evidence of irreversible ischemic brain damage. This case predates the earliest descriptions of brain death by more than 50 years and illustrates the dilemmas facing clinicians at the turn of the twentieth century.

Bypass or Not? Adjustment of Surgical Strategies According to Motor Evoked Potential Changes in Large Middle Cerebral Artery Aneurysm Surgery

Liang Chen, Liqin Lang, Liangfu Zhou, Donglei Song, Ying Mao — 2011-12-02

Objective: To report the use of neuroelectrophysiologic monitoring to alter the course in aneurysm surgery to minimize postoperative infarction and bypass-related adverse events. Methods: Two patients with large middle cerebral artery (MCA) aneurysms were admitted to the authors' hospital. Direct clipping seemed to be difficult, and postoperative paralysis was not rare in the authors' experience owing to prolonged temporal occlusion of the parent artery. Balloon test occlusion (BTO) was positive in one patient, who developed paralysis and aphasia 3 minutes after balloon occlusion of the feeding M1 artery. A bypass procedure seemed to be inevitable in both patients. Motor evoked potentials (MEPs) and sensory evoked potentials (SEPs) were used for monitoring during the operation. Results: For the patient with a positive BTO result, MEP waves did not change until 17 minutes after temporary clip placement. The aneurysm was clipped, and the occlusion time was 24 minutes. MEP waves recovered quickly after reperfusion. In the other patient, there were early changes in MEP waves after temporary clipping. After bypass construction from the temporal artery to the inferior M2 trunk, the time window of safe occlusion was prolonged to 7–8 minutes. Both the aneurysm and the bypassed branch were obliterated, and the clip reconstruction was done to preserve the flow from M1 to the superior M2 trunk. Permanent postoperative disability did not occur in either patient. Conclusions: Intraoperative physiologic monitoring is a complementary method to preoperative BTO to evaluate the window of safe occlusion with high reliability.

Temporary Occlusion Test Using a Microcatheter

Lei Huang, Chi Shing Zee, Xiao Long Zhang — 2011-11-09

Background: The balloon occlusion test (BOT) is a well-accepted technique for the treatment of large or complex aneurysms. However, this procedure may not be feasible for small arteries such as the posterior inferior cerebellar artery (PICA). We report our experience with endovascular treatment of a fusiform PICA aneurysm employing a microcatheter occlusion test. Case Description: A 46-year-old male had a fusiform Type I aneurysm with irregular wall in the lateral medullary segment of left PICA. Because the BOT cannot be safely performed in the PICA, we performed a temporary occlusion test using a microcatheter. Results: The microcatheter occlusion test was successfully performed, and endovascular treatment was performed afterward. The patient remained symptom free after the embolization and at one-year follow-up. Conclusion: The microcatheter occlusion test is an excellent option for performing an occlusion test for vessels that cannot accommodate a balloon because of their diminutive size.

Multiple Intracranial Aneurysms Associated with Multiple Dural Arteriovenous Fistulas and Cerebral Arteriovenous Malformation

Mingchang Li, Ning Lin, Jianwei Wu, Jianfeng Liang, Weiwen He — 2011-11-09

Background: The association between intracranial aneurysms and arteriovenous malformations (AVMs) or dural arteriovenous fistulas (DAVFs) has been well documented, and the changes in cerebral blood flow dynamics were thought to be one of the major causes. There has not been a report on intracranial aneurysms associated with multiple DAVFs and AVMs in the same patient. Methods: The authors report a unique case of multiple intracranial vascular pathologies, including 5 aneurysms, 2 DAVFs, and 1 AVM coexisting in a single patient. The patient presented with headache and left hemiparesis and was found to have 4 bilateral internal carotid aneurysms, 1 ruptured right pericallosal aneurysm, 2 frontoparietal DAVFs, and 1 right temporal AVM. Results: Endovascular coiling and Onyx embolization successfully occluded 4 aneurysms and both DAVFs. The patient remained asymptomatic at 1-year follow-up. Conclusions: To our knowledge, this is the first report of a very rare case with a unique combination of cerebrovascular pathologies including multiple aneurysms, DAVFs, and 1 high-grade AVM. Analyzing the hemodynamic relationships of these concurrent lesions is essential to determine the hemorrhage risk of each lesion and the order of priority in management. Flow-related aneurysms with irregular morphology require early, aggressive treatment.

Anterior-to-Posterior Circulation Approach for Mechanical Thrombectomy of an Acutely Occluded Basilar Artery Using the Penumbra Aspiration System

2011-11-09

Objective: Prompt access to arterial occlusion is the key to successful endovascular revascularization in acute stroke. We present the first reported case utilizing anterior-to-posterior circulation approach for a successful mechanical thrombectomy and chemical thrombolysis of an acute basilar artery (BA) occlusion using the Penumbra Aspiration System. Methods: A 39-year-old man with known left vertebral artery (VA) occlusion presented with a rapid progression of top of the basilar syndrome, resulting in a comatose status with flaccid motor exam and no corneal reflex. Navigation of a guide catheter into the right VA was unsuccessful because of an acute angle created by the previously placed right VA ostial stent that herniated into the subclavian artery. Left internal carotid artery–selective angiography revealed a prominent left posterior communicating artery. A Penumbra 026 reperfusion catheter was advanced into the thrombosed BA via the left internal carotid artery, the posterior communicating artery, and the P1 segment. Mechanical thrombectomy and chemical thrombolysis were successfully performed. Results: TIMI-3 in the BA and TIMI-2 flows in posterior cerebral arteries were restored 8 hours 16 minutes after symptom onset. The patient had recovered full strength in all four extremities at 10 hours after the onset and had a National Institutes of Health Stroke Scale score of 2 at discharge. Conclusion: In patients with unfavorable VA anatomy, anterior-to-posterior thrombectomy of the BA can be successfully achieved using the Penumbra catheter via an anatomically suitable posterior communicating artery.

Endoscopic Supracerebellar Infratentorial Retropineal Approach for Tumor Resection

Kuan-Yin Tseng, Hsin-I Ma, Wei-Hsiu Liu, Chi-Tun Tang — 2011-11-09

Background: Lesions located in the pineal region represent a surgical challenge. Multiple approaches to this region have been described, each with its advantages and disadvantages. We report the first application of the endoscopic supracerebellar infratentorial approach for complete resection of a pineal tumor. Unlike transventricular endoscopy, this technique poses no risk to the fornices and can be applied independent of ventricular size. Case Description: A 21-year-old man sought treatment for diplopia. Magnetic resonance images of brain revealed a heterogeneous, contrast-enhancing mass that originated from the pineal gland. This tumor exerted the mass effect on the tectum and invaded to the bilateral dorso-medial thalamus and hypothalamus but caused no obstructive hydrocephalus. The results of a cytological study of the cerebrospinal fluid, alpha-fetoprotein, and beta-human chorionic gonadotropin were negative. The patient was referred for the surgical work-up. Technique: The patient was positioned in the semi-sitting position. The supracerebellar infratentoria corridor was accessed through two paramedian burr holes, which provided natural by-gravity cerebellar traction. The excellent illumination and magnification without sacrificing the inferior occipital sinus could be achieved with the aid of the endoscope. The pineal tumor was resected completely via the full-endoscopic approach. Postoperatively, the patient's diplopia resolved completely, and his hospital course was uneventful. Conclusions: Taking the advantages of the endoscope and peculiar supracerebellar infratentoria corridor, we could successfully remove the gross-total tumor without violating the critical neurovascular structures. Moreover, this approach can be performed regardless of the size of the ventricle. Consequently, it is an excellent minimally invasive surgical option for resection of symptomatic pineal tumor.

Stepwise Synchronization Through the Corpus Callosum Is One Cause of Myoclonic Jerks

Yasushi Iimura, Hidenori Sugano, Madoka Nakajima, Hajime Arai — 2011-11-09

Background: Epileptic myoclonus is generally treated by valproate monotherapy, and this therapy has confirmed efficacy. However, almost 30% of patients with juvenile myoclonic epilepsy (JME) are valproate-resistant. Case Description: A 23-year-old man with a diagnosis of JME had resistance to multiple antiepileptic drugs (AEDs). Stepwise synchronization of bilateral spikes on electroencephalography (EEG) was found shortly before the clinical myoclonus. The anterior two thirds of the corpus callosum were divided. Desynchronization of spikes by the corpus callosotomy arrested the patient's myoclonus. Conclusions: Interhemispheric recruitment of epileptic spikes through the corpus callosum may induce synchronization of spikes and myoclonus.

Neuroendoscopic Diagnosis of Central Nervous System Histoplasmosis with Basilar Arachnoiditis

Leonardo Rangel-Castilla, Steven W. Hwang, A. Clinton White, Yi Jonathan Zhang — 2011-11-09

Objective: Histoplasmosis of the central nervous system (CNS) is seen in 10% to 20% of patients with disseminated histoplasmosis and/or in association with immunocompromised patients. Meningitis, arachnoiditis, and hydrocephalus are the most common clinical manifestations of CNS histoplasmosis. Patients with CNS histoplasmosis present similarly to other infectious etiologies, and confirmatory diagnosis is important in the management of these patients. However, diagnosis of CNS histoplasmosis can be difficult, and sometimes performing a parenchymal biopsy is necessary to confirm the diagnosis. Methods and Results: We describe the case of a 41-year-old man with HIV/AIDS who presented with the signs, symptoms, and radiologic evidence of basal meningitis and hydrocephalus. Cerebrospinal fluid (CSF) analysis from multiple lumbar punctures was negative. The patient underwent a neuroendoscopic procedure with diagnostic and therapeutic goals. Internal CSF diversion (endoscopic third ventriculostomy) and biopsy of the floor of the third ventricle and subarachnoid space were performed; surgical biopsies identified noncaseating granulomas, and ventricular CSF was positive for Histoplasmosis antibodies. The patient was treated with liposomal amphotericin B and itraconazole. The patient had resolution of his symptoms immediately after surgery, and 1-month follow-up computed tomography of the head demonstrated resolution of the hydrocephalus. At the last follow-up 12 months postoperatively, the patient has not required insertion of a ventriculoperitoneal shunt. Conclusion: Clinicians should maintain a high index of suspicion for fungal basal meningitis in patients with AIDS and hydrocephalus. With nondiagnostic lumbar CSF sampling, neuroendoscopy can be considered as an alternative for diagnosis and treatment of basal meningitis and hydrocephalus.

2012-02-01

Editorial Board

2012-02-01

Global Associates

2012-02-01

Subscription Information

2012-02-01

Member Societies

2012-02-01

Editor's Choices

2012-02-01

World Neurosurgery

A Dragon Rises

WORLD NEUROSURGERY Neurosurgeon of the Year 2012: Liangfu Zhou

The Neurosurgeon “Academician” in China

Liangfu Zhou: Clinical Neurosurgeon, Academician, Teacher, and Friend

Neurosurgeon of the Year

Short comment on Professor Zhou

Neurosurgeon of the Year

Neurosurgeon of the Year

Zhou dynasty and the art of neurosurgery

An Academic Leader, Professor Liang-Fu Zhou

Neurosurgeon of the Year

WORLD NEUROSURGERY's “Neurosurgeon of the Year” for 2012, Liang Fu Zhou

Comment of Prof. Liang-Fu Zhou

Neurosurgeon of the year 2012: Liang-fu Zhou Commentary

Comment to professor Liangfu Zhou in China

Professor L. F Zhou

Comments on “Neurosurgeon of the Year” for 2012

Neurosurgeon of the year 2012, Professor Liangfu Zhou by Professor Dingbiao Zhou

Preoperative Planning for Cerebral Aneurysms Based on In Vitro Experimentation: Are We There Yet?

What Is the Best Medical Treatment for Symptomatic Intracranial Stenosis?

Glioma Stem Cells: Their Role in Chemoresistance

Cerebral Collateral Circulation: Integral to Defining Clinical Outcome in Acute Cerebral Ischemia

Endovascular Neurosurgery in Europe and in Italy: What Is in the Future?

Neurosurgery in Siberia

Tailor the Procedure to the Patient: About Vascular and Endovascular Neurosurgeons or Both

The Way to an Open and Structured Training for Neuroendovascular Therapy in Europe: What Is the Current Situation?

Reflections on the Benefits and Pitfalls of Ultra-Early Aneurysm Treatment After Subarachnoid Hemorrhage

Treatment of Ruptured Aneurysms: Earlier is Better

Transcranial Doppler: A Simple Way to Estimate the Effect of Radiosurgery in Arteriovenous Malformations

Arteriovenous Malformation Radiosurgery: Now You See It, Now You Don't

Transcranial Ultrasound for Arteriovenous Malformations: Something Old Is New Again

The Cost of Brain Metastasis Management

The Evolving Role of the Transsphenoidal Route in the Management of Craniopharyngiomas

Treatment Options for Refractory Trigeminal Neuralgia

The Employment of the “Sniff Test”

Critical Evaluation of Biomechanical Stability of Craniovertebral Junction Realignment Based on an Experimental Study

Does Ganglionectomy Still Have a Role in the Era of Neuromodulation?

Lumbar Textilomas: A Neurosurgical Complication Rarely Touched

The Value of Teleradiology in Neurosurgery

Should a Picture Ever Replace a Thousand Words? Harnessing Technology without Compromising Neurosurgical Resident Education and Patient Care

The Value of Translational Models for Microvascular Anastamosis

To Clip or Not to Clip, That is the Question?

Barber Surgeon, or Surgeon Barber?

Harvey Cushing and the Subject of Brain Death in 1908: An Early Neurosurgical Dilemma and Putting It All into Perspective

Harvey Cushing and Brain Death

Cross-Circulation Techniques for Endovascular Revascularization of Acute Stroke

Surgical Options for Pineal Region Tumors

Corpus Callosotomy: What Is New and What Is Relevant?

Neuroendoscopy in Diagnosis and Treatment of Hydrocephalus by Basal Meningitis

Can the Release of Only Few Subarachnoidal and Basal Cistern Adhesions Resolve Postinfective Hydrocephalus?

Ultra-Early (within 24 Hours) Aneurysm Treatment After Subarachnoid Hemorrhage

Hemodynamic Changes in Arteriovenous Malformations After Radiosurgery: Transcranial Doppler Evaluation

The Cost-Effectiveness of Stereotactic Radiosurgery versus Surgical Resection in the Treatment of Brain Metastasis in Vietnam from the Perspective of Patients and Families

Endoscopic Endonasal Compared with Microscopic Transsphenoidal and Open Transcranial Resection of Craniopharyngiomas

What Bone Part Is Important to Remove in Accessing the Suprachiasmatic Region with Less Frontal Lobe Retraction in Frontotemporal Craniotomies

Do Grossly Identifiable Ganglia Lie Along the Spinal Accessory Nerve? A Gross and Histologic Study with Potential Neurosurgical Significance

Repeated Percutaneous Balloon Compression for Recurrent Trigeminal Neuralgia: A Long-Term Study

Biomechanical Stability of a Posterior-Alone Fixation Technique After Craniovertebral Junction Realignment

Salvage C2 Ganglionectomy After C2 Nerve Root Decompression Provides Similar Pain Relief as a Single Surgical Procedure for Intractable Occipital Neuralgia

Survival and Functional Outcome After Surgical Resection of Intramedullary Spinal Cord Metastases

Paraspinal Textiloma After Posterior Lumbar Surgery: A Wolf in Sheep's Clothing

Operation-Microscope-Mounted Touch Display Tablet Computer for Intraoperative Imaging Visualization

Use of Multimedia Messaging System (MMS) by Junior Doctors for Scan Image Transmission in Neurosurgery

A Simple Method for Evaluating the Quality of Microvascular Anastomoses Performed In Vitro

Outpatient-Based Scalp Surgery without Shaving and Allowing Use of Shampoo

“Any Possible Restoration of Function Could Not Occur”: Harvey Cushing and the Early Description of Brain Death

Bypass or Not? Adjustment of Surgical Strategies According to Motor Evoked Potential Changes in Large Middle Cerebral Artery Aneurysm Surgery

Temporary Occlusion Test Using a Microcatheter

Multiple Intracranial Aneurysms Associated with Multiple Dural Arteriovenous Fistulas and Cerebral Arteriovenous Malformation

Anterior-to-Posterior Circulation Approach for Mechanical Thrombectomy of an Acutely Occluded Basilar Artery Using the Penumbra Aspiration System

Endoscopic Supracerebellar Infratentorial Retropineal Approach for Tumor Resection

Stepwise Synchronization Through the Corpus Callosum Is One Cause of Myoclonic Jerks

Neuroendoscopic Diagnosis of Central Nervous System Histoplasmosis with Basilar Arachnoiditis

Contents

Editorial Board

Global Associates

Subscription Information

Member Societies

Editor's Choices