World Neurosurgery - Articles in Press

Acute Normovolemic Hemodilution is Safe in Neurological Surgery - Accepted Manuscript

Paulo P. Oppitz, Marco A. Stefani — 2012-02-15

Abstract: Background: Neurosurgical procedures can be associated with considerable blood loss and transfusion requirements. Transfusion of allogenic blood products, although potentially life-saving, may lead to complications. The primary aim of this study was to determine the safety of acute normovolemic hemodilution (ANH) for patients undergoing neurosurgical procedures. Method: 100 patients submitted to neurosurgical procedures were assigned prospectively to receive ANH. A group of 47 patients who underwent craniotomy for aneurysm clipping and standard anesthetic management was used as control. Findings: Procedures conducted under ANH were performed without significant variations on the physiologic paramethers. Compared with controls, intraoperative blood loss, operative time, incidence and grade of complications, as well as length of hospital stay were similar between the two groups. Although the ANH group presented a difference in prothrombin levels prior to and post hemodilution procedures, it was still considered within physiologic parameters. Platelet counts and PTT levels indicated no significant variations in either group. During the ANH procedure it was observed a considerable reduction of brain oxygen extraction in individuals with worse preoperative neurological status (p< 0.05), indicating potential benefit. Among cerebral aneurysm patients, those with good initial clinical grades had better clinical results scored by the Glasgow Outcome Scale (p< 0.02). Conclusions: ANH is a safe procedure for neurosurgical patients. Further studies are still necessary in order to confirm the improvement on brain oxygen extraction and the clinical impact. Nonetheless, aneurysm clipping patients with good clinical grades seem to profit from ANH.

The Neapolitan tradition of Yacht clubs - Accepted Manuscript

Claudio Pensa, Paolo Cappabianca — 2012-02-15

An History of Ventricular Neuroendoscopy - Accepted Manuscript

Philippe Decq, Henry Schroeder, Michael Fritsch, Paolo Cappabianca — 2012-02-13

Abstract: Objectives: Description of the history of neuroendoscopy through the history of the major neurosurgeons who worked and published on the field. Material and method: All relevant data described on publications before 1980 about history of neuroendoscopy found through OVID MEDLINE searches and related references. Results: Contribution of 14 pioneers neurosurgeons to neuroendoscopy were described in chronologic order: VD Lespinasse, WE Dandy, E Payr, WJ Mixter, T Fay, F Grant, J Volkman, TJ Putnam, A Dereymacker, JE Scarff, M Feld, G Guiot, T Fukushima and HB Griffith. Conclusion: An historical review of ventricular neuroendoscopy remains by essence incomplete. Medical technical progress is slow but real, proceeding by leaps and bounds, related to the ingenuity of surgeons able to understand rapidly the value of a technical change to improve their surgical procedure. Remaining attentive to our patients, their evolution and the evolution of modern technology, these are the qualities required to make further progress in the field of neuroendoscopy.

The Neurosurgeon “Academician” in China - Uncorrected Proof

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.

How Old Is Cancer? - Uncorrected Proof

Eberval G. Figueiredo, Edson Bor-seng Shu, Manoel J. Teixeira — 2012-02-13

Cancer is second only to cardiovascular disease as cause of death in industrialized societies (). Understanding its etiology, pathogenesis, and occurrence in historical periods has the potential to improve the effectiveness of its treatment (). There seem to be no doubts that the excesses of modern life, such as pollution, alcohol and nicotine use, and poor diet, are related to higher incidence of malignancies. The first reports in the scientific literature of distinctive tumors occurred in the 1700s, including scrotal cancer in chimney sweeps (1775) and nasal cancer in snuff users (1761) (). However, evidence of cancer occurrence in antiquity, when environment factors did not constitute issues, is scarce ().

A Review of Reported Complications Associated with the Pipeline Embolization Device - Uncorrected Proof

Kyle M. Fargen, Gregory J. Velat, Matthew F. Lawson, J. Mocco, Brian L. Hoh — 2012-02-13

Flow diversion devices have gained considerable attention recently as an alternative means of treating large or giant wide-necked aneurysms. The Pipeline Embolization Device (PED; ev3, Plymouth, Minnesota, USA) obtained U.S. Food and Drug Administration approval in April of 2011 for the treatment of aneurysms occurring between the petrous and superior hypophyseal internal carotid artery segments. Initial studies evaluating its efficacy and associated morbidity and mortality have been promising (). However, there have been several recent reports of serious complications after PED deployment that warrant attention from the endovascular community (). The purpose of this article is to collect these reported complications in the literature into one summary, as a reference to enhance physician awareness of the risks associated with PED treatment.

The “cook-book” approach to generating cell type of interest: anterior pituitary cells from embryonic stem cells - Accepted Manuscript

M. Yashar S. Kalani — 2012-02-13

The pharmacogenomics of clopidogrel - Accepted Manuscript

Michael R. Levitt, Joshua W. Osbun, Louis J. Kim — 2012-02-13

Neuroendoscopy in the Youngest Age Group - Accepted Manuscript

Shlomi Constantini, Spyros Sgouros, Abhaya Kulkarni — 2012-02-10

Third ventriculostomy in shunt malfunction - Accepted Manuscript

2012-02-10

Abstract: Background: Endoscopic third ventriculostomy (ETV) is the treatment of choice for non-communicating hydrocephalus. In the last decade, its routine use has taken place also in patients who have previously undergone shunt placement (secondary ETV). Methods: The authors review the specific anatomy of ventricular system in patients presenting with shunt malfunction, the criteria for patients selection and the results of ETV performed as alternative of shunt revision in case of shunt malfunction or infection. Results and conclusions: The success rate of secondary ETV in well selected cases is not different from primary ETV; it should be reasonable to offer all patients with blocked shunts and suitable anatomy indicating an obstructive cause, the opportunity of shunt independence regardless of the original cause of the hydrocephalus. Shunt infection should not be considered a contraindication to ETV, even if the success rate may be lower. Considering the higher complication rate and higher risk of intraoperative failure, secondary ETV should be performed by expert neuro-endoscopists.

Redo third ventriculostomy - Accepted Manuscript

D. Hellwig, M. Giordano, C. Kappus — 2012-02-10

Abstract: Objective: Endoscopic Third Ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus. In some cases a reclosure of the ventriculostoma occurs. This could be caused by different reasons as operative technique, size of the stoma, scarring or a persisting Liliequist’s membrane. Methods: The database of the Neurosurgical Department of the Philipps University Marburg and the International Neuroscience Institute (INI) Hannover have been explored. The medical reports of patients who suffered from hydrocephalus and treated with ETV between 1990 and 2010 were reviewed with special consideration of a not patent ventriculostoma and a repeated ETV. Results: Out of 148 patients with ETV we had 14 patients where the stoma was not patent. In 8 of those we did a successful second ventriculostomy. 5 patients were treated by application of a ventriculo-peritoneal shunt. One patient died due to an acute obstructive hydrocephalus due to the closure of the ventriculostoma. The success rate repeat ETV has been 87.5%. Conclusion: In cases of secondary closure of the stoma after ETV the endoscopic re-ventriculostomy is recommended using the same operative approach and should be taken into consideration before the application of a CSF diversion system.

ETV for Idiopathic Aqueductal Stenosis - Accepted Manuscript

Pietro Spennato, Sanna Tazi, Olivier Bekaert, Giuseppe Cinalli, Philippe Decq — 2012-02-10

Abstract: Background: Idiopathic aqueductal stenosis is a cause of non communicating hydrocephalus which actual treatment by Endoscopic third ventriculostomy (ETV) could be assess without any interference with the etiology. The results of ETV in this indication could be therefore interpret as the results of the surgical procedure alone, without any additional factors related to the etiology of the CSF pathways obstruction like haemorrhage, infection, brain malformations and brain tumors or cysts. Methods: Following a brief description of pathogenesis of hydrocephalus in aqueductal stenosis, the authors review the literature for studies on ETV, extrapolating patients with idiopathic aqueductal stenosis in infancy, childhood and adulthood. Differences in outcome between patients treated with ETV and patients treated with ventriculo-peritoneal shunt (VPS) are also reviewed. Results: The overall success rates of ETV ranges between 23% to 94% , with a mean of 68%; when only patients affected by obstructive tri-ventricular hydrocephalus secondary to aqueductal stenosis are considered, the success rate is actually quite homogeneous and stable, being above 60% at any age, even if a trend in lower success rate in very young infant (under 6 months of age) is noticeable. The few reports on intellectual outcome failed to demonstrate differences between ETV and VPS. Conclusion: Several issues, such as the cause of failures in well selected patients, long term outcome in infant treated with ETV, effect of persistent ventriculomegaly on neuropsychological developmental, remain unanswered. Larger and more detailed studies are needed.

Third ventriculostomy in Normal Pressure Hydrocephalus - Accepted Manuscript

Jothy Kandasamy, Jawad Yousaf, Conor Mallucci — 2012-02-10

MRI of Non-communicating Hydrocephalus - Accepted Manuscript

Jérôme Hodel, Alain Rahmouni, Marc Zins, Alexandre Vignaud, Philippe Decq — 2012-02-10

Interhemispheric and quadrigeminal cysts - Accepted Manuscript

2012-02-10

Abstract: Background: Interhemispheric and quadrigeminal cysts are rare lesions, joined by their propensity to present in young babies and to be associated with other central nervous system malformation, such as corpus callosum agenesia, holoprosencephaly, encephalocele and neuronal heterotopias. Recently endoscopy has obtained increasing popularity in the treatment of arachnoid cysts, but experience with cysts located in the interhemispheric fissure and in the quadrigeminal cistern is limited. Methods: The authors review the specific anatomy of interhemispheric and quadrigeminal cysts and their relationship with the ventricular system and subarachnoid cisterns, in order to select the most appropriated treatment. They also review the literature on endoscopic treatment of interhemispheric and quadrigeminal cysts. Results and conclusions: Interhemispheric and quadrigeminal cysts are not homogeneous, but they have different extension toward surrounding regions. In most cases it is present an area of contiguity between the cyst and ventricular system and/or subarachnoid cisterns, making endoscopic treatment feasible. The success rate for endoscopic treatment is not different from that reported in large series of arachnoid cysts elsewhere. Thereafter endoscopic treatment should be considered the first line option also in the treatment of such lesions, even if, some complications, such as subdural collections, due to thinness of cerebral mantle, or subcutaneous CSF collections, due to often multifactorial associated hydrocephalus, have to be expected.

Neuroendoscopic Management of Suprasellar Arachnoid Cysts - Accepted Manuscript

M. Memet Özek, Kamran Urgun — 2012-02-10

Neuroendoscopic Management of Middle Fossa Arachnoid Cysts - Accepted Manuscript

Guillermo Fernández Molina — 2012-02-10

Endoscopic Aqueductoplasty and Stenting - Accepted Manuscript

Michael J. Fritsch, Henry W.S. Schroeder — 2012-02-10

Complications of Endoscopic Third Ventriculostomy - Accepted Manuscript

Triantafyllos Bouras, Spyros Sgouros — 2012-02-10

Abstract: The treatment of choice for several types of obstructive hydrocephalus is endoscopic third ventriculostomy. However, in certain cases ETV is not clearly superior to shunt placement, and a question of choice rises. Apart from the possibility of success in each case, knowledge of complication rates is of major importance, as well. Several series of ETVs have been published by various specialized centers. Reported overall complication rate is usually between 5 and 15% and related permanent morbidity lower than 3%. The reported mortality of ETV is lower than 1%. The most frequent intra-operative complications of ETV are hemorrhage (the most severe being due to basilar rupture) and injury of neural structures. In the immediate post-operative period, hematomas, infections and CSF leaks may present. Morbidity can be neurological and/or hormonal. Systemic complications are related to the patient’s general status and less to the procedure itself. Late sudden deterioration, leading as a rule to patient’s death, has been reported. It’s incidence is not exactly known but probably is lower than 0.1%. Nevertheless, the severity of this complication necessitates alertness and informing of the patient. In conclusion, the complication rate of ETV is low and rarely a reason of choosing shunt placement instead. However, as a method it requires considerable experience and several studies report a relation of experience not only with success rates, but with complication avoidance as well.

Endoscopic Management of Complex Hydrocephalus - Accepted Manuscript

Charles Teo, David Kadrian, Caroline Hayhurst — 2012-02-10

Indication for ETV - Accepted Manuscript

John Mugamba, Vita Stagno — 2012-02-10

Third Ventriculostomy and Fourth Ventricle outlets obstruction - Accepted Manuscript

Enrique Ferrer, Matteo de Notaris — 2012-02-10

Endoscopic Third Ventriculostomy and Posterior Fossa Tumors - Accepted Manuscript

Federico Di Rocco, Carlos Eduardo Jucá, Michel Zerah, Christian Sainte-Rose — 2012-02-10

Abstract: Background: The management of hydrocephalus associated to a posterior fossa tumor is debated. Some authors emphasize the advantages of an immediate tumor removal which may normalize the cerebrospinal fluid (CSF) dynamics. However, in the clinical practice the mere excision of the lesion has been demonstrated to be accompanied by a persisting hydrocephalus in about one third of the cases. Preoperative endoscopic third ventriculostomy (ETV) offers several advantages. It may control the intracranial pressure (ICP), avoid the necessity of an emergency procedure, allow to schedule the operation for tumor removal appropriately, and eliminate the risks related to the presence of an external drainage. The procedure also reduces the incidence of postoperative hydrocephalus. A final advantage, more difficult to weight, but obvious to the neurosurgeon, is the possibility to remove the lesion with a relaxed brain and normal ICP. In the post-operative phase, ETV can be used in case of persisting hydrocephalus, both in patients who underwent only the excision of the tumor or also in subjects whose preoperative ETV failed as a consequence of intraventricular bleeding with secondary closure of the stoma (redoETV). The main advantage of postoperative ETV is that the procedure is carried out only in case of persisting hydrocephalus; its use is consequently more selective than preoperative ETV. The disadvantage consists in the common use of an external CSF drainage in the first post-operative days which is necessary to control the pressure and for ruling out those cases that reach a spontaneous cure of the hydrocephalus. Methods: The authors review the criteria for patient selection and the results of ETV performed in case of hydrocephalus secondary to a posterior fossa tumor. Results and conclusions: preoperative ETV constitutes an effective procedure for controlling the hydrocephalus associated to posterior fossa tumors. It might lower the rate of persistent postoperative hydrocephalus and result in a short hospital stay. Low rates of patients requiring an extrathecal – CSF shunt device are also reported by authors who utilize ETV postoperatively. As, however, the assessment of the persistent hydrocephalus in these children is based on prolonged ICP monitoring through an external CSF drainage, their results are weighted by a major risk of infective complications and longer duration hospital stay.

Neurocysticercosis - Accepted Manuscript

Samuel T. Zymberg — 2012-02-10

Pineal Region Tumors: Simultaneous Endoscopic Third Ventriculostomy (ETV) and Tumor Biopsy - Accepted Manuscript

Peter F. Morgenstern, Mark M. Souweidane — 2012-02-10

Endoscopic treatment of intraventricular cystic tumors - Accepted Manuscript

Konstantinos Margetis, Mark M. Souweidane — 2012-02-10

Abstract: Objective: Intraventricular cystic tumors constitute a surgical challenge, due to their deep location and the histologically benign nature of most of them. We aim to present concisely yet comprehensively, the role of neuroendoscopy in the treatment of intraventricular cystic tumors. Methods: A literature review searched for applications of endoscopy in the treatment of intraventricular cystic tumors. Our experience was added to the presented data. In controversial issues a comparison was made with traditional treatment methods. Results: Intraventricular endoscopy has been successfully used in the treatment of the whole range of intraventricular cystic tumors. The most common indication is the treatment of colloid cysts. In the treatment of colloid cysts, a comparison with microsurgical techniques showed that endoscopy is advantageous in regards to operative morbidity and post-operative shunt dependency, but is associated with a slightly higher recurrence rate. Conclusion: Intraventricular endoscopy has emerged as a viable option in the treatment of intraventricular cystic tumors.

Endoneurosurgical resection of intraventricular and intraparenchymal lesions using the port technique - Accepted Manuscript

2012-02-10

Intraventricular tumors - Accepted Manuscript

Henry W.S. Schroeder — 2012-02-10

The Keyhole Concept in Neurosurgery - Accepted Manuscript

Robert Reisch, Axel Stadie, Ralf A. Kockro, Nikolai Hopf — 2012-02-10

Abstract: Objective: Improvements in preoperative diagnostic imaging as well as in microsurgical techniques significantly advanced the development of transcranial neurosurgery allowing the treatment of complicated diseases through smaller and more specific approaches. Methods: In this article, authors overviewed their surgical experience in Transcranial Endoscope-Assisted Microsurgical treatment (TEAM), using limited sized keyhole craniotomies. Over a 10-year period, authors treated more than 3000 patients according to the TEAM concept, advanced by the pioneer of minimally invasive neurosurgery, Axel Perneczky. Results and Conclusion: In all cases, meticulous preoperative planning was performed determining site, size and optimal placement of the craniotomy as well as the trajectory towards the surgical target. Most importantly, the surgical approach was performed either completely or at least under permanent presence of the responsible senior surgeon from the moment of patient positioning until wound closure. The minimal invasive keyhole approaches allowed safe intraoperative control and adequate dealing with intracranial lesions. Essential pre-conditions for keyhole surgery were 1. careful selection of cases, 2. accurate praeoperative planning, 3. placement of the craniotomy tailored to the individual case and 4. intraoperative use of TEAM techniques. Advantages of intraoperative endoscopic visualization were increased light intensity, extended viewing angle, and clear depiction of details even in hidden parts of the surgical field.

Endoscopic Management Of Intracerebral Hemorrhage - Accepted Manuscript

Pierluigi Longatti, Luca Basaldella — 2012-02-10

Neuronavigational Neuroendoscopy - To Be or Not To Be? An International Pilot Questionnaire-Based Study - Accepted Manuscript

Yavor Enchev — 2012-02-10

Abstract: Objective: The almost age-old neuroendoscopy (NE) and neuronavigation (NN) in its twenties independently and indisputably have proved their high value as neurosurgical armamentarium and became even indispensable in some pathologies. However, nowadays the effectiveness of their simultaneous and combined application still is a matter of debate. The purpose of our pilot international, questionnaire-based survey was to assess the position of the opinion leaders in the field of neuroendoscopy world-wide toward the neuronavigational neuroendoscopy (NNNE). Methods: Within 3 months, a questionnaire with 17 questions was emailed repeatedly to 55 leading academic neuroendoscopic neurosurgeons from 50 institutions in 24 countries. The questionnaire covered aspects of personal and institutional experience in NE, NN and NNNE, the most frequently treated pathologies by NNNE as well as inquiring the neurosurgeons’ opinion for the importance and future of NNNE. Results: Forty one questionnaires were returned (response rate- 74.6%). Six questionnaires were excluded due to incomplete or incorrect answers, leaving in the survey 35 respondents from 35 institutions in 18 countries. The less experienced neurosurgeons rely in higher degree on NNNE. Most frequently, NNNE is performed for “Hydrocephalus (other procedures than third ventriculostomy)”, “Transsphenoidal surgery”, “Tumor biopsy” and “Cyst fenestration”. Regardless their neurosurgical and NE experience, over 75% of the respondents state that NNNE extends the range of neuroendoscopic procedures in their neurosurgical departments. Conclusion: NNNE represents a valuable operative technique with excellent future prospects. NNNE extends the range of neuroendoscopic procedures, transforming some number of patients from “non-operable” neuroendoscopically to suitable for neuroendoscopy.

Anatomic Skull Base Education Using Advanced Neuroimaging Techniques - Accepted Manuscript

2012-02-10

Abstract: Object: The goal of the present article was to describe our dissection training system applied to a variety of endoscopic endonasal approaches. It allowed to perform a 3D virtual dissection of the desired approach and to analyze and quantify critical surgical measurements. Methods: All the human cadaveric heads were dissected at the Laboratory of Surgical NeuroAnatomy (LSNA) of the University of Barcelona (Spain). The model surgical training protocol was designed as follows: 1) Virtual dissection of the selected approach using our own dissection training 3D model; 2) Preliminary exploration of each specimen using the a second 3D model based on a preoperative CT-scan; 3) Cadaveric anatomical dissection with the aid of a neuronavigation system; 4) Quantification and analysis of the collected data. Results: The virtual dissection of the selected approach, the preliminary exploration of each specimen, a real dissection laboratory experience and, finally, the analysis of data retrieved during the dissection step was a complete method to training manual dexterity, hand-eye coordination and to improve the general knowledge of the surgical approaches. Conclusions: The present model results effective, providing a valuable representation of the surgical anatomy as well as a 3D visual feedback, thus improving the study, design and the execution in a variety of approaches. Such system can also be developed as a pre-operative planning tool that can allow the neurosurgeon to practice and manipulate 3D representations of the critical anatomical landmarks involved in the endoscopic endonasal approaches to the skull base.

The incorporation of neuro-endoscopy in neurosurgical training programs - Accepted Manuscript

Abhishek Agrawal, Yoko Kato, Hirotoshi Sano, Tetsuo Kanno — 2012-02-10

Abstract: Once considered a domain of the otolaryngologists, the endoscope is now a common armamentarium of a neurosurgeon. Neuro-endoscopy or endoscope assisted microsurgery is now being used in almost all routine procedures performed in the Neurosurgical operating room. The hands-on training has become essential to learn the basis of Neuroendoscopy even to those well accustomed to the use of microscopes. To decrease the slope of the learning curve of the residents during their training, and therefore reduce the complications; most of the Neurosurgery training programs across the globe have now incorporated laboratory or dissection programs in their curriculum. The pre-conference workshops held during annual meetings is also an excellent tool for the transition of residents from being a ‘resident’ under the umbrella of an attending; to being an ‘neurosurgeon’ and be able to operate independently and with confidence in the operating room. In this tech-savvy era; various cadaver or synthetic models are readily available for training of endoscopy in a virtually simulated environment. Agreeing with the results of the survey conducted by individual groups and societies, we also firmly believe that incorporation of endoscopy in the neurosurgical curriculum will add a new dimension to the existing protocol. There is an urgent need for dedicated ‘endoscopic’ training programs like the post-residency fellowships; along with encouragement of translational research and establishment of dedicated societies which can lay the guidelines and monitor its progress.

The dedicated endoscopic OR - Accepted Manuscript

Amir Samii, Venelin M. Gerganov — 2012-02-10

Intraventricular Neuroendoscopy: Complication Avoidance and Management - Accepted Manuscript

Shakeel A. Chowdhry, Alan R. Cohen — 2012-02-10

Abstract: In the modern era, neuroendoscopy has been featured in an increasingly prominent role within the field of neurosurgery. As attention has been turned to the development of minimally invasive surgical methods, neuroendoscopy has advanced both as an independent treatment modality for various neurological disorders as well as an adjunct to microneurosurgery. It is distinct from traditional surgery, requiring a thorough understanding of its unique attributes to attain maximal benefit. Along with its advantages come unique obstacles that must be anticipated, appreciated and accounted for to prevent complications. This report outlines techniques to reduce and manage complications during more common intraventricular neuroendoscopic procedures including endoscopic third ventriculostomy, colloid cyst resection, and tumor biopsy and resection, and treatment of loculated hydrocephalus.

Part I: General Principles and Intraventricular Neuroendoscopy: Endoscopic Techniques - Accepted Manuscript

Henry W.S. Schroeder — 2012-02-10

Instrumentation: Endoscopes and Equipment - Accepted Manuscript

Michael R. Gaab — 2012-02-10

NeuroEndoscopy: general aspects and principles - Accepted Manuscript

Felice Esposito, Paolo Cappabianca — 2012-02-10

Stereotactic radiosurgery for trigeminal pain secondary to benign skull base tumors - Accepted Manuscript

Shota Tanaka, Bruce E. Pollock, Scott L. Stafford, Michael J. Link — 2012-02-06

Abstract: Objective: To assess the outcome of stereotactic radiosurgery (SRS) for patients with benign skull base tumors and trigeminal-related facial pain. Methods: Retrospective review of 31 consecutive patients (25 women, 6 men) with benign skull base tumors and trigeminal pain undergoing SRS between 1991 and 2008. The tumors included 17 posterior fossa meningiomas, 9 cavernous sinus meningiomas and 5 trigeminal schwannomas. The median patient age was 62 years (range, 17-81). In all cases the tumor was the primary target for SRS. The median follow-up after SRS was 50 months (range, 12-184). Results: The actuarial tumor control rate after SRS was 95% at both 3 years and 5 years. Eighteen patients (58%) initially achieved complete resolution of trigeminal pain. Higher maximum dose was associated with initial complete pain resolution on a multivariate analysis. However, 7 patients had recurrent pain during follow-up. At last follow-up, only 7 patients (23%) remained pain-free off medications. Further treatment in addition to medical therapy was required for 6 patients (19%). Conclusion: Although SRS offers excellent radiographic tumor control for benign skull base tumors, durable relief of tumor-related trigeminal pain without medication was noted in only one-fourth of patients at last follow-up.

Suprasellar Hamartoma and Arachnoid Cyst A Case Report and Review of Literature - Accepted Manuscript

2012-02-06

Abstract: Objective: The differential diagnosis for suprasellar masses includes a variety of pathologies, ranging from stable and benign lesions to aggressive and malignant ones. We report a case of a suprasellar hamartoma associated with an arachnoid cyst and review the literature surrounding the topic. Case description: A 32-year old male who presented with headaches and nonspecific vision loss and was found to have a cystic, calcified and minimally contrast enhancing lesion of the suprasellar region. Intraoperative inspection revealed a discrete mass in the right side of suprasellar region that resembled normal brain completely enveloped by the basal arachnoid membranes including the membrane of Lillequist and was not connected to the brain. Fenestration and exploration of the cystic portion demonstrated a simple arachnoid cyst filled with fluid with the appearance of CSF. Given the adherence of the lesion to numerous perforating arteries arising from the posterior communicating artery, biopsy with intraoperative confirmation was taken. Pathology was consistent with neuro-glial tissue without evidence of neoplasia. Conclusion: To our knowledge this is only the third case of an isolated suprasellar hamartoma described in the literature and the first of its kind to be associated with an arachnoid cyst.

Endoscopic Endonasal Transmaxillary Approach and Endoscopic Sublabial Transmaxillary Approach: Surgical Decision Making and Implications of the Nasolacrimal Duct - Accepted Manuscript

Andrew S. Little, Peter Nakaji, John Milligan — 2012-02-06

Abstract: Background: The nasolacrimal duct resides in the wall of the medial nasal cavity and influences minimal access endoscopic transmaxillary approaches to the lateral skull base. We describe an algorithm for surgical approach selection based on the relationship of the target lesion to a line drawn from the anterior nasal SEptum through the Nasolacrimal Duct to the lesion (SEND line). Methods: We use the SEND line to estimate the lateral extent in the endonasal middle meatal transmaxillary approach where the surgeon has good surgical freedom without the use of angled instruments and endoscopes. Lesions with an epicenter lateral to the SEND line were addressed through a sublabial anterior antrostomy transmaxillary corridor. Tumors with a more medially located epicenter, such as those involving the lateral sphenoid sinus and pterygoid plates, were addressed through the endonasal middle meatal corridor. Extensive tumors involving both domains were addressed through a combination approach. Results: We describe three instructive cases where approach selection was based in part on preoperative assessment of the location of the tumor relative to the SEND line. Conclusions: The endoscopic sublabial transmaxillary and endoscopic endonasal middle meatal transmaxillary approaches are complementary corridors to the anterior skull base that can be used independently or in combination. The location of the target lesion relative to the SEND line as determined on preoperative imaging can serve as a guide for surgical decision making.

Incidental Consequences of Antihelmintic Treatment in the Central Nervous System - Accepted Manuscript

2012-02-06

Abstract: Background: Neurocysticercosis (NCC) is the most common parasitic infection in the CNS, and the most common cause of acquired neurological symptoms in young adults living in developing countries. Many “asymptomatic” patients start having neurological symptoms after the use of antiparasitic drugs for gastrointestinal (GI) treatment. Patients who are previously diagnosed with NCC require special care during cysticidal treatment, due to inflammatory effects from the interaction between the drug, the parasite and the host. Case Description: Out of a series of 46 cases, we selected 5 patients with a history of being “asymptomatic” and who started having neurologic symptoms after the use of albendazole, which led to a diagnosis of cysticercosis. Another case of the patient, who already had been diagnosed of ventricular cysticercosis, was given drug treatment without consulting the neurosurgeon and had a fatal outcome due to secondary meningoencephalitis. Results: In the first 5 cases, with new neurological symptoms after antihelmintic treatment, the self-prescription is remarkable. The symptoms appear between the third and fifth day of treatment. All of them had a clinical course without complications. Only two cases minimally invasive techniques were required. The case that had been already diagnosed, developed meningoencephalitis and died after 8 days of antihelmintic treatment. Conclusions: Anthelminthic drug treatment requires tailor-based prescription considering risk-benefit ratio with the drug-parasite-host interaction in mind. Treatment is not harmless so patients have to be closely watched. In select cases, medical treatment cannot replace surgical procedures, which can be the primary approach with drug treatment as a complement.

Mobile endoscopy: a treatment and training model for childhood hydrocephalus - Accepted Manuscript

Mubashir Mahmood Qureshi, Jose Piquer, Paul Henry Young — 2012-02-06

Abstract: Hydrocephalus, largely a disease of poverty in many developing regions, such as Sub Saharan Africa, becomes even more challenging to treat due to lack of trained neurosurgical manpower, inadequately equipped public health care facilities, meager resource allocation, high rates of neonatal infection, difficulty of access to tertiary care hospitals able to treat hydrocephalus, and high complication rates in patients who are able to access and receive shunting procedures. Furthermore, conventional methods of training of neurosurgeons and nursing staff to become proficient in neuroendoscpoiic procedures, involve a lengthy period of training, often at specialized centres of training in western or local western style institutions, Such an approach may achieve its impact over several years with only a handful of selected individuals receiving access to the limited opportunities and resources for such hands on training. No amount of cadaveric or animal model training can adequately prepare such individuals for the challenges seen in their local patient populations. Definitive treatment of Hydrocephalus, while avoiding shunting procedures and its attendant long-term shunt dependence, is a safer option. In environments such as Sub-Saharan Africa and some in South America, and indeed, in other similar resource constrained regions, neuroendoscopic ventriculostomy (NEV), in appropriately selected patients, by neurosurgeons and nursing teams trained through hands on courses at their local institutions, can overcome the problems associated with shunting, as well as long term shunt dependence, whilst at the same time rapidly developing the requisite confidence and technical ability of the local neurosurgical and nursing teams at these community based institutions. The novel approach promoted by volunteer neurosurgical teams from Neurosurgery Education Development (NED) Foundation is described, and the its potential role in successfully providing NEV at hospitals in regional sites away from main referral tertiary hospitals is outlined. The impact on the training of local neurosurgical specialists and residents in training as well as nursing staff is highlighted. Using a single portable neuroendoscopy equipment system, and a versatile free-hand, single operator neuroendoscope, this outreach, mobile and readily portable model has been successfully utilized to perform over 250 procedures in 21 different hospital sites around 7 different countries and in two continents . The hands on local courses have imparted hands on training to 62 neurosurgeons and trainee residents and a further 110 operating room nurses at these 21 institutions Neuroendoscopy is not only a priority surgical tool for East Africa. It offers a medical philosophy, promoting it as an application that serves as an art and a science that is dedicated to the development of a complex surgical speciality: Neurosurgery. It calls to attention the need for the specialty of neurosurgery in this region, among medical teams and health care administrators, and helps to improve the kinship and collaborative spirit among African neurosurgeons, and to convince medical students, general residents and nurses that “neurosurgery can indeed be possible” in this unique and wonderful region.

Endoscopic Challenges and Applications in Tuberculous Meningitis - Accepted Manuscript

Anthony A. Figaji, A. Graham Fieggen — 2012-02-06

Abstract: Endoscopy for hydrocephalus due to infectious diseases presents clear challenges to the surgeon. Hydrocephalus due to tuberculous meningitis (TBM) is a good model to explore many of the issues that should be considered in the management of these patients. Tuberculous hydrocephalus may be communicating (CommHC) or non-communicating (NCHC); management options include medical treatment (for CommHC), ventriculoperitoneal shunting, and endoscopic third ventriculostomy (ETV). No guidelines exist currently, so management protocols are center-specific. Because brain ischemia due to vasculitis is common in these patients, optimal treatment of intracranial pressure (ICP) is even more important than usual, and this has implications for the management decisions. Effective treatment of these patients should lead to normalisation of ICP and resolution of the hydrocephalus, rather than merely avoiding extreme elevations of ICP. However, this also must be weighed against the surgical and long term complications associated with the procedures employed. There are specific endoscopic challenges that occur due to abnormal anatomy and the fact that hydrocephalus presents during the acute phase of the disease, rather than being post -infectious. In this article we examine the arguments for various therapeutic approaches and discuss the gathering experience in the literature about endoscopy in TBM in the context of overall management options.

Management of Hydrocephalus Around the World - Accepted Manuscript

Vita Stagno, Esperanza Arcas Navarrete, Giuseppe Mirone, Felice Esposito — 2012-02-06

••• - Uncorrected Proof

Peter Black — 2012-02-03

The growth of neurosurgery in China has been one of the most important recent developments in world neurosurgery. Dr. Liang-Fu 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 Arab Spring in Tunisia: Urgent Peal for a Public Health System (R)Evolution - Accepted Manuscript

Moncef Berhouma — 2012-02-02

Standardizing the Evaluation of Scientific and Academic Performance in Neurosurgery - Critical Review of the “h” Index and its Variants - Accepted Manuscript

Salah G. Aoun, Bernard R. Bendok, Rudy J. Rahme, Ralph G. Dacey, H. Hunt Batjer — 2012-02-02

Abstract: Assessing the academic impact and output of scientists and physicians is essential to the academic promotion process and has largely depended on peer review. The inherent subjectivity of peer review, however, has led to an interest to incorporate objective measures into more established methods of academic assessment and promotion. Journal impact factor has been used to add objectivity to the process but this index alone does not capture all aspects of academic impact and achievement. The “h” index and its variants have been designed to compensate for these shortcomings, and have been successfully utilized in the fields of physics, mathematics and biology, and more recently in medicine. Leaders in academic Neurosurgery should be aware of the advantages offered by each of these indices, as well as of their individual shortcomings, to be able to efficiently use them to refine the peer-review process. This review critically analyzes indices that are currently available to evaluate the academic impact of scientists and physicians. These indices include the total citation count, the total number of papers, the impact factor, as well as the “h” index with eight of its most common variants. The analysis focuses on their use in the field of academic Neurosurgery, and discusses means to implement them in current review processes.

Dural Arteriovenous Fistulas: A Review of the Literature and a Presentation Of a Single Institution’s Experience - Accepted Manuscript

2012-02-02

Abstract: Objectives: Dural arteriovenous fistulas (DAVFs) are arteriovenous shunts from a dural arterial supply to a dural venous channel, typically supplied by pachymeningeal arteries and located near a major venous sinus. A retrospective review was conducted to present the results of endovascular obliteration of DAVFs, with particular emphasis of newer liquid embolic agents, including ONYX-18 (MV3, Irvine, CA). Methods: A review of the literature was performed and a presentation of the number of treatments, complications, and outcomes.(48, 64, 67, 73) The number of arterial embolizations and need for transvenous embolization, open surgery, and radiosurgery was assessed as well as normalization of retrograde cortical venous drainage (CVD). Results: Thirty-nine patients (22 males and 17 females) underwent endovascular treatment of DAVFs at our institution from 2001-2009. Ages ranged from 39-71 (mean 48). Seventy-nine percent of patients had retrograde cortical venous drainage. The average number of embolizations in all patients was 2.1. Twelve patients underwent 40 embolization treatments with Onyx with an obliteration rate of 75% and CVD obliteration rate of 85%. Seventy-one percent (28/39) of patients had complete treatment of the fistula: 21 by purely endovascular treatment and 7 with endovascular therapy followed by craniotomy As well as seven patients who underwent stereotactic radiosurgery after embolization. Conclusions: Endovascular management of DAVFs is a safe and effective method of treating these complex lesions.

Traumatic (Type II) odontoid fracture with transverse atlantal ligament injury: a controversial event - Accepted Manuscript

2012-02-02

Abstract: Objective: Traumatic (Type II) odontoid fractures are very common injuries, nevertheless their connexion with transverse atlantal ligament injury is controversial and poorly defined. Aim of the study is to report a single case of traumatic (Type II) odontoid fracture with transverse atlantal ligament injury, and to critically analyze the role of ligaments and membranes together with neuro-radiological tools in the management of craniovertebral junction traumatized patients. Methods: We here report 27 consecutive cases of traumatic (Type II) odontoid fractures underwent to MR imaging in the acute phase (<72 hours), focussing our attention on the transverse atlantal ligament. Results: One patient (3,7%) showed a transverse atlantal ligament injury on MRI examination. The patient underwent surgical operative treatment. Conclusion: Traumatic (Type II) odontoid fracture with transverse atlantal ligament avulsion can be considered an unusual event. It is our opinion that the routine use of MRI for all patients with Type II odontoid fracture could be unjustified in clinical practice. Whereas, a strict clinical surveillance of all patients managed conservatively and MRI examination for selected cases could be of reasonable management option.