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Background The purpose of this study was to report our operative technique and lessons learned using saphenous vein conduits to revascularize the rostral basilar circulation (ie, bypass to the posterior cerebral or superior cerebellar arteries). We also review the evolution of this technique for the treatment of vertebrobasilar insufficiency (VBI) and complex posterior fossa aneurysms. Methods Data were collected retrospectively for 8 consecutive patients undergoing rostral basilar circulation saphenous vein bypass grafts at our institution between 1989 and 2004 for the treatment of VBI or in conjunction with Hunterian ligation of complex posterior circulation aneurysms. The indications for treatment, pre- and postoperative neurologic status, angiographic results, operative complications, and long-term clinical outcomes were analyzed for each patient. Results With clinical and angiographic follow-up ranging from 3 months to 15 years, 7 of 8 bypasses remained patent, 3 of 3 aneurysms remained obliterated, and 4 of 5 patients with VBI experienced resolution of their preoperative symptoms. There were no surgery-related deaths, but 2 patients did experience major neurologic morbidity. The outcomes for the 217 total patients reported in the literature were as follows: 135 excellent (62%), 26 good (12%), 30 poor (14%), and 26 dead (12%). Conclusions Despite the risk of serious neurologic complications with this procedure, when one considers the natural history of untreated patients, saphenous vein revascularization of the rostral basilar circulation remains an acceptable option. Although surgical technique has varied, patient selection criteria, graft patency, and patient outcomes have been relatively constant over the past 25 years.

A POSTERIOR FORAMINOTOMY (hemilaminotomy and medial facetectomy) is indicated for the treatment of nerve root compression secondary to posterolateral disc herniation or spondylotic foraminal stenosis. We describe the normal and pathological anatomy of the cervical neural foramen as well as our surgical technique, which has been highly effective in cases of cervical discogenic radiculopathy.

Object. The aim of this study was to describe the application of a novel transarterial approach to curative embolization of complex intracranial dural arteriovenous fistulas (DAVFs). This technique is particularly useful in patients harboring high-grade DAVFs with direct cortical venous drainage or for whom transvenous coil embolization is not possible because of limited sinus venous access to the fistula site due to thrombosis or stenotic changes. Methods. Twenty-three DAVFs in 21 patients were treated using a transarterial N-butyl cyanoacrylate (NBCA) embolization technique with the aid of a wedged catheter. In all patients, definitive treatment involved two critical steps: 1) a microcatheter was wedged within a feeding artery, establishing flow-arrest conditions within the catheterized vessel distal to the microcatheter tip; and 2) NBCA was injected under these resultant flow-arrest conditions across the pathological arteriovenous connection and into the immediate draining venous apparatus, definitively occluding the fistula. Patient data were collected in a retrospective manner by reviewing office and inpatient charts and embolization reports, and by directly analyzing all procedural and diagnostic angiograms. Eight patients presented with the principal complaint of tinnitus/bruit, five with intracranial hemorrhage, four with cavernous sinus syndrome, and one each with seizures, ataxia, visual field loss, and hiccups. The parent (recipient) venous structure of the DAVFs in this study included 11 leptomeningeal veins, eight transverse/sigmoid sinuses, three cavernous sinuses, and one sphenoparietal sinus. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein in all DAVFs. Occlusion was confirmed on postembolization angiography studies. No complication occurred in any patient in this series. There has been no recurrence during a mean follow up of 18.7 months (range 2–46 months). Conclusions. Transarterial NBCA embolization with the aid of a wedged catheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.

✓ The authors present the case of a patient who suffered from progressive cranial nerve dysfunction, radiographically documented brainstem compression, and peduncular hallucinosis after undergoing endosaccular coil placement in a giant basilar apex aneurysm. Symptom resolution was achieved following clip ligation of the basilar artery. The pathogenesis of aneurysm mass effect due to coil placement is discussed and the pertinent literature is reviewed.

The goal of this two-part review is to discuss peripheral nerve surgery complications, along with the techniques and principles used to prevent them. In this second article, we concentrate on injuries, tumors, and entrapment of nerves in the extremities, including carpal tunnel syndrome and ulnar nerve compression at the elbow.

In a recent article, our experience and knowledge of the clinical picture, microsurgical anatomy, and long-term surgical outcome of resecting tuberculum sellae meningiomas was described in detail. We now present our surgical technique in a pictorial and video format for the benefit of neurosurgeons in training, as well as for general critique. Attention is given to the details of surgery: patient positioning, surgical approaches, technique of tumor removal, and postoperative care.

OBJECTIVE: The pretemporal approach has gained popularity for the treatment of basilar apex aneurysms. However, it requires the sacrifice of anterior temporal bridging veins to allow posterior temporal lobe retraction and, for patients with dominant pretemporal venous drainage, has the attendant risk of venous hypertension, hemorrhagic venous infarction, or seizures postoperatively. Alternatively, we have found that splitting the sylvian fissure, resecting the uncus, and applying posterolateral retraction to the medial temporal lobe provides a similar exposure to the basilar apex while preserving the anterior temporal bridging veins. To evaluate the transsylvian, trans-uncal approach to the basilar apex, we report our initial clinical results using this exposure in eight consecutive patients. A morphometric cadaveric analysis comparing this approach with the pretemporal approach was also performed. METHODS: For the clinical study, all hospital charts and imaging studies were retrospectively reviewed for patients undergoing the transsylvian, trans-uncal approach for the treatment of an upper basilar trunk aneurysm between July 2000 and July 2002. In the anatomic study, six formalin-fixed cadaver specimens were used. Two sequential exposures of the basilar apex were performed on each specimen side. First, the pretemporal exposure was performed with anteroposterior temporal lobe retraction. Next, after the temporal lobe had been allowed to return to normal anatomic position, the retractor was repositioned on the medial aspect of the temporal lobe superficial to the uncus, and a 10 × 10 × 15-mm volume of uncus was removed. Morphometric measurements were performed for each exposure. RESULTS: Four basilar bifurcation and four superior cerebellar segment aneurysms in eight consecutive patients were successfully clip-ligated by use of the transsylvian, trans-uncal approach. All patients had temporal bridging veins that were preserved, as documented by angiography and operative reports. No patient developed a venous infarction or new postoperative seizures, with a mean follow-up of 9.75 months (range, 0.5–28 mo). The cadaveric analysis revealed that in addition to providing a similar exposure of the upper basilar complex, the transsylvian, trans-uncal approach provided additional exposure of the ipsilateral posterior cerebral and superior cerebellar arteries compared with the pretemporal approach. CONCLUSION: When approaching the basilar bifurcation, the transsylvian, trans-uncal approach provides superior exposure of the ipsilateral superior cerebellar and posterior cerebral arteries compared with the pretemporal approach, while preserving the anterior temporal bridging veins. This approach is most valuable in patients with dominant temporal venous drainage or when additional exposure of the ipsilateral posterior cerebral or superior cerebellar arteries is required.

To the Editor.— The remote telephone linkage of a personal home computer to a hospital laboratory computer offers substantial benefits to attending physicians and their patients. The evolution of computers has recently resulted in widespread hospital applications. Their use in clinical laboratories has helped disseminate patient information, leading to improved care. Paralleling the development and hospital use of the large computer is the use of the small personal microprocessor. Currently, there is widespread application of these relatively inexpensive devices in various medical areas. The remote telephone linkage of a personal home computer to a hospital laboratory computer provides for the retrieval of patient data. The clinical laboratories at Mount Zion Hospital and Medical Center, San Francisco, use a Data General C330 Eclipse central processing unit and Medical Information Technology, Inc (Meditech) software for work load organization and data management. The laboratories provide a full range of virology, microbiology, hematology, chemistry

ISOENZYME fraction 2 (MB-fraction) of creatine phosphokinase (CPK) is being used as a marker of myocardial necrosis. 1 Recently, however, workers have identified this isoenzyme in patients with various muscular dystrophies; polymyositis, dermatomyositis, and viral myositis. 2 We report a case in which high levels of serum CPK 2 isoenzyme were found following ischemic necrosis of an extremity. 3 Report of a Case A 55-year-old man, subject to seizures, was brought to the emergency room after a generalized seizure at the dinner table. He had had multiple admissions for Pickwickian syndrome with carbon dioxide retention, chronic obstructive pulmonary disease, and congestive heart failure. Fifteen years earlier, a left internal carotid aneurysm had been successfully ligated. In the emergency room, the patient had a respiratory arrest but was immediately resuscitated. The ECG at this time showed a supraventricular tachycardia; changes suggestive of myocardial infarction were not present. The patient was admitted

The authors visited these Colombian islands from 7 April through 12 April 1972, spending 10-11 April on Providencia and the remaining time on San Andres. The latter is in the Caribbean Sea about 200 km east of Nicaragua and the former is about 100 km farther north. The most recent paper on birds of the islands (Paulson, Orians, and Leck, Auk 86:755758, 1969) dealt principally with migrants and considered only San Andres. Species found on Providencia were last recorded by Bond (Proc. Acad. Nat. Sci. Philadelphia 102:43-68, 1950) who also discussed the native birds of both islands. Our paper cites migrants we noted and reports on the current status of resident species. San Andres is about 13 X 4 km and its present vegetation consists largely of coconut palms. There are mangrove swamps, overgrown pastures with thickets, and scattered patches of native trees, occasionally to a height of 20 m. We set one to five mist-nets on each of three days in a brushy pasture close to the edge of mangroves south of the village of San Luis. This was adjacent to a fresh-water spring, which seeped out over an area of about 25 m2 and attracted many birds, particularly migrants, under the prevailing dry conditions. Our nets were standard 2 X 12 m with a mesh of 36 mm and were used for a total of about 48 hours. The island of Providencia is of volcanic origin and about 5 X 8 km; steep hills rise to 380 m. Our activities here were largely confined to the southwest along Sweetwater Creek, where it is bordered by brush, vines, a few palms, and native trees. One to three nets were in use along this stream for a total of about 12 hours. On both islands, birds were weighed with Pesola spring balances. Birds kept as specimens are now in the Royal Ontario Museum.

During the course of field studies in 1970 on the Santa Rita Experimental Range, Pima County, Arizona, we observed eight instances of interspecific aggression by Ash-throated Flycatchers (Myiarchus cinerascens) on Cassin's Sparrows (Aimophila cassinii). The former is a medium-sized tyrannid which nests in abandoned woodpecker holes in much of the southwestern United States and into M6xico. It forages mainly by hawking for insects from the upper limbs of trees. The sparrow is a ground-foraging species, feeding on seeds in winter and ground-inhabiting insects during the summer. Nests are placed near the ground in low vegetation. Its song is delivered in an upward arching flight from upper limbs of trees. The pattern of singing flights closely resembles the hawking maneuvers of the flycatcher. It was during the flight song that the sparrows were attacked by the flycatcher. The latter flew straight at the sparrow and usually knocked it to the ground. Apparently, the flycatcher was responding to a behavioral image which approximates its own foraging maneuvers. Selection against such behavior is probably weak since Cassin's Sparrow is rather restricted in its distribution and then only occurs in grasslands. On the other hand, strong selection pressures may operate to maintain this type of behavior in the flycatcher since it overlaps several potential competitors (Myiarchus spp., Tyrannus spp.). One other observation adds strength to the above suggestion. A Cactus Wren (Campylorhynchus brunneicapillus), flying about 3 m above the ground, suddenly made an upward jog in its straight line flight. This deviation was similar in form to a flycatcher foraging maneuver. Immediately, an Ashthroated Flycatcher, which was perched about 4 m away, flew at the wren and knocked it to the ground. These data were obtained during research supported by the US/IBP Desert Biome program under grant no. GB 15886 from the National Science Foundation.