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✓ A small number of patients with an apparently minor head injury will develop a life-threatening intracranial hematoma that must be rapidly detected and removed. To assess the risk of a significant intracranial neurosurgical complication after apparently minor head injury, the authors collected data prospectively on 610 patients who had sustained a transient posttraumatic loss of consciousness or other neurological function and who had a Glasgow Coma Scale (GCS) score of 13, 14, or 15 in the emergency room. Skull x-ray films were obtained in 583 patients, 66 of whom (10.8% of the study population) had cranial fractures. Eighteen of the 610 patients (3.0%) required a neurosurgical procedure. Three acute subdural hematomas, one epidural hematoma, and one traumatic intracerebral hematoma required craniotomy. Of the 66 patients who had skull fracture, 7.6% required a craniotomy for intracranial hematoma. Thirteen (19.7%) of the 66 patients with skull fracture required an operative procedure as compared to five (1.0%) of the 517 patients without skull fracture. Two patients with a normal GCS score of 15 and normal skull x-ray films subsequently underwent operative treatment. The cost of three alternative management schemes for these patients was estimated. A 50% reduction in cost of management could be effected by the use of computerized tomography (CT) scans (or possibly skull x-ray films) in determining which of the patients who are alert at the time of presentation should be admitted for observation. Several other conclusions can be drawn from this study. First, an initial GCS score between 13 and 15 does not necessarily indicate that a patient has sustained a trivial head injury, since 3% of such patients will require an operative procedure despite an initially normal level of alertness. Second, an abnormal skull x-ray film increases by a factor of 20 the probability that a patient will need neurosurgical treatment. Third, it is very unusual for patients who have a GCS score of 15 and a normal skull x-ray film to have a significant neurosurgical complication. Fourth, the alternative management schemes that depend on selective use of skull films and CT scans may significantly reduce the cost of caring for patients with minor head injury.

From the previous papers in this volume, it has become strikingly evident that with the use of CT the diagnosis of intracranial lesionsis now much more accurate. Therefore, it is not surprising that CT has achieved a firm position in daily neurosurgical practice. During our X-ray conferences, CT pictures are regularly demonstrated on special monitors and our staff is enabled to become familiar with all aspects of CT imaging of the brain. In operating room as well, CT scans are displayed next to the angiograms in order to provide additional information for the planning of any neurosurgical procedure with in the brain. Actually, with increasing frequency the neurosurgeon is now relying on CT scans exclusively during the surgical management of intracranial lesions. This is particularly important in head trauma patients where the CT scan shows the extent of traumatic brain edema, the “coup” or “contre-coup” injury from the impact, or the extent of space-occupying hematomas, CT has therefore greatly replaced the need for any conventional neuroradiologic procedures. The neurosurgeon now finds himself in a much better position to decide whether he should proceed with immediate intervention or not. Only in the presence of bilateral chronic hematomas are CT findings occasionally misleading.

Aspiration of tissue and blood is routinely employed in neurosurgical procedures. Since, however, conventional aspiration invariably traumatizes the surrounding tissue by tearing its vessels and cellular constituents, neurosurgeons have long sought an “atraumatic” method of suction. The ultrasonic aspiration device now commercially available (HODGSON et al., 1979) appears to be promising in this respect. However, histologic studies of its effect on nervous structures are still scarce (FLAMM et al., 1978; YOUNG et al., 1981). The aim of the present study was to investigate the histological changes observed in brain tissue at different time intervals after ultrasonic aspiration.

The main venous drainage from the posterior fossa and posterior cervical region is through the cervical vertebral venous plexus (4, 5, 8, 10).

For the great majority of patients with cancer, pain can be managed without neurosurgical intervention. However, for those patients for whom other therapy is unsuccessful, neurosurgery offers a wide array of procedures for decreasing or eliminating pain and suffering. This chapter presents a brief review of the neuroanatomy and neurochemistry of pain transmission. Neurosurgical options for cancer pain management are discussed with regard to indications, expected results and complications. This chapter is not meant to be an exhaustive review, but rather, a useful reference for the range of neurosurgical procedures available for the patient with cancer pain.

Sodium nitroprusside and nitroglycerin have proven effective for the reduction of blood pressure during neurosurgical procedures because their effects are easily controlled (5, 8, 11, 15). An undesirable side-effect is a significant postoperative increase in blood pressure (4, 7, 16). Empirically, we found a way to lower or to abolish these reactions by means of thiopental.

Extracranial shunting of cerebrospinal fluid is a well-known neurosurgical procedure for the treatment of normal pressure hydrocephalus. Research indicating reasonable success using this technique has been based primarily on subjective and global neurosurgical opinion. Given that the treatment carries morbidity risks, and that decisions to shunt are related to increasing adaptive functioning, attention must be paid to adequate measurement of surgical outcome. As part of a larger study, we report pre and postsurgical neuropsychological, neuroradiological, and clinical data on hydrocephalic patients, as well as presurgical intracranial pressure data. Prior to shunting, increase in ventricular dilatation and cerebral atrophy were associated with decreased cognitive functioning, gait disturbance, and bladder dysfunction. Following shunting, there were significant improvements in neuropsychological functioning in terms of attention, concentration, verbal and nonverbal memory, language and communication skills, and constructional skills, as well as clinical improvement in gait and bladder functioning. Improvement was related to presurgical dilatation of the temporal horns of the lateral ventricles and mental status, particularly memory functions.

The neurosurgical procedure of carotid endarterectomy is commonly undertaken to prevent stroke in patients with carotid artery occlusion (22, 27, 28). Recent studies disclose that this procedure can lead to restoration of cognitive function in some cases (6, 11, 12, 14), thus providing a better quality of life for those individuals. Our preliminary findings suggest that the type of cognitive improvement associated with this procedure is a function of the side of the brain receiving the increased blood flow.

The rapid changes in ICP can be dangerous and neurosurgical procedures usually try to avoid the sudden decompression (SD) effect. Nevertheless, some authors advocate the large decompressive craniectomy in the treatment of the acute subdural hematoma (1). However, the results do not show an improvement in mortality or morbidity and previous experimental data (2,3) confirmed the enhancement of brain edema by the SD. The aim of the present study was to define the conditions under which the SD appear to be harmful to the brain.

The flow-guided pulmonary artery catheter (Swan-Ganz) represents a najor advance in the clinician’s ability to evaluate cardiac performance. This catheter permits measurement of cardiac output, calculation of systemic and pulmonary vascular resistances, and mixed venous blood can be obtained for calculation of intrapulmonary shunt. Newer catheters even permit cardiac pacing to be performed with one of these catheters.

Neurosurgery is one of the youngest of the surgical specialties, despite the fact that neurosurgical procedures might well have been carried out in prehistoric times. Certainly, according to the Ebers papyrus, specific neurosurgical operations occurred in ancient Egypt. The beginnings of modern neurosurgery date back to the 1880s, following which this specialty developed with breathtaking speed. Under the guidance of a few outstanding workers, the range of indications for neurosurgical interventions increased with great rapidity, even given the old-fashioned instruments then available. The first true innovation was the introduction of the Bovie knife; subsequently, the bipolar forceps and then, more recently, the operating microscope came into use. For this reason, even some of the more impressive successes were attributable more to improvements in diagnostic methods and anesthetic techniques than to the skill of the surgeon. Thus it was that the industrial production of lasers stimulated great interest in the medical world: The introduction of an “immaterial” knife meant that a true “nontouch technique” was available for the very first time in surgery.

Diagnostic procedures, treatment and follow-up in midline tumours of the brain have been changed by the CT scan [5].

A preclinical evaluation of the technical details and dosimetry for temporary high intensity 192Ir brain implants is presented. The canine brain was used for this quality assurance study in which direct in vivo dose measurements were done by thermoluminescent dosimetry (TLD rods). Precise and reproducible positioning of the TLD rods and 192Ir ribbons were assured by simple accessories which can be utilized in the clinical situation. The neurosurgical procedure for this non-routine interstitial implant of the brain, suitability of type and size of afterloading cannulas and facility for firmly anchoring them to the scalp, and comparison of measured doses with computer-predicted values are details assured by the canine study. Agreement between the in vivo determination and computer-generated doses was consistently in the range 2–5%. Data derived from this preclinical evaluation are currently used in both stereotactic and non-stereotactic brain implants at our institution. Details are presented for the implant procedure, dose measurements and brachytherapy planning for multiple ribbons. The latter incorporates direct interaction on computed tomography (CT) images for a hypothetical patient case.

The introduction of laser use in neurosurgery has modified operative techniques and improved the quality of surgical management, as well as influencing general anesthesia. Surgical and anesthesiological procedures in neurosurgery, more than in the other surgical fields, are strictly complementary. Surgery may be facilitated and its consequences better controlled but anesthesiological procedures may also cause serious damage indirectly to healthy tissue surrounding a lesion. However selective and less traumatic surgical maneuvers can facilitate anesthesia and limit the negative effects of drugs and anesthetic techniques by allowing less prolonged administration and lower doses of drugs, and by requiring less complicated and dangerous techniques or reducing at least the time of their use. The direct relationship of anesthesia to cerebral physiology and intracranial dynamics in surgical procedures suggests on the operative field some anesthesiological considerations for those operations in which laser sources (CO2-Nd-YAG and argon) are routinely employed.

In the Burdenko Neurosurgical Institute of AMS of the U.S.S.R. there has been developed a method of catheterization and vessel occlusion with the help of a detachable balloon catheter. The method appeared to be very effective and has been used extensively in the leading neurosurgical clinics of the country. Today it is being further developed in thoracic and abdominal surgery.

The author recommends the use of angiography during operations for the treatment of cerebral angiomata, the procedure helping the location of fistulae with little dimensions and securing better surgical results. Seven cases of intracranial arteriovenous congenital fistulae are reported in which the neurosurgical procedure was facilitated by transoperatory angiography. There wern't technic difficulties in any occasion.

A group of 5 patients was studied in each of whom a lesion was produced during a neurosurgical procedure in which damage was limited to the fibers of the eighth nerve. Preoperative and postoperative studies of ATA would indicate that in those patients the ATA was specifically related to the conductive function of the eighth nerve fibers. Other studies have shown that ATA can be produced by lesions of higher order neurons (see Parker et al., 1962, 1968). Extent of ATA in these lesions can be independent of threshold sensitivity and discrimination score.

• Chemopallidectomy is a neurosurgical procedure involving the injection of small amounts of absolute alcohol (or a special alcohol solution) into the globus pallidus. The technique has relieved the tremor and rigidity of Parkinsonism, and has also relieved dystonic movements and fixed postures, choreoathetosis, and hemiballismus. In the reported series, 20 of 30 patients undergoing this operation were relieved of their involuntary movements. Chemopallidectomy is aimed only at the relief of hyperkinetic or involuntary movement disorders, and it will not relieve other abnormalities that are so frequently noted in congenital brain lesions.

To illustrate the midline incision in a suboccipital craniotomy, a metastatic tumor of the vermis and right cerebellar hemisphere has been chosen (Figs. 13 and 14). Solitary metastases within the central nervous system should be removed. Many years of functional activity have been added to patients lives even when repeated operations are necessary to remove “solitary” lesions. One patient especially comes to mind. She had three posterior fossa operations over a 12-year period for a metastatic breast lesion. The patient finally died 15 years after her first neurosurgical procedure, and at autopsy the only tumor found was within the cerebellar vermis. Another patient returned to our hospital yearly for seven years to have the current senior resident remove his” solitary “ metastatic melanoma.

T RIGEMINAL neuralgia has been recognized as a definite clinical ent i ty since the middle of the eighteenth century. Various authors have given credit to a Frenchman, Andr6,1 for his early description of this disease, but writings of theGreeks and Romans indicated that they too were well aware of this painful affection of the face. Fothergill, 2 in his analysis of the various types of pain in the face, presented many accurate and careful observations on what we recognize today as trigeminal neuralgia, but wrote: "What therefore I have to offer upon the nature of this disease is rather subnlitted to your consideration as mat ter of farther inquiry, than as opinions sufficiently established." To this day, the etiology in the great majority of instances remains unknown and not all of the answers as to the best form of therapy are at hand. Pioneers of the surgical approach for the control of facial pain in the distribution of the 5th cranial nerve were Horsley (1891), Hart ley (189~), Krause (189~), Tiffany (1894), Cushing (1900), Keen, Spiller and Frazier (1901), and numerous others. Many surgical refinements of the early procedures have been offered more recently, but all of these resulted in numbness in the anatomic distribution of the severed posterior sensory root. Taarnh0j 's 6 paper in 195~ presented a new solution to the problem of pain: merely decompressing the posterior part of the ganglion and the posterior sensory root. This t reatment seemed to control the pain and at the same time preserve the sensation in the face. Immediately this simple neurosurgical procedure was applied in many cases of

Deep Brain Stimulation is currently being investigated as an experimental treatment for patients suffering from treatment-refractory AN, with an increasing number of case reports and small-scale trials published. Although still at an exploratory and experimental stage, initial results have been promising. Despite the risks associated with an invasive neurosurgical procedure and the long-term implantation of a foreign body, DBS has a number of advantageous features for patients with SE-AN. Stimulation can be fine-tuned to the specific needs of the particular patient, is relatively reversible, and the technique also allows for the crucial issue of investigating and comparing the effects of different neural targets. However, at a time when DBS is emerging as a promising investigational treatment modality for AN, lesioning procedures in psychiatry are having a renaissance. Of concern it has been argued that the two kinds of interventions should instead be understood as rivaling, yet “mutually enriching paradigms” despite the fact that lesioning the brain is irreversible and there is no evidence base for an effective target in AN. We argue that lesioning procedures in AN are unethical at this stage of knowledge and seriously problematic for this patient group, for whom self-control is particularly central to wellbeing. They pose a greater risk of major harms that cannot justify ethical equipoise, despite the apparent superiority in reduced short term surgical harms and lower cost.

Herpes simplex virus encephalitis is an unusual diagnosis for postoperative sepsis that occurs after a neurosurgical procedure. We describe a patient for whom early diagnosis and aggressive medical and surgical treatment resulted in a good outcome.

Background: Essential Tremor (ET) is a progressive neurological disorder characterized by postural and kinetic tremor most commonly affecting the hands and arms. Medically intractable ET can be treated by deep brain stimulation (DBS) of the ventral intermediate nucleus of thalamus (VIM). We investigated whether the location of the effective contact (most tremor suppression with at least side effects) in VIM-DBS for ET changes over time, indicating a distinct mechanism of loss of efficacy that goes beyond progression of tremor severity, or a mere reduction of DBS efficacy. Methods: We performed programming sessions in 10 patients who underwent bilateral vim-DBS surgery between 2009 and 2017 at our department. In addition to the intraoperative (T1) and first clinical programming session (T2) a third programming session (T3) was performed to assess the effect- and side effect threshold (minimum voltage at which a tremor suppression or side effects occurred). Additionally, we compared the choice of the effective contact between T1 and T2 which might be affected by a surgical induced "brain shift." Discussion: Over a time span of about 4 years VIM-DBS in ET showed continuous efficacy in tremor suppression during stim-ON compared to stim-OFF. Compared to immediate postoperative programming sessions in ET-patients with DBS, long-term evaluation showed no relevant change in the choice of contact with respect to side effects and efficacy. In the majority of the cases the active contact at T2 did not correspond to the most effective intraoperative stimulation site T1, which might be explained by a brain-shift due to cerebral spinal fluid loss after neurosurgical procedure.

Ventricular shunt insertion is a commonly performed neurosurgical procedure but few studies evaluate the rates of ventricular catheter (VC) misplacement and postoperative intracerebral hemorrhage (ICH) after shunt surgery. In this study, we evaluated the rate of VC misplacement and ICH after shunt insertion in hydrocephalus patients. A consecutive series of adult patients (n = 240) that received a ventricular shunt for hydrocephalus were included in the study. Misplacement was defined as tip of the VC located in the contralateral ventricle or intraparenchymal. The event of ICH was based on verification of intraparenchymal blood on an early ( Misplacement of the VC tip was found in 76 patients (33%); 70 patients with the VC tip in the contralateral ventricle and six patients (3%) with the VC tip intraparenchymal. ICH occurred in 8% of the patients. The shunt revision rate for accurately placed VCs was 17% compared to 21% for misplaced VC (p = 0.37). Proximal shunt failure occurred in 11% of the patients with VC misplacement compared to 5% of the patients with accurate VC placement (p = 0.07). VC misplacement occurred in one third and ICH was evident in 8% of the patients. However, VC misplacement did not significantly increase the shunt revision rate. Still, measures to optimize VC placement may be important to reduce risks following ventricular shunt placement.

Because of the accuracy required in a neurosurgical procedure, tracking intra-operative deformations is a challenging task. Furthermore, the clinical demand for fast non rigid registration will have to be met in a very near future. In this paper, we propose a patient-specific biomechanical model based on block-matching in order to register two MR images of the same patient with a parallel implementation. Compared to other intra-operative registration techniques, this method combines a viscoelastic mechanical regularization with a correlation-based iconic energy term. We first shortly present the theoretical aspects of our method (more detailed in [9]). Then we describe in more details the parallel implementation of the algorithm. Finally we present a retrospective registration study made of four pre/post operative MRI pairs.

Nonsurgicalgical Treatment of Subdural Hematomas" is of considerable interest. The author is a noted neurologist and has made many important contributions to the field of neurology. Unfortunately, this article is not one of them. The surgical treatment of chronic subdural hematomas by evacuation with burr holes and drains is a well established neurosurgical procedure. The morbidity and mortality is negligible. Even the most ill patient can be operated on under local anesthesia with minimal risk. The operation is technically simple, the evacuation immediate, and the results gratifying. Clips placed on the dura and arachnoid at the time of surgery enable follow-up by routine skull x-ray study. In view of this, which no neurosurgeon or neurologist who has had experience with this disease can dispute, what is the rationale for the medical management of subdural hematomas? The use of steroids, osmotic agents, multiple angiography, and prolonged bed rest for results

To the Editor.— This information relates to a recent letter (234:649, 1975). We have used a technique that consists of stimulation of the periosteum of the bone in treatment of phantom limb pain with excellent results over the last four years. In treating approximately ten patients with this technique, we have had 100% success in either reducing or limiting pain in those individuals who have had no prior neurosurgical procedure performed on them. The technique is simple and consists mainly of implantation of hypodermic needles into the periosteum of the bone at various preselected areas. These needles are then attached to an electrical apparatus, and the patient is stimulated for 45 minutes. If anyone is interested, we can send them the details of the technique.

—Dr Harris focuses on specific clinical characteristics of our older adult population (age, ≥50 years) and reiterates concerns regarding efficacy of third-generation cephalosporins in the treatment of gramnegative bacillary meningitis. 1 It is important to differentiate those patients with microbiologically proved bacterial meningitis from those with presumed bacterial infections treated as such. In the latter group, situations associated with a negative bacterial culture included prior antibiotic treatment, parameningeal focus of infection, and CSF leak due to prior trauma or neurosurgical procedure. While higher mortality correlated with positive microbiologie diagnosis in our series of patients,1 characteristics (eg, preexisting neurologic disease, previous neurologic surgical procedures, change in sensorium at time of presentation, and community onset vs hospital onset) did not differ significantly between these two subgroups (Table 1). The eight patients with aseptic meningitis had no preexisting neurologic disease or neurologic surgical procedures, and all had community-acquired infection. The mean CSF white blood cell

Prospective payment systems using the diagnostic related group (DRG) mechanism are being phased in for Medicare inpatient hospital care. The purpose of this study was to examine a common neurosurgical procedure (001), craniotomy without trauma, and characterize the cost dynamics of this DRG. All patients (n = 50) treated in this DRG at the Long Island Jewish Medical Center during 1983 had their financial charges exclusive of physician fees examined. The findings were: (a) each hospital service category had wide charge variances around the mean; (b) emergency (ER) admissions were 200% more expensive than nonemergency (non-ER) admissions; (c) ER admissions seemed to have no greater severity of illness than non-ER admissions, but had a significantly different referral pattern (i.e., admission from the ER to a nonneurosurgical service with a subsequent neurosurgical referral); (d) this DRG when grouped into clinical "subproducts" (i.e., craniotomy for tumor, hematoma, hydrocephalus, aneurysm, benign cyst, and other) showed marked charge differences; and (e) the most expensive 25% of patients had five times higher charges than the least expensive 25% for both ER and non-ER admissions. This type of financial analysis may give surgeons a methodology with which to address the problems of cost containment in a more serious manner.

It is our deep conviction that a report of one case, no matter how interesting to an isolated group, should not be undertaken lightly. It is our opinion, however, that a rare syndrome that combines complete disability, unbearable pain, and convulsions, and that is cured by a simple neurosurgical procedure constitutes a situation in which the report of an isolated case is justifiable. The syndrome we would present is readily diagnosed by the symptoms and is completely cured by the intracranial section of the glossopharyngeal nerve. The symptoms are pain in the region of one ear and one side of the throat, occurring at brief intervals, of short duration, and accompanied by bradycardia, at times resulting in attacks of syncope and convulsions. Glossopharyngeal neuralgia has been a recognized entity for 30 years, and it is similar to tic douloureux except for the location of the pain and the trigger zone.

To the Editor:— In the article by H. Narabayashi, T. Okuma, and S. Shikiba entitled "Procaine Oil Blocking of the Globus Pallidus," published in the January, 1956, issue of the Archives, pages 36-48, the authors discuss at great length the history of Parkinson's disease and quote numerous authors who performed cortical operations in extrapyramidal disorders. They then report the "conception of blocking of the globus pallidus." "The procedure was based on the idea of the antagonistic functional correlation of corpus striatum and the globus pallidus." They quote animal experiments by Wilson and Mettler and Ades in which the globus pallidus was stimulated and Meyer's operation on the caudate nucleus. They "thought that much more selective invasion of the caudate nucleus would be possible with the stereotactic method than by such a major neurosurgical procedure." In this way they try to create the impression that they were the first who performed

For several years the use of intermittent positive-pressure breathing in the postoperative period has been used on neurosurgical patients at this hospital with increasing frequency. The positive pressure with resultant alveolar inflation has helped prevent postoperative atelectasis and pneumonitis. Intermittent positive-pressure breathing has been particularly useful in patients with quadriplegia who lack intercostal respiratory action and for the first 48 hours after a prolonged neurosurgical procedure. Adequate inflation of the alveoli, however, was impossible utilizing the Chevalier Jackson type of tube for tracheotomy as there was no way to prevent air from escaping from around the tube. Small-cuff type of tubes for endotracheal anesthesia were utilized next, but these had no inner cannula and hence secretions would form on the inside of the tube that were impossible to remove. The tube for tracheotomy that is pictured (Figs. I and ~) has been developedt and used with coinplete success. I t provides not only an inner cannula for cleansing but an inflatable cuff for coinplete occlusion when the intermittent positivepressure breathing is administered (usually for a period of 10 minutes every ~ hours) with a Byrd type of respirator, and an adapter to receive a Byrd type of respirator or fitting for anesthesia. The adapter is a standard size-15 Foregger adapter for anesthesia and is coupled permanently to the cannula for tracheotomy so that there is no

Meningitis caused by Acinetobacter baumannii is rare and are mostly hospital acquired after neurosurgical procedure. We report a case of a 40-year old man was admitted to the intensive care unit due to subarachnoid haemorrhage. Our patient developed a ventriculitis due to A.baumannii treated successfully with sulbactam IV and intrathecal amikacin.