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The feasibility of intracranial surgery in the rat fetus is demonstrated by the use of a microsurgical model. In utero craniotomy and cerebral incision have been performed successfully without compromise of the fetal-maternal unit. Maternal and fetal survival rates of 95 and 93%, respectively, are reported. Several principles of fetal surgery have been established and are discussed. These include the inhibition of uterine contraction, monitoring of physiological variables, timing of operation, microsurgical technique, and preservation of amniotic fluid. The fetal rat model is amenable to antenatal research because it fulfills certain criteria, including accurately timed pregnancies, littermate controls, inexpensiveness, and animal availability.

The malignant glioma, grades III and IV, is a cancer of rare biological consistency which until the advent of recent therapeutic advances had a median survival time of 6 months and killed 90% in 18 months [1]. There are 385,000 deaths from cancer each year in the USA of which 50,000 (13%) are associated with central nervous system involvement. It is estimated that of the 50,000 deaths, 8,500 (17%) are caused by primary brain tumors and 5,000 of these can be attributed to the malignant glioma or glioblastoma. The number of deaths from malignant gliomas is about half those reported from leukemia but are, in fact, more common than those from Hodgkin’s disease [2]. At the New York University Medical Center in the last 1,000 surgically verified primary supratentorial tumors in adults, 500 represent tumors of glial origin. Eighty percent of glial tumors were in the malignant glioma and glioblastoma class, 10% in the grade I, II and mixed glial groups and 10% represented oligodendrogliomas, ependymomas and other less common forms of primary tumors of neural origin.

Sixty-five years ago the cerebral ventricles of a hydrocephalic child were first inspected in vivo by means of an endoscope. The pioneering surgeon was Espinasse of Chicago, and the instrument was a cystoscope designed for looking into the adult bladder. This instrument utilized the system of lenses designed by Nitze of Vienna in 1887 illuminated by a distally placed incandescent bulb which appears to have been applied to Nitze’s cystoscope by Newman of Glasgow only three years after Edison had devised the incandescent lamp in 1880. Espinasse’s adventure was described by Davis (L’Espinasse 1943) in the following terms: ‘The first attempt to remove a choroid plexus for hydrocephalus with which I am familiar was made by Dr V. L’Espinasse of Chicago. In 1910, L’Espinasse introduced a small cystoscope into the ventricle and fulgurated the plexus bilaterally in 2 infants. One of his patients died post operatively, and the second lived 5 years. The method was presented before a local medical society and was not otherwise recorded. ’

Controlled arterial hypotension is frequently used during intracranial surgery of vascular tumors, arteriovenous malformations and aneurysms to reduce hemorrhage and prevent rupture of the aneurysm1,2,3,13. In addition, intravenous vasodilators have been used for the control of acute hypertensive crisis associated with malignant hypertension associated with rupture of an intracranial aneurysnr9.

✓ Subarachnoid cisterns and their contents are described briefly in the light of observations made during microsurgical explorations. The concept of intracranial surgery in terms of moving from one cistern to another is presented here with particular emphasis on the cisterns in surgical approaches to intracranial vessels and nerves for the treatment of aneurysms, arteriovenous malformations, and for surgery of basal tumors.

A large number of patients with subarachnoid hemorrhage (SAH) develop neurologic deficits as a result of critical reductions in cerebral blood flow (CBF) and it has been suggested that CBF measurements may be useful in the clinical management of these patients. Although a number of studies have shown that flow is decreased following SAH, the relationship between CBF and clinical status is not well understood and often a poor correlation exists between these two parameters. On the other hand, factors which would tend to cause hemodynamic instability, such as arterial spasm or intracranial surgery, are frequently associated with neurologic deterioration suggesting a cause and effect relationship. In an attempt to clarify these issues, we have examined the progressive changes in CBF at various stages in the clinical course of patients with SAH and have related these changes to the corresponding alterations in neurologic status and angiographic and CT information.

In our Institute, it is our routine to monitor the post-operative Intracranial Pressure (ICP) by the subdural balloon method in the treatment of neurosurgical patients who undergo intracranial surgery.

Twenty-five mongrel dogs had intracranial internal carotid and proximal middle cerebral artery occlusions. The animals were followed for one week and subsequently sacrificed. This method of clipping produced a mean drop in cortical cerebral blood flow of 48.4% as measured by the 85Kr washout technique. Cerebral blood flow was not affected by the brain retraction necessary for clip placements. Mortality in the first week was 16% and neurological deficits were observed in 73% of the animals. Infarction was present in 80% of the animals, and the mean percent infarction of the affected hemisphere was 17.00 +/0 3.98SE. This is a useful stroke model in an animal which is easily available, inexpensive, and suitable for microvascular intracranial surgery research.

In "Lectures on Intracranial Surgery," published in thisJournal, June 8, 1895, by Dr. Emory Lanphear, certain statements are made that are not warranted by pathologic and alienistic knowledge, certain operations are recorded as having been performed that are not justified by the literature or experience of those most competent to judge; and the results of the operations being unfavorable, and in some instances causing death, the conclusions of the paper alluded to are improper, and if recklessly absorbed and acted upon by others may be productive of further discreditable surgical interferences, and revolt of the laity against "butchery," as many unsuccessful operations are styled, even when these are judiciously and justifiably done. That Dr. Lanphear is a "brilliant operator" is well known, but when this ability is unassociated with other requisites it is like pyrotechnics near a powder magazine. He speaks of "insanity from softening of the brain." He

Twenty-five hypertensive patients who had clinically proven intracerebral hematomas, mainly in the internal capsule, were not treated surgically because of stabilization or improvement of their condition or because of extreme brain damage. All of these patients were treated medically, although therapy was not standardized. Ten of the 25 patients were discharged from the hospital and 15 died during their acute illness. Long-term follow-up was ultimately accomplished and the results are recorded. Profound disturbance in sensorium and abnormal pupillary or corneal reflexes were present in those who died, whereas in the group that survived only two patients had coma or stupor and none had bilateral involvement of pupillary or corneal reflexes. Analysis of a group of patients receiving surgery for intracerebral hemorrhage revealed that the mortality was 65%; thus, the results of conservative or surgical therapy were essentially the same.

ThE problem of the swollen or tight brain is one that has plagued the neurosurgeon since- the inception of intracranial surgery. Numerous attempts have been made to offset this condition by hypertonic solulions injected into the blood stream or by a physical approach such as hypothermia. To these technics we wish to add another technic which, in our experience, has proved quite satisfactory. We have used the technic of hyperven/Hation anesthesia since February 1958 for over 3~5 patients who have had intracranial procedures for various types of lesions. H These lesions have been located both supra- and infratentorially. The application of the technic varies in relationship to the locati

ONE OF THE frequent problems in intracranial surgery is gaining control of the cerebral blood flow. It is difficult by conventional neurosurgical methods (ie, suction, cautery, etc) to obtain the hemostasis necessary to approach certain intracranial aneurysms and other vascular anomalies or tumors. When such a situation presents itself, special techniques are required to allow surgical correction of the lesion. By combining profound hypothermia and cardiac arrest, the cerebral blood flow can be completely interrupted for extended periods of time. 4 This prolonged duration of interruption of cerebral blood flow permits intracranial surgery under bloodless conditions. It has been shown by Gordon 7 and others that when the temperature of the brain is reduced to between 12 and 15 C, the cerebral blood flow can safely be interrupted for periods up to one hour. On the basis of this work and the work of others, we have used profound hypothermia

The following report is a study of factors involved in extending the application of hypothermia toward the attainment of a bloodless abdominal field. Since the modernization of hypothermia following the pioneer work of Bigelow,1-4the use of the technique in cardiac and intracranial surgery has become well known. Relatively little has been written, however, on the possible advantages of prolonged occlusion of the abdominal aorta at a high level, such as would be required to arrest the circulation in the entire abdominal field. Of the various tissues subject to ischemic damage by aortic occlusion at any level, the spinal cord appears to be the most vulnerable. This fact has been demonstrated by several workers, perhaps most clearly by Pontius et al.5They also demonstrated that the ischemic damage was enhanced when intercostal vessels were ligated at the same time. Others have reported the safe time of occlusion of

The sixth case of pineal germinoma with hematogenous metastasis occurred in a patient who has survived 11 years following vigorous radiation therapy and chemotherapy and is currently free of disease. The germ cell origin of the tumor is emphasized. While local invasion and subarachnoid metastasis is uncommon, hematogenous spread is very rare, and only following intracranial surgery. Extensive metastasis does not carry a grave prognosis and is controllable, or possibly even curable, by aggressive radiation therapy and chemotherapy.

In every case of epilepsy where an initial spasm of a segment or a part of the body, or a localizing aura can be detected, trephining is imperatively indicated; for epilepsy is a disease incurable by other than surgical measures, as a rule, while many cases can be benefited by operation when the site of focal disease can be determined and reached. This proposition has met, and still meets, with opposition, the reasons urged against it being three in number, viz., 1, in some cases subjected to operation, the convulsions have returned within a few months after removal of the apparent cause; 2, in a number of cases reported the paroxysms continued after operation, undiminished in number and intensity; 3, sometimes epilepsy is cured by a simple exploratory operation, no lesion being discovered—hence the conclusion that whatever good results from surgical treatment arises from the operation per se and not

Now that the cranial cavity is being opened by surgeons with less and less reluctance, the differential diagnosis between a lesion within the brain substance and one on the surface becomes of increasing importance. Especially is this true of tumors of the posterior fossa, in which field have been made some of the most recent advances in the art of intracranial surgery. Cushing's book, "Tumors of the Nervus Acusticus" indicates what measure of success has been attained. Since cerebellopontile angle tumors are accessible, and intrapontile tumors inaccessible, naturally the diagnosis between them should anticipate operation. Tumors of the angle by pressure can cause many of the paralyses, anesthesias and ataxias caused by intrapontile lesions. There is, however, one symptom very characteristic of a lesion within the pons that has not been successfully produced by an acoustic tumor. Though Frankl-Hochwart, Alexander, Cushing and Henschen have reported cases in which associated movements

Continuing the discussion of the operative treatment of idiocy I will first speak of RESULTS. The immediate danger is little. As Packard has said ( Annual of Medical Sciences , 1891): "The procedure is a brilliant one, but of surprising ease in skilled hands." The primary mortality is about 10 per cent. since we have learned exactly how to handle these cases. There is commonly a considerable amount of improvement in many of the symptoms within a very brief period—an improvement that may last but for a few hours or that may be permanent; for example, if the child has been restless and inclined to sway back and forth with the peculiar cry of the idiot, there may at once supervene a condition of happy quietude; if of sufficient age, the patient may begin to notice things that have hitherto passed unnoticed—the general condition is very much as if there were a

SUMMARY The use of a methohexitone drip to supplement nitrous oxide and oxygen anaesthesia for intracranial surgery is described. Operating conditions are equally as good as those with thiopentone, and recovery at the end is more rapid and more complete.

The rapid strides that have been made in the evolution of modern civilization are almost past man's understanding. To the casual observer, the progress of recent times is attributed hastily to the material contributions of the master minds of the industrial world; but a more careful analysis will lead the seeker after truth out of the turmoil and the noise and bustle of the busy centers of population into the seclusion of the laboratory, where, in the quiet of their academic atmosphere, the chemist and the physicist, the geologist and the agriculturist, the psychologist and the pedagogue, the bacteriologist and the physiologist are working out the problems which make it possible for the human race — men, women and children — to live where conditions compel them to work, and not be mowed down by the cruel operation of the law of the survival of the fittest. Would it ever

One of the most important aims in medicine is to prevent diseases or complications of necessary interventions. As you all know, one of the major problems for each neurosurgeon is the increase of intracranial pressure, caused by brain edema, that can develop after intracranial surgery.

Intracranial aneurysms and angiomas are a common cause of spontaneous subarachnoid hemorrhage. Oculomotor palsy and visual-field defects may be caused by aneurysms, and convulsive seizures by angiomas, with or without hemorrhage. In view of recent advances in diagnostic and surgical techniques, intracranial surgery is recommended as the ideal treatment of ruptured intracranial aneurysms. Angiomas should be excised, if feasible, to prevent progressive brain damage or recurrent hemorrhage.

Operation for brain tumor is certainly an enticing one—the possibilities are so great. The first inducement is the fact that the result from the expectant plan is invariably fatal, generally within two years; the sometimes wonderful changes apparently wrought by internal medication are deceptive—they do not prolong life; and this is believed by some to be true even of syphilitic intracranial growths. A second incentive is that in most instances the almost exact position of the neoplasm can be determined by the well-formulated principles of cerebral localization. And the third is that in a large percentage of cases the growth is situated within reach of the surgeon's knife. The objections to operative treatment are: 1, the possibility of erring in the selection of the point for trephining; 2, the recurrence of the disease; and 3, the high mortality. While it is possibly true, as Agnew said, that "the results of

✓ To clarify the development of brain edema, the electrical impedance of white matter was measured with intracerebral implanted electrodes in cold-induced edema in the cat and in cases of edema after major intracranial surgery. Impedance measurements were made at 50 kc using a tetrapolar electrode method with a pair of concentric platinum electrodes. The impedance of the brain gradually decreased 25% after several hours of cold application. The amount of increase of sulfate space of brain showed a good correlation with decrease of impedance. In four postoperative cases of brain tumor, a 7.5% to 25% decrease of impedance was observed within several hours of surgery. A severe case of brain edema, in which the prognosis was poor, showed marked intracranial pressure and 25% decrease of impedance.

A comparative evaluation has been made of the effects of different anaesthetic agents and techniques upon the mortality of patients undergoing intracranial surgery for ruptured intracranial aneurysms. No statistically significant difference was noted when comparing groups in which halothane or trichlorethylene was the main anaesthetic agent. Neither was there any difference in mortality in groups in which halothane was used with or without controlled ventilation. It is concluded that variation in agent or method of general anaesthesia, which should on theoretical grounds result in differences in cerebral blood flow, has not affected postoperative mortality rates either adversely or beneficially.

Objective: Stereotactic interventions started to play a more important role in current neurosurgery interventions. Superficial craniometric calculations based on anatomical reference points are still valid for determining the location of craniotomy site. We compared these two methods to find the ideal craniotomy place for patients in the planning phase of intracranial surgery. Material and Method: We used 22 patients with brain tumor which were operated in Dışkapı Education and Research Hospital between 2010-2011. Stereotactic frame has been installed for each patient and ideal entry point was labeled with the frame. The manual calculations were done according to anatomical reference points based on radiological views and labeled. The variations and the distance between the two ideal entry points were calculated on the same patient before the surgery. Results: The same points were labeled in 11 of 22 patients. The difference between these two points ranged from 5 mm to 3 cm in the other 11 patients. The surgeon’s preference for craniotomy place according to surgery plan made this difference between these two different calculation methods. Conclusion: Use and education of anatomic markers and craniometric methods is of great importance especially for neurosurgeons in centers without stereotactic frame., Amaç: Günümüz nöroşirürji pratiğinde stereotaktik girişimler giderek daha fazla önemli hale gelmektedir. Kranial anatomik belirteçler ve radyolojik yöntemler kullanılarak yapılan yüzeysel manuel ölçümler kafa içindeki lezyon girişimlerinde kraniotomi fleplerinin yerleşimini belirlemede hala oldukça önemli bir yere sahiptir. Biz bu çalışmada her iki farklı yöntemi kullanarak ideal kraniotomi giriş noktaları asasıdaki farkları belirlemeye çalıştık. Gereç ve Yöntem: Dışkapı Eğitim ve Araştırma Hastanesinde 2010-2011 yılları arasında beyin tümörü nedeniyle ameliyat planlanan hastalarda, ideal giriş yerinin belirlenmesinde bilgisayar eşliğinde stereotaktik çerçeveyle yapılan ölçümler ile hastanın radyolojik görüntüleri baz alınarak yüzeysel anatomik noktalarından manuel olarak yapılan ölçümler karşılaştırılmıştır. Her hasta için stereotaktik çerçeve takıldıktan ve gerekli görüntülemeler yapıldıktan sonra, bilgisayarda hedefleme ve giriş koordinatları hesaplanıp uygun giriş noktası işaretlenmiş, aynı hastada kraniometrik yöntemlerle hesaplamalar yapılıp, uygun giriş noktası hastanın kafasına çizildikten sonra her iki farklı giriş noktası fotoğraflanarak aradaki mesafe hesaplanmıştır. Bulgular: Çalışmaya dahil edilen 22 hastanın 11’de giriş yeri seçimi açısından hiç fark yok iken diğer 11 hastada fark 5 mm ile 3 cm arasında değişmekle birlikte, oluşan bu fark cerrahın giriş yeri tercihinden kaynaklanmıştır. Sonuç: Anatomik belirteçlerin ve kraniometrik yöntemlerin kullanılması ve öğretilmesi, özellikle stereotaktik çerçeve bulunmayan merkezlerde çalışacak nöroşirürjiyenler açısından önem taşımaktadır.

Author(s): Sanjeevan-Cabeza, Irina; Oakland, Morgan | Abstract: Introduction: Pneumocephalus (PNC) is most commonly associated with trauma or intracranial surgery, less commonly secondary to an infectious source, and is rarely caused by barotrauma.Case report: A 32-year-old woman presented to the emergency department with complaint of resolved left-sided facial droop and a lingering paresthesia of her left upper extremity after a cross-country flight. Computed tomography demonstrated several foci of air in the subdural space consistent with PNC.Conclusion: For PNC to occur there must be a persistent negative intracranial pressure gradient, with or without an extracranial pressure change. In this case the pressure change occurred due to cabin pressure.

Thirty-two elderly patients were reviewed six months to six years after intracranial surgery for subarachnoid haemorrhage. Out of 24 patients whose surgical outcome had been satisfactory, one had died from an unrelated illness and the remainder were well and leading normal lives. Eight patients had a poor outcome, which in some cases was due to factors other than age. In only three could a poor outcome be attributed to early surgery and advanced age. The results confirm that in at least three-quarters of patients aged 60-65 the risk of further haemorrhage can be removed by surgery without causing a major neurological deficit.

Two cases of Pitutary Tumours operated by a team of E.N.T. and Neuro-surgeons are presented here. The various surgical techniques, advantages and disadvantages are discussed. The role of E.N.T. surgeon in intracranial surgery via E.N.T. fields is highlighted.

✓ A fine-tipped bipolar nerve-stimulator probe has been developed and has proved especially useful in intracranial surgery of the cranial nerves.

Fifteen institutions participated in a cooperative study for treatment of single ruptured intracranial aneurysms. Between June, 1963, and February, 1970, 1,005 protocols were submitted to the Central Registry. All patients had a single ruptured aneurysm on the internal carotid, middle cerebral, anterior cerebral-anterior communicating or vertebral-basilar arteries. The four treatments allocated randomly were regulated bed rest, drug-induced hypotension, carotid ligation, and intracranial surgery. This study was an attempt to provide the relative merits of these several modes of therapy.

A method is presented for the repeated Summary measurement of cerebral blood-flow coupled with cerebral angiography during intracranial operations. The technique involves cannulation of the common carotid artery via the superficial temporal artery and intracarotid injection of a bolus of xenon- 133. The cerebral washout curve is detected by an external scintillation counter. Normally the initial slope index of mean cerebral blood-flow is calculated, but grey and white matter flows may also be obtained. The method is being applied in the direct surgery of cerebral-artery aneurysms, where the results assist in the management of the patient.

Drs Horwitz and Rizzoli are to be complimented for performing the monumental task of describing postoperative complications of intracranial surgery. In this volume, to be followed by a second volume delineating complications associated with spinal surgery, there is a comprehensive review of all aspects of complications relating to intracranial neurological surgery. The book covers the general complications accompanying intracranial surgery, including brain edema, postoperative hemorrhage, wound problems, and sepsis, as well as neurological deficits. The various aspects of complications are further categorized into intracranial neoplasms, aneurysms, arteriovenous malformations, head injuries, cranial operations for pain, intracranial infections, and congenital and acquired defects. Each chapter is excellently referenced and gives a historical background into various factors that affect mortality and morbidity in the various surgical procedures. This edition, which is a revision of a 1967 text, again is invaluable to the neurosurgical community. One must be aware that certain complications occur, so

During the previous five years, there were 133 cases of intracranial surgery for cerebral artery aneurysms. For patients with aneurysms in the anterior circulation and in good preoperative condition, the surgical morbidity was 28% and the mortality was 19%. A depressed sensorium preoperatively, an age of 50 years or above, and an interval of less than 15 days from rupture to surgery were associated with markedly increased mortality. The results of this series, which do not compare favorably with those from foreign referral centers, are partially the result of disproportionate numbers of patients in those poor-risk groups. The possible advantages of regionalization are, nevertheless, apparent. Further comparative studies should be conducted on an interinstitutional basis. ( JAMA 236:1707-1710, 1976)

One of the most catastrophic complications of intracranial surgery is infection. These infections present frequently as postoperative fever and a change in sensorium. Phenytoin is used frequently in conjunction with intracranial operation to prevent seizures. We report two patients in whom, although the full phenytoin sensitivity syndrome ultimately developed, the presenting sign was postoperative fever. The phenytoin sensitivity syndrome is reviewed with emphasis on the fact that all components of the syndrome are not always present initially. The clinical significance of the presentation of phenytoin hypersensitivity as postoperative fever is discussed.