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R. Shane Tubbs, William Stetler, Robert G. Louis Jr., Ankmalika A. Gupta, Marios Loukas, David R. Kelly, Mohammadali M. Shoja, and Aaron A. Cohen-Gadol

Object

The spinal accessory nerve (SAN) has been reported to have a distinctly coiled appearance in its course through the posterior cervical triangle of the neck. As this is unusual compared with other peripheral nerves including the cranial nerves, the present histological analysis was performed to further elucidate the reason for this anatomy with potential application in nerve injury and repair.

Methods

Ten adult cadavers underwent dissection of the neck. The SAN was harvested proximally and within the posterior cervical triangle. For comparison with other cranial nerves within the neck, the cervical vagus and hypoglossal nerves were also harvested. All nerves underwent histological analysis. Additionally, 2 human fetuses (11 and 20 weeks' gestation) underwent examination of the SAN in the posterior cervical triangle, and 3 randomly selected specimens were submitted for electromicroscopy.

Results

All SANs were found to have a straight gross configuration proximal to the posterior triangle and a coiled appearance within this geometrical area. Histologically, no differences were identified for the SAN in these 2 locations (that is, proximal to and within the posterior cervical triangle). The histology of the SAN both with routine analysis and electron microscopy was similar in both regions and to nerves used as controls (for example, vagus and hypoglossal nerves). Interestingly, both fetal specimens were found to have coiled SANs in the posterior cervical triangle.

Conclusions

Based on this study, it appears that the tortuous course of the SAN in the posterior triangle arises from functional as opposed to structural forces. It is hoped that this analysis will provide some insight into the nature behind the morphology observed in the SAN within the posterior cervical triangle and aid in future investigations regarding its injury. Moreover, such a coiled nature of this nerve may assist the neurosurgeon in identifying it during, for example, neurotization procedures.

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R. Shane Tubbs, Mohammadali M. Shoja, Marios Loukas, W. Jerry Oakes, and Aaron Cohen-Gadol

William Henry Battle (1855–1936) practiced medicine in England > 1 century ago and is primarily remembered for his description of ecchymosis over the mastoid, which indicates fracture of the skull base. Although Mr. Battle made many contributions to medicine, almost nothing exists in the literature regarding his life and findings, especially in regard to head injury. The following is a review of Battle's background and his contributions to medicine, specifically his observations associated with basilar skull fractures.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, and Aaron A. Cohen-Gadol

Object

Emergency access to the ventricular system is sometimes necessary for the treatment of raised intracranial pressure with ensuing herniation. One procedure described in the literature is a transorbital approach performed using a spinal needle. Because past publications have been case reports with minimal definition of external landmarks, the present study was performed.

Methods

Five adult cadavers (10 sides) underwent transorbital puncture of the lateral ventricles. This approach was performed following an axial section through the cranium that exposed the lateral ventricular system. Landmarks for the ideal placement of catheters into the ventricular system were then evaluated.

Results

The authors found that the lateral ventricular system was consistently entered just superior to the level of the foramen of Monro by puncturing the roof of the orbit just medial to a midpupillary line, with the trajectory of the perforation aimed 45° from a horizontal line and 15–20° medial to a vertical line.

Conclusions

Although it is uncommon, transorbital ventriculostomy may be used in emergency cases of raised intracranial pressure. Such refined landmarks as described in the present study may be of use to the neurosurgeon.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, John C. Wellons, and Aaron A. Cohen-Gadol

Object

Cadavers are often used in the teaching of various neurosurgical procedures. One aspect of this resource that has not been previously explored is the postmortem dilation of the ventricular system, which is often collapsed, for the purpose of training neurosurgeons in the use of intraventricular endoscopy.

Methods

Nine adult cadavers without a history of hydrocephalus or other known intracranial pathology were used for this study. Four specimens were obtained post embalming, and 5 specimens were fresh (time from death until the procedure < 5 hours). In all cadavers catheters were placed into the lateral ventricles; saline and then air were injected into the ventricles through the catheters. Ventriculostomy sites were filled with rubber stoppers, and in fresh specimens, formal embalming was performed with cadavers in the Trendelenburg position. Lastly, serial horizontal sectioning of the cranium was performed in all cadavers to verify ventricular dilation.

Results

None of the 4 embalmed specimens were found to have ventriculomegaly following injection. However, this condition was found in 4 of the 5 fresh specimens. In the single fresh cadaver without ventriculomegaly, the cause of death had been massive intracranial subarachnoid hemorrhage, which distorted the ventricular system. This may have prevented cannulation of the ventricle and ventricular expansion in this specimen.

Conclusions

The ventricular system of fresh human cadavers can be dilated postmortem. The method described herein may be useful to neurosurgical trainees or those trained neurosurgeons wishing to practice intraventricular endoscopy.

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Aaron A. Cohen-Gadol, Jonathan A. Friedman, Jennifer D. Friedman, R. Shane Tubbs, James R. Munis, and Fredric B. Meyer

Object

A review of the literature has revealed scant data related to neurosurgical treatment of gravid patients. The authors reviewed their experience with the neurosurgical treatment of pregnant women to better characterize the optimal management strategies for intracranial pathological entities in this population.

Methods

Between July 1969 and July 2005, 34 patients with documented pregnancy and concomitant intracranial pathological entities were treated at the authors' institution. The average age of the gravid patients at presentation was 27 ± 6 years. Twelve patients harbored vascular and 14 patients harbored neoplastic lesions. Four gravid patients suffered from traumatic intracranial hemorrhage, 2 had primary intracerebral hemorrhage, and 2 had hydrocephalus. The medical records of these patients were reviewed to assess the outcome for the mothers and fetuses.

Results

Nineteen pregnant patients (56%) underwent a neurosurgical procedure after induction of general anesthesia. Of these, 14 (74%) underwent craniotomies for clipping/resection of their lesion, 2 (10%) underwent stereotactic biopsies, and 3 (16%) underwent CSF shunting procedures. Three patients (9%) delivered by cesarean section followed by their neurosurgical procedure, and 5 (15%) underwent therapeutic abortion preoperatively to allow for radiation therapy early in their pregnancy (4 of these patients underwent surgery prior to their therapeutic abortion). Eleven patients (32%) were treated nonoperatively while pregnant, and 3 of these received their treatment after delivery. There was no operative maternal mortality or permanent morbidity. The fetuses did not suffer from any complications related to the mother's neurosurgical procedure.

Conclusions

Based on the authors' experience and a review of the literature, surgery for intracranial lesions in pregnant patients is generally well tolerated by both mother and fetus. Preoperative delivery by cesarean section of term or near-term babies is reasonable. Some patients treated conservatively may deteriorate and require an operation.

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Roberto C. Heros

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Christopher J. Wahl, R. Shane Tubbs, Dennis D. Spencer, and Aaron A. Cohen-Gadol

Influenced by individuals such as his parents, Osler, and Halsted, and by his early medical student experience, Harvey Cushing developed a strong interest in collecting, especially antiquarian medical books. Even today, his collection housed at Yale University is one of the most prestigious in the world. Cushing's interest in archives is further manifested and reinforced by his establishment of the Cushing Brain Tumor Registry. The following is a review of Cushing's background not as an eminent clinician and surgeon but as an individual best described as a bibliophile, archivist, and ardent collector of medical paraphernalia.

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Andrew S. Ferrell, R. Shane Tubbs, Leslie Acakpo-Satchivi, John P. Deveikis, and Mark R. Harrigan

Foix-Alajouanine syndrome has become a well-known entity since its initial report in 1926. The traditional understanding of this clinical syndrome is as a progressive spinal cord venous thrombosis related to a spinal vascular lesion, resulting in necrotic myelopathy. However, spinal venous thrombosis is extremely rare and not a feature of any common spinal vascular syndrome. A translation and review of the original 42-page French report revealed 2 young men who had presented with progressive and unrelenting myelopathy ultimately leading to their deaths. Pathological analysis demonstrated endomesovasculitis of unknown origin, including vessel wall thickening without evidence of luminal narrowing, obliteration of cord vessels, or thrombosis. Foix and Alajouanine also excluded the presence of intramedullary arteriovenous malformations. At the time, dural arteriovenous fistulas (dAVFs) had not been described, and therefore this type of lesion was not specifically sought. In retrospect, it seems possible that both patients had progressive myelopathy due to Type I dAVFs. In the decades since that original report, numerous authors have included spinal cord venous thrombosis as a central feature of Foix-Alajouanine syndrome. The inclusion of thrombosis in the clinical picture of this syndrome is not only incorrect but may leave one with the impression of therapeutic futility, thus possibly preventing successful surgical or endovascular therapy.

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R. Shane Tubbs, Marios Loukas, Michael Hill, Mohammadali M. Shoja, and Aaron A. Cohen-Gadol

Richard Lower (1631–1691), an anatomist and physician, was born in St. Tudy, Cornwall, England, and became an avid follower of William Harvey and a pupil to Sir Thomas Willis. Unfortunately, little is written of his contributions to the study of the nervous system despite his successful medical career and his regard as one of the most significant English physiologists of the 17th century. Lower was best known for his remarkable studies within the cardiovascular and respiratory disciplines. However, although not as well documented and thus often overlooked, Lower produced noteworthy advancements within the field of neuroscience such as studying the hindbrain innervation of the heart, CSF formation and circulation, cranial nerve function, and the structural sources of seizures. Some have even attributed the results of Willis' anatomical and physiological studies to Lower rather than to Willis himself. Lower has not received the recognition he is owed as a highly skilled and trained anatomist and physician. In this paper, the neurological contributions, with a brief mention of challenges, delivered during the 17th century by this influential historical physician will be highlighted with an emphasis on the impact each contribution made.

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R. Shane Tubbs, Cormac O. Maher, Ronald L. Young, and Aaron A. Cohen-Gadol

The authors describe a new technique for revision of an occluded distal ventriculoperitoneal shunt catheter that obviates the need for laparotomy or trocar insertion into the peritoneal cavity. The authors review their early experience with 34 patients suffering from a distal ventriculoperitoneal shunt failure and treated with this technique. There were no incidents of intraabdominal injury or wound complications. In 2 patients conversion to a minilaparotomy was required for safe placement of the shunt. Proper peritoneal placement was confirmed with abdominal radiographs in all cases. This technique has been safe and effective and may be considered an alternative to traditional laparotomy or laparoscopic methods.