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Robert F. Spetzler and Alfred A. Iversen

. 1. Four different sizes of the malleable microsurgical suction device. The third sample incorporates suction and irrigation action. The fourth sample has been bent to demonstrate the memory of the suction tubing. This device comes in various sizes to allow irrigation and drainage from any operative field. With the use of this suction device, microsurgical procedures can be performed in a cleaner operative field and without the need to put down an instrument in order to pick up the suction tube ( Fig. 2 ). We have used this suction instrument in over 100

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Robert F. Spetzler and Nader Sanai

-lighted instruments. Used with permission from Barrow Neurological Institute. In contrast to fixed retraction, retractorless technique allows the tissue planes to move in unison, avoiding the risk of anchoring. Effective use of the handheld suction device in one hand while the operating instrument is held in the other hand provides dynamic retraction through a small corridor that serves as a sufficient substitute for fixed brain retraction in most complex vascular and skull base tumor cases. Strategic and deliberate placement of the suction shaft and operating instrument, which

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Adib A. Abla, Hasan A. Zaidi, R. Webster Crowley, Gavin W. Britz, Cameron G. McDougall, Felipe C. Albuquerque and Robert F. Spetzler

T he Pipeline Embolization Device (PED) (ev3 Inc.) is now approved by the FDA for use in the US for internal carotid artery (ICA) aneurysms. Despite excellent results in a host of series, 1 , 6 , 8 there are still some disadvantages and caveats when the device is used for the treatment of difficult intracranial aneurysms. 2–5 , 9 , 13 , 14 , 16 We describe a case in which Pipeline embolization resulted in incomplete treatment and intraaneurysmal thrombus formation, causing mass effect on the optic chiasm and necessitating further treatment. Case

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Leonardo B. C. Brasiliense, Ramon Navarro, Paul Brazis and Rabih G. Tawk

TO THE EDITOR: We read with great interest the recent article by Abla et al., 1 wherein the authors describe the case of a giant fusiform internal carotid artery (ICA) aneurysm that was treated with a Pipeline Embolization Device (PED) (Abla AA, Zaidi HA, Crowley RW, et al: Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion. J Neurosurg Pediatr 14: 31–37, July 2014). The patient

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Jonathan S. Hott, Vivek R. Deshmukh, Stephen M. Papadopoulos and Robert F. Spetzler

application of the headholder frequently complicates surgical positioning. We have developed a variation of the headholder device that offers an unencumbered view of the odontoid process. In contrast to existing headholders, the Spetzler Headrest System (V. Mueller, Cardinal Health) has three articulation ports ( Fig. 1 ). F ig . 1. Photograph showing the headholder with options for a central port and two paramedian ports for the articulating arm attachment. Surgical Technique The patient is positioned supine on the operating room table, and his or her head

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Cardiac standstill

Giuseppe Lanzino and Philipp Taussky

patients who have adequate supply from the anterior circulation. 6 The last and most challenging category is the patient with fusiform and often dolichoectatic vertebrobasilar aneurysms. There is significant hope that new flow diverters may represent a definite advancement in the treatment of this disease. Despite some early successes, 1 however, complication rates are significant even with these newer devices, and definitive treatment is not always achieved. Overall, this is a landmark experience. Complex posterior circulation aneurysms continue to be a formidable

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John G. Golfinos, Brian C. Fitzpatrick, Lawrence R. Smith and Robert F. Spetzler

of the rigid attachment of the frame to the patient's head. 11 In frameless systems, at least three fiducial markers are attached directly to the patient's scalp. The markers are usually small beads composed of material that is obvious on either computerized tomography (CT) or magnetic resonance (MR) imaging. Recently, the patient's scalp itself has been used as a fiducial marker. 21 When the position of the markers is measured with a digitizing device, it can be correlated with the position of the markers on the imaging study. From this correlation, the imaging

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Tim E. Darsaut and Jean Raymond

together, in real time. ISAT was a conventional randomized controlled trial (RCT), while BRAT's unusual design used a kind of prerandomization, a device proposed by Zelen that notoriously “saved” a difficult, nonrecruiting breast cancer trial. 3 The trial eventually produced “extraordinarily significant human benefits”; nevertheless, Zelen's design has ever since remained “ethically suspicious,” for consent-related reasons too intricate to rehearse here. 4 In a previous comment we, perhaps too hastily, carried over a number of scientific and ethical concerns related

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Robert W. Ryan, Robert F. Spetzler and Mark C. Preul

, perhaps it is not surprising that some patients, hoping to benefit from the newest and best, ask whether the laser will be used for their operation. Although in many cases there is no role for such a device, the history of the use of lasers in neurosurgery reveals ingenuity in diverse settings, taking advantage of the individual properties of different laser types. In certain cases, lasers remain a distinct and important addition to the neurosurgical armamentarium. Basic Laser Physics “Laser” is an acronym for “light amplification by stimulated emission of

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Robert F. Spetzler, Charles B. Wilson and John M. Grollmus

through the trochar into the peritoneal cavity. A spinal fluid reservoir is placed above the iliac crest, anchored, and connected to the two catheters tunneled subcutaneously around the flank. The reservoir we use is a one-way valve Silastic dome-shaped flushing device similar to the units used for intracranial shunts, except that it holds a larger volume of CSF in order to make it palpable through the subcutaneous tissue of the flank. The reservoir can be used to flush the tubing, collect a CSF specimen, or inject a radioisotope to check shunt function. Any slack