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Robert F. Spetzler and K. Stuart Lee

Neurosurg 66: 482, 1987 (Letter) 2. Rhoton AL Jr : Anatomy of saccular aneurysms. Surg Neurol 14 : 59 – 66 , 1980 Rhoton AL Jr: Anatomy of saccular aneurysms. Surg Neurol 14: 59–66, 1980 3. Spetzler RF : Two technical notes for microsurgery. Barrow Neurol Instit Q 4 (2) : 38 – 39 , 1988 Spetzler RF: Two technical notes for microsurgery. Barrow Neurol Instit Q 4(2): 38–39, 1988 4. Yaşargil MG : Microneurosurgery , Volume 1 . Stuttgart : Thieme Verlag , 1984

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attempted to concentrate on cardiac standstill with extracorporeal circulation. Their technique has the advantage of eliminating heparinization but it does have significant drawbacks: 1) a thoracotomy is required; 2) there is a lack of deep hypothermia, allowing a maximum arrest time of 4 minutes (with intermittent recirculation if more arrest time is required); 3) no blood volume drainage is performed; and 4) the operative and anesthetic field are crowded due to the close proximity of the chest and head. Because of these drawbacks, we prefer to use the heart pump, which

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Robert F. Spetzler and Hartmut Spetzler

tongs applied to the temporal bone under moderate tension. Notice the complicated swirling pattern of stress lines emerging from the point of clamp application (arrow) . If the skull is filled with putty and a small balloon is placed adjacent to the inner table of the skull, tiny increments of fluid injected into the balloon can be detected by examining the outer surface of the skull with holographic interferometry. Lesions considerably smaller than the resolving power of computerized tomography can thus be detected. By increasing the volume of the balloon

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Robert F. Spetzler and Nader Sanai

retract the brain. Used with permission from Barrow Neurological Institute. Electroencephalographic burst suppression with thiopental was routinely used to provide additional protection in case temporary vessel occlusion was inadvertently needed and to decrease the intracranial blood volume, which further increased the working space. Mannitol was not routinely administered before surgery, but it was used when significant tumor mass effect, brain edema, or both were present. Lumbar drains were not routinely placed. The choice of operative corridor was dictated by

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Patrick W. McCormick, John McCormick, Joseph M. Zabramski and Robert F. Spetzler

catheter. One port of the suprasellar catheter was attached by a low-volume fluid-filled pressure-monitoring line to a transducer and the other to the femoral-cisternal shunt line. With the guidance of stereotactic coordinates, the lateral ventricle was cannulated and similarly monitored. The cisterna magna was also cannulated for pressure recordings. All pressures were referenced to the level of the heart and recorded on a multichannel strip recorder. The femoral-cisternal shunt was adapted from that described by Steiner, et al. 15 Our modification consisted of

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Matthew Quigley

T o T he E ditor : I read with interest the recent article by Gore et al. (Gore PA, Maan H, Chang S, et al.: Normobaric oxygen therapy strategies in the treatment of postcraniotomy pneumocephalus. J Neurosurg 108: 926–929, May, 2008). I was initially surprised that a significant difference was found in the experimental versus control groups despite the fact that only 11 patients enrolled in the study. Indeed, on analyzing the data provided in Table 1, I discovered no difference in the change in volume (ΔV) using either the t-test or Mann

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Julian E. Bailes, Robert F. Spetzler, Mark N. Hadley and Hillel Z. Baldwin

volume given as crystalloid and half as colloid solutions. 70 This allowed maintenance of a relative hypertensive, hypervolemic, hemodilutional state in anticipation of cerebral vasospasm. 5, 13, 30, 45, 56 This therapy consisted of intravenuous fluid administration to obtain a pulmonary artery diastolic pressure of 14 mm Hg or greater and a cardiac output of at least 7 liters/min. If the latter could not be obtained despite adequate pulmonary artery pressure, a beta-adrenergic agonist such as dopamine or dobutamine was used. In patients with persistent neurological

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Response L. Dade Lunsford , M.D. University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania I am pleased with the eloquent response to our article by Drs. Wascher and Spetzler. I concur with many of the comments raised by the correspondents. Interventional neuroradiology (endovascular embolization) was performed as an adjunct in approximately 20% of our patients. The goal of embolization was to reduce the residual angiographically visible arteriovenous malformation (AVM) nidus to a volume that was more likely to respond (total

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intracranial aneurysms, even in patients in Hunt and Hess Grades 4 and 5, and have had several surprising and rewarding results. The elimination of the ruptured aneurysm from the cerebral circulation allows aggressive treatment of vasospasm with both volume expansion and pressor agents as required. The outcome of Grade 4 and 5 patients is not as consistently good as that observed in patients with lower preoperative Hunt and Hess grades; however, we are achieving some good functional recoveries among Grade 4 and 5 patients, and we believe that the good outcome of even these

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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