✓ The decade of the 1990's has provided neurosurgery with multiple challenges and opportunities. Numerous developments hold a promise for making the 1990's the most rewarding decade of the 20th century for neurosurgery. The “Decade of the Brain” resolution, adopted by the United States House and Senate and signed into law by President Bush in 1989, has provided the specialty with staggering opportunities. Neurosurgery and the basic and clinical neurosciences would be strengthened by the development of a major new philanthropic organization called the “American Brain Association” that would carry the activities of the Decade of the Brain into the 21st century. Major efforts are being made to improve organized neurosurgery's responsiveness to member needs. These include the strategic planning project undertaken by the Board of Directors of the American Association of Neurological Surgeons (AANS) and efforts to strengthen the Joint Council of State Neurosurgical Societies. The AANS has been extremely active in representing the specialty in legislative matters in Washington and in multiple other forums. This Association has joined The American Board of Neurological Surgery and the Residency Review Committee in responding to orthopedic surgery's proposal for spine fellowships. It is proposed that the logo of the state, regional, and national neurosurgical societies be changed to depict our involvement in spinal surgery (as well as brain surgery) because spinal surgery represents more than half of the total effort of this specialty. The standards of worth and value that provide the driving force behind our work emphasize the need to grow in compassion as manifested by our kindness, sincerity, and concern as we grow in professional competence as reflected by our training, knowledge, and skill.
Albert L. Rhoton Jr.
Albert L. Rhoton Jr.
✓ Microsurgical exploration of 15 adults with Arnold-Chiari malformation with and without hydromyelia using 3 to 20 × magnification has led to the following conclusions. Hydromyelia, associated with Arnold-Chiari malformation, is a progressive mechanical disorder that causes spinal cord deficits by pressure distention of the cord. Arnold-Chiari malformation causes slowly or suddenly progressive bulbar dysfunction by impaction of the malformation in the foramen magnum. Decompression of both can be achieved by a suboccipital craniectomy, upper cervical laminectomy, establishing an outlet from the fourth ventricle, and opening the distended cord in the thinnest exposed area, which is usually along the dorsal root entry zone. If Pantopaque myelography in patients in the supine position shows the Arnold-Chiari malformation, hydromyelia can be established as a cause of central cord deficit even if myelography shows the cord size to be normal. Syringomyelia, traditionally considered a degenerative disease, is a less common cause of a slowly progressive central cord deficit than either hydromyelia or intramedullary tumor.
Eric L. Rhoton and Albert L. Rhoton Jr.
✓ A 69-year-old white woman presented with a left hemiparesis which progressed to quadriparesis and encephalopathy. Computerized tomography and magnetic resonance imaging revealed a Chiari I malformation and a hydromyelic cavity extending from C-2 to T-6. Rostrally, the cavity extended through the ventral medulla, pons, and right cerebral peduncle into the right cerebral hemisphere, where the cavity enlarged and was associated with mass effect. The patient has made a dramatic neurological recovery following suboccipital craniectomy with insertion of a dural graft to decompress the Chiari malformation and upper cervical laminectomy and dorsal root entry zone myelotomy to decompress the hydromyelia.
Yoshihiro Natori and Albert L. Rhoton Jr.
✓ An anatomical study of three microsurgical intraorbital routes to the optic nerve and orbital apex, which can be reached through a fronto-orbital craniotomy, was conducted on cadaver specimens. The structures that could be exposed via the medial, central, or lateral approaches directed through the orbital roof were defined. The medial approach, directed through the space between the superior oblique and the levator muscles, provides good access to all parts of the intraorbital optic nerve. The central approach, between the levator and the superior rectus muscles, provides the shortest route to the optic nerve. Two variants of the central approach were examined. In the first, the levator muscle and frontal nerve are retracted medially and the superior rectus muscle laterally. This variant provides access to only the midportion of the intraorbital segment of the optic nerve. In the second variant, the frontal nerve is retracted laterally together with the superior rectus muscle. This variant provides access to the posterior two-thirds of the intraorbital portion of the optic nerve.
The lateral approach is directed between the levator and lateral rectus muscles. This approach also has two variants, depending on whether the superior ophthalmic vein is retracted medially or laterally. The variant in which the superior ophthalmic vein is retracted medially with the levator and superior rectus muscles provides access to the lateral side of the optic nerve except in the region adjacent to the superior orbital fissure. The variant in which the superior ophthalmic vein is retracted laterally together with the lateral rectus muscle provides excellent access to the optic nerve in the region of the superior orbital fissure. It is an ideal approach for lesions that involve both the cavernous sinus and orbit.
Albert L. Rhoton Jr. and William Merz
✓ A clip for aneurysm surgery has been designed with several unique features. The coil spring is fully hidden and protected within two hub sections so that it cannot be handled or become entrapped in tissue. The clip is milled from a piece of solid stock of nonmagnetic stainless steel to the desired size and shape by a computer milling process, thus avoiding the stresses and structural weaknesses caused by the bending, curling, and milling needed to prepare clips made from wire or sheet metal. The only means of opening the clip is by applying pressure to the solid milled surfaces, thus the spring cannot be weakened or bent by squeezing it or by trauma applied to the clip. The clip may be grasped in either a clip applier that holds the clip in one fixed position or in an applier that allows the clip to be rotated through an arc of 180°.
Naokatsu Saeki and Albert L. Rhoton Jr.
✓ The microvascular anatomy of the posterior part of the circle of Willis, important in surgery of pituitary tumors and basilar aneurysms, was defined in 50 cadaver brains. Significant findings were as follows: 1) Anomalies of the posterior half of the circle of Willis were found in 46% of cases. 2) Hypoplastic P-1 (posterior cerebral segment) and posterior communicating segments gave origin to the same number and size of perforating arteries, having the same termination as normal-sized segments. Thus hypoplastic segments should be handled with care and divided to aid in exposure of the basilar bifurcation only after careful consideration. 3) An average of four perforating branches arose from P-1; most from the superior and posterior surfaces. No branches arose from the anterior surface of the basilar bifurcation. The most proximal P-1 branch originated 2 to 3 mm distal to the basilar bifurcation. It was most commonly a thalamoperforating artery. The largest P-1 branch was usually a thalamoperforating or a posterior choroidal artery. 4) An average of seven branches emerged from the superior and lateral surfaces of the posterior communicating artery. The anterior half was a richer source of perforators than the posterior half. The largest communicating branch in 80% of specimens supplied the premamillary area. 5) The anterior choroidal artery originated from the carotid artery on both sides in all cases. A double anterior choroidal artery was present in 4% of cases.
David Perlmutter and Albert L. Rhoton Jr.
✓ The microsurgical anatomy of the distal anterior cerebral artery (ACA) has been defined in 50 cerebral hemispheres. The distal ACA, the portion beginning at the anterior communicating artery (ACoA), was divided into four segments (A2 through A5) according to Fischer. The distal ACA gave origin to central and cerebral branches. The central branches passed to the optic chiasm, suprachiasmatic area, and anterior forebrain below the corpus callosum. The cerebral branches were divided into cortical, subcortical, and callosal branches. The most frequent site of origin of the cortical branches was as follows: orbitofrontal and frontopolar arteries, A2; the anterior and middle internal frontal and callosomarginal arteries, A3; the paracentral artery, A4; and the superior and inferior parietal arteries, A5. The posterior internal frontal artery arose with approximately equal frequency from A3 and A4 and the callosomarginal artery. All the cortical branches arose more frequently from the pericallosal than the callosomarginal artery. Of the major cortical branches, the internal frontal and paracentral arteries arose most frequently from the callosomarginal artery. The distal ACA of one hemisphere sent branches to the contralateral hemisphere in 64% of brains. The anterior portions of the hemisphere between the 5-cm and 15-cm points on the circumferential line showed the most promise of revealing a recipient artery of sufficient size for an extracranial-intracranial artery anastomosis. The distal ACA was the principal artery supplying the corpus callosum. The recurrent artery, which arose from the A2 segment in 78% of hemispheres, sent branches into the subcortical area around the anterior limb of the internal capsule.
Arnold A. Zeal and Albert L. Rhoton Jr.
✓ In order to define the microsurgical anatomy, 50 posterior cerebral arteries (PCA's) were examined using × 3 to × 40 magnification. The PC A was divided into four segments: Pt was the segment proximal to the posterior communicating artery (PCoA); P2 extended from the PCoA to the posterior margin of the midbrain and was subdivided into an equal anterior (P2A) and posterior (P2P) half; P3 began at the posterior midbrain, ran within the quadrigeminal cistern, and ended at the anterior limit of the calcarine fissure. The PCA had three types of branches: 1) cortical branches to the cerebrum; 2) central branches to the brain stem; and 3) ventricular branches to the choroid plexus. The largest branches reaching the lateral surface of the cerebrum were located immediately anterior to the preoccipital notch, and in most cases were branches of the posterior temporal artery. This area offers a greater than 75% chance of finding a vessel large enough to perform a microvascular anastomosis. The central branches were of two types: 1) direct perforating, and 2) circumferential. The direct perforating branches arising on P1 were the posterior thalamoperforating arteries. The “thalamogeniculate artery,” the vessel said to be occluded in the “thalamic syndrome,” was also of the direct perforating type, but it was a series of small arteries arising from P2A and P2P rather than being a single vessel. The circumferential arteries usually arose from P1 and encircled the midbrain providing branches as far posteriorly as the colliculi. The branches to the choroid plexus were the medial and lateral posterior choroidal arteries; the former usually arose from P2A and entered the roof of the third ventricle, and the latter arose as a series of arteries from P2P and passed over the pulvinar to enter the lateral ventricle.
David Perlmutter and Albert L. Rhoton Jr.
✓ The microvascular relationships important to surgery of aneurysms in the anterior communicating region were defined in 50 cadaver brains. The recurrent artery of Heubner was frequently exposed before the A-1 segment in defining the neck on anterior cerebral aneurysms because it commonly courses anterior to A-1. It arose from the A-2 segment of the anterior cerebral artery (ACA) in 78% and most commonly terminated in the area of the anterior perforated substance, and lateral to it in the Sylvian fissure. The anterior communicating artery (ACoA) frequently gave rise to perforating arteries which terminated in the superior surface of the optic chiasm and above the chiasm in the anterior hypothalamus. This finding contrasts with previous reports that no perforating branches arise from the communicating artery. The proximal half of the A-1 segment was a richer source of perforating arteries than the distal half. The A-1 branches most commonly terminated in the anterior perforated substance, the optic chiasm, and the region of the optic tract. The ACoA increased in size as the difference in the diameter between the right and left A-1 segments increased. Frequent variants such as double or triple ACoA's, triple A-2 segments, and duplication of the A-1 segments were encountered. The clinical consequences of occlusion of the recurrent artery and of the perforators from the ACoA and medial and lateral segment of A-1 are reviewed.