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David E. Connor Jr. and Anil Nanda
In the 1970s, the membrane of Liliequist became the accepted name for a small band of arachnoid membrane separating the interpeduncular and chiasmatic cisterns, making it one of the most recent of the universally accepted medical eponyms. The story of its discovery, however, cannot be told without a thorough understanding of the man responsible and his contribution to the growth of a specialty. Bengt Liliequist lived during what many would consider the Golden Age of neuroradiology. With his colleagues at the Serafimer Hospital in Stockholm, he helped set the standard for appropriate imaging of the CNS and contributed to more accurate localization of intracerebral as well as spinal lesions. The pneumoencephalographic discovery of the membrane that was to bear his name serves merely as a starting point for a career that spanned five decades and included the defense of two separate doctoral theses, the last of which occurred after his 80th birthday. Although the recognition of neuroradiology as a subspecialty did not occur in his home country of Sweden until after his retirement, and technological progress saw the obsolescence of the procedure that he had mastered, Dr. Liliequist's accomplishments and his contributions to the current understanding of neuroanatomy merit our continued praise.
Amitabha Chanda and Anil Nanda
Object. An anatomical study in which measurements were obtained was undertaken to demonstrate that the orbitozygomatic transcavernous—transclinoidal approach provides excellent exposure of the trunk of the basilar artery (BA) and its bifurcation.
Methods. Bilateral stepwise dissections were performed on 10 fixed cadaver heads with the aid of × 3 to × 40 magnifications. A frontotemporal craniotomy was made, followed by an orbitozygomatic osteotomy. After the dura mater had been opened, the sylvian fissure was widely separated. The anteromedial triangle of the cavernous sinus was opened to mobilize the internal carotid artery medially. The sella turcica and the dorsum sellae were exposed. The posterior clinoid process and the dorsum sellae were drilled to expose a length of BA that included its bifurcation. Measurements were obtained following the frontotemporal craniotomy, orbitozygomatic osteotomy, and drilling of the posterior clinoid process to quantify the exposures provided by these procedures.
Excellent exposure of the trunk of the BA and its bifurcation was achieved. The structures in the interpeduncular cistern and the prepontine cistern were also exposed. There was an average gain of a 13.4-mm-long segment of the BA, which in some surgeries can be invaluable. The angle of exposure that was achieved with the BA bifurcation located at the apex increased markedly. Moreover, this method widened the oculomotor nerve—carotid artery corridor for easier access to the BA bifurcation region.
Conclusions. This approach combines the advantages granted by most conventional approaches to aneurysms of the BA bifurcation. The approach is suitable for aneurysms situated at a high, normal, or low position on the BA bifurcation. It exposes a sufficient length of the BA trunk to place a temporary clip.
Anil Nanda, Vijayakumar Javalkar, and Anirban Deep Banerjee
Petroclival meningiomas are notoriously difficult lesions to manage surgically, given the critical neurovascular structures that are intimately associated with the tumors. In this paper, the authors' aim was to review their series of patients with petroclival meningiomas who underwent surgical treatment; emphasis was placed on evaluating modes of presentation, postoperative neurological outcome, complications, and recurrence rates.
Fifty patients underwent surgical treatment for petroclival meningiomas. The majority of the patients were women (72%). The authors retrospectively reviewed the patients' medical records, imaging studies, and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, and recurrence rates.
Headache was the most common presentation (58%). The most commonly used approach was the transpetrous approach (in 16 patients), followed by the orbitozygomatic approach (in 13). Gross-total resection was performed in 14 patients (28%), and in the remaining patients there was residual tumor (72%). Eighteen patients with tumor remnants were treated with Gamma Knife surgery. New postoperative cranial neuropathies were noted in 22 patients (44%). The most common cranial nerve (CN) deficit following surgery was CN III dysfunction (in 11 patients) and facial weakness (in 10). In 9 patients, the CN dysfunction was transient (41%), and 7 patients had permanent dysfunction (32%). Eight patients developed hydrocephalus and all required placement of a ventriculoperitoneal shunt. A CSF leak was noted in only 2 patients (4%), and wound dehiscence was noted in 1. The CSF leaks and the wound dehiscence occurred in patients who were undergoing reoperations. Adequate radiographic follow-up (minimum 6 months) was available for 31 patients (62%). The mean follow-up was 22.1 months. In 6 patients, tumor progression or recurrences were noted. The median time to recurrence was 84 months. At the time of discharge from the hospital, 92% of the patients had good outcomes (Glasgow Outcome Scale Scores 4 and 5). Three patients died of causes not directly related to the surgery.
Petroclival meningiomas still pose a formidable challenge to neurosurgeons. In their series, the authors used multiple skull base approaches and careful microneurosurgical technique to achieve a good functional outcome (Glasgow Otcome Scale Score 4 or 5) in 92% of patients, although the extent of gross-total resection was only 28%. The authors' primary surgical goal was to achieve maximal tumor resection while maintaining or improving neurological function. The authors favor the treatment of residual tumor or recurrent tumor with stereotactic radiosurgery.
Charles Stent and the mystery behind the word “stent”
Sudheer Ambekar and Anil Nanda
Stents have come to be well-known devices and are being used widely in numerous branches of medicine. It is intriguing that the word “stent” actually derives from the name of a dentist, Charles Stent, who developed a material to obtain dental impressions. There are numerous other theories as to the origin of the word and how its use has been extended to various fields in medicine. The origin of intravascular stenting took place as early as 1912, but it was not until Charles Dotter reinvented the wheel in 1969 that further development took place in the technology and techniques of stenting. Intracranial stenting is a relatively new and rapidly developing field that came into being not more than 12 years ago. The authors describe the life and works of Charles Stent, discuss the possible origins of the word stent, and discuss how intravascular and intracranial stenting came into existence.
Shyamal C. Bir, Sudheer Ambekar, Sunil Kukreja, and Anil Nanda
Julius Caesar Arantius is one of the pioneer anatomists and surgeons of the 16th century who discovered the different anatomical structures of the human body. One of his prominent discoveries is the hippocampus. At that time, Arantius originated the term hippocampus, from the Greek word for seahorse (hippos [“horse”] and kampos [“sea monster”]). Arantius published his description of the hippocampus in 1587, in the first chapter of his work titled De Humano Foetu Liber. Numerous nomenclatures of this structure, including “white silkworm,” “Ammon's horn,” and “ram's horn” were proposed by different scholars at that time. However, the term hippocampus has become the most widely used in the literature.
Impact of body habitus on fluoroscopic radiation emission during minimally invasive spine surgery
Presented at the 2014 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves
Sunil Kukreja, Justin Haydel, Anil Nanda, and Anthony H. Sin
Minimally invasive spine surgeries (MISSs) have gained immense popularity in the last few years. Concern about the radiation exposure has also been raised. The purpose of this study was to demonstrate the impact of body habitus on the radiation emission during various MISS procedures. The authors also aim to evaluate the effect the surgeon's experience has on the amount of radiation exposure during MISS especially with regard to patient size.
The authors conducted a retrospective analysis of 332 patients who underwent 387 MISS procedures performed at their institution from January 2010 to August 2013 by a single surgeon. The dose of radiation emission available from the fluoroscopic equipment was recorded from the electronic database. The authors analyzed mainly 3 procedure groups: microdiscectomy/decompression (MiDD, n = 211) and transforaminal lumbar interbody fusion (TLIF) either with unilateral instrumentation (UnTLIF, n = 106) or bilateral instrumentation (BiTLIF, n = 70). The patients in each procedure group were divided into 6 categories based on the WHO criteria for obesity: underweight (body mass index [BMI] < 18.50), normal (18.50–24.99), overweight (25.00–29.99), Class 1 obese (30.00–34.99), Class 2 obese (35.00– 39.99), and Class 3 obese (> 40.00).
Patients who underwent BiTLIF had the highest median radiation exposure (113 mGy, SD 9.44), whereas microdiscectomy required minimal exposure (12.62 mGy, SD 2.75 mGy). There was a significant correlation between radiation emission and BMI of the patients during all MISS procedures (p < 0.05). The median radiation exposure was substantially greater with larger patients (p ≤ 0.001). In the analyses within the procedure groups, radiation exposure was found to be significantly high in patients who were severely obese (Class 2 and Class 3 obesity). The radiation emission was lower during the surgeries performed in 2013 than during those performed in 2010 especially in obese patients; however, this observation was not statistically significant.
Body habitus of the patients has a substantial impact on radiation emission during MISS. Severe obesity (BMI ≥ 35) is associated with a significantly greater risk of radiation exposure compared with other weight categories. Surgical experience seems to be associated with lower radiation emission especially in cases in which patients have a higher BMI; however, further studies should be performed to examine this effect.
Amitabha Chanda, Donald R. Smith, and Anil Nanda
Object. The authors used a modern cell saver technique to perform autotransfusion in patients undergoing instrument-assisted lumbar and/or thoracic spinal fusion, in whom significant blood loss was anticipated. The safety and benefits of this procedure as well as its cost effectiveness were analyzed.
Methods. The authors studied 50 patients who underwent lumbar and/or thoracic spinal fusion in which instrumentation was placed between January 1998 and June 2000 and in whom an estimated blood loss of 500 ml or more was expected. All surgeries were conducted by a single neurosurgeon (D.R.S.). During surgery, the Brat 2 cell saver system was used to salvage the autologous blood. The anesthesiologist and surgeon jointly decided, on the basis of hematocrit and clinical stability, whether transfusion was necessary in each patient. Various parameters (hematocrit, plasma and urine hemoglobin, platelet counts, coagulation profile, and serum bilirubin) were measured pre-, intra-, and postoperatively.
Thirty-three patients (66%) required transfusion. The mean blood loss in these patients was 1046 ml. The most important factor affecting blood loss was the number of levels fused (p < 0.0001). Only two patients required postoperative homologous transfusion. The mean decrease in hematocrit was 7.82%. The maximum reduction of platelet count was limited to 80,000/mm3. Major complications such as hemoglobinuria, coagulopathy, cardiopulmonary problems, air embolism, and major sepsis were not observed in this study.
Conclusions. Autotransfusion performed using a modern cell saver technique is safe and has many advantages over homologous transfusion. It conserves the homologous blood resources. The costs of the two modes are statistically comparable when greater than 500 ml of red blood cell transfusion is necessary.
Nasser Mohammed, Devi Patra, and Anil Nanda
Magnetic resonance–guided focused ultrasound (MRgFUS) is a novel technique that uses high-intensity focused ultrasound to achieve target ablation. Like a lens focusing the sun’s rays, the ultrasound waves are focused to generate heat. This therapy combines the noninvasiveness of Gamma Knife thalamotomy and the real-time ablation of deep brain stimulation with acceptable complication rates. The aim of this study was to analyze the overall outcomes and complications of MRgFUS in the treatment of essential tremor (ET).
A meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was made by searching PubMed, Cochrane library database, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Patients with the diagnosis of ET who were treated with MRgFUS were included in the study. The change in the Clinical Rating Scale for Tremor (CRST) score after treatment was analyzed. The improvement in disability was assessed with the Quality of Life in Essential Tremor Questionnaire (QUEST) score. The pooled data were analyzed by the DerSimonian-Laird random-effects model. Tests for bias and heterogeneity were performed.
Nine studies with 160 patients who had ET were included in the meta-analysis. The ventral intermediate nucleus was the target in 8 of the studies. The cerebellothalamic tract was targeted in 1 study. There was 1 randomized controlled trial, 6 studies were retrospective, and 2 were prospective. The mean number of sonications given in various studies ranged from 11 ± 3.2 to 22.5 ± 7.5 (mean ± SD). The maximum delivered energy ranged from 10,320 ± 4537 to 14,497 ± 6695 Joules. The mean of peak temperature reached ranged from 53°C ± 2.3°C to 62.0°C ± 2.5°C. On meta-analysis with the random-effects model, the pooled percentage improvements in the CRST Total, CRST Part A, CRST Part C, and QUEST scores were 62.2%, 62.4%, 69.1%, and 46.5%, respectively. Dizziness was the most common in-procedure complication, occurring in 43.4%, followed by nausea and vomiting in 26.85% (pooled percentage). At 3 months, ataxia was the most common complication, occurring in 32.8%, followed by paresthesias in 25.1% of the patients. At 12 months posttreatment, the ataxia had significantly recovered and paresthesias became the most common persisting complication, at 15.3%.
The MRgFUS therapy for ET significantly improves the CRST scores and improves the quality of life in patients with ET, with an acceptable complication rate. Therapy with MRgFUS is a promising frontier in functional neurosurgery.