In this paper the authors trace the history of early craniometry, referring to the technique of obtaining cranial measurements for the accurate correlation of external skull landmarks to specific brain regions. Largely drawing on methods from the newly emerging fields of physical anthropology and phrenology in the late 19th and early 20th centuries, basic mathematical concepts were combined with simplistic (yet at the time, innovative) mechanical tools, leading to the first known attempts at craniocerebral topography. It is important to acknowledge the pioneers of this pre-imaging epoch, who applied creativity and ingenuity to tackle the challenge of reproducibly and reliably accessing a specific target in the brain. In particular, with the emergence of Broca’s theory of cortical localization, in vivo craniometric tools, and the introduction of 3D coordinate systems, several innovative devices were conceived that subsequently paved the way for modern-day stereotactic techniques. In this context, the authors present a comprehensive and systematic review of the most popular craniometric tools developed during this time period (prior to the stereotactic era) for the purposes of craniocerebral measurement and target localization.
Demitre Serletis and T. Glenn Pait
Demitre Serletis and Mark Bernstein
The authors prospectively assessed the value of awake craniotomy used nonselectively in patients undergoing resection of supratentorial tumors.
The demographic features, presenting symptoms, tumor location, histological diagnosis, outcomes, and complications were documented for 610 patients who underwent awake craniotomy for supratentorial tumor resection. Intraoperative brain mapping was used in 511 cases (83.8%). Mapping identified eloquent cortex in 115 patients (22.5%) and no eloquent cortex in 396 patients (77.5%).
Neurological deficits occurred in 89 patients (14.6%). In the subset of 511 patients in whom brain mapping was performed, 78 (15.3%) experienced postoperative neurological worsening. This phenomenon was more common in patients with preoperative neurological deficits or in those individuals in whom mapping successfully identified eloquent tissue. Twenty-five (4.9%) of the 511 patients suffered intraoperative seizures, and two of these individuals required intubation and induction of general anesthesia after generalized seizures occurred.
Four (0.7%) of the 610 patients developed wound complications. Postoperative hematomas developed in seven patients (1.1%), four of whom urgently required a repeated craniotomy to allow evacuation of the clot. Two patients (0.3%) required readmission to the hospital soon after being discharged. There were three deaths (0.5%).
Awake craniotomy is safe, practical, and effective during resection of supratentorial lesions of diverse pathological range and location. It allows for intraoperative brain mapping that helps identify and protect functional cortex. It also avoids the complications inherent in the induction of general anesthesia. Awake craniotomy provides an excellent alternative to surgery of supratentorial brain lesions in patients in whom general anesthesia has been induced.
Marc R. Del Bigio, Ravinder K. Sidhu, Colin J. Kazina, and Demitre Serletis
Tissue reactions that contribute to obstruction of peritoneal catheters in ventriculoperitoneal shunt systems are not well characterized. Several recent rapid obstructions in children prompted a retrospective quality assurance review.
The authors conducted a detailed investigation of 22 surgically explanted peritoneal shunt catheters and 8 autopsy cases with documented distal shunt obstruction. Patients’ medical histories were reviewed, and the catheters and/or tissues were subjected to conventional histological and immunohistochemical evaluations. In addition, 3 cases were subjected to electron microscopic examination including elemental analysis.
The majority of symptomatic obstructions were associated with distal slit catheters (17 slit, 3 open-end, and 2 unknown type). Among the autopsy cases, deaths were attributed to shunt failure in 2 cases of slit catheter obstruction, 1 case of open-end catheter obstruction, and 1 case of catheter withdrawal from the peritoneal cavity. The early tissue response consisted of a predominantly T lymphocyte accumulation with phagocytosis of graphite particles by macrophages. This is associated with proliferation of fibroblasts, mesothelial cells, and blood vessels, which can grow through the slits and occlude the catheter lumen. As the inflammation subsides after approximately 1 year, the tissue plug becomes collagenized and calcified.
This study, supported by experimental literature in other organ systems, indicates that graphite used to coat the slit openings of distal catheters from ventriculoperitoneal shunts likely predisposes to obstruction. Neurosurgeons and manufacturers should consider the potential negative consequences of this shunt design. The authors concur with previous recommendations that slit-valve distal catheters should not be used for ventriculoperitoneal shunting unless they can be proven safe and efficacious in a controlled trial.
Tomasz Szmuda, Shan Ali, and Paweł Słoniewski
Andrew Ajisebutu, Marc R. Del Bigio, Colin J. Kazina, Michael West, and Demitre Serletis
In 1950, Dwight Parkinson was the first qualified neurosurgeon to arrive in Winnipeg, Manitoba. He played a monumental role in developing one of the earliest neurosurgical training programs in Western Canada. Parkinson was a pioneering neurosurgeon who served as the first president of the Canadian Neurosurgical Society in 1965. He was the epitome of the skull base neurosurgeon, which was not recognized as a distinct discipline at that time. He contributed to its development through detailed neuroanatomical study of the lateral sellar compartment (housing the parasellar venous plexus, a term he emphasized as more accurate than “cavernous sinus”). Parkinson also made seminal contributions to the management of cerebrovascular disease and offered new insights on cerebral concussion. Parkinson’s dedication to clinical excellence and education laid a cornerstone for the development of neurosurgery and the neurosciences in Manitoba, making him a key figure in Canadian neurosurgery. Using published materials, online resources, hospital archives, and personal interviews, the authors conducted a systematic review of Parkinson’s formative years, his development of the Section of Neurosurgery at the University of Manitoba, his achievements, and his legacy. This updated biography captures the exploits of this remarkable, and at times strictly disciplinarian, neurosurgeon-anatomist.
Demitre Serletis, Sami Khoshyomn, J. Ted Gerstle, and James T. Rutka
Demitre Serletis, Juan Bulacio, William Bingaman, Imad Najm, and Jorge González-Martínez
Stereoelectroencephalography (SEEG) is a methodology that permits accurate 3D in vivo electroclinical recordings of epileptiform activity. Among other general indications for invasive intracranial electroencephalography (EEG) monitoring, its advantages include access to deep cortical structures, its ability to localize the epileptogenic zone when subdural grids have failed to do so, and its utility in the context of possible multifocal seizure onsets with the need for bihemispheric explorations. In this context, the authors present a brief historical overview of the technique and report on their experience with 2 SEEG techniques (conventional Leksell frame-based stereotaxy and frameless stereotaxy under robotic guidance) for the purpose of invasively monitoring difficult-to-localize refractory focal epilepsy.
Over a period of 4 years, the authors prospectively identified 200 patients with refractory epilepsy who collectively underwent 2663 tailored SEEG electrode implantations for invasive intracranial EEG monitoring and extraoperative mapping. The first 122 patients underwent conventional Leksell frame-based SEEG electrode placement; the remaining 78 patients underwent frameless stereotaxy under robotic guidance, following acquisition of a stereotactic ROSA robotic device at the authors' institution. Electrodes were placed according to a preimplantation hypothesis of the presumed epileptogenic zone, based on a standardized preoperative workup including video-EEG monitoring, MRI, PET, ictal SPECT, and neuropsychological assessment. Demographic features, seizure semiology, number and location of implanted SEEG electrodes, and location of the epileptogenic zone were recorded and analyzed for all patients. For patients undergoing subsequent craniotomy for resection, the type of resection and procedure-related complications were prospectively recorded. These results were analyzed and correlated with pathological diagnosis and postoperative seizure outcomes.
The epileptogenic zone was confirmed by SEEG in 154 patients (77%), of which 134 (87%) underwent subsequent craniotomy for epileptogenic zone resection. Within this cohort, 90 patients had a minimum follow-up of at least 12 months; therein, 61 patients (67.8%) remained seizure free, with an average follow-up period of 2.4 years. The most common pathological diagnosis was focal cortical dysplasia Type I (55 patients, 61.1%). Per electrode, the surgical complications included wound infection (0.08%), hemorrhagic complications (0.08%), and a transient neurological deficit (0.04%) in a total of 5 patients (2.5%). One patient (0.5%) ultimately died due to intracerebral hematoma directly ensuing from SEEG electrode placement.
Based on these results, SEEG methodology is safe, reliable, and effective. It is associated with minimal morbidity and mortality, and serves as a practical, minimally invasive approach to extraoperative localization of the epileptogenic zone in patients with refractory epilepsy.
Demitre Serletis, Patricia Parkin, Eric Bouffet, Manohar Shroff, James M. Drake, and James T. Rutka
The authors review their experience with massive plexiform neurofibromas (PNs) in patients with pediatric neurofibromatosis Type 1 (NF1) to better characterize the natural history and management of these complex lesions.
The authors performed a retrospective review of data obtained in seven patients with NF1 in whom massive PNs were diagnosed at The Hospital for Sick Children in Toronto, Ontario, Canada. These patients attended routine follow-up examinations conducted by a number of specialists, and serial neuroimaging studies were obtained to monitor disease progression.
The most common presenting feature of PN was that of a painful, expanding lesion. Furthermore, two patients harbored multiple, distinct PNs affecting different body sites. With respect to management, two patients were simply observed, undergoing serial neuroimaging studies; two patients underwent biopsy sampling of their plexiform lesions; two patients underwent attempted medical treatment (farnesyl transferase inhibitor, R11577, and cyclophosphamide chemotherapy); and three patients required surgical debulking of their PNs because the massive growth of these tumors caused functional compromise. Ultimately, one patient died of respiratory complications due to progressive growth of the massive PN lesion.
In this review of their experience, the authors found certain features that underscore the presentation and natural history of PNs. The management of these complex lesions, however, remains unclear. Slow-growing PNs may be observed conservatively, but the authors' experience suggests that resection should be considered in selected cases involving significant deterioration or functional compromise. Nevertheless, patients with massive PNs will benefit from close surveillance by a team of specialists to monitor for ongoing disease progression.