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Eugene S. Flamm

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Eugene S. Flamm

✓ A technique utilizing suction decompression of large aneurysms to allow safer application of a clip is described. Large aneurysms are punctured with a No. 21 scalp vein needle attached to the operating room suction device. This procedure causes relaxation of the aneurysm itself and allows safer application of the clip. The technique has been used in six cases of giant aneurysms.

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Eugene S. Flamm

✓ This paper examines neurosurgery in the 18th century and suggests that the origins of the specialty can be recognized at the time when surgeons began to use the neurological status of the patient as a guide for surgical intervention. Percivall Pott (1714–1788) was one of the leading surgeons in London in the 18th century. He is remembered through eponyms of Pott's puffy tumor, Pott's fracture, and Pott's disease. A review of his writings and those of his contemporaries indicates that these surgeons were aware of the importance of changes in level of consciousness after head injury. The recognition and significance of the lucid interval was described and understood as a neurosurgical sign in the 18th century. Because of Pott's pre-eminence in the surgery of his time through his writings and lectures, he should be considered one of the founders of neurosurgery as a separate surgical discipline.

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Alan Hirschfeld and Eugene S. Flamm

✓ A case is presented of an aneurysm arising from an extracranial loop of the right posterior inferior cerebellar artery (PICA). No similar case has been found in a review of the literature. The anatomy of the PICA is discussed, and the literature on aneurysms arising from this artery is summarized.

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Michael J. Banach and Eugene S. Flamm

✓ The case of an aneurysm occurring at the site of fenestration of the supraclinoid portion of the left internal carotid artery (ICA) is reported. A 37-year-old woman presenting with subarachnoid hemorrhage was found to have bilateral ICA aneurysms at the level of the posterior communicating arteries (PCoA's). The patient underwent right-sided craniotomy with uneventful clipping of the right PCoA aneurysm, and attempted clip placement on the contralateral left ICA aneurysm. The follow-up angiogram revealed a residual dome on the left ICA aneurysm, which was noted to originate at the proximal end of a fenestration of the left supraclinoid ICA. This represents the third reported case of fenestration of the intracranial ICA associated with an aneurysm. Intracranial artery fenestrations and their embryological origins are also reviewed.

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Donald J. Moyer and Eugene S. Flamm

✓ A case of anomalous origin of the anterior choroidal and posterior communicating arteries in a 36-year-old woman with aneurysmal subarachnoid hemorrhage is presented. Preoperative four-vessel angiography revealed a reverse relationship of these vessels, wherein the anterior choroidal artery origin was proximal to the origin of the posterior communicating artery. This arrangement is extremely rare; the only other reported case was in a patient undergoing angiography prior to acoustic neurinoma resection. It is believed that this is the first case reported in a patient with subarachnoid hemorrhage from rupture of an aneurysm arising from a vessel of such anomalous origin.

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Arthur A. Grigorian, Alvin Marcovici, and Eugene S. Flamm

Object. Some well-known predictors of clinical outcomes in patients with ruptured aneurysms are not useful for forecasting outcome in patients with unruptured aneurysms. The goal of this study was to analyze outcomes in patients harboring unruptured cerebral aneurysms in different locations and to create a predictive tool for assessing both favorable outcome and morbidity in a large series of unruptured aneurysms.

Methods. The authors analyzed data from 387 patients with nonruptured intracranial cerebral aneurysms who underwent surgery for clip placement. Intraoperative data were reviewed and seven factors that might influence outcomes were identified. These included the following: 1) aneurysm size larger than 10 mm; 2) presence of a broad aneurysm neck; 3) presence of plaque calcification near the aneurysm neck; 4) application of clips to more than one aneurysm during the same surgery; 5) temporary occlusion; 6) multiple clip applications and repositioning; and 7) use of multiple clips. The entire group of patients with unruptured aneurysms was divided into two subgroups on the basis of outcome. Each patient was subsequently assessed to formulate the factor accumulation index (FAI), the sum of different factors observed in a given patient.

The subgroup of patients with expected outcomes was composed of 312 patients, whereas the subgroup of unexpected outcomes consisted of 31 patients. Depending on the anatomical locations of the aneurysms, the combined mortality—morbidity rate ranged from 5.7 to 25%, with the best results for patients harboring ophthalmic artery aneurysms and the worst results for those with vertebrobasilar system (VBS) aneurysms. The majority of patients with expected outcomes who harbored aneurysms of the middle cerebral artery, the internal carotid artery, and the VBS had a lower FAI, whereas the majority of patients with unexpected outcomes had a higher FAI.

Conclusions. It is possible to predict outcomes in patients with unruptured cerebral artery aneurysms by calculating the FAI. The rate of postoperative morbidity increases with the FAI within the range of three to four factors.

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Wise Young and Eugene S. Flamm

✓ High-dose methylprednisolone (15 to 30 mg/kg), administered 45 minutes after severe contusion injury (400 gm-cm) to cat spinal cords, rapidly reverses the typical posttraumatic ischemia that occurs in spinal injuries. White matter blood flow improves despite the systemic hypotension associated with bolus intravenous injections of such massive corticosteroid doses. In addition, this treatment facilitates extracellular calcium ionic recovery in contused spinal cords, and salvages evoked potential activity that is lost in untreated cats. These data suggest that high-dose corticosteroid treatment causes local vasodilation of spinal cord blood vessels. The consequent blood flow increase may account for the beneficial effects of high-dose corticosteroid treatment on both functional recovery and histopathological appearance of injured spinal cords.