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Maryam Rahman, Gregory J. A. Murad and J Mocco

Stereotactic neurosurgery has a rich history, beginning with the first stereotactic frame described by Horsley and Clarke in 1908. It is now widely used for delivery of radiation, surgical targeting of electrodes, and resection to treat tumors, epilepsy, vascular malformations, and pain syndromes. These treatments are now available due to the pioneering efforts of neurosurgeons and scientists in the beginning of the 20th century. Their efforts focused on the development of stereotactic instruments for accurate lesion targeting. In this paper, the authors review the history of the stereotactic apparatus in the early 20th century, with a focus on the fascinating people key to its development.

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Matthew I. Tomey, Ricardo J. Komotar and J Mocco

✓Since the early 19th century, significant controversy has persisted over the competing claims of two men, Charles Bell and François Magendie, to a pivotal discovery: that the dorsal spinal roots subserve sensation, whereas the ventral spinal roots subserve motion. However, the foundations of neuroanatomy on which Bell and Magendie built their research was formed two millennia in advance. Exploration of the work of four ancient scholars—Herophilus, Erasistratus, Aretaeus, and Galen–reveals a remarkable early appreciation of the separate neural pathways (if not the correct physiology) responsible for sensory and motor control.

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William J. Mack, Louis J. Kim, Demetrius K. Lopes and J Mocco

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J Mocco and L. Nelson Hopkins

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Maryam Rahman, Gregory J. Velat, Brian L. Hoh and J Mocco

Cerebral venous sinus thrombosis (CVST) is an increasingly diagnosed disease with a wide range of symptoms, ranging from a mild headache to cerebral herniation. A potentially devastating syndrome, CVST has been associated with a mortality rate of 6–10%. In prospective studies, the overall rate of death and dependency from CVST ranges from 8.8 to 44.4%. Systemic anticoagulation remains the first-line treatment. However, a percentage of patients deteriorate despite medical therapy. These cases have resulted in the development of thrombolysis or endovascular treatment for CVST. Initial reports of the use of endovascular treatment of CVST have been promising. However, enthusiasm for the use of endovascular thrombolysis and thrombectomy should be tempered by an understanding of possible risks such as intracerebral hemorrhage and/or vessel dissection. The authors review the literature regarding endovascular treatment of CVST with a description of the chemical and mechanical thrombolytic techniques.

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Ricardo J. Komotar, J Mocco, Sean D. Lavine and Robert A. Solomon

✓Hunterian ligation is a well-known treatment for complex aneurysms not amenable to direct microsurgical clip application. After proximal parent vessel occlusion, cerebral angiography is typically used to confirm aneurysm thrombosis. The authors report on a vertebral artery (VA) aneurysm that had progressively expanded and caused brainstem compression after hunterian ligation, despite nondiagnostic findings on both conventional and computed tomography (CT) angiography at multiple time points.

This 64-year-old woman underwent hunterian ligation of a 1.8-cm VA aneurysm at the origin of the right posterior inferior cerebellar artery. An immediately postoperative conventional angiogram and follow-up CT angiograms obtained 5 and 6 years postligation confirmed complete obliteration of the lesion. Nine years after the initial surgery, however, the patient experienced neurological deterioration. Although CTs showed substantial aneurysm enlargement together with pontine compression, angiograms once again demonstrated complete right VA occlusion with no retrograde filling of the aneurysm. On reexploration, the aneurysm was effectively debulked, clipped, and obliterated. Arterial bleeding was found in the lesion neck, as was evidence of microrecanalization.

Hunterian ligation for complex aneurysms carries the risk of microrecanalization and lesion expansion despite non-diagnostic angiography. Although this ligation procedure remains a viable treatment option in carefully selected patients, an extended follow-up evaluation period may be required even when imaging suggests aneurysm obliteration.

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J Mocco, Brad E. Zacharia, Ricardo J. Komotar and E. Sander Connolly Jr.

✓In an effort to help clarify the current state of medical therapy for cerebral vasospasm, the authors reviewed the relevant literature on the established medical therapies used for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH), and they discuss burgeoning areas of investigation. Despite advances in the treatment of aneurysmal SAH, cerebral vasospasm remains a common complication and has been correlated with a 1.5- to threefold increase in death during the first 2 weeks after hemorrhage. A number of medical, pharmacological, and surgical therapies are currently in use or being investigated in an attempt to reverse cerebral vasospasm, but only a few have proven to be useful. Although much has been elucidated regarding its pathophysiology, the treatment of cerebral vasospasm remains a dilemma. Although a poor understanding of SAH-induced cerebral vasospasm pathophysiology has, to date, hampered the development of therapeutic interventions, current research efforts promise the eventual production of new medical therapies.

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Editorial

Urinary tract infection

Ciaran J. Powers and E. Antonio Chiocca

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J Mocco, Carlton S. Prickett, Ricardo J. Komotar, E. Sander Connolly and Stephan A. Mayer

✓In an attempt to elucidate the pathophysiology and clinical significance of global cerebral edema (GCE) following aneurysmal subarachnoid hemorrhage (SAH), the authors explored potential mechanisms and reviewed findings associated with this phenomenon. Admission computed tomography (CT) scans show GCE in up to 20% of patients experiencing aneurysmal SAH. This edema is likely to have been initiated by transient global ischemia, as indicated by an association between ictal loss of consciousness and the development of edema. A further cascade of events, including a rise in intracranial pressure and compromise of the blood–brain barrier, are also likely contributors. Clinically, GCE on CT after aneurysmal SAH is predictive of a poor outcome. Further investigation is needed to gain a full understanding of edema development following SAH, with the hope that the knowledge can be used to influence treatment positively and improve outcome.

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Maryam Rahman, Gregory J. A. Murad, Frank Bova, William A. Friedman and J Mocco

The search for efficacious, minimally invasive neurosurgical treatment has led to the development of the operating microscope, endovascular treatment, and endoscopic surgery. One of the most minimally invasive and exciting discoveries is the use of targeted, high-dose radiation for neurosurgical disorders. Radiosurgery is truly minimally invasive, delivering therapeutic energy to an accurately defined target without an incision, and has been used to treat a wide variety of pathological conditions, including benign and malignant brain tumors, vascular lesions such as arteriovenous malformations, and pain syndromes such as trigeminal neuralgia. Over the last 50 years, a tremendous amount of knowledge has been garnered, both about target volume and radiation delivery. This review covers the intense study of these concepts and the development of linear accelerators to deliver stereotactic radiosurgery. The fascinating history of stereotactic neurosurgery is reviewed, and a detailed account is given of the development of linear accelerators and their subsequent modification for radiosurgery.