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Leon E. Moores

The desire to assist in a crisis should be tempered by a serious assessment of the technical preparation one has undertaken. Additionally, in the same way that a needs assessment is undertaken before prescribing a course of treatment, one should evaluate the actual staffing requirements of the situation. Many physician volunteers were turned away after the World Trade Center attacks because the overwhelming response of available medical personnel quickly exceeded the requirement. Finally, the duration and intensity of preparation should be based on a realistic evaluation of the likelihood of an event occurring that would necessitate use of the training. Before jumping into action in a situation in which weapons of mass destruction have been used, several issues must be addressed. Prior to the crisis, all professionals, neurosurgeons included, should ask how they can prepare themselves and their communities. During the crisis, neurosurgeons should evaluate their roles based on specialized triage training and experience, personal and equipment decontamination training, and the importance of neurosurgical skills. Finally, one should continually ask if there is anything he/she should be doing during the crisis in addition to performing neurosurgical tasks.

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Leon E. Moores

Individual or collective preparedness for an attack involving weapons of mass destruction (WMD) must be based on an analysis of the threat. In threat assessment one takes many factors into account, including the physical and psychological parameters of the attacker. Although the potential devastation caused by WMD is significant, there are many limitations to the effective use of such weapons. Casualty rates will likely be measured in the thousands rather than millions because of factors that will be discussed. The psychological ramifications, it should be noted, the permutations of which have not yet been defined, will be much longer lasting. In this paper the author discusses these and other characteristics of the current threat.

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Chris J. Neal and Leon E. Moores

The purpose of this review is to present a concise overview of the types of radiation, methods of dispersal, injury patterns, and treatment considerations in a scenario involving radiation-based weapons of mass destruction. Radiation-related casualties, although uncommon, are a potential threat because more nations and organizations are developing the technology for producing radioactive substances capable of being used as weapons.

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Diana Barrett Wiseman and Leon E. Moores

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Frederick L. Stephens, Correy M. Mossop, Randy S. Bell, Teodoro Tigno Jr., Michael K. Rosner, Anand Kumar, Leon E. Moores and Rocco A. Armonda


In support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom-Afghanistan (OEF-A), military neurosurgeons in the combat theater are faced with the daunting task of stabilizing patients in such a way as to prevent irreversible neurological injury from cerebral edema while simultaneously allowing for prolonged transport stateside (5000–7000 miles). It is in this setting that decompressive craniectomy has become a mainstay of far-forward neurosurgical management of traumatic brain injury (TBI).

As such, institutional experience with cranioplasty at the Walter Reed Army Medical Center (WRAMC) and the National Naval Medical Center (NNMC) has expanded concomitantly. Battlefield blast explosions create cavitary injury zones that often extend beyond the border of the exposed surface wound, and this situation has created unique reconstruction challenges not often seen in civilian TBI. The loss of both soft-tissue and skull base support along with the need for cranial vault reconstruction requires a multidisciplinary approach involving neurosurgery, plastics, oral-maxillofacial surgery, and ophthalmology. With this situation in mind, the authors of this paper endeavored to review the cranial reconstruction complications encountered in these combat-related injuries.


A retrospective database review was conducted for all soldiers injured in OIF and OEF-A who had undergone decompressive craniectomy with subsequent cranioplasty between April 2002 and October 2008 at the WRAMC and NNMC. During this time, both facilities received a total of 408 OIF/OEF-A patients with severe head injuries; 188 of these patients underwent decompressive craniectomies in the theater before transfer to the US. Criteria for inclusion in this study consisted of either a closed or a penetrating head injury sustained in combat operations, resulting in the performance of a decompressive craniectomy and subsequent cranioplasty at either the WRAMC or NNMC. Excluded from the study were patients for whom primary demographic data could not be verified. Demographic data, indications for craniectomy, as well as preoperative, intraoperative, and postoperative parameters following cranioplasty, were recorded. Perioperative and postoperative complications were also recorded.


One hundred eight patients (male/female ratio 107:1) met the inclusion criteria for this study, 93 with a penetrating head injury and 15 with a closed head injury. Explosive blast injury was the predominant mechanism of injury, occurring in 72 patients (67%). The average time that elapsed between injury and cranioplasty was 190 days (range 7–546 days). An overall complication rate of 24% was identified. The prevalence of perioperative infection (12%), seizure (7.4%), and extraaxial hematoma formation (7.4%) was noted. Twelve patients (11%) required prosthetic removal because of either extraaxial hematoma formation or infection. Eight of the 13 cases of infection involved cranioplasties performed between 90 and 270 days from the date of injury (p = 0.06).


This study represents the largest to date in which cranioplasty and its complications have been evaluated in a trauma population that underwent decompressive craniectomy. The overall complication rate of 24% is consistent with rates reported in the literature (16–34%); however, the perioperative infection rate of 12% is higher than the rates reported in other studies. This difference is likely related to aspects of the initial injury pattern—such as skull base injury, orbitofacial fractures, sinus injuries, persistent fluid collection, and CSF leakage—which can predispose these patients to infection.

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Rare giant cell ependymoma in an octogenarian

Case report and review of the literature

Patrick B. Cooper, Matthew Katus, Leon Moores, Dennis Geyer, James G. Smirniotopoulos, Glenn D. Sandberg and Elisabeth J. Rushing

✓Ependymomas are glial tumors that occur most often in children. In adults, ependymomas most often appear in the spinal cord. The World Health Organization recognizes several rare ependymoma subtypes, including the giant cell ependymoma of the terminal filum. The authors describe an unusual case of a posterior fossa giant cell ependymoma in an 89-year-old man presenting with vertigo and disequilibrium. Only seven cases of this tumor have been reported in the literature to date. The authors discuss the clinical presentation, radiological findings, pathological considerations, and surgical intervention in this patient and review the relevant literature.