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Mitchel S. Berger

✓ A skull-mounted apparatus is described for use with ultrasound probes 16 mm in diameter (5.0-MHz probes for near-field and 7.5-MHz probes for far-field lesions). The system permits ultrasound-guided stereotaxic biopsy of intracranial lesions through a burr hole in awake or anesthetized patients. This apparatus has been used in 19 patients for biopsy of central nervous system lesions 1.5 to 5 cm in diameter and for drainage of abscess cavities and cysts. The time required to obtain a tissue sample after incision of the skin ranged from 25 to 40 minutes. The only complication was a delayed hemorrhage in a patient with acquired immunodeficiency syndrome. The advantages of this method over those guided by computerized tomography (CT) include less time required for the entire procedure, immediate confirmation of the biopsied target by imaging the echogenic needle track, assessment of cyst or abscess drainage, and detection of hemorrhage within minutes after biopsy. The apparatus may be especially useful in pediatric patients because it obviates the need for general anesthesia during transport to and from the CT scanner. This ultrasound-guided system does not require a craniotomy, craniectomy, or two separate burr holes.

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Introduction

Language localization in the dominant hemisphere

Mitchel S. Berger

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Mitchel S. Berger

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Nader Sanai and Mitchel S. Berger

Although a primary tenet of neurosurgical oncology is that survival can improve with greater tumor resection, this principle must be tempered by the potential for functional loss following a radical removal. Preoperative planning with functional and physiological imaging paradigms, combined with intraoperative strategies such as cortical and subcortical stimulation mapping, can effectively reduce the risks associated with operating in eloquent territory. In addition to identifying critical motor pathways, these techniques can be adapted to identify language function reliably. The authors review the technical nuances of intraoperative mapping for low- and high-grade gliomas, demonstrating their efficacy in optimizing resection even in patients with negative mapping data. Collectively, these surgical strategies represent the cornerstone for operating on gliomas in and around functional pathways.

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Anil Sehgal and Mitchel S. Berger

The immune system is a complex network of specialized cells and organs that defends the human body against attack from foreign pathogens. The major lymphocytes involved in protecting the body against potential infections are B and T cells, which also play an important role in combating tumor growth. The cells of the immune system patrol the tissues and organs through both blood and lymphatic vessels, but some organs—including cornea, testes, and brain—are usually not patrolled by these cells. The brain has been thought to be an immune-privileged site because of the tight blood–brain barrier (BBB) that protects it. Few cells migrate to the brain under normal circumstances, because the BBB permits only certain molecules to cross into brain tissue. Recently, however, studies have shown that activated T cells exposed to antigen can cross the intact BBB and migrate into brain. This finding opens the path to developing effective means of immunotherapy for lesions of the central nervous system. The authors discuss basic facets of the immune system, review the current knowledge about human neuroimmunology, and survey current strategies for developing immunotherapy-based treatments for human brain tumors.

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David Schiff

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Mitchel S. Berger and Yoshio Hosobuchi

✓ A persistent carotid-basilar anastomosis (primitive trigeminal artery), identified by four-vessel vertebral angiography, was shown to be the cause of a cavernous sinus fistula in a 51-year-old woman. The fistula, but not the primitive artery, was identified on a carotid arteriogram. Because of the flow contribution from the posterior circulation, balloon embolization via the carotid system failed, and the fistula was repaired through a direct surgical approach. The operative technique is described and the hemodynamic aspects of a cavernous sinus fistula that is related to this primitive anastomosis are reviewed.