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Setti S. Rengachary, Andrew Xavier, Sunil Manjila, Usha Smerdon, Brandon Parker, Suzan Hadwan and Murali Guthikonda

Thomas Willis established neurology as a distinct discipline and made significant original contributions to many related fields including anatomy, pathology, cardiology, endocrinology, and gastroenterology. He is most remembered for his work in elucidating the function and anatomy of the circle of Willis. Willis' accomplishments and research methods can be credited in large part to his unconventional medical education which did not include traditional teachings, but rather emphasized learning through clinical practice. Although Willis was not the first to describe the arterial circle, he was the first to describe its function and provide a complete, undisputed illustration through his own innovative use of dye studies. The Willis classification of cranial nerves was still in use over 100 years after its original description. He has also described several disease entities and named many brain structures. Willis' accomplishments in comparative anatomy and understanding the pathophysiology of various diseases through original multidisciplinary experimental work in a clinical setting reveal that he was a true pioneer in translational research.

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Sunil Manjila, Setti Rengachary, Andrew R. Xavier, Brandon Parker and Murali Guthikonda

The history of modern psychosurgery has been written in several ways, weaving around many pioneers in the field during the 19th century. Often neglected in this history is Gottlieb Burckhardt (1836–1907), who performed the first psychosurgical procedures as early as 1888, several decades before the work of Egas Moniz (1874–1955). The unconventional and original case series of Burckhardt, who claimed success in 50% of patients (3 of 6), had met with overt criticism from his contemporary medical colleagues. The authors describe 2 illustrative cases of cortical extirpation performed by Burckhardt and review his pioneering case series for surgical outcome, despite the ambiguity in postoperative evaluation criteria. Although Burckhardt discontinued the project after publication of his surgical results in 1891, neurosurgeons around the world continued to investigate psychosurgery and revitalized his ideas in 1910; psychosurgery subsequently developed into a full-fledged neurosurgical specialty.

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Richard Rhiew, Sunil Manjila, Adam DeZure, Monir Tabbosha, Murali Guthikonda and Hazem Eltahawy

The authors describe a technique for minimally invasive anterior vertebroplasty for treating metastatic disease of the C-2 vertebra and discuss its application in 2 cases. After a 2-cm lateral neck incision is made, blunt dissection is performed toward the anterior inferior endplate of the C-2 vertebra. An 11-gauge needle is introduced through a tubular sheath and tapped into the inferior endplate of C-2, with biplanar fluoroscopy being performed to confirm position. The needle is subsequently advanced across the fracture line and into the odontoid process. Under fluoroscopic guidance, 2 ml of methylmethacrylate is injected into the odontoid process and vertebral body. This method is advantageous as 1) hyperextension of the neck is not performed, 2) the chance of inadvertent neurovascular or submandibular gland injury is minimized, 3) the possibility of cement leakage is decreased, and 4) hemostasis is better achieved under direct vision.

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Sunil Manjila, Nivin Haroon, Brandon Parker, Andrew R. Xavier, Murali Guthikonda and Setti S. Rengachary

The artery of Adamkiewicz is an important radiculomedullary artery supplying the spinal cord, especially the lumbar enlargement. Anatomical knowledge of this artery is important for avoiding serious neurological complications during surgery performed in this region—for neurosurgeons and interventional radiologists treating intramedullary tumors and spinal arteriovenous malformations, traumatologists performing spinal fusions, thoracic surgeons treating aortic aneurysms, and urologists and pediatric surgeons conducting retroperitoneal dissections. However, the biography of the talented Polish pathologist Albert Adamkiewicz, after whom the landmark artery is named, has not been described adequately in the existing neurosurgical literature. The authors bring to light the historical perspective of the eponymic artery and provide a recapitulation of other significant contributions made by Adamkiewicz, mostly involving the nervous system. His research papers on the histology of neuronal tissues and neurodegenerative diseases had high scientific merit, but the discovery of the anticancer antitoxin “cancroin” and his postulation of a cancer-causing parasite he named “Coccidium sarcolytus” met with harsh criticism and eventually led to his ill fame. The biography is supplemented with a brief overview of the important surgical implications of the artery of Adamkiewicz.

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Sunil Manjila, Setti Rengachary, Andrew R. Xavier and Murali Guthikonda

The use of the term “chair” in medical literature probably started in the Late Middle Ages with the Italian anatomist Mondino de Liuzzi. History reveals the term's origin at Bologna, one of the oldest degree-granting universities in Europe. Nobody has been shown in documented literature before Mondino to have reached the level of chair, the zenith of hierarchy in Western scholastic medicine. Mondino is remembered for his preparation of the Anathomia, a compendium for medical scholars, and his description of several anatomical structures and their functions, especially from a forensic perspective. Starting out as a demonstrator displaying various anatomical structures to medical students, Mondino worked his way up to becoming the first documented chair in medical history, and indeed physically occupying the chair. Marking an epoch in academia with his revised method of medical teaching and creative interaction with surgical colleagues, he carved a niche for himself and his department with his illustrious chairmanship. The authors revisit the history of the “chair” as a title and position in the medieval anatomical period and discuss the career of the first and foremost in the documented medical literature.

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Jaechan Park, Ealmaan Kim, Gyoung-Ju Kim, Yun-Kyung Hur and Murali Guthikonda

Decompressive craniectomy procedures are used for malignant hemispheric infarctions. However, the temporal muscle and fascia are significant limiting factors for external herniation of an edematous brain. Therefore, the authors performed a decompressive craniectomy and expansive duraplasty combined with resection of the temporal muscle and fascia for 15 patients with a malignant hemispheric infarction.

The volume of the maximum external herniation that was measured on the basis of a CT volumetry study ranged from 130 to 300 ml (mean ± standard deviation, 200 ± 64 ml) on postoperative Day 3.2 ± 1.5 (range 2–5 days postoperatively). The mean value represented a 2-fold volume expansion in comparison with the conventional decompressive craniectomy, and the greater the external herniation obtained by external decompression, the smaller the midline brain shift after surgery. The mortality rate, favorable outcomes (modified Rankin Scale Scores 1–3), and unfavorable outcomes were 20, 60, and 20%, respectively, and the masticatory function was only minimally affected. Furthermore, a cranioplasty involving reconstruction of the temporal muscle defect performed using a MEDPOR implant resulted in good cosmetic outcomes with no temporal hollow.

Resection of the temporal muscle in a decompressive craniectomy was shown to provide greater decompression and better clinical outcomes for malignant hemispheric infarctions at an acceptable cost of minimal masticatory dysfunction and cosmetic disfigurement.

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Matthew Schreckinger, Todd Francis, Gary Rajah, Jay Jagannathan, Murali Guthikonda and Sandeep Mittal

Lymphocytic hypophysitis is an uncommon autoimmune condition that often results in significant morbidity. Although most cases resolve spontaneously or after a short course of steroids, rarely, refractory cases can cause persistent neurological deficits despite aggressive medical and surgical management.

A 41-year-old woman presented with progressive visual loss in the left eye and was found to have a sellar mass. She underwent transsphenoidal surgery because of lesion enlargement. Histopathology was consistent with adenohypophysitis with B-cell predominance. Despite steroid treatment, her neurological condition worsened and she experienced loss of vision in the right eye. Craniotomy with decompression of the right optic nerve was performed. Her condition improved initially, but she continued to have progressive visual compromise over the following months. She was therefore treated with rituximab, a monoclonal antibody against B cells. Her vision improved significantly within a few weeks. There was no clinical or radiographic exacerbation 2 years after starting immunotherapy.

Rituximab, an anti-CD20 antibody that specifically depletes B lymphocytes, can be an effective treatment strategy for patients with steroid-refractory, B cell–predominant lymphocytic hypophysitis.

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Mahmoud Rayes, Chaim B. Colen, Diaa A. Bahgat, Tetsuhiro Higashida, Murali Guthikonda, Setti Rengachary and Hazem A. Eltahawy

Object

Treatment of spine infection remains a challenge for spine surgeons, with the most effective method still being a matter of debate. Most surgeons agree that in early stages of infection, antibiotic treatment should be pursued; under certain circumstances, however, surgery is recommended. The goals of surgery include radical debridement of the infective focus. In some cases, when surgery causes mechanical spinal instability, the question arises whether the risk of recurrent infection outweighs the benefits of spinal instrumentation and stabilization. The authors report their series of cases in which instrumentation was placed in actively infected sites and review the relevant literature.

Methods

The authors performed a retrospective analysis of all cases of spinal infection that were surgically treated with debridement and placement of instrumentation at their institution between 2000 and 2006. Patient presentation, risk factor, infective organism, surgical indication, level of involvement, type of procedure, and ultimate outcome were reviewed. Improved outcome was based on improvement of initial American Spinal Injury Association Impairment Score.

Results

Forty-seven patients (32 men, 15 women) were treated with instrumented surgery for spinal infection. Their average age at presentation was 54 years (range 37–78 years). Indications for placement of instrumentation included instability, pain after failure of conservative therapy, or both. Patients underwent surgery within an average of 12 days (range 1 day to 5 months) after their presentation to the authors' institution. The average length of hospital stay was 25 days (range 9–78 days). Follow-up averaged 22 months (range 1–80 months). Eight patients died; causes of death included sepsis (4 patients), cardiac arrest (2), and malignancy (2). Only 3 patients were lost to follow-up. Using American Spinal Injury Association scoring as the criterion, the patients' conditions improved in 34 cases and remained the same in 5. Complications included hematoma (2 cases), the need for hardware revision (1), and recurrent infection (2). Hardware replacement was required in 1 of the 2 patients with recurrent infection.

Conclusions

Instrumentation of the spine is safe and has an important role in stabilization of the infected spine. Despite the presence of active infection, we believe that instrumentation after radical debridement will not increase the risk of recurrent infection. In fact, greater benefit can be achieved through spinal stabilization, which can even promote accelerated healing.

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Tony Wang, David Yu-Te Chou, Jamie Y. Ding, Vance Fredrickson, Changya Peng, Steven Schafer, Murali Guthikonda, Christian Kreipke, José A. Rafols and Yuchuan Ding

Object

Previous studies have demonstrated that traumatic brain injury (TBI) causes brain edema by allowing excessive water passage through aquaporin (AQP) proteins. To establish the potential neuroprotective properties of ethanol as a post-TBI therapy, in the present study the authors determined the effect of ethanol on brain edema, AQP expression, and functional outcomes in a post-TBI setting.

Methods

Adult male Sprague-Dawley rats weighing between 425 and 475 g received a closed head TBI in which Maramarou's impact-acceleration method was used. Animals were given a subsequent intraperitoneal injection of 0.5 g/kg or 1.5 g/kg ethanol at 60 minutes post-TBI and were killed 24 hours after TBI. Brains were subsequently examined for edema along with AQP mRNA and protein expression. Additional animals treated with either 0.5 g/kg or 1.5 g/kg ethanol at 60 minutes post-TBI were designated for cognitive and motor testing for 3 weeks.

Results

Ethanol administration post-TBI led to significantly (p < 0.05) lower levels of brain edema as measured by brain water content. This downregulation in brain edema was associated with significantly (p < 0.05) reduced levels of AQP mRNA and protein expression as compared with TBI without treatment. These findings concur with cognitive studies in which ethanol-treated animals exhibited significantly (p < 0.05) faster radial maze completion times. Motor behavioral testing additionally demonstrated significant (p < 0.05) beneficial effects of ethanol, with treated animals displaying improved motor coordination when compared with untreated animals.

Conclusions

The present findings suggest that acute ethanol administration after a TBI decreases AQP expression, which may lead to reduced cerebral edema. Ethanol-treated animals additionally showed improved cognitive and motor outcomes compared with untreated animals.

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Jingwen Hu, Xin Jin, Jong B. Lee, Liying Zhang, Vipin Chaudhary, Murali Guthikonda, King H. Yang and Albert I. King

Object

The aims of this study were to develop a three-dimensional patient-specific finite element (FE) brain model with detailed anatomical structures and appropriate material properties to predict intraoperative brain shift during neurosurgery and to update preoperative magnetic resonance (MR) images using FE modeling for presurgical planning.

Methods

A template-based algorithm was developed to build a 3D patient-specific FE brain model. The template model is a 50th percentile male FE brain model with gray and white matter, ventricles, pia mater, dura mater, falx, tentorium, brainstem, and cerebellum. Gravity-induced brain shift after opening of the dura was simulated based on one clinical case of computer-assisted neurosurgery for model validation. Preoperative MR images were updated using an FE model and displayed as intraoperative MR images easily recognizable by surgeons. To demonstrate the potential of FE modeling in presurgical planning, intraoperative brain shift was predicted for two additional head orientations.

Two patient-specific FE models were constructed. The mesh quality of the resulting models was as high as that of the template model. One of the two FE models was selected to validate model-predicted brain shift against data acquired on intraoperative MR imaging. The brain shift predicted using the model was greater than that observed intraoperatively but was considered surgically acceptable.

Conclusions

A set of algorithms for developing 3D patient-specific FE brain models is presented. Gravity-induced brain shift can be predicted using this model and displayed on high-resolution MR images. This strategy can be used not only for updating intraoperative MR imaging, but also for presurgical planning.