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The Current Procedural Terminology and the Medicare Resource Based Relative Value Scale in neurosurgical practice

Richard A. Roski

Changes in healthcare have made it increasingly more important for neurosurgeons to understand the economic pressures that effect their reimbursement. Two fundamental concepts that are of the greatest importance are the Current Procedural Terminology coding and the Medicare Resource Based Relative Value Scale. The impact of these two entities on neurosurgical reimbursement in analyzed in this review.

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Elective extracranial-intracranial arterial bypass in the treatment of inoperable giant aneurysms of the internal carotid artery

Robert F. Spetzler, Herbert Schuster, and Richard A. Roski

✓ Thirteen patients with giant aneurysms of the internal carotid artery (ICA) were treated with ICA ligation and an extracranial-intracranial arterial bypass. A method for establishing a proper superficial temporal artery to middle cerebral artery pressure gradient while maintaining partial flow through the ICA is presented. This procedure allows the anastomosis to become established before full occlusion of the cervical ICA. None of these patients suffered any immediate or delayed ischemic or rebleed complications over an average follow-up period of 18 months.

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Late complications of carotid ligation in the treatment of intracranial aneurysms

Richard A. Roski, Robert F. Spetzler, and Frank E. Nulsen

✓ The results in 57 consecutive patients treated with carotid ligation for an intracranial aneurysm were analyzed to define the risks of late complications. The average age for the group was 46 years. Eighty percent of the aneurysms were located on the internal carotid artery (ICA). The acute morbidity and mortality of the treatment and the natural history of the disease was 29%. Twenty-four patients were discharged with a common carotid artery (CCA) ligation, and 21 patients with an ICA ligation. Three patients from each ligation group could not be located for review. The follow-up period for the 21 patients with CCA ligation ranged from 1 to 15 years, with an average of 8.4 years, and for the 18 patients with ICA ligation it ranged from 2 to 19.5 years, with an average of 12.5 years.

Excluding deaths from unrelated causes, five of the 21 patients with CCA ligation developed a late complication. Two patients had a transient ischemic attack (TIA). Two patients had a subarachnoid hemorrhage (SAH), one of which was fatal and was preceded by a TIA. Two patients developed monocular blindness. None of the patients had a stroke. Excluding deaths from unrelated causes, five of the 18 patients with ICA ligation developed a late complication. One patient had a fatal SAH. Three patients had a TIA, two of which were followed by a stroke. One patient had a stroke in the cerebral hemisphere contralateral to the side of the carotid ligation.

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Intrachiasmatic arteriovenous malformation

Case report

Richard A. Roski, John H. Gardner, and Robert F. Spetzler

✓ A patient presented with an abrupt monocular decrease in visual acuity and a bitemporal hemianopsia. At surgery, a totally intrachiasmatic arteriovenous malformation was removed, with subsequent resolution of the visual deficit.

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The “bonnet bypass”

Case report

Robert F. Spetzler, Richard A. Roski, Robert S. Rhodes, and Michael T. Modic

✓ A saphenous vein bypass graft from the contralateral superficial temporal artery to the ipsilateral middle cerebral artery was performed in a patient who required occlusion of his left common carotid artery. This procedure was used because of the unavailability of an ipsilateral donor artery. The bypass is working well 8 months postoperatively.

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Subclavian to middle cerebral artery saphenous vein bypass graft

Robert F. Spetzler, Robert S. Rhodes, Richard A. Roski, and Matt J. Likavec

✓ A variation of an extracranial-intracranial arterial bypass is presented. The subclavian artery is used as the donor vessel and the saphenous vein as the graft; thus, a bypass to a cortical branch of the middle cerebral artery can be accomplished. The advantage of this modification is that the saphenous vein, when tunneled subcutaneously behind the ear, is positioned in a straight line from the donor to the recipient vessel. Since the vein lies in the axis of head rotation, turning of the head causes little displacement of the graft, as opposed to a graft from the common carotid artery to the middle cerebral artery. An additional advantage over the superficial temporal artery to middle cerebral artery bypass is the large flow obtained immediately after anastomosis.

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Atypical trigeminal neuralgia in a 6-year-old boy

Case report

Richard A. Roski, Samuel J. Horwitz, and Robert F. Spetzler

✓ This boy first contracted atypical trigeminal neuralgia at the age of 6 years. Four years later, he underwent a microvascular decompression of a venous loop from his trigeminal nerve. He remains asymptomatic 2 years after surgery.

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Barbiturate coma in focal cerebral ischemia

Relationship of protection to timing of therapy

Warren R. Selman, Robert F. Spetzler, Richard A. Roski, Uros Roessmann, Ralph Crumrine, and Richard Macko

✓ The therapeutic application of barbiturate-induced coma was evaluated in a primate model of focal cerebral ischemia. A standardized regimen of pentobarbital was used, and the times of initiation of administration were varied following a 6-hour middle cerebral artery occlusion in baboons. Three groups of five animals were treated at 30, 120, and 240 minutes after occlusion, while one group of five animals received no barbiturate therapy. Complete protection from intracranial pressure (ICP) elevation and ischemic damage was seen only in the group treated at 30 minutes. Those treated at 120 minutes, while doing better than untreated animals, still had ICP elevation and a marked neuropathological deficit. Animals treated at 240 minutes suffered a detrimental effect, in that malignant ICP and marked ischemic damage occurred earlier than in the untreated animals. The safe “therapeutic window” for barbiturate-induced coma in this animal model does not extend beyond 2 hours. Delayed administration results in a deleterious response and not merely a lack of protection.

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Clinical and pathological study of dysplastic gangliocytoma

Case report

Richard A. Roski, Uros Roessmann, Robert F. Spetzler, Benjamin Kaufman, and Frank E. Nulsen

✓ A case of dysplastic gangliocytoma of the cerebellum (Lhermitte-Duclos disease) is reported. Computerized tomography revealed a nonenhancing mass lesion surrounded by areas of calcification. Surgical excision resulted in complete resolution of the patient's symptoms. The histological findings support the concept that this tumor represents a congenital abnormality in granule-cell migration and is not a true neoplasm.