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Fast forwarding: the evolution of neurosurgery

The 2005 presidential address

Robert A. Ratcheson

✓ Despite the major social and economic reorganization of medical practice that has taken place during the past 40 years, neurosurgery—the most fascinating specialty in all of clinical medicine—has grown and prospered. Today, this specialty is poised for an era of spectacular advancement and improvement in care; however, significant problems with the potential to retard this growth face neurosurgery. Among these problems is the medical liability situation, which has the potential to destabilize neurosurgical practices and the current health care delivery system. Other issues facing neurosurgery include the potential for loss of the unique nature of the specialty through a conversion to shift-worker surgeons and increasing reliance on profit-seeking institutions for financial stability and liability protection. Lifestyle choices are of growing importance and currently discourage women from entering the field. With a growing knowledge base, there is the recognition that it may not be possible for most individuals to master all aspects of the specialty. There is continued confusion about manpower needs. In addition, some neurosurgeons are choosing to practice in ways that fail to meet the neurosurgeon's obligations to society. There is a growing number of neurosurgeons who dislike providing trauma coverage and there is the potential for some neurosurgeons to give up intracranial neurosurgery. The author believes that it is not competition that will improve the delivery of neurosurgical care and allow for continued growth, but cooperation, and that it will be possible to alleviate many of our problems through increased regionalization of neurosurgical care delivery. This proposal has the potential to promote the formation of neurosurgical teams, ameliorate the problem of physician fatigue, allow greater development of subspecialty skills, and ease the burden of trauma call. It should allow satisfactory solutions to lifestyle considerations and encourage more women to enter the field of neurosurgery. Such a transformation would encourage advances in care to be brought rapidly into the clinical setting and allow neurosurgery to be practiced at the very highest level.

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Robert A. Ratcheson

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Robert A. Ratcheson and James A. Ferrendelli

✓ Regional cortical levels of organic phosphates and carbohydrates were measured in cat brains, enzymatically inactivated by the technique of “funnel freezing” 1 hour after occlusion of a middle cerebral artery (MCA). Significant metabolic alterations occurred in all hemispheres ipsilateral to the site of occlusion. However, there was marked interindividual variability, with changes ranging from only slight increases in lactate, pyruvate, and adenosine monophosphate (AMP) in small regions of cortex at one extreme, to profound depletion of high-energy phosphates, depression of glucose and pyruvate levels, and increased lactate, adenosine diphosphate (ADP) and AMP levels in much of the hemisphere of the most severely involved animals. In contrast, metabolic changes in the hemisphere contralateral to the site of occlusion were very few or nonexistent. In addition, in all ipsilateral hemispheres there were regions peripheral to the areas of greatest metabolic alteration where there was excessive elevation of glucose levels. The results demonstrate that occlusion of a major cerebral vessel does not produce metabolic changes that are consistent in their distribution or severity. However, the findings of this study probably depict some of the complicated metabolic events that occur clinically during thrombotic or embolic infarction of brain.

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Mary Louise Hlavin and Robert A. Ratcheson

✓ There is a strong tradition of neurosurgery in Cleveland. This article traces the origin of Case Western Reserve University School of Medicine and University Hospitals of Cleveland and examines the evolution of neurological surgery at these institutions. It looks at the strong Cushing influence on the process, by both Harvey Cushing and his family. The contributions of such luminaries as George Crile, Elliott Cutler, Claude Beck, and Frank Nulsen are described.

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M. Peter Heilbrun and Robert A. Ratcheson

✓ A case with multiple extracranial vessel involvement following closed head and neck trauma is described. The use of selective cerebral angiography through the femoral route as a diagnostic aid is stressed. The etiology of the neurological deficit and the role of intensive supportive care is discussed.

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Henry G. Schwartz

Edited by Robert A. Ratcheson

✓ In his final address to the Society of Neurological Surgeons, Henry G. Schwartz, M.D., shared his thoughts on mentoring and recalled specific mentors who contributed to his professional life.

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Timothy B. Mapstone, Benjamin Kaufman, and Robert A. Ratcheson

✓ This paper presents a rare case of intradural chordoma which involved the pons but had no radiological or surgical evidence of bone involvement. The appearance of this tumor on nuclear magnetic resonance imaging is presented.

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Nicholas C. Bambakidis, Tina Rodrigue, Cliff A. Megerian, and Robert A. Ratcheson

✓ Endolymphatic sac tumors (ELSTs) are aggressive papillary lesions of the temporal bone. Although histologically benign, they may exhibit invasive growth and destruction of the skull base. Patients generally present with symptoms referable to the lesion's location within the middle or posterior cranial fossa. Although well characterized as a distinct entity, ELSTs involved in metastatic dissemination have never been reported. In the present report the authors describe a case of ELST metastatic to the spine treated with resection.

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Meg Verrees, Jose Americo Fernandes Filho, Jose I. Suarez, and Robert A. Ratcheson

✓ Hypertension-induced encephalopathy is a recognized pathological process commonly focused in the parietal and occipital lobes of the cerebral hemispheres. The parenchyma of the posterior fossa is infrequently involved. The authors report on two cases of isolated edema of the cerebellar hemispheres, which occurred in the setting of hypertensive crisis and led to complete obstruction of or significant impingement on the fourth ventricle and potentially lethal hydrocephalus. To the best of the authors' knowledge, these are the first reported cases of hypertensive encephalopathy centered in the posterior fossa.

Two patients presented with profound decreases in neurological status subsequent to development of malignant hypertension. Imaging studies revealed diffusely edematous cerebellar hemispheres with effacement of the fourth ventricle, causing dilation of the lateral and third ventricles. Following emergency placement of external ventricular drains, control of systemic blood pressure was accomplished, and neurological functioning returned to baseline.

Although neurological deterioration resolved swiftly following placement of ventricular catheters and administration of diuretic agents, systemic blood pressure did not fluctuate with the release of cerebrospinal fluid and resolution of increased intracranial pressure. Decrease in systemic blood pressure lagged well behind improvement in neurological status; the patients remained morbidly hypertensive until systemic blood pressure was controlled with multiple parenteral medications.

The authors hypothesize that the development of hypertension beyond the limits of cerebral autoregulation led to breakdown of the blood—brain barrier in the cerebellum and development of posterior fossa edema secondary to the focal transudation of protein and fluid. Correction of the elevated blood pressure led to amelioration of cerebellar edema. In the appropriate clinical setting, hypertension as the inciting cause of cerebellar encephalopathy should be considered.