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Roberto C. Heros

✓ A case is reported of a patient who suffered a gunshot wound of the neck which resulted in occlusion of a vertebral artery. Within a few hours he deteriorated neurologically to a comatose state with a gaze paresis and a facial paresis ipsilateral to the occluded vertebral artery. The diagnosis of cerebellar infarction with brain-stem compression was made clinically, and a posterior fossa decompression was carried out promptly. The patient has made an excellent recovery. Cerebellar infarction, like cerebellar hemorrhage, may act as a posterior fossa mass requiring neurosurgical decompression. This report emphasizes that such a pathological process may occur after certain injuries that are likely to result in occlusion of a vertebral artery.

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Roberto C. Heros

✓ A modification of the unilateral suboccipital approach is elaborated and illustrated. This modification is useful for aneurysms of the vertebral artery, the vertebrobasilar junction, and the proximal basilar trunk, and for arteriovenous malformations of the inferolateral cerebellum. It entails extreme lateral removal of the rim of the foramen magnum toward the condylar fossa and posterolateral removal of the arch of the atlas toward the exposed vertebral artery. This extra bone removal allows an approach to the front of the brain stem from inferolaterally, after gentle upward and medial retraction of the tonsil, with minimal or no retraction of the medulla.

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Arteriovenous malformations of the medial temporal lobe

Surgical approach and neuroradiological characterization

Roberto C. Heros

✓ Arteriovenous malformations (AVM's) of the medial temporal lobe frequently involve the basal ganglia and the thalamus and, for this reason, are commonly judged to be inoperable. However, when the medial involvement is limited to the posterolateral part of the thalamus and to the inferior portion of the basal ganglia lateral to the internal capsule, the lesions may be excised safely. Three patients who underwent successful excision of AVM's of this region are presented. A transcortical surgical approach through the inferior portion of the temporal lobe was used to minimize retraction of the temporal lobe and damage to the optic radiation, and to avoid postoperative dysphasia.

The following neuroradiological criteria indicate that the bulk of the lesion is in the temporal lobe, that only noncritical portions of the basal ganglia and thalamus are involved, and that, therefore, surgical resection is relatively safe: 1) primary supply by the anterior choroidal artery and by laterally oriented branches of the posterior cerebral artery; 2) primary venous drainage into the basal vein of Rosenthal and medial Sylvian veins; 3) projection below the plane of the middle cerebral artery in the lateral carotid arteriogram; 4) projection lateral to the sweep of the posterior cerebral artery in the anteroposterior or Towne's view of the vertebral angiogram; and 5) demonstration of an intratemporal clot or intraventricular blood by computerized tomography.

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Roberto C. Heros

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Policy on Conflict of Interest

Journal of Neurosurgery Publishing Group

Roberto C. Heros

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Roberto C. Heros

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Roberto C. Heros

✓ In his 2003 Presidential Address to the American Association of Neurological Surgeons, Dr. Heros discusses his personal additions to the six basic competencies for which all neurosurgical residents must be tested. The basic competencies are as follows: 1) patient care; 2) medical knowledge; 3) practice-based learning and improvement; 4) interpersonal and communication skills; 5) professionalism; and 6) system-based practice. To these, Dr. Heros proposes to add six supplemental competencies: 1) intellectual honesty, which involves frank discussions about patient complications and admissions of the physician's frailties; 2) scholarship—the art and science of medicine, which recognizes the value of evidence-based medicine but does not discount knowledge derived from experience; 3) practicing in a hyperlegalistic society, which involves tailoring informed consent to fit individual patients' circumstances; 4) time- and cost-efficient practices, in which the physician strives to conserve time and resources by forgoing testing that is not strictly necessary, doing only what is needed to return patients to wellness; 5) approach to patients, which entails acknowledging and respecting the dignity of all patients; and 6) pride in being a neurosurgeon, which carries a sense of elitism without arrogance.

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Roberto C. Heros

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Roberto C. Heros