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Thomas H. Milhorat

✓ The author reviews modern information concerning the formation, flow, and functions of the cerebrospinal fluid. Particular attention is given to the lymphatic-like features of the third circulation and to its importance as an internal milieu for nervous tissue.

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Thomas H. Milhorat

Syringomyelia poses special challenges for the clinician because of its complex symptomatology, uncertain pathogenesis, and multiple options of treatment. The purpose of this study was to classify intramedullary cavities according to their most salient pathological and clinical features.

Pathological findings obtained in 175 individuals with tubular cavitations of the spinal cord were correlated with clinical and magnetic resonance (MR) imaging findings in a database of 927 patients. A classification system was developed in which the morbid anatomy, cause, and pathogenesis of these lesions are emphasized.

The use of a disease-based classification of syringomyelia facilitates diagnosis and the interpretation of MR imaging findings and provides a guide to treatment.

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Experimental Hydrocephalus

Part 1: A Technique for Producing Obstructive Hydrocephalus in the Monkey

Thomas H. Milhorat

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Thomas H. Milhorat

✓ Ventricular collapse following intraventricular surgery is a formidable complication. In patients with significant dilation of the lateral ventricles, the operative mortality may exceed 40%. In the current report, a technique for closing cerebral incisions is described which has prevented this complication in 18 intraventricular operations in which it has been used. The essential steps include: 1) linear incision of a cerebral gyrus; 2) closure of the incision using bordering vessels for traction; 3) inflation of the ventricles with saline; and 4) attachment of the incision to the overlying dura.

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David E. Adler and Thomas H. Milhorat

Object. Variations in the structure of the tentorial notch may influence the degree of brainstem distortion in transtentorial herniation, concussion, and acceleration—deceleration injuries. The authors examined the anatomical relationships of the mesencephalon, cerebellum, and oculomotor nerves to the dimensions of the tentorial aperture. On the basis of numerical data collected from this study, the authors have developed the first classification system of the tentorial notch and present new neuroanatomical observations pertaining to the subarachnoid third cranial nerve and the brainstem.

Methods. The mesencephalon was sectioned at the level of the tentorial edge in 100 human autopsy cases (specimens from 23 female and 77 male cadavers with a mean age at time of death of 42.5 years [range 18–80 years]). The following measurements were determined: 1) anterior notch width, the width of the tentorial notch in the axial plane through the posterior aspect of the dorsum sellae; 2) maximum notch width (MNW), the maximum width of the notch in the axial plane; 3) notch length (NL), the length of the tentorial notch from the superoposterior edge of the dorsum sellae to the apex of the notch; 4) posterior tentorial length, the shortest distance between the apex of the notch and the most anterior part of the confluence of the sinuses; 5) interpedunculoclival (IC) distance, the distance from the interpeduncular fossa to the superoposterior edge of the dorsum sellae; 6) apicotectal (AT) distance, the distance from the tectum in the median plane to a perpendicular line dropped from the apex of the tentorial notch to the cerebellum; 7) cisternal third nerve distance, the distance covered by the cisternal portion of the third cranial nerve; and 8) inter—third nerve angle, the angle between the two third cranial nerves.

The quartile distribution technique was applied to all measurements. Mean values are presented as the means ± standard deviations. Quartile groups defined by NL (mean 57.7 ± 5.6 mm) were labeled long, short, and midrange, and those defined by MNW (mean 29.6 ± 3 mm) were labeled wide, narrow, and midrange. Combining these groups into a matrix formation resulted in the classification of the tentorial notch into the following eight types: 1) narrow (15% of specimens); 2) wide (12% of specimens); 3) short (8% of specimens); 4) long (15% of specimens); 5) typical (24% of specimens); 6) large (9% of specimens); 7) small (10% of specimens); and 8) mixed (7% of specimens). The IC distance (mean 20.4 ± 3.2 mm) was used to characterize brainstem position as prefixed (28% of specimens), postfixed (36% of specimens), or midposition (36% of specimens). The IC distance was correlated with the left and right cisternal third nerve distances (means 26.7 ± 2.9 mm and 26.1 ± 3.2 mm, respectively) and the inter—third nerve angle (mean 57.3 ± 7.3°). The exposed cerebellar parenchyma within the notch, the relationship between the brainstem and tentorial edge, and the brainstem position varied considerably among individuals. The cisternal third nerve distance, its trajectory, and its anatomical relation to the skull base also varied widely. Two anatomically distinct segments of the subarachnoid third cranial nerves were characterized with respect to the skull base as suspended and supported segments.

Conclusions. The authors present a new classification system for the tentorial aperture to help explain variations in herniation syndromes in patients with otherwise similar intracranial pathological conditions, and responses to concussive and acceleration—deceleration injuries. The authors present observations not previously described regarding the position of the brainstem within the tentorial aperture and the cisternal portion of the third cranial nerves. A significant statistical correlation was discovered among specific morphometric parameters of the tentorial notch, brainstem, and oculomotor nerves. These findings may have neurosurgical implications in clinical situations that cause brainstem distortion. Additionally, this analysis provides baseline data for interpreting magnetic resonance and computerized tomography images of the tentorial notch and its regional anatomy.

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Thomas H. Milhorat and James E. McClenathan

✓ The authors describe a technique for direct cardiac shunting in which an adult-size ventriculoatrial catheter is coiled in an intrathoracic Silastic pouch and implanted in infants with hydrocephalus. In three patients so treated, serial chest films have shown progressive uncoiling of the catheter over a follow-up interval of 6 to 14 months.