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Wesley Hsu, Khan W. Li, Markus Bookland and George I. Jallo

In the early 1920s, Walter E. Dandy began translating the field of endoscopy to neurosurgery. In the ensuing years, Dandy, who would become known as the “Father of Neuroendoscopy,” applied his own ingenuity in combination with guidance from prominent medical contemporaries in the development of the early neuroendoscope. This paper reviews his contributions to the early evolution of this growing and important field of neurosurgery.

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Wesley Hsu, Ryan M. Kretzer, Michael J. Dorsi and Ziya L. Gokaslan

Wrong-site surgery (WSS) is a rare occurrence that can have devastating consequences for patient care. There are several factors inherent to spine surgery that increase the risk of WSS compared with other types of surgery. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but there are unique issues related to spinal localization that can be challenging for even the most experienced clinicians. The following review discusses important issues that can help prevent WSS during spinal procedures.

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Michael J. Dorsi, Wesley Hsu and Allan J. Belzberg

Object

The aim of this study was to estimate the prevalence of brachial plexus injury (BPI) in pediatric multitrauma patients.

Methods

The National Pediatric Trauma Registry was queried using the ICD-9 code 953.4, injury to brachial plexus, to identify cases of BPI. The patient demographics, mechanism of trauma, and associated ICD-9 diagnoses were analyzed.

Results

Brachial plexus injuries were identified in 113 (0.1%) of the 103,434 injured children entered in the registry between April 1, 1985, and March 31, 2002. Sixty-nine patients (61%) were male. Injuries were most often caused by motor vehicle accidents involving passengers (36 cases [32%]) or pedestrians (19 cases [17%]). Head injuries were diagnosed in 47% of children and included concussion in 27%, intracranial bleeds in 21%, and skull fractures in 14%. Upper-extremity vascular injury occurred in 16%. The most common musculoskeletal injuries were fractures of the humerus (16%), ribs (16%), clavicle (13%), and scapula (11%). Spinal fractures occurred in 12% of patients, and spinal cord injury occurred in 4%. The Injury Severity Score ranged from 1 to 75, with a mean score of 10, and 6 patients (5%) died as a result of injuries sustained during a traumatic event.

Conclusions

Brachial plexus injuries occur in 0.1% of pediatric multitrauma patients. Motor vehicle accidents and pedestrians struck by a motor vehicle are the most common reasons for BPIs in this population. Common associated injuries include head injuries, upper-extremity vascular injuries, and fractures of the spine, humerus, ribs, scapula, and clavicle.

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Aravind Somasundaram, Glenn J. Lesser, Ryan T. Mott and Wesley Hsu

Malignant transformation of epidermoid cysts (ECs) to squamous cell carcinomas (SCCs) in the CNS is exceedingly rare and has only been described in intracranial ECs. In this article, the authors describe a 53-year-old man with a history of a previously resected T3–4 EC, who presented with a 2-month history of progressively worsening weakness in the left side of his body. Magnetic resonance imaging revealed an enhancing mass in the T3–4 region, the exact location of the previous cyst. The mass was resected in gross-total fashion, and pathological analysis revealed an SCC. Postoperatively, the patient regained full strength in his lower extremities. After the resection, he received radiotherapy administered at an isodose of 50 Gy. To the authors' knowledge, this is the first reported case of malignant transformation of an intramedullary spinal EC in the literature.

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Veit Rohde and Uzma Samadani

Object

Currently no adequate surgical treatment exists for spontaneous intracerebral hemorrhage (ICH). Implantable polymers can be used effectively to deliver therapeutic agents to the local site of the pathological process, thus reducing adverse systemic effects. The authors report the use of stereotactically implanted polymers loaded with tissue plasminogen activator (tPA) to induce lysis of ICH in a rabbit model.

Methods

Ethylene vinyl acetate (EVAc) polymers were loaded with bovine serum albumin (BSA) only or with BSA plus tPA. In vitro pharmacokinetic (three polymers) and thrombolysis (12 polymers) studies were performed. For the in vivo study, 12 rabbits were fixed in a stereotactic frame, and 0.2 ml of clotted autologous blood was injected into the right frontal lobe parenchyma. After 20 minutes, control BSA polymers were stereotactically implanted at the hemorrhage site in six rabbits, and experimental BSA plus tPA polymers were implanted in six rabbits. Animals were killed at 3 days, and blood clot volume was assessed.

The pharmacokinetic study showed release of 146 ng of tPA over 3 days. The tPA activity correlated with in vitro thrombolysis. In the in vivo study, the six animals treated with tPA polymers had a mean (±standard error of the mean [SEM]) thrombus volume of 1.43 ±0.29 mm3 at 3 days, whereas the six animals treated with blank (BSA-only) polymers had a mean (±SEM) thrombus volume of 19.99 ±3.74 mm3 (p <0.001).

Conclusions

Ethylene vinyl acetate polymers release tPA over the course of 3 days. Stereotactic implantation of tPA-loaded EVAc polymers significantly reduced ICH volume. Polymers loaded with tPA may be useful clinically for lysis of ICH without the side effects of systemic administration of tPA.

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James L. West, Kyle M. Fargen, Wesley Hsu, Charles L. Branch Jr. and Daniel E. Couture

Global access to neurosurgical care is still a work in progress, with many patients in low-income countries not able to access potentially lifesaving neurosurgical procedures. “Big Data” is an increasingly popular data collection and analytical technique predicated on collecting large amounts of data across multiple data sources and types for future analysis. The potential applications of Big Data to global outreach neurosurgery are myriad: from assessing the overall burden of neurosurgical disease to planning cost-effective improvements in access to neurosurgical care, and collecting data on conditions which are rare in developed countries. Although some global neurosurgical outreach programs have intelligently implemented Big Data principles in their global neurosurgery initiatives already, there is still significant progress that remains to be made. Big Data has the potential to drive the efficient improvement of access to neurosurgical care across low- and medium-income countries.

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Wesley Hsu, Thomas A. Kosztowski, Hasan A. Zaidi, Ziya L. Gokaslan and Jean-Paul Wolinsky

Chordomas are rare tumors that arise from the sacrum, spine, and skull base. Surgical management of these tumors can be difficult, given their locally destructive behavior and predilection for growing near delicate and critical structures. En bloc resection with negative margins can be difficult to perform without damaging adjacent structures and causing significant clinical morbidity. For chordomas of the upper cervical spine, surgical options traditionally involve transoral or submandibular approaches. The authors report the use of the image-guided, endoscopic, transcervical approach to the upper cervical spine as an alternative to traditional techniques for addressing upper cervical spine tumors, particularly for tumors where gross-total resection is not feasible.

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Quoc-Anh Thai, Gustavo Pradilla, Federico G. Legnani, Ryan M. Kretzer, Wesley Hsu and Rafael J. Tamargo

Object

Currently no adequate surgical treatment exists for spontaneous intracerebral hemorrhage (ICH). Implantable polymers can be used effectively to deliver therapeutic agents to the local site of the pathological process, thus reducing adverse systemic effects. The authors report the use of stereotactically implanted polymers loaded with tissue plasminogen activator (tPA) to induce lysis of ICH in a rabbit model.

Methods

Ethylene vinyl acetate (EVAc) polymers were loaded with bovine serum albumin (BSA) only or with BSA plus tPA. In vitro pharmacokinetic (three polymers) and thrombolysis (12 polymers) studies were performed. For the in vivo study, 12 rabbits were fixed in a stereotactic frame, and 0.2 ml of clotted autologous blood was injected into the right frontal lobe parenchyma. After 20 minutes, control BSA polymers were stereotactically implanted at the hemorrhage site in six rabbits, and experimental BSA plus tPA polymers were implanted in six rabbits. Animals were killed at 3 days, and blood clot volume was assessed.

The pharmacokinetic study showed release of 146 ng of tPA over 3 days. The tPA activity correlated with in vitro thrombolysis. In the in vivo study, the six animals treated with tPA polymers had a mean (± standard error of the mean [SEM]) thrombus volume of 1.43 ± 0.29 mm3 at 3 days, whereas the six animals treated with blank (BSA-only) polymers had a mean (± SEM) thrombus volume of 19.99 ± 3.74 mm3 (p < 0.001).

Conclusions

Ethylene vinyl acetate polymers release tPA over the course of 3 days. Stereotactic implantation of tPA-loaded EVAc polymers significantly reduced ICH volume. Polymers loaded with tPA may be useful clinically for lysis of ICH without the side effects of systemic administration of tPA.

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Aravind Somasundaram, Robert T. Wicks, Adrian L. Lata, Shadi A. Qasem and Wesley Hsu

In this article, the authors describe a 48-year-old man who initially presented with progressively worsening back pain. Magnetic resonance imaging revealed a soft-tissue mass involving the T10–11 vertebral bodies with extension anteriorly into the aorta as well as epidural extension without spinal cord compression. A biopsy of the mass showed findings consistent with a malignant fibrous histiocytoma (MFH). A total en bloc spondylectomy with resection and reconstruction of the involved aorta using a vascular graft was performed. The patient received postoperative radiation therapy and is neurologically intact at 18 months postoperatively. To the authors' knowledge, this is the first reported case of a spinal MFH resection with aortic reconstruction.

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Philippe Metellus, Wesley Hsu, Siddharth Kharkar, Sumit Kapoor, William Scott and Daniele Rigamonti

The authors report their experience using preoperative chest radiography and intraoperative ultrasonography for percutaneous positioning of the distal end of the catheter when placing ventriculoatrial (VA) shunts in patients with hydrocephalus. The distal portion of VA shunt catheters were percutaneously placed into the internal jugular vein with the aid of intraoperative ultrasonography in 14 consecutive adults. In all cases, the technique was easy, there were no postoperative complications, and postoperative chest radiography demonstrated good positioning of the distal catheter tip. One patient presented with a shunt infection and needed a shunt replacement. The authors therefore conclude that percutaneous placement of a VA shunt under preoperative radiographic guidance and ultrasonographic monitoring is a safe, effective, and reliable technique that is simple to learn.