Neurosurgery
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In 1917, the Sugeon General of the United States Army, William Gorgas, learned that almost 15% of the casualties on the Western Front sustained intracranial injuries. Soon after the United States declared war in April 1917, the Council of National Defense established a General Medical Board and attached a brain surgery subsection to its Committee of Ophthalmology. Postcards were sent to experts around the country, asking for the names of individuals who had specialty training or practice in brain surgery. ⋯ Only three 70-day brain surgeons participated in the postwar development of the specialty. However, 9 of 10 original members of the Neurosurgical Club, which was established 18 months after the armistice, taught in American Army Medical Department courses or served on the Western Front. The schools and their teachers emphasized a growing recognition of neurosurgical expertise in the early 20th century.
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This study examined the efficacy of computed tomographic angiography (CTA) for detection of ruptured and unruptured aneurysms after adjustment for their size distributions under various conditions of aneurysm prevalence. ⋯ Small aneurysms detected on CTA should be investigated further unless there is a high pretest probability of a ruptured aneurysm. During screening for ruptured aneurysms, a negative CTA should be investigated further. During screening for unruptured aneurysms, a negative CTA results in a very low probability of a clinically important aneurysm.
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Managing lesions situated in the anterior aspect of the craniovertebral junction (CVJ) remains a challenging neurosurgical problem. The purposes of this study were to examine the microsurgical anatomy of the anterior extradural aspect of the CVJ and the differences in the exposure obtained by the far lateral and extreme lateral atlanto-occipital transarticular approaches. The far lateral approach, as originally described, is a lateral suboccipital approach directed behind the sternocleidomastoid muscle and the vertebral artery and just medial to the occipital and atlantal condyles and the atlanto-occipital joint. The extreme lateral approach, as originally described, is a direct lateral approach deep to the anterior part of the sternocleidomastoid muscle and behind the internal jugular vein along the front of the vertebral artery. Both approaches permit drilling of the condyles at the atlanto-occipital joint but provide a different exposure because of the differences in the direction of the approach. ⋯ The far lateral and extreme lateral variants of the atlanto-occipital transarticular approach provide an alternative to the transoral approach to the anterior extradural structures at the CVJ. Compared with the transoral approach, both approaches provide a shorter operative route, avoid the contaminated nasopharynx, reduce the incidence of cerebrospinal fluid leak, and are not limited laterally by the atlanto-occipital joint.
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Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed. ⋯ We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.
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We sought to determine the tumor control rate and cranial nerve function outcomes in patients with vestibular schwannomas who were treated with proton beam stereotactic radiosurgery. ⋯ Proton beam stereotactic radiosurgery has been shown to be an effective means of tumor control. A high radiological response rate was observed. Excellent facial and trigeminal nerve function preservation rates were achieved. A reduced prescribed dose is associated with a significant decrease in facial neuropathy.