Neurosurgery
-
Magnetically guided neuronavigation of flexible instruments is a new tool that can be used in the frameless navigation of deep-seated lesions or shunt placements. Disadvantages of optical systems such as the line-of-sight problem, the necessity of rigid pin fixation of the head, and missing tracking of the tip of flexible instruments should be solved by the new tracking system. Until now, the accuracy of magnetically guided systems was mostly estimated in laboratory setups. ⋯ Tracking of flexible instruments was easily accomplished as the tip of the instrument was followed within the patient's head. There were no major interferences with other metallic instruments within the surgical field.
-
Although endovascular coiling has been used for 15 years in the treatment of intracranial aneurysms, fewer than 60 published studies have directly compared microsurgical clipping and endovascular coiling, and only two studies have used a randomized, prospective design. The objective of this review is to weigh evidence for the efficacy of endovascular coiling compared with microsurgical clipping based on published head-to-head comparisons. ⋯ The earliest randomized prospective study by Koivisto et al. found clinical and angiographic results between the two methodologies to be statistically equivalent. The more recent and larger randomized, prospective study from the International Subarachnoid Aneurysm Trial group suggests that endovascular coiling is statistically superior to microsurgical clipping in clinical outcomes, although the recently published long-term follow-up of International Subarachnoid Aneurysm Trial patients documents higher recurrence and rehemorrhage rates after endovascular coiling. Although there is no clear consensus in these two studies or in the 45 observational studies included, clinically useful information can be extracted to improve shared decision making and interaction between interventionalists and neurosurgeons, create more individualized treatment algorithms, and enhance future research.
-
The disciplines of microneurosurgery and cranial base surgery have reached maturity, and technical advances in the surgical management of aneurysms are limited. Although most aneurysms can be clipped microsurgically or coiled endovascularly, a subset of patients may require a combined approach. A consecutive series of patients with aneurysms in one surgeon's cerebrovascular practice was reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex aneurysms. ⋯ Evolving endovascular technologies need to be integrated into the microsurgical management of aneurysms. Multimodality approaches are best used with complex aneurysms in which conventional therapy with a single modality has failed. Revascularization remains a unique surgical contribution to the overall management of aneurysms with which current endovascular techniques cannot be used. Multimodality management should be considered an elegant addition to the therapeutic armamentarium that, through simplification and increased safety, improves the treatment of complex aneurysms beyond what is achievable by performing clipping or coiling alone.
-
Controlled Clinical Trial
Temporal window of metabolic brain vulnerability to concussion: a pilot 1H-magnetic resonance spectroscopic study in concussed athletes--part III.
In the present study, the occurrence of the temporal window of brain vulnerability was evaluated in concussed athletes by measuring N-acetylaspartate (NAA) using proton magnetic resonance (H-MR) spectroscopy. ⋯ Results of this pilot study carried out in a cohort of singly and doubly concussed athletes, examined by H-MR spectroscopy for their NAA cerebral content at different time points after concussive events, demonstrate that also in humans, concussion opens a temporal window of brain metabolic imbalance, the closure of which does not coincide with resolution of clinical symptoms. The recovery of brain metabolism is not linearly related to time. A second concussive event prolonged the time of NAA normalization by 15 days. Although needing confirmation in a larger group of patients, these results show that NAA measurement by H-MR spectroscopy is a valid tool in assessing the full cerebral metabolic recovery after concussion, thereby suggesting its use in helping to decide when to allow athletes to return to play after a mild traumatic brain injury.
-
The emerging future of cerebral surgery will witness the refined evolution of current techniques, as well as the introduction of numerous novel concepts. Clinical practice and basic science research will benefit greatly from their application. The sum of these efforts will result in continued minimalism and improved accuracy and efficiency of neurosurgical diagnostic and therapeutic methodologies. ⋯ A number of topics relevant to cerebral surgery are discussed, including the operative environment, imaging technologies, endoscopy, robotics, neuromodulation, stem cell therapy, radiosurgery, and technical methods of restoration of neural function. Cerebral surgery in the near and distant future will reflect the application of these emerging technologies. As this article indicates, the key to maximizing the impact of these advancements in the clinical arena is continued collaboration between scientists and neurosurgeons, as well as the emergence of a neurosurgeon whose scientific grounding and technical focus are far removed from those of his predecessors.