Neurosurgery
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The fiber dissection technique involves peeling away the white matter tracts of the brain to display its three-dimensional anatomic organization. Early anatomists demonstrated many tracts and fasciculi of the brain using this technique. The complexities of the preparation of the brain and the execution of fiber dissection have led to the neglect of this method, particularly since the development of the microtome and histological techniques. Nevertheless, the fiber dissection technique is a very relevant and reliable method for neurosurgeons to study the details of brain anatomic features. ⋯ The complex structures of the brain can be more clearly defined and understood when the fiber dissection technique is used. This knowledge can be incorporated into the preoperative planning process and applied to surgical strategies. Fiber dissection is time-consuming and complex, but it greatly adds to our knowledge of brain anatomic features and thus helps improve the quality of microneurosurgery. Because other anatomic techniques fail to provide a true understanding of the complex internal structures of the brain, the reestablishment of fiber dissection of white matter as a standard study method is recommended.
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Intraoperative aneurysmal rupture represents a potentially catastrophic event. We describe the use of an intravenous adenosine bolus to induce transient cardiac asystole to control a severe intraoperative aneurysmal rupture. This treatment resulted in a brief period of severe hypotension, which enabled successful clipping of the aneurysm. ⋯ In the setting of severe intraoperative aneurysmal rupture, intravenous adenosine represents a potential means of achieving a near-immediate profound decrease in the blood pressure that may allow for safe completion of the dissection and aneurysm clipping.
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The technical difficulty of using the petrosal approach and the likelihood of encountering venous complications depend on the particular temporal venous anatomy. To reduce such potential risks, neurosurgeons must have adequate knowledge of the variations in the anatomy of the temporal venous drainage system, particularly of the temporal bridging veins. ⋯ In planning the petrosal approach, great care should be taken not only with the vein of Labbé but also with the petrosal bridging veins. Knowledge of this venous anatomy can reduce venous complications during the lateral cranial base approach.
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Ommaya reservoirs are frequently used to deliver intraventricular chemotherapy in cancer patients with leptomeningeal metastases. We review techniques of catheter placement and complication avoidance. ⋯ Complications associated with Ommaya reservoirs can be minimized by intraoperative confirmation of the catheter position with fluoroscopic guidance and/or endoscopy. We recommend postoperative computed tomographic scans before initiation of intraventricular chemotherapy. Patients with elevated intracranial pressure may require shunting procedures in lieu of Ommaya reservoir placement.