World Neurosurg
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Review Historical Article
"Through the looking glass": optical physics, issues, and the evolution of neuroendoscopy.
Although the concept of endoscopy has existed for centuries, a practical, working neuroendoscopic system did not emerge until last century, as a result of numerous contributions and refinements in optical technology, illumination sources, and instrumentation. Modern neuroendoscopy would not be a flourishing field, as it is today, without the dedication, innovation, and implementation of emerging technology by key contributors including Maximilian Nitze, Walter Dandy, and Harold Hopkins. ⋯ In this review, the history of neuroendoscopy, key players who envisioned how the inner workings of the human body could be visualized "through the looking glass," and current state and future potential for neuroendoscopic surgery are discussed. Future directions of neuroendoscopic surgery will likely be guided by further miniaturization in camera and optical technology, innovations in surgical instrumentation design, the introduction of robotics, multi-port minimally invasive surgery, and an enhanced ability to perform bimanual microdissection.
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Idiopathic aqueductal stenosis is a cause of noncommunicating hydrocephalus, which actual treatment with endoscopic third ventriculostomy (ETV) could assess without any interference with the etiology. The results of ETV in this indication therefore could be interpreted as the result of the surgical procedure alone, without any additional factors related to the etiology of the cerebrospinal fluid pathway obstruction, such as hemorrhage, infection, brain malformations, or brain tumors or cysts. ⋯ Several issues, such as the cause of failures in well-selected patients, long-term outcome in infants treated with ETV, effects of persistent ventriculomegaly on neuropsychological developmental, remain unanswered. Larger and more detailed studies are needed.
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Adequate training based on cadaveric dissection is essential to acquire a practical knowledge of surgical anatomy and microsurgical/endoscopic dissection techniques. Endoscopic procedures for the treatment of pathologies of the skull base are becoming increasingly common. The endoscopic training curve for tool handling and a detailed knowledge of the topographic anatomy of the skull base require intensive training on cadavers before approaching living patients, which is why cadaver laboratory experience should be mandatory for every resident and surgeon preparing to use microsurgical and endoscopic techniques. We describe the basic principles of the philosophy of anatomic dissection and the equipment necessary to set up an endoscopic cadaver laboratory.
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To summarize the current knowledge of the mechanisms leading to rebleeding and the prevention of rebleeding after subarachnoid hemorrhage (SAH). ⋯ Further studies are warranted before the exact mechanisms leading to rebleeding are established and the optimal preventive measures are made available. At the present time, antifibrinolytic therapy remains the only realistic protective measure during the initial 6 hours after SAH during which the rebleeding rate is highest.