In this issue…

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The “Rainbow Team” from Finland reports on its experience with 1456 patients who had 1706 middle cerebral aneurysms. This is another article accompanied by videos in the series to be published by Surgical Neurology. This article is superb. It is full of surgical “tips,” wisdom, and experience in operating on these aneurysms. I agree with virtually every point made by Hernesniemi and his colleagues. I differ in one aspect, and that is I believe in obtaining proximal control first in all aneurysms. So, for middle cerebral artery (MCA) aneurysms, I open the carotid cistern first, dissect slightly around the carotid artery so that a temporary clip can be applied. Then I continue the dissection along the carotid to the middle cerebral origin and follow the middle cerebral distally. My dissection is on top of the MCA to avoid any branch that may be coming off of the sides. This maneuver allows me to maintain control of the MCA all the way to the aneurysm. The rest of the operation proceeds as Hernesniemi and colleagues have described. Of note in the Finnish article, 29% of MCA aneurysms were less than 8 mm in diameter. This fact argues against those who state that aneurysms of less than 1 cm do not rupture. The International Study of Unruptured Intracranial Aneurysms initially stated 10 mm, and then revised the number down to 7 mm. Also interesting is the 80% of MCA aneurysms that were ruptured, higher than I would expect, but apparently a figure that is increased in the Finnish population (see Hernesniemi's references 1 and 2 in the Nussbaum article that follows). The 5-minute temporary occlusion time is important to emphasize. Although I temporary clips that were first started by Jiro Suzuki in Japan in the 1960s, I do not know if the brain protective agents work and thus believe in a short temporary occlusion time. This is an outstanding contribution to the literature by superb clinicians and scientists. This is a must read with the videos.

Nussbaum et al from the United States report on one surgeon's experience in treating 450 unruptured intracranial aneurysms in 376 patients. This is an excellent article written carefully and comprehensively reflecting on the surgeon's approach to the aneurysms he treats. His results are outstanding. There are minor complications that are not reported in table form that occurred in 14 patients, most of them temporary. The major complication rate of 1% with 1 death in 376 patients is a fine achievement. More than 90% of his patients returned to work, but this fact is not a measure of cognitive ability best measured by neuropsychologic testing. I disagree, as do Hernesniemi and Drake and Peerless, that skull base approaches are necessary for aneurysm surgery. The combined experience of the above mentioned neurosurgeons is close to 10000 cases in disagreement with the skull base approaches. The skull base difference is not a major issue. The discussion is excellent, particularly the section on “Surgical judgment” and “Subspecialization and the learning curve”. To me surgical judgment is the most important thing a surgeon must learn. Obviously, Nussbaum has learned this lesson well from what he writes. This article is an example of a neurosurgeon who has developed a “focused factory” (Regina Herzlinger, Market Driven Healthcare, May 1999) in cerebral aneurysms in his private practice. This task is not easy to accomplish and is usually based on excellent results in his community. Yes, others can develop focused factories, but this is not the future of aneurysm treatment in a practice setting. Sorry, folks, aneurysms will be best treated in major centers where all the talent and experience will exist to treat these cases. Hernesniemi et al state that in the last paragraph of their article in this issue. I agree. Nussbaum's article is excellent and should be read by all residents.

Debing and Van den Brande, vascular surgeons from Belgium, report on their experiences with carotid endarterectomy in the elderly. They compared their results in those who were older than 75 with those younger than 75 years. Their risk of major stroke in each group was less than 1.0%, an admirable accomplishment. Their conclusion that those older than 75 years with fewer cardiovascular risk factors do as well as the younger patients is obvious. Yet, there is a subtle message in their data, which, to me, is a warning of things to come. The younger group of patients has multiple cardiovascular risk factors and diabetes. In an age when everyone's life span is increasing because of advances in medical care, the life span of the younger generation may be shortened because of the rising incidence of obesity and diabetes. These diseases are the result of the rejection by the younger generation of the practices in life leading to a longer life span, such as proper diet and exercise. Watch for more of these complications to occur in the young. These are already being reported in other journals.

Liang-fu Zhou, an accomplished cerebrovascular neurosurgeon from China, and his colleagues report their results with 5 tentorial dural atriovenous fistulas. These are very challenging lesions to treat, and their combined approach with endovascular and surgical teams is excellent. I agree with what they have stated in managing these problems. Their results are good in a challenging series of patients. The discussion provides a nice review of this subject.

Moreno-Jiménez et al from the National Institute of Neurology and Neurosurgery in Mexico report on their experience with arteriovenous malformations treated with lineae-based radiosurgery. Read DeSalles' comments at the end for his perspective on this article. As reported by others, the smaller the malformation, the higher the chance of obliteration with radiosurgery.

Westhout and Nwagwu from the United States report on seizures related to the use of intravenous verapamil for treating vasospasm and review the literature.

Dagcinar et al from Turkey have a nice technical note on the use of the simple sponge as a retractor or tissue separator in neurosurgery. This is a neat idea.

Cappabianca and his colleagues from France and Germany have written a very interesting article about the future of endoscopy in neurosurgery. This is a sensible, objective analysis of the pros and cons of this technology.

Spennato et al from Italy report a case that developed a cerebrospinal fluid leak and led to dysphagia after an anterior cervical fusion at C4-5. It was successfully treated with repeated lumbar punctures. To me the real question is, “What are the complications from anterior cervical fusion surgery?” Listing some such as collapse of the bone graft, failure of the fusion to occur, cerebrospinal fluid leak, vertebral artery injury, vocal cord paralysis, carotid occlusion, tear of the esophagus, tracheoesophageal fistula, quadriplegia, and others should be enough to make one wonder why these operations are being done when the risks are so high. There are better ways to remove a disk posteriorly with far less chances of complications.

Surgical Neurology is publishing the article of Bekar et al from Turkey to bring to neurosurgeons attention a pain procedure that is not used much in the United States and probably other countries. Cordotomy can be of tremendous clinical benefit. The authors use Kanpolat's technique for radiofrequency cordotomy. Interestingly, the patient developed pain on the opposite side after the first unilateral cordotomy. I have seen this occurrence before, as have others who have done cordotomies in the past. The reason is that the intense pain on one side overwhelms the nervous system to ignore the pain on the opposite side (gate theory). Neurosurgeons should learn this procedure. It is excellent for selected patients with cancer pain.

There are a number of other interesting case reports.

I have written an editorial for this issue on physicians' power and why they do not have it.