The Rainbow Team from Finland has written its third article on aneurysms with videos. This one is about distal middle cerebral artery aneurysms after bifurcation. They report on 69 patients with 78 distal middle cerebral artery aneurysms. This is the largest experience in the world of which I am aware. Again, the article contains many excellent suggestions from their surgical experience to guide the surgeon. This is superb work and should be read by all residents and those interested in vascular neurosurgery.
I have known Javad Hekmatpanah from the University of Chicago, since I was an intern there 40 years ago. Javad is a neurosurgeon who is thoughtful, credible, and careful. His article in this issue on cerebral neurovascular changes with drowsiness and coma is superb. In a very simple but elegant experiment; he uses a rat model with an induced brain tumor to produce increased intracranial pressure and ultimate herniation of the brain. He follows what happens to the microvasculature in the animal as they become drowsy and comatose. He found that the blood vessels of the hemispheres and the brain stem become narrow and occluded with small infarcts resulting from this diffuse vascular injury. It is easy to see that these events can happen. This is a must-read article. It is an example to everyone that you do not need fancy equipment to do experiments but a good mind and the ability to ask the right question.
Gong et al from Canada studied the endoscopic approach to the pituitary with and without image guidance. In an era of proliferation of technology, this work is another example of the way to evaluate these new advances. This is another fine article from Mohr and his group in Canada (he has authored many over the years). Mohr is another investigator whose work is credible and good. The value in image guidance in endoscopic pituitary surgery is not only in the saving of operating time but in increasing the safety and efficiency in the operating room for the patient, while producing better results and lower risks particularly in complex cases. This article will provide convincing evidence to hospital administrators that the addition of this technology is beneficial in patient care. The volume of cases would justify the cost of the equipment unless it is used in other procedures that will further validate its use.
Miller et al from Germany present the use of intraoperative ultrasound combined with navigation techniques to guide their surgery. Their results are good, and the technology is useful. The challenge today is to find an alternative to the intraoperative magnetic resonance, which is exceedingly costly and cannot always be used for other imaging when surgery is not being done. Furthermore, there is no proof that intraoperative magnetic resonance provides meaningful resection in terms of the patient's survival compared with conventional surgery. Yet, it does have value in detecting brain shift. Ultrasound may be a cheaper yet valuable alternative, at least to recognize brain shift and to provide other guides to resection with continuous real-time feedback. Read Auer's excellent comments at the end.
Mascott et al from Ireland and the United States propose an imaging technique to demonstrate nonenhancing or minimally enhancing lesions using FLAIR (fluid-attenuated inversion) and volumetric computerized tomograhy (CT) data that they fuse. The data were then used to direct intraoperative image-guided resection. Read Mafee's comments at the end.
Kanazawa et al from Japan have written what, I think, will be a leading article in the diagnosis of cerebral vasospasm by perfusion CT. The authors performed extensive work using positron emission tomography and cerebral blood flow and other measures with which they have worked for years. They are leaders in this area. They have shown that there are significant correlations with cerebral blood flow and mean transit time and the perfusion CT. This will be a technique that will be useful.
Nonaka et al from Japan report on their experiences in surgically treating paraclinoid aneurysms in patients with visual compromise. Forty-four percent of the patients in the direct surgical group had improved vision, whereas 87% of those in the indirect surgical treatment group had visual improvement. One patient's radial artery extracranial-intracranial bypass graft occluded leading to cerebral infarction. Seven patients had some form of bypass radial artery (5), saphenous vein (1), or superficial temporal artery (1). The authors have written an excellent review of the literature in their discussion that describes the improvement in vision after coiling or even carotid occlusion. The question here is not what surgical procedure we can do, but what is best and safest for the patient. In my experience, the aneurysms shown in the figures are large or giant and are very difficult to treat with direct surgery. Often, the wall of the aneurysm is calcified or the aneurysm is partially thrombosed and its manipulation can further compromise an already impaired optic nerve. So, I would prefer an indirect approach because I believe that the chances of impairing vision will be less with this approach than with direct surgery. Sixteen years ago, we described our experience with STA bypass and gradual carotid occlusion with a Selverstone clamp. (Ausman JI, Diaz FG, Sadasivan B, Gonzales-Portillo M Jr, Malik GM, Deopujari CE: Giant intracranial aneurysm surgery: the role of microvascular reconstruction. Surg Neurol 34:8-15, 1990.) This operation is very safe and eliminates the risk associated with arterial or venous grafts. It provides a controlled situation to evaluate the enlargement of the STA while the carotid is being occluded gradually. Moreover, as Debrun states in his comments, the advances in stenting and coiling are such that the interventional alternatives should be considered. Our first choice for paraclinoid aneurysms is interventional. (Thornton, J, Aletich VA, Debrun GM, Alazzaz A, Misra M, Charbel F, Ausman JI: Endovascular treatment of paraclinoid aneurysms. Surg Neurol 54:288-99, 2000.) The goal is to make surgical approaches with NO mortality and NO morbidity. We cannot accept complications in view of alternative therapies.
Lee et al from South Korea describe a reproducible mouse model of cerebral infarction. This model appears superior to other models. Read Roitberg's comments at the end.
Sure and his colleagues from Germany have written an article on problems with neurosurgical training in Europe and some possible solutions. I have solicited comments from around the world: Amirjamshidi (Iran), Cappabianca (Italy), Couldwell (United States), Dempsey (United States), DiRocco (Italy), Haase (Denmark), Kanpolat (Turkey), Kodama (Japan), and Niemelä and Hernesniemi (Finland). All of these commentators have involvement and experience in resident education. Read Haase's comments particularly. I have written an editorial on my thoughts about this subject: “If you don't know where you are going, you will never get there.”
Sanus et al from Turkey report an excellent surgical result in a rare case of hyperteliorism in an adult from a mucocoele since childhood.
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