Chibbaro et al from Italy used a heparin-like drug to treat a large series of patients postoperatively (except some additional high-risk cases treated preoperatively) to prevent thromboembolism. Their results are impressive. Read Macdonald's comments at the end. He has done some very good work in this area. As yet, there is no randomized study to prove definitively what we should do, but the data are impressive.
Matsumoto et al from Japan and the United States have performed a first-class experiment to demonstrate protection of the spinal cord by glutamine synthetase while the cords were exposed to a hypoxic challenge. This article is not easy to read, so I suggest you read the Introduction, which is an excellent summary of what happens to the cord during ischemia and what glutamine synthetase actually does. Basically with hypoxia, glutamate, a neural transmitter, is released from nerve endings into the synaptic space. Excessive amounts of glutamate will continuously depolarize the postsynaptic neuron and produce toxicity for that cell, as its calcium channels remain open for ion flux into and out of the cell. Glutamine synthetase is normally made by the astrocytes and converts glutamate to glutamine, which is nontoxic to the neurons. However, there may not be enough glutamine synthetase to convert all the glutamate released during hypoxia. So, the investigators added glutamine synthetase exogenously. They found that the glutamine synthetase they added had a protective effect during spinal cord hypoxia and maintained the compound action potentials of the neurons that they recorded. The glutamine synthetase also seemed to block the action of the excess inhibitory transmitter, Gamma-aminobutyric acid, also released during hypoxia. Read Chris Shields's comments at the end. Chris has one of the leading laboratories in the world doing spinal cord injury research. He believes that this is significant work. For more information, read the Discussion. This is excellent work that could lead to clinical trials.
Lee et al from Taiwan describe the use of extracorporeal shock wave treatment for the enhancement of bony fusion. This is an interesting application of a technology used to treat patients with kidney stones. Read the Introduction and Discussion to learn how the shock waves are believed to act.
Lehecka et al and “The Rainbow Team” from Finland report on their experience in treating 174 A3 aneurysms (A3 segment of the anterior cerebral artery). The article is nicely illustrated on the videos, which are excellent. This is another superb article from the Helsinki group led by Dr Hernesniemi.
I have known Kyu Chang Lee, who was also on the Editorial Board of Surgical Neurology, for many years. He is an excellent cerebrovascular neurosurgeon with a very large range of experience. In this article, Lee et al report on their experience with distal anterior cerebral artery aneurysms. Note the similarity with the article from “The Rainbow Team.” These are 2 fine articles from highly experienced and skilled neurosurgeons.
Byrne et al from the United States describe their experience of cylinder electrodes placed epidurally to monitor electroencephalographic changes in patients with epilepsy. These electrodes have a number of advantages over other cortical presurgical recording devices.
Yilmazlar et al from Turkey provide us with an anatomical study measuring the quantitative distance between the cavernous carotid arteries in the sella as seen through the transphenoidal access route. Although subject to concerns raised by Malkasian in his publication comments, this work is valuable to those doing pituitary surgery to understand the parameters within which they can work. There can be variations from these numbers, but they provide a guide in most cases.
Labauge et al from a consortium of neurologists and neurosurgeons from France report their combined 10-year experience with 53 spinal cord cavernomas. This is the largest collection of such cases in the literature and serves as a reference for those doing spinal cord cavernomas. Read Brotchi's comments at the end.
Nabika et al from Japan report an interesting case of primary angiitis of the central nervous system. This is a good case to read. Central nervous system angiitis is a difficult diagnosis to make, and neurosurgeons should be aware of this problem.
Seckin et al from Turkey report on serial magnetic spectroscopy findings in a patient with a hydatid cyst undergoing albendazole therapy. It is interesting to see the spectroscopic changes over time as the cyst disappears. Read the Discussion. Glucose is metabolized in the cell to pyruvate and then further in the tricarboxylic acid cycle (TCA), which produces more energy for the cell in the form of ATP. The authors explain the spectroscopic changes in an understandable way, and the reason for why the action of the drug that inhibits the tricarboxylic acid cycle molecules causes the death of the parasite—as it loses its energy sources—and the decrease in the various molecules in the TCA cycle. The decrease in the TCA molecules is measured spectroscopically.
Varma et al from the United States and Canada report on their use of photodynamic therapy for malignant brain tumors and the side effects this treatment can produce in cranial nerve palsies, of which 2 of the 3 are resolved. Read the Introduction for a quick review of this therapy and what it does. Trials of this technology are underway to see if this treatment has value.
Senoglu et al from Turkey describe their management of a scalp arteriovenous malformation or arteriovenous fistula. The Discussion is a very nice readable summary of this problem. Hage et al from the United States also report on their experience with embolization and resection of a similar lesion. I have seen 1 or perhaps 2 large cirsoid aneurysms of the scalp, larger than either of these 2 lesions. Cirsoid aneurysms of the scalp consist of an extensive subcutaneous malformation of the scalp vessels covering a large area. These lesions are rare, but embolization, if available, can be used. If not, they can be treated surgically. One technique is to place a tourniquet around the scalp preoperatively to reduce blood flow before the actual excision. A meticulous, but rapid, neurosurgical excision of these lesions is the key to prevent blood loss. The surgeon needs to remain in the subcutaneous plane so as not to penetrate the scalp from the inside.
My editorial in this issue discusses the impact of technology on neurosurgery and also medicine. Is this technology necessary and is it used appropriately in each case? Do you really need it to do good neurosurgery? Has it become a replacement for thinking on the part of the doctor? Or, is it really helpful in diagnosis and treatment?
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