Gomez-Pinilla et al from the United States have written a superb editorial on the benefits of diet and exercise on brain repair. Also, Dr Joe Maroon, a neurosurgeon who is also an expert on exercise and diet from a sports medicine background, adds some valuable comments about Resveratrol—which is found in red wine and other dietary supplements. This article is key to both you and your patients' lives, not only for brain repair, but also for maintaining brain growth as we age.
Karaoglan et al from Turkey have performed an interesting experiment in rats given subarachnoid hemorrhage (SAH). They have administered Resveratrol—“the biologically active factor in red wine”—that has neuroprotective and vasodilatory action. They found that rats with SAH—which were given Resveratrol—had reduced vascular narrowing microscopically and also found lower brain and serum levels of endothelin-1, a vasoconstrictor produced by the endothelium. Read the Abstract and Introduction for a quick update in vasospasm and the Discussion for a more detailed explanation of what the authors believe is happening in their experiment. Also note the previous article by Gomez-Pinilla and Maroon's comments at the end about Resveratrol. You will be hearing more about Resveratrol in the future.
Seckin et al from Turkey report on a second animal study of vasospasm. The authors used Lamotrigine (an anti-convulsant drug) to prevent vasospasm. For a simple explanation of what Lamotrigine does, the authors describe in the Discussion that the antiepileptic drug works by stabilizing Na, K, and Ca fluxes across the membranes by blocking the Na, K, and Ca channels in neurons that transfer these ions back and forth from the extracellular to the intracellular space. This is the mechanism by which the drug acts to prevent seizures and epilepsy. Also, by preventing these ion fluxes in the smooth muscle cells of the cerebral vessels, the depolarization of the membranes leading to contraction of the smooth muscles from the Ca entering the cell that initiates muscle fiber contraction can be stopped. It is obvious from reading this and the previous article that we have still not found the treatment for vasospasm, but we are getting closer. It appears that a “cascade” of events leads to and follows vasospasm after SAH appears. What we are reading in these articles is the action of various agents and molecular treatments that are working at different parts of this ischemic “cascade.” As of this time, all of the components leading to the events surrounding vasospasm are not understood.
The article by Lehecka et al from Finland and “The Rainbow Team” is the last of the anterior cerebral artery aneurysm articles from this group. This article will be the gold standard in the scientific literature for its explanation of the anatomy and surgical approach to these rare aneurysms. (The videos are excellent.) These are complex aneurysms because their location is difficult to find. If you do not have the neuronavigation systems, as the authors describe, you can still operate on these aneurysms by making sure that your surgical approach is anterior to the aneurysm so that you have proximal control. This is another outstanding article from Dr Juha Hernesniemi and his colleagues.
Waldenberger et al from Austria report on the endovascular treatment of distal anterior cerebral artery aneurysms. This is an outstanding piece of work. As you read the article, you will be impressed with the experience of the endovascular surgeons. Their results are excellent. This is a fine article in comparison with the previous surgical work from Finland.
Kai et al from Japan report an interesting article on the angiographic follow-up of patients after coiling of aneurysms and the retreatment of residual aneurysms with coils or surgery. To me, Fig. 1 is the key. It is a nice summary of what happens to a population of patients with coiled aneurysms who serially underwent angiography. Two thoughts come to mind: First, why was there coil compaction? If you look at Figs. 4 and 5, you can see that after compaction, the coils are denser in the aneurysm. Does this finding mean that interventionalists should be more aggressive in densely packing aneurysms with coils on the first try? Second, we published an article in 2000 (Surg Neurol 2000;54:352-360) on the removal of coils from aneurysms. I believe coils should be removed before clipping the aneurysm if there is not enough room to place a clip on the neck of the aneurysm. This article is significant in that endovascular treatment of aneurysms is late in being adopted in Japan, compared with other parts of the developed world, because neurosurgeons there have a surgical bias. Also, the article may show what the real world of coiling is like. (Read my editorial in this issue entitled, “The Death of Cerebral Aneurysm Surgery” Revisited in 2008.)
Nancy Epstein from the United States discussed an important subject of underreporting errors with a new procedure—in this case, minimally invasive spine procedures. Dr Ron Pawl, also a longtime spine and pain neurosurgeon, adds his concerns about properly informing the patients of our experience and gaining the necessary laboratory experience with new procedures. Both are right. This underreported problem relates not only to spine surgery, but also to endonasal skull base surgery and many other new procedures we do. Dr Epstein's experience could be a sampling bias because she sees referrals of complex spine problems (as does Dr Pawl); however, it is my belief from a nonquantitative sampling of neurosurgeons that the problem of underreported complications with new procedures is a major one.
Arnold et al from the United States report an excellently done spine study using interbody fusion cages for treatment of adjacent segment degeneration that is clinically symptomatic. They report good results with fewer complications than with standard anterior fusion (with or without plating). The real value of this article is in the Introduction and Discussion. These 2 sections have a thorough and readable analysis of the scientific literature on this subject. The reported complication rates at the iliac donor site of up to 25% or of adjacent segment degeneration postfusion of 25% are astounding. Read this information with Epstein's previous article in mind. What Arnold et al have proposed to treat symptomatic adjacent segment degeneration seems reasonable and well thought out.
Folman et al from Israel retrospectively studied a series of patients with lumbar disc herniation operated early or delayed by one surgeon. The results of the study are to be expected. Those who at surgery had a “noncontained” disc fragment were improved after surgery as expected. The authors state that surgery on these patients can be delayed to allow disc reabsorption. They state that the decision to operate is based on the patient's symptoms, which is obvious. They even delayed surgery in those with mild motor weakness to allow for improvement. I do not agree with this plan because of concern of permanent motor deficit, but their point-of-view is different. Basically, the point of the article is that the decision to operate is based on the patient's choice.
Yamaguchi et al from Japan have an interesting case of a clival plasmacytoma with multiple myeloma diagnosed by biopsy. The lesion was then aggressively treated with radiation therapy and chemotherapy followed by surgical removal of the remaining lesion and then continued chemotherapy. The result was good in a very difficult problem to treat.
Kawai et al from Japan present interesting case report of a 9-year-old boy with a basal ganglia lesion diagnosed as MS. Further investigation with positron emission tomography indicated a high signal in the anterior limb of the internal capsule. This area was biopsied and found to be a germinoma. The treatment was followed with C-methionine and positron emission tomography imaging. Why was the diagnosis of multiple sclerosis in a 9-year-old boy made before the neurosurgeons saw the patient? What do you think? The diagnosis and treatment plan of the neurosurgeons is of interest to neurosurgeons.
This month's editorial revisits my predictions from the 2001 editorial entitled, “The Death of Cerebral Aneurysm Surgery.” Were the predictions accurate?
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