Temporary vessel occlusion during intracranial aneurysm repair.

Any method that decreases the risk of intraoperative rupture should improve outcome if complications associated with its use do not negate positive effect. If application time is limited and a form of cerebral protection and appropriate monitoring of cerebral function are used, temporary clip application may meet these requirements. The efficacy of temporary occlusion as an adjunct to aneurysm clipping may be limited by technical considerations with respect to regional anatomy, aneurysm size, and aneurysm consistency. In areas of limited access, positioning proximal clips may not be feasible. The use of endovascular techniques of balloon occlusion may provide proximal control in these situations (9, 106). The decision to use total circulatory arrest and profound hypothermia, as opposed to temporary clip application, remains largely a matter of the surgeon's judgment. The role of proximal parent vessel ligation must also be considered in the decision-making process regarding the treatment of giant or technically difficult aneurysms (114). Further refinements in cerebral monitoring that can accurately reflect intracellular processes in all territories affected by the application of temporary clips or balloon occlusion and development of more effective forms of cerebral protection may permit safer use of this technique. An adequately controlled clinical trial of temporary occlusion with or without putative "cerebral protection" is needed to confirm the efficacy of this technique.

Harvey Cushing and Claude Beck: a surgical legacy.

Harvey cushing's contribution to neurosurgery and other surgical specialties has been profound. The accomplishments of his many pupils have further immortalized Cushing's role as a pioneering advocate of surgical science. Claude S. Beck, the first professor of cardiovascular surgery in the United States, was one such student. Beck's career and successes are illustrative of Cushing's guidance and enduring support for his surgical heirs. Beck's first encounter with Cushing evoked a spirit of fraternity and fashioned a respect and loyalty to Cushing that lasted for the duration of Beck's career. Cushing's personality and the methods by which he perpetuated a rich surgical tradition are illuminated by details of Beck's stay at the Peter Bent Brigham Hospital as a Cabot Fellow in Cushing's laboratory, by diary accounts of his later 6-week visit in 1927, and by the numerous telling correspondences between the two men. This article traces Beck's association with Cushing and provides unique insights into Cushing, his Cleveland connections, and his neurosurgical service at the Brigham.

Leptomeningeal and calvarial sarcoidosis: CT and MR appearance.

We report an unusual case of biopsy-proven combined leptomeningeal and calvarial sarcoidosis, as seen on CT and MRI. A solitary large thick plaque was present in the left hemisphere, with overlying bony infiltration and erosion and associated abundant vasogenic edema in the brain. The lytic lesion was visible on Scout digital radiography for CT slice positioning. The typical manifestations of CNS sarcoidosis, i.e., chronic leptomeningitis in the basilar cisterns and hypothalamic regions, were absent.