The "combined eye" of surgeon and artist: evaluation of the artists who illustrated for Cushing, Dandy and Cairns.

Medical illustration is an essential device for the teaching of anatomy, physiology and pathology. In surgery, illustration is more than a teaching aid and has been instrumental in the development the surgical art. This has required a close collaboration between surgeon and artist. This has been particularly evident in neurosurgery where surgeon and artist worked together with a "combined eye", to help develop and disseminate surgical techniques. In this article we review the lineage of medical illustration in neurosurgery and three important partnerships between artist and neurosurgeon that have helped forge a lineage of surgical and artistic technique. Max Brödel and Harvey Cushing worked closely together at The Johns Hopkins Hospital, a collaboration which led to the opening of the Department of Art as Applied to Medicine. Brödel trained two talented artists, Hager Padget and Audrey Arnott, who worked for Walter Dandy and Hugh Cairns respectively. The techniques used in these collaborations between artist and surgeon were inspired by the art of Da Vinci, and the work of the anatomist Vesalius and the artist Jan Stefan van Calcar in the 16th century. We discuss how the combined eye of artist and surgeon is an important aspect of art history and we consider whether the illustrations of Brödel, Padget and Arnott can be considered as works of art.

Technical aspects of decompressive craniectomy for malignant middle cerebral artery infarction.

Decompressive craniectomy is considered a life-saving procedure for malignant middle cerebral artery territory infarction in selected patients. However, the procedure is associated with a significant risk of morbidity and mortality, and there is no universal agreement as to how this operation should be combined with optimal medical management. In this review we consider the goals of this procedure and the technical aspects which may be employed to optimise results.

Decompressive craniectomy for malignant middle cerebral artery infarction: evidence and controversies.

Malignant middle cerebral artery (MCA) infarction (MMI) is associated with a mortality rate of 80%. Decompressive craniectomy is considered a life-saving procedure for patients with this devastating condition. Preclinical and clinical data suggest that this procedure should be undertaken as early as possible, prompting increasing demand for emergency surgery. This article reviews the pathophysiology of MMI, and the experimental and clinical evidence supporting this procedure. We consider some of the controversies surrounding patient selection for this procedure and discuss the role of intracranial pressure monitoring in MMI.

Endoscopic fenestration of middle cranial fossa arachnoid cysts: does size matter?

The middle cranial fossa (MCF) is the commonest location for intracranial arachnoid cysts and there has long been controversy regarding the optimal surgical management. Over the last 10 years there has been an increased interest in the potential of endoscopic techniques to treat these. In a review of the literature we identified 91 patients with MCF cysts treated with endoscopic techniques. Clinical improvement was seen in 95% of patients and radiological improvement was seen in 74%. The most common complications reported are subdural hygromas (9%) and subdural haematomas (5%). There does not appear to be an undue increased risk of complications compared to open surgical techniques. Reported methods of endoscopic fenestration advocate making as wide an opening as possible without damage to the surrounding neurovascular structures. We consider the possibility that smaller cystocisternostomy may be effective in achieving therapeutic goals while reducing potential risks to the patient.

Perioperative seizures following deep brain stimulation in patients with multiple sclerosis.

Following a total of 386 deep brain stimulation (DBS) procedures in Oxford, only two seizures have been recorded in the peri-operative period. Both patients had MS and underwent thalamic DBS for tremor and these 2 cases are presented here. The incidence of peri-operative seizures in MS patients undergoing DBS procedures is more than 8-fold greater than that expected for patients undergoing DBS procedures. Further experience with DBS procedures in MS patients is needed to determine whether there is a role for peri-operative anticonvulsants in these patients.

Audrey Juliet Arnott (1901-1974): the legacy of an artist in neurosurgery.

Audrey Arnott, a graduate of the Royal College of Art, was first employed as an artist by Hugh Cairns at the London Hospital. Cairns arranged for Arnott to be trained as a medical illustrator under Max Brödel, a close friend of Harvey Cushing and founder of the first 'Department of Art as Applied to Medicine' at Johns Hopkins University. During her time at John Hopkins Arnott developed a close friendship with Dorcas Padget, medical illustrator to Walter Dandy. Arnott was a highly accomplished artist and trained numerous other British medical illustrators and was one of the founders of the Medical Artists Association. Arnott's training and friendship with Brödel and Padget enabled her to pass on a legacy of neurosurgical illustration to the United Kingdom.

SNARE proteins and schizophrenia: linking synaptic and neurodevelopmental hypotheses.

Much of the focus of neurobiological research into schizophrenia is based on the concept that disrupted synaptic connectivity underlies the pathology of the disorder. Disruption of synaptic connectivity is proposed to be a consequence of both disrupted synaptic transmission in adulthood and abnormalities in the processes controlling synaptic connectivity during development of the central nervous system. This synaptic hypothesis fits with neurodevelopmental models of schizophrenia and our understanding of the mechanisms of antipsychotic medication. This conceptual model has fostered efforts to define the exact synaptic pathology further. Synaptic proteins are obvious candidates for such studies, and the integral role of the SNARE complex, and SNARE-associated proteins, in synaptic transmission will ensure that it is the focus of much of this research. Significant new insights into the role of this complex are arising from new mouse models of human disease. Here the evidence from both animal and human clinical studies showing that the SNARE complex has a key role to play in the aetiology and pathogenesis of schizophrenia is discussed.