Burr hole washout versus craniotomy for chronic subdural hematoma: patient outcome and cost analysis.

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients' clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings.

Delayed repair of myelomeningoceles.

OBJECTIVE: Myelomeningocele is a defect that typically is repaired surgically within the first few days of life in developed countries to minimize the risk of meningitis. If left unrepaired, these children may survive to have their meningocele sac epithelialize. The surgical reduction and closure of an epithelialized myelomeningocele represents a unique challenge for the neurosurgeon because it requires a modification of the typical closure technique. METHODS: Our 10 years' experience in 97 patients with the delayed (>6 months) repair of myelomeningoceles formed the basis of this report. RESULTS: We present repair techniques in a child with a myelomeningocele that was not repaired at birth and presented a surgical challenge. CONCLUSION: Delayed closure of myelomeningoceles is facilitated by lessons learned from our surgical experience during a medical missions to Guatemala.

Crucifixion and median neuropathy.

Crucifixion as a means of torture and execution was first developed in the 6th century B.C. and remained popular for over 1000 years. Details of the practice, which claimed hundreds of thousands of lives, have intrigued scholars as historical records and archaeological findings from the era are limited. As a result, various aspects of crucifixion, including the type of crosses used, methods of securing victims to crosses, the length of time victims survived on the cross, and the exact mechanisms of death, remain topics of debate. One aspect of crucifixion not previously explored in detail is the characteristic hand posture often depicted in artistic renditions of crucifixion. In this posture, the hand is clenched in a peculiar and characteristic fashion: there is complete failure of flexion of the thumb and index finger with partial failure of flexion of the middle finger. Such a "crucified clench" is depicted across different cultures and from different eras. A review of crucifixion history and techniques, median nerve anatomy and function, and the historical artistic depiction of crucifixion was performed to support the hypothesis that the "crucified clench" results from proximal median neuropathy due to positioning on the cross, rather than from direct trauma of impalement of the hand or wrist.

Charles Edouard Brown-Séquard's departure from the Medical College of Virginia: incompatible science or incompatible social views in pre-Civil War southern United States.

Charles Edouard Brown-Séquard was one of the most colorful characters in modern physiology. His scientific methods of self-experimentation and animal vivisection led to many great observations, including the eponymous syndrome of hemisection of the spinal cord. Despite his renown, he stayed but one year in his first major academic post. Details of his sojourn at the Medical College of Virginia (now part of Virginia Commonwealth University) in Richmond were divined from perusal of archival material, letters, and from the available literature. His notoriety in the field of physiology landed him a post at the Medical College of Virginia in 1854 as the chair of physiology. During a brief time here, he was able to publish his landmark monograph of 1855 on the pathways of the spinal cord "Experimental and Clinical Researches on the Physiology and Pathology of the Spinal Cord." He had a near-death experience while experimenting on himself to determine the function of the skin. It was rumored that his English was poor, his lectures unintelligible, and his scientific methods disturbing to the neighbors and that for those reasons he was asked to vacate his post. Personal communications and other accounts indicate a different view: his mixed-blood heritage and his views on slavery were unpopular in the pre-Civil War southern United States. These disparate viewpoints lend an insight into the life and career of this pioneer in modern medicine and experimental design and to the clash of science and social views.

The intriguing encounters of Pavlov and Cushing.

Ivan Petrovich Pavlov and Harvey William Cushing were two of the most prominent neuroscientists of the early 20th century. Their contributions helped advance the understanding of the brain and its disorders, and propelled neuroscience into a new era of research and treatment. Although separated geographically and culturally, Pavlov and Cushing exchanged letters and followed one another's careers from afar. They met only a few times, during international scientific gatherings in the US and abroad. These encounters were captured in journal entries, letters, and photographs, and provide a glimpse into the lives of these two great men and the history of neuroscience at the turn of the last century.

Simultaneous symptomatic Rathke's cleft cyst and GH secreting pituitary adenoma: a case report.

A case of symptomatic Rathke's cleft cyst and growth hormone (GH) secreting pituitary adenoma is described. A patient presented with a visual field deficit and a brain magnetic resonance imaging (MRI) study demonstrated compression of the optic chiasm by a large suprasellar cyst and a small lesion in the sellar consistent with a microadenoma. Preoperative clinical evaluation revealed mild acromegalic features, glucose intolerance, hypertension, hypercholesterolemia, and carpel tunnel syndrome, and blood testing confirmed an elevated insulin-like growth factor-1 (IGF-1). A modified transsphenoidal skull based approach was performed for selective transsphenoidal adenomectomy and decompression of the surprasellar cyst. The patient had an uneventful postoperative course with resolution of the visual field deficits and dysmenorrhea. Endocrine testing at two-month post procedure were normal. While there have been a small number of cases reported of concomitant pituitary adenomas and Rathke's cleft cysts, there is no report known to these authors of coexisting symptomatic lesions.

Real-time detection of vascular occlusion and reperfusion of the brain during surgery by using infrared imaging.

OBJECT: Application of sensitive infrared imaging is ideally suited to observe blood vessels and blood flow in exposed organs, including the brain. Temporary vascular occlusion is an important part of neurosurgery, but the capacity to monitor the effects of these occlusions in real time is limited. In surgical procedures that require vascular manipulation, such as those involving aneurysms, arteriovenous malformations (AVMs), or tumors, the ability to visualize blood flow in vessels and their distribution beds would be beneficial. The authors recount their experience in the use of a sensitive (0.02 degrees C), high-resolution (up to 50 microm/pixel) infrared camera with a rapid shutter speed (up to 2 msec/frame) for localizing cortical function intraoperatively. They observed high-resolution images of cerebral arteries and veins. The authors hypothesized that infrared imaging of cerebral arteries, performed using a sensitive, high-resolution camera during surgery, would permit changes in arterial flow to be be seen immediately, thus providing real-time assessment of brain perfusion in the involved vascular territory. METHODS: Cynomolgus monkeys underwent extensive craniectomies, exposing the frontal, parietal, and temporal lobes. Temporary occlusions of the internal carotid artery and middle cerebral artery branches (30 events) were performed serially and were visualized with the aid of an infrared camera. Arteries and veins of the monkey brain were clearly visualized due to cooling of the exposed brain, which contrasted with blood within the vessels that remained at core temperature. Blood flow changes in vessels were seen immediately (< 1 second) in real time during occlusion and reopening of the vessels, regardless of the duration of the occlusion. Areas of decreased cortical blood flow rapidly cooled (-0.3 to 1.3 degrees C) and reheated in response to reperfusion. Rewarming occurred faster in arteries than in the cortex (for a 20-minute occlusion, the change in temperature per second was 2 x 10(-2) degrees C in the artery and 7 x 10(-3) degrees C in the brain). Collateral flow could be evaluated by intraoperative observations and data processing. CONCLUSIONS: Use of high-resolution, digital infrared imaging permits real-time visualization of arterial flow. It has the potential to provide the surgeon with a means to assess collateral flow during temporary vessel occlusion and to visualize directly the flow in parent arteries or persistent filling of an aneurysm after clipping. During surgery for AVMs, the technique may provide a new way to assess arterial inflow, venous outflow, results of embolization, collateral flow, steal, and normal perfusion pressure breakthrough.