Spontaneous intracerebral hemorrhage: to operate or not to operate, that's the question.

BACKGROUND: The occurrence of a spontaneous intracerebral hemorrhage in Israel's Prime Minister attracted the scrutiny of local and international media on neurosurgeons as they made therapeutic decisions. In the ensuing public debate, it was suggested that extraordinary measures (surgical treatment) were undertaken only because of the celebrity of the patient. OBJECTIVES: To evaluate the criteria used to select surgical versus medical management for SICH. METHODS: We retrospectively reviewed the files of 149 consecutive patients with SICH admitted to our medical center from January 2004 through January 2006. Their mean age was 66 (range 3-92 years), and 62% were male. SICH localization was lobar in 50% of patients, thalamus in 23%, basal ganglia in 15%, cerebellum in 13%, intraventricular in 6%, and pontine in 1%. Mean admission Glasgow Coma Score was 9 (range 3-15). Risk factors included hypertension (74%), diabetes mellitus (34%), smoking (14%) and amyloid angiopathy (4%). Fifty percent of patients were on anticoagulant/antiplatelet therapy, including enoxaparin (3%), warfarin (7%), warfarin and aspirin (9%), or aspirin alone (34%). RESULTS: Craniotomy was performed in 30% of patients, and ventriculostomy alone in 3%. Rebleed occurred in 9% of patients. Six months after treatment 36% of operated patients were independent, 42% dependent, and 13% had died. At 6 months, 37% of non-operated patients were independent, 15% dependent, and 47% had died. CONCLUSIONS: One-third of the SICH patients, notably those who were experiencing ongoing neurologic deterioration and had accessible hemorrhage, underwent craniotomy. The results are good, considering the inherent mortality and morbidity of SICH.

Fibrous dysplasia in combination with aneurysmal bone cyst of the occipital bone and the clivus: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Fibrous dysplasia of the cranium is a relatively uncommon disorder that affects primarily the anterior cranial region; its occurrence in the cranial base in combination with aneurysmal bone cyst (ABC) constitutes an extremely rare condition, only two cases of which have been reported previously in the literature. It is important to recognize and treat these cases properly because of the special location in the cranial base and the possibility of neural structure impingement. CLINICAL PRESENTATION: We report the case of a 19-year-old man with a slowly enlarging mass of the occiput, with computed tomographic and magnetic resonance imaging revealing involvement of petrous and basisphenoid bone and growing ABC. INTERVENTION: Open biopsy confirmed the diagnosis of fibrous dysplasia. Partial excision of the lesion and removal of the ABC were performed in a second stage after embolization. CONCLUSION: ABC associated with fibrous dysplasia of the cranial base may enlarge rapidly after puberty and require excision. This is facilitated by preoperative embolization.

Results of endovascular treatment of traumatic intracranial aneurysms.

OBJECTIVE: To present results of early angiographic diagnosis and endovascular treatment of traumatic intracranial aneurysms (TICA). METHODS: From June 2002 to December 2006, diagnostic angiography was performed on patients with moderate to severe traumatic brain injury that involved a cranial base fracture or a penetrating brain injury with a tract from the penetrating agent that entered at the pterional area, went through the middle cerebral artery candelabra, and crossed the midline. TICAs were treated by various endovascular techniques during the same angiographic procedure. RESULTS: Thirty-four patients with traumatic brain injury underwent angiography (25 penetrating brain injuries, nine blunt injuries); 13 TICAs were diagnosed (10 penetrating brain injuries, three blunt injuries). The Glasgow Coma Scale score at diagnosis ranged from 5 to 15. Angiography was performed for screening in eight patients and for clinical indications in five patients; 11 TICAs were diagnosed before rupture. Seven aneurysms were located on branches of the middle cerebral artery, two on pericallosal branches of the anterior cerebral artery, and four on the internal carotid artery. No recanalization was detected in 12 patients. One patient treated with a bare stent and coiling had a growing intracavernous pseudoaneurysm; therefore, internal carotid artery occlusion with extracranial-intracranial microvascular bypass was performed. Six patients refused angiographic follow-up, but computed tomographic angiography has failed to show recanalization. No patient presented with delayed bleeding (mean follow-up, 2.6 yr). There were no procedure-related complications or mortality. CONCLUSION: Early angiographic diagnosis with immediate endovascular treatment provided an effective approach for TICA detection and management. Endovascular therapy is versatile and offers a valuable alternative to surgery, allowing early aneurysm exclusion with excellent results.

Neurosurgery at the Hadassah-Hebrew University Medical Center in Jerusalem.

Henrietta Szold founded the Hadassah Women's Organization in the United States in 1912 to alleviate widespread disease and poverty in Jerusalem. In 1918, the Rothschild-Hadassah Hospital and the Hadassah School of Nursing opened in central Jerusalem. Chaim Weizmann and Albert Einstein, together with a small group of visionaries, founded the Hebrew University in 1923. After 1933, many physicians and scientists fled from Europe to Jerusalem, where they carried on their tradition of academic research at the university and Hadassah, and British military doctors joined medical rounds and lectures at Hadassah beginning in the 1930s. Young physicians who had graduated from European medical schools were trained in the subspecialties at Hadassah beginning in the 1940s, and the Hebrew University-Hadassah Medical School enrolled its first class in 1949. These were the first academic institutions of their kind in Israel. The Department of Neurosurgery at Hadassah was established in 1941 under the leadership of Dr. Henry Wigderson, who was recruited from the United States. Dr. Aaron Beller became chairman in 1951, Dr. Mordechai Shalit became chairman in 1977, and Dr. Felix Umansky, the current chairman, was appointed in 1993. Today, more than 900 neurosurgical procedures spanning the spectrum of subspecialties and using state-of-the-art techniques and equipment are performed annually.