Neurosurgery

Mazzola, Catherine A.; Lobel, Darlene A.; Krishnamurthy, Satish; Bloomgarden, Gary M.; Benzil, Deborah L.

Neurosurgery. 67(2):225-233, August 2010.

doi: 10.1227/01.NEU.0000372206.41812.23

BACKGROUND: Neurosurgical residency training paradigms have changed in response to Accreditation Council for Graduate Medical Education mandates. OBJECTIVE: To assess the efficacy of resident training in preparing young neurosurgeons for practice. METHODS: A survey was developed for neurosurgeons who applied for Part II of the American Board of Neurological Surgery boards, from 2002–2007 (N = 800). The survey was sent to 775 of 800 (97%) neurosurgeons for whom e-mail addresses were available. RESULTS: The response rate was 30% (233/775). Most neurosurgeons were board certified (n = 226, 97%). General neurosurgical training was deemed adequate by a majority (n = 188, 80%). Sixty-percent pursued at least 1 additional year of fellowship training (n = 138, 60%). Surgical skills training was acceptable, but 6 skill-technique areas were deemed inadequate (endovascular techniques, neurosurgical treatment of pain, stereotactic radiosurgery, epilepsy surgery, cranial base surgery, and stereotactic neurosurgery). Respondents also noted inadequate education in contract negotiation, practice evaluation, and management. CONCLUSION: The study suggests that neurosurgeons believed they were well trained in their surgical skills except for some areas of subspecialization. However, there is a significant need for improvement of resident training in the areas of socioeconomic and medicolegal education.

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Kakarla, Udaya K.; Beres, Elisa J.; Ponce, Francisco A.; Chang, Steven W.; Deshmukh, Vivek R.; Bambakidis, Nicholas C.; Zabramski, Joseph M.; Spetzler, Robert F.

Neurosurgery. 67(2):237-250, August 2010.

doi: 10.1227/01.NEU.0000371727.71991.64

BACKGROUND: Pediatric aneurysms are rare and complex, and long-term data after microsurgical or endovascular therapies are lacking. OBJECTIVE: To study the clinical and radiographic outcomes of aneurysms in pediatric patients treated with microsurgery. METHODS: A retrospective chart review of 48 patients ≤ 18 years of age (28 boys, 20 girls; mean age, 12.3 years) who were treated for intracranial aneurysms between 1989 and 2005 was performed. RESULTS: Seventy-two aneurysms were treated. Presentations included incidental aneurysm (35%), aneurysmal subarachnoid hemorrhage (17%), stroke (13%), and traumatic subarachnoid hemorrhage (10%). Location was anterior circulation in 76% and posterior circulation in 24%. Twenty-eight (39%) were fusiform/dissecting, and 16 (23%) were giant. Most aneurysms were clipped directly. The long-term morbidity rate was 14%, and the mortality rate was 3%. Clinical outcome was favorable in 94% at follow-up (mean, 59 months; median 32, months). At angiographic follow-up (mean, 53 months; median, 32 months), the annual recurrence rate was 2.6%, and the annual rate of de novo formation or growth was 7.8%. CONCLUSION: Pediatric aneurysms require complex microsurgical techniques to achieve favorable outcomes. They leave higher rates of recurrence and de novo formation or growth than their adult counterparts, which mandates lifelong follow-up.

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Xu, David S.; Abruzzo, Todd A.; Albuquerque, Felipe C.; Dabus, Guilherme; Eskandari, Mark K.; Guterman, Lee R.; Hage, Ziad A.; Hurley, Michael C.; Hanel, Ricardo A.; Levy, Elad I.; Nichols, Christopher W.; Ringer, Andrew J.; Batjer, H. Hunt; Bendok, Bernard R.

Neurosurgery. 67(2):314-321, August 2010.

doi: 10.1227/01.NEU.0000371728.49216.3B

BACKGROUND: The external carotid artery (ECA) is an important source of collateral circulation to the brain. Stenosis of the ECA in ipsilateral ICA occlusion can produce ischemia. OBJECTIVE: To examine the effectiveness of ECA stenting in treating symptomatic ipsilateral ICA occlusion. METHODS: We retrospectively reviewed patient databases from 5 academic medical centers to identify patients who underwent ECA stenting after 1998. RESULTS: Twelve patients (median age, 66 years; range, 45–79 years) were identified. There was severe ECA stenosis ≥ 70% in 11 patients and ipsilateral ICA occlusion in all patients. Symptoms included transient ischemic attack and stroke. ECA stenting was associated with preservation of neurological status in 11 patients and resolution of symptoms in 5 patients at a median follow-up time of 26 months (range, 1–87 months; mean, 29 months). Symptomatic in-stent restenosis did not occur during the follow-up period. CONCLUSION: ECA stenting in symptomatic ipsilateral ICA disease was a potentially effective strategy to preserve neurological function and to relieve ischemic symptoms.

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Pan, Hung-Chuan; Yang, Dar-Yu; Ou, Yen-Chuan; Ho, Shu-Peng; Cheng, Fu-Chou; Chen, Chun-Jung

Neurosurgery. 67(2):376-389, August 2010.

doi: 10.1227/01.NEU.0000371729.47895.A0

BACKGROUND: A short-term course of a high-dose statin pretreatment has demonstrated neuroprotective effects against neurological diseases. OBJECTIVE: We investigated whether a short-term course of high-dose atorvastatin pretreatment has beneficial effects in protecting sciatic nerve from crush injury. METHODS: Atorvastatin (5 mg/kg) or saline was given orally to Sprague-Dawley rats for 7 days before injury. The rats were subjected to crush injury in the left sciatic nerve with a vessel clamp. Biochemical, functional, electrophysiological, and morphological alterations were examined. RESULTS: Atorvastatin improved injury-induced neurobehavioral/electrophysiological changes and axonal loss. Structural disruption, oxidative stress, inflammation, and apoptosis, were attenuated by atorvastatin. After injury, regeneration-associated genes, including growth-associated protein-43, myelin basic protein, ciliary neurotrophic factor, and collagen, were upregulated. Extracellular signalregulated kinase, AKT, signal transducer and activators of transcription-1, and necrosis factor-κB were suppressed and c-Jun N-terminal kinase, Smad2/3, and activating protein-1 were elevated neuroprotective action of atorvastatin. CONCLUSION: These findings suggest that a short-term course of high-dose atorvastatin pretreatment can protect against sciatic nerve crush injury through modifying intracellular or extracellular environments.

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Soto-Pérez-de-Celis, Enrique

Neurosurgery. 67(2):417-423, August 2010.

doi: 10.1227/01.NEU.0000371968.27560.6C

LEON TROTSKY WAS one of the founders of the Soviet Union and an obvious candidate to replace Lenin after his death. Unfortunately for him, it was Joseph Stalin who came to power, and Trotsky went into a long forced exile that eventually took him to Mexico, where he found asylum. On August 20, 1940, a Stalinist agent wounded Trotsky in the head with an ice axe in his house in Coyoacán, Mexico. Mexican neurosurgeons operated on him at the Cruz Verde Hospital in Mexico City. The axe had damaged the encephalon. Despite the care provided, Trotsky passed away 25 hours later. This article presents a review of Trotsky's last day, with emphasis on the doctors who performed the surgery and the results of his autopsy.

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Dempsey, Robert J.; Vemuganti, Raghu; Varghese, Tomy; Hermann, Bruce P.

Neurosurgery. 67(2):484-494, August 2010.

doi: 10.1227/01.NEU.0000371730.11404.36

This review focuses an impact of embolic cerebral vascular disease on vascular cognitive decline. It examines “silent” strokes and the relationship between the structural stability of atherosclerotic carotid plaque and the development of nonmotor symptomatology, including cognitive decline.

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