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SCHMIDEK & SWEET

Operative
Neurosurgical
Techniques
INDICATIONS, METHODS,
AND RESULTS
Sixth Edition
Volume 1

Alfredo Quiñones-Hinojosa, MD
Professor of Neurological Surgery and Oncology
Department of Neurosurgery
The Johns Hopkins University
Neuroscience and Cellular and Molecular Medicine
Director, Brain Tumor Surgery Program, Johns Hopkins Bayview
Director, Pituitary Surgery Program, Johns Hopkins Hospital
Baltimore, Maryland
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

SCHMIDEK & SWEET OPERATIVE NEUROSURGICAL TECHNIQUES:


INDICATIONS, METHODS, AND RESULTS,  ISBN: 978-1-4160-6839-6
SIXTH EDITION
Copyright © 2012, 2006, 2000, 1995, 1988, 1982 by Saunders, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek permission,
further information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treat-
ment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
ing and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instruc-
tions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data


Schmidek & Sweet operative neurosurgical techniques : indications, methods, and results. -- 6th ed.
/ [edited by] Alfredo Quiñones-Hinojosa.
p. ; cm.
Schmidek and Sweet operative neurosurgical techniques
Operative neurosurgical techniques
Rev. ed. of: Schmidek & Sweet operative neurosurgical techniques / [edited by] Henry H. Schmidek,
David W. Roberts. 5th ed. c2006.
Includes bibliographical references and index.
ISBN 978-1-4160-6839-6 (set : hardcover : alk. paper) -- ISBN 978-9996086854 (v. 1) -- ISBN 9996086852
(v. 1) -- ISBN 978-9996086915 (v. 2) -- ISBN 9996086917 (v. 2)
I. Quiñones-Hinojosa, Alfredo. II. Schmidek, Henry H., [date]. III.
Title: Schmidek and Sweet operative neurosurgical techniques. IV. Title:
Operative neurosurgical techniques.
[DNLM: 1. Neurosurgical Procedures--methods. 2. Brain
Neoplasms--surgery. 3. Craniocerebral Trauma--surgery. 4. Nervous System
Diseases--surgery. WL 368]
617.4’8--dc23 2012005310

Content Strategist: Julie Goolsby


Content Development Specialists: Agnes Byrne and Lisa Barnes
Publishing Services Manager: Pat Joiner-Myers
Senior Project Manager: Joy Moore
Designer: Lou Forgione

Printed in China

Last digit is the print number:  9  8  7  6  5  4  3  2  1


DEDICATION

died in the fall of 2008. Our field lost a hero, but he has left
behind a legacy of many contributions to the field of neuro-
science, neurosurgery, and medicine.
Born in China on September 10, 1937, Dr. Schmidek stud-
ied medicine at the University of Western Ontario, where
he was awarded all of their gold medals for his year. He
then continued at McGill University and the University
of London. He completed his residency in neurosurgery
at the Massachusetts General Hospital under his mentor,
Dr. William H. Sweet. At Hahnemann Medical College in
Philadelphia, he became the youngest chairman of a neuro­
surgical department in its history. This was followed by
the Chairmanship at the University of Vermont College of
Medicine and then the esteemed positions of Chief of the
Neurosurgical Service at The New England Deaconess Hos-
pital and an Associate Professor of Surgery at the Harvard
­Medical School. Dr. Schmidek authored or edited 10 neu-
rosurgical texts, most notably five editions of Schmidek &
Sweet Operative Neurosurgical Techniques. This book is cur-
rently the most universal text in neurosurgery. He retired in
2001 in Vermont, where he became the CEO of Brigadoon
Farm and raised prized Kobe cattle.
In 1984, Dr. Schmidek initiated a course, Review and
Update on Neurobiology for Neurosurgeons, at the Marine
Biological Laboratories in Woods Hole, Massachusetts.
Designed to inspire all neurosurgeons in cutting-edge
research in the field, this course has been proven to be
extremely successful and has motivated many residents to
pursue careers in academic surgery and beyond.
This new edition of Schmidek & Sweet Operative
­Neurosurgical Techniques is part of Dr. Schmidek’s legacy.
Henry Schmidek was undoubtedly an extraordinary man. I tried to keep the same spirit that characterized the prior
He was intellectually gifted with a voracious curiosity and editions of this book and made it a favorite among ­students,
neverending gusto for knowledge and life. His immense residents, and faculty alike since its first printing. As I edited
love of his family was apparent to everyone who had the this text with the help of a superb team of section editors
pleasure of his company. By trade he was a neurosurgeon, and contributors, I reflected on the life of Dr. Schmidek and
author, mentor, cattle farmer, and naval officer, but he took came to realize that it is not about how long we live but the
the time to enjoy the simple pleasures of sailboat racing and contributions we make to this world, the people we touch,
fly-fishing and was a loving husband, father, and grandfa- and the legacy we leave behind.
ther. He did all of these things with impeccable perfection.
I heard the shocking news that Dr. Schmidek had suddenly Alfredo Quiñones-Hinojosa
This page intentionally left blank
     
SECTION EDITORS

SECTION ONE: SURGICAL MANAGEMENT SECTION THREE: VASCULAR DISEASES


OF BRAIN AND SKULL BASE TUMORS;
SECTION SEVEN: TRAUMA

Christopher S. Ogilvy, MD
Director, Endovascular and Operative Neurovascular Surgery
Alfredo Quiñones-Hinojosa, MD Massachusetts General Hospital
EDITOR-IN-CHIEF Robert G. and A. Jean Ojemann Professor of Neurosurgery
Professor of Neurological Surgery and Oncology Harvard Medical School
Department of Neurosurgery Boston, Massachusetts
The Johns Hopkins University
Neuroscience and Cellular and Molecular Medicine
Director, Brain Tumor Surgery Program, Johns Hopkins
Bayview
Director, Pituitary Surgery Program, Johns Hopkins Hospital
Baltimore, Maryland

SECTION TWO: OPERATIVE TECHNIQUES


IN PEDIATRIC NEUROSURGERY

Brian L. Hoh, MD, FACS, FAHA, FAANS


William Merz Associate Professor
Department of Neurosurgery
University of Florida
Gainesville, Florida

Kurtis Auguste, MD
Assistant Professor
Director, Pediatric Epilepsy Surgery
Department of Neurological Surgery
UCSF Children’s Hospital
Children’s Hospital Oakland
Oakland, California

v
vi SECTION EDITORS

SECTION FOUR: HYDROCEPHALUS; SECTION SEVEN: TRAUMA;


SECTION FIVE: STEREOTACTIC RADIOSURGERY SECTION EIGHT: SURGICAL MANAGEMENT OF
NERVOUS SYSTEM INFECTIONS

Daniele Rigamonti, MD, FACS


Professor of Neurosurgery, Oncology, and Radiation Geoffrey T. Manley, MD, PhD
Departments of Oncology and Molecular Radiation Sciences Professor and Vice Chairman
Director, Stereotactic Radiosurgery Department of Neurological Surgery
Director, Hydrocephalus and Pseudotumor Cerebri Program University of California, San Francisco
Departments of Neurosurgery and Radiation Oncology Chief of Neurosurgery
Johns Hopkins School of Medicine Co-Director
Baltimore, Maryland Brain and Spinal Injury Center (BASIC)
San Francisco General Hospital
San Francisco, California

SECTION SIX: FUNCTIONAL NEUROSURGERY SECTION NINE: NEUROSURGICAL MANAGEMENT


OF SPINAL DISORDERS

Emad Eskandar, MD
Director, Neurosurgical Residency Program Ziya L. Gokaslan, MD, FACS
Director, Functional Neurosurgery Danlin M. Long Professor of Neurosurgery, Oncology,
Massachusetts General Hospital and Orthopedic Surgery
Associate Professor Vice Chairman
Harvard Medical School Department of Neurosurgery
Boston, Massachusetts Director
Johns Hopkins Hospital Neurosurgical Spine Program
Baltimore, Maryland

SECTION TEN: SURGICAL MANAGEMENT OF THE


PERIPHERAL NERVOUS SYSTEM

G. Rees Cosgrove, MD, FRCSC


Stoll Professor and Chairman
Department of Neurosurgery
The Warren Alpert Medical School of Brown University
Chief of Neurosurgery
Rhode Island Hospital and Miriam Hospital Allan J. Belzberg, MD, FRCSC
Providence, Rhode Island Associate Professor of Neurosurgery
The Johns Hopkins University School of Medicine
Director, Peripheral Nerve Surgery
Johns Hopkins Hospital
Baltimore, Maryland
CONTRIBUTORS

Frank L. Acosta, MD Manmeet S. Ahluwalia, MD


Assistant Professor Section Head
Department of Neurological Surgery Neuro-Oncology Outcomes
Director of Spinal Deformity Brain Tumor and Neuro-Oncology Center
Cedars–Sinai Medical Center Neurological Institute
Los Angeles, California Associate Staff
Spinal Infections: Vertebral Osteomyelitis and Spinal Taussig Cancer Institute
Epidural Abscess Cleveland Clinic
Anterior Lumbar Interbody Fusion: Indications Assistant Professor
and Techniques Department of Medicine
Surgical Management of Cerebrospinal Fluid Leakage after Cleveland Clinic
Spinal Surgery Lerner College of Medicine of Case Western University
Cleveland, Ohio
P. David Adelson, MD
Chemotherapy for Brain Tumors
Director of Neurosciences and Neurosurgery
Department of Neurosurgery Faiz Ahmad, MD
Phoenix Children’s Hospital Fellow
Phoenix, Arizona University of Miami
Management of Pediatric Severe Traumatic Brain Injury Miami Children’s Hospital
Jackson Memorial Hospital
John R. Adler, Jr., MD
Management of Nerve Sheath Tumors Involving the Spine
Dorothy and TK Chan Professor
Department of Neurosurgery Ellen Air, MD, PhD
Stanford University Medical Center Assistant Professor
Stanford, California Director of Epilepsy Surgery
CyberKnife Radiosurgery for Spinal Neoplasms Department of Neurosurgery
Radiation Therapy and Radiosurgery in the Management University of Cincinnati College of Medicine and Mayfield
of Craniopharyngiomas Clinic
Cincinnati, Ohio
Kamran V. Aghayev, MD
Radiation Therapy of Epilepsy
Spine Fellow
Department of Neurosurgery Pablo Ajler, MD
University of South Florida Department of Neurosurgery
Neuro-Oncology Hospital Italiano de Buenos Aires
H. Lee Moffitt Cancer Center and Research Institute Assistant Professor
Tampa, Florida Department of Surgery
Transtemporal Approaches to Posterior Cranial Fossa Instituto Universitario del Hospital Italiano de Buenos Aires
Buenos Aires, Argentina
Manish K. Aghi, MD, PhD
Management of Shunt Infections
Assistant Professor in Neurological Surgery
University of California, San Francisco Felipe C. Albuquerque, MD
San Francisco, California Assistant Director of Endovascular Neurosurgery
Cerebellar Tumors in Adults Barrow Neurological Institute
Surgical Management of Intracerebral Hemorrhage Phoenix, Arizona
Embolization of Tumors: Brain, Head, Neck, and Spine
Basheal M. Agrawal, BS, MD
Department of Neurological Surgery Arun P. Amar, MD
University of Wisconsin Hospital and Clinics Associate Professor
Madison, Wisconsin Department of Neurosurgery
Transforaminal Lumbar Interbody Fusion: Indications University of Southern California
and Techniques Los Angeles, California
Prolactinomas

vii
viii CONTRIBUTORS

Luca Amendola, MD Michael L. J. Apuzzo, MD, PhD


Department of Orthopedics and Traumatology Edwin Todd/Trent H. Wells, Jr. Professor of ­Neurological
Spine Surgery ­Surgery and Radiation Departments of Oncology,
Ospedale ­Biology, and Physics
Bologna, Italy University of Southern California, Los Angeles
Management of Primary Malignant Tumors of the Osseous Keck School of Medicine
Spine Director of Neurosurgery
Director of the Cyber Knife Unit
Christopher Ames, MD
University of Southern California Kenneth Norris, Jr. Cancer
Director
Hospital
University of California Spine Center
Director, Center for Stereotactic Neurosurgery
University of California, San Francisco
and Associated Research
San Francisco, California
Clinical Director of Surgical Neuro-Oncology
Anterior Lumbar Interbody Fusion: Indications
Director of the Gamma Unit Facility
and Techniques
University of Southern California Hospital
Beejal Y. Amin, MD Editor in Chief
Fellow World Neurosurgery
Department of Neurosurgical Surgery Los Angeles, California
University of California, San Francisco Transcallosal Surgery of Lesions Affecting the Third
San Francisco, California Ventricle: Basic Principles
Surgical Management of Posterior Fossa Meningiomas
Rocco Armonda, MD
Sepideh Amin-Hanjani, MD, FAANS, FACS, FAHA Director
Professor and Program Director Cerebrovascular Surgery, Interventional Neuroradiology,
Co-Director of Neurovascular Surgery and Neurotrauma
Department of Neurosurgery Department of Neurosurgery
University of Illinois at Chicago Walter Reed Military Medical Center
Chicago, Illinois Director
Surgical Management of Cavernous Malformations Department of Neurosurgery
of the Nervous System Uniformed Services University of the Health Sciences
Bethesda, Maryland
Joshua M. Ammerman, BS, MD Management of Penetrating Brain Injury
Assistant Clinical Professor
Department of Neurosurgery Paul M. Arnold, MD
George Washington University School of Medicine Professor of Neurosurgery
Washington, District of Columbia University of Kansas Medical Center
Video-Assisted Thoracoscopic Discectomy: Indications Kansas City, Kansas
and Techniques Thoracolumbar Anterolateral and Posterior Stabilization
William S. Anderson, PhD, MD Harel Arzi, MD
Assistant Professor of Neurosurgery Spine Fellow
The Johns Hopkins University School of Medicine Department of Neurosurgery
Department of Neurosurgery University of Kansas Medical Center
Johns Hopkins Hospital Kansas City, Kansas
Baltimore, Maryland Thoracolumbar Anterolateral and Posterior Stabilization
Dorsal Root Entry Zone Lesions
Ashok R. Asthagiri, MD
Ronald I. Apfelbaum, MD Staff Neurosurgeon
Professor National Institutes of Health
Department of Neurosurgery Bethesda, Maryland
University of Utah Surgical Management of Parasagittal and Convexity
Salt Lake City,  Utah Meningiomas
Neurovascular Decompression in Cranial Nerves V, VII, IX,
Kurtis Auguste, MD
and X
Assistant Professor
Director, Pediatric Epilepsy Surgery
Department of Neurological Surgery
UCSF Children’s Hospital
Children’s Hospital Oakland
Oakland, California
Contemporary Dorsal Rhizotomy Surgery for the Treatment
of Spasticity in Childhood
CONTRIBUTORS ix

Tariq E. Awad, MD, MSc, PhD Stefano Bandiera, MD


Assistant Professor Attending Surgeon
Department of Neurosurgery Department of Oncologic and Degenerative Spine Surgery
Suez Canal University Rizzoli Institute
Assistant Professor Bologna, Italy
Department of Neurosurgery Management of Primary Malignant Tumors of the Osseous
Suez Canal University Hospital Spine
Ismailia, Egypt
Nicholas M. Barbaro, MD
Dynamic Stabilization of the Lumbar Spine: Indications
Professor and Chair
and Techniques
Department of Neurological Surgery
Khaled M. Aziz, MD, PhD University of Indiana School of Medicine
Assistant Professor of Neurosurgery Medical Director
Director of the Division of Complex Intracranial Surgery Indiana University Health Neuroscience Center
Department of Neurosurgery Indianapolis, Indiana
Allegheny General Hospital Radiation Therapy of Epilepsy
Drexel Medical School Corpus Callosotomy: Indications and Techniques
Pittsburgh, Pennsylvania
Frederick G. Barker II, MD
Surgical Management of Petroclival Meningiomas
Associate Professor of Surgery
Management of Cranial Nerve Injuries
Department of Neurosurgery
Tipu Aziz, FRCS(SN), D.Med.Sci Harvard Medical School
Head of Oxford Functional Neurosurgery Associate Visiting Neurosurgeon
Nuffield Department of Neurosurgery Neurosurgical Service
University of Oxford Massachusetts General Hospital
Department of Neurological Surgery Boston, Massachusetts
John Radcliffe Hospital Surgical Approach to Falcine Meningiomas
Oxford, United Kingdom
Daniel L. Barrow, MD
Cervical Dystonia and Spasmodic Torticollis: Indications
MBNA/Bowman Professor and Chairman
and Techniques
Department of Neurosurgery
Joachim M. Baehring, MD, DSc Emory University School of Medicine
Associate Professor Atlanta, Georgia
Departments of Neurology, Medicine, and Neurosurgery Surgical Management of Terminal Basilar and Posterior
Yale University School of Medicine Cerebral Artery Aneurysms
New Haven, Connecticut
Sachin Batra, MD, MPH
Surgical Approaches to Lateral and Third Ventricular
Research Fellow
Tumors
Department of Neurological Surgery
Mirza N. Baig, MD, PhD Johns Hopkins Hospital
Neurosurgeon Baltimore, Maryland
Department of Neurological Surgery Adult Pseudotumor Cerebri Syndrome
Mercy Brain and Spine Center Stereotactic Radiosurgery for Pituitary Adenomas
Des Moines, Iowa
Joshua Bederson, MD
Cerebellar Tumors in Adults
Professor and Chair
Roy Bakay, MD Department of Neurosurgery
The A. Watson Armor III and Sarah Armour Presidential FPA Neurosurgery Department
Chair and Residency Research Director The Mount Sinai Hospital
Rush University Medical Center New York, New York
Chicago, Illinois Management of Spinal Cord Tumors and Arteriovenous
Brain–Computer Interfacing Prospects and Technical Malformations
Aspects
Kimon Bekelis, MD
Perry A. Ball, MD, FACS Resident
Neurosurgeon Department of Neurosurgery
Departments of Medicine and of Orthopedics Dartmouth-Hitchcock Medical Center
Section of Neurosurgery Lebanon, New Hampshire
Dartmouth-Hitchcock Medical Center Ensuring Patient Safety in Surgery―First Do No Harm
The Dartmouth Institute for Health Policy and Clinical Surgical Management of Infratentorial Arteriovenous
Practice Malformations
Lebanon, New Hampshire
Spinal Cord Stimulation and Intraspinal Infusions for Pain
x CONTRIBUTORS

Carlo Bellabarba, MD Chetan Bettegowda, MD, PhD


Director Resident
Orthopaedic Spine Service Department of Neurosurgery
Department of Orthopaedics and Sports Medicine The Johns Hopkins University School of Medicine
University of Washington/Harborview Medical Center Baltimore, Maryland
Professor Supratentorial Tumors in the Pediatric Population:
Department of Orthopaedics and Sports Medicine Multidisciplinary Management
University of Washington School of Medicine
Ravi Bhatia, MS, MCh
Seattle, Washington
Professor and Head of the Department of Neurosurgery
Management of Sacral Fractures
(Retired)
Lorenzo Bello, MD All India Institute of Medical Sciences, New Delhi
Associate Professor of Neurosurgery New Delhi, India
Neurological Sciences and Istituto Clinico Humanitas Management of Tuberculous Infections of the Nervous System
Università degli Studi di Milano
Sanjay Bhatia, MBBS, MS, MCh
Milano, Italy
Assistant Professor
Surgical Management of Low-Grade Gliomas
Department of Neurosurgery
Allan J. Belzberg, MD, FRCSC West Virginia University
Associate Professor of Neurosurgery Assistant Professor
The Johns Hopkins University School of Medicine Department of Neurosurgery
Director Ruby Memorial Hospital
Peripheral Nerve Surgery Morgantown, West Virginia
Johns Hopkins Hospital Surgical Management of Petroclival Meningiomas
Baltimore, Maryland
Allen T. Bishop, MD
Dorsal Root Entry Zone Lesions
Professor
Peripheral Nerve Tumors of the Extremities
Department of Orthopedics
Bernard R. Bendok, MD Mayo Clinic College of Medicine
Associate Professor of Neurological Surgery and Radiology Mayo Clinic
Department of Neurosurgery Rochester, Minnesota
Northwestern University Nerve Transfers: Indications and Techniques
Chicago, Illinois
Keith L. Black, MD
Endovascular Management of Spinal Vascular
Chairman and Professor
Malformations
Department of Neurosurgery
Ludwig Benes, MD Director
Vice Chairman Maxine Dunitz Neurosurgical Institute
Department of Neurosurgery Cedars-Sinai Medical Center
Philipps University Hospital Los Angeles, California
Marburg, Germany Current Surgical Management of High-Grade Gliomas
Surgical Management of Aneurysms of the Vertebral
Lewis S. Blevins, MD
and Posterior Inferior Cerebellar Artery Complex
Medical Director
Edward C. Benzel, MD California Center for Pituitary Disorders at University
Chairman of California, San Francisco
Department of Neurosurgery Department of Neurological Surgery
Staff, Center for Spine Health University of California, San Francisco
Neurological Institute San Francisco, California
Cleveland Clinic Multimodal Assessment of Pituitary and Parasellar Lesions
Cleveland, Ohio
George T. Blike, MD
Management of Cervical Spondylotic Myelopathy
Medical Director, Patient Safety and Training Center
Helmut Bertalanffy, MD Dartmouth-Hitchcock Medical Center
Professor and Chairman Lebanon, New Hampshire
Department of Neurosurgery Ensuring Patient Safety in Surgery―First Do No Harm
University Hospital
Ari Blitz, MD
Zurich, Switzerland
Assistant Professor
Surgical Management of Aneurysms of the Vertebral
Department of Radiology and Radiological Science
and Posterior Inferior Cerebellar Artery Complex
Division of Neuroradiology
The Johns Hopkins University and Medical Center
Baltimore, Maryland
Adult Pseudotumor Cerebri Syndrome
CONTRIBUTORS xi

Göran C. Blomstedt, MD, PhD Henry Brem, MD


Assistant Professor Harvey Cushing Professor of Neurosurgery
Department of Neurosurgery Departments of Ophthalmology and Oncology
Helsinki University Hospital The Johns Hopkins Medical Institutions
Helsinki, Finland Director
Management of Infections After Craniotomy Hunterian Neurosurgical Laboratory
Department of Neurosurgery
Benjamin Blondel, MD
Chairman
Spine Division
Department of Neurosurgery
Department of Orthopedic Surgery
The Johns Hopkins University School of Medicine
Hospital for Joint Diseases
Baltimore, Maryland
New York, New York
Transcranial Surgery for Pituitary Macroadenomas
Université de la Méditerranée
Orthopedic Surgery Department Albino Bricolo, MD
Marseille, France Professor and Chairman
Management of Degenerative Lumbar Stenosis Department of Neurosurgery
and Spondylolisthesis University of Verona Medical School
University Hospital of Verona
Kofi Boahene, MD, FACS
Verona, Italy
Assistant Professor
Surgical Management of Petroclival Meningiomas
Department of Otolaryngology, Head, and Neck Surgery
The Johns Hopkins School of Medicine Jason A. Brodkey, MD, FACS, FIPP
Baltimore, Maryland Neurosurgeon
Management of Cerebrospinal Fluid Leaks Ann Arbor Spine Center
Ann Arbor, Michigan
Bernardo Boleaga, MD
Transtemporal Approaches to Posterior Cranial Fossa
Department of Magnetic Resonance Imaging
Clinica Londres Jacques Brotchi, MD, PhD
Mexico City, Mexico Emeritus Professor and Honorary Chairman
Presurgical Evaluation for Epilepsy Including Intracranial Department of Neurosurgery
Electrodes Erasme Hospital
Brussels, Belgium
Markus Bookland, MD
Surgical Management of Intramedullary Spinal Cord Tumors
Resident
in Adults
Department of Neuroscience
Center for Neurovirology Jeffrey N. Bruce, MD
Temple University School of Medicine Professor of Neurological Surgery
Philadelphia, Pennsylvania Edgar M. Housepian Professor of Neurological Surgery
Surgical Management of Extracranial Carotid Artery Disease Columbia University College of Physicians and Surgeons
Attending Neurosurgeon
Stefano Boriani, MD
New York Presbyterian Medical Center
Head
New York, New York
Department of Oncologic and Degenerative Spine Surgery
Management of Pineal Region Tumors
Rizzoli Institute
Bologna, Italy Michael Bruneau, MD
Management of Primary Malignant Tumors of the Osseous Neurosurgeon
Spine Department of Neurosurgery
Erasme Hospital
Christopher M. Boxell, MD
Brussels, Belgium
Neurosurgeon
Surgical Management of Intramedullary Spinal Cord Tumors
Department of Neurological Surgery
in Adults
University of Oklahoma
Oklahoma City,  Oklahoma Bradley R. Buchbinder, MD
Tulsa Spine and Specialty Hospital Director
Tulsa, Oklahoma Clinical Functional Magnetic Resonance Imaging
Cervical Laminoplasty: Indications and Techniques Staff Neuroradiologist
Division of Neuroradiology
Massachusetts General Hospital
Boston, Massachusetts
Motor Cortex Stimulation for Intractable Facial Pain
xii CONTRIBUTORS

Kim J. Burchiel, MD Ricardo L. Carrau, MD


John Raaf Professor and Chairman Professor of Otolaryngology-Head and Neck Surgery
Oregon Health and Science University and Neurosurgery
Portland, Oregon Director of the Maxillofacial Trauma Service
Deep Brain Stimulation in Movement Disorders: Parkinson’s Director of the Consult Service
Disease, Essential Tremor, and Dystonia Director of the Tracheotomy and Swallowing Unit
University of Pittsburgh Medical Center
Timothy G. Burke, MD
Pittsburgh, Pennsylvania
Neurosurgeon
Endoscopic Endonasal Approach for Craniopharyngiomas
Department of Neurosurgery
Anne Arundel Medical Center Benjamin S. Carson, MD
Annapolis, Maryland Professor and Director
Circumferential Cervical Spinal Fusion Department of Pediatric Neurosurgery
Professor of Neurosurgery, Oncology, Plastic Surgery,
Ali Bydon, MD and Pediatrics
Assistant Professor
The Johns Hopkins Medical Institutions
Department of Neurosurgery
Department of Neurosurgery
The Johns Hopkins University
The Johns Hopkins Medical Institutions
Clinical Director of Spinal Surgery
Baltimore, Maryland
Department of Neurosurgery
Neurosurgical Problems of the Spine in Achondroplasia
The Johns Hopkins Bayview Medical Center
Baltimore, Maryland Bob S. Carter, MD
Posterior Lumbar Fusion by Open Technique: Indications Professor and Chief
and Techniques Department of Neurosurgery
University of California, San Diego
Francesco Cacciola, MD
San Diego, California
Walton Centre for Neurology and Neurosurgery
Surgical Management of Intracerebral Hemorrhage
Liverpool, United Kingdom
Anterior Approaches for Multilevel Cervical Spondylosis Giuseppe Casaceli, MD
Resident in Neurosurgery
Kevin Cahill, MD, PhD, MPH
Neurological Sciences and Istituto Clinico Humanitas
Spine Fellow
Università degli Studi di Milano
Department of Neurosurgery
Milano, Italy
University of Miami Miller School of Medicine
Surgical Management of Low-Grade Gliomas
Miami, Florida
Dorsal Root Entry Zone Lesions Laura Castana, MD
Epilepsy and Parkinson Surgery Centre
Paolo Cappabianca, MD
C. Munari Ospedale Niguarda Ca'Granda
Professor and Chairman
Milan, Italy
Department of Neurological Sciences
Multilobar Resection and Hemispherectomy in Epilepsy
Division of Neurosurgery
Surgery
Università degli Studi di Napoli Federico II
Naples, Italy Gabriel Castillo, MD
Endocrinologically Silent Pituitary Tumors Associate Neurosurgeon
Puerta de Hierro Medical Center
Anthony J. Caputy, MD
Guadalajara, Mexico
Professor and Chairman
Surgical Treatment of Paraclinoid Aneurysms
Department of Neurosurgery
The George Washington University Luigi M. Cavallo, MD, PhD
Washington, District of Columbia Neurosurgeon
Video-Assisted Thoracoscopic Discectomy: Indications Department of Neurological Sciences
and Techniques Division of Neurosurgery
Università degli Studi di Napoli Federico II
Francesco Cardinale, MD
Naples, Italy
Neurosurgeon
Endocrinologically Silent Pituitary Tumors
Centre Claudio Munari for Epilepsy and Parkinson Surgery
Niguarda Hospital C. Michael Cawley, MD
Milan, Italy Associate Professor
Multilobar Resection and Hemispherectomy in Epilepsy Departments of Neurosurgery and Radiology
Surgery Emory University School of Medicine
Atlanta, Georgia
Surgical Management of Terminal Basilar and Posterior
Cerebral Artery Aneurysms
CONTRIBUTORS xiii

Aabir Chakraborty, MD Douglas Chen, MD, FACS


Honorary Senior Lecturer Co-Director, Hearing and Balance Center
Neurosciences Adjunct Associate Professor of Surgery
Institute of Child Health (Otolaryngology and Neurosurgery)
University College, London Allegheny University of the Health Sciences
Consultant Pittsburgh, Pennsylvania
Pediatric Neurosurgery Management of Cranial Nerve Injuries
Great Osmond Street Hospital for Children
James Chen, BS
London, United Kingdom
Division of Interventional Neuroradiology
Methods for Cerebrospinal Fluid Diversion in Pediatric
Department of Radiology
Hydrocephalus: From Shunt to Scope
Johns Hopkins Hospital
Edward F. Chang, MD Baltimore, Maryland
Chief Resident Imaging Evaluation and Endovascular Treatment
Department of Neurological Surgery of Vasospasm
University of California, San Francisco
Linda C. Chen, BS
San Francisco, California
Medical Student
Corpus Callosotomy: Indications and Techniques
Department of Neurosurgery
Eric C. Chang, BS, MD The Johns Hopkins University
Resident Baltimore, Maryland
Department of Neurosurgery Supratentorial Tumors in the Pediatric Population:
Massachusetts General Hospital Multidisciplinary Management
Harvard University
Boyle C. Cheng, PhD
Boston, Massachusetts
Associate Professor
Surgical Approach to Falcine Meningiomas
Department of Neurosurgery
Steven D. Chang, MD Drexel University College of Medicine
Robert C. and Jeannette Powell Professor Director
Department of Neurosurgery Department of Neurosurgery
Stanford University Division of Research
Stanford, California Allegheny General Hospital
CyberKnife Radiosurgery for Spinal Neoplasms Pittsburgh, Pennsylvania
Radiation Therapy and Radiosurgery in the Management Dynamic Stabilization of the Lumbar Spine: Indications
of Craniopharyngiomas and Techniques
Jens R. Chapman, MD Joshua J. Chern, MD, PhD
Professor Neurosurgeon
Department of Orthopaedics and Sports Medicine Children’s Healthcare of Atlanta
University of Washington Atlanta, Georgia
Seattle, Washington Instrumentation and Stabilization of the Pediatric Spine:
Management of Sacral Fractures Technical Nuances and Age-Specific Considerations
E. Thomas Chappell, MD John H. Chi, MD, MPH
Neurosurgeon Assistant Professor
Department of Neurosurgery Department of Neurosurgery
University of California, Irvine Brigham and Women’s Hospital
Irvine, California Harvard Medical School
Neurosurgical Management of HIV-Related Focal Brain Boston, Massachusetts
Lesions Lateral Lumbar Interbody Fusion: Indications
and Techniques
Neeraj Chaudhary, MD, MRCS(UK), FRCR(UK)
Assistant Professor Wade W. Chien, MD
Fellowship Program Co-Director Clinical Fellow
Division of Neurointerventional Surgery Division of Otology/Neurotology
Departments of Radiology and Neurosurgery Department of Otolaryngology
University of Michigan Health System The Johns Hopkins School of Medicine
Ann Arbor, Michigan Baltimore, Maryland
Endovascular Management of Intracranial Aneurysms Hearing Prosthetics: Surgical Techniques
xiv CONTRIBUTORS

E. Antonio Chiocca, MD, PhD Alan Cohen, MD, FACS, FAAP


Chairman Robert and William Reinberger Chair in Pediatric
Department of Neurological Surgery Neurological Surgery
Dardinger Family Professor of Oncologic Neurosurgery Professor
Physician Director Departments of Neurological Surgery and Pediatrics
OSUMC Neuroscience Signature Program Director
Co-Director Neurological Surgery Residency Program
Dardinger Center for Neuro-Oncology and Neurosciences Case Western Reserve University School of Medicine
Co-Director Cleveland, Ohio
Viral Oncology Program of the Comprehensive Cancer Management of Tumors of the Fourth Ventricle
Center
Annamaria Colao, MD, PhD
James Cancer Hospital and Solove Research Institute
Professor of Endocrinology
The Ohio State University Medical Center
Chief of the Neuroendocrine Unit
Columbus, Ohio
University Federico II
Cerebellar Tumors in Adults
Naples, Italy
Rohan Chitale, MD Endocrinologically Silent Pituitary Tumors
Neurosurgeon
Geoffrey P. Colby, MD, PhD
Department of Neurosurgery
Neurosurgeon
Thomas Jefferson University Hospital
The Johns Hopkins Medical Center
Philadelphia, Pennsylvania
Baltimore, Maryland
Endovascular Treatment of Cerebral Arteriovenous
Endovascular Management of Dural Arteriovenous Fistulas
Malformations
Massimo Collice, MD†
Bhupal Chitnavis, BSc(Hons) MBBS, FRCS(Eng), FRCS(SN)
Former Professor and Chairman
Consultant Neurosurgeon
Department of Neurological Sciences
Department of Neurosurgery
A.O. Niguarda
London Bridge Hospital
Chief
London, United Kingdom
Department of Neurosurgery
Disc Replacement Technologies in the Cervical and Lumbar
Niguarda Ca’Granda Hospital
Spine
Milan, Italy
Lana D. Christiano, MD Management of Traumatic Intracranial Aneurysms
Department of Neurological Surgery
Daniel Condit, BS
University of Medicine and Dentistry of New Jersey
ThedaCare Behavioral Health–Midway
Newark, New Jersey
Menasha, Wisconsin
Surgical Management of Tumors of the Jugular Foramen
Deep Brain Stimulation for Pain
Ray M. Chu, MD
Alexander L. Coon, MD
Neurosurgeon
Assistant Professor of Neurosurgery, Neurology,
Department of Neurosurgery
and Radiology
Cedars–Sinai Medical Center
Director, Endovascular Neurosurgery
Los Angeles, California
Johns Hopkins Hospital
Current Surgical Management of High-Grade Gliomas
Department of Neurosurgery
Elisa F. Ciceri, MD Baltimore, Maryland
Director Endovascular Management of Dural Arteriovenous Fistulas
Department of Interventional Neuroradiology
Cassius Vinícius Corrêa Dos Reis, MD
Fondazione
Assistant Professor of Neurosurgery
Milan, Italy
Medical School
Endovascular Management of Dural Arteriovenous Fistulas
Universidade Federal de Minas Gerais
Michelle J. Clarke, MD Belo Horizonte, Brazil
Assistant Professor of Neurosurgery Surgical Management of Tumors of the Foramen Magnum
Mayo Clinic
Rochester, Minnesota
Management of Penetrating Injuries to the Spine

†Deceased.
CONTRIBUTORS xv

G. Rees Cosgrove, MD, FRCSC Mark J. Dannenbaum, MD


Stoll Professor and Chairman Clinical Instructor/Cerebrovascular Fellow
Department of Neurosurgery Departments of Neurosurgery and Radiology
The Warren Alpert Medical School of Brown University Emory University
Chief of Neurosurgery Atlanta, Georgia
Rhode Island Hospital and Miriam Hospital Surgical Management of Terminal Basilar and Posterior
Providence, Rhode Island Cerebral Artery Aneurysms
Temporal Lobe Operations in Intractable Epilepsy
Ronan M. Dardis, MD, MPhil, FRCSI(Neuro Surg)
Cingulotomy for Intractable Psychiatric Illness
Consultant Neurosurgeon
Massimo Cossu, MD Department of Neurosurgery
Claudio Munari Epilepsy Surgery Center University Hospitals Coventry and Warwickshire
Niguarda Hospital Honorary Associate Clinical Professor
Milan, Italy University of Warwick
Multilobar Resection and Hemispherectomy in Epilepsy Warwickshire, United Kingdom
Surgery Disc Replacement Technologies in the Cervical and Lumbar
Spine
William T. Couldwell, MD, PhD
Professor and Chairman of Neurosurgery Hormuzdiyar H. Dasenbrock, MD
Department of Neurosurgery Department of Neurosurgery
University of Utah Health Science Center Brigham and Women’s Hospital
Salt Lake City, Utah Children’s Hospital of Boston
Prolactinomas Harvard Medical School
Boston, Massachusetts
William T. Curry, MD
Posterior Lumbar Fusion by Open Technique: Indications
Attending Neurosurgeon
or Techniques
Department of Neurosurgery
Massachusetts General Hospital Reza Dashti, MD, PhD
Assistant Professor Associate Professor
Department of Surgery Department of Neurosurgery
Harvard Medical School Istanbul University
Boston, Massachusetts Cerrahpasa Medical Faculty
Surgical Approach to Falcine Meningiomas Istanbul, Turkey
Endovascular Neurosurgery Fellow
Guilherme Dabus, MD
Department of Neurosurgery
Associate Professor
University of Illinois at Chicago
Departments of Radiology and Neurological Surgery
Chicago, Illinois
Wertheim College of Medicine–Florida International
Surgical Management of Aneurysms of the Middle Cerebral
University
Artery
Director, Fellowship Program
Department of Neurointerventional Surgery Arthur L. Day, MD
Baptist Cardiac and Vascular Institute Professor and Chairman
Miami, Florida Harvard Medical School
Endovascular Management of Spinal Vascular Brigham and Women’s Hospital
Malformations Boston, Massachusetts
Management of Unruptured Intracranial Aneurysms
Teodoro Forcht Dagi, MD, DMedSC
Surgical Management of Cerebellar Stroke—Hemorrhage
Chief Medical Officer
and Infarction
AventuraHQ Inc.
Denver, Colorado John Diaz Day, MD
Management of Cerebrospinal Fluid Leaks Associate Professor
Director
Giuseppe D’Aliberti, MD
Cranial Base Surgery Program
Department of Neurosurgery
Department of Neurosurgery
Niguarda Ca'Granda Hospital
University of Texas Health Science Center at San Antonio
Milan, Italy
San Antonio, Texas
Management of Traumatic Intracranial Aneurysms
Tumors Involving the Cavernous Sinus
Moise Danielpour, MD Vedran Deletis, MD, PhD
Director
Associate Professor
Pediatric Neurosurgery Program
Institute for Neurology and Neurosurgery
Department of Neurosurgery
Roosevelt Hospital
Cedars-Sinai Medical Center
New York, New York
Los Angeles, California
Intraoperative Neurophysiology: A Tool to Prevent and/or
Contemporary Dorsal Rhizotomy Surgery for the Treatment
Document Intraoperative Injury to the Nervous System
of Spasticity in Childhood
xvi CONTRIBUTORS

Ramiro Del-Valle, MD Doniel Drazin, MD, MA


Chairman Department of Neurosurgery
Gamma Knife Neurosurgery Center Cedars-Sinai Medical Center
Mèdica Sur Clinical Foundation Los Angeles, California
Mexico City, Mexico Contemporary Dorsal Rhizotomy Surgery for the Treatment
Role of Gamma Knife Radiosurgery in the Management of Spasticity in Childhood
of Arteriovenous Malformations Spinal Infections: Vertebral Osteomyelitis and Spinal
Epidural Abscess
Franco DeMonte, MD
Anterior Lumbar Interbody Fusion: Indications
Professor
and Techniques
Mary Beth Pawelek Chair
Surgical Management of Cerebrospinal Fluid Leakage after
Department of Neurosurgery
Spinal Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas Rose Du, MD, PhD
Spheno-Orbital Meningioma Instructor
Department of Neurosurgery
Francesco Dimeco, MD
Brigham and Women’s Hospital
Department of Neurological Surgery
Harvard Medical School
Fondazione Istituto Neurologico
Boston, Massachusetts
Milan, Italy
Management of Intracranial Aneurysms Caused by Infection
Surgical Management of Low-Grade Gliomas
Thomas B. Ducker, MD
Robert Dodd, MD, PhD Professor
Assistant Professor
Department of Neurological Surgery
Department of Neurosurgery
The Johns Hopkins School of Medicine
Stanford University School of Medicine
Baltimore, Maryland
Stanford, California
Circumferential Cervical Spinal Fusion
CyberKnife Radiosurgery for Spinal Neoplasms
Hugues Duffau, MD, PhD
Francesco Doglietto, MD, PhD Professor and Chairman
Department of Neurosurgery
Department of Neurosurgery
Catholic University School of Medicine
Hôpital Gui de Chauliac
Rome, Italy
CHU de Montpellier
Surgical Management of Lesions of the Clivus
Montpellier, France
Lutz Dörner, MD Cortical and Subcortical Brain Mapping
Department of Neurosurgery
Bradley S. Duhon, MD
Universitätsklinikum
Neurosurgeon
Kiel, Germany
Gordon Spine & Brain Associates
Surgical Navigation with Intraoperative Imaging: Special
Tyler, Texas
Operating Room Concepts
Lumbar Microdiscectomy: Indications and Techniques
Michael J. Dorsi, MD Paula Eboli, MD
Chief Resident
Resident
Department of Neurosurgery
Department of Neurological Surgery
The Johns Hopkins School of Medicine
Cedars–Sinai Medical Center
Baltimore, Maryland
Los Angeles, California
Peripheral Nerve Tumors of the Extremities
Spinal Infections: Vertebral Osteomyelitis and Spinal
Gaby D. Doumit, MD, MSc Epidural Abscess
Staff
Mohamed Samy Elhammady, MD
Department of Plastic Surgery
Instructor of Clinical Neurological Surgery
Cleveland Clinic
Department of Neurological Surgery
Cleveland, Ohio
University of Miami Miller School of Medicine
Principles of Scalp Surgery and Surgical Management
Miami, Florida
of Major Defects of Scalp
Far Lateral Approach and Transcondylar and Supracondylar
James M. Drake, MSc, FRCS(C), MBBCh Extensions for Aneurysms of the Vertebrobasilar Junction
Professor
Pamela Ely, MD, PhD
Department of Surgery
Associate Professor of Medicine, Emeritus
Division of Neurosurgery
Section of Hematology/Oncology
University of Toronto
Dartmouth Medical School
Pediatric Neurosurgeon
Hanover, New Hampshire
Hospital for Sick Children
Management of Primary Central Nervous System
Toronto, Canada
Lymphomas
Methods for Cerebrospinal Fluid Diversion in Pediatric
Hydrocephalus: From Shunt to Scope
CONTRIBUTORS xvii

Nancy E. Epstein, MD Gilbert J. Fanciullo, MD, MS


Clinical Professor of Neurological Surgery Director
The Albert Einstein College of Medicine Section of Pain Medicine
Bronx, New York Dartmouth-Hitchcock Medical Center
Chief of Neurosurgical Spine and Education Lebanon, New Hampshire
Winthrop University Hospital Professor of Anesthesiology
Mineola, New York Dartmouth Medical School
Management of Far Lateral Lumbar Disc Herniations Hanover, New Hampshire
Spinal Cord Stimulation and Intraspinal Infusions for Pain
Kadir Erkmen, MD
Associate Professor Kyle M. Fargen, MD, MPH
Department of Neurosurgery Resident
Dartmouth-Hitchcock Medical Center Department of Neurosurgery
Lebanon, New Hampshire University of Florida
Ensuring Patient Safety in Surgery―First Do No Harm Gainesville, Florida
Endovascular Treatment of Stroke
Thomas Errico, MD
Professor and Chief Gidon Felsen, PhD
Division of Spine Surgery Departments of Physiology and Biophysics
Departments of Orthopedic Surgery (Ortho Spine Surgery University of Colorado School of Medicine
Division Director) and Neurosurgery Aurora, Colorado
New York University Langone Medical Center Novel Targets in Deep Brain Stimulation for Movement
New York, New York Disorders
Management of Degenerative Lumbar Stenosis
Dong Xia Feng, MD, PhD
and Spondylolisthesis
Department of Neurosurgery
Emad N. Eskandar, MD University of Arkansas College of Medicine
Director, Neurosurgical Residency Program Department of Neurosurgery
Director, Functional Neurosurgery Little Rock,  Arkansas
Massachusetts General Hospital Tumors Involving the Cavernous Sinus
Associate Professor
Richard G. Fessler, MD, PhD
Harvard Medical School
Professor of Neurological Surgery
Boston, Massachusetts
Northwestern University Feinberg School of Medicine
Temporal Lobe Operations in Intractable Epilepsy
Chicago, Illinois
Motor Cortex Stimulation for Intractable Facial Pain
Surgical Approaches to the Cervicothoracic Junction
Clifford J. Eskey, MD, PhD
Aaron G. Filler, MD, PhD, FRCS
Associate Professor of Radiology and Surgery
Medical Director
Department of Radiology
Institute for Nerve Medicine
Dartmouth-Hitchcock Medical Center
Santa Monica, California
Lebanon, New Hampshire
Imaging for Peripheral Nerve Disorders
Vertebroplasty and Kyphoplasty: Indications and Techniques
John C. Flickinger, MD, FACR
Felice Esposito, MD, PhD
Professor of Radiation Oncology and Neurological Surgery
Division of Neurosurgery
University of Pittsburgh School of Medicine
Division of Maxillo-Facial Surgery
Pittsburgh, Pennsylvania
Università degli Studi di Napoli Federico II
Vestibular Schwannomas: The Role of Stereotactic Surgery
Napoli, Italy
Endocrinologically Silent Pituitary Tumors John R. Floyd, MD
Assistant Professor of Neurological Surgery
Camilo E. Fadul, MD
Department of Neurological Surgery
Professor
University of Texas Health Science Center, San Antonio
Departments of Medicine and Neurology
San Antonio, Texas
Dartmouth Medical School
Spheno-Orbital Meningioma
Hanover, New Hampshire
Director of Neuro-Oncology Program Kevin T. Foley, MD
Norris-Cotton Cancer Center Professor
Dartmouth-Hitchcock Medical Center Department of Neurological Surgery
Lebanon, New Hampshire Semmes-Murphey Neurologic and Spine Institute
Management of Primary Central Nervous System Memphis, Tennessee
Lymphomas Percutaneous Placement of Lumbar Pedicle Screws:
Indications and Techniques
xviii CONTRIBUTORS

Kostas N. Fountas, MD, PhD Sergio Maria Gaini, MD


Associate Professor of Neurosurgery Professor in Neurosurgery
Department of Neurosurgery Department of Neurological Sciences
University Hospital of Larissa School of Medicine Università degli Studi di Milano
University of Thessaly Milano, Italy
Larissa, Greece Surgical Management of Low-Grade Gliomas
Mesencephalic Tractotomy and Anterolateral Cordotomy
Chirag D. Gandhi, MD
for Intractable Pain
Assistant Professor of Neurological Surgery and Radiology
Howard Francis, MD Director of Endovascular Neurosurgery Fellowship Program
Associate Professor Director of Undergraduate Neurosurgical Education
The Johns Hopkins University Director of Traumatic Brain Injury Basic Science Laboratory
Baltimore, Maryland Neurological Institute of New Jersey
Hearing Prosthetics: Surgical Techniques Newark, New Jersey
Endovascular Treatment of Head and Neck Bleeding
James L. Frazier, MD
Chief Resident Dheeraj Gandhi, MD, MBBS
Department of Neurosurgery Director, Interventional Neuroradiology
Johns Hopkins Hospital The Johns Hopkins Bayview
Baltimore, Maryland Associate Professor
Surgical Management of Brain Stem Tumors in Adults Departments of Radiology, Neurosurgery, and Neurology
The Johns Hopkins School of Medicine
Kai Frerichs, MD
Baltimore, Maryland
Director of Endovascular Neurosurgery
Imaging Evaluation and Endovascular Treatment of
Neuro-Oncology
Vasospasm
Harvard Medical School
Dana-Farber Cancer Center Institute Gale Gardner, MD
Boston, Massachusetts Professor
Management of Unruptured Intracranial Aneurysms Department of Otology/Neurotology
Louisiana State University Shreveport
David M. Frim, MD, PhD
Shreveport, Louisiana
Ralph Cannon Professor and Chief
Transtemporal Approaches to Posterior Cranial Fossa
Section of Neurosurgery
The University of Chicago Paul Gardner, MD
Chicago, Illinois Assistant Professor
Surgical Management of Neurofibromatosis Types 1 and 2 Department of Neurosurgery
Surgical Management of Hydrocephalus in the Adult University of Pittsburgh
Pittsburgh, Pennsylvania
Sebastien Froelich, MD
Endoscopic Endonasal Approach for Craniopharyngiomas
Department of Neurosurgery
Strasbourg University Hospital Mark Garrett, MD
Strasbourg, France Neurosurgical Resident
Surgical Management of Petroclival Meningiomas Division of Neurological Surgery
Barrow Neurological Institute
Takanori Fukushima, MD
St. Joseph’s Hospital and Medical Center
Consulting Professor of Surgery
Phoenix, Arizona
Department of Surgery
Posterior Lumbar Interbody Fusion
Division of Neurosurgery
Duke University Medical Center Tomás Garzón-Muvdi, MD, MS
Durham, North Carolina Postdoctoral Fellow
Tumors Involving the Cavernous Sinus Department of Neurosurgery
Surgical Management of Tumors of the Jugular Foramen The Johns Hopkins Medical Institutions
Baltimore, Maryland
Philippe Gailloud, MD
Surgical Management of Infratentorial Arteriovenous
Director of the Division of Interventional Neuroradiology
Malformations
Director of the Endovascular Surgical Neuroradiology
Management of Neurocysticercosis
Program
Co-Director of The Johns Hopkins Center for Pediatric Alessandro Gasbarrini, MD
Neurovascular Diseases Medical Director
Johns Hopkins Hospital Istituto Ortopedico Rizzoli
Baltimore, Maryland Bologna, Italy
Surgical Management of Infratentorial Arteriovenous Management of Primary Malignant Tumors of the Osseous
Malformations Spine
Adult Pseudotumor Cerebri Syndrome
CONTRIBUTORS xix

Fred H. Geisler, MD, PhD Takeo Goto, MD


Founder c/o Kenji Ohata, MD
Illinois Neuro Spine Center Orbitozygomatic Infratemporal Approach to Parasellar
Aurora, Illinois Meningiomas
Lumbar Spinal Arthroplasty: Clinical Experiences of Motion
Grahame C. Gould, MD
Preservation
Resident
Joseph J. Gemmete, MD Department of Neurological Surgery
Associate Professor of Radiology Yale University
Departments of Radiology, Neurosurgery, Yale New Haven Hospital
and Otolaryngology New Haven, Connecticut
University of Michigan Hospitals Surgical Approaches to Lateral and Third Ventricular Tumors
Ann Arbor, Michigan
M. Sean Grady, MD
Endovascular Management of Intracranial Aneurysms
Chairman and Professor
Massimo Gerosa, MD Department of Neurosurgery
Professor of Neurosurgery University of Pennsylvania School of Medicine
University of Verona Philadelphia, Pennsylvania
Chairman Surgical Management of Major Skull Defects and Potential
Department of Neurosurgery Complications
University Hospital
Andrew W. Grande, MD
Verona, Italy
Assistant Professor
Stereotactic Radiosurgery Meningiomas
Department of Neurosurgery
Atul Goel, MCh University of Minnesota
Residency Program Director Minneapolis, Minnesota
Neurosurgery Department Chairman Percutaneous Stereotactic Rhizotomy in the Treatment
Consulting Surgeon of Intractable Facial Pain
Seth Medical College
Ramesh Grandhi, MD
Mumbai, India
Resident
Anterior Approaches for Multilevel Cervical Spondylosis
University of Pittsburgh Medical Center
Ziya L. Gokaslan, MD, FACS Pittsburgh, Pennsylvania
Danlin M. Long Professor of Neurosurgery,  Oncology, Perioperative Management of Severe Traumatic Brain Injury
and Orthopedic Surgery in Adults
Vice Chairman
Alexander L. Green, FRCS(SN), MD, BSc, MBBS
Department of Neurosurgery
Spalding Senior Lecturer
Director
Consultant Neurosurgeon
Johns Hopkins Hospital Neurosurgical Spine Program
John Radcliffe Hospital
Baltimore, Maryland
Oxford, United Kingdom
Surgery for Metastatic Spine Disease
Functional Tractography, Diffusion Tensor Imaging,
Surgical Resection of Sacral Tumors
Intraoperative Integration of Modalities,
L. Fernando Gonzalez, MD and Neuronavigation
Thomas Jefferson University Surgical Management of Extratemporal Lobe Epilepsy
Jefferson Medical College
Jeffrey P. Greenfield, MD, PhD
Assistant Professor
Assistant Professor of Neurological Surgery
Department of Neurological Surgery
Department of Neurological Surgery
Division of Neurovascular Surgery and Endovascular
Weill Cornell Medical College
Neurosurgery
Assistant Member
Philadelphia, Pennsylvania
Department of Neurosurgery
Endovascular Treatment of Cerebral Arteriovenous
Memorial Sloan-Kettering Cancer Center
Malformations
New York, New York
C. Rory Goodwin, BS Endoscopic Approach to Intraventricular Brain Tumors
Resident
Bradley A. Gross, MD
Johns Hopkins Hospital
Resident
UNCF/Merck Postdoctoral Fellow
Harvard Medical School
Baltimore, Maryland
Resident
Transcranial Surgery for Pituitary Macroadenomas
Department of Neurosurgery
Brigham and Women’s Hospital
Boston, Massachusetts
Management of Intracranial Aneurysms Caused by Infection
xx CONTRIBUTORS

Rachel Grossman, MD Griffith R. Harsh IV, MD, MA, MBA


Neurosurgical Oncology Fellow Professor
Department of Neurosurgery Stanford Medical School
The Johns Hopkins University Stanford, California
Baltimore, Maryland Management of Recurrent Gliomas
Management of Suppurative Intracranial Infections
Alia Hdeib, MD
Mari Groves, MD Department of Neurological Surgery
Neurosurgical Resident University Hospitals Case Medical Center
Johns Hopkins Hospital Cleveland, Ohio
Baltimore, Maryland Management of Tumors of the Fourth Ventricle
Neurosurgical Problems of the Spine in Achondroplasia
Stefan Heinze, MD
Gerardo Guinto, MD Neurosurgeon
Professor and Chairman Department of Neurosurgery
Department of Neurosurgery Philips University Marburg
Hospital de Especialidades Centro Medico Siglo XXI Marburg, Germany
Mexico City,  Mexico Surgical Management of Aneurysms of the Vertebral
Surgical Management of Sphenoid Wing Meningiomas and Posterior Inferior Cerebellar Artery Complex
Richard Gullan, BSc, MBBS, MRCP, FRCS John Heiss, MD
Consultant Neurosurgeon Head, Clinical Unit
BMI Healthcare Surgical Neurology Branch
London, United Kingdom National Institute of Neurological Disorders and Stroke
Disc Replacement Technologies in the Cervical and Lumbar National Institutes of Health
Spine Bethesda, Maryland
Management of Chiari Malformations and Syringomyelia
Gaurav Gupta, MD
Senior Fellow Dieter Hellwig, MD, PhD
Department of Neurosurgery Head, Stereotactic and Functional Neurosurgery
University of Medicine and Dentistry of New Jersey International Neuroscience Institute
New Jersey Medical School Hanover, Germany
Newark, New Jersey Arachnoid, Suprasellar, and Rathke’s Cleft Cysts
Surgical Management of Tumors of the Jugular Foramen
Juha Hernesniemi, MD, PhD
Management of Ulnar Nerve Compression
Professor and Chairman
Nalin Gupta, MD, PhD Department of Neurosurgery
Associate Professor University Hospital of Helsinki
Neurological Surgery and Pediatrics Helsinki, Finland
Chief, Division of Pediatric Neurosurgery Surgical Management of Aneurysms of the Middle Cerebral
University of California, San Francisco Artery
San Francisco, California
Roberto C. Heros, MD
Fetal Surgery for Open Neural Tube Defects
Professor
Todd C. Hankinson, MD, MBA Co-Chairman and Program Director of Neurological
Assistant Professor Surgery
Department of Neurosurgery University of Miami
Children’s Hospital Colorado Miami, Florida
University of Colorado, Denver Far Lateral Approach and Transcondylar and Supracondylar
Aurora, Colorado Extensions for Aneurysms of the Vertebrobasilar Junction
Surgical Decision-Making and Treatment Options for Chiari
Todd Hillman, MD
Malformations in Children
Otolaryngologist
Ake Hansasuta, MD Pittsburgh Ear Associates
Neurosurgeon Co-Director of the Hearing and Balance Center
Ramathibodi Hospital Pittsburgh, Pennsylvania
Bangkok, Thailand Surgical Management of Petroclival Meningiomas
CyberKnife Radiosurgery for Spinal Neoplasms
Jose Hinojosa, MD, PhD
James S. Harrop, MD Servicio de Neurocirugìa Peditrica
Associate Professor of Neurologic and Orthopedic Surgery Hospital Universitario Infantil
Jefferson Medical College Madrid, Spain
Philadelphia, Pennsylvania Methods of Cranial Vault Reconstruction
Management of Injuries of the Cervical Spine and Spinal for Craniosynostosis
Cord
CONTRIBUTORS xxi

Girish K. Hiremath, MD Jonathan A. Hyam, MBBS, BSc, MRCS


Chief Resident Neurosurgery Specialist Registrar
Department of Neurosurgery Oxford Functional Neurosurgery
Cleveland Clinic John Radcliffe Hospital
Cleveland, Ohio Clinical Researcher
Fellow Department of Physiology, Anatomy, and Genetics
Minimally Invasive Spine Surgery Tutor in Basic Medical Sciences
William Beaumont Hospital Lincoln College
Royal Oak, Michigan University of Oxford
Minimally Invasive Posterior Cervical Foraminotomy Oxford, United Kingdom
and Microdiscectomy Functional Tractography, Diffusion Tensor Imaging,
Intraoperative Integration of Modalities,
Brian L. Hoh, MD, FACS, FAHA, FAANS and Neuronavigation
William Merz Associate Professor
Department of Neurosurgery Adriana G. Ioachimescu, MD, PhD
University of Florida Assistant Professor
Gainesville, Florida Medicine and Neurological Surgery
Management of Dissections of the Carotid and Vertebral Emory School of Medicine
Arteries Co-Director
Endovascular Treatment of Stroke Department of Neurological Surgery
Emory Neuroendocrine Pituitary Center
L. Nelson Hopkins, MD
Emory University Hospital
Professor of Neurosurgery and Radiology
Atlanta, Georgia
Director
Growth Hormone–Secreting Tumors
Toshiba Stroke Research Center
State University of New York at Buffalo Pascal M. Jabbour, MD
Buffalo, New York Assistant Professor
Endovascular Treatment of Intracranial Occlusive Disease Department of Neurosurgery
Thomas Jefferson University Hospital
Wesley Hsu, MD
Philadelphia, Pennsylvania
Assistant Professor
Endovascular Treatment of Cerebral Arteriovenous
Departments of Neurosurgery and Orthopedic Surgery
Malformations
Wake Forest Baptist Health
Winston-Salem, North Carolina Juan Jackson, MD
Transoral Approaches to the Cervical Spine Clinical Dosimetrist
Surgical Resection of Sacral Tumors The Johns Hopkins University
Baltimore, Maryland
Yin C. Hu, MD
Stereotactic Radiosurgery for Pituitary Adenomas
Fellow
Barrow Neurosurgical Associates George I. Jallo, MD
Phoenix, Arizona Professor of Neurosurgery, Pediatrics, and Oncology
Embolization of Tumors: Brain, Head, Neck, and Spine The Johns Hopkins University School of Medicine
Baltimore, Maryland
Jason H. Huang, MD
Surgical Management of Brain Stem Tumors in Adults
Associate Professor
Supratentorial Tumors in the Pediatric Population:
Department of Neurosurgery
Multidisciplinary Management
University of Rochester
Endoscopic Third Ventriculostomy
Rochester, New York
Peripheral Nerve Injury Ivo P. Janecka, MD, MBA, PhD
Director
Judy Huang, MD
Foundation for Surgical Research and Education
Associate Professor
New York, New York
Department of Neurosurgery
Anterior Midline Approaches to the Skull Base
Johns Hopkins Hospital
Baltimore, Maryland Mohsen Javadpour, MB, BCh, FRCS(SN)
Surgical Management of Posterior Communicating, Anterior Consultant Neurosurgeon
Choroidal, Carotid Bifurcation Aneurysms Walton Centre for Neurology and Neurosurgery
Liverpool, United Kingdom
Peter J. Hutchinson, BSc(Hons), MBBS, PhD, FRCS(Surg
Surgical Management of Cranial Dural Arteriovenous
Neurol) Fistulas
Senior Academy Fellow
Reader and Honorary Consultant Neurosurgeon
Academic Division of Neurosurgery
Addenbrooke’s Hospital and University of Cambridge
Cambridge, United Kingdom
Surgical Management of Chronic Subdural Hematoma in
Adults
xxii CONTRIBUTORS

Andrew Jea, MD M. Yashar S. Kalani, MD, PhD


Assistant Professor Neurosurgical Resident
Department of Neurosurgery Division of Neurological Surgery
Baylor College of Medicine Barrow Neurological Institute
Staff Neurosurgeon St. Joseph’s Hospital and Medical Center
Department of Pediatric Neurosurgery Phoenix, Arizona
Texas Children’s Hospital Posterior Lumbar Interbody Fusion
Houston, Texas
Hideyuki Kano, MD, PhD
Instrumentation and Stabilization of the Pediatric Spine:
Research Assistant Professor of Neurological Surgery
Technical Nuances and Age-Specific Considerations
University of Pittsburgh
Sunil Jeswani, MD Pittsburgh, Pennsylvania
Resident Vestibular Schwannomas: The Role of Stereotactic
Department of Neurosurgery Radiosurgery
Cedars–Sinai Medical Center
Silloo B. Kapadia, MD
Los Angeles, California
Professor
Spinal Infections: Vertebral Osteomyelitis and Spinal
Department of Pathology
Epidural Abscess
Penn State College of Medicine
Anterior Lumbar Interbody Fusion: Indications
Director, Surgical Pathology
and Techniques
Department of Anatomic Pathology
Surgical Management of Cerebrospinal Fluid Leakage after
Penn State
Spinal Surgery
Milton S. Hershey Medical Center
David H. Jho, MD, PhD Hershey, Pennsylvania
Neurosurgery Resident Anterior Midline Approaches to the Skull Base
Department of Neurosurgery
Michael G. Kaplitt, MD, PhD
Massachusetts General Hospital
Vice Chairman for Research
Harvard Medical School
Department of Neurological Surgery
Boston, Massachusetts
Weill Cornell Medical College
Endoscopic Endonasal Pituitary and Skull Base Surgery
New York, New York
Anterior Cervical Foraminotomy (Jho Procedure):
Molecular Therapies for Movement Disorders
Microscopic or Endoscopic
Christoph Kappus, MD
Diana H. Jho, MD, MPH
Department of Neurosurgery
Neurosurgery Resident
University of Marburg UKGM
Department of Neurosurgery
Marburg, Germany
Allegheny General Hospital
Arachnoid, Suprasellar, and Rathke’s Cleft Cysts
Pittsburgh, Pennsylvania
Endoscopic Endonasal Pituitary and Skull Base Surgery Eftychia Z. Kapsalaki, MD
Anterior Cervical Foraminotomy (Jho Procedure): Professor of Diagnostic Radiology
Microscopic or Endoscopic Department of Radiology
University Hospital of Larissa
Hae-Dong Jho, MD, PhD
University of Thessaly School of Medicine
Professor and Chairman
Larissa, Greece
Department of Neuroendoscopy
Mesencephalic Tractotomy and Anterolateral Cordotomy
Jho Institute, Allegheny General Hospital
for Intractable Pain
Pittsburgh, Pennsylvania
Endoscopic Endonasal Pituitary and Skull Base Surgery Yuval Karmon, MD
Anterior Cervical Foraminotomy (Jho Procedure): Department of Neurosurgery
Microscopic or Endoscopic State University of New York at Buffalo
Buffalo, New York
Bowen Jiang, MD
Endovascular Treatment of Intracranial Occlusive Disease
Stanford University
School of Medicine Amin B. Kassam, MD
Stanford, California Professor and Chairman
Radiation Therapy and Radiosurgery in the Management Department of Neurological Surgery
of Craniopharyngiomas University of Pittsburgh School of Medicine
Director
Tae-Young Jung, MD, PhD
Minimally Invasive Endoneurosurgery Center
Associate Professor
University of Pittsburgh Medical Center
Department of Neurosurgery
Pittsburgh, Pennsylvania
Chonnam National University Hwasun Hospital
Endoscopic Endonasal Approach for Craniopharyngiomas
Chonnam National University Medical School
Hwasun-Gun Jeonnam, Korea
Posterior Fossa Tumors in the Pediatric Population:
Multidisciplinary Management
CONTRIBUTORS xxiii

Sudhir Kathuria, MD, MBBS Douglas Kondziolka, MD, MSc, FRCSC


Assistant Professor Peter J. Jannetta Professor of Neurological Surgery
Department of Radiology Department of Neurological Surgery
Assistant Professor University of Pittsburgh
Department of Neurosurgery Pittsburgh, Pennsylvania
Johns Hopkins Hospital Vestibular Schwannomas: The Role of Stereotactic
Baltimore, Maryland Radiosurgery
Imaging Evaluation and Endovascular Treatment
Marcus C. Korinth, MD, PhD Professor Dr. med.
of Vasospasm
Department of Neurosurgery
Takeshi Kawase, MD, PhD Medizinisches Zentrum Stadteregion Aachen
Honorary Professor Aachen, Germany
Department of Neurosurgery Treatment Evolution in Management of Cervical Disc
Keio University School of Medicine Disease
Tokyo, Japan
Dietmar Krex, MD
Surgery for Trigeminal Neurinomas
Department of Neurosurgery
Alexander A. Khalessi, MD Carl Gustav Carus University Hospital
Co-Director of Neurovascular Surgery and Neurosurgical University of Technology
Director of NeuroCritical Care Dresden, Germany
Division of Neurological Surgery Surgical Management of Midline Anterior Skull Base
University of California, San Diego Meningiomas
San Diego, California
Mark D. Krieger, MD
Endovascular Treatment of Intracranial Occlusive Disease
Associate Professor
Kathleen Khu, MD Department of Neurological Surgery
Clinical Associate Professor University of Southern California
Section of Neurosurgery Los Angeles, California
Department of Neurosciences Prolactinomas
University of the Philippines–Philippine General Hospital
Kartik G. Krishnan, MD, PhD
Manila, Philippines
Department of Neurosurgery
Management of Adult Brachial Plexus Injuries
Center for Clinical Neurosciences
Daniel H. Kim, MD Johann Wolfgang Goethe University
Professor Frankfurt, Germany
Director, Spinal Neurosurgery and Reconstructive Management of Median Nerve Compression
Peripheral Nerve Surgery
Ajit A. Krishnaney, MD
Department of Neurosurgery
Staff
Baylor College of Medicine
Center for Spine Health
Houston, Texas
Department of Neurosurgery
Surgical Approaches to the Cervicothoracic Junction
Cleveland Clinic
Matthias Kirsch, PD Dr. med. Cleveland, Ohio
Department of Neurosurgery Management of Cervical Spondylotic Myelopathy
Carl Gustav Carus University Hospital
Maureen Lacy, PhD
Dresden, Germany
Associate Professor of Psychiatry, Behavioral Neurosciences,
Surgical Management of Midline Anterior Skull Base
and Surgery
Meningiomas
Department of Psychiatry
Riku Kivisaari, MD, PhD University of Chicago Medical Center
Neurosurgeon and Radiologist Chicago, Illinois
Department of Neurosurgery Surgical Management of Hydrocephalus in the Adult
Helsinki University Central Hospital
Santosh D. Lad, MS, MRSH
Helsinki, Finland
Senior Consultant Neurosurgeon
Surgical Management of Aneurysms of the Middle Cerebral
Department of Anesthesiology and Intensive Care
Artery
and Neurosurgery
Angelos G. Kolias, BM, MSc, MRCS Khoula Hospital
Academic Clinical Registrar in Neurosurgery Muscat, Oman
Academic Division of Neurosurgery Fungal Infections of the Central Nervous System
Addenbrooke’s Hospital and University of Cambridge
Jose Alberto Landeiro, MD, PhD
Cambridge, United Kingdom
Neurosurgery Clinic
Surgical Management of Chronic Subdural Hematoma
Hospital da Força Aérea do Galeão
in Adults
Rio de Janeiro, Brazil
Surgical Management of Tumors of the Foramen Magnum
xxiv CONTRIBUTORS

Frederick F. Lang, MD Elad I. Levy, MD


Professor Associate Professor
The University of Texas MD Anderson Cancer Center Department of Neurosurgery
Houston, Texas Associate Professor
Surgical Management of Cerebral Metastases Department of Radiology
State University of New York at Buffalo
Shih-Shan Lang, MD
Buffalo, New York
Resident
Endovascular Treatment of Intracranial Occlusive Disease
Department of Neurosurgery
University of Pennsylvania Robert E. Lieberson, MD
Philadelphia, Pennsylvania Assistant Professor of Neurosurgery
Surgical Management of Major Skull Defects and Potential Department of Neurosurgery
Complications Stanford University
Stanford, California
Françoise LaPierre, MD
CyberKnife Radiosurgery for Spinal Neoplasms
Professor Emeritus
Department of Neurosurgery Michael Lim, MD
Poitiers University Medical School Assistant Professor
Poitiers, France Department of Neurosurgery
Management of Cauda Equina Tumors Assistant Professor
Department of Oncology
Paul S. Larson, MD
The Johns Hopkins University
Associate Professor
Baltimore, Maryland
Department of Neurological Surgery
Stereotactic Radiosurgery for Trigeminal Neuralgia
University of California, San Francisco
Chief, Neurosurgery Ning Lin, MD
Surgical Section Clinical Fellow in Surgery
San Francisco VA Medical Center Department of Neurosurgery
San Francisco, California Brigham and Women’s Hospital
Deep Brain Stimulation for Intractable Psychiatric Illness Boston, Massachusetts
Management of Intracranial Aneurysms Caused by Infection
Michael T. Lawton, MD
Professor Göran Lind, MD
University of California, San Francisco Consultant Neurosurgeon
San Francisco, California Department of Neurosurgery
Surgical Management of Anterior Communicating Karolinska University Hospital
and Anterior Cerebral Artery Aneurysms Stockholm, Sweden
Retrogasserian Glycerol Rhizolysis in Trigeminal Neuralgia
Marco Lee, MD
Clinical Assistant Professor Bengt Linderoth, MD, PhD
Department of Neurosurgery Professor of Neurosurgery
Stanford University School of Medicine Karolinska Institutet
Stanford, California Stockholm, Sweden
Radiation Therapy and Radiosurgery in the Management Professor of Physiology
of Craniopharyngiomas Oklahoma University Health Sciences Center
Oklahoma City, Oklahoma
Martin Lehecka, MD, PhD
Retrogasserian Glycerol Rhizolysis in Trigeminal Neuralgia
Consultant Neurosurgeon
Spinal Cord Stimulation for Chronic Pain
Department of Neurosurgery
Helsinki University Central Hospital Timothy Lindley, MD, PhD
Helsinki, Finland Department of Neurosurgery
Surgical Management of Aneurysms of the Middle Cerebral University of Iowa
Artery Iowa City, Iowa
Craniovertebral Abnormalities and Their Neurosurgical
Allan Levi, MD, PhD
Management
Professor
Departments of Neurological Surgery, Orthopedics, Antoine Listrat, MD
and Rehabilitation Neurosurgeon
Chief of Neurospine Service Department of Pediatric Neurosurgery
Jackson Memorial Hospital University Hospital
University of Miami Poitiers, France
Miami, Florida Management of Cauda Equina Tumors
Management of Nerve Sheath Tumors Involving the Spine
CONTRIBUTORS xxv

Charles Y. Liu, MD, PhD Yi Lu, MD, PhD


Associate Professor Department of Neurosurgery
Department of Neurological Surgery Brigham and Women’s Hospital
University of Southern California Harvard Medical School
Keck School of Medicine Boston, Massachusetts
Los Angeles, California Lateral Lumbar Interbody Fusion: Indications and Techniques
Transcallosal Surgery of Lesions Affecting the Third
L. Dade Lunsford, MD
Ventricle: Basic Principles
Lars Leksell and Distinguished Professor of Neurological
James K. Liu, MD Surgery
Assistant Professor University of Pittsburgh Medical Center
Director of Skull Base and Pituitary Surgery Pittsburgh, Pennsylvania
Department of Neurological Surgery Vestibular Schwannomas: The Role of Stereotactic
University of Medicine and Dentistry of New Jersey Radiosurgery
New Jersey Medical School
M. Mason Macenski, PhD
Newark, New Jersey
Masonovations Medical Consulting
Prolactinomas
Minneapolis, Minnesota
Surgical Management of Tumors of the Jugular Foramen
Dynamic Stabilization of the Lumbar Spine: Indications
John C. Liu, MD and Techniques
Vice Chair Spine Surgery
Jaroslaw Maciaczyk, MD
Department of Neurosurgery
Department of General Neurosurgery
Cedars–Sinai Medical Center
University Clinic Medical Center
Los Angeles, California
Freiburg im Breisgau, Germany
Anterior Lumbar Interbody Fusion: Indications
Interstitial and LINAC-Radiosurgery for Brain Metastases
and Techniques
Joseph R. Madsen, MD
Giorgio Lo Russo, MD
Director
Chief Epilepsy Neurosurgeon
Epilepsy Surgery Program
Epilepsy Surgery Centre
Director
Niguarda Hospital
Neurodynamics Laboratory
Milan, Italy
Department of Neurosurgery
Multilobar Resection and Hemispherectomy in Epilepsy
Children’s Hospital Boston
Surgery
Associate Professor of Surgery
Christopher M. Loftus, MD, DHC(Hon), FACS Department of Surgery
Chairman Harvard Medical School
Department of Neurosurgery Boston, Massachusetts
Temple University Hospital Treatment of Intractable Epilepsy by Electrical Stimulation
Philadelphia, Pennsylvania of the Vagus Nerve
Surgical Management of Extracranial Carotid Artery Disease
Subu N. Magge, MD
Russell R. Lonser, MD Department of Neurosurgery
Chief Spine Center
Surgical Neurology Branch Lahey Clinic Medical Center
National Institute of Neurological Disorders and Stroke Burlington, Massachusetts
National Institutes of Health Thoracoscopic Sympathectomy for Hyperhidrosis
Bethesda, Maryland
Giulio Maira, MD
Surgical Management of Parasagittal and Convexity
Director
Meningiomas
Università Cattolica del Sacro Cuore
Neurovascular Decompression in Cranial Nerves V, VII, IX,
Institute of Neurosurgery
and X
Catholic University School of Medicine
Daniel C. Lu, MD, PhD Rome, Italy
Assistant Professor Surgical Management of Lesions of the Clivus
Department of Neurosurgery
Martijn J. A. Malessy, MD, PhD
University of California, Los Angeles
Department of Neurosurgery
Los Angeles, California
Leiden University Medical Center
Percutaneous Placement of Lumbar Pedicle Screws:
Leiden, The Netherlands
Indications and Techniques
Nerve-Grafting Procedures for Birth-Related Peripheral
Nerve Injuries
xxvi CONTRIBUTORS

David G. Malone, MD Paul McCormick, MD, MPH


Oklahoma Spine and Brain Institute Herbert and Linda Gallen Professor of Neurological
Tulsa, Oklahoma Surgery
Cervical Laminoplasty: Indications and Techniques Department of Neurosurgery
Columbia University College of Physicians and Surgeons
Allen Maniker, MD
New York, New York
Chief
Intradural Extramedullary Tumors
Department of Neurosurgery
Beth Israel Medical Center Michael W. McDermott, MD
New York, New York Professor in Residence of Neurological Surgery, Halperin
Management of Ulnar Nerve Compression Endowed Chair
Neurosurgical Director
Geoffrey T. Manley, MD, PhD
UCSF Gamma Knife® Radiosurgery Program
Professor and Vice Chairman
Vice Chairman
Department of Neurological Surgery
Department of Neurological Surgery
University of California,  San Francisco
University of California, San Francisco
Chief of Neurosurgery
San Francisco, California
Co-Director
Craniopharyngiomas
Brain and Spinal Injury Center (BASIC)
San Francisco General Hospital Cameron G. McDougall, MD, FRCSC
San Francisco, California Director of Endovascular Neurosurgery
Decompressive Craniectomy for Traumatic Brain Injury Barrow Neurological Institute
Management of Penetrating Brain Injury Phoenix, Arizona
Embolization of Tumors: Brain, Head, Neck, and Spine
Jotham Manwaring, BS, MD
Physician H. Maximilian Mehdorn, MD, PhD
Department of Neurosurgery Professor and Chairman
University of South Florida Department of Neurosurgery
Tampa, Florida University Hospital Schleswig-Holstein
Management of Pediatric Severe Traumatic Brain Injury Kiel, Germany
Surgical Navigation with Intraoperative Imaging: Special
Mitchell Martineau, MS
Operating Room Concepts
Oklahoma Spine and Brain Institute
Tulsa, Oklahoma Vivek A. Mehta, MD
Cervical Laminoplasty: Indications and Techniques Neurosurgery Resident
Department of Neurosurgery
Robert L. Martuza, MD
University of Southern California
Chief of Neurosurgery Service
Neurosurgery Resident
Department of Neurosurgery
Department of Neurosurgery
Massachusetts General Hospital
University of Southern California
William and Elizabeth Sweet Professor of Neuroscience
Los Angeles, California
Department of Surgery
Supratentorial Tumors in the Pediatric Population:
Harvard Medical School
Multidisciplinary Management
Boston, Massachusetts
Suboccipital Retrosigmoid Surgical Approach for Vestibular Arnold Menezes, MD
Schwannoma (Acoustic Neuroma) Professor and Vice Chairman
University of Iowa Carver College of Medicine
Marlon S. Mathews, MD
Professor of Neurosurgery
Resident
University of Iowa Hospitals and Clinics
Department of Neurological Surgery
Iowa City, Iowa
State University of New York at Buffalo
Craniovertebral Abnormalities and Their Neurosurgical
Buffalo, New York
Management
Neurosurgical Management of HIV-Related Focal Brain
Lesions Patrick Mertens, MD
Department of Neurosurgery
Nestoras Mathioudakis, BA, MD
Hôpital Neurologique
Clinical Fellow
Lyon, France
Department of Endocrinology and Metabolism
Surgery for Intractable Spasticity
The Johns Hopkins University School of Medicine
Baltimore, Maryland Frederic B. Meyer, MD
Medical Management of Hormone-Secreting Pituitary Chair, Neurosurgery
Tumors Department of Neurosurgery
Mayo Clinic
Rochester, Minnesota
Tumors in Eloquent Areas of Brain
CONTRIBUTORS xxvii

Matthew K. Mian, BSE Alim Mitha, MD, SM


Medical Student Assistant Professor
Division of Health Sciences and Technology Clinical Neurosciences and Radiology
Harvard Medical School University of Calgary
Department of Neurosurgery Cerebrovascular/Endovascular/Skull Base Neurosurgeon
Massachusetts General Hospital Department of Neurosurgery
Boston, Massachusetts Foothills Medical Centre
Temporal Lobe Operations in Intractable Epilepsy Calgary, Canada
Motor Cortex Stimulation for Intractable Facial Pain Surgical Management of Midbasilar and Lower Basilar
Aneurysms
Rajiv Midha, MD, MSc, FRCSC
Professor J. Mocco, MD, MS
Department of Neurosurgery Associate Professor
University of Calgary Department of Neurological Surgery
Calgary, Canada Vanderbilt University Medical Center
Management of Adult Brachial Plexus Injuries Nashville, Tennessee
Endovascular Treatment of Stroke
Diego San Millán Ruíz, MD
Neuroradiology Unit Abhay Moghekar, MD
Department of Diagnostic and Interventional Radiology Assistant Professor of Neurology
Hospital of Sion The Johns Hopkins Hospital
Sion, Switzerland Baltimore, Maryland
Adult Pseudotumor Cerebri Syndrome Adult Pseudotumor Cerebri Syndrome
Jonathan Miller, MD Jacques J. Morcos, MD, FRCS(Eng), FRCS(Ed)
Director, Functional and Restorative Neurosurgery Professor of Clinical Neurosurgery and Otolaryngology
Assistant Professor of Neurological Surgery Department of Neurological Surgery
Case School of Medicine University of Miami
University Hospitals Case Medical Center Miami, Florida
Cleveland, Ohio Far Lateral Approach and Transcondylar and Supracondylar
Management of Tumors of the Fourth Ventricle Extensions for Aneurysms of the Vertebrobasilar Junction
Neil R. Miller, MD Chad J. Morgan, MD
Professor of Ophthalmology, Neurology, and Neurosurgery Cox Monett Hospital
Frank B. Walsh Professor of Neuro-Ophthalmology Monett, Missouri
The Johns Hopkins University Percutaneous Stereotactic Rhizotomy in the Treatment
Baltimore, Maryland of Intractable Facial Pain
Adult Pseudotumor Cerebri Syndrome
John F. Morrison, MD, MS
Zaman Mirzadeh, MD, PhD Department of Surgery
Department of Neurological Surgery Boston University School of Medicine
University of California, San Francisco Boston, Massachusetts
San Francisco, California Thoracoscopic Sympathectomy for Hyperhidrosis
Surgical Management of Anterior Communicating
Henry Moyle, MD
and Anterior Cerebral Artery Aneurysms
Neurosurgery Associates
Ganpati Prasad Mishra, MS, MCh New York, New York
c/o Shrikant Rege, MD Endovascular Treatment of Extracranial Occlusive Disease
Fungal Infections of the Central Nervous System
Carrie R. Muh, MD, MSc
Symeon Missios, MD Pediatric Neurosurgical Associates
Resident Children’s Healthcare of Atlanta
Department of Neurosurgery Atlanta, Georgia
Dartmouth-Hitchcock Medical Center Growth Hormone–Secreting Tumors
Lebanon, New Hampshire
Debraj Mukherjee, MD, MPH
Ensuring Patient Safety in Surgery―First Do No Harm
Resident
James B. Mitchell, BS, MSN Department of Neurosurgery
Service Manager Cedars–Sinai Medical Center
Department of Pediatric Neurosurgery Los Angeles, California
Kaiser Permanente Spinal Infections: Vertebral Osteomyelitis and Spinal
Oakland, California Epidural Abscess
Surgical Management of Spinal Dysraphism
xxviii CONTRIBUTORS

Arya Nabavi, MD, MaHM, PhD Audumbar Shantaram Netalkar, MD


Professor Consultant Neurosurgeon
Vice Chairman Apollo Victor Hospitals
Department of Neurosurgery Goa Medical College
University-Hospital Schleswig-Holstein, Campus Kiel Goa, India
Kiel, Germany Fungal Infections of the Central Nervous System
Surgical Navigation with Intraoperative Imaging: Special
C. Benjamin Newman, MD
Operating Room Concepts
Resident Physician and Surgeon
Michael J. Nanaszko, BA Department of Neurosurgery
Department of Neurosurgery University of California, San Diego
Weill Cornell Medical College San Diego, California
New York, New York Embolization of Tumors: Brain, Head, Neck, and Spine
Molecular Therapies for Movement Disorders
Trang Nguyen, MD
Dipankar Nandi, MBBS, MChir, DPhil, FRCS Department of Neurosurgery
Honorary Senior Lecturer Johns Hopkins Hospital
Imperial College Baltimore, Maryland
Consultant Neurosurgeon Stereotactic Radiosurgery for Trigeminal Neuralgia
Charing Cross Hospital
Laura B. Ngwenya, MD, PhD
London, United Kingdom
Department of Neurological Surgery
Cervical Dystonia and Spasmodic Torticollis: Indications
The Ohio State University Medical Center
and Techniques
Columbus, Ohio
Raj Narayan, MD, FACS Cerebellar Tumors in Adults
Senior Vice President of Neurosurgery
Antonio Nicolato, MD
North Shore–LIJ Health System
Department of Neurosurgery
Chairman of Neurosurgery
University of Verona and University Hospital
North Shore University Hospital and LIJ Medical Center
Verona, Italy
Manhassett, New York
Stereotactic Radiosurgery Meningiomas
Management of Penetrating Injuries to the Spine
Mika Niemelä, MD, PhD
Sabareesh K. Natarajan, MD, MBBS, MS
Associate Professor
Department of Neurosurgery
Head of Section (Neurosurgical OR)
State University of New York at Buffalo
Head of Neurosurgery Research Group at Biomedicum
Buffalo, New York
Helsinki
Endovascular Treatment of Intracranial Occlusive Disease
Department of Neurosurgery
Edgar Nathal, MD, DMSc Helsinki University Central Hospital
Head Helsinki, Finland
Department of Neurosurgery Surgical Management of Aneurysms of the Middle Cerebral
Instituto Nacional de Ciencias Médicas y de la Nutrición Artery
Professor of Vascular Neurosurgery
Guido Nikkhah, MD, PhD
Division of Neurosurgery
Department of Stereotactic and Functional Neurosurgery
Instituto Nacional de Neurología y Neurocirugía
Hospital of the Albert-Ludwigs-University
Coordinator of Neurosurgery
Freiburg, Germany
Medical Sciences
Interstitial and LINAC-Radiosurgery for Brain Metastases
Medica Sur, Hospital and Foundation
Titular Professor Anitha Nimmagadda, MD
Vascular Neurosurgery Department of Neurological Surgery
Universidad Nacional Autónoma de México (UNAM) Rockford Health Physicians
Mexico, Distrito Federal, Mexico Rockford, Illinois
Surgical Treatment of Paraclinoid Aneurysms Endovascular Management of Spinal Vascular
Malformations
Vikram V. Nayar, MD
Department of Neurosurgery John K. Niparko, MD
Georgetown University Hospital Professor of Otolaryngology-Head and Neck Surgery
Washington, DC Director
Management of Unruptured Intracranial Aneurysms Otology, Neurotology,  Skull Base Surgery
Surgical Management of Cerebellar Stroke—Hemorrhage Director
and Infarction The Hearing Center
Director
The Listening Center
The Johns Hopkins Hospital
Baltimore, Maryland
Hearing Prosthetics: Surgical Techniques
CONTRIBUTORS xxix

Ajay Niranjan, MBBS, MCh Jeffrey G. Ojemann, MD


Associate Professor of Neurosurgery Professor
University of Pittsburgh Department of Neurological Surgery
Pittsburgh, Pennsylvania University of Washington
Vestibular Schwannomas: The Role of Stereotactic Center for Integrative Brain Research
Radiosurgery Seattle Children’s Research Institute
Seattle, Washington
Richard B. North, MD
Mapping, Disconnection, and Resective Surgery in Pediatric
Professor (retired)
Epilepsy
Departments of Neurosurgery, Anesthesiology, and Critical
Care Medicine Steven Ojemann, MD
The Johns Hopkins University School of Medicine Department of Neurological Surgery
Director University of California, San Francisco
Neuromodulation, Surgical Pain Management, and Surgical San Francisco, California
Spine Pain Program Novel Targets in Deep Brain Stimulation for Movement
Berman Brain and Spine Institute Disorders
Sinai Hospital
David O. Okonkwo, MD, PhD
Baltimore, Maryland
Chief of Neurotrauma
Spinal Cord Stimulation for Chronic Pain
University of Pittsburgh Medical Center
José María Núñez, MD, MSc Pittsburgh, Pennsylvania
Neurosurgeon Perioperative Management of Severe Traumatic Brain Injury
Epilepsy Clinic in Adults
Mexico General Hospital
Edward H. Oldfield, MD
Mexico City, Mexico
Professor of Neurosurgery and Internal Medicine
Presurgical Evaluation for Epilepsy Including Intracranial
University of Virginia
Electrodes
Charlottesville,Virginia
W. Jerry Oakes, MD Cushing’s Disease
Professor Management of Chiari Malformations and Syringomyelia
Departments of Surgery and Pediatrics
Brent O’Neill, MD
Division of Neurosurgery
Department of Neurosurgery
University of Alabama Health System
University of Colorado
Birmingham, Alabama
Aurora, Colorado
Surgical Decision-Making and Treatment Options for Chiari
Mapping, Disconnection, and Resective Surgery in Pediatric
Malformations in Children
Epilepsy
Management of Occult Spinal Dysraphism in Adults
Nelson M. Oyesiku, MD, PhD, FACS
Christopher S. Ogilvy, MD
Professor of Neurological Surgery
Director,  Endovascular and Operative Neurovascular
Director of the Laboratory of Molecular Neurosurgery
Surgery
and Biotechnology
Massachusetts General Hospital
Emory University
Robert G.  and A.  Jean Ojemann Professor of Neurosurgery
Atlanta, Georgia
Harvard Medical School
Growth Hormone–Secreting Tumors
Boston, Massachusetts
Management of Dissections of the Carotid and Vertebral Roberto Pallini, MD, PhD
Arteries Assistant Professor
Surgical Management of Intracerebral Hemorrhage Department of Neuroscience
Surgical Management of Cavernous Malformations Institute of Neurosurgery
of the Nervous System Catholic University School of Medicine
Rome, Italy
Kenji Ohata, MD, PhD
Surgical Management of Lesions of the Clivus
Professor and Chairman
Department of Neurosurgery Aditya S. Pandey, MD
Osaka City University Assistant Professor of Neurosurgery
Osaka, Japan Department of Neurosurgery
Orbitozygomatic Infratemporal Approach to Parasellar University of Michigan
Meningiomas Ann Arbor, Michigan
Endovascular Management of Intracranial Aneurysms
xxx CONTRIBUTORS

Dachling Pang, MD, FRCSC, FACS Sanjay J. Pawar, MBBS, MS, MCh
Professor of Pediatric Neurosurgery Neurosurgeon
Department of Neurological Surgery Department of Neurosurgery
University of California, Davis Khoula Hospital
Sacramento, California Muscat, Oman
Chief of Pediatric Neurosurgery Fungal Infections of the Central Nervous System
Department of Pediatric Neurosurgery
Richard Penn, MD
Kaiser Permanente Hospitals
Professor
Oakland, California
Department of Surgery
Surgical Management of Spinal Dysraphism
University of Chicago
Kyriakos Papadimitriou, MD Chicago, Illinois
Postdoctoral Fellow Surgical Management of Hydrocephalus in the Adult
Department of Neurosurgery
Erlick A. C. Pereira, MA, DM, BCh, MRCS(Eng)
Johns Hopkins Hospital
Neurosurgery Specialty Registrar
Baltimore, Maryland
Nuffield Department of Surgery
Surgical Management of Posterior Communicating, Anterior
University of Oxford
Choroidal, Carotid Bifurcation Aneurysms
Oxford, United Kingdom
José María Pascual, MD Functional Tractography, Diffusion Tensor Imaging,
c/o Ruth Prieto Intraoperative Integration of Modalities,
Surgical Management of Severe Closed Head Injury and Neuronavigation
in Adults Surgical Management of Extratemporal Lobe Epilepsy
Aman Patel, MD Mick J. Perez-Cruet, MD, MSc
Professor of Neurosurgery and Radiology Vice Chairman, Neurosurgery
Department of Neurosurgery Director, Spine Program
Mount Sinai School of Medicine Department of Neurosurgery
New York, New York William Beaumont Hospital
Endovascular Treatment of Extracranial Occlusive Disease Royal Oak, Michigan
Minimally Invasive Posterior Cervical Foraminotomy
Anoop P. Patel, MD and Microdiscectomy
Resident
Department of Neurosurgery Eric C. Peterson, MD
Massachusetts General Hospital Resident in Neurological Surgery
Boston, Massachusetts University of Washington
Surgical Management of Cavernous Malformations Seattle, Washington
of the Nervous System Far Lateral Approach and Transcondylar and Supracondylar
Extensions for Aneurysms of the Vertebrobasilar Junction
Toral R. Patel, MD
Neurosurgery Resident Mark A. Pichelmann, MD
Department of Neurosurgery Assistant Professor of Neurosurgery
Yale University School of Medicine Department of Neurosurgery
New Haven, Connecticut Mayo Clinic
Surgical Approaches to Lateral and Third Ventricular Tumors Rochester, Minnesota
Tumors in Eloquent Areas of Brain
Vincenzo Paterno, MD
Department of Neurosurgery Joseph M. Piepmeier, MD
International Neurosurgery Institute Nixdorff-German Professor of Neurosurgery
Hanover, Germany Vice Chair of Clinical Affairs, Neurosurgery
Arachnoid, Suprasellar, and Rathke’s Cleft Cysts Section Chief
Department of Neuro-Oncology
Rana Patir, MS, MCh
Director
Director
Department of Surgical Neuro-Oncology
Department of Neurosurgery
Yale School of Medicine
Max Super Speciality Hospital
New Haven, Connecticut
New Delhi, India
Surgical Approaches to Lateral and Third Ventricular
Management of Tuberculous Infections of the Nervous System
Tumors
Alexandra R. Paul, MD Marcus O. Pinsker, MD
Department of Neurosurgery
Department of Stereotactic and Functional Neurosurgery
Johns Hopkins Hospital
University Medical Center Freiburg
Baltimore, Maryland
Freiburg, Germany
Endovascular Management of Dural Arteriovenous Fistulas
Interstitial and LINAC-Radiosurgery for Brain Metastases
CONTRIBUTORS xxxi

Lawrence H. Pitts, MD Daniel M. Prevedello, MD


Professor of Neurosurgery Assistant Professor
University of California, San Francisco Department of Neurological Surgery
San Francisco, California University of Pittsburgh
Decompressive Craniectomy for Traumatic Brain Injury Pittsburgh, Pennsylvania
Endoscopic Endonasal Approach for Craniopharyngiomas
Rick J. Placide, MD
Chief of Orthopedic Surgery Ruth Prieto, MD
Spine Surgeon and Orthopaedic Surgeon Department of Neurosurgery
Chippenham Medical Center Clinico San Carlos University Hospital
Richmond,Virginia Madrid, Spain
Management of Cervical Spondylotic Myelopathy Surgical Management of Severe Closed Head Injury in Adults
Willem Pondaag, MD Alfredo Quiñones-Hinojosa, MD
Department of Neurosurgery Professor of Neurological Surgery and Oncology
Leiden University Medical Center Department of Neurosurgery
Leiden, The Netherlands The Johns Hopkins University
Nerve-Grafting Procedures for Birth-Related Peripheral Neuroscience and Cellular and Molecular Medicine
Nerve Injuries Director, Brain Tumor Surgery Program,  Johns Hopkins
Bayview
Kalmon Post, MD Director, Pituitary Surgery Program,  Johns Hopkins Hospital
Professor and Chairman
Baltimore, Maryland
Department of Neurosurgery
Transcranial Surgery for Pituitary Macroadenomas
Mount Sinai School of Medicine
Supraorbital Approach Variants for Intracranial Tumors
New York, New York
Multimodal Treatment of Orbital Tumors
Management of Spinal Cord Tumors and Arteriovenous
Management of Cerebrospinal Fluid Leaks
Malformations
Management of Suppurative Intracranial Infections
Matthew B. Potts, MD Leonidas M. Quintana, MD
Resident
Professor
Department of Neurological Surgery
Neurosurgical Department
University of California, San Francisco
Valparaíso University School of Medicine
San Francisco, California
Valparaíso, Chile
Decompressive Craniectomy for Traumatic Brain Injury
Surgical Treatment of Moyamoya Disease in Adults
Lars Poulsgaard, MD Scott Y. Rahimi, MD
Consultant Neurosurgeon
Assistant Professor
University Clinic of Neurosurgery
Department of Neurosurgery
The Neuroscience Center
Georgia Health Sciences University
University Hospital of Copenhagen, Rigshospitalet
Augusta, Georgia
Copenhagen, Denmark
Surgical Management of Terminal Basilar and Posterior
Translabyrinthine Approach to Vestibular Schwannomas
Cerebral Artery Aneurysms
Gustavo Pradilla, MD Rudy J. Rahme, MD
Resident
Postdoctoral Research Fellow
Department of Neurosurgery
Department of Neurological Surgery
The Johns Hopkins University School of Medicine
Northwestern University Feinberg School of Medicine
Baltimore, Maryland
Chicago, Illinois
Surgical Management of Infratentorial Arteriovenous
Endovascular Management of Spinal Vascular
Malformations
Malformations
Charles J. Prestigiacomo, MD, FACS Rodrigo Ramos-Zúñiga, MD, PhD
Associate Professor
Chairman
Department of Neurological Surgery
Department of Neurosciences
Associate Professor
Universidad de Guadalajara
Department of Radiology
Guadalajara, Mexico
New Jersey Medical School
Supraorbital Approach Variants for Intracranial Tumors
University of Medicine and Dentistry of New Jersey
Management of Neurocysticercosis
Research Professor
Department of Biomedical Engineering Nathan J. Ranalli, MD
New Jersey Institute of Technology Senior Resident
Newark, New Jersey Department of Neurosurgery
Endovascular Treatment of Head and Neck Bleeding University of Pennsylvania
Philadelphia, Pennsylvania
Management of Median Nerve Compression
xxxii CONTRIBUTORS

Shaan M. Raza, MD Philippe Rigoard, MD, PhD


Neurosurgery Resident Neurosurgeon
Department of Neurosurgery Department of Spine Neurosurgery
Johns Hopkins Hospital University Hospital
Baltimore, Maryland Poitiers, France
Supraorbital Approach Variants for Intracranial Tumors Management of Cauda Equina Tumors
Multimodal Treatment of Orbital Tumors
Jaakko Rinne, MD, PhD
Pablo F. Recinos, MD Associate Professor
Resident Department of Neurosurgery
Department of Neurosurgery University of Eastern Finland
The Johns Hopkins University School of Medicine Director
Baltimore, Maryland KUH Neurocenter
Transcranial Surgery for Pituitary Adenomas Kuopio University Hospital
Endoscopic Third Ventriculostomy Kuopio, Finland
Stereotactic Radiosurgery for Trigeminal Neuralgia Surgical Management of Aneurysms of the Middle Cerebral
Artery
Violette Renard Recinos, MD
Section Head Jon H. Robertson, MD
Pediatric Neurosurgical Oncology Professor and Chairman
Cleveland Clinic Foundation Department of Neurosurgery
Cleveland, Ohio University of Tennessee Health Science Center
Endoscopic Third Ventriculostomy Memphis, Tennessee
Transtemporal Approaches to Posterior Cranial Fossa
Shrikant Rege, MD
Neurologist Shimon Rochkind, MD
Tukoganj, South Indore Director
Fungal Infections of the Central Nervous System Division of Peripheral Nerve Reconstruction
Tel Aviv Sourasky Medical Center
Thomas Reithmeier, MD
Tel Aviv, Israel
Department of Neurosurgery
Management of Adult Brachial Plexus Injuries
University of Cologne
Management of Thoracic Outlet Syndrome
Cologne, Germany
Interstitial and LINAC-Radiosurgery of Brain Metastases Jack P. Rock, MD
Residency Program Director
Katherine Relyea, MS
Department of Neurosurgery
Medical Illustrator
Henry Ford Hospital
Department of Pediatric Neurosurgery
Detroit, Michigan
Baylor College of Medicine
Surgical Management of Posterior Fossa Meningiomas
Houston, Texas
Instrumentation and Stabilization of the Pediatric Spine: Rossana Romani, MD
Technical Nuances and Age-Specific Considerations Department of Neurosurgery
Helsinki University Central Hospital
Daniel Resnick, MD, MS
Helsinki, Finland
Associate Professor and Vice Chairman
Surgical Management of Aneurysms of the Middle Cerebral
Department of Neurosurgery
Artery
University of Wisconsin
Madison, Wisconsin Guy Rosenthal, MD
Transforaminal Lumbar Interbody Fusion: Indications Department of Neurosurgery
and Techniques Hadassah-Hebrew University Medical Center
Jerusalem, Israel
Daniele Rigamonti, MD, FACS
Department of Neurosurgery
Professor of Neurosurgery,  Oncology,  and Radiation
San Francisco General Hospital
Departments of Oncology and Molecular Radiation
University of California, San Francisco
Sciences
San Francisco, California
Director,  Stereotactic Radiosurgery
Management of Penetrating Traumatic Brain Injury
Director,  Hydrocephalus and Pseudotumor Cerebri
Program Robert H. Rosenwasser, MD, FACS, FAHA
Departments of Neurosurgery and Radiation Oncology Professor and Chairman
The Johns Hopkins School of Medicine Department of Neurological Surgery
Baltimore, Maryland Professor
Adult Pseudotumor Cerebri Syndrome Department of Radiology
Stereotactic Radiosurgery for Pituitary Adenomas Thomas Jefferson University
Philadelphia, Pennsylvania
Endovascular Treatment of Cerebral Arteriovenous
Malformations
CONTRIBUTORS xxxiii

Nathan C. Rowland, MD, PhD Amar Saxena, MBBS, MS, MCh(Neurosurgery), FRCS(Eng),
Resident FRCS(Surg Neurol)
Department of Neurological Surgery Chairman
University of California, San Francisco Higher Surgical Committee in Neurosurgery
San Francisco, California for West Midlands
Corpus Callosotomy: Indications and Techniques University Hospitals Coventry and Warwickshire
Coventry, United Kingdom
James T. Rutka, MD, PhD, FRCSC
Disc Replacement Technologies in the Cervical and Lumbar
Professor
Spine
Department of Surgery
Division Neurosurgery Gabriele Schackert, Professor Dr. med.
University of Toronto Department of Neurosurgery
Toronto, Canada University Hospital
Posterior Fossa Tumors in the Pediatric Population: Dresden, Germany
Multidisciplinary Management Surgical Management of Midline Anterior Skull Base
Supratentorial Tumors in the Pediatric Population: Meningiomas
Multidisciplinary Management
Uta Schick, MD, PhD, Priv.-Doz. Dr. med.
Samuel Ryu, MD Department of Neurosurgery
Radiation Oncologist University of Heidelberg
Henry Ford Health System Heidelberg, Germany
Detroit, Michigan Surgical Approaches to the Orbit
Surgical Management of Posterior Fossa Meningiomas
Thomas A. Schildhauer, MD, PhD
Francesco Sala, MD BG-Kliniken Bergmannsheil
Assistant Professor of Neurosurgery Ruhr-Universitat
Department of Neurological Sciences and Vision Bochum, Germany
University Hospital Management of Sacral Fractures
Verona, Italy
Intraoperative Neurophysiology: A Tool to Prevent and/or Alexandra Schmidek, MD
Document Intraoperative Injury to the Nervous System Division of Plastic Surgery
Beth Israel Deaconess Medical Center
Roberto Salvatori, MD Harvard Medical School
Associate Professor Boston, Massachusetts
Department of Medicine Principles of Scalp Surgery and Surgical Management
The Johns Hopkins University of Major Defects of Scalp
Baltimore, Maryland
Medical Management of Hormone-Secreting Pituitary Tumors Henry H. Schmidek, MD, FACS†
Stereotactic Radiosurgery for Pituitary Adenomas Formerly Visiting Professor in Neurosurgery
Nuffield Department of Surgery
Kari Sammalkorpi, MD Lecturer in Neuroscience
c/o Göran Blomstedt, MD Balliol College
Management of Infections After Craniotomy Oxford University
Oxford, England
Nader Sanai, MD
Management of Suppurative Intracranial Infections
Director, Division of Neurosurgical Oncology
Director, Barrow Brain Tumor Research Center Meic H. Schmidt, MD
Barrow Neurological Institute Chief
St. Joseph’s Hospital and Medical Center Division of Spine Surgery
Phoenix, Arizona Associate Professor of Neurosurgery
Surgical Management of Midbasilar and Lower Basilar Director, Spinal Oncology Service, Huntsman Cancer
Aneurysms Institute
Director, Neurosurgery Spine Fellowship
Thomas Santarius, MD, PhD, FRCS(Surg Neurol)
Department of Neurosurgery
Specialist Registrar in Neurosurgery
University of Utah
Academic Division of Neurosurgery
Salt Lake City, Utah
Addenbrooke’s Hospital and University of Cambridge
Lumbar Microdiscectomy: Indications and Techniques
Cambridge, United Kingdom
Surgical Management of Chronic Subdural Hematoma Paul Schmitt, MD
in Adults New Jersey Medical School
University of Medicine and Dentistry of New Jersey
Newark, New Jersey
Endovascular Treatment of Head and Neck Bleeding

†Deceased.
xxxiv CONTRIBUTORS

Johannes Schramm, MD Patrick Senatus, MD, PhD


Professor and Chairman Assistant Professor
Department of Neurosurgery Department of Neurosurgery
University of Bonn University of Connecticut
Bonn, Germany Farmington, Connecticut
Mapping, Disconnection, and Resective Surgery in Pediatric Deep Brain Stimulation for Pain
Epilepsy
Amjad Shad, MBBS, FRCS(Ed), FRCS(SN)MR
Joseph Schwab, MD Department of Neurosurgery
Massachusetts General Hospital Radcliffe Infirmary
Boston, Massachusetts Oxford, United Kingdom
Management of Primary Malignant Tumors of the Osseous Disc Replacement Technologies in the Cervical and Lumbar
Spine Spine
Theodore H. Schwartz, MD, FACS Ali Shaibani, MD
Professor of Neurosurgery, Otorhinolaryngology, Neurology, Associate Professor in Radiology and Neurological Surgery
and Neuroscience Northwestern University Feinberg School of Medicine
Weill Cornell Medical College Chicago, Illinois
New York Presbyterian Hospital Endovascular Management of Spinal Vascular
New York, New York Malformations
Endoscopic Approach to Intraventricular Brain Tumors
Manish S. Sharma, MBBS, MS, MCh
Patrick Schweder, MD Fellow
Department of Neurosurgery Department of Neurological Surgery
The Royal Melbourne Hospital Mayo Clinic
Parkville, Australia Rochester, Minnesota
Cingulotomy for Intractable Psychiatric Illness Assistant Professor
Department of Neurosurgery
Daniel M. Sciubba, BS, MD
All India Institute of Medical Sciences
Assistant Professor of Neurosurgery, Oncology,
New Delhi, India
and Orthopaedic Surgery
Nerve Transfers: Indications and Techniques
Director of Spine Research
Department of Neurosurgery Rewati Raman Sharma, MBBS, MS(Neurosurgery),
The Johns Hopkins Institutions DNB(Neurosurgery)
Baltimore, Maryland Senior Consultant Neurosurgeon
Management of Injuries of the Cervical Spine and Spinal National Neurosurgical Centre
Cord Department of Neurosurgery
Management of Degenerative Scoliosis Chairman
Surgery for Metastatic Spine Disease Hospital Staff Development: CME, RESEARCH,
CPD activities
R. Michael Scott, MD
Khoula Hospital
Professor of Surgery (Neurosurgery)
Senior Consultant Neurosurgeon
Harvard Medical School
Department of Neurosurgery
Neurosurgeon-in-Chief
Al Raffah Hospital
The Children’s Hospital Boston
Senior Consultant Neurosurgeon
Boston, Massachusetts
Department of Neurosurgery
Revascularization Techniques in Pediatric Cerebrovascular
Muscat Private Hospital
Disorders
Muscat, Oman
Raymond F. Sekula, Jr., MD Fungal Infections of the Central Nervous System
Surgical Director
Sameer A. Sheth, MD, PhD
Microvascular and Skull Base Neurosurgery Program
Resident
and the Cranial Nerve Disorders Program
Department of Neurosurgery
Department of Neurosurgery
Massachusetts General Hospital
UPMC Hamot
Boston, Massachusetts
Associate Professor
Temporal Lobe Operations in Intractable Epilepsy
Co-Director, Center for Cranial Nerve Disorders
Motor Cortex Stimulation for Intractable Facial Pain
Director, Chiari Clinic
Allegheny Neuroscience Institute Alexander Y. Shin, MD
Drexel University College of Medicine Professor of Orthopedic Surgery
Pittsburgh, Pennsylvania Department of Orthopedic Surgery
Surgical Management of Petroclival Meningiomas Mayo Clinic College of Medicine
Management of Cranial Nerve Injuries Rochester, Minnesota
Nerve Transfers: Indications and Techniques
CONTRIBUTORS xxxv

Ali Shirzadi, MD Edward Smith, MD


Senior Resident, Neurological Surgery Residency Program Staff Neurosurgeon
Department of Neurosurgery Department of Neurosurgery
Cedars–Sinai Medical Center Children’s Hospital Boston
Los Angeles, California Boston, Massachusetts
Spinal Infections: Vertebral Osteomyelitis and Spinal Revascularization Techniques in Pediatric Cerebrovascular
Epidural Abscess Disorders
Surgical Management of Cerebrospinal Fluid Leakage after
Joseph R. Smith, MD, FACS
Spinal Surgery
Professor Emeritus
Adnan H. Siddiqui, MD, PhD Department of Neurosurgery
Assistant Professor of Neurosurgery Medical College of Georgia
Assistant Professor of Radiology Augusta, Georgia
Director of Neuroendovascular Critical Care Mesencephalic Tractotomy and Anterolateral Cordotomy
Director of Neurosurgical Research for Intractable Pain
Department of Neurosurgery
Patricia Smith, MD
State University of New York at Buffalo
Postdoctoral Research Fellow
Buffalo, New York
Department of Neurosurgery
Endovascular Treatment of Intracranial Occlusive Disease
Strong Hospital
Roberto Leal Silveira, MD, PhD University of Rochester Medical Center
Neurosurgeon in Chief Rochester, New York
Department of Neurosurgery Peripheral Nerve Injury
Hospital Madre Teresa
Matthew Smyth, MD
Belo Horizonte, United Kingdom
Associate Professor of Neurosurgery and Pediatrics
Surgical Management of Tumors of the Foramen Magnum
Department of Neurological Surgery
Nathan E. Simmons, MD Washington University
Assistant Professor of Neurosurgery Director, Pediatric Epilepsy Surgery Program
Dartmouth-Hitchcock Medical Center Neurosurgeon, Craniofacial Surgery Program
Lebanon, New Hampshire St. Louis Children’s Hospital
Surgical Techniques in the Management of Thoracic Disc St. Louis, Missouri
Herniations Mapping, Disconnection, and Resective Surgery in Pediatric
Epilepsy
Marc Sindou, MD, DSc
Professor of Neurosurgery Domenico Solari, MD
University Claude Bernard de Lyon Department of Neurological Sciences
Chairman Università degli Studi di Napoli Federico II
Department of Neurosurgery Naples, Italy
Hôpital Neurologique P. Wertheimer PH. D Endoscopic Endonasal Approach for Craniopharyngiomas
Neurophysiology
David Solomon, MD, PhD
Lyon, France
Assistant Professor of Neurology and Otolaryngology—
Surgery for Intractable Spasticity
Head and Neck Surgery
Marco Sinisi, MD Department of Neurology
Consultant Neurosurgeon Johns Hopkins Hospital
Peripheral Nerve Injury Unit Baltimore, Maryland
Royal National Orthopaedic Hospital Adult Pseudotumor Cerebri Syndrome
Honorary Senior Lecturer
Adam M. Sonabend, MD
Department of Nerve Surgery
Department of Neurological Surgery
Imperial College of London
Columbia University Medical Center
London, United Kingdom
New York, New York
Management of Entrapment Neuropathies
Peripheral Nerve Injury
Timothy Siu, MBBS, FRACS, PhD
Clinical Senior Lecturer
Australian School of Advanced Medicine
Macquarie University
Sydney, Australia
Surgical Management of Cerebral Metastases
xxxvi CONTRIBUTORS

Mark M. Souweidane, MD Philip A. Starr, MD, PhD


Vice Chairman and Professor Associate Professor of Neurosurgery
Director University of California, San Francisco
Pediatric Neurosurgery San Francisco, California
Department of Neurological Surgery Deep Brain Stimulation for Intractable Psychiatric Illness
Weill Cornell Medical College
Ladislau Steiner, MD, PhD
Associate Attending Neurosurgeon
Professor
Department of Pediatric Neurosurgery
Lars Leksell Center for Gamma Surgery
New York Presbyterian Hospital
Professor of Neurosurgery and Radiology
Associate Attending Surgeon
University of Virginia
Department of Pediatric Neurosurgery
Charlottesville,Virginia
Memorial Hospital for Cancer and Allied Diseases
Gamma Knife Surgery for Cerebral Vascular Malformations
Assistant Attending Orthopedic Surgeon
and Tumors
Department of Neurosurgery
Gamma Surgery for Functional Disorders
Hospital for Special Surgery
New York, New York Michael P. Steinmetz, MD
Endoscopic Approach to Intraventricular Brain Tumors Chairman, Department of Neuroscience
MetroHealth Medical Center
Edgardo Spagnuolo, MD
Associate Professor
Assistant Professor
Case Western Reserve University School of Medicine
Chief of Neurosurgical Department
Cleveland, Ohio
Surgical Department Teaching Unit
Management of Cervical Spondylotic Myelopathy
School of Medicine
Universidad de la República Shirley I. Stiver, MD, PhD
Maciel Hospital Assistant Professor of Neurological Surgery
Montevideo, Uruguay Principal Investigator, Brain and Spinal Injury Center
Chief of Neurosurgical Department University of California, San Francisco
Neurosurgical Departments of Private Institutions San Francisco, California
Montevideo, Uruguay Decompressive Craniectomy for Traumatic Brain Injury
Chief of Vascular Committee, Southern Chapter Management of Skull Base Trauma
Vascular Committee
Federación Latinoamericana de Neurocirugía Prem Subramanian, MD, PhD
Montevideo, Uruguay Associate Professor of Ophthalmology, Neurology,
Surgical Management of Cerebral Arteriovenous and Neurosurgery
Malformations Wilmer Eye Institute
The Johns Hopkins University School of Medicine
Robert F. Spetzler, MD Baltimore, Maryland
Director and J. N. Harber Chair of Neurological Surgery Associate Professor of Surgery
Division of Neurological Surgery Division of Ophthalmology
Barrow Neurological Institute Uniformed Services University of the Health Sciences
Phoenix, Arizona Bethesda, Maryland
Professor Multimodal Treatment of Orbital Tumors
Department of Surgery Adult Pseudotumor Cerebri Syndrome
Section of Neurosurgery
University of Arizona College of Medicine Michael E. Sughrue, MD
Tucson, Arizona Department of Neurological Surgery
Surgical Management of Midbasilar and Lower Basilar University of California, San Francisco
Aneurysms San Francisco, California
Craniopharyngiomas
Robert J. Spinner, MD Decompressive Craniectomy for Traumatic Brain Injury
Professor
Departments of Neurologic Surgery, Orthopedics, Ian Suk, BScBMC, CMI
and Anatomy Associate Professor of Neurosurgery and Art as Applied
Mayo Clinic to Medicine
Rochester, Minnesota Department of Neurosurgery
Nerve Transfers: Indications and Techniques Johns Hopkins Hospital
Baltimore, Maryland
Andreas M. Stark, MD Posterior Lumbar Fusion by Open Technique: Indications
Department of Neurosurgery and Techniques
Universitätsklinikum Schleswig-Holstein, Campus Kiel
Kiel, Germany
Surgical Navigation with Intraoperative Imaging: Special
Operating Room Concepts
CONTRIBUTORS xxxvii

Daniel Q. Sun, MD Nicholas Theodore, MD, FAANS, FACS


Department of Neurosurgery Chief, Spine Section
The Johns Hopkins University School of Medicine Division of Neurological Surgery
Baltimore, Maryland Barrow Neurological Institute
Stereotactic Radiosurgery for Pituitary Adenomas Phoenix, Arizona
Clinical Professor
Ulrich Sure, MD
Department of Surgery
Neurosurgeon
Creighton University School of Medicine
Department of Neurosurgery
Omaha, Nebraska
Philipps University
Posterior Lumbar Interbody Fusion
Marburg, Germany
Surgical Management of Aneurysms of the Vertebral Philip V. Theodosopoulos, MD
and Posterior Inferior Cerebellar Artery Complex Associate Professor
Residency Program Director
Oszkar Szentirmai, MD
Department of Neurosurgery
Chief Resident
University of Cincinnati
Department of Neurosurgery
Cincinnati, Ohio
University of Colorado
Craniopharyngiomas
Aurora, Colorado
Novel Targets in Deep Brain Stimulation for Movement B. Gregory Thompson, Jr., MD
Disorders Professor and Vice-Chair
Department of Neurosurgery
Alexander Taghva, MD
University of Michigan
Department of Neurological Surgery
Ann Arbor, Michigan
University of Southern California
Endovascular Management of Intracranial Aneurysms
Keck School of Medicine
Los Angeles, California Wuttipong Tirakotai, MD, MSc
Transcallosal Surgery of Lesions Affecting the Third Doctor
Ventricle: Basic Principles Department of Neurosurgery
Prasat Neurological Institute
Giuseppe Talamonti, MD
Bangkok, Thailand
Department of Neurosurgery
Arachnoid, Suprasellar, and Rathke’s Cleft Cysts
Niguarda Ca'Granda Hospital
Surgical Management of Aneurysms of the Vertebral
Milan, Italy
and Posterior Inferior Artery Complex
Management of Traumatic Intracranial Aneurysms
Stavropoula I. Tjoumakaris, BS, MD
Rafael J. Tamargo, MD, FACS Instructor
Walter E. Dandy Professor of Neurosurgery
Department of Neurosurgery
Director, Division of Cerebrovascular Neurosurgery
Thomas Jefferson University Hospital
Professor of Neurosurgery and Otolaryngology
Philadelphia, Pennsylvania
Vice Chairman
Endovascular Treatment of Cerebral Arteriovenous
Department of Neurosurgery
Malformations
Neurosurgery Co-Director
Neurosciences Critical Care Unit James H. Tonsgard, MD
Department of Neurosurgery Associate Professor
Johns Hopkins Hospital Department of Pediatrics and Neurology
Baltimore, Maryland Director
Surgical Management of Infratentorial Arteriovenous Neurofibromatosis Program
Malformations The University of Chicago
Chicago, Illinois
Richard J. Teff, MD
Surgical Management of Neurofibromatosis Types 1 and 2
Neurological Surgeon
Department of Surgery David Trejo, MD
San Antonio Military Medical Center Unit of Stereotactic, Functional Neurosurgery
San Antonio, Texas and Radiosurgery
Management of Penetrating and Blast Injuries Hospital General de México
of the Nervous System Mexico City, Mexico
Presurgical Evaluation for Epilepsy Including Intracranial
John M. Tew, Jr., MD
Electrodes
The Neuroscience Institute
University of Cincinnati College of Medicine Michael Trippel, MD, Dipl.-Ing.
and the Mayfield Clinic Stereotactic Neurosurgery
Cincinnati, Ohio University Hospital
Percutaneous Stereotactic Rhizotomy in the Treatment Freiburg, Germany
of Intractable Facial Pain Interstitial and LINAC-Radiosurgery for Brain Metastases
xxxviii CONTRIBUTORS

R. Shane Tubbs, MS, PA-C, PhD Gregory J. Velat, MD


Associate Professor Clinical Lecturer
Departments of Cell Biology and Surgery Department of Neurological Surgery
Division of Neurosurgery University of Florida
University of Alabama at Birmingham Gainesville, Florida
Director, Anatomical Donor Program/Gross Anatomy Management of Dissections of the Carotid and Vertebral
Laboratory Arteries
University of Alabama at Birmingham School of Medicine Endovascular Treatment of Stroke
Director of Research in Pediatric Neurosurgery
Angela Verlicchi, MD
Children’s Hospital of Alabama
Neurologist
Birmingham, Alabama
Free University of Neuroscience Anemos
Surgical Decision-Making and Treatment Options for Chiari
Reggio Emilia, Italy
Malformations in Children
Stereotactic Radiosurgery for Meningiomas
Management of Occult Spinal Dysraphism in Adults
Frank D. Vrionis, MD, MPH, PhD
Luis M. Tumialan, MD, LCDR MC(DMO) USN
Senior Member and Director, Spinal and Skull Base
Department of Neurosurgery
Oncology
Naval Medical Center San Diego
Department of Neuro-Oncology
San Diego, California
H. Lee Moffitt Cancer Center
Minimally Invasive Lumbar Microdiscectomy: Indications
Professor of Neurosurgery, Orthopaedics, and Oncology
and Techniques
Department of Neurosurgery
Andreas Unterberg, MD, PhD University of South Florida
Professor of Neurosurgery Tampa, Florida
Universitätsklinikum Heidelberg Transtemporal Approaches to Posterior Cranial Fossa
Neurochirurgische Universitätsklinik
Michel Wager, MD, PhD
Heidelberg, Germany
Professor of Neurosurgery
Surgical Approaches to the Orbit
Department of Neurological Surgery
Michael S. Vaphiades, DO University Hospital
Professor Poitiers, France
Department of Ophthalmology Management of Cauda Equina Tumors
University of Alabama at Birmingham
M. Christopher Wallace, MD, FACS, FRCSC
Birmingham, Alabama
Professor
Multimodal Assessment of Pituitary and Parasellar Lesions
Department of Neurosurgery
T. Brooks Vaughan, MD University of Toronto
Assistant Professor Toronto, Canada
Department of Medicine and Pediatrics Surgical Management of Cranial Dural Arteriovenous
The University of Alabama at Birmingham Fistulas
Birmingham, Alabama
Gary S. Wand, MD
Multimodal Assessment of Pituitary and Parasellar Lesions
Professor of Medicine and Psychiatry
Anand Veeravagu, MD The Johns Hopkins University School of Medicine
Stanford University Baltimore, Maryland
School of Medicine Multimodal Assessment of Pituitary and Parasellar Lesions
Stanford, California
Benjamin C. Warf, MD
Radiation Therapy and Radiosurgery in the Management
Department of Neurosurgery
of Craniopharyngiomas
Children’s Hospital Boston/Harvard Medical School
Ana Luisa Velasco, MD, PhD Boston, Massachusetts
Head of Epilepsy Clinic Methods for Cerebrospinal Fluid Diversion in Pediatric
Functional Neurosurgery Unit Hydrocephalus: From Shunt to Scope
General Hospital of Mexico
Michael F. Waters, MD, PhD
Mexico City, Mexico
Assistant Professor
Presurgical Evaluation for Epilepsy including Intracranial
Departments of Neurology and Neuroscience
Electrodes
Stroke Program Director
Francisco Velasco, MD University of Florida
Senior Investigator Gainesville, Florida
Department of Neurology and Neurosurgery Endovascular Treatment of Stroke
General Hospital of Mexico
Mexico City, Mexico
Presurgical Evaluation for Epilepsy including Intracranial
Electrodes
CONTRIBUTORS xxxix

Joseph Watson, MD Jean-Paul Wolinsky, MD


Associate Professor Associate Professor of Neurosurgery and Oncology
Department of Neurosurgery Department of Neurosurgery
Virginia Commonwealth University The Johns Hopkins University
Director Inova Regional Neurosurgery Service Baltimore, Maryland
Department of Neuroscience Transoral Approach to the Cervical Spine
Inova Health System Atlantoaxial Instability and Stabilization
Falls Church,Virginia
Judith M. Wong, MD
Cushing’s Disease
Department of Neurosurgery
Martin H. Weiss, MD Brigham and Women’s Hospital
Professor of Neurological Surgery Harvard Medical School
University of Southern California Boston, Massachusetts
Los Angeles, California Lateral Lumbar Interbody Fusion: Indications
Prolactinomas and Techniques
Nirit Weiss, MD Shaun Xavier, MD
Department of Neurosurgery New York Hospital for Joint Diseases
Mount Sinai Hospital New York, New York
New York, New York Management of Degenerative Lumbar Stenosis
Management of Spinal Cord Tumors and Arteriovenous and Spondylolisthesis
Malformations
Bakhtiar Yamini, MD
William Welch, MD, FACS, FICS Assistant Professor of Surgery
Department of Neurosurgery University of Chicago Medical Center
University of Pennsylvania Chicago, Illinois
Chief of Neurosurgery Surgical Management of Neurofibromatosis Types 1 and 2
Pennsylvania Hospital
Claudio Yampolsky, MD
Philadelphia, Pennsylvania
Department of Neurosurgery
Dynamic Stabilization of the Lumbar Spine: Indications
Muñiz Infectious Diseases Hospital
and Techniques
Buenos Aires, Argentina
J. Kent Werner, Jr., BS Management of Shunt Infections
MD, PhD Candidate
Michael J. Yaremchuk, MD, FACS
Department of Neuroscience
Craniofacial Surgery Fellow
The Johns Hopkins University School of Medicine
Professor of Surgery
Baltimore, Maryland
Harvard School of Medicine
Ensign
Assistant in Surgery
Medical Corps, United States Navy
Plastic and Reconstructive Surgery
Bethesda, Maryland
Director, Craniofacial Surgery
Management of Penetrating Brain Injury
Plastic and Reconstructive Surgery
Louis A. Whitworth, MD Massachusetts General Hospital
Assistant Professor in Neurosurgery Boston, Massachusetts
Director of Functional and Stereotactic Neurosurgery Principles of Scalp Surgery and Surgical Management
University of Texas Southwestern Medical Center at Dallas of Major Defects of Scalp
Dallas, Texas
Reza Yassari, MD, MS
Deep Brain Stimulation in Movement Disorders: Parkinson’s
Section of Neurosurgery
Disease, Essential Tremor, and Dystonia
Department of Surgery
Christopher Winfree, MD, FACS University of Chicago Hospital
Assistant Professor of Neurological Surgery Chicago, Illinois
Department of Neurological Surgery Atlantoaxial Instability and Stabilization
Neurological Institute Neurologic Problems of the Spine in Achondroplasia
Columbia University Medical Center
Chun-Po Yen, MD
New York, New York
Department of Neurological Surgery
Peripheral Nerve Injury
University of Virginia
Timothy F. Witham, BS, MD Charlottesville,Virginia
Assistant Professor of Neurosurgery Gamma Knife Surgery for Cerebral Vascular Malformations
Department of Neurosurgery and Tumors
The Johns Hopkins University School of Medicine Gamma Surgery for Functional Disorders
Baltimore, Maryland
Management of Penetrating Injuries to the Spine
xl CONTRIBUTORS

John Yianni, MD, MBBS, BSc, FRCS Marco Zenteno, MD


Department of Neurosurgery Department of Neurological Endovascular  Therapy
John Radcliffe Hospital Instituto Nacional de Neurología y Neurocirugía
Oxford, United Kingdom Universidad Nacional Autonoma de Mexico
Cervical Dystonia and Spasmodic Torticollis: Indications Comprehensive Stroke Center,  Hospital
and Techniques Mexico City,  Mexico
Role of Gamma Knife Radiosurgery in the Management
Alexander K. Yu, MD, MSBE, MS of Arteriovenous Malformations
Chief Resident
Department of Neurosurgery Mehmet Zileli, MD
Allegheny General Hospital Professor of Neurosurgery
Pittsburgh, Pennsylvania Department of Neurosurgery
Surgical Management of Petroclival Meningiomas Ege University Faculty of Medicine
Management of Cranial Nerve Injuries Izmir, Turkey
Stabilization of the Subaxial Cervical Spine (C3–C7)
Eric L. Zager, MD
Professor of Neurosurgery Alexandros D. Zouzias, MD
University of Pennsylvania Resident
Philadelphia, Pennsylvania Neurological Institute of New Jersey
Management of Median Nerve Compression Newark, New Jersey
Management of Thoracic Outlet Syndrome Endovascular Treatment of Head and Neck Bleeding
Bruno Zanotti, MD
Neurosurgeon and Neurologist
Unit of Neurosurgery
Azienda Ospedaliero-Universitaria S.M. della Misericordia
Udine, Italy
Stereotactic Radiosurgery for Meningiomas
PREFACE

Drs. Schmidek and Sweet co-edited the first single volume authored by 510 contributors representing neurosurgical ser-
entitled Current Techniques in Operative Neurosurgery vices from several different countries. It was the intention
in 1977. At the time, this first edition reflected their own of Dr. Schmidek in the previous editions to reflect the ongo-
interests in contemporary neurosurgical procedures. This ing worldwide changes, to include contributions of interna-
book has continued the same tradition in the subsequent tionally renowned doctors, and to perpetuate the idea of a
editions: to provide the working neurosurgeon with infor- worldwide text in neurosurgery. This edition has lived up to
mation that would be useful when taking a patient to the that goal. Approximately 43% of the chapters deal with mate-
operating room. The chapters provided an overview of the rial not previously addressed in this text, including the topics
topic, a discussion of available options, and results. In many of pediatric neurosurgery, endovascular surgery, new spine
cases, alternative surgical and nonsurgical options were and skull base minimally invasive techniques, and the study
included for dealing with a particular clinical situation. of peripheral nerves. Where appropriate, chapters published
The goal from the first edition has been to provide a single in earlier editions have been extensively rewritten. All the
source that would allow a neurosurgeon to develop a surgi- chapters have been reviewed by myself and my co-editors to
cal plan for the patient. The chapter references would be up ensure that they reflect the current state of the art.
to date and allow further immersion in the topic as needed. This edition could not have been accomplished without
The success of these volumes places Operative Neurosur- the enthusiastic participation of the section editors and
gical Techniques: Indications, Methods, and Results among contributors who put in extraordinary efforts to complete
the most widely used neurosurgical texts worldwide. Now their chapters in time. Every effort has been made to pro-
in its sixth edition, this title is dedicated to Dr. Schmidek’s duce a product worthy of the contributions. This could only
unending effort to advance the knowledge and expertise have been accomplished with the professionalism of Julie
of medical students throughout the world. The field of neu- Goolsby, Agnes Hunt Byrne, and Lisa Barnes at Elsevier; my
rological surgery has experienced a tremendous evolution staff Colleen Hickson and Caitlin Rogers; and Cassie Carey
during the last decade, and I have added multiple section at Graphic World Publishing Services. I extend to all of the
editors to keep the current edition as modern as possible. section editors, contributors, and staff members from Else-
The sixth edition continues to reflect the same underly- vier, Graphic World, and Hopkins my most sincere thanks
ing vision for the book and attempts to keep up to date with for a tremendous job, which was incredibly well done.
the rapidly evolving changes in neurosurgery. This new and
improved edition consists of 10 sections and 206 chapters Alfredo Quiñones-Hinojosa, MD

xli
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CONTENTS

Volume 1 14. Cerebellar Tumors in Adults  169


LAURA B. NGWENYA  •  MIRZA N. BAIG  •
1. E nsuring Patient Safety in Surgery―First Do MANISH K.  AGHI  •  E. ANTONIO CHIOCCA
No Harm  1 15. Surgical Management of Cerebral Metastases  178
SYMEON MISSIOS  •  KIMON BEKELIS  • 
TIMOTHY SIU  •  FREDERICK F.  LANG
GEORGE T. BLIKE  •  KADIR ERKMEN
2. S urgical Navigation with Intraoperative Imaging: PITUITARY AND PARAPITUITARY TUMORS
Special Operating Room Concepts  12 16. Multimodal Assessment of Pituitary and Parasellar
ARYA NABAVI  •  ANDREAS M. STARK  •  LUTZ DÖRNER  • Lesions  192
H. MAXIMILIAN MEHDORN
T. BROOKS VAUGHAN  •  LEWIS S. BLEVINS  •
MICHAEL S.VAPHIADES  •  GARY S. WAND

Section One 17. M


 edical Management of Hormone-Secreting Pituitary
Tumors  203
SURGICAL MANAGEMENT OF BRAIN NESTORAS MATHIOUDAKIS  •  ROBERTO SALVATORI
AND SKULL BASE TUMORS 18. Growth Hormone–Secreting Tumors  215
INTRA-AXIAL BRAIN TUMORS CARRIE R. MUH  •  ADRIANA G. IOACHIMESCU  •
NELSON M. OYESIKU
3. F unctional Tractography, Diffusion Tensor 19. Prolactinomas  221
Imaging, Intraoperative Integration of Modalities, JAMES K. LIU  •  MARK D. KRIEGER  •  ARUN P.  AMAR  •
and Neuronavigation  23 WILLIAM T. COULDWELL  •  MARTIN H. WEISS
JONATHAN A. HYAM  •  ALEXANDER L. GREEN  •
20. Cushing’s Disease  228
ERLICK A.C. PEREIRA
JOSEPH WATSON  •  EDWARD H. OLDFIELD
4. Intraoperative Neurophysiology: A Tool to
Prevent and/or Document Intraoperative Injury 21. Endocrinologically Silent Pituitary Tumors  246
to the Nervous System  30 PAOLO CAPPABIANCA  •  FELICE ESPOSITO  •
LUIGI M. CAVALLO  •  ANNAMARIA COLAO
VEDRAN DELETIS  •  FRANCESCO SALA
22. E ndoscopic Endonasal Pituitary and Skull Base
5. G
 amma Knife Surgery for Cerebral Vascular
Surgery  257
Malformations and Tumors  46
DAVID H. JHO  •  DIANA H. JHO  •  HAE-DONG JHO
CHUN-PO YEN  •  LADISLAU STEINER
23. T ranscranial Surgery for Pituitary
6. Cortical and Subcortical Brain Mapping  80
Macroadenomas  280
HUGUES DUFFAU
PABLO F. RECINOS  •  C. RORY GOODWIN  •
7. Chemotherapy for Brain Tumors  94 HENRY BREM  •  ALFREDO QUIÑONES-HINOJOSA
MANMEET S. AHLUWALIA 24. Craniopharyngiomas  292
8. C
 urrent Surgical Management of High-Grade PHILIP V. THEODOSOPOULOS  •  MICHAEL E. SUGHRUE  • 
Gliomas  105 MICHAEL W. McDERMOTT
RAY M. CHU  •  KEITH L. BLACK 25. E ndoscopic Endonasal Approach for
9. Surgical Management of Low-Grade Gliomas  111 Craniopharyngiomas  303
LORENZO BELLO  •  FRANCESCO DIMECO  • DANIEL M. PREVEDELLO  •  DOMENICO SOLARI  • 
GIUSEPPE CASACELI  •  SERGIO MARIA GAINI RICARDO L. CARRAU  •  PAUL GARDNER  •  AMIN B. KASSAM

10. Management of Recurrent Gliomas  127 26. A


 rachnoid, Suprasellar, and Rathke’s
GRIFFITH R. HARSH IV
Cleft Cysts  311
DIETER HELLWIG  •  WUTTIPONG TIRAKOTAI  • 
11. Tumors in Eloquent Areas of Brain  141 VINCENZO PATERNO  •  CHRISTOPH KAPPUS
MARK A. PICHELMANN  •  FREDERIC B. MEYER
12. M
 anagement of Primary Central Nervous System INTRAVENTRICULAR TUMORS
Lymphomas  149 27. S urgical Approaches to Lateral and Third Ventricular
CAMILO E. FADUL  •  PAMELA ELY Tumors  330
13. S urgical Management of Brain Stem Tumors in TORAL R. PATEL  •  GRAHAME C. GOULD  • 
Adults  160 JOACHIM M. BAEHRING  •  JOSEPH M. PIEPMEIER
JAMES L. FRAZIER  •  GEORGE I. JALLO
xliii
xliv CONTENTS

28. T ranscallosal Surgery of Lesions Affecting the Third CEREBELLOPONTINE ANGLE TUMORS
Ventricle: Basic Principles  339
45. S uboccipital Retrosigmoid Surgical Approach for
ALEXANDER TAGHVA  •  CHARLES Y. LIU  • 
MICHAEL L. J. APUZZO
Vestibular Schwannoma (Acoustic Neuroma)  546
ROBERT L. MARTUZA
29. E ndoscopic Approach to Intraventricular Brain
Tumors  351 46. T ranslabyrinthine Approach to Vestibular
JEFFREY P. GREENFIELD  •  MARK M. SOUWEIDANE  • 
Schwannomas  555
THEODORE H. SCHWARTZ LARS POULSGAARD
30. Management of Pineal Region Tumors  357 47. T ranstemporal Approaches to Posterior Cranial
JEFFREY N. BRUCE Fossa  565
31. Management of Tumors of the Fourth Ventricle  367 FRANK D. VRIONIS  •  KAMRAN V. AGHAYEV  • 
GALE GARDNER  •  JON H. ROBERTSON  • 
JONATHAN MILLER  •  ALIA HDEIB  •  ALAN COHEN JASON A. BRODKEY

EXTRA-AXIAL AND POSTERIOR TUMORS 48. S urgical Management of Neurofibromatosis


Types 1 and 2  581
32. S urgical Management of Parasagittal and Convexity JAMES H. TONSGARD  •  BAKHTIAR YAMINI  •  DAVID M. FRIM
Meningiomas  398 49. Hearing Prosthetics: Surgical Techniques  588
ASHOK R. ASTHAGIRI  •  RUSSELL R. LONSER WADE W. CHIEN  •  HOWARD FRANCIS  •  JOHN K. NIPARKO
33. Surgical Approach to Falcine Meningiomas  410
ERIC C. CHANG  •  FREDRICK G. BARKER II  •  WILLIAM T. CURRY LESIONS AT THE SKULL BASE
34. S urgical Management of Midline Anterior Skull Base 50. Multimodal Treatment of Orbital Tumors  597
Meningiomas  417 SHAAN M. RAZA  •  ALFREDO QUIÑONES-HINOJOSA  • 
MATTHIAS KIRSCH  •  DIETMAR KREX  •  PREM S. SUBRAMANIAN
GABRIELE SCHACKERT
51. Surgical Approaches to the Orbit  603
35. S upraorbital Approach Variants for Intracranial UTA SCHICK  •  ANDREAS UNTERBERG
Tumors  428
52. Anterior Midline Approaches to the Skull Base  613
RODRIGO RAMOS-ZÚÑIGA  •  SHAAN M. RAZA  • 
ALFREDO QUIÑONES-HINOJOSA IVO P. JANECKA  •  SILLOO B. KAPADIA

36. S urgical Management of Sphenoid Wing 53. O


 rbitozygomatic Infratemporal Approach to Parasellar
Meningiomas  435 Meningiomas  622
GERARDO GUINTO KENJI OHATA  •  TAKEO GOTO

37. Spheno-Orbital Meningioma  444


JOHN R. FLOYD  •  FRANCO DEMONTE Section Two
38. Tumors Involving the Cavernous Sinus  451 OPERATIVE TECHNIQUES IN PEDIATRIC
JOHN DIAZ DAY  •  DONG XIA FENG  •  TAKANORI FUKUSHIMA NEUROSURGERY
39. Surgery for Trigeminal Neurinomas  468
TAKESHI KAWASE
54. M
 ethods for Cerebrospinal Fluid Diversion in Pediatric
Hydrocephalus: From Shunt to Scope  631
40. S urgical Management of Petroclival AABIR CHAKRABORTY  •  JAMES M. DRAKE  • 
Meningiomas  473 BENJAMIN C. WARF
KHALED M. AZIZ  •  SEBASTIEN FROELICH  • 
SANJAY BHATIA  •  ALEXANDER K. YU  • 
55. P osterior Fossa Tumors in the Pediatric Population:
ALBINO BRICOLO  •  TODD HILLMAN  •  Multidisciplinary Management  654
RAYMOND F. SEKULA, JR. TAE-YOUNG JUNG  •  JAMES T. RUTKA
41. Surgical Management of Lesions of the Clivus  486 56. S upratentorial Tumors in the Pediatric Population:
GIULIO MAIRA  •  FRANCESCO DOGLIETTO  •  ROBERTO PALLINI Multidisciplinary Management  669
42. S urgical Management of Posterior Fossa CHETAN BETTEGOWDA  •  LINDA C. CHEN  • 
VIVEK A. MEHTA  •  GEORGE I. JALLO  •  JAMES T. RUTKA
Meningiomas  501
BEEJAL Y. AMIN  •  SAMUEL RYU  •  JACK P. ROCK 57. M
 apping, Disconnection, and Resective Surgery
in Pediatric Epilepsy  684
43. S urgical Management of Tumors of the Foramen
BRENT O’NEILL  •  JEFFREY G. OJEMANN  • 
Magnum  517 MATTHEW SMYTH  •  JOHANNES SCHRAMM
JOSE ALBERTO LANDEIRO  •  ROBERTO LEAL SILVEIRA  • 
CASSIUS VINÍCIUS CORRÊA DOS REIS 58. S urgical Decision-Making and Treatment Options
for Chiari Malformations in Children  695
44. S urgical Management of Tumors of the Jugular
TODD C. HANKINSON  •  R. SHANE TUBBS  • 
Foramen  529 W. JERRY OAKES
JAMES K. LIU  •  GAURAV GUPTA  • 
LANA D. CHRISTIANO  •  TAKANORI FUKUSHIMA 59. Fetal Surgery for Open Neural Tube Defects  702
NALIN GUPTA
CONTENTS xlv

60. Surgical Management of Spinal Dysraphism  707 75. S urgical Management of Aneurysms of the Middle
JAMES B. MITCHELL  •  DACHLING PANG Cerebral Artery  897
61. R
 evascularization Techniques in Pediatric MARTIN LEHECKA  •  REZA DASHTI  •  JAAKKO RINNE  • 
ROSSANA ROMANI  •  RIKU KIVISAARI  •  MIKA NIEMELÄ  • 
Cerebrovascular Disorders  735 JUHA HERNESNIEMI
EDWARD SMITH  •  R. MICHAEL SCOTT
76. S urgical Management of Terminal Basilar and Posterior
62. M
 anagement of Pediatric Severe Traumatic Cerebral Artery Aneurysms  914
Brain Injury  741 SCOTT  Y. RAHIMI  •  MARK J. DANNENBAUM  • 
JOTHAM MANWARING  •  P. DAVID ADELSON C. MICHAEL CAWLEY  •  DANIEL L. BARROW
63. C
 ontemporary Dorsal Rhizotomy Surgery for the 77. S urgical Management of Midbasilar and Lower Basilar
Treatment of Spasticity in Childhood  753 Aneurysms  925
DONIEL DRAZIN  •  KURTIS AUGUSTE  •  MOISE DANIELPOUR NADER SANAI  •  ALIM MITHA  •  ROBERT F. SPETZLER
64. Instrumentation and Stabilization of the Pediatric 78. S urgical Management of Aneurysms of the Vertebral
Spine: Technical Nuances and Age-Specific and Posterior Inferior Cerebellar Artery Complex  937
Considerations  759 HELMUT BERTALANFFY  •  LUDWIG BENES  • 
JOSHUA J. CHERN  •  KATHERINE RELYEA  •  ANDREW JEA STEFAN HEINZE  •  WUTTIPONG TIRAKOTAI  • 
ULRICH SURE
65. M
 ethods of Cranial Vault Reconstruction for
Craniosynostosis  768 79. F ar Lateral Approach and Transcondylar
and Supracondylar Extensions for Aneurysms
JOSE HINOJOSA
of the Vertebrobasilar Junction  951
MOHAMED SAMY ELHAMMADY  •  ERIC C. PETERSON  • 
Section Three ROBERTO C. HEROS  •  JACQUES J. MORCOS

VASCULAR DISEASES 80. S urgical Management of Cranial Dural


Arteriovenous Fistulas  959
OPEN TREATMENT MOHSEN JAVADPOUR  •  M. CHRISTOPHER WALLACE

66. S urgical Management of the Extracranial Carotid 81. S urgical Management of Cavernous Malformations
Artery Disease  793 of the Nervous System  977
MARKUS BOOKLAND  •  CHRISTOPHER M. LOFTUS ANOOP P. PATEL  •  SEPIDEH AMIN-HANJANI  • 
CHRISTOPHER S. OGILVY
67. M
 anagement of Dissections of the Carotid
82. S urgical Management of Infratentorial Arteriovenous
and Vertebral Arteries  806
Malformations  995
GREGORY J. VELAT  •  BRIAN L. HOH  • 
CHRISTOPHER S. OGILVY TOMÁS GARZÓN-MUVDI  •  GUSTAVO PRADILLA  • 
KIMON BEKELIS  •  PHILIPPE GAILLOUD  • 
68. M
 anagement of Unruptured Intracranial RAFAEL J. TAMARGO
Aneurysms  812 83. S urgical Management of Cerebral Arteriovenous
VIKRAM V. NAYAR  •  KAI FRERICHS  •  ARTHUR L. DAY Malformations  1003
69. S urgical Management of Intracerebral EDGARDO SPAGNUOLO
Hemorrhage  823
MANISH K. AGHI  •  CHRISTOPHER S. OGILVY  •  ENDOVASCULAR TREATMENT
BOB S. CARTER
84. E ndovascular Management of Intracranial
70. S urgical Management of Cerebellar Stroke— Aneurysms  1019
Hemorrhage and Infarction  837
JOSEPH J. GEMMETE  •  ADITYA S. PANDEY  • 
VIKRAM V. NAYAR  •  ARTHUR L. DAY NEERAJ CHAUDHARY  •  B. GREGORY THOMPSON, JR.
71. S urgical Treatment of Moyamoya Disease 85. Endovascular Treatment of Stroke  1029
in Adults  845 KYLE M. FARGEN  •  GREGORY J. VELAT  • 
LEONIDAS M. QUINTANA MICHAEL F. WATERS  •  BRIAN L. HOH  •  J. MOCCO
72. S urgical Treatment of Paraclinoid 86. E ndovascular Treatment of Cerebral Arteriovenous
Aneurysms  855 Malformations  1037
EDGAR NATHAL  •  GABRIEL CASTILLO ROHAN CHITALE  •  PASCAL M. JABBOUR  • 
L. FERNANDO GONZALEZ  •  ROBERT H. ROSENWASSER  • 
73. S urgical Management of Posterior Communicating, STAVROPOULA I. TJOUMAKARIS
Anterior Choroidal, Carotid Bifurcation
Aneurysms  872 87. E ndovascular Treatment of Intracranial Occlusive
Disease  1045
KYRIAKOS PAPADIMITRIOU  •  JUDY HUANG
SABAREESH K. NATARAJAN  •  ALEXANDER A. KHALESSI  • 
74. S urgical Management of Anterior Communicating YUVAL KARMON  •  ADNAN H. SIDDIQUI  • 
and Anterior Cerebral Artery Aneurysms  882 L. NELSON HOPKINS  •  ELAD I. LEVY
MICHAEL T. LAWTON  •  ZAMAN MIRZADEH
xlvi CONTENTS

88. E ndovascular Treatment of Extracranial Occlusive 102. R


 adiation Therapy and Radiosurgery in the
Disease  1059 Management of Craniopharyngiomas  1187
HENRY MOYLE  •  AMAN PATEL ANAND VEERAVAGU  •  MARCO LEE  •  BOWEN JIANG  • 
JOHN R. ADLER, JR.  •  STEVEN D. CHANG
89. E mbolization of Tumors: Brain, Head, Neck,
and Spine  1065 103. V
 estibular Schwannomas: The Role of Stereotactic
YIN C. HU  •  C. BENJAMIN NEWMAN  •  Radiosurgery  1193
CAMERON G. McDOUGALL  •  FELIPE C. ALBUQUERQUE DOUGLAS KONDZIOLKA  •  L. DADE LUNSFORD  • 
AJAY NIRANJAN  •  HIDEYUKI KANO  •  JOHN C. FLICKINGER
90. E ndovascular Management of Dural Arteriovenous
Fistulas  1079 104. Stereotactic Radiosurgery Meningiomas  1203
GEOFFREY P. COLBY  •  ALEXANDRA R. PAUL  •  MASSIMO GEROSA  •  BRUNO ZANOTTI  • 
ELISA F. CICERI  •  ALEXANDER L. COON ANGELA VERLICCHI  •  ANTONIO NICOLATO

91. E ndovascular Management of Spinal Vascular 105. R


 ole of Gamma Knife Radiosurgery in the Management
Malformations  1089 of Arteriovenous Malformations  1223
ANITHA NIMMAGADDA  •  RUDY J. RAHME  •  RAMIRO DEL-VALLE  •  MARCO ZENTENO
ALI SHAIBANI  •  GUILHERME DABUS  •  BERNARD R. BENDOK 106. Radiation Therapy of Epilepsy  1235
92. E ndovascular Treatment of Head and Neck ELLEN AIR  •  NICHOLAS M. BARBARO
Bleeding  1105 107. Gamma Surgery for Functional Disorders  1241
ALEXANDROS D. ZOUZIAS  •  PAUL SCHMITT  • 
CHUN-PO YEN  •  LADISLAU STEINER
CHIRAG D. GANDHI  •  CHARLES J. PRESTIGIACOMO
93. Imaging Evaluation and Endovascular Treatment
of Vasospasm  1115
Volume Two
JAMES CHEN  •  SUDHIR KATHURIA  •  DHEERAJ GANDHI Section Six
Section Four FUNCTIONAL NEUROSURGERY
SURGICAL MANAGEMENT OF MEDICALLY INTRACTABLE
HYDROCEPHALUS EPILEPSY
94. S urgical Management of Hydrocephalus
in the Adult  1127 108. P resurgical Evaluation for Epilepsy Including
DAVID M. FRIM  •  RICHARD PENN  •  MAUREEN LACY Intracranial Electrodes  1251
95. Adult Pseudotumor Cerebri Syndrome  1135 ANA LUISA VELASCO  •  FRANCISCO VELASCO  •  BERNARDO
BOLEAGA  •  JOSÉ MARÍA NÚÑEZ  •  DAVID TREJO
SACHIN BATRA  •  ABHAY MOGHEKAR  • 
DAVID SOLOMON  •  ARI BLITZ  •  109. T emporal Lobe Operations in Intractable
DIEGO SAN MILLÁN RUÍZ  •  PHILIPPE GAILLOUD  •  Epilepsy  1265
PREM SUBRAMANIAN  •  NEIL R. MILLER  • 
SAMEER A. SHETH  •  MATTHEW K. MIAN  • 
DANIELE RIGAMONTI
EMAD N. ESKANDAR  •  G. REES COSGROVE
96. Endoscopic Third Ventriculostomy  1143 110. S urgical Management of Extratemporal Lobe
PABLO F. RECINOS  •  GEORGE I. JALLO  •  Epilepsy  1273
VIOLETTE RENARD RECINOS
ERLICK A.C. PEREIRA  •  ALEXANDER L. GREEN
97. Management of Shunt Infections  1151
111. M
 ultilobar Resection and Hemispherectomy in Epilepsy
CLAUDIO YAMPOLSKY  •  PABLO AJLER
Surgery  1281
MASSIMO COSSU  •  FRANCESCO CARDINALE  • 
Section Five LAURA CASTANA  •  GIORGIO LO RUSSO
112. C
 orpus Callosotomy: Indications
STEREOTACTIC RADIOSURGERY and Techniques  1295
98. Interstitial and LINAC-Radiosurgery for Brain
EDWARD F. CHANG  •  NATHAN C. ROWLAND  • 
Metastases  1159 NICHOLAS M. BARBARO
GUIDO NIKKHAH  •  JAROSLAW MACIACZYK  • 
THOMAS REITHMEIER  •  MICHAEL TRIPPEL  •  113. T reatment of Intractable Epilepsy by Electrical
MARCUS O. PINSKER Stimulation of the Vagus Nerve  1301
99. S tereotactic Radiosurgery for Trigeminal JOSEPH R. MADSEN
Neuralgia  1167
SURGICAL MANAGEMENT OF PSYCHIATRIC AND
PABLO F. RECINOS  •  TRANG NGUYEN  •  MICHAEL LIM
MOVEMENT DISORDERS
100. CyberKnife Radiosurgery for Spinal Neoplasms  1173
ROBERT E. LIEBERSON  •  AKE HANSASUTA  •  114. D
 eep Brain Stimulation in Movement Disorders:
ROBERT DODD  •  STEVEN D. CHANG  •  JOHN R. ADLER, JR. Parkinson’s Disease, Essential Tremor,
101. S tereotactic Radiosurgery for Pituitary and Dystonia  1309
Adenomas  1181 LOUIS A. WHITWORTH  •  KIM J. BURCHIEL

DANIEL Q. SUN  •  SACHIN BATRA  •  JUAN JACKSON  •  115. C


 ervical Dystonia and Spasmodic Torticollis:
ROBERTO SALVATORI  •  DANIELE RIGAMONTI Indications and Techniques  1321
JOHN YIANNI  •  DIPANKAR NANDI  •  TIPU AZIZ
CONTENTS xlvii

116. N
 ovel Targets in Deep Brain Stimulation for Movement 133. S urgical Management of Severe Closed Head Injury in
Disorders  1327 Adults  1513
STEVEN OJEMANN  •  OSZKAR SZENTIRMAI  •  GIDON FELSEN JOSÉ MARÍA PASCUAL  •  RUTH PRIETO
117. Molecular Therapies for Movement Disorders  1337 134. M
 anagement of Penetrating and Blast Injuries of the
MICHAEL J. NANASZKO  •  MICHAEL G. KAPLITT Nervous System  1539
118. Cingulotomy for Intractable Psychiatric Illness  1347 RICHARD J. TEFF

PATRICK SCHWEDER  •  G. REES COSGROVE 135. D


 ecompressive Craniectomy for Traumatic Brain
119. D
 eep Brain Stimulation for Intractable Psychiatric Injury  1551
Illness  1355 MATTHEW B. POTTS  •  MICHAEL E. SUGHRUE  • 
SHIRLEY I. STIVER  •  LAWRENCE H. PITTS  • 
PAUL S. LARSON  •  PHILIP A. STARR GEOFFREY T. MANLEY
120. B
 rain–Computer Interfacing Prospects and Technical 136. Management of Skull Base Trauma  1559
Aspects  1361 SHIRLEY I. STIVER
ROY BAKAY
137. S urgical Management of Chronic Subdural Hematoma
121. T horacoscopic Sympathectomy for in Adults  1573
Hyperhidrosis  1373 THOMAS SANTARIUS  •  ANGELOS G. KOLIAS  • 
SUBU N. MAGGE  •  JOHN F. MORRISON PETER J. HUTCHINSON
122. Surgery for Intractable Spasticity  1377 138. Management of Cerebrospinal Fluid Leaks  1579
MARC SINDOU  •  PATRICK MERTENS KOFI BOAHENE  •  TEODORO FORCHT DAGI  • 
ALFREDO QUIÑONES-HINOJOSA
SURGICAL MANAGEMENT OF INTRACTABLE PAIN 139. P rinciples of Scalp Surgery and Surgical Management
123. R
 etrogasserian Glycerol Rhizolysis in Trigeminal of Major Defects of Scalp  1597
Neuralgia  1393 GABY D. DOUMIT  •  ALEXANDRA SCHMIDEK  • 
MICHAEL J. YAREMCHUK
BENGT LINDEROTH  •  GÖRAN LIND
140. S urgical Management of Major Skull Defects and
124. P ercutaneous Stereotactic Rhizotomy in the Treatment Potential Complications  1607
of Intractable Facial Pain  1409
SHIH-SHAN LANG  •  M. SEAN GRADY
JOHN M. TEW, JR.  •  CHAD J. MORGAN  • 
ANDREW W. GRANDE 141. M
 anagement of Traumatic Intracranial
125. N
 eurovascular Decompression in Cranial Nerves V, VII, Aneurysms  1611
IX, and X  1419 GIUSEPPE TALAMONTI  •  GIUSEPPE D’ALIBERTI  • 
MASSIMO COLLICE
RUSSELL R. LONSER  •  RONALD I. APFELBAUM
142. Management of Penetrating Brain Injury  1619
126. Deep Brain Stimulation for Pain  1433
J. KENT WERNER, JR.  •  ROCCO ARMONDA  • 
PATRICK SENATUS  •  DANIEL CONDIT GEOFFREY T. MANLEY  •  GUY ROSENTHAL
127. M
 esencephalic Tractotomy and Anterolateral
Cordotomy for Intractable Pain  1443 Section Eight
KOSTAS N. FOUNTAS  •  EFTYCHIA Z. KAPSALAKI  • 
JOSEPH R. SMITH SURGICAL MANAGEMENT OF NERVOUS
128. Spinal Cord Stimulation for Chronic Pain  1455 SYSTEM INFECTIONS
RICHARD B. NORTH  •  BENGT LINDEROTH 143. M
 anagement of Suppurative Intracranial
129. S pinal Cord Stimulation and Intraspinal Infusions for Infections  1631
Pain  1469 RACHEL GROSSMAN  •  HENRY H. SCHMIDEK  • 
GILBERT J. FANCIULLO  •  PERRY A. BALL ALFREDO QUIÑONES-HINOJOSA

130. Dorsal Root Entry Zone Lesions  1481 144. Management of Infections After Craniotomy  1643
KEVIN CAHILL  •  ALLAN J. BELZBERG  •  WILLIAM S. ANDERSON GÖRAN C. BLOMSTEDT  •  KARI SAMMALKORPI

131. M
 otor Cortex Stimulation for Intractable Facial 145. S pinal Infections: Vertebral Osteomyelitis and Spinal
Pain  1487 Epidural Abscess  1649
SAMEER A. SHETH  •  MATTHEW K. MIAN  •  SUNIL JESWANI  •  DONIEL DRAZIN  •  ALI SHIRZADI  • 
BRADLEY R. BUCHBINDER  •  EMAD N. ESKANDAR PAULA EBOLI  •  DEBRAJ MUKHERJEE  •  FRANK L. ACOSTA
146. N
 eurosurgical Management of HIV-Related Focal Brain
Lesions  1659
Section Seven MARLON S. MATHEWS  •  E. THOMAS CHAPPELL
TRAUMA 147. Management of Neurocysticercosis  1667
RODRIGO RAMOS-ZÚÑIGA  •  TOMÁS GARZÓN-MUVDI
132. P erioperative Management of Severe Traumatic Brain
Injury in Adults  1495 148. M
 anagement of Tuberculous Infections of the Nervous
RAMESH GRANDHI  •  DAVID O. OKONKWO
System  1679
RANA PATIR  •  RAVI BHATIA
xlviii CONTENTS

149. F ungal Infections of the Central Nervous 162. M


 inimally Invasive Lumbar Microdiscectomy:
System  1691 Indications and Techniques  1865
REWATI RAMAN SHARMA  •  SANJAY J. PAWAR  •  LUIS M. TUMIALAN
SANTOSH D. LAD  •  GANPATI PRASAD MISHRA  • 
AUDUMBAR SHANTARAM NETALKAR  •  SHRIKANT REGE
163. M
 anagement of Far Lateral Lumbar Disc
Herniations  1871
150. M
 anagement of Intracranial Aneurysms Caused by
NANCY E. EPSTEIN
Infection  1733
BRADLEY A. GROSS  •  NING LIN  •  ROSE DU
164. L umbar Spinal Arthroplasty: Clinical Experiences of
Motion Preservation  1883
FRED H. GEISLER
Section Nine 165. M
 anagement of Degenerative Lumbar Stenosis and
NEUROSURGICAL MANAGEMENT OF SPINAL Spondylolisthesis  1891
BENJAMIN BLONDEL  •  SHAUN XAVIER  • 
DISORDERS THOMAS ERRICO
DEGENERATIVE SPINE DISORDER 166. P osterior Lumbar Fusion by Open Technique:
Indications and Techniques  1899
CERVICAL SPINE
ALI BYDON  •  HORMUZDIYAR H. DASENBROCK  •  IAN SUK
151. T reatment Evolution in Management of Cervical Disc 167. P ercutaneous Placement of Lumbar Pedicle Screws:
Disease  1747 Indications and Techniques  1931
MARCUS C. KORINTH DANIEL C. LU  •  KEVIN T. FOLEY
152. A
 nterior Cervical Foraminotomy (Jho Procedure): 168. D
 ynamic Stabilization of the Lumbar Spine:
Microscopic or Endoscopic  1757 Indications and Techniques  1939
DAVID H. JHO  •  DIANA H. JHO  •  HAE-DONG JHO WILLIAM WELCH  •  BOYLE C. CHENG  •  TARIQ E. AWAD  • 
153. M
 inimally Invasive Posterior Cervical Foraminotomy M. MASON MACENSKI
and Microdiscectomy  1771 169. Posterior Lumbar Interbody Fusion  1947
GIRISH K. HIREMATH  •  MICK J. PEREZ-CRUET M. YASHAR S. KALANI  •  MARK GARRETT  • 
NICHOLAS THEODORE
154. D
 isc Replacement Technologies in the Cervical and
Lumbar Spine  1777 170. T ransforaminal Lumbar Interbody Fusion:
RONAN M. DARDIS  •  AMAR SAXENA  •  AMJAD SHAD  • 
Indications and Techniques  1951
BHUPAL CHITNAVIS  •  RICHARD GULLAN BASHEAL M. AGRAWAL  •  DANIEL RESNICK
155. A
 nterior Approaches for Multilevel Cervical 171. A
 nterior Lumbar Interbody Fusion: Indications and
Spondylosis  1789 Techniques  1955
ATUL GOEL  •  FRANCESCO CACCIOLA SUNIL JESWANI  •  DONIEL DRAZIN  •  JOHN C. LIU  • 
CHRISTOPHER AMES  •  FRANK L. ACOSTA
156. M
 anagement of Cervical Spondylotic
Myelopathy  1801 172. L ateral Lumbar Interbody Fusion: Indications and
MICHAEL P. STEINMETZ  •  RICK J. PLACIDE  • 
Techniques  1963
EDWARD C. BENZEL  •  AJIT A. KRISHNANEY YI LU  •  JUDITH M. WONG  •  JOHN H. CHI
157. C
 ervical Laminoplasty: Indications 173. V
 ertebroplasty and Kyphoplasty: Indications and
and Techniques  1815 Techniques  1973
CHRISTOPHER M. BOXELL  •  DAVID G. MALONE  •  CLIFFORD J. ESKEY
MITCHELL MARTINEAU
158. Circumferential Cervical Spinal Fusion  1825 SPINE TRAUMA
THOMAS B. DUCKER  •  TIMOTHY G. BURKE 174. M
 anagement of Injuries of the Cervical Spine and
Spinal Cord  1985
THORACIC SPINE
DANIEL M. SCIUBBA  •  JAMES S. HARROP
159. S urgical Techniques in the Management of Thoracic 175. Transoral Approaches to the Cervical Spine  1993
Disc Herniations  1833 WESLEY HSU  •  JEAN-PAUL WOLINSKY
NATHAN E. SIMMONS
176. Atlantoaxial Instability and Stabilization  2003
160. V
 ideo-Assisted Thoracoscopic Discectomy: JEAN-PAUL WOLINSKY  •  REZA YASSARI
Indications and Techniques  1843
177. S tabilization of the Subaxial Cervical Spine
JOSHUA M. AMMERMAN  •  ANTHONY J. CAPUTY
(C3–C7)  2013
MEHMET ZILELI
LUMBAR SPINE
178. T horacolumbar Anterolateral and Posterior
161. L umbar Microdiscectomy: Indications Stabilization  2027
and Techniques  1853 HAREL ARZI  •  PAUL M. ARNOLD
BRADLEY S. DUHON  •  MEIC H. SCHMIDT
CONTENTS xlix

179. Management of Sacral Fractures  2035 192. Surgery for Metastatic Spine Disease  2193
CARLO BELLABARBA  •  THOMAS A. SCHILDHAUER  •  DANIEL M. SCIUBBA  •  ZIYA L. GOKASLAN
JENS R. CHAPMAN
193. Surgical Resection of Sacral Tumors  2201
180. M
 anagement of Penetrating Injuries to the ZIYA L. GOKASLAN  •  WESLEY HSU
Spine  2047
MICHELLE J. CLARKE  •  RAJ NARAYAN  •  SPECIFIC COMPLICATIONS OF SPINE SURGERY
TIMOTHY F. WITHAM
194. S urgical Management of Cerebrospinal Fluid Leakage
CONGENITAL AND DEVELOPMENTAL SPINAL after Spinal Surgery  2217
ABNORMALITIES SUNIL JESWANI  •  DONIEL DRAZIN  • 
ALI SHIRZADI  •  FRANK L. ACOSTA
181. C
 raniovertebral Abnormalities and Their Neurosurgical
Management  2055
ARNOLD MENEZES  •  TIMOTHY LINDLEY Section Ten
182. M
 anagement of Chiari Malformations SURGICAL MANAGEMENT OF THE
and Syringomyelia  2071
PERIPHERAL NERVOUS SYSTEM
JOHN HEISS  •  EDWARD H. OLDFIELD
183. M
 anagement of Occult Spinal Dysraphism 195. Peripheral Nerve Injury  2225
in Adults  2081 ADAM M. SONABEND  •  PATRICIA SMITH  • 
JASON H. HUANG  •  CHRISTOPHER WINFREE
R. SHANE TUBBS  •  W. JERRY OAKES
184. N
 eurologic Problems of the Spine 196. Imaging for Peripheral Nerve Disorders  2239
in Achondroplasia  2091 AARON G. FILLER

BENJAMIN S. CARSON  •  MARI GROVES  •  REZA YASSARI 197. Management of Adult Brachial Plexus Injuries  2247
KATHLEEN KHU  •  RAJIV MIDHA  •  SHIMON ROCHKIND
SPINAL DEFORMITY 198. Nerve Transfers: Indications and Techniques  2261
185. Management of Degenerative Scoliosis  2101 MANISH S. SHARMA  •  ALLEN T. BISHOP  • 
ALEXANDER Y. SHIN  •  ROBERT J. SPINNER
DANIEL M. SCIUBBA
199. Management of Median Nerve Compression  2273
SPINE TUMORS NATHAN J. RANALLI  •  KARTIK G. KRISHNAN  •  ERIC L. ZAGER

186. S urgical Management of Intramedullary Spinal Cord 200. Management of Ulnar Nerve Compression  2287
Tumors in Adults  2111 GAURAV GUPTA  •  ALLEN MANIKER
MICHAEL BRUNEAU  •  JACQUES BROTCHI 201. Management of Entrapment Neuropathies  2299
187. Intradural Extramedullary Tumors  2127 MARCO SINISI
PAUL McCORMICK 202. M
 anagement of Nerve Sheath Tumors Involving the
188. M
 anagement of Spinal Cord Tumors and Arteriovenous Spine  2309
Malformations  2135 FAIZ AHMAD  •  ALLAN LEVI
NIRIT WEISS  •  JOSHUA BEDERSON  •  KALMON POST 203. Peripheral Nerve Tumors of the Extremities  2319
189. Management of Cauda Equina Tumors  2153 MICHAEL J. DORSI  •  ALLAN J. BELZBERG
FRANÇOISE LaPIERRE  •  ANTOINE LISTRAT  •  PHILIPPE 204. Management of Cranial Nerve Injuries  2329
RIGOARD  •  MICHEL WAGER KHALED M. AZIZ  •  ALEXANDER K. YU  • 
190. M
 anagement of Primary Malignant Tumors of the DOUGLAS CHEN  •  RAYMOND F. SEKULA, JR.
Osseous Spine  2169 205. Management of Thoracic Outlet Syndrome  2339
ALESSANDRO GASBARRINI  •  STEFANO BANDIERA  •  SHIMON ROCHKIND  •  ERIC L. ZAGER
LUCA AMENDOLA  •  JOSEPH SCHWAB  •  STEFANO BORIANI
206. N
 erve-Grafting Procedures for Birth-Related Peripheral
191. S urgical Approaches to the Cervicothoracic Nerve Injuries  2349
Junction  2177 MARTIJN J. A. MALESSY  •  WILLEM PONDAAG
RICHARD G. FESSLER  •  DANIEL H. KIM
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VIDEO CONTENTS

SURGICAL MANAGEMENT OF BRAIN AND Transconjunctival Approach


SKULL BASE TUMORS/INTRA-AXIAL BRAIN CHAPTER 51, VIDEO 1 – Courtesy of Uta Schick
TUMORS Contralateral Pterional Approach
CHAPTER 51, VIDEO 2 – Courtesy of Uta Schick
Cerebellar Tumor Resection
CHAPTER 14, VIDEO 1 – Courtesy of E. Antonio Chiocca, Manish K. Demonstration of Craniofacial Resection for
Aghi, Laura B. Ngwenya, and Mirza N. Baig Anterior-Midline Pathology
CHAPTER 52, VIDEO 1 – Courtesy of Ivo P. Janecka

SURGICAL MANAGEMENT OF BRAIN AND OPERATIVE TECHNIQUES IN PEDIATRIC


SKULL BASE TUMORS/INTRAVENTRICULAR NEUROSURGERY
TUMORS
Choroid Plexus Tumor
Trans-Sulcal Approach for Resection of an Atrial CHAPTER 55, VIDEO 1 – Courtesy of James T. Rutka
Meningioma
CHAPTER 27, VIDEO 1 – Courtesy of Toral R. Patel, Frontal Disconnection
Grahame C. Gould, Joachim M. Baehring, and Joseph M. Piepmeier CHAPTER 57, VIDEO 1 – Courtesy of Matthew Smyth

Endoscopic Resection of a Colloid Cyst Corpus Callosotomy


CHAPTER 27, VIDEO 2 – Courtesy of Toral R. Patel, CHAPTER 57, VIDEO 2 – Courtesy of Matthew Smyth
Grahame C. Gould, Joachim M. Baehring, and Joseph M. Piepmeier Hemispherotomy
Transcallosal Transvelum Interpositum Approach to the CHAPTER 57, VIDEO 3 – Courtesy of Matthew Smyth
Third Ventricle Surgery for Chiari Malformations in Children
CHAPTER 27, VIDEO 3 – Courtesy of Toral R. Patel, CHAPTER 58, VIDEO 1 – Courtesy of R. Shane Tubbs
Grahame C. Gould, Joachim M. Baehring, and Joseph M. Piepmeier and W. Jerry Oakes
Fetal Repair of Myelomeningocele
SURGICAL MANAGEMENT OF BRAIN CHAPTER 59, VIDEO 1 – Courtesy of Nalin Gupta
AND SKULL BASE TUMORS/EXTRA-AXIAL Total Resection of Transitional Lipoma and Complete
AND POSTERIOR TUMORS Reconstruction of Neural Placode
CHAPTER 60, VIDEO 1 – Courtesy of Dachling Pang
Small Sphenoid Wing Meningioma
and James B. Mitchell
CHAPTER 36, VIDEO 1 – Courtesy of Gerardo Guinto
Incision of Lumbar Arachnoid
Giant Sphenoid Wing Meningioma
CHAPTER 63, VIDEO 1 – Courtesy of Doniel Drazin, Kurtis Auguste,
CHAPTER 36, VIDEO 2 – Courtesy of Gerardo Guinto and Moise Danielpour
Sublabial Transsphenoidal Chordoma
CHAPTER 41, VIDEO 1 – Courtesy of Giulio Maira, Francesco VASCULAR DISEASES/OPEN TREATMENT
Doglietto, and Roberto Pallini
Right ICA Bifurcation Aneurysm
Sublabial Transsphenoidal, Endoscope-Assisted CHAPTER 68, VIDEO 1 – Courtesy of Vikram V. Nayar, Kai Frerichs,
Chondrosarcoma and Arthur L. Day
CHAPTER 41, VIDEO 2 – Courtesy of Giulio Maira, Francesco
Doglietto, and Roberto Pallini Paraclinoid Aneurysms
CHAPTER 72, VIDEO 1 – Courtesy of Edgar Nathal and Manuel
Left Cerebellopontine Angle Meningioma: Velasco Suarez, National Institute of Neurology and Neurosurgery
Retromastoid Approach
CHAPTER 42, VIDEO 1 – Courtesy of Jack P. Rock, Beejal Y. Amin, Carotid Cave Aneurysm
and Sue MacPhee CHAPTER 72, VIDEO 2 – Courtesy of Edgar Nathal and Manuel
Velasco Suarez, National Institute of Neurology and Neurosurgery
Posterior Communicating Aneurysm
SURGICAL MANAGEMENT OF BRAIN AND
CHAPTER 73, VIDEO 1 – Courtesy of Judy Huang and Kyriakos
SKULL BASE TUMORS/CEREBELLOPONTINE Papadimitriou
ANGLE TUMORS
Microsurgical Clipping of Right-Sided Unruptured M1
Transtemporal Approaches to the Posterior Cranial Fossa Aneurysm
CHAPTER 47, VIDEO 1 – Courtesy of Gale Gardner CHAPTER 75, VIDEO 1 – Courtesy of Juha Hernesniemi
li
lii VIDEO CONTENTS

Microsurgical Clipping of Right-Sided Unruptured M1 Ventricular Peritoneal Shunt Implant


Aneurysm CHAPTER 97, VIDEO 1 – Courtesy of Claudio Yampolsky and Pablo
CHAPTER 75, VIDEO 2 – Courtesy of Juha Hernesniemi, Helsinki Ajler
University Central Hospital
Microsurgical Clipping of Right-Sided Unruptured M1 STEREOTACTIC RADIOSURGERY
Aneurysm
CHAPTER 75, VIDEO 3 – Courtesy of Juha Hernesniemi, Helsinki CyberKnife Robotic Radiosurgery System
University Central Hospital CHAPTER 100, VIDEO 1 – Courtesy of Robert E. Lieberson, Ake
Hansasuta, Robert Dodd, Steven D. Chang, John R. Adler, Jr, and
Microsurgical Clipping of Right-Sided Unruptured MCA Accuray Incorporated
Bifurcation Aneurysm
CHAPTER 75, VIDEO 4 – Courtesy of Juha Hernesniemi, Helsinki
University Central Hospital TRAUMA
Microsurgical Clipping of Right-Sided Ruptured MCA Eyelid Approach for Trauma CSF Leak
Bifurcation Aneurysm CHAPTER 138, VIDEO 1 – Courtesy of Alfredo Quiñones-Hinojosa
CHAPTER 75, VIDEO 5 – Courtesy of Juha Hernesniemi, Helsinki
University Central Hospital Iatrogenic Aneurysm
CHAPTER 141, VIDEO 1 – Courtesy of Giuseppe Talamonti,
Microsurgical Clipping of Right-Sided Ruptured MCA Giuseppe D’Aliberti, and Massimo Collice
Bifurcation Aneurysm
CHAPTER 75, VIDEO 6 – Courtesy of Juha Hernesniemi, Helsinki
University Central Hospital SURGICAL MANAGEMENT OF NERVOUS
Microsurgical Clipping of Right-Sided Ruptured M2 SYSTEM INFECTIONS
Aneurysm
Cysticercosis
CHAPTER 75, VIDEO 7– Courtesy of Juha Hernesniemi, Helsinki
University Central Hospital CHAPTER 147, VIDEO 1 – Courtesy of Tomás Garzón-Muvdi and
Rodrigo Ramos-Zúñiga
An AICA Retrosigmoid Craniotomy
Lumbar Disc Replacement
CHAPTER 77, VIDEO 1 – Courtesy of Robert F. Spetzler, Nader
Sanai, and Andrew Wachtel CHAPTER 154, VIDEO 1 – Courtesy of Amjad Shad, University
Hospital Coventry and Warwickshire, United Kingdom
Total Cervical Disc Replacement
VASCULAR DISEASES/ENDOVASCULAR
CHAPTER 154, VIDEO 2 – Courtesy of Amar Saxena, University
TREATMENT Hospital Coventry and Warwickshire, United Kingdom
NBCA AVM Embolization
CHAPTER 86, VIDEO 1 – Courtesy of Stavropoula I. Tjoumakaris
NEUROSURGICAL MANAGEMENT OF SPINAL
Onyx AVM Embolization
DISORDERS/DEGENERATIVE SPINE DISORDER/
CHAPTER 86, VIDEO 2 – Courtesy of Stavropoula I. Tjoumakaris
CERVICAL SPINE
Navigation of Wingspan Stent System Across Middle
Cerebral Artery Lesion Posterior Cervical Decompression and Instrumented
CHAPTER 87, VIDEO 1 – Courtesy of L. Nelson Hopkins, Yuval Fusion
Karmon, Alexander A. Khalessi, Elad I. Levy, Sabareesh K. CHAPTER 156, VIDEO 1 – Courtesy of Edward C. Benzel,
Natarajan, and Adnan H. Siddiqui Michael P. Steinmetz, and Ajit A. Krishnaney

Deployment of Wingspan Stent System Across Middle


Cerebral Artery Lesion NEUROSURGICAL MANAGEMEMENT OF
CHAPTER 87, VIDEO 2 – Courtesy of L. Nelson Hopkins, Yuval SPINAL DISORDERS/DEGENERATIVE SPINE
Karmon, Alexander A. Khalessi, Elad I. Levy, Sabareesh K.
Natarajan, and Adnan H. Siddiqui DISORDER/LUMBAR SPINE
Intracranial Atherosclerotic Stenosis Crossed with Lumbar LP
Microwire-Microcatheter System CHAPTER 161, VIDEO 1 – Courtesy of Meic H. Schmidt
CHAPTER 87, VIDEO 3 – Courtesy of L. Nelson Hopkins, Yuval
Karmon, Alexander A. Khalessi, Elad Levy, Sabareesh K. Natarajan,
and Adnan Siddiqui NEUROSURGICAL MANAGEMENT OF
SPINAL DISORDERS/CONGENITAL AND
DEVELOPMENTAL SPINAL ABNORMALITIES
HYDROCEPHALUS
Treatment of Chiari Malformation
Optic Nerve Sheath Fenestration CHAPTER 182, VIDEO 1 – Courtesy of John Heiss
CHAPTER 95, VIDEO 1 – Courtesy of Daniele Rigamonti, S. Prem
Subramanian, and George I. Jallo
Endoscopic Third Ventriculostomy
CHAPTER 96, VIDEO 1 – Courtesy of Pablo F. Recinos,
George I. Jallo, and Violette Renard Recinos
CHAPTER 1

Ensuring Patient Safety in Surgery―


First Do No Harm
SYMEON MISSIOS  •  KIMON BEKELIS  •  GEORGE T. BLIKE  •  KADIR ERKMEN

Primum non nocere—first do no harm. This often-quoted that iatrogenic failure occurs in approximately 4% of all
phrase epitomizes the importance the medical community hospitalizations and is the eighth leading cause of death in
places on avoiding iatrogenic complications.1 In the process ­America—responsible for up to 100,000 deaths per year in
of providing care, patients, physicians, and the entire clinical the United States alone.7
team join to use all available medical weapons to combat A subsequent review of over 14,700 hospitalizations in
disease to avert the natural history of pathologic processes. Colorado and Utah identified 402 surgical adverse events,
Iatrogenic injury or, simply, “treatment-related harm” occurs producing an annual incidence rate of 1.9%.8 The nature of
when this implicit rule to “first do no harm” is violated. Both surgical adverse events were categorized by type of injury
society and the medical community have historically been and by preventability (Table 1-1).
intolerant of medical mistakes, associating them with negli- These two studies were designed to characterize iatro-
gence. The fact is that complex medical care is prone to fail- genic complications in health care. While not statistically
ure. Medical mistakes are much like “friendly-fire” incidents powered to allow surgical subspecialty analysis, it is likely
in which soldiers in the high-tempo, complex fog of war that the types of failures and subsequent injuries that this
mistakenly kill comrades rather than the enemy. Invariably, study identified can be generalized to the neurosurgical
medical error and iatrogenic injury are associated with mul- patient population. More recent literature supports the find-
tiple latent conditions (constraints, hazards, system vulner- ings of these landmark studies.9-11
abilities, etc.) that predispose front-line clinicians to err. This The Institute of Medicine used the Harvard Practice
chapter will review the science of human error in medicine Study as the basis for its report, which endorsed the need
and surgery. The specific case of wrong-sided brain surgery to discuss and study errors openly with the goal of improv-
will be used as an illustration for implementation of emerg- ing patient safety.7 The Institute of Medicine report on
ing new strategies for enhancing patient safety. medical errors, “To Err Is Human: Building a Safer Health
System,” must be considered a landmark publication.12 It
was published in 1999 and focused on medical errors and
The Nature of Iatrogenic Injury their prevention. This was followed by the development of
in Medicine and Surgery other quality improvement initiatives such as the Joint Com-
mission on the Accreditation of Healthcare Organizations
The earliest practitioners of medicine recognized and (JCAHO) Sentinel Events Program.12
described iatrogenic injury. Iatrogenic (Greek, iatros = One might argue that morbidity and mortality reviews
doctor, genic = arising from or developing from) literally already achieve this aim. The “M&M” conference has a long
translates to “disease or illness caused by doctors.” Famous history of reviewing negative outcomes in medicine. The
examples exist of likely iatrogenic deaths, such as that goal of this traditional conference is to learn how to pre-
of George Washington, who died while being treated for vent future patients from suffering similar harm, and thus
pneumonia with blood-letting. The Royal Medical and Sur- incrementally improve care. However, frank discussion of
gical Society, in 1864, documented 123 deaths that “could error is limited in M&M conferences. Also, the actual review
be positively assigned to the inhalation of chloroform.”2 practices fail to support deep learning regarding systemic
Throughout history, physicians have reviewed unexpected vulnerabilities13; indeed, since M&M conferences do not
outcomes related to the medical care they provided to explicitly require medical errors to be reviewed, errors
learn and improve that care. The “father” of modern neuro- are rarely addressed. One prospective investigation of four
surgery, Harvey Cushing, and his contemporary Sir ­William U.S. academic hospitals found that a resident vigilantly
Osler modeled the practice of learning from error by pub- attending weekly internal medicine M&M conferences for
lishing their errors openly so as to warn others on how to an entire year would discuss errors only once. The surgi-
avert future occurrences.3-5 However, the magnitude of iat- cal version of the M&M conference was better with error
rogenic morbidity and mortality was not quantified across discussion. However, while surgeons discussed adverse
the spectrum of health care until the Harvard Practice events associated with error 77% of the time, individual
Study, published in 1991.6 This seminal study estimated provider error was the focus of the discussion and cited
1
2 1  •  Ensuring Patient Safety in Surgery―First Do No Harm

Table 1-1  Surgical Adverse Events Categorized by Type and reliability in aviation, nuclear power, and other high
of Injury and Preventability hazard work settings. Membership in the Human Factors
and Ergonomics Society in North America alone has grown
Percentage of Percentage to over 15,000 members. Human factors engineering and
Type of Event Adverse Events Preventable
related disciplines are deeply interested in modeling and
Technique-related complication 24 68 understanding mechanisms of complex system failure. Fur-
Wound infection 11 23 thermore, these applied sciences have developed strategies
Postoperative bleeding 11 85 for designing error prevention and building error tolerance
Postpartum/neonatal related 8 67 into systems to increase reliability and safety, and these strat-
Other infection 7 38 egies are now being applied to the healthcare industry.16-21
Drug-related injury 7 46 The specialty of anesthesiology has employed this science
Wound problem (noninfectious) 4 53 to reduce the anesthesia-related mortality rate from approx-
Deep venous thrombosis 4 18 imately 1 in 10,000 in the 1970s to over 1 in 250,000 three
Nonsurgical procedure injury 3 59 decades later.22 Critical incident analysis was used by a bio-
Diagnostic error/delay 3 100 engineer (Jeffrey Cooper) to identify preventable anesthesia
Pulmonary embolus 2 14 mishaps in 1978.23 Cooper’s seminal work was supplemented
Acute myocardial infarction 2 0 by the “closed-claim” liability studies, which delineated the
Inappropriate therapy 2 100 most common and severe modes of failure and factors that
Anesthesia injury 2 45 contributed to those failures. The specialty of anesthesiol-
Congestive heart failure 1 33 ogy and its leaders endorsed the precepts that safety stems
Stroke 1 0 more from improved system design than from increasing
Pneumonia 1 65 vigilance of individual practitioners. As a direct result, anes-
Fall 0.5 50 thesiology was the first specialty to adopt minimal standards
Other 5.5 32 for care and monitoring, preanesthesia equipment check-
lists similar to those used in commercial aviation, standard-
ized medication labels, interlocking hardware to prevent gas
as causative of the negative outcome in 8 of 10 conference mix-ups, international anesthesia machine standards, and
discussions.13 Surgical conference discussion rarely iden- the development of high-fidelity human simulation to sup-
tified structural defects, resource constraints, team com- port crisis team training in the management of rare events.
munication, or other system problems. Further limiting its Lucien Leape, a former surgeon, one of the lead authors
utility, the M&M conference is reactive by nature and highly of the Harvard Practice Study, and a national advocate for
subject to hindsight bias. This is the basis for most clinical patient safety, has stated, “Anesthesia is the only system in
outcome reviews, focusing solely on medical providers and healthcare that begins to approach the vaunted ‘six sigma’ (a
their decision making.14 In their report, titled “Nine Steps defect rate of 1 in a million) level of clinical safety perfection
to Move Forward from Error” in medicine, human factors that other industries strive for. This outstanding achievement
experts Cook and Woods challenged the medical commu- is attributable not to any single practice or development of
nity to resist the temptation to simplify the complexities that new anesthetic agents or even any type of improvement
practitioners face when reviewing accidents post hoc. Pre- (such as technological advances) but to application of a
mature closure by blaming the closest clinician hides the broad array of changes in process, equipment, organization,
deeper patterns and multiple contributors associated with supervision, training, and teamwork. However, no single one
failure, and ultimately leads to naive “solutions” that are of these changes has ever been proven to have a clear-cut
weak or even counterproductive.15 The Institute of Medicine impact on mortality. Rather, anesthesia safety was achieved
has also cautioned against blaming an individual and rec- by applying a whole host of changes that made sense, were
ommending training as the sole outcome of case review.7 based on an understanding of human factors principles, and
While the culture within medicine is to learn from failure, had been demonstrated to be effective in other settings.”24
the M&M conference does not typically achieve this aim. The Anesthesia Patient Safety Foundation, which has
become the clearinghouse for patient safety successes in
anesthesiology, was used as a model by the American Medi-
A Human Factors Approach cal Association to form the National Patient Safety Founda-
to Improving Patient Safety tion in 1996.25 Over the subsequent decade, the science of
safety has begun to permeate health care.
Murphy’s law—that whatever can go wrong will—is the The human factors psychologist James Reason has char-
common-sense explanation for medical mishaps. The sci- acterized accidents as evolving over time and as virtually
ence of safety (and how to create it), however, is not com- never being the consequence of a single cause.26,27 Rather,
mon sense. The field of human factors engineering grew he describes accidents as the net result of local triggers that
out of a focus on human interaction with physical devices, initiate and then propagate an incident through a hole in
especially in military or industrial settings. This initial focus one layer of defense after another until irreversible injury
on how to improve human performance addressed the prob- occurs (Fig. 1-1). This model has been referred to as the
lem of workers that are at high risk for injury while using a “Swiss cheese” model of accident causation. Surgical care
tool or machine in high-hazard industries. In the past several consists of thousands of tasks and subtasks. Errors in the
decades, the scope of this science has broadened. Human execution of these tasks need to be prevented, detected,
factors engineering is now credited with advancing safety and managed, or tolerated. The layers of Swiss cheese
1  •  Ensuring Patient Safety in Surgery―First Do No Harm 3

Local triggers
Intrinsic defects
Identification
atypical conditions of care
management
Identification of
problem/
Latent contributory
threat
failures Process A factors
Surveillance
at the source, story
managerial
levels Enhanced
patient Active error
safety Prioritization
management
Trajectory Broad
cycle
of accident dissemination
opportunity of effective
Process B counter- Counter-
measures measure
Psychological Unsafe design and local
precursors acts Counter-
measure implementation
Defense in depth evaluation and
validation
FIGURE 1-1  Reason’s model of accident causation. Accidents (adverse
outcomes) require a combination of latent failures, psychological pre-
cursors, event triggers, and failures in several layers of the system’s
“defense in depth.” (Copyright Dr. Reason.) FIGURE 1-2  Sequence of steps for identifying vulnerabilities and then
implementing corrective measures. (Copyright Blike 2002.)

represent the system of defenses against such error. Latent If this schema is used to structure a review of a morbid-
conditions is the term used to describe “accidents waiting to ity or mortality, that review will be extended beyond myo-
happen” that are the holes in each layer that will allow an pic attention to the singular practitioner. Furthermore, the
error to propagate until it ultimately causes injury or death. array of identified factors that undermine safety can then be
The goal in human factors system engineering is to know countered systematically by tightening each layer of defense,
all the layers of Swiss cheese and create the best defenses one hole at a time. I have adapted active error management
possible (i.e., make the holes as small as possible). This as described by Reason and others into a set of steps for
very approach has been the centerpiece of incremental making incremental systemic improvements to increase
improvements in anesthesia safety. safety and reliability. In this adaptation, a cycle of active
One structured approach designed to identify all holes error management consists of (1) surveillance to identify
in the major layers of cheese in medical systems has been potential threats, (2) investigation of all contributory factors,
described by Vincent.28,29 He classifies the major categories (3) prioritization of failure modes, (4) development of coun-
of factors that contribute to error as follows: termeasures to eliminate or mitigate individual threats, and
1. Patient factors: condition, communication, availability, (5) broad implementation of validated countermeasures
and accuracy of test results and other contextual factors (Fig. 1-2).
that make a patient challenging The goal is to move from a reactive approach based
2. Task factors: using an organized approach in reliable on review of actual injuries toward a proactive approach
task execution, availability, and use of protocols, and that anticipates threats based on a deep understanding of
other aspects of task performance human capabilities and system design that aids human per-
3. Practitioner factors: deficits and failures by any individual formance rather than undermines it.
member of the care team that undermines management A comprehensive review of the science of human fac-
of the problem space in terms of knowledge, attention, tors and patient safety is beyond the scope of this chapter;
strategy, motivation, physical or mental health, and other neurosurgical patient safety has been reviewed, including
factors that undermine individual performance ethical issues and the impact of legal liability.30 Safety in
4. Team factors: verbal/written communication, super- aviation and nuclear power has taken over four decades to
vision/seeking help, team structure, and leadership, achieve the cultural shift that supports a robust system of
and other failures in communication and coordination countermeasures and defenses against human error. How-
among members of the care team such that manage- ever, it is practical to use an example to illustrate some of
ment of the problem space is degraded the human factors principles introduced. Consider this case
5. Working conditions: staffing levels, skills mix and workload, example as a window into the future of managing the most
availability and maintenance of equipment, administrative common preventable adverse events associated with sur-
and managerial support, and other aspects of the work gery (see Table 1-1).
domain that undermine individual or team performance
6. Organization and management factors: financial
resources, goals, policy standards, safety culture and EXAMPLE OF MEDICAL ERROR: “WRONG-SIDED BRAIN
priorities, and other factors that constrain local micro- SURGERY”
system performance
7. Societal and political factors: economic and regulatory Wrong-site surgery is an example of an adverse event
issues, health policy and politics, and other societal fac- that seems as though it should “never happen.” However,
tors that set thresholds for patient safety given over 40 million surgical procedures annually, we
4 1  •  Ensuring Patient Safety in Surgery―First Do No Harm

should not be surprised when it occurs. The news media the surgical team as to the approach for the same surgery
has diligently reported wrong-site surgical errors, espe- makes it unlikely anyone would trap an error in position-
cially when they involve neurosurgery. Headlines such ing or draping. It is known that patient position and opaque
as “Brain Surgery Was Done on the Wrong Side, Reports draping can remove external cues as to left and right ori-
Say” (New York Daily News, 2001) and “Doctor Who entation of the patient and thus predispose surgeons to
Operated on the Wrong Side of Brain Under Scrutiny” wrong-sided surgery. When a patient is lateral, fully draped,
(New York Times, 2000), are inevitable when wrong-site and the table rotated 180 degrees prior to the attending sur-
brain surgery occurs.31-33 As predicted, these are not iso- geon entering the operating theater, it is difficult to verify
lated stories. A recent report from the state of Minnesota right from left. Furthermore, the language for positioning
found 13 instances of wrong-site surgery in a single year creates ambiguity since the terminology of left lateral decu-
during which time approximately 340,000 surgeries were bitus, right side up, and left side down are used interchange-
performed.34 No hospital appeared to be immune to ably by the surgical team to specify the position. A patient
what appears on the surface to be such a blatant mistake. with bilateral disease, predominant right-sided symptoms,
Indeed, an incomplete registry collecting data on wrong- and left-sided pathology having a left-sided craniotomy in
site surgery since 2001 now includes over 150 cases. Of the right lateral decubitus position with the table turned 180
126 instances that have been reviewed, 41% relate to degrees and fully draped obviously creates more confusion
orthopedic surgery, 20% relate to general surgery, 14% to than a gallbladder surgery in the supine position.
neurosurgery, 11% to urologic surgery, and the remaining
to the other surgical specialties.35 In a recent national sur-
Communication (Factors That Undermine the
vey,36 the incidence of wrong-sided surgery for cervical
discectomies, craniotomies, and lumbar surgery was 6.8,
Patient’s Ability to Be a Source of Information
2.2, and 4.5 per 10,000 operations, respectively. Regarding Conditions That Increase the Risk
The sensational “front-page news” media fails to iden- for Complications and Need to Be Managed)
tify the deeper second story behind these failures and Obviously, patients with language barriers or cognitive defi-
how to prevent future failures through creation of safer cits represent a group that may be unable to communicate
systems.37 In this example, we provide an analysis of their understanding of the surgical plan. This can increase
contributory factors associated with wrong-site surgery the chance of patient identification errors that lead to
to reveal the myriad of holes in the defensive layers of wrong-site surgery. In a busy practice, patients requiring the
“cheese.” These holes will need to be eliminated to truly same surgery might be scheduled in the same operating
impact the frequency of this already rare event and create room (OR). It is not uncommon to perform five carotid end-
more reliable care for our patients. arterectomies in a single day.40 When one patient is delayed
and the order switched to keep the OR moving, this vulner-
ability is expressed. Patients with common names are espe-
Contributory Factor Analysis cially at risk. A 500-bed hospital will have approximately
1,000,000 patients in the medical record system. About 10%
PATIENT FACTORS ASSOCIATED of patients will have the same first and last names. Five
WITH WRONG-SITE SURGERY percent will have a first, middle, and last name in common
Patient Condition (Medical Factors That If Not with one other individual. Only by cross-checking the name
Known Increase the Risk for Complications) with one other patient identifier (either birth date or a medi-
Neurosurgical patients are at higher risk for wrong patient cal record number) can wrong-patient errors be trapped.41
surgery than average. Patients and their surgical conditions Another patient communication problem that increases
contribute to error. When patients are asked what surgery risk for wrong-site surgery consists of patients marking
they are having done on the morning of surgery, only 70% themselves. Marking the skin on the side of the proposed
can correctly state and point to the location of the planned surgery with a pen is now common practice by the surgi-
surgical intervention.38 Patients are a further source of cal team and part of the Universal Protocol. However, some
misinformation of surgical intent when the pathology and patients have placed an X on the site not to be operated on.
symptoms are contralateral to the site of surgery, a com- The surgical team has then confused this patient mark with
mon condition in neurosurgical cases. Patients scheduled their own in which an X specifies the side to be operated on.
for brain surgery and carotid surgery often confuse the side Patients are often not given information of what to expect
of the surgery with the side of the symptoms. Patients with and will seek outside information. For example, a neurosur-
educational or language barriers or cognitive deficits are geon on a popular daytime talk show discussing medical
more vulnerable since they are unable to accurately com- mistakes stated incorrectly that patients should mark them-
municate their surgical condition or the planned surgery. selves with an X on the side that should not be operated
Certain operations in the neurosurgical population pose on.42 This error in information reached millions of viewers,
higher risk for wrong-site surgery. While left–right symme- and was in direct violation of recommendations for mark-
try and sidedness represents one high-risk class of surger- ing provided by the Joint Commission on Accreditation of
ies, spinal procedures in which there are multiple levels is Healthcare Organizations (and endorsed by the American
another.39 College of Surgeons, American Society of Anesthesiology,
Patients with anatomy and pathology that disorient the and Association of Operating Room Nurses). Patients who
surgical team to side or level are especially at risk. Ante- watched this show and took the advice of the physician are
rior cervical discectomies can be approached by surgeons now at higher risk than average for a wrong-sided surgical
from either side. This lack of a consistent cue for the rest of error.
1  •  Ensuring Patient Safety in Surgery―First Do No Harm 5

these components functioned nominally.45 This checklist


Availability and Accuracy of Test Results
includes over 40 items and has included redundancy for
(Factors That Undermine Awareness checking critical components. It has been introduced as a
of Conditions That Increase the Risk standard operating procedure for the discipline of anesthe-
for Complications and Need to Be Managed) sia and is now mandated by the U.S. Food and Drug Admin-
Radiologic imaging studies can be independent markers istration46 (Fig. 1-3).
of surgical pathology and anatomy. However, films and/or
reports are not always available. Films may be lost or mis-
placed. Also, they may be unavailable because they were
Availability and Use of Protocols (If Standard
performed at another facility. New digital technology has Protocols Exist, Are They Well Accepted
created electronic imaging systems that virtually eliminate and Are They Being Used Consistently?)
lost studies. However, space constraints have led many hos- The first attempts to establish standardized protocols for
pitals to remove old view boxes to make room for digital patient safety began with JCAHO.35 The JCAHO Sentinel
radiologic monitors. When patients bring films from an out- Event system began monitoring major quality issues in the
side hospital, this decision to eliminate view boxes prevents late 1980s about the same time the original AAOS Sign Your
effective use of the studies. Even when available, x-rays Site program launched. A sentinel event was defined as “an
and diagnostic studies are not labeled with 100% reliabil- unexpected occurrence involving death or serious physical
ity. Imaging studies have been mislabeled and/or oriented or psychological injury, or the risk thereof.”35 In addition to
backward, leading to wrong-sided surgery.43 the reporting aspect of the program, a quality review is trig-
gered that requires a root cause analysis to try to determine
TASK FACTORS ASSOCIATED WITH WRONG-SITE factors contributing to the sentinel event.
SURGERY The Universal Protocol was a logical extension of the
Tasks are the steps that need to be executed to accomplish Sentinel Events quality improvement program. ­Wrong-site
a work goal. It is especially important to structure tasks and surgery is considered a sentinel event. Because of the man-
task execution procedures when work domains are com- datory reporting of Sentinel Events, some of the best data
plex, the task must be executed under time pressure, and on the incidence and anatomic location of wrong-site sur-
the consequences of errors in task execution are severe. geries come from the JCAHO. Before implementation of
Typical tools for structuring task execution are protocols, the Universal protocol, the JCAHO analyzed 278 reports
checklists, and algorithms. of wrong-site surgery in the Sentinel Events database up
to 2003.47 This review showed that in 10% of the cases the
wrong procedure had been performed, in 12% surgery had
Task Design and Clarity of Structure (Consider
been performed on the wrong patient, and a further 19%
This to Be an Issue When Work Is Being Performed of the reports characterized miscellaneous wrongs. Thus it
in a Manner That Is Inefficient and Not Well was felt that a protocol to address this issue must include
Thought Out) provisions to avoid wrong patient, wrong procedure, as well
In large hospitals, ORs do not execute a consistent set of as wrong-site surgery.
checks and balances to verify that the right patient, the sur- In May 2003, the JCAHO convened a “Wrong Site Surgery
gical intent, and critical equipment and implants are pres- Summit” to look into possible quality initiatives in this area.
ent. If surgical team members think that they can announce The three most effective measures identified were patient
the patient name and procedure aloud and that this will reli- identification, surgical site marking, and calling a “time
ably prevent wrong-site surgery, they are mistaken. Structur- out” before skin incision to verify factors such as the ini-
ing tasks for reliability such that current failure rates will tial patient identification, patient allergies, completion of
be moved from approximately 1 in 30,000 to 1 in 1 million preoperative interventions such as intravenous antibiotics,
will take the kind of task structure and consistency seen on the procedure to be performed, available medical records,
the flight decks of commercial planes. For decades, pilots imaging studies, equipment etc. When correlated to Sen-
have used well-organized preflight checklists to perform tinel Event Data, it was found that only 12% of wrong-site
the tasks to start up an engine and verify that all mission- surgeries occurred in institutions with two of three proto-
critical equipment is present and functional. cols applied.48 More importantly, no incidences of wrong-
An example of a mature use of checklists exists in sided surgery were detected in institutions with all three
anesthesiology. An anesthesia machine (and other criti- measures in place. Therefore, these three key processes
cal equipment) must be present and functional prior to the became the Core Elements of the Universal Protocol, which
induction of anesthesia and initiation of paralysis so that is a mandatory quality screen in all JCAHO-certified hospi-
a patient can have an airway as well as breathing and cir- tals since July 1, 2004.48
culatory support provided within seconds to avoid hypoxia The universal protocol for preventing wrong-patient,
and subsequent cardiovascular complications. Until 1990, wrong-site errors is based on checklist principles; but it is not
equipment failures were a significant problem leading yet a validated comprehensive checklist that will trap errors
to patient injury in anesthesia, even though anesthesia in the way aviation checklists do. This is largely due to the
machines and equipment had been standardized and were lack of consistent execution of the checklists in a challenge-
being used on thousands of patients in a given facility.44 response format that is identical in procedure and practice
At this time, a preanesthesia checklist was established to throughout a single hospital’s ORs.49,50 This protocol is a first
structure the verification of mission critical components step, but the barriers to effective implementation are exten-
required to provide the anesthetic state and to verify that sive at present and hinder improved safety.51,52
6 1  •  Ensuring Patient Safety in Surgery―First Do No Harm

Power Up Vaporizers FULL

Vaporizer Caps TIGHT


High Pressure System
Open Vaporizer To Be Used OPEN
Oxygen Analyzer Calibration
Low Pressure Leak Test NO LEAK × 10 SECS
Low Pressure Systems
Common Gas Line CONNECTED
Breathing System
Vaporizers Closed VAPORIZORS OFF
Scavenger System
Machine Main Switch MAIN ON
Ventilator Flowmeter O2 Ratio Protection INTACT
Standard Monitors Floats DO NOT STICK

Final Set-Up Decrease Flows MINIMUM FLOW

Example of electronic pre-anesthesia checklist used


to train anesthesia residents into this standard Video
procedure. Challenge response format used with Help
Task Done
indexing to allow one to know where they are, what
is done, and steps remaining. Video help
demonstrates proper execution of the checks.

FIGURE 1-3  Example of computer implementation.

Another hazard is the lack of clarity for marking surgi- seen even when the patient is prepared and draped. Again,
cal sites. Marking the surgical site has been endorsed to we used the mark to specify the target, not the incision or
improve safety and is a major component of the Universal body entry point. In addition, we have had every procedure
Protocol. However, as described previously, the mark can in our booking system labeled as “mark required” or “mark
be a source of error when placed inappropriately by the not required,” because this was not always clear. Even with
patient or any other member of the surgical team. Some this level of specificity, we have found marking to be erro-
specifics regarding the details of what, when, and how to neous and inconsistent during our initial implementation.
mark are lacking. Do you mark the incision site or the tar- Marking the skin for spine surgery to indicate the level may
get of the surgery? What constitutes a unique and definitive increase the risk of wrong-site errors.53 A superior method
mark? What shape and color should be used? What type of for “marking” to verify the correct spinal level to be oper-
pen should be used? Does the ink pose any risk for infec- ated upon is to perform an intraoperative radiologic study
tion or is it washed off during the course of preparation? with a radiopaque marker. We expect that many revisions
Who should place the mark? What are the procedures that to this type of safety measure will be needed before the
get marked and which should not? Are there any patients marking procedure is robust and truly adds safety value.
for whom the mark is dangerous? How do you mark for Cross-checking procedures in aviation were developed and
a left liver lobe resection or other procedures like brain matured over decades to achieve the reliability and consis-
surgery in which there is a single organ but still sidedness tency now observed.54
that is critical? I worked with over 10 surgical specialties Statistics for the first two quarters after implementation
to develop specific answers to these questions. Multiple of the Universal Protocol were encouraging.55 It appeared
marks and pens were tested. Not all symbols and pens that reports of wrong-site surgeries had declined below the
were equally effective. Many inks did not withstand prep- rate of approximately 70 cases per year for the previous
aration and remain visible in the operative field. We now 2 years. However, after a full year’s statistics had been accu-
use specific permanent pens (Carter fine and Sharpie very mulated, it was found that the incidents of wrong-site sur-
fine) and a green circle to mark only “sided” procedures. gery had actually increased to about 88 for 2005.12 Overall,
We specified that the target is marked rather than the inci- wrong-site surgery had climbed to the number 2 ranking in
sion, the mark must be done by the surgeon, and the mark frequency of sentinel events. Whether these data represent
must be placed in a manner in which it is visible during the a true increase in the frequency of wrong-site surgery or
preincision check after the position, preparation, and drape are simply explained by better awareness and reporting is
have been completed. For example, a procedure requiring unclear at this time.
cystoscopy to inject the right ureteral orifice to treat reflux is Currently the direction in patient safety is more toward a
now marked on the right thigh so that the green circle mark holistic surgical checklist, including all aspects of a patient
is a cue to all members of the surgical team and can be visit to the hospital and not only the limited time out before
1  •  Ensuring Patient Safety in Surgery―First Do No Harm 7

surgery.56 A number of studies have been conducted that sources of information as to the surgical plan. Instead, they
evaluated the use of checklists in medicine and their effect often propagate errors and/or enter new misinformation
in behavior modification.56 To that effect, the WHO surgi- into scheduling systems and patient records.
cal checklist has been developed.57 The features of the
Universal Protocol have been integrated in this checklist Attention (Factors That Undermine Attention)
with the addition of preprocedural and postprocedural Task execution is degraded when attention is pulled away
checkpoints. Results from the implementation of the WHO from the work being performed. Distraction and noise are
checklist are encouraging. These initial attempts have been significant problems in the operating theater that can dra-
extended to the development of checklists, like the SUR- matically affect performance and vigilance. Because the
PASS checklist,58 that cover the whole surgical pathway wall and floor surfaces are designed to be cleaned easily,
from admission to discharge. Overall, although it has been noise levels in the OR are similar to those on a busy high-
shown that aviation based team training elicits initially sus- way.62,63 The preincision interval is a very active time, when
tainable responses, effects may take years to be part of the the patient is being given anesthesia, being positioned, and
surgical culture.59 being prepared. These parallel activities represent compet-
ing priorities that conflict with a coordinated effort by the
PRACTITIONER FACTORS ASSOCIATED entire surgical team to verify surgical intent.
WITH WRONG-SITE SURGERY
Knowledge, Skills, and Rules (Individual Deviation Strategy (Given Many Alternatives, Was
from Standard of Care Due to Lack of Knowledge, the Strategy Optimized to Minimize Risks
Poor Skills, or a Failure to Use Rules Associated through Preventive Measures and through
with Best Practice) Recovery Measures That Use Contingency
Knowledge deficits are often due to over-reliance on mem- Planning and Anticipatory Behaviors?)
ory for information used rarely. Measures that increase Strategic planning is not a major contributory factor for
availability of referent knowledge when needed would be wrong-site surgery in my opinion. However, we have found
helpful. Unfortunately, references at the point of care on the that our initial attempts to use the exact same preincision
day of surgery are not standard or reliable. Three descrip- checklist for all types of surgical populations was a strategic
tions of the surgery often exist. The operative consent lists error and overly simplistic.
the planned surgery in lay language patients should be able
to understand. The surgical preoperative note may provide
Motivation/Attitude (Motivational Failures and Poor
a technical description of the planned surgery but often Attitudes Can Undermine Individual Performance—
is incomplete, failing to include such information as the the Psychology of Motivation Is Complex)
specific reason for surgery, sidedness, target, approach, Because wrong-site surgery is a rare event, motivating the
position, need for implants, and/or special equipment. operative team to invest significant energy into preventive
The booking system will often use a third nomenclature measures can be challenging. Even though the career risk
to describe the planned surgery that is administrative and for performing a wrong-site surgery is significant, the rar-
linked to billing codes. The use of three different references ity of this complication predisposes surgeons to deny this
for the same surgical procedure creates ambiguity. A “right complication as a significant problem. Part of the problem
L3–L4 facetectomy in the prone position” may be listed on is that surgeons do not have an adequate understanding of
the consent form as a “right third lumbar vertebrae joint sur- human vulnerabilities and the potential for error. Many sur-
gery” on the consent and a CPT code “LUMBAR FACETEC- geons see wrong-site surgery as purely a failure in vigilance
TOMY 025-36047.”60 by an individual surgeon. The motivation to lead a team
Subtle knowledge deficits are more likely to reach a effort and accept cross-checking is therefore low. Human
patient and cause harm when individuals are charged to do error training in surgery is just now beginning to address the
work that is at the limits of their competency. The culture decreased performance associated with fatigue, personal
of medicine does not encourage knowledge calibration, the stress, production pressure, and so forth. Motivational bar-
term used to describe how well individuals know what they riers are not limited to the surgeon. Many nurses and anes-
know and know what they do not know.61 At our institution, thesiologists see wrong-site surgery as an isolated surgeon
when preoperative nurses were assigned the role of mark- failure and believe that they should have no responsibility
ing patients to identify sidedness, they routinely marked for verifying patient and/or procedure. Individual training
the wrong site or marked in a manner such that the mark about human error is needed across all members of the
was not visible after the position, prep, and drape. These operative team to increase motivation to change behavior
nurses accepted this assigned role because our medical and use new methods (such as a team-executed checklist)
culture encourages guessing and assertiveness. On further to prevent wrong-site surgery.
review, we have found that only the surgeon has the knowl-
edge required to specify the surgical plan in detail and
Physical/Mental Health (Provider Performance
to mark patients correctly. Other members of the surgical Deviations from Standard “Competencies”
team often have subtle knowledge deficits regarding surgi- Can Be Due to Physical or Mental Illness)
cal anatomy, terminology, and technical requirements such Industries that have come to accept the human component
that they are prone to err in marking or positioning patients. as having requirements for optimal human–machine sys-
Similarly, nurses and anesthesiologists in the presurgical tem performance have thus promoted regular “fit-for-duty”
areas are not able to verify or reconcile multiple differing examinations.64 In the aviation industry, job screening
8 1  •  Ensuring Patient Safety in Surgery―First Do No Harm

includes a “color-blindness” test for air traffic controllers tend to be nursing roles, and diagnostic decision making
since many of the monitors encode critical information in and treatment selection tend to be physician roles.71 A myr-
color.65 Some specific provider health conditions can pre- iad of supporting clinicians and nonclinicians are vital in
dispose to wrong-site surgery. Surgeons and other members medical teams. The nurse, nurse practitioner, medical stu-
of the perioperative team with dyslexia and related neuro- dent, physicians, and others must be able to detect problem
psychiatric deficits have particular difficulty with sidedness states or deviations from the “expected course” and activate
and left–right orientation. control measures. When a practitioner fails to work within
his or her competencies or is on the learning curve for his
TEAM FACTORS ASSOCIATED or her role on the team, failure to get or provide supervi-
WITH WRONG-SITE SURGERY sion comes into play. For wrong-site surgery errors, this
A complex work domain will overwhelm the cognitive abili- issue manifests when one surgeon does the preoperative
ties of any one individual and not permit expertise of the consultation and operative planning and the other starts
entire field of practice. A common strategy for managing the the surgery with incomplete knowledge. For example, a
excess demands that complex systems (like that of human resident or fellow may fail to call an attending physician to
physiology and pathophysiology) place on any individual is seek clarification of the operative plan.
to subspecialize. Breaking a big problem into smaller parts
that are then more manageable by a group of individuals is
Team Structure and Leadership (Teams That Do Not
rational. However, by “fixing” the problem of individual cog-
nitive work overload, a new class of problems manifests—
Have Structure, Role Delineation, and Clarity, and
those due to team communication and coordination failure. Methods for Flattening Hierarchy While Resolving
Many human factors experts consider team failures to be the Conflict Will Have Suboptimal Team Performance)
most common contributory factor associated with error in Teams will inevitably have to face ambiguous situations that
complex sociotechnical work systems.66 Crisis resource man- need immediate action. Authority gradients prevent junior
agement training and team training in aviation is considered members of the team from questioning the decision making
to have played a major role in improving aviation safety.67 and action planning of the leader (a nurse might be hesitant
These methods are just now being applied in medicine.68 to tell a senior surgeon that he or she is violating a safety
procedure, and/or the surgeon might disregard the nurse).70
Verbal/Written Communication (Any Methods for flattening hierarchy will lead to more robust
Communication Mode That When It Fails Leads team situational awareness and support cross-checking
to a Degradation in Team Performance) behavior. In contrast, it is essential to have efficient ways of
Verbal communications fail due to noise (just do not resolving conflict, especially under emergency conditions.
hear) or content comprehension (mismatch between what Some surgeons view the Universal Protocol as a ridicu-
was intended and what was understood). Noise should lous requirement forced upon them by regulatory bodies
be minimized to support verbal communication in the responding to liability pressure. This can create a void in
OR. Comprehension problems have many mechanisms. leadership regarding team behaviors that would otherwise
Human-to-human communication requires “grounding,” help to trap errors that predispose to wrong-site surgery.
which is the process whereby both parties frame the com-
munication episode based on how the one conveying a Working Conditions Associated with Wrong-Site
message discovers the frame of reference of the one receiv- Surgery
ing the message. This activity represents a significant part Individuals and teams cannot perform optimally when they
of effective communication. Agreeing on a common lan- have inadequate resources to manage the work at hand. Typi-
guage and structuring communication goes a long way cally, workers have little control over the conditions in which
toward increasing accuracy and speed of communication they are required to work. Managers make decisions that
of mission-critical information.17,18,69 While isolated exam- ultimately aid or constrain practitioners in terms of ratios of
ples of structured communication across members of the patients per provider, the physical space available, and the
operative team exist, it is usually confined to individuals tools and/or technology available to front-line workers.
knowledgeable in safety science and the use of structured
communication in the military and in aviation. Staffing Levels, Skills Mix, and Workload
(Managers Facing Financial Pressures, a Nursing
Supervision/Seeking Help (Any Member of the Team Shortage, and Increasing Patient Acuity Can Choose
Who Fails to Mobilize Help When Getting into a to Institute Hiring Freezes and Reduce Staffing
Work Overload Situation, or a Team Member in Ratios to Decrease the Costs Associated with Care)
a Supervisory Role Failing to Provide Adequate While institutions and providers that have high surgical
Oversight, Especially in Settings in Which There Are case volumes have been noted to have the best surgical
Learners and/or Transient Rotating Team Members) outcomes, medical mishaps occur even in these institutions.
True team performance is only realized when a group of indi- Providing exceptional care to a few patients is easier than
viduals share a common goal, divide work tasks between providing reliable care to everyone.72 Indeed, excessive pro-
individuals to create role delineation and role clarity within duction pressure and patient volumes are associated with
the team, and know each other’s roles well enough to pro- safety violations due to cutting corners when productivity
vide cross-checks of mission-critical activities.70 On medi- goals are unrealistic. Over two thirds of wrong-site surgeries
cal teams, data gathering and treatment implementation occurred in ambulatory surgery settings in which patient
1  •  Ensuring Patient Safety in Surgery―First Do No Harm 9

acuity is the lowest but productivity pressures are high.73 such as the operative position required, the need for surgi-
Financial constraints have forced more ORs to be staffed by cal implants, or the requirement for special equipment, is
temporary traveling position nurses, have resulted in nurs- not obvious, and thus fail to be explicit. In addition, this
ing orientations that have been reduced, and have increased work and the expertise required are often undervalued.
production pressure on surgeons to increase their utilization The result can be to hire inexperienced secretaries and
of OR time. Unfortunately, such aggressive measures to uti- accept high support staff turnover.
lize all the capacity of the OR resources conflicts with the
need for some reserve capacity to manage the inherent ORGANIZATIONAL FACTORS ASSOCIATED
uncertainty and variability associated with medical dis- WITH WRONG-SITE SURGERY
ease and surgical care. As a result, emergency situations can Organizations must make safety a priority. If production pres-
easily overwhelm care systems that lack reserve resources. sure and economic goals are in conflict with safety, organiza-
Providers calling in sick during flu season and/or a flurry of tions must have structure and methods for ensuring safety
surgical emergencies can create dangerous conditions for as the priority.75 Independent offices of patient safety and
elective surgery due to the need to redirect those resources patient safety officers with the authority to stop operations
that might otherwise be available. when necessary are examples of organizational structures
designed to maintain safety in the face of economic pressure.
Availability and Maintenance of Equipment Financial Resources (Safety Is Not Free: The Costs
(Technology and Tools Vary in their Safety Features Associated with Establishing Safe Practices and
and Usability: Equipment Must Be Maintained Acquiring Safety Technology May Be Prohibitive)
or It Can Become a Liability) Many organizations have implemented the Universal Proto-
For preventing wrong-site surgery, we have found that the col, but have done so in an incomplete manner, performing
specific marking pen we are utilizing needs to be stocked the minimum to pass a regulatory review. Given the rarity
and available throughout the hospital to allow surgeons to of wrong-site surgery, the cost of preventing each instance
perform the safety practices we have required. Surgeons would appear significant (although good safety habits or
unable to find a green marker will use alternative pens, practice can or should be generalizable). The financial
resulting in a variation in practice that degrades the value of impact of correcting computer system flaws, improving sec-
the safety measure. Other aspects of our wrong-site surgery retarial support, and slowing down throughput to perform
safeguards have proved difficult to maintain. A computer- safety checks is unknown. Costs are a significant barrier to
ized scheduling system had triggers to cue the operative implementing safeguards robustly.
team as to the marking protocol and special equipment
needs. When a new procedure was added to the schedul-
Goals and Policy Standards (Practice of Front-Line
ing system, the programmers overlooked the “needs to be Workers Is Shaped by Clear Goals and Consistent
marked” trigger, and for a period of time these patients were Policies That Are Clinically Relevant)
not marked. The operative team had been using technology Policies and procedures regarding prevention of wrong-site
designed to support their work, but that technology was not surgery are difficult to develop. Legal liability tends to con-
maintained. The best team of practitioners can perform strain medical policymakers to be purposely vague. Explicit
even better when provided state-of-the-art working condi- procedures that are standardized would be helpful. Unfortu-
tions. For example, patient identification technology that nately, newly developed procedures may be recommended
utilizes bar coding and radiofrequency identification tags as policy prior to proper testing and validation for effective-
will virtually eliminate wrong patient errors.74 Although this ness. For example, the Universal Protocol has not been fully
technology is currently available, few organizations have validated and yet this protocol has been mandated.
been able to afford this technology to prevent wrong-site
errors due to patient misidentification.
Safety Culture and Priorities (A Safety Culture
of an Organization May Be Pathologic, Reactive,
Proactive, or Generative)
Administrative and Managerial Support (In Complex
Most hospitals today are reactive in their culture of safety.27
Work Settings, Domain Experts That Perform the
The result is that those institutions that have had the most
Work Need to Be Supported by Personnel Who Are public wrong-site surgeries have done the most to establish
Charged with Managing Resources, Scheduling, safety countermeasures to prevent future wrong-site sur-
Transcription, Billing, etc.) gery. Proactive action to invest in creating safeguards was
Clinical information systems (e.g., an OR scheduling sys- beyond the capability or commitment of most healthcare
tem) are not reliable or robust at confirming operative organizations as of 2005.
intent early in the process or planning for surgery.51 Busy
surgical clinics often do not have efficient and reliable
SOCIOPOLITICAL FACTORS ASSOCIATED
mechanisms for providing a scheduling secretary with the
information they need or for verifying that booking informa-
WITH WRONG-SITE SURGERY
tion is accurate. Secretaries may be using a form that is illeg- Economic, Regulatory Issues, Health Policy,
ible or may simply be working from a verbal description and Politics
of the planned surgery. Because these support personnel We practice medicine within large national healthcare
may not understand the terminology, errors are common. In systems. Currently, third-party payers wish for safety to
addition, busy surgeons may forget that other information, be a priority. However, organizations that invest in safety
10 1  •  Ensuring Patient Safety in Surgery―First Do No Harm

Procedures NOT Safety


True team
defined for Motivation behaviors Production programs
Sided, multiples, verification, weak
low, nurses lacking pressure
internal, position, marking, and final marking high
special equipment check

Wrong patient,
procedure, or
site

1 per 30,000
that will
suffer event

Patients and Structured Providers’ Team Working Org. priority Sociopolitical Patients with
procedures approach or knowledge, cross-checking conditions, of safety procedure
at risk process skills, multiple cues staffing, done
attention, workload
motivation
FIGURE 1-4  This graphic summarizes the major vulnerabilities identified as contributory toward wrong-site surgical error.

technologies to avert error do not typically get a return on adverse events and complications. The nonreimbursable
that investment. In fact, hospital investment to prevent iatro- conditions apply only to those events deemed “reasonably
genic injury directly benefits third-party payers, not the hos- preventable” through the use of evidence-based guidelines.
pital. Similarly, our legal system does not serve as a strong The need to address this problem effectively and to verify
incentive for safety because jury verdicts do not accurately the solution through double-blind, placebo-controlled ran-
identify and punish negligent care. Rather, patients with domized trials is therefore imperative.
negative outcomes that were not preventable still win
jury verdicts, while patients that truly suffered a prevent-
able adverse event commonly fail to seek legally allowed
Summary
compensation.76 Reducing iatrogenic injury has become a priority in health
care. The scientific disciplines that have advanced safety in
SUMMARY OF CONTRIBUTORY FACTOR ANALYSIS other high-hazard industries such as aviation and nuclear
This example of wrong-site surgery was used to illustrate power are just beginning to be used to help advance safety
the multiple contributory factors that allow error to propa- in health care. The causes of iatrogenic injury are complex,
gate and evolve into an injury-causing accident. Even with as are robust solutions. Success in other industries has
an error as blatant as wrong brain surgery, one can identify been achieved through the use of a global strategy based
multiple vulnerabilities in the multiple layers of our com- on small incremental changes to identify threats and then
plex medical care systems (Fig. 1-4). While hindsight bias systematically counter each one. Aviation started using this
tempts one to blame the individuals involved as the sole approach over 40 years ago. This strategy appears viable in
causative factor, it is clear that the individuals are part of health care but requires a long-term commitment. In addi-
a complex system with multiple latent conditions (hazards tion, the battle to improve reliability and safety will be ongo-
and “accidents waiting to happen”). High-reliability orga- ing. Eliminating one set of vulnerabilities always reveals
nizations are notable for their dedication to systematically new ones that did not previously exist. Thus, the goal is to
identify all hazards and then counter each one. These orga- trade in the old problems for new ones that are more bear-
nizations understand that failure is multidimensional and able. The future is hopeful as new safety sciences support
so is maximizing safety. medicine’s quest to “first do no harm.”

Perspective KEY REFERENCES


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11.e1
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CHAPTER 2

Surgical Navigation with Intraoperative


Imaging: Special Operating Room Concepts
ARYA NABAVI  •  ANDREAS M. STARK  •  LUTZ DÖRNER  •  H. MAXIMILIAN MEHDORN

One of the most challenging technological innovations in accuracy.10,11 The concept of intraoperative imaging resur-
neurosurgery encompasses the interdisciplinary effort to faced. With magnetic resonance imaging (MRI) becoming
integrate microneurosurgery and imaging. Neurosurgical the method of choice for the imaging of the central ner-
techniques have reached a high level of sophistication. vous system, pioneering efforts to introduce this modality
Increasing understanding of neurophysiology as well as into surgery provided proof of the concept.12-14 These ini-
neuropathology, precise preoperative imaging, small tailored tial experiences with intraoperative MRI (iMRI)15-17 ignited
approaches, and specialized instruments, as well as detailed diversification into a variety of approaches.
monitoring techniques have led to improved results, and The integration of surgery and imaging technology,
generated higher standards for safety and outcome. especially MRI, demands consideration of safety, as well
However, the means to confirm the surgeon’s intraopera- as procedural and architectural issues. In this chapter, we
tive evaluation, whether or not the desired surgical objec- focus on those imaging technologies that have resulted in
tive was achieved, were limited. Postoperative imaging for modified operating room (OR) designs and changes in the
neurooncologic, neurovascular, and instrumented spine surgical workflow.
surgery supported the ambition to obtain intraoperative
quality insurance.
For high-grade gliomas, in 1994 Albert reported that Computer-Assisted, Image-Guided
post-operative imaging showed tumor remnants in 77% of
patients who were presumed to have undergone gross total
Neuronavigation
resection.1 In 2006,2 Stummer et al. published a multicenter The major link between imaging and integration of this
randomized study, which, as a byproduct, showed residual information into surgery is provided by navigation sys-
tumors in 64% of the patients undergoing conventional tems. Diagnostic computer-based image-analysis and three-
microsurgical tumor resection (only patients with high- dimensional (3D) modeling facilitated the spatial definition
grade gliomas were included, which was deemed—by imag- of complex pathologic processes. The desire to use this
ing criteria—to be fully resectable). With the importance of information directly in the surgical field led to the introduc-
the extent of resection for high-1,2 as well as low-grade glio- tion of IGN systems in the mid-1980s8,9 and their commercial
mas,3,4 these findings emphasize the need for improvement. availability in the early 1990s. These systems provided the
In neurovascular surgery the routine use of intraopera- surgeon with a tool that allowed the transfer of presurgi-
tive angiography has been advocated to avoid undetected cal image information in an intuitive and interactive fash-
residual disease.5,6 In spinal surgery, the significant percent- ion into the surgical field (see Chapter 3 for more detail on
age of misplaced screws could be reduced from 10%, but neuronavigation).
still occurs with approximately 5%, even with modern navi- By combining a computer with a detection system (at
gation techniques.7 These findings underscored the desire present, generally light-emitting diodes [LEDs]), the loca-
to complement advanced preoperative evaluation with tion of a pointer tip (or likewise registered tool) within the
intraoperative quality control. Thus various surgical groups surgical field can be viewed on a computer display. This is
proceeded to integrate imaging into their procedures. achieved by registering “physical” (the surgical field) with
The earliest attempts were made with ultrasound (US) “image” (the preoperative images within the computer)
and computed tomography (CT). The immediate impact space. The surgeon uses the pointer like a 3D mouse to
on surgical procedures was small, due to limited resolution scroll through the images. Pointing at specific areas within
(US and CT) and cumbersome integration into the operat- the surgical field, the correlating location in the preopera-
ing room (CT). Another avenue opened with the introduc- tive images is displayed on the computer screen in its ana-
tion of image-guided neuronavigation (IGN) systems.8,9 tomic context. Generally this method is an asset in planning
These systems allowed the transfer of increasingly refined approaches and verifying various internal landmarks.
presurgical image information into the operating theater Meanwhile, the technology has proceeded from being
to guide surgical procedures. However, intraoperative a novelty to an established asset for neurosurgical proce-
changes (“brain shift”) critically limited their application dures. Questions of prior consideration, that is, application
12
2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts 13

accuracy and integration of instruments, were overcome. and miniaturization of the hand-pieces enhanced appli-
However, the major shortcoming was the dependence on cability. Advantages are the dynamic, surgeon-driven, on-
preoperative image data. Since intraoperative changes line character of the information.26 Particularly in vascular
(e.g., CSF drainage, tumor resection, sagging of the cor- surgery, the flow-related analysis of duplex sonography
tex, swelling of underlying tissue, summarized as “brain provides additional flexibility. Further major developments
shift”), accumulate throughout surgery, preoperative data were the introduction of spatially accurate 3D ultrasound,27
become invalidated.10,11,18 This has particular influence on of contrast agents28 and the integration of US into naviga-
glioma surgery. While enabling precise approach planning tion systems.26,29-31 In particular, the last aspect provided
and localization, resection control is generally beyond the the means for easier interpretation of the images, which
capacity of these systems, since they cannot account for generally demands experience.
intraoperative changes. Intraoperative imaging resolved For the last 20 years, IoUS has been regarded as the most
this issue directly. It enables continued use of these systems promising system for online information acquisition in neu-
with newly acquired accurate data. rosurgery. Still, these systems remain limited in their distri-
A different avenue investigates mathematical models to bution. Potential reasons may be the unfamiliarity with the
compensate for brain shift. Various algorithms can char- technique of ultrasound and its limitations in tissue differ-
acterize and calculate deformation matrixes.10,11,19 Various entiation,32 differing from the most widely distributed pri-
brain shift patterns were identified. A multimodal approach mary diagnostic modality of MRI.33
appears potentially useful, which uses intraoperative Major indications are circumscribed lesions, such as
“sparse” US data20-22 to calculate a deformation matrix, metastasis, cavernomas, vascular pathologies, and for spi-
which is then used to elastically deform preoperative MRI nal intradural lesions. With its integration into conventional
images. Albeit all these efforts advances were meager and navigation systems and in combination with iMRI34 the unfa-
the only option to provide precise updated navigation miliarity with this modality might potentially be overcome.
remains the integration of intraoperative images.
INTRAOPERATIVE COMPUTED TOMOGRAPHY
Intraoperative Imaging Shalit and Lunsford first reported the integration of a sta-
tionary CT into OR.35,36 The next generation of CTs was
We provide an overview and comprehensive organizational mobile, permitting shared application in the OR and the
framework for imaging modalities that influence surgical ICU. However, image quality and radiation exposure limited
work flow and OR-suite design. While this relates to CT and the application and further implementation of this modality.
primarily MRI, recent multimodal imaging implemented in Further advances in CT- and OR-table technology and inte-
OR suites includes US and fluoroscopy, and these will be gration with navigation systems have led to a reappraisal.
addressed as well. Modern CT-OR (Fig. 2-1) solutions use a rail system to
move the CT between a parking position and the patient
INTRAOPERATIVE FLUOROSCOPY for scanning,37 which provides full access to the patient. In
Operating theaters for stereotactic neurosurgery had built- spine surgery, intraoperatively acquired images can be used
in biplane x-ray to eliminate parallax artifacts in imaging of to update navigation systems to provide additional image
electrode placement. With the limited scope of this appli- guidance for screw placement, as well as verification of cor-
cation, these ORs remained rare and have largely been rect positioning. For neurovascular surgery, intraoperative
replaced by standard fluoroscopy, or more recently intra-
operative MRI.23,24
In instrumented spinal surgery, fluoroscopy is used as an
online imaging modality for planning and verifying screw
positioning. Combinations with navigation systems have
been propagated. Intraoperative angiography has been
employed by major vascular centers for quality insurance
in aneurysm and AVM surgery.5,6
For both angiography and spinal instrumentation, a
major shortcoming was the planar imaging, providing indi-
rect spatial information. While the integration of IGN added
this dimension, reservations about accuracy led to reeval-
uation of CT for spinal instrumentation. A more recent
development allowing 3D rotation fluoroscopy may result
in an easier way to obtain spatial information. Initial ques-
tions as to the spatial accuracy of these systems have been
addressed in more recent generations. Recently hybrid
angiography ORs combining neurointervention and neuro-
surgery for neurovascular cases have been introduced.
FIGURE 2-1  Overview of iCT unit. The CT is moved along the patient
INTRAOPERATIVE ULTRASOUND axis on a rail system. Navigation system in the left corner of the image
is mobile. (From Uhl E, Zausinger S, Morhard D, Heigl T, Scheder B,
Intraoperative US (IoUS) was one of the first to be employed Rachinger W, Schichor C, Tonn JC. Intraoperative computed tomogra-
as an intraoperative imaging modality in neurosurgery.25 phy with integrated navigation system in a multidisciplinary operating
With subsequent new generations, image quality improved suite. Neurosurgery. 2009;64:231-239, Fig. 1D.)
14 2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts

CT-angiography has the potential to provide information on became evident, that the synthesis of open surgery and MRI
obtained occlusion of vascular pathologies, but also with into a comprehensive new method proved too complex.
perfusion CT on potential vascular compromise. Either imaging potential, in comparison to preoperative
For the definition of brain tumors—particularly low- high-field diagnostic scans, patient access or both, were
grade lesions, but also high-grade gliomas—the intraop- restricted.
erative imaging quality remains less informative. Gross total While various systems of low- and mid-field range per-
surgical resection may be documented, but the sensitivity sist, the limitations of the prototypes, in regards to field
to detect residual tumor, even with the present CT genera- strength and thus image quality as well as patient access,
tion, remains inferior to MRI. Furthermore, cumulative radia- have led development in different directions. Installations
tion exposure limits the number of potential intraoperative with various MR designs and a wide, increasing range of
scans. field strength (0.15–3.0 Tesla) are currently in use.
With emphasis on accessibility, a minimized, compact
INTRAOPERATIVE MAGNETIC RESONANCE open MRI (0.12 T, 0.15 T) was introduced, which fit beneath
­IMAGING the surgical table.51,52 To integrate high-field (1.5 T and
MRI is the diagnostic standard for lesions of the central ner- higher) imaging, while providing ample patient access and
vous system. Its imaging capability extends beyond pure only minimal influence on microneurosurgical instruments
anatomic resolution into function (fMRI) and connectivity and techniques, surgical and imaging sites were separated.
(DTI), as well as pathophysiologic conditions (spectros- This can be achieved within an integrated OR-MR design
copy, perfusion). (“dedicated”),15,40,53 or by arranging MR and OR into sepa-
Postoperative MRI remains the gold-standard for defin- rate adjacent modules/rooms41,54-56 (“shared resources”).
ing the extent of resection in neurooncology1,2 and pituitary A comprehensive classification, which encompasses
lesions.38 present arrangements and accommodates potential future
The desire to employ the potential of MRI to monitor developments and expansions, cannot be based on vari-
open neurosurgical procedures, as means to quality insur- able characteristics such as field-strength and MR-design.
ance, resection control, and complication detection led Since the original concept was to merge surgery and imag-
to the combination of MRI and surgery.13 Presently intra- ing, it is reasonable to use work flow to distinguish among
operative MRI is used primarily for gliomas and pituitary different installations. Specific issues for the integration of
lesions,38-40 but also for vascular41 and epilepsy surgery.42 MRI into the surgical surrounding such as MR safety and
In the mid-1990s, two major approaches spearheaded compatibility of equipment, field strength, shielding, MR
the implementation of intraoperative MRI for neurosurgical design,47,57,58 and imaging characteristics will be outlined
procedures and forecast the future direction of this emerg- before discussing various MR-OR integrations.
ing specialty.
The “twin operating theater”14,16 combined surgery and MR Safety, Compatibility, and Shielding
imaging (low-field, open 0.2 T MR system with a horizon- The introduction of a magnet into a surgical surround-
tal opening) by using two adjacent rooms. The patient was ing raises safety issues pertaining to interaction of the
transferred between surgical and imaging site. Thus con- magnetic field and OR equipment.47,58-61 The magnet can
ventional OR equipment could be used without MR-safety exert a pull on ferromagnetic instruments. Generally the
or compatibility issues. To minimize the time for the trans- strength of the pull is related to field strength (and MR
fer, this approach was modified by operating in the vicinity shielding) and distance to the MRI. The so-called 5-gauss
of the MRI, the “fringe field.”43,44 line demarcates the inner area, in which the pull increases
The open magnet design (“double doughnut”)12,13,17 and the outer zone, in which ferromagnetic instruments
aimed at a full integration of surgery and MRI. The verti- can be safely used without being drawn into the MRI. In
cal opening provided the surgeon with access to the most MR-ORs, this demarcation is indicated on the floor.
patient. Surgical and imaging site were merged, a transfer The immediate area around the 5-gauss line, which is
was unnecessary. For practical reasons, surgery was dis- within the magnetic field but still has no significant pull, is
continued during scanning. However, this design held the called the “fringe” field.
potential to provide real-time imaging, such as in biopsies, Instruments and equipment that are nonferromagnetic,
or through “continuous imaging” protocols.45 Furthermore, and can be used in either area without being drawn into
a navigation system was an integral part of the MRI. With the MR, are called MR-safe. However, contrary to MR-
a localizer, the surgeon controlled the scanning plane of compatible equipment, they cause image artifacts when
the MRI interactively.46,47 Specially developed software for left in the imaging field during scanning, or as with electri-
intraoperative navigation extended the functionality.48,49 cal equipment, cause interference with the imaging. Thus,
This solution is closest to the symbiosis of surgery and imag- equipment that is neither magnetic nor interferes with the
ing. However, by operating in a magnetic field, constraints imaging is called MR-compatible.
in regards to technical equipment, in particular the micro- Shielding is necessary to prevent the interaction of the
scope, the 56-cm gap for the surgeon, and the need for non- magnet with radio-frequency (RF) technology. Normally
ferromagnetic instruments, microneurosurgical standards the entire room is shielded to prevent the magnet’s influ-
were difficult to uphold. ence on electrical devices and vice versa. Alternatively, a
These pioneering clinical experiences proved that the specific shielding can be laced around the patient for scan-
vision50 to bring MRI into the surgical surrounding could ning. While all nonessential electrical equipment can be
be realized. Biopsies as well as interstitial therapies could turned off during scanning, or is primarily based outside
be blended with MRI into a novel procedure. However, it the shielded room (e.g., the computer for image guided
2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts 15

navigation), special anesthesia equipment is used to pre- this phenomenon is of major importance for intraoperative
vent RF noise (artifacts) in the images. MRI (iMRI) to avoid over-resection. Thus scans for the ini-
tial neuronavigation-assisted resection should be acquired
MR Design (“Open-Bore” and “Closed-Bore” prior to surgery. When imaging is for resection control, pre-
Systems) and Field Strength and post-contrast T1 images and subtraction are compared
The static magnetic field of the MRI is generated within its to identify residual contrast enhancement. New sequences
bore. In open-bore (i.e., open-magnet) systems, the magnet capturing the dynamic nature of neovascularized areas, in
is divided into two poles. The gap can be horizontal or ver- particular dynamic susceptibility contrast-weighted perfu-
tical (“double doughnut”),59 resulting in different access to sion MRI (DSC-MRI), provide more accurate intraoperative
the patient. information than conventional contrast-enhanced T1WI.67
In diagnostic high-field scanners, the bore is a closed Future development of specific contrast media may lead to
tunnel. With improved MR design, so-called “short-bore” sys- a resolution of this problem.68,69
tems, with shorter tunnel length, became available, providing
some access to the patient. Thus smaller operations like biop- Integration of Intraoperative Navigation and MRI
sies or deep brain stimulation (DBS) electrode placement The shortcomings of image-guided navigation in detecting
can be performed within the bore (“in-bore” procedures). intraoperative changes were a major motivation to imple-
Generally the open-magnet design has lower field ment intraoperative imaging. Since surgery and imaging
strength than the “short-bore” closed systems. Higher take place in different coordinate systems, the transfer of
field strength generally promotes acquisition speed (tem- the images between these venues represents the crucial
poral resolution) as well as quality of the subsequently integrating step. IGN provides this essential link.40,70,71
acquired images (spatial resolution). A wider range of In most MRI-installations, navigation systems are ceiling
image sequences is available (e.g., spectroscopy, DTI, fMRI, mounted. Initial navigation is performed with preoperative
dynamic scanning).15,62,63 Furthermore, the homogeneity images until the surgeon deems an update necessary to
of the magnetic field increases, reducing geometric distor- regain accurate navigation. The intraoperative images are
tions. This issue is of major importance in low- and mid- sent directly from the scanner console to the navigation sys-
field scanners. Phantom studies performed on the compact tem. The images are fused (automated image fusion algo-
0.12 T system provided acceptable application accuracy.52 rithm) to the already registered preoperative images and
However, studies in a stronger magnetic field (mid-field 0.5 shown on the display (Fig. 2-2). With the DRF reattached
T, open MR system) have shown that significant geometric in its original position, the images can be used for updated
distortions are present,64 which are machine- and patient- navigation without additional re-referencing. Thus intraop-
induced. These findings have to be considered when using erative updates for neuronavigation can be acquired at the
non–high-field MR units (below 1 T) for resection control surgeon’s discretion, and used for updated navigation.
and updated neuronavigation.
OR-MR INTEGRATIONS
Imaging The horizontal systems were mostly adjacent to a conven-
Which imaging to choose depends on the lesion’s imaging tional OR.14,16 The patient was moved from the surgical site
characteristics in diagnostic studies. Enhanced and non- to the imaging site. An improved workflow left the patient
enhanced T1WI, T2, and occasionally FLAIR answer most within the fringe field to shorten the transfer.43,44
questions.39,40,53,54,62,65 For low-grade lesions, T2 and FLAIR The vertical units (i.e., “double doughnut”) had the
images are the most appropriate.40,53,54 For enhancement, advantage, that patient transport was not necessary
pre- and post-contrast T1 images are acquired. because imaging and surgical sites were the same. The ver-
Further sequences may potentially yield additional infor- tical orientation of the gap between the poles gave, how-
mation,53 such as location of functional centers or fiber ever confined, acceptable access to the positioned patient.
tracts. Both features can be extracted from intraoperative This facilitated the workflow but posed high demands on
MRI, especially the latter.66 the equipment and surgical workflow.17,47,50
The intraoperative MRI is essentially a surgical tool. It The basic concept of these original designs persists in
is implemented to support surgical decision making. Thus current solutions. In the shared-resource and more elabo-
the surgeon has to define his or her intention and the sub- rate multimodal imaging OR concepts, surgical site and
sequent question, which primarily relates to the achieved imager are separated into adjacent rooms. In “dedicated,
extent of resection (residual tumor and its localization) and integrated MR-OR” environments, surgical and imaging
complication avoidance (distance to critical structures). It is sites are separated but in the same specially planned room.
essential that the surgeon acquires a good working knowl- The pivotal links are the physical arrangement between
edge of MRI to compile the individual imaging protocol and surgical and imaging sites (patient or MR transport) and the
analyze the images according to surgical objectives.40,41,53,62 information transfer (updated imaging for neuronavigation).
Practical challenges in interpreting intraoperative
images largely pertain to nonspecific contrast enhancement Shared Resources and Multimodal
(“spread enhancement”). The surgical result is described Imaging OR Concepts
by “removed percent of contrast-enhancing lesion.” Since The separated room concept for surgical and imaging sites
contrast enhancement merely reflects the local breakdown was developed to allow the unimpeded usage of surgical
of the blood–brain barrier, it is unsurprising that contrast tools as well as perfect imaging. An additional economic
spreads into surrounding regions over time. While almost aspect was that while surgery was progressing, the idle
inconsequential in diagnostic imaging, acknowledging MRI could be used for routine imaging—hence, the notion
16 2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts

IntraOp #2 A IntraOp #1 A
MRI #1 MRI #1
Axial Axial

R L R L

P P
IntraOp #2 A IntraOp #1 A
MRI #2 MRI #2
Axial Axial

R L R L

FIGURE 2-2  Updated navigation


with intraoperative images (screen
shot of navigation system display).
Images were acquired after tumor
(anaplastic astrocytoma) bulk resec-
tion for localization of residual
tumor. T2 and T1WI intra- and pre-
operative for comparison. P P

of shared resources. However, this demanded special


arrangements for connecting surgical and imaging sites.
Potentially, the patient can be brought to the MRI or the MRI
to the patient.
The first mobile MRI (Fig. 2-3) was developed and
installed in Calgary.41 The 1.5-T unit is mounted on a ceil-
ing rail system, which permits transporting the MRI into
the surgical area (overhead crane technology). The spe-
cially designed operating table is MR-compatible, as
patient positioning can be adjusted hydraulically. Further-
more, the RF coils are integrated into the surgical table.
The upper detachable portion can be repositioned for
imaging. The MRI usually resides in a separate room. On
its way in and during scanning, ferromagnetic instruments
have to be removed from its path and beyond the 5-gauss
line. If not needed during the procedure, the magnet can
be potentially used as a shared resource for conventional
scanning, or serve adjacent ORs connected by a common FIGURE 2-3  Ceiling-mounted, mobile MRI (1.5 T) in Calgary. Overhead
rail system. crane technology permits the transfer of the MRI to the surgical site. (From
Kaibara T, Saunders JK, Sutherland GR. Advances in mobile intraoperative
Stationary MRIs in separated rooms are presently 3-T magnetic resonance imaging. Neurosurgery. 2000;47:131-138, Fig. 4.)
MRI units, where the higher field necessitates more elabo-
rate shielding (Fig. 2-4). The 5-gauss line extends farther
away from the MRI, raising demands on MR-safe and com- The surgical site is a conventional operating theater. The
patible equipment and instruments. This and the fact that patient is positioned on a surgical OR table with a floating
3-T systems are not yet widely used led to implementation top, which can be connected to the MR system. Either a rail
as separated rooms, permitting shared imaging resources system56 or a wheeled transfer table54 is used. The head-
between surgery and radiology.54,56 holder can be either separated from flexible surface coils,56
2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts 17

Control
room
OR-hall
MRI
waiting
room

0.5G
1G
ioMRI-OR Gantry

FIGURE 2-4  Example of shared-resources layout. (From


Pamir MN, Ozduman K, Dincer A, Yildiz E, Peker S,
Ozek MM. First intraoperative, shared-resource, ultra-
high-field 3-Tesla magnetic resonance imaging sys-
tem and its application in low-grade glioma resection.
J Neurosurg. 2010;112:57-69, Fig. 1.)

Technical room Storage Shaft

Operation
light
ER

Operation FIGURE 2-5  Multimodality imaging OR layout for the


MR light CT modular expansion of shared-resources twin-OR. Due
Angio to the modular design, various modalities can be used.
OP (From Matsumae M, Koizumi J, Fukuyama H, et  al.
World’s first magnetic resonance imaging/x-ray/operat-
ing room suite: A significant milestone in the improve-
ment of neurosurgical diagnosis and treatment.
J Neurosurg. 2007;107:266-273, Fig. 1.)

or integrated into the rigid imaging coils.54 In the latter case, suites have separate entrances to admit patients from radiol-
a removable sterile top portion is disconnected for surgery ogy (MRI) and the emergency room (CT), adherent to the
and replaced for scanning. shared-resources concept. This setup is primarily designed
The rooms have additional entrances to provide access for neurosurgical applications.
to the MR while surgery progresses in the adjacent room. In the planned AMIGO (advanced multimodality image
Thus during the surgical time, routine diagnostics can be guided operative)72 design, the fully equipped surgical room
performed. Costs and function can be shared between (fluoroscopy, US, navigation system) will be flanked by a 3-T
neurosurgery and radiology. While the economic aspect MRI unit and a PET-CT. With this design, the applicability
is appealing, the concept of obtaining image-information of the suite is not only as a shared resource in regards to
on demand for surgical decision making is impeded. If the simultaneous imaging of other patients during surgery, but
MR is occupied, the surgical patient has to wait. Presently also expandable to an interdisciplinary suite serving differ-
the transfer distance, as well as the preparations to provide ent specialties.
safety, represents an additional delay.56 It becomes cum-
bersome, and thus less likely, that repeated intraoperative Dedicated OR-MR Environment
scans are obtained. Dedicated systems realize the close integration of MRI and
The separation of imaging and surgery into adjacent rooms surgery within one OR-MR environment.
establishes a modular design. Accordingly separate modules
can be added to extend the single-modality imaging OR. Dedicated Low-Field System
Such a multimodal-imaging OR concept is based on a con- The 0.15-T MRI (previous generation 0.12 T) is an open-bore
ventional OR with fluoroscopy at its core. US can be added. system with two poles.51,52,73 The MRI is positioned beneath
Ceiling-mounted navigation systems are the connecting link the patient’s head (Fig. 2-6). On demand the magnet is
to the imaging units. The moveable OR table has a floating raised to place the surgical field in the imager. Images are
top, which can be connected to either imaging gantry. acquired and transmitted to the connected navigation unit
In the MRXO55 concept (Fig. 2-5), the central OR-angiog- for updated navigation. The OR has to be shielded to avoid
raphy room is connected to a 1.5-T MRI and a CT suite. Both RF interference, and all other nonessential equipment has to
18 2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts

be turned off. Alternatively, the patient and the scanner can


be shielded separately.74 This compact MRI provides the clos-
est approximation to the original concept of merging imag-
ing and surgery in space. The application can be integrated
into a conventional OR, provided shielding is implemented
and used on demand by raising the poles to imaging level.
Despite the application comfort, the low field holds chal-
lenges in regards to homogeneity (spatial resolution and
geometric distortions) and field of view (120–160 mm vs.
220 mm in high-field systems). These systems are used for
intraoperative imaging in glioma51,52 and pituitary surgery.75,76
Dedicated High-Field System
These installations combine a fully equipped neurosurgi-
cal OR with a high-field scanner, primarily 1.5-T MR units,
into a comprehensive unit.15,40,53 Two main setups provide FIGURE 2-7  Fully integrated OR-MR (1.5 T) environment at the authors’
this dedicated environment.15,40,53 The 5-gauss border rep- institution. Patient is turned away from MR axis by 30 degrees to posi-
tion the head into the primary surgical area outside the 5-gauss line.
resents a demarcation that permits the spatial division of Ceiling-mounted navigation system. Open procedure for left frontal
the OR-MR suite.40,53,60 Surgical and imaging site are con- glioma. (OR-MR setup in Kiel/Germany.)
nected by a surgical table, which attaches directly to the
scanner. The surgical area is reached by disconnecting the
table and rotating it either by 30 degrees15,40 (Fig. 2-7) or mounted, with the computer placed outside the shielded
160 degrees53 (Fig. 2-8) away from the MR axis, to place the room. After craniotomy, the operation is performed, using
operating field outside the 5-gauss line. state-of-the art microneurosurgical techniques. For lesions
The primary fully equipped surgical site for microneu- in eloquent areas the authors’ group utilizes the technique
rosurgery is outside the 5 gauss line, where ferromagnetic of awake craniotomy with cortical stimulation.77
tools and equipment (e.g., microscope, ultrasonic aspira- Imaging can be initiated at every point the surgeon
tor, bipolar coagulation, and cortical stimulation) can be deems feasible. Ferromagnetic material is removed and
used unimpeded. The rigid head fixation has to be fully MR the surgical field covered with additional sterile drapes.
compatible. The material of the pins has no influence on The table is returned into the MR axis, connected, and the
the overall imaging (local artifacts with metal pins). The patient transferred to the imaging site.
head fixation can be integrated into the rigid RF coil with In both arrangements,40,53 the interval from stopping the
restricted degrees of freedom.53 More flexibility for position- surgery to initial scanning commonly takes about 3 to 5 min.
ing is achieved by a modified carbon-fiber, MR-compatible The surgeon determines the imaging protocols based on
Mayfield clamp attached to the table top used with surface presurgical imaging characteristics. The images are trans-
coils.40 One coil is positioned below the patient’s head, ferred to the navigation system as soon as they are acquired
within the Mayfield clamp, while the top coil is removed for updated accurate navigation.40,71
during surgery and replaced for scanning. The surgical field is redraped on top of the previous
For surgical navigation, the dynamic reference frame draping. If residual tumor is identified, updated neuronavi-
(DRF) is attached to the head-holder. The navigation sys- gation allows the precise localization for resection. If no
tem is registered, the craniotomy planning finalized. In
integrated MR-OR solutions the navigation system is ceiling

FIGURE 2-6  Compact low-field MRI (0.12-15 T). Position before drap- FIGURE 2-8  Depiction of the system with table turned away 160
ing. Ceiling-mounted navigation system. Special headrest with inte- degrees from MR axis, to position head outside 5-gauss line (1.5 T MR).
grated coil and flexible coil positioned for pituitary surgery. (Courtesy Pituitary surgery. (Courtesy Prof. C. Nimsky, OR-MR setup in Erlangen,
of M. Hadani, Sheba Medical Center; Tel Hashomer, Israel.) Germany.)
2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts 19

further resection is necessary or deemed feasible, surgery The evolution of IoUS and fluoroscopy has facilitated inte-
is concluded. gration into the surgical surrounding. Current-­generation
Biopsies and burr-hole procedures in a dedicated, high- equipment has been reduced in size, while significant
field MRI can be performed in the primary surgical site out- improvements have been achieved in functionality.
side the 5-gauss line with standard equipment (conventional CT and MRI are less prone to undergo simultaneous
stereotactic frames; computer-guided, navigated free-hand miniaturization and improvement. These cut-plane imaging
biopsies; navigated endoscopy).40 More sophisticated in-bore modalities are primarily integrated through workflow and
procedures use the capacity of real-time imaging. Burr-hole suite design.
and dural opening are performed outside the 5-gauss line The latest iCT generation shows significant improvement
with standard equipment. After a MR-compatible burr hole in image quality and integration into the surgical workflow.
mounted device is attached, the patient is transferred into Spinal instrumentation and vascular neurosurgery are the
the MR for scanning. The mounted guide is fixed to preserve main indications. In brain tumor surgery, the use of iCT is
the planed trajectory. During the probe’s advance in-plane less conclusive, albeit there have been significant improve-
imaging (1–3 images/second) provides real-time control and ments, in particular for low-grade gliomas.
final image confirmation of the target point.78 With short- In iMRI suites, intraoperative imaging has taken its most
bore MRs, the needle can be advanced by the surgeon reach- elaborate form. Despite its cost, special demands, and labor
ing into the bore. However, remote control or robotic devices intensiveness, this field keeps expanding, due to the unparal-
provide more comfortable reach and can be potentially leled imaging capabilities for the analysis of structural pathol-
employed within MRIs with less access.78,79 Current studies ogy as well as physiologic investigations of the central nervous
discuss in-bore procedures for deep brain stimulation.24 system (e.g., neurooncology, epilepsy surgery). Various groups
Within the integrated system originally described by reported more complete resections for high-grade gliomas
Hall et al.15 a secondary surgical site can be used for spe- and pituitary lesions employing intraoperative low-,52,83
cific tasks.40,65 When the MRI table is extended beyond the mid-,84,85 and high-field systems.39,86 Increased resection per-
back of the MRI, the patient’s head can be accessed freely centages were also shown for low-grade lesions.53,87
for surgery. This area is within the 5-gauss line, thus neces- The attempt to decrease MRI size to facilitate integration,
sitating the use of MR-safe equipment. While ultrasonic resulted in a compact low-field system, albeit with limited
aspirator and bipolar coagulation can be used in this site, imaging potential.51 Higher-field MRIs providing diagnostic
microscopes which provide familiar illumination and mag- imaging capability are integrated primarily through their
nification qualities are not available. The transfer to the MRI suite design, which separates surgical and imaging site within
is much shorter, repeated imaging becomes easier. This the same (dedicated systems) or adjacent rooms (twin oper-
secondary surgical site returns to the idea of a close inter- ating theater, shared resource). In dedicated systems, the
lacing of imaging and surgery. However, as long as micro- transfer between surgical and imaging site can be achieved
neurosurgical techniques are hampered, the utility of this swiftly.40,53 In shared resource concepts, transfer is longer. Fur-
area is limited to smaller interventions. thermore potential conflicts in using the imaging for surgery
Interestingly despite this restrain, this secondary surgi- and routine diagnostics may lead to prolonged waiting peri-
cal site allowed a major development: the inception of an ods before intraoperative imaging can be commenced.54,56
integrated, dedicated 3-T system within an operating the- Long envisioned intraoperative MRI has been success-
ater.80,81 Contrary to shared-resources solutions, this setup fully combined with standard microneurosurgical and
is the only one to attempt the combination of intraopera- navigation techniques into comprehensive units for neu-
tive 3-T system and surgery. While there are still significant rosurgical procedures.50,88 High-field MRI and its intra-
drawbacks, this installation provides the proof of concept, operative application represent a major interdisciplinary
that dedicated high-field OR-MR rooms for biopsies and challenge and opportunity. Further refinements may lead
open craniotomies can be realized.80-82 back to the original concept of merging therapy and MRI,
with robotic devices for surgery, focused US for noninvasive
Summary ablative procedures88 or open high-field magnet designs.
Multimodal imaging OR concepts (MRXO and AMIGO)
Intraoperative imaging addresses the crucial need to sup- extend the modular arrangement as realized by the shared-
port surgical decision making with online information to resources concept. Additional modalities have been inte-
improve quality control and complication avoidance. The grated into adjacent rooms (CT, PET-CT, and high-field MRI)
main modalities are US, fluoroscopy, CT, and MRI. of a hybrid neurointerventional-neurosurgical OR (angiog-
Ultrasound can be easily integrated into the surgical raphy and US). The modular shared-resources design pro-
workflow. Combination with navigation systems facilitates vides the structural framework for integrating otherwise
interpretation. The capacity to simultaneously capture flow incompatible units. Such installations represent a major
and structure is particularly useful in vascular malforma- research effort to evaluate the impact and value of different
tions. Resection control for gliomas is of limited use, even imaging modalities.
with the most recent contrast-enhanced US. The essential link between imaging and surgery is the
Mobile fluoroscopy has been integrated into conventional computer-assisted IGN system. It represents the platform
ORs for spinal surgery and DBS. The biplane representation on which the pre- and intra-operative multimodal imag-
has been extended to a 3D perspective by rotating units. ing information coalesces to enable surgical decision
This enhances their potential application for vascular neu- making.71,88-90
rosurgery and spinal instrumentation, where 3D rotational In current systems, imaging interrupts surgery for vari-
fluoroscopy may become a competitor for intraoperative CT. ous periods of time. While microneurosurgical techniques
20 2  •  Surgical Navigation with Intraoperative Imaging: Special Operating Room Concepts

remain unrestricted, the surgical workflow is disrupted and Hall WA, Galicich W, Bergman T, Truwit CL. 3-Tesla intraoperative MR
the procedure prolonged. Thus intraoperative imaging rep- imaging for neurosurgery. J Neurooncol. 2006;77:297-303.
Hall WA, Martin AJ, Liu H, et al. High-field strength interventional
resents a compromise balancing the additional value of the ­magnetic resonance imaging for pediatric neurosurgery. Pediatr
imaging information versus timely conclusion of the surgery. Neurosurg. 1998;29:253-259.
Especially for MRI, the overabundance of high-quality Jankovski A, Francotte F,Vaz G, et al. Intraoperative magnetic resonance
image information becomes a challenge in its own right. imaging at 3-T using a dual independent operating room-magnetic
resonance imaging suite: development, feasibility, safety, and prelimi-
Fiber tracking has been employed in sophisticated ways,
nary experience. Neurosurgery. 2008;63:412-424.
delineating the major fiber connections.91,92 Spectroscopy Jolesz FA, Nabavi A, Kikinis R. Integration of interventional MRI with
has been used to guide stereotactic biopsies,93 and with fur- computer-assisted surgery. J Magn Reson Imaging. 2001;13:69-77.
ther refinement may yield information on resection borders Matsumae M, Koizumi J, Fukuyama H, et al. World’s first magnetic reso-
in open surgery.54 nance imaging/x-ray/operating room suite: a significant milestone in
the improvement of neurosurgical diagnosis and treatment. J Neuro-
Intraoperative imaging has to be carefully balanced to surg. 2007;107:266-273.
minimize delay while obtaining the best information pos- Nabavi A, Black PM, Gering DT, et al. Serial intraoperative magnetic
sible. Any device used for intraoperative imaging becomes ­resonance imaging of brain shift. Neurosurgery. 2001;48:787-797.
a surgical tool, and has to be employed with the same scru- Nabavi A, Dorner L, Stark AM, Mehdorn HM. Intraoperative MRI with 1.5
Tesla in neurosurgery. Neurosurg Clin North Am. 2009;20:163-171.
tiny and deliberation. It remains the surgeon’s obligation to
Nabavi A, Goebel S, Doerner L, et al. Awake craniotomy and intraop-
decide, ideally in close communication with neuroradiolo- erative magnetic resonance imaging: patient selection, preparation,
gists, when to obtain which information as a basis for surgi- and technique. Top Magn Reson Imaging. 2009;19:191-196.
cal decision making. Nimsky C, Fujita A, Ganslandt O, et al. Volumetric assessment of glioma
removal by intraoperative high-field magnetic resonance imaging.
Neurosurgery. 2004;55:358-370.
Conclusion Nimsky C, Ganslandt O, Cerny S, et al. Quantification of, visualization
of, and compensation for brain shift using intraoperative magnetic
Intraoperative imaging and navigation have developed from resonance imaging. Neurosurgery. 2000;47:1070-1079.
a vision50 to a neurosurgical reality. The development of Nimsky C, Ganslandt O, Kober H, et al. Intraoperative magnetic reso-
nance imaging combined with neuronavigation: a new concept.
various OR designs to accommodate intraoperative imaging
Neurosurgery. 2001;48:1082-1089.
and surgery has accelerated. Solutions apparently prohibi- Nimsky C, Ganslandt O, Von Keller B, et al. Intraoperative high-field-
tive in scope and cost 10 years ago have been implemented strength MR imaging: implementation and experience in 200 patients.
and surpassed. The higher the expectation of image infor- Radiology. 2004;233:67-78.
mation, the more complex the resulting design. The most Pamir MN, Ozduman K, Dincer A, et al. First intraoperative, shared-
resource, ultrahigh-field 3-Tesla magnetic resonance imaging system
intricate, but at present also the most flexible and informa- and its application in low-grade glioma resection. J Neurosurg. 2010;
tive modality for cranial neurosurgery, is intraoperative 112:47-69.
MRI. The multitude of designs, implementations, and field Schulder M. Intracranial surgery with a compact, low-field-strength mag-
strengths make this a most multifaceted area of expertise. netic resonance imager. Top Magn Reson Imaging. 2009;19:179-189.
Steinmeier R, Fahlbusch R, Ganslandt O, et al. Intraoperative magnetic
Incorporation of magnets with increasing field strengths
resonance imaging with the magnetom open scanner: concepts,
and multimodal imaging concepts (MRXO) including meta- ­neurosurgical indications, and procedures: A preliminary report.
bolic information (AMIGO) represent the next challenges. Neurosurgery. 1998;43:739-747.
Technological advances almost appear to gain autono- Sutherland GR, Kaibara T, Louw D, et al. A mobile high-field magnetic
mous momentum. It is essential to ensure that surgical resonance system for neurosurgery. J Neurosurg. 1999;91:804-813.
Sutherland GR, Latour I, Greer AD. Integrating an image-guided robot
needs remain at the core of this multidisciplinary effort. with intraoperative MRI: a review of the design and construction of
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Tronnier VM, Wirtz CR, Knauth M, et al. Intraoperative diagnostic and
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Section One

SURGICAL MANAGEMENT
OF BRAIN AND SKULL BASE
TUMORS
ALFREDO QUIÑONES-HINOJOSA
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INTRA-AXIAL BRAIN TUMORS

CHAPTER 3

Functional Tractography, Diffusion Tensor


Imaging, Intraoperative Integration of
Modalities, and Neuronavigation
JONATHAN A. HYAM  •  ALEXANDER L. GREEN  •  ERLICK A.C. PEREIRA

Diffusion tensor imaging (DTI) with functional tractography Despite great care taken by the neurosurgeon to avoid
is a noninvasive MRI modality which depicts the probable injury to eloquent cortex through careful pre-operative and
location and orientation of subcortical white matter tracts intra-operative functional mapping and meticulous surgical
in vivo. DTI offers a variety of possible applications for neu- technique, straying into critical subcortical white matter
rosurgeons and neuroscientists to help further the under- tracts can still result in devastating deficits. There is con-
standing of neurologic organization and function and to cern that localization using subcortical white matter stimu-
advance patient care which explains the enthusiasm and lation is less reliable and safe than cortical stimulation.18,19
optimism with which it has been received. Potential clini- By visually representing white matter tracts to the surgeon,
cal applications for individual patients include prediction DTI promises to improve the safety of tumor resections,
of neurologic outcome from tumor1 and stroke,2-4 targeting especially when involving subcortical areas.
for functional and stereotactic neurosurgery5-7 and pre- and
intra-operative planning for the surgical resection of space-
occupying lesions. This chapter shall focus on the appli-
Scientific Principles of DTI
cation of DTI in the surgical resection of intra-axial brain Diffusion MRI scans image the molecular diffusion of water
tumors. at the same scale as cellular dimensions and therefore
Surgery occupies a vital place in the management of allow the microarchitecture of the brain to be investigated.
intra-axial brain tumors by virtue of providing symptom The constant random motion of molecules is described by
relief, recovery of pathologic tissue for diagnosis and ben- Brownian motion and is exploited by diffusion imaging to
eficial influence on long-term outcome. The ultimate aim of specifically detect the displacement of water molecules
resection of intra-axial brain tumors is to achieve as com- through the brain tissue medium. Diffusion-weighted scan-
plete excision of neoplastic tissue as possible. A substantial ning consists of a T2-weighted spin-echo sequence with
body of evidence exists to suggest that a greater extent of the addition of two diffusion-sensitizing gradients applied
resection results in extended mean survival time in low- before and after the 180o refocusing pulse, through an
grade and high-grade glioma.8-17 However, the neurosur- identical axis. Therefore, there is a loss of signal intensity
geon is limited in the scope of surgical resection possible as a result of incomplete rephasing of water proton spins
by the imperative to avoid injury to eloquent brain tissue after they have moved during the time elapsed between
and therefore the development of post-operative neurologic the two diffusion-sensitizing gradients.20 Diffusion times in
deficits. Knowledge of which tissue is functionally impor- the region of 10 to 50 ms are used which provides micro-
tant in the individual patient is therefore crucial in pre- scopic detail, capturing average molecular displacements
operative and intra-operative decision making. Although of 10  μm.20 Scan acquisition using standard MRI systems
imaging in the form of computerized tomography (CT) and takes 3 to 10 min,21 and therefore is minimally burdensome
MRI can define structural anatomy, they do not provide reli- on patient, radiographer, or scanner time.
able information on functional anatomy in the individual. The direction of the passage of water is different depend-
Other modalities need to be employed by the neurosurgeon ing on the nature of tissue in which it is found. Where no
to delineate areas of functional importance. This functional structural boundaries exist nearby, the molecular motion
mapping can be performed by invasive and non-invasive of water is unimpeded and equal in all directions. This is
methods. Invasive examinations include pre-operative cor- known as isotropic diffusion. This is exhibited within the
tical electrode grid recordings and intra-operative cortical cerebrospinal fluid spaces of the brain, with the exception
and subcortical stimulation. Non-invasive examinations of sites of bulk flow such as the aqueduct of Sylvius or fora-
include functional MRI and magnetoencephalography men of Munro.20 Isotropic diffusion is also believed to occur
(MEG). Of those studies performed pre-operatively, none in grey matter.22,23 In contrast, myelinated white matter fiber
provide information on subcortical functional anatomy. tracts are arranged into parallel, densely packed bundles
23
24 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

that impede the diffusion of water molecules perpendicular DTI fiber tract data can be presented in two forms. Func-
to the fibers’ direction. Therefore, diffusion of water mol- tional anisotropy maps provide information on fiber anat-
ecules in this situation is not equal in all directions and is omy in cross-sectional two-dimensional (2D) images with
defined as anisotropic diffusion. Detection of water mole- color-coded axes where the brightness is proportional to
cule anisotropy is the basis of diffusion tensor imaging and the degree of anisotropy (see Fig. 3- 1). By convention, the
tractography. anteroposterior axis is represented by green, left-right by
The diffusion tensor is a 3 × 3 matrix of vectors which red, and up-down by blue. Therefore, the corpus callosum
mathematically describes the three-dimensional (3D) will appear red, for example. Alternatively, deterministic
directionality and magnitude, or diffusion anisotropy, of or probabilistic25 functional tractography performs a 3Ddi-
water molecules.20,21,24 The three principal axes of the dif- mensional reconstruction and portrayal of the fiber path-
fusion tensor are termed eigenvectors. When plotted as an ways based on following a white matter tract from voxel
ellipsoid, isotropic diffusion is a sphere whereas anisotropic to voxel as described above (Fig. 3-2). Specified anatomic
diffusion forms an elongated ellipsoid, becoming a prolate points, known as “seeds” (see Fig. 3-1), can be selected by
(cigar) shape when the eigenvector of greatest magnitude the user from where the tractogram can be plotted by the
is much larger than the other two. Prolate diffusion within processing software to delineate proposed neural connec-
a brain voxel is assumed to represent a white matter fiber tivity with the selected site. Alternatively, larger volumes of
bundle where the primary eigenvector is aligned with the brain can be selected as regions of interest or “masks.” To
axonal axis. Tracing of white matter tracts to produce func- reduce dependence on the user and therefore the inherent
tional tractograms uses each voxel’s diffusion tensor to link subjectivity of seed selection while also increasing the like-
it to adjacent voxels and in this way trace out the likely path lihood of depicting functionally relevant tracts, ­Schonberg
of a fiber bundle in 3D space (Fig. 3-1). et  al. used functional MRI to define where seed points

A B
FIGURE 3-1  Main eigenvectors in adjacent voxels providing the basis for tractogram construction (A). Fractional anisotropy map derived from
diffusion tensor image (B). Examples of seed points are seen overlying both thalami.

FIGURE 3-2  Tractogram representing the ascending and descending pathways among cortex, brainstem, and cerebellum after seed selected in
pons. (Courtesy of Prof. Peter Silburn and Dr. Terry Coyne, University of Queensland, Brisbane, Australia.)
3  •  Functional Tractography, Diffusion Tensor Imaging, Intraoperative Integration of Modalities, and Neuronavigation 25

should be sited.26 Although this represents an extra stage of been proposed as the preoperative investigation to assess
patient assessment, they found that it enabled a more com- individual patients’ risk of visual field defect prior to ante-
prehensive mapping of fiber systems such as the pyramidal rior temporal lobe resection as it images the Meyer loop of
tract and the superior longitudinal fasciculus. See glossary the optic radiation as it courses anteriorly from the lateral
of terms in Table 3-1. geniculate nucleus and around the tip of the temporal horn
before projecting to the visual cortex. The individual varia-
Preoperative Planning Applications tion of this white matter pathway33 increases the risk of a
deficit which can permanently disqualify the patient from
DTI shows the surgeon the relationship of the intra-axial holding a driving license. Therefore, preoperative warning
tumor to local white matter tracts in multiple planes. A vari- of a more ventral position of the Meyer loop along its course
ety of aspects of the tumor–tract relationship can therefore anterior to the temporal horn should identify those with a
be demonstrated. The identity of the tract can be surmised higher likelihood of postoperative deficit.34,35
from its position and course, such as the corticospinal tract Although DTI visualizes white matter tracts, it is pos-
and optic radiations. The proximity of the tumor to the tract sible to extrapolate these projections and therefore visual-
can be appreciated. Also the position of the tumor can be ize their grey matter cortical projections/origins. Kamada
seen in relation to the tract, for example superior, lateral, et  al. applied this technique to map the primary motor
medial etc., allowing optimal approach to be determined area (PMA) preoperatively in thirty patients with supra-
to highly eloquent and complex areas such as the pons.27 tentorial lesion affecting the motor system.36 By selecting
Displacement of the tract by the tumor or edema can also seed points within the corticospinal tract at the cerebral
be demonstrated.28,29 This is crucial information when peduncle, plus the medial lemniscus to differentiate from
planning a surgical trajectory in order to avoid eloquent somatosensory projections, a PMA map was produced that
tissue. DTI has been found to provide important preopera- was successfully validated against subsequent intraop-
tive warning of this surgical hazard in situations where a erative cortical somatosensory evoked potentials. Indeed,
precisely planned trajectory is imperative such as during fMRI failed to identify the PMA in eight patients. The
resection of thalamic juvenile pilocytic astrocytoma with reasons for this were inherent in the patients’ pathology
displacement of the posterior limb of the internal capsule.30 through its effect on the motor system in that they were
Incorporation of white matter fibers within the tumor mass, incapable of successfully completing the self-paced fin-
seen especially in low-grade tumors,31 and destruction ger tapping task required to elicit the blood oxygenation
of white matter fibers by the tumor can also be depicted. level dependent signal that fMRI detects. In contrast, DTI
These features will have profound implications for the requires no patient tasks to acquire its data and there-
extent of resection amenable for the individual tumor. fore offers an important alternative for preoperative non- 
DTI can also help elucidate the anatomy of poorly invasive cortical mapping in patients who, for whatever
described pathways in vivo in the human to inform and reason, cannot complete them.
advance established surgical strategies. Resection strat- DTI has been applied in neuro-oncology beyond not
egies that aim to excise normal as well as neoplastic tis- only functional mapping but for noninvasive assessment
sue with a view to minimizing the likelihood of recurrence of tumor architecture in terms of cell density, white mat-
such as frontal and temporal lobectomy can be enhanced ter invasion and even histologic discrimination such as
by DTI to maintain safety. The anatomico-functional con- the distinction between primary and secondary intra-axial
nectivity of the dominant temporal lobe, for example, was tumors.37-41 It has been proposed that DTI can distinguish
reviewed by Duffau et al. using a combination of DTI and between vasogenic edema and tumor-infiltrated edema.
subcortical intraoperative stimulation studies to elucidate Edematous tissue surrounding glioma is generally accepted
the white matter pathways, which should represent the to be infiltrated by tumor cells. In contrast, edema surround-
resection boundaries of temporal lobectomy such as the ing cerebral metastases or meningioma is considered to be
pyramidal tract and the anterior wall of the temporal part vasogenic.40,42 Therefore, hyperintensity surrounding tumor
of the superior longitudinal fasciculus.32 Indeed, DTI has on T2-weighted MRI may reflect any of glioma, metastasis or
meningioma. However, as the FA at the voxels correspond-
ing to the site of edema has been shown in some studies to
Table 3-1  Glossary of Diffusion Tensor Imaging Terms be of a lower value in infiltrative pathologies such as glioma,
a tumor infiltration index was derived by Lu et al. to help
Motion of Molecules Being Equal in all distinguish against pathologies producing only vasogenic
Isotropic diffusion Directions
edema.39 There have been contradictory reports including
Anisotropic diffusion Motion of molecules not being equal in a PET-labeling study questioning whether this DTI analysis
all directions is specific enough to differentiate between tumor-infiltrated
Fractional anisotropy Directionally averaged diffusion of edema and vasogenic edema.41,43 Further investigation will
water molecules within a voxel mea-
sured as its deviation from isotropic
determine whether DTI can fulfill this potential and provide
diffusion reliable presurgical histologic tumor characterization.
Diffusion tensor Matrix of vectors which mathematically Therefore, DTI provides advanced warning of potential
describe anisotropic diffusion within a intraoperative misadventures to help surgeons adapt their
3D space approach subsequently in theater to minimize these. Even
Tractography Representation of white matter fiber prior to this stage, DTI can inform the surgeon of how ame-
tracts produced by following eigenvec- nable the tumor is to surgery by virtue of its relationship
tors of adjacent voxels in 3D space
to eloquent brain and even potentially its histologic nature,
26 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

and therefore what surgery can offer in terms of likely ben- The perceived benefits of fiber tract neuronaviga-
efits and associated risk of adverse effects. tion need to be translated into objective improvements
in aspects of patient care; however, few studies have
Intraoperative Neuronavigation addressed this rigorously with objective endpoints. Nota-
bly, Wu et  al. performed a prospective, randomized con-
The prospect of intraoperative tract navigation is possibly trolled trial to attend to this deficiency in the literature.53
the most exciting application of DTI for the surgeon. It is They studied 238 patients undergoing resection for high-
logical to expect that an intraoperative map of functionally and low-grade supratentorial glioma involving the pyrami-
important subcortical tracts should reduce the likelihood dal tracts over 4 years. A total of 118 patients underwent
of inadvertent straying into white matter pathways, reassure preoperative DTI scanning to aid preoperative planning
the surgeon to be more aggressive allowing optimization and integration by rigid registration into the neuronaviga-
of resection limits or, conversely, restraint when critical tion system for intraoperative image guidance. This cohort
tracts are close leading to an associated reduction in the was compared to 120 similar controls undergoing resec-
incidence of postoperative neurologic deficits and increase tion aided by standard neuronavigation. Multiple outcome
in tumor volume reduction. A number of studies have measures were improved by the implementation of fiber
sought to establish whether current DTI techniques fulfill tracking. Gross total resection of high-grade glioma in the
this promise. DTI group was achieved in more than twice the number of
Various neuronavigation systems capable of integrating cases than in the control group (74.4% vs. 33.3%). Median
DTI with frameless stereotaxy exist. The DTI FA sequence can survival was 21.2 months in the DTI group compared to 
be subjected to predefined thresholds to delineate in three 14 months and DTI neuronavigation estimated hazard ratio
dimensions the white matter tracts of interest and the sur- was 0.570, conferring a 43% reduction in mortality risk.
geon can then also manipulate the final renditions using the With respect to neurologic function, 6-month Karnofsky
drawing tools available in the software. A standard 3D stereo- Performance Scale score was significantly better in the
tactic neuronavigational MRI sequence is selected to provide DTI group (32.8% vs. 15.3%). A criticism of this investiga-
the reference images for navigating and the DTI sequence is tion was the lack of physician blinding in the nonradiologic
selected to provide the working images to be merged with it. assessments. However, it provides Class I evidence that
The intensity of the tractograms can be altered to optimize fiber tract neuronavigation can improve patient mortality
the prominence of the tracts with respect to the structures and morbidity in glioma surgery, and that this technology
of interest, usually the tumor, and the surgeon’s preference. can be successfully integrated into a routine neurosurgical
Standard patient registration and navigating strategies are practice.
then employed as in conventional navigation. Depending on The promising results of these investigations need to be
the surgeon’s preferences and the particular software and repeated, particularly as scanner technology, analysis tech-
hardware facilities available, the navigational display can be niques, and intraoperative imaging advances. The impact
presented on the workstation beside the patient or projected on preservation of other tracts such as the optic radiations
through the microscope’s heads-up display. and language pathways also warrants examination.
The feasibility of intraoperative guidance by incorpora-
tion of DTI fiber tracking into neuronavigation systems has
been demonstrated by a number of investigators within the
Limitations of DTI
last decade.44-49 White matter pathways such as the pyra- Although DTI promises to be an effective tool in the sur-
midal tract and the optic radiation were successfully por- geon’s armamentarium, its limitations must be borne in
trayed in relation to intra-axial tumors such as cavernoma mind so that it is appropriately interpreted in individual
and glioma. Coenen et  al. were the first to report the use patients. DTI does not directly trace fibers unlike tracer
of intraoperative neuronavigation with 3D tract reconstruc- injection studies, which remain the gold standard for defin-
tion to assist the resection of glioblastoma associated with ing neural connectivity. Rather it produces representations
the pyramidal tract. They found fiber tract navigation to be of white matter tracts based on the fundamental assump-
a helpful adjunct to resection in the four patients in whom tion that the dominant direction of water movement is
it was applied. Subsequent studies have also underlined its aligned with the predominant direction of white matter
potential for efficiency and patient safety.47,48 The ability of fiber bundles within each voxel.21,54 This is closer to the
DTI to reliably predict the true location of critical white mat- biological reality in some circumstances more than oth-
ter pathways intraoperatively is crucial for the technique to ers. Neuronal axons are micrometers wide but the voxels
be applied with confidence during surgery. Investigators used are in the order of a few millimeters in each plane;
have evaluated intraoperative DTI’s accuracy in depicting therefore, one voxel may contain some tens of thousands
motor pathways by comparing it to intraoperative electro- of axons. If a voxel contains groups of nearby axons with
physiologic methods, in particular cortical ­stimulation.50,51 differing longitudinal axes such as are found at sites where
One particular study of 13 patients employed electrical different tracts cross or axons whose path is tortuous and
motor cortex stimulation to verify the location of the precen- change course within a very short distance, their anatomy
tral gyrus and indirectly the pyramidal tract, DTI neuronavi- will be misrepresented by current DTI methods. Advances
gation correctly predicted the principal motor pathways’ in resolution and modeling of water diffusion are improving
position in 92%.51 DTI has not only been applied to surgery this limitation such that complex fiber architectural relation-
for supratentorial tumors but also to the resection of brain- ships can be depicted more reliably and accurately in the
stem lesions such as cavernoma with promise of improving future.55-61 In larger, densely packed parallel fiber bundles
operative safety.52 such as the corpus callosum, this is much less of a problem. 
3  •  Functional Tractography, Diffusion Tensor Imaging, Intraoperative Integration of Modalities, and Neuronavigation 27

Other limitations include the inability to decipher whether a


tract is projecting retrograde or anterograde,55 which ham-
Intraoperative Integration of Modalities
pers neuroscientific investigation. However, in the context In view of the limitations of DTI described above and the
of surgical planning and intraoperative neuronavigation, complementary information that can be provided by other
the presence and location of major white matter tracts is techniques, integration of DTI with other modalities has
the critical information rather than the direction in which been implemented in the hope of harnessing all of their
they project. advantages to enhance neuronavigation. Some modalities,
A further limitation is that tractography is a user- such as CT and MEG, can be integrated directly with the
dependent technique. The ultimate results of fiber tracking neuronavigation images while others, such as subcortical
reflect the chosen thresholding of the functional anisot- stimulation, are used alongside the neuronavigation system.
ropy, the site and size of selected seed areas, and which The term “functional neuronavigation” has been coined
algorithm is used.62 A threshold value of 0.15 to 0.2 has been to describe the incorporation of MEG and fMRI data into
suggested by a rigorous, albeit retrospective, comparison frameless stereotactic neuronavigation systems.48 This
of DTI tract representation and stereotactic biopsy histo- has been an important adjunct to modern tumor surgery
logic findings, although the functionality of the tracts was and has been demonstrated to reduce morbidity during
not evaluated.40 Therefore, interuser variation can produce resection of lesions adjacent to eloquent brain.68 These
important differences in the tractogram generated. modalities provide truly functional information generated
Acquisition and processing of DTI images is affected preoperatively during series of patient tasks, whereas DTI
by multiple sources of spatial inaccuracy therefore allow- provides only structural information. All three imaging
ances need to be made when interpreting tractograms dur- modalities can be incorporated into the neuronavigation
ing surgical resection to maintain patient safety. During the system to provide simultaneous representations of the corti-
scanning process, static and encoding direction-dependent cal and subcortical functionally important tissue which is
distortions occur due to factors such as magnetic field inho- then displayed on the workstation or heads-up display. Suc-
mogeneity, imperfections in gradient waveforms, and eddy cessful incorporation and navigation using fMRI and DTI
currents.52 Although progress has been made in minimizing together has been reported to be user-friendly and suitable
the impact of these by correcting for the resulting misrepre- for routine use within a neurosurgical service69 and to help
sentations,63,64 some inaccuracy remains in the current DTI facilitate maximal tumor resection,70 although there has
technique. The integration of DTI images with neuronaviga- been no control group to compare outcomes with. Other
tion systems produces further discrepancy with an image imaging modalities such as CT or MR angiography can also
registration error in the region of 2 to 3 mm, although this be incorporated within the neuronavigation system provid-
is comparable to the error encountered when integrating ing the surgeon with the optimal anatomic and functional
functional MRI data.48 representation of the intracranial cavity.
Neuronavigation using functional tractography also If preoperative imaging, such as MEG, fMRI, and angi-
suffers from the same limitations as conventional neuro- ography, are integrated with DTI and stereotactic images
navigation. Patient registration error must be factored in and intraoperative MRI is performed then registration will
to the overall inaccuracy.48 Further, any change in patient be lost due to the brain shift associated with surgery.71
position with respect to the registration landmarks will There are potential solutions to this problem whereby the
severely diminish accuracy. As neuronavigation images are preoperative data are registered with the intraoperative
acquired preoperatively, they do not respond in real-time to data; however, as brain shift is complex and difficult to
the changing anatomy and brain shifts of cranial surgery. predict reliably,47 suitable algorithms to make this correc-
Therefore, head positioning, continuing resection, cerebro- tion are some way off. Therefore, as intraoperative DTI has
spinal fluid loss, breach of the ventricles and brain retrac- been shown to be a more reliable possibility in respond-
tion, for example, will diminish the accuracy. However, ing to brain shift,47 this may be the most accurate intraop-
with the advent of intraoperative MRI, this limitation could erative functional imaging modality once the resection has
in future be overcome. Nimsky et al.47 successfully applied advanced.
preoperative and intraoperative DTI and stereotactic MRI An alternative solution to the brain shift problem during
acquisition with a 1.5-Tesla scanner in 37 patients undergo- surgery is the use of intraoperative 3D ultrasound scanning
ing glioma surgery. They first demonstrated that it was fea- (3D USS). It has the advantage over intraoperative MRI of
sible to perform intraoperative DTI in all patients and that not requiring modifications to the operating theater and it is
the encountered brain shift was reflected in DTI white mat- much less expensive. 3D USS acquired intraoperatively can
ter tract shifts of up to 15 mm. be used to update preoperative stereotactic MRI images,
The multiple sources of spatial inaccuracy described allowing continued navigation with fMRI and DTI data
above must be taken into consideration when employing throughout the resection.72 Two studies of patients under-
DTI during tumor resection in patients. Animal, phantom, going resection of cavernoma or glioma have found that
and patient studies have attempted to quantify this dis- intraoperative updates of fMRI and DTI neuronavigation
crepancy.65-67 Berman et al. compared the location of DTI- by 3D USS has been feasible,69,70 and that the combination
imaged fiber tracts to intraoperative subcortical stimulation facilitates maximal tumor resection.70
and found a mean distance between stimulation sites and Subcortical stimulation has been used in trials to verify
imaged tracts of 8.7 mm.65 Investigators therefore advise a the reliability of depicted DTI fiber tracts; however, it can
safety margin of up to 1 cm to be maintained around the be used in tandem with DTI to confirm functional tissue
depicted white matter pathways, such as the corticospinal location. Bello et  al. reported the accurate identifica-
tract, during surgery.31,48,65 tion of eloquent fiber tracts using a combination of DTI
28 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

FIGURE 3-3  Example of a brainstem cavernoma (white arrow) depicted FIGURE 3-4  Example of a subcortical cavernoma (red) represented on
on a virtual reality workstation by incorporation of T1-weighted MRI, a virtual reality workstation. Integration of T1-weighted MRI and DTI
DTI tractography, and MR angiography. The cavernoma is intimate to tractography demonstrates distortion of the left pyramidal tract by the
the posterior circulation which lies against its anterior and superior sur- cavernoma. (Courtesy of Dr. Ralf A. Kockro, University Hospital of Zur-
faces, but the tumor is predominantly anterior to white matter tracts. ich, Switzerland, and Volume Interactions PTE Ltd.)
(Courtesy of Dr. Ralf A. Kockro, University Hospital of Zurich, Switzer-
land, and Volume Interactions PTE Ltd.)
of pre-existing functional tracts would imply that direct
neuronavigation and subcortical electrical stimulation dur- surgical injury had been the cause. Alternatively, an intact
ing resection of low- and high-grade glioma in 64 patients.31 pathway in the presence of a novel deficit may suggest that
They concluded that surgery safety was improved with a there had been indirect injury to eloquent tissue from inter-
shorter operative time and fewer intraoperative seizures. ruption of the white matter bundles’ blood supply such as
The use of combined intraoperative recorded motor- the perforators to the pyramidal tract.81
evoked potentials with neuronavigation has been sup- Just as DTI has been shown to predict functional out-
ported by other investigators with reported benefits such come after stroke,2-4 it may provide prognostic information
as real-time demonstration of spatial relationships, less with regard to postoperative deficits. If relevant tracts are
injury to eloquent tracts and optimal tumor resections.73,74 spared this may suggest a more favorable prognosis with
Again, no controlled trials currently exist; however, the function potentially returning in some degree with time.
addition of direct functional monitoring would be expected It is important to bear in mind, however, that intact tract
to increase the likelihood of identifying eloquent pathways. anatomy alone does not guarantee functional recovery as
Intraoperative DTI has been successfully coregistered with DTI describes the tissue architecture but does not provide
the electrical stimulation probe to facilitate both navigation information on the level of physiologic performance.
and stimulation of cortical and subcortical tracts during
resection of recurrent glioblastoma beside eloquent brain.75
Therefore, it is possible for both of these modalities to be
Summary
truly integrated in the operating theater. Diffusion tensor imaging is an exciting and developing non-
Virtual reality technology in neurosurgery has emerged invasive modality, which has the potential to help surgical
during the last decade as a viable complement to surgical decision making and improve safety for patients. It can be
planning and intraoperative performance.76-79 It is possible applied in diagnosis, preoperative planning, intraoperative
to integrate the variety of imaging modalities including fiber navigation with or without other complementary modali-
tracking into the virtual display (Figs. 3-3 and 3-4). Intra- ties, and in postoperative assessment. DTI does have a
operative neuronavigation using this technology has also number of limitations which the neurosurgeon must keep
been achieved.80 This therefore allows a preoperative “dry in mind when treating patients, although several of these
run” of surgery in the virtual world using multiple anatomic may be addressed by advances in the state of the art.
and functional image data followed by the retracing of the
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grade (WHO grade II) gliomas of the cerebral hemispheres: the role tensor MR imaging. Radiology. 2006;239:217-222.
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14. Lote K, Egeland T, Hager B, et al. Survival, prognostic factors, and tumor cell density of the tumor core show positive correlation in
therapeutic efficacy in low-grade glioma: a retrospective study in diffusion tensor magnetic resonance imaging of malignant brain
379 patients. J Clin Oncol. 1997;15:3129-3140. tumors. Neuroimage. 2008;43:29-35.
15. Peraud A, Ansari H, Bise K, et al. Clinical outcome of supratento- 39. Lu S, Ahn D, Johnson G, et al. Diffusion-tensor MR imaging of intra-
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1213-1222. of the tumor infiltration index. Radiology. 2004;232:221-228.
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1999;26:18-22. evaluation of tumor-invaded white matter structures. Neuroimage.
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of the corticospinal tract: diffusion magnetic resonance tractogra- tration index cannot discriminate vasogenic edema from tumor-
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29.e1
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CHAPTER 4

Intraoperative Neurophysiology: A Tool to


Prevent and/or Document Intraoperative
Injury to the Nervous System
VEDRAN DELETIS  •  FRANCESCO SALA

Over the past 25 years, intraoperative neurophysiology somatosensory-evoked potentials (SEPs) or electroenceph-
(ION) has established itself as a clinical discipline that uses alography is a typical example of a provocative test that
neurophysiologic methods—especially developed or modi- measures the ability of the collateral cerebral circulation
fied from existing methods of clinical neurophysiology—to to supply a potentially ischemic hemisphere. Endovascu-
detect and prevent intraoperatively induced neurologic lar injection of a short-acting barbiturate or lidocaine into
injuries. Recent developments have solidified its role in a vascular malformation of the spinal cord, before emboli-
neurosurgery and other surgical disciplines. Ideally, ION not zation, and observation of its influence on the neurophysi-
only predicts but serves to prevent intraoperatively induced ologic signals is another example of a provocative test.
injury to the nervous system. Furthermore, ION can be used
to document the exact moment when the injury occurred.
As a result, it can be used for both educational and medico-
Supratentorial Surgery
legal purposes. Surgery for brain gliomas has become more and more
Generally, ION techniques can be divided in two groups: aggressive. This is based on clinical data that support better
mapping and monitoring. Neurophysiologic mapping is a patient survival and quality of life after gross total removal
technique that, when applied intraoperatively, enables us of both low- and high-grade lesions.1,2
to identify anatomically indistinct neural structures by their However, the resection of tumors located in eloquent
neurophysiologic function. This allows the surgeon to avoid brain areas, such as the rolandic region and frontotemporal
lesioning critical structures in the course of the surgical speech areas, requires the identification of functional cor-
procedure. In essence, the information gained from neuro- tical and subcortical areas that must be respected during
physiologic mapping allows the surgeon to operate more surgery. Moreover, the dogmatic assumption that tumoral
safely. tissue could not retain function has been repeatedly ques-
The following procedures use a neurophysiologic map- tioned by neurophysiologic and functional magnetic reso-
ping technique: identification of the primary motor cortex nance imaging studies.3-5 In response to the need for a safe
with direct cortical stimulation, identification of the cranial surgery in eloquent brain areas, the past decade has seen
nerve motor nuclei on the surgically exposed floor of the the development of a number of techniques to map brain
fourth ventricle, mapping of the corticospinal tract (CT) functions, including, but not limited to, functional magnetic
subcortically (i.e., at the level of the cerebral peduncle or at resonance imaging, magnetoencephalography, and posi-
the spinal cord), mapping of the pudendal afferents in the tron emission tomography.6-11
sacral roots, before selective dorsal rhizotomy, and so on. The neurophysiologic contribution to brain mapping
Neurophysiologic monitoring is a technique that contin- has been evident since the late 19th century with the pio-
uously evaluates the functional integrity of nervous tissue neering work of Fritsch and Hitzig12 and Bartholow.13 In the
and gives feedback to the (neuro)surgeon. This feedback 20th century, Penfield and colleagues14,15 made invaluable
can be instantaneous, as in a recently developed technique contributions through intraoperative mapping of the senso-
of monitoring motor-evoked potentials (MEPs) from the rimotor cortex, whose findings have been substantiated by
epidural space of the spinal cord or limb muscles. If the a number of recent studies.16-18
surgical procedure allows us to combine monitoring with
mapping techniques, then optimal protection of nervous SOMATOSENSORY-EVOKED POTENTIAL
tissue can be achieved during neurosurgery. ­PHASE-REVERSAL TECHNIQUE
Furthermore, ION uses provocative tests to exam- To indirectly identify the central sulcus, SEPs can be
ine their influence on neurophysiologic signals before recorded from the exposed cerebral cortex by using the
the surgical procedure. A temporary clamping of the phase-reversal technique. SEPs are elicited by stimulation
carotid artery during endarterectomy with monitoring of of the median nerve at the wrist and the posterior tibial
30
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 31

nerve at the ankle (40-mA intensity, 0.2-msec duration, 4.3-Hz stimulation of 50 to 60 Hz and observation of muscle move-
repetition rate). Recordings are performed from the scalp at ments.14,16,27 An initial current intensity of 4 mA is used
CZ′-FZ (for legs) and C3′/C4′-CZ′ (for arms) according to the and, if no movements are elicited in contralateral muscles
10–20 International Electroencephalography System. After of the limbs and face, stimulation is increased in steps of
craniotomy, a strip electrode is placed across the exposed 2 mA to the point at which movements are elicited.16 Muscle
motor cortex and primary somatosensory cortex, transvers- responses can either be observed visually or documented
ing the central sulcus. This technique is based on the princi- by multichannel electromyography, which appears to be
ple that an SEP, elicited by median nerve stimulation at the more sensitive.28 If no response is elicited with an intensity
wrist, can be recorded from the primary sensory cortex.19 as high as approximately 16 mA, that area of cortex is con-
Its mirror-image waveform can be identified if some of the sidered not functional and can therefore be removed.29 It
contacts of the strip electrode are placed on the opposite should be emphasized that a negative mapping does not
side of the central sulcus, over the motor cortex20-22 (Fig. 4-1). always ensure safety. To increase the chances of obtaining
For phase reversal, a strip electrode with four to eight stain- a positive mapping result, technical and anesthesiologic
less steel contacts with an intercontact distance of 1 cm is drawbacks have to be carefully ruled out and cortical expo-
used. In the literature, the success rate of the phase reversal sure should be generous.
technique to indirectly localize the primary motor cortex More in general, a limitation to the reliability of cortical
ranges between 91%20,21 and 97%.18 Interestingly, identifi- mapping is the large variability of threshold for a positive
cation of the central sulcus by magnetic resonance imag- mapping response across and within individuals.30 A motor
ing provided contradictory results when compared with response from the same muscular group can be elicited
intraoperative phase reversal.20 Although it is expected from more than one cortical site, using different stimulation
that ongoing progress in the field of functional magnetic intensities.
resonance imaging will eventually replace the need for neu- Therefore, function localization may vary in different
rophysiologic tests, ION still retains the highest reliability studies as a result of stimulation parameters and mapping
in mapping of the motor cortex and language areas when strategies. Mapping strategies appear as one of the main vari-
compared with functional neuroimaging.23-26 ables that may affect the results of stimulation. Two different
theories underline the choice of one or the other strategy:
DIRECT CORTICAL STIMULATION (60-HZ PENFIELD 1. Some authors apply the concept that thresholds (the min-
TECHNIQUE) imum stimulation current required to induce functional
Once the motor strip has indirectly been identified by the changes) vary across the exposed cortex depending on
phase reversal technique, direct cortical stimulation is the task being assessed and the location being maped.
needed to confirm the localization of the motor cortex. This is in keeping with the observation that even after-
Most current methods are based on the original Penfield discharge (AD) thresholds can vary significantly, not
technique. This calls for continuous direct cortical stimu- only across the population but in the same subject at
lation over a period of a few seconds with a frequency of different cortical sites.30,31 Accordingly, they attempt to

N20
Cz
P30
1
cen

2
tral

8
3 C4
7
6
5
sul

4 4
3
cus

2
5 1

6 T4
Phase
reversal Inion
7

8

P20 N30
40µV
+
50 ms
FIGURE 4-1  Identification of the central sulcus by phase reversal of median nerve cortical somatosensory-evoked potentials. To the right is a sche-
matic drawing of the exposed brain surface with a grid electrode position orthogonally to the central sulcus. On the left are the recorded evoked
potentials phase reversed between electrode 6 and 7, showing a mirror image of the evoked potential between the motor and sensory cortices,
depicting the central sulcus lying between electrodes 6 and 7. (From Deletis V. Intraoperative neurophysiological monitoring. In: McLone D, ed.
Pediatric Neurosurgery: Surgery of the Developing Nervous System, 4th ed. Philadelphia: WB Saunders; 1999:1204-1213.)
32 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

­ aximize stimulation currents at each cortical site to


m to keep in mind that a distal muscle response after stimu-
ensure the absence of eloquent function. Doing so, it is lation of subcortical motor pathways can be misleading.
more ­common to exceed AD thresholds in adjacent cor- Although this stimulation activates axons distal to the
tices, and there is a higher risk of distal activation due to stimulation point, the possibility of damage to the path-
current spreading to adjacent sites. ways proximal to that point cannot be ruled out. This is a
2. Other authors29,32,33 keep stimulation intensity constant concern, especially when dealing with an insular tumor
while mapping the entire cortex and set threshold just where there is a risk of cortical or subcortical ischemia
below the lowest current observed to induce AD. This induction secondary to manipulation of perforating ves-
strategy is aimed to minimize the risk of inducing ADs sels (Fig. 4-2).
(which may invalidate the results) and clinical sei- Despite its popularity in the past, this 60-Hz Penfield
zures, but may miss the identification of eloquent corti- technique has some disadvantages. With the exception of
cal sites. speech mapping, it is our opinion that these disadvantages
Spreading of the current using the 60-Hz stimulation should prevent its use as a motor cortex/pathways mapping
technique is limited to 2 to 3 mm as detected by opti- technique. First, this technique can induce seizures in as
cal imaging in monkeys. 34 Accordingly, one can assume many as 20% of patients, despite therapeutic levels of anti-
that using this technique is safe for removal of tumors convulsants and regardless of whether there is a preopera-
very close to the motor and sensory pathways as long as tive history of intractable epilepsy.36,37 Second, in children
stimulation is repeated whenever a 2- to 3-mm section younger than 5 years old, direct stimulation of the motor
of tumoral tissue is removed. 29 Similarly, this technique cortex for mapping purposes may not yield localizing infor-
allows us to map motor pathways subcortically while mation because of the relative unexcitability of the motor
removing tumors that arise or extend to the insular, sub- cortex.19,38 Third, because this is a mapping and not a moni-
insular, or thalamic areas. 27,35 At the subcortical level, the toring technique, no matter how often cortical or subcorti-
stimulation intensity required to elicit a motor response cal stimulation is repeated, the functional integrity of the
is usually lower than that required for cortical mapping. motor pathways cannot be assessed continuously during
When performing subcortical mapping, however, we have surgery.

A - Tumor removed

B - Hemostasis

C - C2/17ST130MA

D - PA 90/50 mmHg

E - Papaverine
PA 100/50 mmHg
T
F - PA 120/65 mmHg

Papaverine

10' after papaverine


C
G - Closing
MCA
L-APB L-TA

FIGURE 4-2  Upper left: Preoperative axial contrast-enhanced, magnetic-resonance, T1-weighted image of a right frontotemporoinsular anaplas-
tic astrocytoma that was removed with the assistance of intraoperative neurophysiologic monitoring. Lower left: Intraoperative view at the end
of tumor resection. The internal capsule (C ) has been identified using mapping of the subcortical motor pathways with the short train of stimuli
technique. The temporal lobe (T ) and branches of the middle cerebral artery (MCA) are on view. Right: Motor-evoked potentials (MEPs) recorded
intraoperatively from the left abductor brevis pollicis (L-APB) and tibialis anterior (L-TA) muscles. MEP recordings at the end of tumor removal (A);
MEP loss during hemostasis (B); transitory MEP reappearance by increasing stimulation to seven stimuli and 130-mA intensity (C ); new disappear-
ance of MEPs despite increased stimulation (D); progressive MEP reappearance after papaverine infusion and increased systemic blood pressure
(E and F ); MEPs at the end of the procedure (G). (Modified from Sala F, Lanteri P. Brain surgery in motor areas: The invaluable assistance of intraop-
erative neurophysiological monitoring. J Neurosurg Sci. 2003;47:79-88.)
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 33

In the illustrative case presented in Fig. 4-2,39 an impair-


DIRECT CORTICAL STIMULATION AND ment of muscle MEPs occurred at the end of tumor removal
­MOTOR-EVOKED POTENTIAL MONITORING when opening and closing mapping procedures had already
(SHORT TRAIN OF STIMULI TECHNIQUE) been done and confirmed the integrity of motor pathways
Recently, mapping techniques have integrated monitoring distal to the stimulation point at the level of the internal cap-
techniques to continuously assess the functional integrity sule. However, ischemia of the pyramidal tracts secondary
of the motor pathways and therefore increase the safety of to severe vasospasm of the main perforating branches of
these procedures.20,39-41 The following is a description of the middle cerebral artery occurred during hemostasis and
the technique that we use at our institutions and have found was detected by muscle MEP monitoring. If not detected in
suitable for both mapping and monitoring. time, this event would have likely resulted in an irreversible
Muscle MEPs are initially elicited by multipulse trans­ loss of muscle MEPs and, consequently, a permanent motor
cranial electrical stimulation (TES). Short trains of five to deficit. Mapping techniques are unlikely to detect these
seven square-wave stimuli of 500-μsec duration with an events because they do not allow a continuous “online”
interstimulus interval of 4 msec are applied at a repetition assessment of the functional integrity of neural pathways.
rate of as high as 2 Hz through electrodes placed at C1 and In our experience with using the short-train technique,
C2 scalp sites, according to the 10–20 International Electro- a threshold lower than 5 mA for eliciting muscle MEPs usu-
encephalography System. The maximum stimulation inten- ally indicated proximity to the motor cortex. When muscle
sity should be as high as 200 mA, which is strong enough responses are elicited through higher stimulation intensi-
for most cases. Muscle responses are recorded via needle ties, activation of the CT is of less localizing value because
electrodes inserted into the contralateral upper and lower of the possibility of spreading of the current to adjacent
extremity muscles. We usually monitored the abductor areas.39
pollicis brevis and the extensor digitorum communis for Once mapping of the cortex has clarified the relation-
the upper extremities and the tibialis anterior and the ship between eloquent motor areas and the lesion, con-
abductor hallucis for the lower extremities. For the face tinuous MEP monitoring of the contralateral muscles can
area, the orbicularis oculi and orbicularis oris muscles are be sustained throughout the procedure to assist during the
typically used. surgical manipulation. To do so, one of the same contacts
After exposure of the cortex and once phase reversal has of the strip electrode can be used as an anode for stimula-
been performed, direct cortical stimulation of the motor tion while the cathode is at Fz. The stimulation point on the
cortex can be achieved by using a monopolar-stimulating motor cortex with the lowest threshold used to elicit muscle
probe to identify the cortical representation of contra- MEPs from contralateral limbs or face usually corresponds
lateral facial and limb muscles. The same parameters of with the contact from which the largest amplitude of the
stimulation used for TES, except for a much lower inten- mirror-image SEPs was obtained. The same stimulation
sity (≤20 mA), can be used.39 Sometimes the short train of parameters as those used for the short-train mapping tech-
stimuli technique requires slightly higher current intensities nique can be used.
than those required by the Penfield technique. However, by When removing a tumor that extends subcortically, pres-
using a very short train, the charge applied to the brain is sig- ervation of muscle MEPs during monitoring from the strip
nificantly reduced42 and, consequently, the risk of inducing electrode will guarantee the functional integrity of motor
seizures. The number of pulses in the short-train technique pathways and avoid the need for periodic remapping of the
is five to seven pulses per second, whereas in the Penfield cortex at known functional sites.39
technique, there are 60 pulses per second. The effect of For insular tumors where the motor cortex is not exposed
stimulation on the cerebral cortex, from a neurophysiologic by the craniotomy, a strip electrode can still be gently
point of view, differs between the Penfield technique and inserted into the subdural space to overlap the motor cor-
the short train of stimuli technique. The Penfield technique tex. Phase reversal and/or direct cortical stimulation can
delivers one stimulus every 15 to 20 msec continuously for be used to identify the electrode with the lowest threshold
a couple of seconds. The short train of stimuli technique to elicit muscle MEPs. The use of MEPs during surgery for
delivers five to seven stimuli in a period of approximately insular tumors has proved very useful to identify impend-
30 msec with a long pause between trains (470 to 970 msec, ing vascular derangements to subcortical motor pathways
which depends on train repetition rate—1 or 2 Hz). There- in time for corrective measures to be taken. In spite of the
fore, the Penfield technique is more prone to produce sei- observation that intraoperative MEP changes occurred in
zures, activating the cortical circuitry more easily than nearly half of the procedures, these were reversible in two
short-train stimuli do. Furthermore, compared with the Pen- thirds of the cases.43
field technique, the short-train technique does not induce
strong muscle twitches that may interfere with the surgical WARNING CRITERIA AND CORRELATION
procedure. Responses are usually recorded from needle WITH POSTOPERATIVE OUTCOME
electrodes used to record muscle MEPs elicited by TES. Still debated are the warning criteria for changes in muscle
However, any combination of recording muscles can be MEPs that are used to inform the surgeon about an impend-
used, according to the tumor location. The larger the num- ing injury to the motor system. It should be stressed that
ber of monitored muscles, the lower the chance of a false- although for spinal cord surgery, a “presence/absence” of
negative mapping result. We suggest that stimulation of the muscle MEPs criterion has proved to be reliable and strictly
tumoral area should always be performed to rule out the correlates with postoperative results,44,45 there are not defi-
presence of some functional cortex. As already described, nite MEP parameters indicative of significant impairment
this is especially true in the case of low-grade gliomas.3-5 during supratentorial surgery.46 We believe that the predictive
34 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

value of muscle MEPs is different for supratentorial and spi-


nal cord surgeries. As such, different warning criteria must MAPPING OF THE CORTICOSPINAL TRACT
be employed. This judgment is based on the difference in AT THE LEVEL OF THE CEREBRAL PEDUNCLE
types of CT fibers in supratentorial portion of the CT as com- This is a recently described technique used to map the
pared with the spinal cord. Different groups with established CT tract within the brain stem at the level of the cerebral
experience in this field have proposed similar criteria,40,46 peduncle.54,55 To identify the CT, we use a hand-held mono-
suggesting that a shift in latency between 10% and 15% and polar-stimulating probe (0.75-mm tip diameter) as a cath-
a decrease in amplitude of more than 50% to 80% correlate ode, with a needle electrode inserted in a nearby muscle
with some degree of postoperative motor deficit. However, as an anode. If the response (D wave) is recorded from an
a permanent new motor deficit has consistently correlated epidural electrode, a single stimulus is used. Conversely,
only with irreversible complete loss of muscle MEPs.46 if the response is recorded as a compound muscle action
A persistent increase in the threshold to elicit muscle potential from one or more muscles of contralateral limbs,
MEPs or a persistent drop in muscle MEP amplitude, despite a short train of stimuli should be used.
stable systemic blood pressure, anesthesia, and body tem- We usually increase stimulation intensity to 2 mA. When
perature, represents a warning sign. However, it should be a motor response is recorded, the probe is then moved in
noted that muscle MEPs are easily affected by muscle relax- small increments of 1 mm to find the lowest threshold to
ants, bolus of intravenous anesthetics and high concen- elicit that response.
trations of volatile (and other) anesthetics such that wide This technique is particularly useful for midbrain tumors
variation in muscle MEP amplitude and latency can be that have displaced the CT tract from its original position.
observed.47 Due to this variability, the multisynaptic nature Usually, the so-called midbrain lateral vein described by
of the pathways involved in the generation of muscle MEPs, Rhoton56 represents a useful anatomic landmark because
and the nonlinear relationship between stimulus intensity it allows an indirect identification of the CT tract, located
and the amplitude of muscle MEPs, the correlation between anterior to the vein. However, when an expansive lesion dis-
intraoperative changes in muscle MEPs (amplitude and/or torts anatomy, only neurophysiologic mapping allows the
latency) and the motor outcome are not linear. Further clini- identification of the CT and, consequently, a safe entry zone
cal investigation is needed to clarify sensitive and specific to the lateral midbrain.
neurophysiologic warning criteria for brain surgery. In the case of a cystic midbrain lesion, sometimes
mapping of the CT is negative at the beginning of the pro-
Brain Stem Surgery cedure, but a positive response can be recorded when
mapping from within the cystic cavity toward the antero-
The human brain stem is a small and highly complex struc- lateral cystic wall.57
ture containing a variety of critical neural structures. These
include sensory and motor pathways; sensory and motor
MAPPING OF MOTOR NUCLEI OF CRANIAL
cranial nerve nuclei; cardiovascular and respiratory cen- NERVES ON THE FLOOR OF THE FOURTH
ters; neural networks supporting swallowing, coughing, ­VENTRICLE
articulation, and oculomotor reflexes; and the reticular This technique is based on intraoperative electrical stimula-
activating system. In such a complex neural structure, even tion of the motor nuclei of the cranial nerves on the floor
small lesions can produce severe and life-threatening neu- of the fourth ventricle, using a hand-held monopolar stimu-
rologic deficits. lating probe. Compound muscle action potentials are then
The neurosurgeon faces two major problems when elicited in the muscles innervated by the cranial motor
attempting to remove brain stem tumors. First, if the tumor nerves. A single stimulus of 0.2-msec duration is delivered
is intrinsic and does not protrude on the brain stem sur- at a repetitive rate of 2.0 Hz. Stimulation intensity starts at
face, approaching the tumor implies a violation of the ana- approximately 1 mA and is then reduced to determine the
tomic integrity of the brain stem. Knowledge of the location point with the lowest threshold that elicits muscle responses
of critical neural pathways and nuclei is mandatory when corresponding with the mapped nucleus (Fig. 4-3). No stim-
considering a safe entry into the brain stem,48,49 but may not ulation intensity higher than 2 mA should be used.50,51 To
suffice when anatomy is distorted. Morota and colleagues50 record the responses from cranial motor nerves VII, IX/X, and
reported that visual identification of the facial colliculus XII, wire electrodes are inserted into the orbicularis oculi
based on anatomic landmarks was possible in only three of and orbicularis oris muscles, the posterior wall of the phar-
seven medullary tumors and was not possible in five pon- ynx, and the lateral aspect of the tongue muscles, respec-
tine tumors. The striae medullares were visible in four of tively. Based on mapping studies, characteristic patterns
five patients with pontine tumors and in five of nine patients of motor cranial nerve displacement, secondary to tumor
with medullary tumors. growth, have been described (Fig. 4-4).58 The case described
Therefore, functional rather than anatomic localization in Fig. 4-5 is consistent with this observation.
of brain stem nuclei and pathways should be used to iden- A similar methodology can be applied to identify the
tify safe entry zones. motor nuclei of cranial nerves innervating ocular muscles
(nerves III, IV, and VI) during a dorsal approach to midbrain
MAPPING TECHNIQUES lesions as well as quadrigeminal plate, tectal, and pineal
Neurophysiologic mapping techniques have been increas- region tumors.59,60
ingly used to localize CT and cranial nerve motor nuclei Despite the relative straightforwardness of the fourth ven-
on the lateral aspect of the midbrain and on the floor of the tricle mapping technique and its indisputable usefulness in
fourth ventricle.50-54 planning the most appropriate surgical strategy to enter the
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 35

FIGURE 4-3  Mapping of the brain stem cranial nerve motor nuclei. Upper left: Drawing of the exposed floor of the fourth ventricle with the sur-
geon’s handheld stimulating probe in view. Upper middle: The sites of insertion of wire hook electrodes for recording the muscle responses are
depicted. Far upper right: Compound muscle action potentials recorded from the orbicularis oculi and oris muscles after stimulation of the upper
and lower facial nuclei (upper two traces) and from the pharyngeal wall and tongue muscles after stimulation of the motor nuclei of cranial nerves
IX/X and XII (lower two traces). Lower left: Photograph obtained from the operating microscope shows the hand-held stimulating probe placed on
the floor of the fourth ventricle (F ). A, aqueduct. (Reproduced from Deletis V, Sala F, Morota N. Intraoperative neurophysiological monitoring and
mapping during brain stem surgery: A modern approach. Oper Tech Neurosurg. 2000;3:109-113.)

lt. VII lt. VII


rt. VII rt. VII

Tumor Tumor
rt. XII
rt. XII
lt. XII lt. XII

Upper pontine tumor Lower pontine tumor

lt. VII lt. VII


rt. VII rt. VII

rt. XII
rt. XII lt. XII
Tumor
lt. XII Tumor

Medullary tumor Cervicomedullary junction spinal cord tumor


FIGURE 4-4  Typical patterns of cranial nerve motor nuclei displacement by brain stem tumors in different locations. Upper and lower pontine
tumors: Pontine tumors typically grow to push the facial nuclei around the edge of the tumor, suggesting that precise localization of the facial nuclei
before tumor resection is necessary to avoid their damage during surgery. Medullary tumors: Medullary tumors typically grow more exophytically
and compress the lower cranial nerve motor nuclei ventrally; these nuclei may be located on the ventral edge of the tumor cavity. Because of the
interposed tumor, in these cases mapping before tumor resection usually does not allow identification of cranial nerve IX/X and XII motor nuclei.
Responses, however, could be obtained close to the end of the tumor resection when most of the tumoral tissue between the stimulating probe
and the motor nuclei has been removed. At this point, repeat mapping is recommended because the risk of damaging motor nuclei is significantly
higher than at the beginning of tumor debulking. Cervicomedullary junction spinal cord tumors: These tumors simply push the lower cranial nerve
motor nuclei rostrally when extending into the fourth ventricle. (Reproduced from Morota N, Deletis V, Lee M, et al. Functional anatomic relation-
ship between brain stem tumors and cranial motor nuclei. Neurosurgery. 1996;39:787-794.)
36 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

Pre-op

Post-op

A B

1.5 mA

0.5 mA

0.2 mA

0.2 mA

C RU RL LU LL D
A
FIGURE 4-5  Upper panel: (Top): Preoperative contrast-enhanced, T1-weighted magnetic resonance imaging (MRI) of an upper left pontine low-
grade astrocytoma in a 16 year old female. Bottom: Postoperative MRI study showing complete tumor removal. Surgery was performed under
neurophysiologic guidance. Middle panel: Direct mapping of the facial nerve motor nuclei on the floor of the fourth ventricle. The tumor was
approached through a median suboccipital craniectomy. When the floor of the fourth ventricle was exposed, the median sulcus appeared dislocated
to the right and the left median eminence was expanded. Electromyographic wire electrodes were inserted bilaterally in the left (LU ) and right (RU )
orbicularis oculi and left (LL) and right (RL) orbicularis oris muscles for mapping and monitoring of the seventh nerve, and in the abductor pollicis
brevis (LA and RA) for continuous monitoring of the corticospinal tract integrity. We initially stimulated on the left side, approximately 1.5 cm rostral
to the striae medullares, where the motor nuclei were expected to be according to normal brain stem functional anatomy. A response was obtained
from the left orbicularis oculi (LU ) at a stimulation intensity of 1.5 mA (A). By moving the stimulating probe caudally and to the right, a consistent
response from the left orbicularis oris (LL) was recorded at a stimulation intensity of 0.5 mA (B). At this point, we moved the stimulation probe more
laterally to the right side, approximately 1 cm above the striae medullares, and a clear response was recorded from the right orbicularis oris (RL) at
the lowest threshold intensity of 0.2 mA (C ). Finally, by moving the stimulating probe paramedially to the left side, a few millimeters above the striae
medullares, a consistent response was recorded from both the left orbicularis oris (LL) and orbicularis oculi (LU), using the same low threshold (0.2
mA) (D). The conclusion was drawn that the tumor displaced caudally the facial nerve motor nuclei, especially on the left side. Based on mapping
results, the surgeon decided to enter the brain stem on the left side in correspondence with the higher threshold stimulating point (A).
Continued

brain stem, postoperative functional outcome is not always This could result in a false-negative peripheral response still
predicted by postresection responses.50 In the case of map- being recorded despite an injury to the motor nuclei.50
ping of the motor nuclei of the seventh cranial nerve, brain Mapping of the glossopharyngeal nuclei is also of lim-
stem mapping cannot detect injury to the supranuclear tracts ited benefit. Recording activity from the muscles of the
originating in the motor cortex and ending on the cranial posterior pharyngeal wall after stimulation of the ninth cra-
nerve motor nuclei. Consequently, a supranuclear paralysis nial nerve motor nuclei on the floor of the fourth ventricle
would not be detected, although lower motoneuron integrity assesses the functional integrity of the efferent arc of the
has been preserved. Similarly, the possibility of stimulating swallowing reflex. This technique, however, does not pro-
the intramedullary root more than the nuclei itself exists. vide information on the integrity of afferent pathways and
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 37

I
B C
A

B 2:LL+/LL– 4:LA+/LA–
FIGURE 4-5, cont’d  Lower left: Schematic summary of mapping results. A and B represent the original position of the left and right facial colliculi,
as expected according to brain stem anatomy. A, B, C, and D correspond to the stimulating point illustrated in the upper panel. C and D also
correspond to the lower threshold to elicit a consistent response from, respectively, the right and left muscles innervated by the facial nerve. The
conclusion was made that real location of facial nerve motor nuclei (C and D) was more caudal than expected, especially on the left side, due to
the tumor mass effect. Accordingly, initial incision (I ) was carried on transversely in correspondence with stimulating point A. Lower right: Continu-
ous neurophysiologic monitoring of muscle motor-evoked potentials during tumor removal. Electromyographic wire electrodes were inserted in
the left orbicularis oris (LL) and abductor pollicis brevis (LA) muscles for continuous monitoring of, respectively, the corticobulbar and corticospinal
tract integrity, after transcranial electrical stimulation (electrode montage C4/Cz; short train of four stimuli; intensity 50 mA). (Modified from Sala F,
Lanteri P, Bricolo A. Intraoperative neurophysiological monitoring of motor evoked potentials during brain stem and spinal cord surgery. Adv Tech
Stand Neurosurg. 2004;29:133-169.)

afferent/efferent connections within brain stem, which are manipulation of the brain stem and/or of the cerebellum is
indeed necessary to provide functions involving reflexive expected. When interpreting brain stem auditory-evoked
swallowing, coughing, and the complex act of articulation. potential recordings, a thoughtful analysis of the waveform
Recently, however, Sakuma and colleagues61 succeeded and of their correlation with neural generators provides use-
in monitoring glossopharyngeal nerve compound action ful information about the localization of the changes.
potentials after stimulation of the tongue in dogs, opening When an initial myelotomy is performed at the region
the possibility of a new field of investigation in humans. of dorsal column nuclei of the medulla, further monitor-
Functional magnetic resonance imaging of the brain stem ing with SEPs is compromised due to limitations similar to
has also provided a new, yet experimental, tool to localize those related to intramedullary spinal cord tumor surgery
cranial nerve nuclei in humans.62 after myelotomy.54 For pontine and midbrain tumors, SEPs
An intrinsic limitation of all mapping techniques, how- have little localizing value but can still be used to provide
ever, is that these do not allow the continuous evaluation of nonspecific information about the general functional integ-
the functional integrity of a neural pathway. The identifica- rity of the brain stem (because it is expected that a major
tion of the safe entry zone for approaching a pontine astro- impending brain stem failure will be detected by changes
cytoma, as in Fig. 4-5, does not provide any information on in SEP parameters).
the well-being of the adjacent corticospinal, corticobulbar, Similar to what has occurred for brain and spinal cord
sensory, and auditory pathways during the surgical manipu- surgery, the major breakthrough in modern ION of the brain
lation aimed to remove the tumor.  Therefore, it is essential stem has been the advent of MEP-related techniques.
to combine mapping with monitoring techniques. With regard to motor function within the brain stem, stan-
dard techniques for continuously assessing the functional
MONITORING TECHNIQUES integrity of motor cranial nerves relies on the recording
SEPs and brain stem auditory-evoked potentials have been of spontaneous electromyographic activity in the muscles
extensively used to assess the functional integrity of the innervated by motor cranial nerves.60,64,65 Several criteria
brain stem, and we refer the reader to the related literature have been proposed to identify electromyographic activity
for a review of these classic techniques. Unfortunately, SEPs patterns that may anticipate transitory or permanent nerve
and brain stem auditory-evoked potentials can evaluate only injury, but these patterns are not always easily recognizable
approximately 20% of brain stem pathways.63 As a result, their and criteria remain vague or at least subjective. Overall,
use is of limited valued when the major concern is related to convincing data regarding a clinical correlation between
corticospinal and cranial nerve motor function. Still, brain electromyographic activity and clinical outcomes is still
stem auditory-evoked potentials can provide useful informa- lacking.60,64
tion on the general well-being of the brain stem, especially Seeking more reliable techniques in the neurophysi-
during those procedures in which a significant surgical ologic monitoring of motor cranial nerve integrity, the
38 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

possibility of extending the principles of CT monitoring to monitoring.68 The battery of techniques to be used should
the corticobulbar tracts is currently under investigation.57,66 be tailored to each individual patient according to tumor
location and clinical status. Keeping this in mind, SEPs and
Monitoring of Corticobulbar (Corticonuclear) brain stem auditory-evoked potentials should always be
Pathways considered. However, unlike in the past decade when these
For this purpose, TES with a train of four stimuli, with an classic monitoring methods allowed only a very limited
interstimulus interval of 4 msec, and a train-stimulating assessment of the brain stem functional integrity, current
rate of 1 to 2 Hz, intensity between 60 and 100 mA can be techniques of MEP monitoring and motor nuclei mapping
used. The stimulating electrode montage is usually C3/Cz are receiving increasing credit in assisting the neurosur-
for right-side muscles and C4/Cz for left-side muscles. For geon during brain stem surgery.
recording muscle MEPs, electromyographic wire electrodes
are inserted in the orbicularis oris and orbicularis oculi
muscles for nerve VII, in the posterior pharyngeal wall
Spinal and Spinal Cord Surgery
for the cranial motor nerves IX and X, and in the tongue These surgeries are potentially burdened with serious neu-
muscles for the hypoglossal nerve (i.e., in the same man- rologic deficits such as para- or quadri-plegia (paresis). As
ner as described for mapping of motor nuclei of the cranial a rule, the closer to the spinal cord that the neurosurgeon
nerves). Reproducible muscle MEPs can be continuously operates, the higher is the risk of injury. Of course, there is
recorded from the facial, pharyngeal, and tongue muscles always the possibility that surgeries on the bony structures
while the brain stem is surgically manipulated (see Fig. 4-5). of the spinal cord can result in paraplegia.69,70 Furthermore,
This technique allows one to monitor the entire pathway, long-lasting intraoperative hypotension can be disastrous
from the motor cortex down to the neuromuscular junction for the spinal cord if neurophysiologic monitoring has not
so that a supranuclear injury can be detected. However, the been used because no other routine methods are available
corticobulbar tract monitoring technique is still far from to evaluate the functional integrity of the spinal cord during
becoming standardized due to some theoretical and practi- hypotension.
cal drawbacks. First, from a neurophysiologic perspective, It has been shown that the use of SEPs to monitor the
use of the lateral montage as an anodal stimulating elec- functional integrity of the spinal cord is inadequate and
trode (C3 or C4) increases the risk that strong TES may not can result in false-negative results (i.e., no changes in
activate the corticobulbar pathways but the cranial nerve SEP parameters intraoperatively, but the patient wakes up
directly. Accordingly, an injury to the corticobulbar path- paraplegic after surgery69,70). Therefore, it is mandatory
way rostral to the point of activation may be masked by a that during spinal and spinal cord surgeries, monitoring of
misleading preservation of the muscle MEP. To minimize both sensory and motor modalities of evoked potentials is
this risk, stimulation intensity should be kept as low as pos- conducted. Each of these methods evaluates different long
sible. One of the ways to recognize structure generating this tracts; SEPs evaluate the dorsal columns, whereas MEPs
response is as follows; 90 msec after delivering train of stim- evaluate CT If a lesion to the spinal cord is diffuse in nature,
uli a single stimulus was delivered through the same stimu- affecting both long tracts, monitoring one of them may suf-
lating montage. The rationale for this kind of stimulation is fice. Unfortunately, this is not always the case. A typical
the fact that in most patients under general anesthesia, only example is anterior spinal cord artery syndrome with pres-
a short train of stimuli can elicit “central” responses gener- ervation of SEPs and disappearance of MEPs.70
ated by the motor cortex or subcortical part of corticobulbar Surgery for intramedullary spinal cord tumors requires
tract (CBT). If a single stimulus elicits a response, this should a special approach concerning monitoring with MEPs. Dur-
be considered a “peripheral” response which activates the ing this type of surgery, very precise surgical instruments
cranial nerve directly by spreading current more distally.67 are used, such as the Contact Laser System (SLT, Montgom-
Furthermore, given the continuous fluctuations in the eryville, PA),71 and a very selective lesion within the spinal
threshold required to elicit muscle MEPs intraoperatively cord can occur. Therefore, monitoring this type of surgery
(i.e., due to variability in room temperature, anesthesiologic using only MEPs recorded from limb muscles can be insuf-
regimen, and physiologic variability in muscle MEP thresh- ficient. Monitoring the D wave (i.e., recording descending
old, and so on), the appropriate threshold for monitoring activity of the CT using catheter electrodes placed over the
corticobulbar pathways should be rechecked throughout exposed spinal cord) should be combined with MEP record-
the surgical procedure. Another limitation of this technique ing from limb muscles. Combining both of these techniques
is that spontaneous electromyographic activity can some- proved highly effective in preventing paraplegia/quadriple-
times hinder the recording of reliable muscle MEPs from the gia. This gives the neurosurgeon the opportunity to be more
same muscles. In our experience, this spontaneous activ- radical in tumor resection. This combined type of monitor-
ity appears to be more common in the pharyngeal muscles ing can precisely predict transient postoperative motor defi-
as compared with the facial and tongue muscles. Further cits45,72 and clearly distinguish them from permanent ones.
experience with this technique will indicate the extent to
which monitoring of the corticobulbar tract predicts post-
NEUROPHYSIOLOGIC MONITORING OF THE
operative function and allows an impending injury to the SPINAL CORD AND SPINAL SURGERIES
motor cranial nerves to be recognized in time to be cor- WITH MOTOR-EVOKED POTENTIALS
rected (see Fig. 4-5). A schematic drawing of techniques for eliciting MEPs by
Due to the complexity of the brain stem’s functional anat- TES or direct electrical stimulation of the exposed motor
omy, the more neurophysiologic techniques that can be cortex while recording them from the spinal cord (D wave)
rationally integrated, the better the chances for successful or limb muscles (muscle MEPs) is presented in Fig. 4-6.
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 39

Transcranial Direct Table 4-1  Principles of Motor-Evoked Potential


­Interpretation
C2 Cz C1
D Wave Muscle MEP* Motor Status
Unchanged or Preserved Unchanged
30%–50% decrease
C4 C3 Unchanged or Lost uni- or bilaterally Transient motor
Grid electrode 30%–50% decrease deficit
A 6 cm B >50% decrease Lost bilaterally Long-term motor
deficit
*In the tibial anterior muscle(s).
Epidural recording Source: Deletis V. Intraoperative neurophysiological monitoring. In: McLone D.
Pediatric Neurosurgery: Surgery of the Developing Nervous System, 4th ed.
D-wave I-waves Philadelphia: WB Saunders; 1999:1204-1213.

explanation for transient paraplegia is that the D wave is


20 µV
generated exclusively by the descending activity of the
transcranially activated fast neurons of the CT, whereas
2 ms
muscle MEPs are generated by the combined action of the
fast neurons of the CT and propriospinal and other descend-
ing tracts within the spinal cord (of course, with consecu-
C S
tive activation of alpha motoneurons, peripheral nerves,
and muscles). The selective lesion to the propriospinal and
Muscle recording other descending tracts can occur with the use of precise
neurosurgical instruments (e.g., contact laser with a tip of
200 μm, producing minimal collateral damage).71 Lesion-
ing of the propriospinal system and other descending tracts
can be functionally compensated postoperatively, whereas
a lesion to the fast neurons of the CT cannot. Empirically,
we have discovered that decrements in the amplitude of the
D wave occur in a stepwise fashion (except in the case of
D anterior spinal artery lesion). Therefore, the neurosurgeon
has enough time to make a decision and can immediately
FIGURE 4-6  A, Schematic illustration of electrode positions for trans­
cranial electrical stimulation of the motor cortex according to the 
stop the surgery when a critical decrement in D-wave ampli-
10-20 International Electroencephalography System. The site labeled tude occurs. The previous statement has been tested in 100
6 cm is 6 cm anterior to Cz. B, Illustration of grid electrode overlying surgeries for intramedullary spinal cord tumors performed
the motor and sensory cortexes. C, Schematic diagram of the positions by one neurosurgeon and using a combined monitoring
of the catheter electrodes (each with three recording cylinders) placed method. This approach showed a sensitivity of 100% and
cranial to the tumor (control electrode) and caudal to the tumor to
monitor the descending signal after passing through the site of surgery a specificity of 91%.45 Based on these results, Table 4-1 was
(left). In the middle are D and I waves recorded rostral and caudal to produced to explain the meaning and predictive features
the tumor site. On the right is depicted the placement of an epidural of combined monitoring of the spinal cord surgery using
electrode through a flavectomy/flavotomy when the spinal cord is not muscle MEPs and D wave.
exposed. D, Recording of muscle motor-evoked potentials from the
thenar and tibial anterior muscles after eliciting them with short train
Combined monitoring of MEPs in one typical patient
of stimuli applied either transcranially or over the exposed motor cor- with an intramedullary spinal cord tumor showed a disap-
tex. (Modified from Deletis V, Rodi Z, Amassian VE. Neurophysiologi- pearance of muscle MEPs and a sustained D wave. This
cal mechanisms underlying motor evoked potentials in anesthetized resulted in a transient postoperative paraplegia, with a
humans. Part 2: Relationship between epidurally and muscle recorded complete recovery from paraplegia, as presented in Fig. 4-7.
MEPs in man. Clin Neurophysiol 2001;112:445-452.)
MAPPING OF THE CORTICOSPINAL TRACT WITHIN
Table 4-1 summarizes the results from the combined use THE SURGICALLY EXPOSED SPINAL CORD
of D-wave and muscle MEP recordings during surgery for Further improvement in the prevention of lesioning of the
intramedullary spinal cord tumors. The neurosurgeon can CT during spinal cord surgery has been achieved by intro-
proceed with the surgery aggressively, without jeopardizing ducing a neurophysiologic method of mapping the CT by
the patient’s motor status despite the complete disappear- using a D-wave collision technique. This technique has
ance of the muscle MEPs during surgery. This is only allowed recently been developed by our group and has allowed us
when the D-wave amplitude does not decrease more than to precisely map the anatomic location of the CT when the
50% from the baseline amplitude. After disappearance of anatomy of the spinal cord has been distorted.73,74 The ana-
muscle MEPs, patients will have only transient postopera- tomic position of the CT is difficult to determine by visual
tive motor deficits, with a full recovery of muscle strength inspection alone. D-wave collision is accomplished by
later on. Therefore, to achieve a good postoperative motor simultaneously stimulating the exposed spinal cord (with a
outcome, it is imperative that the critical decrement in small handheld probe delivering a 2-mA intensity stimulus),
D-wave amplitude not be permitted. The neurophysiologic with TES to elicit a D wave. Because the resulting signals are
40 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

Right anterior tibial precise determination of the anatomic midline by visual


inspection and anatomic landmarks. Therefore, to facilitate
the precise determination of the medial border between
Baseline
the left and right dorsal columns of the spinal cord, a tech-
Left anterior tibial nique for dorsal column mapping has been developed.75
Dorsal column mapping is based on two basic principles.
First, after stimulation of the peripheral nerves, evoked
potentials traveling through the dorsal columns can be
Right anterior tibial recorded. Second, the area over the dorsal columns of the
spinal cord where the maximal amplitude of the SEPs is
Closing Left anterior tibial recorded represents the point on the recording electrode
in closest proximity to the dorsal columns. For recording
these traveling waves, a miniature multielectrode is placed
10 ms 10 µV over the surgically exposed dorsal columns of the spinal
cord. This electrode consists of eight parallel wires, 76 μm
D wave
in diameter and 2 mm in length, placed 1 mm apart and
embedded in a 1-cm2 (approximately) silicone plate (Fig.
4-9). An extremely precise amplitude gradient of the SEPs
Baseline
is recorded as the conducted potentials pass beneath the
electrodes after alternating stimulation of the tibial nerves.
The amplitude gradient of the conducted potentials indi-
cates the precise location of the functional midline corre-
D wave
sponding to the dorsal fissure of the spinal cord (i.e., the
optimal site for myelotomy). These data can be used by the
Closing neurosurgeon to prevent injury to the dorsal columns that
could occur through an imprecise midline myelotomy. This
is especially useful during surgery for intramedullary spi-
2 ms 25 µV
nal cord tumors or during the placement of a shunt to drain
syringomyelic cysts (see Fig. 4-9).74
FIGURE 4-7  A 9-year-old boy underwent gross total resection of a
pilocytic astrocytoma of the thoracic spinal cord that spanned four NEUROPHYSIOLOGIC MONITORING DURING
spinal segments. Preoperatively, there were no motor deficits. During ­SPINAL ENDOVASCULAR PROCEDURES
surgery, the muscle motor-evoked potentials from the left and right
tibial anterior muscles were lost (upper) and the D wave decreased, Endovascular procedures for the embolization of spinal
although not less than 50% of baseline value (lower). Postoperatively, and spinal cord vascular lesions carry the risk of spinal cord
the patient was paraplegic. Within 1 week, he regained antigravity ischemia.76 Whenever these procedures are performed
force in both legs, and by 2 weeks he walked again. (Reproduced from under general anesthesia, only neurophysiologic monitor-
Kothbauer K, Deletis V, Epstein FJ. Intraoperative spinal cord monitor-
ing for intramedullary surgery: An essential adjunct. Pediatr Neurosurg. ing can provide an “online” assessment of the functional
1997;26:247-254.) integrity of sensory and motor pathways. Monitoring of
SEPs and muscle MEPs is performed in the same fashion
as described for monitoring of intramedullary spinal cord
transmitted along the same axons, the descending D wave tumor surgery.77,78 The D wave, in contrast, is usually not
collides with the ascending signal carried antidromically monitored during these procedures because these patients
along the CT (Fig. 4-8). This results in a decrease in the receive a considerable amount of heparin in the periopera-
D-wave amplitude recorded cranially to the collision site. tive period and the percutaneous placement of the record-
This phenomenon indicates that the spinal cord-stimulating ing epidural electrode would expose the patient to the risk
probe is in close proximity to the CT. This could potentially of an epidural bleed. Besides safety issues, there is also no
guide surgeons to stay away from the “hot spot.” Mapping evidence that monitoring the D wave is an essential adjunct
of the CT is now in the process of a technical refinement. to muscle MEPs during these endovascular procedures.
Its initial use indicates an impressive ability to selectively Both peripheral and myogenic MEPs have, in fact, been
map the spinal cord for the CT’s anatomic location. Using proven to be more sensitive than the D wave in detecting
this method, the CT can be localized within 1 mm. This spinal cord ischemia. Similar results have been consis-
is in concordance with the other CT mapping techniques tently reported both in experimental and clinical studies,
used within the brain stem that show the same degree of supporting the hypothesis that whenever the mechanism
selectivity.50 of spinal cord injury is purely ischemic, muscle MEPs may
suffice.79-82 Given the complexity of spinal cord hemody-
MAPPING OF THE DORSAL COLUMNS namics, which is even more unpredictable in the presence
OF THE SPINAL CORD of a spinal cord hypervascularized lesion, it is mandatory
To protect the dorsal columns from lesioning during to perform both SEP and MEP monitoring to enhance the
myelotomy, a novel neurophysiologic technique has been safety of these risky procedures.78
developed. To approach an intramedullary tumor, accepted A critical step regarding neurophysiologic monitor-
neurosurgical techniques require a midline dorsal myelot- ing during these procedures consists of the provocative
omy. Distorted anatomy, however, often does not allow a tests.78,83,84 These tests rely on the properties of two drugs,
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 41

TES

C2 C1

Collision site
R
S1 S2

S1 S2 + S1 S1 S2 + S1

mm
D1 D2 D1 D2

50 µV 50 µV

0 5 10 15 20 25 30 35 40 ms 0 5 10 15 20 25 30 35 40 ms
Negative mapping - no collision, D1 = D2 Positive mapping - collision occurs, D2 = 42% of D1
FIGURE 4-8  The neurophysiologic basis for intraoperative mapping of the corticospinal tract (CT). Mapping of the CT by the D-wave collision
technique (see text for details). S1, transcranial electrical stimulation (TES); S2, spinal cord electrical stimulation; D1, control D wave (TES only); D2,
D wave after combined stimulation of the brain and spinal cord; R, the cranial electrode for recording D wave in the spinal epidural space. Lower
left: Negative mapping results (D1 = D2). Lower right: Positive mapping results (D2-wave amplitude significantly diminished after collision). Inset:
Handheld stimulating probe over the exposed spinal cord. (Modified from Deletis V, Camargo AB. Interventional neurophysiological mapping during
spinal cord procedures. Stereotact Funct Neurosurg. 2001;77:25-28.)

R.P., 18 y.o.
C2-7 syrinx

SSEP - LPTN SSEP - RPTN

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8 10
µV
0 10 20 30 40 50 ms 0 10 20 30 40 50 ms
FIGURE 4-9  Dorsal column mapping in an 18-year-old patient with a syringomyelic cyst between the C2 and C7 segments of the spinal cord. Upper
right: Magnetic resonance imaging shows the syrinx. Lower middle: Placement of miniature electrode over surgically exposed dorsal column; vertical
bars on the electrode represent the location of the underlying exposed electrode surfaces. Sensory-evoked potentials after stimulation of the left
and right tibial nerves showing maximal amplitude between electrodes 1 and 2 (lower left and right). These data strongly indicate that both dorsal
columns from the left and right lower extremities have been pushed to the extreme right side of the spinal cord. Using these data as a guideline,
the surgeon performed the myelotomy using a YAG laser through the left side of the spinal cord and inserted the shunt to drain the cyst (upper
middle). The patient did not experience a postoperative sensory deficit. (Reproduced from Krzan MJ. Intraoperative neurophysiological mapping
of the spinal cord’s dorsal column. In: Deletis V, Shils JL, eds. Neurophysiology in Neurosurgery. A Modern Intraoperative Approach. San Diego:
Academic Press; 2002:153-164.)
42 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

lidocaine and amobarbital, to selectively block axonal and cut during untethering. Direct electric stimulation of these
neuronal conduction (respectively) when injected intra- structures in the surgical field or direct recording from
arterially in the spinal cord.85 Provocative tests are usually them after peripheral nerve stimulation has proven helpful.
performed once the endovascular catheter has reached Using mapping techniques, functional neural structures of
the embolizing position, before any embolizing material is the lumbosacral region can be correctly identified and thus
injected. If that specific vessel not only feeds the target of possibly preserved. In Fig. 4-10, schematic drawings of the
the embolization (e.g., spinal cord arteriovenous malforma- most important neurophysiologic techniques for monitor-
tion, hemangioblastoma, arteriovenous fistula) but also per- ing afferent and efferent events (i.e., recording and monitor-
fuses normal spinal cord, it is expected that the provocative ing neurophysiologic signals from sensory or motor parts of
drug will block the white and/or gray matter conduction, the lumbosacral system) are presented. During intraopera-
and this will be reflected in neurophysiologic tests. Criteria tive testing with these techniques, it has been found that
for positive provocative tests are the disappearance of the some of them are more important than others, from prag-
MEPs and/or a 50% decrease in SEP amplitude. If the test matic point of view. Only these are described.
is positive, embolization from that specific catheter posi-
tion is not performed and embolization from a different PUDENDAL DORSAL ROOT ACTION POTENTIALS
feeder or from a more selectively advanced catheter posi- In the treatment of spasticity (e.g., in cerebral palsy), sacral
tion is attempted. Provocative tests mimic the effect of the roots are increasingly being included during rhizotomy
embolization and select those patients amenable to a safe procedures.89 Children who underwent L2–S2 rhizotomies
embolization. Although the specificity of provocative tests had an 81% greater reduction in plantar/flexor spasticity
has not been tested (because the procedure is abandoned compared with children who underwent only L2–S1 rhi-
whenever provocative tests are consistently positive), their zotomies. However, as more sacral dorsal roots have been
sensitivity has proven to be very high and no false-negative included in rhizotomies, neurosurgeons have experienced
results (i.e., new postoperative neurologic deficit despite an increased rate of postoperative complications, espe-
embolization performed after a negative provocative test) cially with regards to bowel and bladder functions.
have so far been reported.78 To spare sacral function, we have attempted to identify
those sacral dorsal roots carrying afferents from pudendal
nerves using recordings of dorsal root action potentials
Surgery of the Lumbosacral Nervous after stimulation of dorsal penile or clitoral nerves. Patients
System were anesthetized with isoflurane, nitrous oxide, fen-
tanyl, and a short-acting muscle relaxant introduced only
Intraoperative monitoring during surgery of the lumbosa- at the time of intubation. The cauda equina was exposed
cral nervous system is a very demanding task and is still through a T12–S2 laminotomy/laminectomy, and the sacral
not developed in comparison with monitoring of the sur- roots were identified using bony anatomy. The dorsal
geries for other parts of the central and peripheral nervous roots were separated from the ventral ones, and dorsal
systems. The neurophysiologic techniques used to moni- root action potentials were recorded by a hand-held ster-
tor the lumbosacral nervous system are dependent on the ile bipolar hooked electrode (the root being lifted outside
pathology and structures involved. Generally, monitoring the spinal canal) (Fig. 4-11). The dorsal root action poten-
of the lumbosacral system involves the epiconus, conus, tials were evoked by electrical stimulation of the penile
and cauda equina. These structures are essential in both or clitoral nerves. One hundred responses were averaged
voluntary and reflexive control of micturition, defecation, together and filtered between 1.5 and 2100 Hz. Each aver-
and sexual function as well as somatosensory and motor age response was repeated to assess its reliability. Afferent
innervation of the pelvis and lower extremities. So far, only activity from the right and left dorsal roots of S1, S2, and
methodologies for monitoring and mapping of the somato- S3 were always recorded, along with occasional record-
motor and somatosensory components of the lumbosacral ings from the S4–S5 dorsal roots. Of special relevance was
nervous system have been developed. Intraoperative moni- the finding that in 7.6% of these children, all afferent activ-
toring of the vegetative component of the lumbosacral ner- ity was carried by only one S2 root (see Fig. 4-11C and F).
vous system is still in the embryonic stage.86 These findings were confirmed by a later analysis of results
One of the most widely used applications of intraopera- of mapping in 114 children (72 male, 42 female; mean age,
tive monitoring of the lumbosacral nervous system, at least 3.8 years).90 Mapping was successful in 105 of 114 patients.
in the pediatric population, is for patients undergoing sur- S1 roots contributed 4%, S2 roots 60.5%, and S3 roots 35.5%
gery for a tethered spinal cord. During these procedures, of the overall pudendal afferent activity. The distribution
the surgeon cuts the filum terminale or removes the tether- of responses was asymmetrical in 56% of the patients (see
ing tissue that envelopes the conus and/or the cauda equina Fig. 4-11B, C, and F). Pudendal afferent distribution was
roots. In a large series of patients operated on for tethered confined to a single level in 18% (see Fig. 4-11A) and even
spinal cords, permanent neurologic complications have to a single root in 7.6% of patients (see Fig. 4-11C and F).
been described in as many as 4.5%.87,88 The rate increased Fifty-six percent of the pathologically responding S2 roots
to 10.9% when transient complications were considered. during rhizotomy testing (using electrical stimulation of
Due to the tethering, the lumbosacral nerve roots leave the dorsal roots with spreading activity in adjacent myotomes)
spinal cord in different directions than in a healthy spinal were preserved because of the significant afferent activ-
cord. Furthermore, the cord may be skewed and sometimes ity (as demonstrated during pudendal mapping). None of
a nerve root may pass through a lipoma. Nerve roots may the 105 patients developed long-term bowel or bladder
also be involved in the thickened filum terminale that is complications.
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 43

Afferent events Efferent events

Pudendal SEPs
(Traveling waves)
Stimulation

1.
1 µV
10 ms

Anal M-wave
4.
Pudendal DRAP 100 µV
5 ms
2.
Anal MEP
50 µV 5.
4 ms 50 µV
Pudendal SEPs 20 ms
(Stationary wave) BCR

3.
6.
10 µV
10 ms 70 µV
50 ms

FIGURE 4-10  Neurophysiologic events used to intraoperatively monitor the sacral nervous system. Left: Afferent events after stimulation of the
dorsal penile/ clitoral nerves and recording over the spinal cord: 1, pudendal somatosensory-evoked potentials (SEPs), traveling waves; 2, pudendal
dorsal root action potential; and 3, pudendal SEPs, stationary waves recorded over the conus. Right: Efferent events: 4, anal M wave recorded from
the anal sphincter after stimulation of the S1–S3 ventral roots; 5, anal motor-evoked potentials recorded from the anal sphincter after transcranial
electrical stimulation of the motor cortex; 6, bulbocavernosus reflex obtained from the anal sphincter muscle after electrical stimulation of the dorsal
penile/ clitoral nerves. BCR, bulbocavernosus reflex; DRAP, dorsal root action potentials; MEP, motor-evoked potential. (From Deletis V. Intraopera-
tive neurophysiological monitoring. In: McLone D, ed. Pediatric Neurosurgery: Surgery of the Developing Nervous System, 4th ed. Philadelphia: WB
Saunders; 1999:1204-1213.)

All our results in the early series of dorsal root mapping anal plug electrodes and recording them in the same way
with 19 patients have been confirmed by analysis of the as penile/clitoral afferents.91
larger series of 105 patients.90 With this series, we showed
that selective S2 rhizotomy can be performed safely without MAPPING AND MONITORING OF MOTOR
an associated increase in residual spasticity while preserv- RESPONSES FROM THE ANAL SPHINCTER
ing bowel and bladder function by performing pudendal These responses can be elicited by direct stimulation of the
afferent mapping.89 Therefore, we suggest that the map- S2 to S5 motor roots and recording from the anal sphincters,
ping of pudendal afferents in the dorsal roots should be after surgical exposure of the cauda equina, or by TES of
employed whenever these roots are considered for rhizot- the motor cortex. The first method of cauda equina stimula-
omy in children with cerebral palsy without urinary reten- tion, using a small hand-held monopolar probe, is easy to
tion. In children with cerebral palsy with hyper-reflexive perform with recording of responses from each anal hemi-
detrusor dysfunction, in whom sacral rhizotomy may be sphincter with intramuscular wire electrodes identical to
considered to alleviate the problem, preoperative neuro- the ones used to record the bulbocavernosus reflex.92 This
logic investigation of the child should help in making appro- mapping method is very useful when it becomes necessary
priate decisions. In any case, intraoperative mapping of to identify roots within the cauda equina during tethered
sacral afferents should make selective surgical approaches cord or tumor surgeries in which the normal anatomy is
possible and provide the maximal benefit for children with distorted. To perform mapping, the surgeon must stop sur-
cerebral palsy. Mapping of pudendal afferents has been gery and map the roots with a monopolar probe. To con-
further expanded by introducing methodology that maps tinuously monitor the functional integrity of parapyramidal
afferents from the anal mucosa by stimulating them using motor fibers (for volitional control of the anal sphincters)
44 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

Patient: W. A., 4y Patient: L. M., 3y Patient: M. G., 4y


Dg: Cerebral palsy Dg: Cerebral palsy Dg: Cerebral palsy
RIGHT LEFT RIGHT LEFT RIGHT LEFT
S1 S1 S1
S2 S2
S2
S3 S3
S3
S S 40 µV S S S S
5 ms
A B C

Patient: Z. M., 4y Patient: R. S., 4y Patient: L. M., 6y


Dg: Cerebral palsy Dg: Cerebral palsy Dg: Cerebral palsy

RIGHT LEFT RIGHT LEFT RIGHT LEFT


S1 S1
S1

S2 S2 S2

S3 S3
S3
S S
S S S S

D E F

FIGURE 4-11  Six characteristic examples of dorsal root action potentials showing the entry of a variety of pudendal nerve fibers to the spinal cord
via S1–S3 sacral roots. A, Symmetrical distribution of dorsal root action potentials confined to one level (S2) or three levels (D). Asymmetrical
distribution of dorsal root action potentials confined to the one side (B), only one root (C or F), or all roots except right S1 (E). Recordings were
obtained after electrical stimulation of bilateral penile/clitoral nerves. (From Vodušek VB, Deletis V. Intraoperative neurophysiological monitoring of
the sacral nervous system. In: Deletis V, Shils J, eds. Neurophysiology in Neurosurgery: A Modern Intraoperative Approach. San Diego: Academic
Press; 2002:197-217.)

and the motor aspects of the pudendal nerves from the nerves and the gray matter of the S2–S4 sacral segments (see
anterior horns to the anal sphincters, the method of TES Fig. 4-10). Because of a lack of published statistical data col-
and recording of anal responses was introduced. Because lected for large groups of patients, the reliability of monitor-
the response recorded from the anal sphincter after TES has ing for conus and cauda equina surgeries remains unclear.
to pass multiple synapses at the level of the spinal cord, this
method is moderately sensitive to anesthetics and rather Special Consideration for ION in Children
light anesthesia should be maintained. So far no clinical ION techniques are extensively used in adult neurosurgery
correlation using this method has been published. and, in their principles, can be applied to the pediatric pop-
ulation. However, especially in younger children, the motor
MONITORING OF THE BULBOCAVERNOSUS system is still under development, making both mapping
REFLEX and monitoring techniques more challenging.
The bulbocavernosus reflex is an oligosynaptic reflex medi- With regard to D-wave monitoring, Szelenyi et al. reviewed
ated through the S2–S4 spinal cord segments that is elicited D-wave data from 19 children aged 8 to 36 months operated
by electrical stimulation of the dorsal penis/clitoris nerves on for intramedullary spinal cord tumors.95 The D-wave
with the reflex response recorded from any pelvic floor was present in 50% of children aged 21 months or older but
muscles. The afferent paths of the bulbocavernosus reflex was never recorded in children younger than 21 months.
are the sensory fibers of the pudendal nerves and the reflex Although the preoperative neurologic status of these
center in the S2–S4 spinal segment. The efferent paths are children was not specified, a 50% D-wave monitor ability
the motor fibers of the pudendal nerves and anal sphincter rate compares unfavorably to the data reported in adults,
muscles. In neurophysiologic laboratories, the bulbocav- where mean monitor ability rate is around 66% and reaches
ernosus reflex is usually recorded from the bulbocaver- 80% in patients in McCormick grade I.45 This is likely due to
nosus muscles, and this is where it gets its name. We have the immaturity of the CT in younger children where incom-
described an intraoperative method for recording the bul- pletely myelinated fibers have variable conduction veloci-
bocavernosus reflex from the anal sphincter muscle, with ties resulting in desynchronization.96 A few studies have
improvement in methodology reported by others.92–94 The recently looked at the feasibility of muscle MEP monitor-
advantage of bulbocavernosus reflex monitoring is that it ing in children after TES, and consistently reported higher
tests the functional integrity of the three different anatomic threshold in younger children.95,97,98 Our data are in agree-
structures: the sensory and motor fibers of the pudendal ment with those reported by Journee et al., who suggested
4  •  Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System 45

preconditioning TES to overcome some of the limitations in Jones SJ, Buonamassa S, Crockard HA. Two cases of quadriparesis fol-
eliciting MEPs in this subgroup of patients. 96,99 lowing anterior cervical discectomy, with normal perioperative
somatosensory evoked potentials. J Neurol Neurosurg Psychiatry.
According to Nezu, electrophysiologic maturation of 2003;44:273-276.
the CT innervating hand muscles is complete by the age of Kothbauer K, Deletis V, Epstein FJ. Motor evoked potential monitoring
13 and the CT appears to be the only spinal cord pathway for intramedullary spinal cord tumor surgery: correlation of clinical
with incomplete myelination at birth.100,101 There is likely a and neurophysiological data in a series of 100 consecutive proce-
dures. Neurosurg Focus. 1998;4:1-9.
discrepancy between the anatomic and neurophysiologic
Minahan RE, Sepkuty JP, Lesser RP, et al. Anterior spinal cord injury with
development of the CT. Cortico-motoneuronal connections preserved neurogenic “motor” evoked potentials. Clin Neurophysiol.
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CHAPTER 5

Gamma Knife Surgery for Cerebral Vascular


Malformations and Tumors
CHUN-PO YEN  •  LADISLAU STEINER

The gamma knife is a neurosurgical tool used either as a by Cushing, of radiofrequency treatment of lesions are
primary or adjuvant procedure for intracranial pathologies. just a few examples of “technology transfer.”
It was developed in the late 1960s as an alternative to open 2. The difficulty of accepting a neurosurgical procedure
stereotactic lesioning for functional disorders. Variations in without opening the skull, despite the fact that every
anatomy and needs for physiologic confirmation of the tar- neurosurgeon knows that trephination is itself a minor
get limited its usefulness for these indications at that time. part of the neurosurgical act. The laser beam, the bipo-
However, the technology was found to be efficacious in lar coagulator, and the ultrasound probe are accepted
the management of structural disorders later on. The lim- without resistance because they are used after trephin-
ited scope of the pathologies treated with the gamma knife ing the skull. The recently introduced “photon radiosur-
(intracranial) and unique technology make the gamma gery” with its limited scope compared to gamma surgery
knife an extension of the neurosurgeons’ therapeutic arma- is accepted widely as “neurosurgery” because it reaches
mentarium and not a separate specialty. It should not be the target through a small burr hole.
mistaken for a form of radiation therapy, for it differs in 3. The loss of the thrill and glamor provided by open
concept from the radiation oncologists’ idea of tumor treat- ­surgery.
ment that is based on variable tissue response to fraction- 4. The deeply rooted acceptance of the dogma that where
ated radiation. It is a single session, stereotactically guided ionizing beams are involved a radiotherapist is needed.
procedure for various neurosurgical pathologic processes The last 40 years have demonstrated that a neurosurgeon
limiting exposure to radiation as much as possible to the can acquire the necessary knowledge of radiophysics
lesion only. and radiobiology to handle ionizing beams. This is much
Recently it has been shown that the gamma knife can easier than for a radiation oncologist to master neuro-
palliate some ocular tumors. In a more limited applica- anatomy and management of neurosurgical lesions, and
tion of the concept, the treatment of extracranial tumors thus to exclude bias when deciding whether to use the
in abdominal and thoracic locations has evolved with microscope or the gamma knife in each particular case.
the use of the various stereotactic body radiation therapy The trend in cranial as well as spinal neurosurgery
machines.1–4 Obviously, lesions that lie outside the cen- has been minimally invasive approaches. These may be
tral nervous system will not be treated by a neurosurgeon. achieved with the increasing skill of the operators and by
However, when it is used for neurosurgical pathology, no new technology. If the result of these changes in the proce-
one is more qualified to apply it. It is the operator and the dure, aspects are modified or even eliminated, the procedure
pathology that define the use of a technology. When Walter is still neurosurgical. To relegate less-invasive procedures to
Dandy placed a cystoscope in a ventricle for the first time, non-surgeons is to argue that the only aspect of a patient’s
he was not performing a urologic procedure.5 The micro- care that is unique to a surgeon is purely technical. This is
scope when used by the neurosurgeon, ophthalmologist, patently untrue; it is the surgeon’s responsibility to maintain
or otolaryngologist is a neurosurgical, ophthalmologic, or surgical care standards by adapting to new technologies.
otolaryngologic instrument, respectively. There is no substitute at this time for the physical extir-
It is remarkable how difficult it was, and still is for some pation of a mass lesion in terms of cure or control of either
neurosurgeons, to accept the use of gamma knife as a neu- vascular or oncologic pathologies. The attractiveness of
rosurgical tool. Some of the causes of this reticence can be radiosurgery is not that it supplants open neurosurgical
identified: procedures, but that it allows treatment of pathologies only
1. Lack of historic perspective makes it difficult for some treated earlier with unacceptable morbidity or mortality.
neurosurgeons to realize that Leksell’s concept was There is, and likely always will be a gray area where the
rooted in the philosophy of the founders of neurosurgery, benefits of various modalities are debated. It will only be
that is, recognition of technological advances and their through evaluation of long-term results of these various
application to neurosurgical practice. The early adoption therapies as well as their availability, cost, experience of the
by Cushing of the x-ray machine, his use of the “radium operators and individual patient preferences that the “best”
bomb” in glioma treatment,6 and the ­introduction, also therapy in any given case is decided.
46
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 47

In this chapter we describe the results of our experience procedures. The convergence of multiple ionizing beams
with the gamma knife as well as published results of other at one stereotactically defined point was the result. A nomi-
centers where required. nal dose is delivered to the paths of each incident beam.
Table 5-1 lists all the cases treated with the gamma knife However, at the point of intersection of the beams, a dose
worldwide through 2006. It should be kept in mind that proportional to the number of individual beams is deliv-
many of the indications listed are not universally accepted ered. The physical specifications of the device would be
as appropriate for gamma surgery. In this chapter we will designed to ensure steep drop-off of delivered radiation at
give our version of the facts for each indication. the edge of the intersection point. This would allow precise
selection of the targeted lesion and minimization of trauma
History to surrounding tissue. He named this concept radiosurgery
in 1951.9
Clarke and Horsley developed the first stereotactic system,7 Various sources of ionizing radiation were tried. Leksell
and the method was first applied clinically by Spiegel et al.8 first used an orthovoltage x-ray tube coupled to a stereotac-
This system allowed for the localization of intracranial tic frame in the treatment of trigeminal neuralgia and for
structures by their spatial relationship to Cartesian coordi- cingulotomy in obsessive compulsive disorders.9 A cyclo-
nates relative to a ring rigidly affixed to the skull. This was tron was then used as an accelerated proton source and
a prerequisite to the development of radiosurgery by Lars used to treat various pathologies.10,11 The cyclotron was too
Leksell. His ambition was to develop a method of destroy- cumbersome and expensive for widespread application. A
ing localized structures deep within the brain without the linear accelerator was evaluated but found at that time to
degree of coincident brain trauma associated with open lack the inherent precision necessary for this work. Fixed
gamma sources of cobalt-60 and a fixed stereotactic target
fulfilled the requirements of precision and compactness.
Table 5-1  Cases Treated with Gamma Knife Worldwide The first gamma knife was built between 1965 and 1968.
through December 2008 The use of a single high dose of ionizing beams to treat
Diagnosis n Percentage
neurosurgical problems was a novel and creative concept
40 years ago, which changed the direction of development
Vascular 65,084 12.95 in many fields of neurosurgery. However, a creative innova-
Arteriovenous malformation 57,136 11.37 tion is not perfect in its inception. The gamma knife was
Cavernous angioma 3,258 0.65 not an exception. Contributions of excellence by numer-
Other vascular 4690 0.93 ous neurosurgeons and physicists, and utilizing advances
Tumor 397,215 79.01 in computer technology to improve the software used in
Benign 176,319 35.07 planning have over the years defined the present use of
Vestibular schwannoma 46,835 9.32 the tool. For instance improvements in the planning system
Trigeminal schwannoma 2,822 0.56 now allow for systematic shielding of the optic apparatus
Other schwannoma 1,590 0.32 from exposure during treatment of parasellar masses. In
Meningioma 64,115 12.75 lesions only 2 to 5 mm away, the dose to sensitive struc-
Pituitary tumor 38,553 7.67 tures can be limited to less than 2% to 7% of the maximum
Pineal tumor 3,540 0.70 dose. However, in spite of all the changes in application of
Craniopharyngioma 4,053 0.81 gamma surgery the underlying concepts behind it have not
Hemangioblastoma 2,056 0.41 changed since its inception. This speaks for the sagacity of
Chordoma 1,911 0.38 Lars Leksell and his invention.
Hemaniopericytoma 1,151 0.23 Doses delivered and indications for the various pathol-
Benign glial tumors 3,594 0.71 ogies treated were all empiric initially. In the subsequent
Other benign tumors 6,099 1.21 discussions this should be considered when doses, both
Malignant 220,896 43.94 minimal and maximal are discussed, as well as results.
Metastasis 185,070 36.81
Malignant glial tumors
Chondrosarcoma
26,437
775
5.26
0.15
Pathophysiology
Nasopharyngeal carcinoma 1,454 0.29 The effects of single high-dose gamma radiation on patho-
Other malignant tumors 7,160 1.42 logic and normal tissue have been studied on clinical
Ocular Disorder 1,966 0.39 human and experimental animal tissue. These studies are
Functional 38,461 7.65 incomplete because the human material tends to come
Intractable pain targets 622 0.12 from treatment failures and the experimental material is
Trigeminal neuralgia 32,798 6.52 from normal animals. However some conclusions as to the
Parkinson’s disease 1,473 0.29 method of effectiveness and of tissue tolerances can be
Obsessive compulsive disorder 154 0.03 drawn.
Epilepsy 2,399 0.48
Other functional targets 1,015 0.20
NORMAL TISSUE
Total indications 502,726 100.0 The relative radioresistance of normal brain relates to its
low mitotic activity. Also, the rate at which a total dose of
Note: These figures include cases treated at gamma knife sites throughout the
world from 1968 through December 2008. radiation is applied affects the damage caused by the dose.
Source: Elekta Radiosurgery Inc. This is due to the ability of the cell to effect repairs during
48 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

the actual time of irradiation. A higher dose rate (same total used for gamma surgery (e.g., in functional cases). Ideally
dose applied over a shorter period of time) consequently following gamma surgery, tumors begin to shrink without
increases the lethality of the dose. The normal tissue sur- changes in the normal tissue. The rate of shrinkage in gen-
rounding the stereotactically targeted pathologic tissue eral is slower in more benign tumors.
receives a markedly lower dose but over the same time. The effectiveness of the therapy is most dependent on
Therefore, not only is the total dose lower, but the dose rate the ability to define and treat the entire lesion. However, the
is lower as well. The radiation effect is seen most clearly result can also be obtained at times by treating the nutrient
at doses above and below 1 Gy/min.12 This radiobiological or feeding vessels of tumors (e.g., meningiomas). Malignant
phenomenon explains part of the relative safety of single gliomas do poorly with any surgical technique, including
dose radiation with steep gradients at the edge of targeted gamma surgery because of the inability to include all of
tissue on the surrounding structures. There are likely addi- the microscopic disease within the treated area. Individual
tional mechanisms of such sparing. metastatic deposits and small benign tumors are adequately
The steep gradient of dose and consequently dose rate handled with both open resection and with the gamma
described above does not exist in conventional radiother- knife because the tumor margin can be well-defined intra-
apy. When treating tumors the radiation oncologist uses operatively or on neuroimaging studies.
“fractionation” or dividing the total dose into smaller por- In order to conformally cover the target more than one
tions, which allows repair of normal tissue as well as transi- isocenter is nearly always utilized. When multiple radiation
tion of dormant cells within the target to cells in division (at fields are made to overlap the radiation dose distribution
which time they are more sensitive to radiation). Creating a becomes inhomogeneous. The resulting areas of local max-
dose gradient at the lesion’s margin not only eliminates the ima are called “hot spots.” Controversy exists as to whether
need for fractionation but also improves the effectiveness of the presence of “hot spots” in gamma surgery is beneficial
the delivered dose within the target (high-dose rate zone) or detrimental. An even dose distribution is an essential
2.5 to 3 times that of the same dose delivered in a fraction- and basic concept in radiotherapy. There is some evidence
ated manner. The gamma knife stereotactically excludes that these areas may be of benefit in gamma surgery. The
normal tissue from the high-dose rate zone as much as pos- factors to keep in mind to understand this line of reason-
sible. It may also take advantage of the natural difference in ing are as follows: due to radiation geometry hot spots are
susceptibility of pathologic versus normal tissue. usually located in the deep portions of the target. In tumors
In order to understand the radiobiology of a single high- this is usually the area that receives the poorest blood sup-
dose of radiation on normal brain the parietal lobe of rats ply and is therefore relatively hypoxic and radioresistant.
treated by a gamma knife was studied at our center. It was Furthermore the ability of a cell to respond to otherwise
found that a dose of 50 Gy caused astrocytic swelling with- sublethal dosages of radiation can be affected by its own
out changes in neuronal morphology or breakdown of the condition as well as the state of the cells near it. Cells that
blood–brain barrier at 12 months. There was fibrin deposi- are sublethally injured and are in the vicinity of similar
tion in the walls of capillaries. At 75 Gy, necrosis was seen cells recover more often than cells that are in the vicinity of
at 4 months as was breakdown of the blood–brain bar- lethally injured cells. The hot spots therefore create islands
rier. More vigorous morphological changes were seen in of lethally injured cells that will enhance the cell kill in the
astrocytes and hemispheric swelling coincident with the sublethal injury zone.19 Oxygen is a radiosensitizer, and the
necrosis occurred at 4 months. With the dose increased to relatively high-dose rate of the hot spots will act to offset
120 Gy, necrosis was seen at 4 weeks but not associated any loss of efficacy in the hypoxic core of the target. This
with hemispheric swelling. Astrocytic swelling occurred at position is supported by the work of other authors.20
only 1 week postirradiation.13 These findings are consistent
with earlier reports on the effective dose to produce well- CRANIAL NERVES
defined lesions in the thalamus in patients treated with the The susceptibility of cranial nerves to injury from gamma
gamma knife.14,15 surgery is of great interest. Tolerance is dependent on the
particular nerve and the individual nerves involvement by
TUMOR RESPONSE the pathologic process requiring treatment. Because of
Little is known about the pathophysiologic changes induced these it is difficult to extrapolate exact numbers in many
by gamma surgery at the cellular level in tumors. Division instances. Some statements can be made with some
of tumor cells is presumably inhibited by radiation induced certainty.
damage to DNA. Also it has been shown that the microvas- The optic and acoustic nerves are the most sensitive
cular supply to tumors is inhibited by changes resulting to radiation of the cranial nerves. Being central nervous
from gamma surgery. In meningiomas studied after this system tracts, containing oligodendrocytes, and carrying
treatment there was reduction of blood flow over time.16 complex information is thought to be the source of their
Tumors responding early showed the greatest reduction in vulnerability. These tracts are unable to regenerate follow-
blood flow. Other authors have proposed that the induction ing injury. Optic neuropathy has been reported as a com-
of apoptosis by gamma radiation to proliferating cells may plication following single doses greater than 8 Gy.21 The
be responsible for at least a portion of the effect of gamma tolerable level of radiation to the optic apparatus is still a
surgery on tumors.17,18 Although such contentions may be subject of debate. Some advocate that the optic apparatus
premature they may point the direction to future research. can tolerate doses as high as 12 to 14 Gy.22-24 Others rec-
Thus the pathophysiologic effect of gamma surgery ommend an upper limit of 8 Gy.21,25 Small volumes of the
seems not to be tumor necrosis. For this, higher doses than optic apparatus exposed to doses of 10 Gy or less may be
typically used would be required. Necrotic doses are rarely acceptable in some cases.26,27 Both the tolerable absolute
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 49

dose and volume undoubtedly vary from patient to patient. Experimental studies done on normal vasculature in the
This degree of variability likely depends upon the extent brains of rats and cats showed similar findings.34,35 The pri-
of damage to the optic apparatus by pituitary adenoma mary injury was endothelial necrosis and desquamation,
compression, ischemic changes, type and timing of previ- muscular coat hypertrophy and fibrosis at lower doses (25
ous interventions (e.g., fractionated radiation therapy and to 100 Gy). At doses up to 300 Gy necrosis of the muscular
surgery), the patient’s age, and the presence or absence of layer was seen in cats. In only one instance, a rat anterior
other co-morbidities (e.g., diabetes). cerebral artery treated with 100 Gy was occlusion of a ves-
On the other hand the trigeminal and facial nerves sel seen. Similar studies on hypercholesterolemic rabbits
are significantly more resilient. Few developed profound treated with 10 to 100 Gy showed no histologic changes in
hypoesthesia in trigeminal neuralgia patients treated with the basilar arteries and no instances of occlusion after 2 to
gamma knife using doses of 80 to 90 Gy. Vey few facial 24 months.36
pareses were reported in several large groups of vestibular
schwannomas treated with radiosurgery. ARTERIOVENOUS MALFORMATIONS
The cranial nerves in the cavernous sinus are relatively The minimal clinical and only moderate histologic change
robust. Low incidence of neuropathies has been reported in the normal cerebral vasculature after high doses of
with doses up to 40 Gy.21 We have not observed any neu- gamma radiation is in sharp contrast to the response of the
ropathies of CN IX through XII in the treatment of glomus vessels of an arteriovenous malformation (AVM). Complete
jugulare tumors. radiographic obliteration can be achieved after appropri-
ate gamma surgery. The effects of ionizing radiation and a
NORMAL CEREBRAL VASCULATURE role in the management of AVMs was first reported in 1928
There is both clinical and experimental data regarding by Cushing and Bailey.37 During craniotomy for an AVM
the effect of single high-dose gamma irradiation of normal he had to interrupt surgery due to major hemorrhage from
cerebral vasculature. In treating 1,917 arteriovenous mal- the lesion. He then treated the patient with fractionated
formations we have seen only two incidences of clinical radiation. At reoperation 5 years later only an obliterated
syndromes possibly associated with the stenosis of nor- avascular mass was discovered. This early success was
mal vessels. This low incidence has occurred even though overshadowed by numerous series of failures.38-40 In this
occasionally normal vessels are included in the treatment early period, Johnson was the only one to report reason-
field. One case was reported after treating a glioma with able results with a 45% angiographic obliteration.41 The
90  Gy gamma surgery followed by 40 Gy of fractionated introduction of the gamma knife rekindled interest in the
whole brain irradiation of a middle cerebral artery occlu- treatment of AVMs with radiation.42
sion. Steiner et al. described two cases in which dispropor- The pathologic changes in AVMs treated with the gamma
tionate white matter changes might have been ascribed to knife have been described by several authors.43-45 The earli-
venous stenosis and occlusion.28 Another case, of a dience- est change is damage to the endothelium with swelling of
phalic AVM, demonstrated marked edema associated with the endothelial cells and subsequent denudation or sepa-
venous outflow occlusion. This patient suffered visual and ration of the endothelium from the underlying vessel wall.
cognitive deficits but over the course of months his neuro- The most important changes are seen later in the intima
logic status returned to baseline (Fig. 5-1). with the appearance of loosely organized spindle cells
In our treatment of pituitary adenomas with cavernous (myofibroblasts) and an extracellular matrix containing col-
sinus extension or parasellar meningiomas, we have not lagen type IV, not seen in the intima of untreated vessels.
observed occlusion of normal vasculature. This absence of Expansion of the extracellular matrix and cellular degen-
stenosis is noted even though the internal carotid artery or eration define the final stage prior to luminal obliteration.
portions of the circle of Willis, or its proximal branches, are The occlusion of the vessels is not a thrombotic process but
often included in the treatment field. The only incidence rather the culmination of concentric narrowing of the ves-
of treating an intracranial aneurysm by us with a gamma sel by an expanding vessel wall.
knife did lead to narrowing and eventual occlusion of
the adjacent small posterior communicating artery seg-
ment.29 Whether this was associated with the obliteration Gamma Surgery Procedure
of the aneurysm neck or primary changes in the artery is
unknown. It is possible that the incidence of occlusion of PERIOPERATIVE MANAGEMENT
smaller vessels is more common than recognized as the Patients are routinely evaluated the day prior to gamma
occlusion would occur slowly and compensatory changes surgery. Preoperative consults are obtained as necessary
could take place preventing clinical syndromes from occur- including evaluation by the neuroradiology service. The
ring. Regardless, the clinical impact is minimal. Others have patients are loaded with anti-seizure medications and lev-
noted injury to the cavernous segment of the carotid artery els drawn prior to therapy. Patients already on medication
following radiosurgery for pituitary adenomas. A total of for seizures also have their levels evaluated. Although we
four cases have been reported and in only two of these have never had a patient have a seizure during therapy, the
cases were the patients symptomatic from carotid artery small but serious risk of a generalized seizure while the
stenosis.30-32 Pollock et  al. have recommended that the patient is secured within the gamma unit makes every pre-
prescription dose should be limited to less than 50% of the caution reasonable. Patients are also started on systemic
intracavernous carotid artery vessel diameter.32 Shin et al. dexamethasone the evening prior to therapy and this is
recommended restricting the dose to the internal carotid continued until the following evening. The use of high-
artery to less than 30 Gy.33 dose peri-operative dexamethasone is empiric. Although
50 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

A B

Left Left
lateral lateral
vertebral vertebral

C D
FIGURE 5-1  A, Thalamic AVM shown with lateral vertebral arteriography. B, Similar view obtained 17 months after gamma surgery shows partial
obliteration of the nidus. The basal vein of Rosenthal, the vein of Galen, and the straight sinus were not visualized. Venous drainage of the residual
AVM appears to be through ascending choroidal veins and the internal cerebral veins. Early (C) and late (D) filling vertebral arteriogram obtained 37
months after gamma surgery shows obliteration of the AVM and complete absence of the deep venous system.

we have used steroids throughout our experience with We have fashioned a simple strap with Velcro ends that
the gamma knife, their original purpose, to minimize is placed across the patients head and then fastened above
vasogenic edema at the time of therapy, has never been the frame after it has been lowered into the desired posi-
documented as a problem. Hence its prophylactic use is tion. This holds the frame in position while the pins are
debatable. secured. This eliminates the need for the earplugs in the
auditory canal, which can be painful.
FRAME PLACEMENT The space available within the gamma knife is limited
The placement of the head frame is done in the operating as is the three dimensional coordinate system within the
room at our institution. The patient is given intravenous frame itself. For these reasons care must be taken to skew
sedation, usually short acting narcotics (e.g., fentanyl) and the placement of the frame in the direction of the pathology
propofol, until they are no longer responsive to verbal or if it is far off the center of the brain. The shifting of the frame
moderate physical stimuli. The anesthesia service monitors is of less importance with the latest gamma knife model,
the patient throughout the procedure. We have found this Perfexion, which has a much larger radiation cavity.
far superior to the previous practice of applying the frame
using only local anesthesia. Patients that were treated both IMAGING AND DOSE PLANNING
before and since we have applied the frame in this way have The accuracy of a gamma surgery is ultimately dependent
provided clear feedback preferring frame placement under on the neurosurgeon’s ability to visualize the intended
anesthesia. target. Thus, the technique would be impossible without
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 51

imaging studies that allow three-dimensional views of ana- These changes allow a single isocenter composed of differ-
tomic structures in the brain. Magnetic resonance image ent beam diameters to optimize dose distribution shape for
(MRI) is the most used imaging modality because of its each individual shot.
superior visualization of soft tissue structures and solid
tumors. Typical MRI protocols include T1-weighted pre- TREATMENT EXECUTION
and postcontrast (Gadolinium-enhanced) images through After the treatment plan has been made the patient is
the entire volume of the head. Sequences may be a collec- moved on to the gamma knife couch and the y and z coordi-
tion of 2D image slices, or a true 3D acquisition such as the nates for the first exposure are set on the frame attached to
MP-RAGE or its successors. Specialized sequences such as the patient’s head. The patient’s head is then placed within
constructive interference in steady state (CISS) protocols the collimator helmet and secured on either side by trun-
may be used for circumstances such as visualization of the ions and the x coordinate is set. The head at this point is
internal auditory canals, the cerebellopontine angle, and suspended by the frame within the helmet. The exposure
parasellar regions. time of the corresponding isocenter is entered at the con-
In planning the treatment of an AVM, digital subtraction trol panel twice for confirmation and the session then com-
angiography remains the imaging modality of choice. As mences with the entire couch being mechanically pulled
with the MRI and computed tomography (CT), images are into the body of the unit. The external collimator helmet
acquired using a fiducial system. However the digital sub- locks into place with the internal collimators. After each
traction angiography is based on projections rather than exposure the patient is withdrawn from the collimator hel-
tomographic information. Images need to be geometrically met and the process is repeated. Necessary changes of the
corrected to account for the curvature of the image intensi- collimator helmet are made as needed according to the
fier screen before importing the images into the treatment plan. The introduction of the Automatic Positioning System
planning system. Gadolinium-enhanced MRI is currently (APS), a system that sets the coordinates by six independent
often used to correlate the extent of the AVM nidus with motors just outside the irradiation field, has led to shorter
angiography. It helps to define the shape of the AVM and treatment times, enhanced selectivity, and better physi-
confirms angiographically obtained information. However, cian work-flow. In the gamma knife Perfexion, the treat-
it is sometimes difficult to differentiate the nidus from the ment table itself acts as a positioning device (the Patient
feeding arteries and draining veins so the MRI tends to Position System, or PPS). The stereotactic frame is attached
overestimate the size of the AVM. The capability to incorpo- to the treatment table via a removable frame adapter that
rate CTA and MRA data into the planning process is under attaches to the frame and acts as an interface with the treat-
investigation. ment table. Treatment execution with Perfexion is a fully
automated process including set up of the stereotactic coor-
THE GAMMA KNIFE dinates, alignment of different sector positions and set up of
The gamma knife assembly is comprised of unit that con- exposure times. Obviously these changes will not affect the
tains the radiation source and treatment couch that delivers efficacy of the treatment but will make the process simpler
the patient into the unit. Within the unit are 201 cobalt-60 for the operator.
source capsules aligned with two internal collimators that At the end of the treatment the frame is removed from the
direct the gamma radiation toward the center of the unit. A head within the suite. There is usually a sensation of tighten-
third external collimator helmet is attached to the treatment ing and discomfort reported by the patient during removal.
couch. Four external collimator helmets are provided, and At least two pairs of hands should be available to steady
they have fixed diameter apertures that create a 4-, 8-, 14-, the frame and prevent injury by a pin as they are removed.
or 18-mm diameter isocenter. By changing external collima- Venous bleeding when it occurs can be controlled with
tor helmets, the diameter of the roughly spherical isocenter hand held pressure for a few minutes. The occasional arte-
can be varied. The 201 individual collimators within the rial bleeder might require a suture. After frame removal the
helmet are machined to exact standards to direct the 201 pin sites are dressed in a sterile fashion, steri-strips are used
beams of gamma radiation to a common point where they to oppose the skin edges for optimal cosmesis, and a mod-
intersect, creating the isocenter. The frame attached to the est head wrap applied.
patient’s head is adjusted within the collimator helmet so
that the area to be treated is at that point of intersection.
In the new gamma knife model, Perfexion, the central Indications
body contains 192 cobalt-60 sources that are grouped
into eight independent source sectors and collimators are VASCULAR MALFORMATION
entirely internal to the radiation body. Each source sector Arteriovenous Malformations
is housed in an aluminum frame that is attached to sec- The indications for gamma surgery of arteriovenous malfor-
tor drive motors at the rear of the radiation body via lin- mations (AVMs) versus other treatment options are in many
ear graphite bushings. There are 576 collimators machined cases unclear at best. Small asymptomatic inoperable AVMs
into 12 cm-thick tungsten in five concentric rings to align are clearly best treated with the gamma knife while AVMs
with the source assembly configurations. Each source with a large symptomatic hemorrhage in noneloquent super-
has three available collimators (4, 8, and 16 mm) as well ficial brain are best treated with open surgery. The reason
as shielded positions (‘‘blocked’’) to shield a critical struc- for this is that the risk-benefit value is clear in both of these
ture. To achieve a particular collimation, the sector drive situations. In other situations it is more ambiguous. Knowl-
motors move the sources along their bushings to the cor- edge of the capabilities of various treatments to effect cure,
rect position over the appropriate collimator opening. the associated morbidity and mortality associated with the
52 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

treatment and the natural history of the disease following that the limitation of the allowed margin dose by the size of
various treatments must be known to accurately prescribe the malformation decreases the rate of obliteration. There
the most efficacious treatment plan. Unfortunately these are are reports contending that low-dose gamma surgery with
in most instances not known. The natural history of AVMs large malformations results in obliteration rates that are
is not fully understood. Some authors believe that size mat- comparable to smaller lesions treated with a larger margin
ters, with smaller AVMs bleeding at a higher rate than larger dose. It is doubtful that these results will hold up with larger
ones or at a lower rate.46-49 There is also evidence that size is series. Thus far at our center, larger AVMs have had a lower
independent of the hemorrhage rate.50-52 Similarly the rate obliteration rate.
of hemorrhage of an AVM following a previous hemorrhage Between 1970 and 1990, 880 AVM patients were optimally
is thought to be higher than the rate in unruptured AVMs by treated. Optimally is defined as at least 25 Gy at the margin
some authors46,52,53 but not by others.47,54,55 The effects of of the entire nidus of the AVM. Of these patients the age
age, gender, pregnancy and AVM location also confound range was 3 to 76 years. Approximately 15% were pediat-
the question of risk of rupture.50-52,56-58 ric patients (<18 years old). The presenting symptoms were
The results of microsurgery published in the literature hemorrhage (70%), seizures (16%), headache (5%), neuro-
tend to come from centers of excellence and the patients logic deficits not associated with acute hemorrhage (4%),
they treat with open surgery are, by definition more ame- and other symptoms (5%). The majority of referrals were for
nable to this treatment. The effectiveness of the treatment AVMs deemed operable only with unacceptable morbidity
by this manner and its co-morbid results are known shortly explaining the fact that 73% of the AVMs were located in
after surgery. The short-term morbidity of treatment with deep areas of the brain or within eloquent cortex. Patients
the gamma knife approaches zero but because the benefit treated earlier were subjected to a vigorous protocol of
and potential complications require time to become appar- repeated angiograms. Later with the introduction of CT and
ent follow-up of these patients is problematic. The quality of then MRI, angiography was not performed until nidus was
the AVMs treated with the gamma knife also varies in large no longer evident on these screening examinations. The
series with those treated by microsurgery. All of these make angiogram should be complete, of high quality, and should
comparison of the modalities difficult. Add to that the addi- be reviewed by an experienced and interested neuroradi-
tional risks and benefits of preoperative embolization and ologist or neurosurgeon.
the matter is that much less clear. It is paramount to the phy-
sician treating a patient harboring an AVM to be aware, as Imaging Outcomes.  Following gamma surgery, angiogra-
much as possible, of the options that are available and the phy reveals hemodynamic changes occur before changes
magnitude of the risks and benefits associated with each. in the size and shape of an AVM.59 First, the flow rate
decreases progressively. This may be related to the changes
Early Experience in the sizes of the feeding arteries and outflow veins. The
Since the first AVM case treated by Steiner et al. in 1972,42 outcome of an AVM following radiosurgery may be a total,
we have treated over 2500 AVMs with the gamma knife. As subtotal, or partial obliteration of the nidus.
experience with this tool grows the capabilities and limita- Total obliteration of the AVM after radiosurgery was
tions of the gamma knife are being defined. defined as “complete absence of former nidus, normaliza-
Serendipitously the first AVM was treated by prescribing tion of afferent and efferent vessels, and a normal circulation
a 25 Gy peripheral dose. Subsequent changes in protocol time on high-quality rapid serial subtracted angiography”59
showed a significant decrease in success with doses less (Fig. 5-2). Any remaining nidus, regardless of its size, is con-
than 23 Gy and small improvements in obliteration rates sidered partial obliteration (Fig. 5-3). Subtotal obliteration of
but with significantly more radiation associated complica- an AVM means the angiographic persistence of an early fill-
tions with higher doses. Optimally, therefore, we treat most ing draining veins without demonstrable nidus (Fig. 5-4).60
AVMs with 23 to 25 Gy at the margin. While more patients Of the 880 patients treated 461 had adequate angio-
with relatively large AVMs were treated, dose lower than graphic follow-up. Of these 461 patients, 80% were found to
23  Gy was quite often used in hopes of achieving a total be cured within 2 years. At the time of the last evaluation of
obliteration with reasonable risk of complications. the results only 5% of patients had no change in the status
As in microsurgery, also when performing gamma sur- of their AVMs. Ten percent had subtotal obliteration and 5%
gery, feeding arteries or draining veins should be left alone were partially obliterated. In this group of patients oblitera-
and only the nidus should be treated. In very large AVMs, tion rates were affected by the size of the nidus. The rate for
only partially treated due to the excessive dose necessary AVMs less than 1 cm3 in volume was 88%. For 1 to 3 cm3 it
to treat optimally, occasional cures have been achieved. was 78% and for greater than 3 cm3 it was 50%.
This is thought to be due to fortuitous inclusion of all the No patient that was harboring an angiographically
pathologic shunts within the higher dose treatment field. proven obliterated AVM has ever hemorrhaged in our expe-
Targeting only the feeding vessels to the AVM have had rience. Nor has a patient with a subtotally obliterated AVM
very limited success because of recruitment of small angio- sustained a postradiosurgery hemorrhage. Regardless of
graphically occult feeding arteries. Interestingly, the first this we do not consider a patient cured until he has total
patient ever treated had only the feeding vessels targeted obliteration of the AVM. The early draining vein represents
and a cure was obtained.42 The early success with this strat- persistence of the shunt.
egy has not been reproduced.
The results of gamma surgery on AVMs is affected by the Clinical Outcomes.  A review of the long-term clinical
minimum dose applied to the AVM and the size of the AVM. outcomes following gamma surgery was carried out on 247
These two factors are interdependent. It has been shown patients we treated between 1970 and 1983.61 The presenting
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 53

A B

C D
FIGURE 5-2  Obliteration of a midbrain AVM. Vertebral arteriogram showing (A) frontal and (B) lateral views before and (C and D) two years after
gamma surgery. There was no neurologic deficit.

symptoms widely varied and 94% of the patients had hem- responsible for a portion of the gains made by the patients.
orrhaged prior to therapy. Ninety-eight of these patients had Whatever the reason is, significant improvement is seen in
chronic headaches and 66% had complete relief following many patients.
gamma surgery. An additional 9% improved. Twenty-six per-
cent had seizures prior to therapy and 19% of these became Outcomes of Gamma Surgery for Arteriovenous Mal-
seizure free and 51% improved. Eleven patients (5%) with- formations after 1989.  Since 1989, a total of 1350 AVM
out prior seizures had at least one seizure following therapy. patients were treated with gamma surgery at the Lars
Resolution or significant improvements were also seen in 53 Leksell center for Gamma Surgery, University of Virginia,
of 74 patients with motor deficits (72%), 19 out of 46 with a Charlottesville. Excluding 82 patients completely lost to fol-
sensory deficit (41%), 23 out of 44 with memory disturbance low-up, 139 patients with follow-up of less than 2 years and
(52%), and 26 out of 35 with language dysfunction (74%). additional 106 patients with large AVMs undergoing only
The cause for clinical improvement following gamma partial treatment, we analyze the outcome of 1023 AVMs.
surgery in such a large number of patients is unknown. The There were 523 males and 500 females with a mean age
natural history of neurologic deficits to improve over time of 34 years (range 4–82 years). The presenting symptoms
must be presumed to play a major role. The improvement in leading to the diagnosis of AVMs was hemorrhage in 529
regional blood flow following AVM obliteration may also be (52%), seizure in 237 (23%), headache in 133 (13%), and
54 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

A B

C D
FIGURE 5-3  Partial obliteration of an AVM. Left sylvian AVM shown in anteroposterior (A) and lateral (B) views of a left carotid angiogram. Same
views 4 years later (C and D) show a decrease in the size of the nidus but persistent shunting of blood through the partially obliterated malformation
(arrowheads). The residual AVM was recently retreated.

neurologic deficits in 94 (9%). In 30 patients (3%), the AVMs The mean follow-up was 80 months. Gamma surgery
were incidental findings. The locations of the AVMs were in yielded a total angiographic obliteration in 552 (54%)
the cerebral hemispheres in 630 (62%), basal ganglion in and subtotal obliteration in 42 (4%) patients. In 290 (28%)
96 (9%), thalamus in 82 (8%), corpus callosum in 38 (4%), patients, the AVMs remained patent and in 139 patients
brain stem in 84 (8%), cerebellum in 68 (7%), and insula in (14%) no flow voids were observed on the MRI. The angio-
25 patients (2%). The Spetzler-Martin grading of the AVMs graphic total obliteration was achieved in 66% of patients
were Grade I in 174 (17%) patients, grade II in 328 (32.1%), with nidus less than 3 cm3; 44% between 3 and 8 cm3, and
Grade III in 440 (43%), Grade IV in 78 (7.6%) and grade V in 28% with nidus volume larger than 8 cm3. Small nidus vol-
three (0.3%). One hundred and twenty-two patients (12%) ume, high prescription dose, and low number of isocenters
had previous partial resection of the nidi, and 244 patients are predictive of obliteration. Preradiosurgical emboliza-
(24%) underwent preradiosurgical embolization. The nidus tion has a negative effect on obliteration.
volume ranged from 0.1 to 33 cm3 (mean 3.5 cm3). The The reported obliteration rate following radiosurgery
mean prescription dose was 21.1 Gy (range 5–36 Gy), and varied greatly.62-65 One should be cautious when interpret-
the mean maximum dose was 39.0 Gy (range 10–60 Gy). ing the results owning to the biases injected from different
The mean number of isocenters was 2.7 (range 1–22). cut-off time and imaging modality used to conclude total
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 55

A B

C D
FIGURE 5-4  Subtotal obliteration of an AVM after gamma surgery. Anteroposterior (A) and lateral (C) vertebral angiograms demonstrating AVM
located within the vermis of the cerebellum. Control angiography with the same views (B and D) obtained 3 years after gamma surgery shows no
demonstrable nidus but the presence of an early filling vein (arrowheads).

obliteration. Studies only including patients with long fol- to gamma surgery. Incomplete surgical resection was car-
low-up, reporting only patients undergoing angiography or ried out in 24 patients. Five patients had partial resection
including MRI as imaging study to conclude obliteration and embolization before undergoing gamma surgery.
tend to overestimate the success rate of radiosurgery.63,66,67 The locations of the AVMs were hemispheric in 101
(54%) patients, thalamus in 24 (13%), basal ganglia in 23
Gamma Surgery for AVMs in Pediatric Patients.  (12%), corpus callosum in 9 (5%), brain stem in 18 (10%),
Between 1989 and 2007, we treated 200 AVM patients less insula/sylvian fissure in 5 (3%), and cerebellum in 6 (3%).
than 18  years of age. Fourteen cases with follow-up less The nidus volumes ranged from 0.1 to 24 cm3 (mean 3.2
than 2 years were excluded, leaving 186 patients for analy- cm3). The treatment parameters were: mean prescription
sis. There were 98 males and 88 females with a mean age dose 21.9 Gy (range 7.5–35 Gy); mean maximum dose 40.1
of 12.7 years (range 4–18 years). The presenting symptoms Gy (range 20–50 Gy).
leading to the diagnosis of AVMs were hemorrhage in 133 Following gamma surgery, a total obliteration was con-
(72%) patients, seizure in 29 (16%), headache in 11 (6%), and firmed in 109 (59%) and subtotal obliteration in 9 (5%).
neurologic deficits in 8 (4%). Five (3%) patients were asymp- Forty-nine (26%) patients still had patent residual nidus.
tomatic. Thirty-eight patients underwent embolization prior In 19 (10%) patients, obliteration was confirmed on MRI
56 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

only. The actuarial angiographic obliteration rate was 34% favorable outcome in patients with preradiosurgical embo-
at 2 years, 46% at 3 years, and 51% at 5 years. In general, lization. Theoretically, volume reduction following embo-
the imaging outcome of pediatric patients is similar to that lization affords a lower chance of radiosurgery-related
observed in adult population. A negative history of prera- adverse effect; however, our data do not show this. Addi-
diosurgical embolization and a high prescription dose were tionally, the complications from embolization are not neg-
significantly associated with increased rate of obliteration. ligible. Therefore, the use of embolization before gamma
Only a small series of children went through a systemic knife treatment remains problematic and awaits further
psychological test analyzing the cognitive deficits after investigation.
gamma surgery. However, yearly follow-ups including ques-
tioning the parents, the patients, and the referring doctors Gamma Surgery for Large Arteriovenous Malforma-
about the intellectual development and possible cognitive tions.  Recently, there has been much discussion of gamma
or endocrinologic deficits were conducted. According to surgery for large AVMs. The main problem with large AVMs
this information, 95% of the children had normal intellec- is due to the dependence of the obliteration response on
tual development after radiosurgery with satisfactory or dose and volume; this dependency requires a delicate bal-
good school performance. As adults, they performed from ance in deciding an efficient dose but low enough to avoid
average to excellent and were socially well-adjusted. adverse neurologic deficits.
Some studies had proposed that in pediatric patients The following strategies are currently available to treat
the response to radiosurgery seems to be less favorable.66 large AVMs with radiosurgery.
Hypotheses such as the immature vessels in pediatric cases 1. Embolization of a portion of the AVMs then performing
more likely to recover from radiation induced damage and radiosurgery if the nidus shrinks to a size manageable
neovascularization in response to radiation have been pro- with radiosurgery. However, embolization should effec-
posed. Our experience show comparable result in children tively shrink the nidus for radiosurgery to achieve good
compared to adults. Additionally, we observe that adverse results; otherwise fragmentation of the nidus into a num-
radiation induced damage seems to be more tolerable for ber of segments will make the radiosurgical planning
kids, which proves that radiosurgery has a favorable benefit difficult and increasing the probability of radiosurgery
risk profile in the management of pediatric AVMs. However, failure.
the risk of hemorrhage remained in pediatric patients and 2. Staged radiosurgery to selected volumes of the AVMs.
the development of secondary tumor cannot be overlooked. Sirin et al.71 used staged volumetric radiosurgery in 28
large AVMs. Out of the 21 patients, seven underwent
Gamma Surgery following Embolization of Arteriove- repeat radiosurgery and were eliminated from outcome
nous Malformations.  The effectiveness of partial embo- analysis. Of the remaining 14 patients, three had total
lization followed by gamma surgery in the management of obliteration on angiograms, and 4 had no flow voids on
relatively large AVMs still remains controversial. When com- MRI but had no follow-up angiography. Four patients
paring the outcome in patients treated with gamma knife had hemorrhages after radiosurgery resulting in two
alone to those with combined embolization and gamma deaths. Worsened neurologic deficits occurred in one
knife treatment, recent studies reported less favorable out- patient.
come in patients with preradiosurgical embolization.65,68 3. Treating the whole nidus in one session with low-dose
Between 1989 and 2007, a total number of 217 AVMs with radiosurgery. Pan et  al.72 reported an obliteration rate
prior partial embolization were treated with gamma surgery of 25% for AVMs with volume larger than 15 cm3. The
at the Lars Leksell center. There were 107 males (49%) and obliteration rate increased to 50% at 50 months follow-
110 females (51%) with a mean age of 32.8 years. Most of the up. The morbidity was 3.3%. Post-treatment hemorrhage
AVMs were embolized with liquid embolics such as NBCA occurred in 9.2% of cases.
or ethanol. In 167 patients the nidus was compact after the 4. At Lars Leksell center, we evaluated a protocol using
embolization, whereas the angiogram of 50 cases revealed combined radiosurgery and microsurgery for the man-
that the nidus was broken apart after the endovascular pro- agement of large AVMs. Gamma surgery was performed
cedures. The mean volume of the nidus at the time of GKS for the deep medullary portion of the AVMs as a first
was 5.1 cm3 (range 0.02–24.9 cm3). The mean prescription step. The second step was planned as microsurgical
dose was 19.6 Gy (range 10–28.0 Gy) and the mean maxi- extirpation of the superficial segment if the goal of the
mum dose was 37.2 Gy (range 20–50 Gy). first step, obliteration of the deep segment of the AVM,
After gamma surgery an angiographically confirmed was achieved. However, in less than 5% of the patients,
total obliteration of the AVMs was achieved in 71 patients this goal was achieved.
(27%) (Fig. 5-5). A total obliteration on MRI was observed The management of large AVMs demonstrates that
in 26 patients (10%). In 157 patients (60%) only a partial every treatment has its limitations. In an effort to solve the
obliteration could be obtained after a follow-up period of problems of the management of large AVMs, a cautious
at least 2 years. Eight patients (3%) presented with a subtotal approach is warranted pending the development of new
obliteration. The outcome after gamma surgery in emboli- techniques and agents for embolization.
zed AVMs (obliteration rate 27%) is much less favorable than
AVMs treated with gamma knife only (obliteration rate 72%). Hemorrhage Risk in the Treatment–Response Interval
Recanalization of previously embolized parts of the Whether gamma surgery without obliteration of the nidus
nidus,69 difficulty in nidus delineation following previous provides partial protection from hemorrhage is still contro-
embolization,65 and attenuation of radiation dose by embo- versial. It has been demonstrated by some authors that there
lization materials70 have been proposed to explain the less may be some degree of protective effect.73-75 Because the
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 57

A B

C D
FIGURE 5-5  Gamma surgery following a partial embolization of the AVM. A 24-year-old male diagnosed with a left-sided AVM at the left senso-
rimotor cortex following a hemorrhage (A and B lateral and frontal projections of angiograms). The patient underwent a partial embolization. The
nidus obliterated completely 3 years following gamma surgery (C and D).

incidence of hemorrhage in a matched group of untreated to hemodynamic factors in 16, recanalization of embolized
patients will likely never be known and the timing of oblit- AVM compartments in 6, and suboptimal dose (<20 Gy) in
eration is not known except as being between diagnostic 23 patients. Nineteen patients had repeat gamma surgery
scans, it is a difficult position to support. for subtotal obliteration of AVMs. In 62 patients, the AVMs
The incidence of hemorrhage following gamma surgery failed to obliterate in spite of correct target definition and
during the first 2 years was studied in 1604 of our patients adequate dose. At the time of retreatment, the nidus volume
and reported by Karlsson et al.76 There were 49 hemor- ranged from 0.1 to 6.9 cm3 (mean 1.4 cm3) and the mean
rhages for an annual incidence of 1.4%. This is slightly prescription dose was 20.3 Gy. Clinical follow-up ranged
lower than the generally accepted rate of 2% to 4% per year from 15 to 220 months with a mean of 84.2 months after
but includes all 1604 patients, consisting of those known repeat gamma surgery.
and not known to have obliterated AVMs. Of these hemor- Repeat treatment yielded a total angiographic oblitera-
rhages, 14 were fatal (annual rate of 0.4%) and 9 had perma- tion in 77 (55%) (Fig. 5-6) and subtotal obliteration in 9
nent neurologic deficits (annual rate of 0.3%). (6.4%) patients. In 38 (27.1%) patients, the AVMs remained
patent. In 16 patients (11.4%) no flow voids were observed
Repeat Gamma Surgery for Incompletely Obliterated on the MRI. High prescription dose, small nidus volume,
Arteriovenous Malformations.  In general, the risk of nidi with only superficial venous drainage, and a negative
hemorrhage persists as long as the AVM nidus is still patent. history of prior embolization were significantly associated
This provided the rationale for retreatment of still patent with increased rate of AVM obliteration. Clinically, 126
AVMs following the initial gamma surgery. patients improved or remained stable and 14 experienced
In our experience, 74 males and 66 females with a mean deterioration (8 due to a rebleed, 2 caused by persistent
age of 33 years underwent repeat gamma surgery for still- arteriovenous shunting, and 4 related to radiation induced
patent AVMs following initial gamma surgery from 1989 to changes).
2007. Causes of initial treatment failure included inaccurate We advise repeat gamma surgery in cases with still pat-
nidus definition in 14, failure to fill part of the nidus due ent nidi 3 to 4 years after initial gamma surgery when open
58 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

A B C
FIGURE 5-6  Repeat gamma surgery for AVM. A 33-year-old male with a left parietal AVM presenting with seizure. The patient underwent first
gamma surgery with a prescription of 20 Gy in 1991 (A). The flow of the nidus seemed to be reduced but the overall size of the nidus had not
changed (B). He had a repeat gamma surgery in 2002 with 18 Gy as a prescription dose and the nidus completely obliterated in 2005 (C). His seizure
frequency decreased significantly.

surgery or endovascular procedures were expected to yield neuroimaging studies or inadequate interpretation leading
higher risk of complications than gamma surgery. Our expe- to the misdiagnosis of angiographic cure.
rience showed that when repeating gamma knife treatment
a dose of at least 20 Gy led to a higher chance of subsequent Subtotal Obliteration of Arteriovenous Malforma-
nidus obliteration (77% vs. 47% with prescription dose less tions.  Subtotal obliteration of an AVM following gamma
than 20 Gy). surgery has been reported sporadically. This angiographic
phenomenon implies a complete disappearance of AVM
Hemorrhage from Angiographically Confirmed Oblit- nidus but persistence of early filling drainage veins (see Fig.
erated Arteriovenous Malformations.  Some studies 5-4). Theoretically, the early filling venous drainage sug-
have noted AVM reappearance after apparent gamma gests that some shunting still persists.
knife surgery obliteration.77 In our histopathologic analy- We reported a series of 159 patients with subtotal oblit-
sis, gamma surgery of AVMs caused endothelial damage, eration of AVMs (SOAVMs).60 The incidence of SOAVMs was
proliferation of smooth muscle cells, and the elaboration 7.6% from a total of 2093 AVM patients who were treated
of extracellular collagen by these cells, which led to pro- with gamma surgery and had angiographic follow-up avail-
gressive stenosis and obliteration of the AVM nidus.43 In this able. The diagnosis was made after a mean of 29.4 months
same report, there was evidence of small trapped vessels (range 4–178 months) following gamma surgery.
that would have very little blood flow. It is unclear what During the cumulative period of 767 patient-years
histopathologic process would permit the formation of (a mean of 4.9 years per patient) after the diagnosis of
new vessels following radiosurgical-induced obliteration of SOAVMs, no SOAVMs had ruptured. Follow-up angiography
the AVM nidus. However, it is clear that the infrequent and was performed in 90 of 136 patients in whom SOAVMs had
small trapped vessels observed by Schneider et al.43 could no further treatment. These studies showed a total oblitera-
not explain the angiographic findings reported by Linqvist tion of the original AVMs as well as disappearance of the
et  al.78 Such inconsistent findings following radiosurgical early filling vein in 66 patients (73%). Twenty-four patients
treatment of AVMs suggest the need for further clinical and (27%) had persistent SOAVMs. Twenty-three patients with
histopathologic investigation and the continued follow-up SOAVMs were treated with gamma knife targeting the proxi-
of patients, particularly pediatric ones, following gamma mal end of the early filling veins. In this group, follow-up
surgery. angiography was performed in 19 patients, confirming
In our series of AVMs treated with gamma surgery, we disappearance of the early filling vein in 15 patients (79%)
observed no recurrent hemorrhage after angiographically and persistent SOAVMs in four patients (21%). None of the
confirmed obliteration of the AVMs. In one case reported by patients suffered a rupture of the lesion. This suggests that
Guo et al., a rebleed occurred after angiographic documen- the protection from rebleeding at the stage of subtotal oblit-
tation of nidus obliteration.79 The MRI findings suggested eration is significant.
that hemorrhage possibly resulted from radiation-induced Our series shows that subtotal obliteration of the AVMs
tissue damage. Furthermore, the histologic examination did not necessarily prove to be a premature stage of an
of the suspected recanalized AVM revealed channels that ongoing obliteration, and instead might be the end point of
were one-fiftieth the size of the smallest vascular channels the obliteration process. Earlier in our series, we repeated
in AVMs, making it unlikely that these were vessels with sig- gamma surgery for SOAVMs, targeting the proximal seg-
nificant blood flow. This view has been further confirmed ment of the early filling vein. After repeat treatment, 79%
by the fact that a repeat angiogram revealed no evidence SOAVMs were obliterated. However, the necessity of retreat-
of residual malformation or recanalization. Rebleeding, ment remains to be determined given the fact that in the
in spite of post-treatment angiograms interpreted as nor- whole group no hemorrhage occurred and that 73% of
mal, may be explained by unsatisfactory quality of the SOAVMs obliterated spontaneously.
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 59

A B

FIGURE 5-7  Onset and resolution


of radiation-induced changes of
normal brain tissue. Radiation-
induced changes 6 months follow-
ing radiosurgical treatment of a left
basal ganglia arteriovenous malfor-
mation with a margin dose of 20
Gy. Appearance on (A) T2- and (B)
T1-weighted MRI. These changes
showed progressive regression
and complete disappearance at
2 years following onset (C and D).
Angiography documented total
C D obliteration of the arteriovenous
malformation.

Complications sulci) and 7% had severe (midline shift) radiation-induced


changes. The mean time to the development of radiation-
Radiation-Induced Changes induced changes was 13 months after gamma surgery. Reso-
Radiation-induced change is an increased T2 signal around lution of these changes was the usual course and the mean
the AVMs on MRI following radiosurgery (Fig. 5-7). Radiation duration of the changes was 22 months. Large nidus vol-
damage of glial cells, endothelial cells damage followed by umes, high prescription doses, history with preradiosurgical
breakdown of blood–brain barrier, excessive generation of embolization, and nidus without previous hemorrhage were
free radicals or release of vascular endothelial growth fac- associated with higher risk of radiation-induced changes.
tors have been proposed to explain this imaging finding. The Of the patients who developed radiation-induced
severity of radiation-induced changes on images and associ- changes, 122 (8.7%) patients had headache, worsening or
ated neurologic deficits varied ranging from asymptomatic, new seizures, or neurologic deficits. Patients with severe
a few millimeters increased T2 signal surrounding the treated radiation induced changes and nidus at eloquent areas
nidus to massive brain edema with symptoms and signs of were more likely to develop symptoms. Twenty six patients
increased intracranial pressure. From our 1500 gamma knife (1.8%) had permanent neurologic deficits.
procedures performed for AVM patients with follow-up MRI
available for analysis, 34% of patients developed radiation- Cyst Formation
induced changes. Among them, 60% had mild (a few milli- A rare occurrence following gamma surgery for AVMs is
meters of increased T2 signal surrounding the nidus), 33% the development of an expansive cyst at or adjacent to an
had moderate (compression of ventricle and effacement of obliterated AVM (Fig. 5-8). Cyst developed after resolution of
60 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

A B C

D E
FIGURE 5-8  Delayed occurrence of cyst formation following gamma surgery for an AVM. This small, right-sided AVM visualized on anteroposterior
(A) and lateral carotid arteriography (B) was cured as shown on this control angiogram obtained 2 years after gamma surgery (C). The development
of headaches and personality changes prompted an MRI examination 7 years after gamma surgery (D and E). This cyst was surgically decompressed.
Biopsy of the cyst wall did not reveal any evidence of tumor. (Follow-up MRI courtesy of Professor J. Camaert, Chairman, Department of Neurosur-
gery, Gent, Belgium.)

previous hemorrhages or fluid cavities from encephaloma- time interval, then our incidence of radiosurgery-induced
lacia after surgeries should not be considered as complica- neoplasia is 2 in 2880 person-years or 69 in 100,000 person-
tions related to gamma surgery. First reported in 199245 in two years. Thus, there is a 0.7% chance that a radiation-induced
patients out of a series of forty, we found a total of 20 patients tumor may develop within 10 years following gamma sur-
(1.6%) developing a cyst after a mean of 8.1 years postra- gery. The long latency and relative rarity of these lesions
diosurgery from our 1272 patients with follow-up MRI avail- ­following radiosurgery may defy a conclusive determina-
able.80 Six patients had large cysts and three of them were tion of the true incidence.
symptomatic requiring surgery. Two cases underwent crani-
otomy and drainage of the cyst. The cyst wall showed no evi- Dural Arteriovenous Fistulas
dence of neoplasia. Direct radiation injury to the perilesional Although dural arteriovenous fistulas (dAVFs) comprise
brain tissue, increased permeability of the blood–brain bar- approximately 15% of all intracranial vascular malfor-
rier with accumulation of the exudative fluid, hemodynamic mations, the precise mechanism of formation remains
perturbations during gradual obliteration of the nidus with unknown. The leading theories include adjacent venous
subsequent ischemic tissue damage, and tissue destruction sinus stasis as well as alterations in local expression of
due to subclinical perilesional hemorrhages have been vasogenic factors, such as vascular endothelial growth fac-
­proposed as the ­possible ­mechanisms of cyst formation. tor and fibroblastic growth factor.82,83
From a treatment standpoint, experience with dAVFs is
Radiosurgery-Induced Neoplasia distinct from AVMs. Studies have established that the flow
We found two meningiomas from 1333 AVM patients treated dynamics of dAVFs are the most important indicator of
with gamma surgery (Fig. 5-9); however, follow-up imaging the need to treat and modality to choose, be it emboliza-
was performed over a period of at least 10 years in only 288 tion, open microsurgery, or radiosurgery. As the aggressive
of these patients.81 If we conservatively estimate that radio- natural history of lesions with cortical venous reflux differs
surgery-induced lesions would be evident within a 10-year significantly from lesions without angiographic evidence of
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 61

A B

C D

L
L
5 cm
5 cm

E F A
FIGURE 5-9  Radiation-induced neoplasia. Anteroposterior (A) and lateral (B) views of vertebral angiograms demonstrate a right temporal AVM
before gamma surgery. Two years after treatment the nidus obliterated completely (C and D). Axial and coronal contrast-enhanced, T1-weighted
MRI (E and F) obtained 10 years postradiosurgery show a meningioma adjacent to the superior surface of tentorium. It is located in the area where
the previous AVM was situated.

cortical venous reflux, early definitive therapy via endovas- Lars Leksell center between 1989 and 2005, 55 patients with
cular procedures or open surgical resection appears to be dAVFs were treated with gamma surgery, primarily as an
preferable to radiosurgery as a first-line treatment. Although adjunct to surgery or embolization. Obliteration rates mea-
radiosurgery is thought to be an effective agent for decreas- sured by angiography at 3 years ranged from 54% to 65%,
ing neovascularization in dAVFs, the time interval needed with the 16 patients classified as Borden I lesions (Fig. 5-10).
for the desired effect is too great to justify radiosurgery as a Unlike the Karolinska study, the majority of patients treated
first-line therapy.84 at the Lars Leksell center received gamma surgery as a sec-
The long-term analysis of radiosurgery for dAVFs over ondary therapy, with 41 of the 54 patients receiving surgical
25 years at the Karolinska University Hospital in Stockholm, or endovascular intervention prior to radiosurgery. Regard-
Sweden included 52 patients treated between 1978 and 2003. less of the difference in utilization of radiosurgery as a pri-
The obliteration rate reported in this study was 68% with mary or secondary treatment modality, the results of these
16 dAVFs presenting as less aggressive Borden I or Cognard long-term studies indicate that gamma knife is an effective
I/IIa lesions.85 In a similar institutional experience at the and safe treatment for intracranial dAVFs.
62 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

A B

FIGURE 5-10  Total obliteration of


dural arteriovenous fistula follow-
ing gamma surgery. Left common
carotid angiogram lateral (A) and
(C) frontal projections of a dural
arteriovenous fistula in the region
of the left transverse sinus. Com-
plete obliteration is demonstrated
at 2 years following gamma sur-
gery in the (B) lateral and (D) frontal C D
projections.

Vein of Galen Malformations evidence of a hemorrhage as well as in determining the


We have treated nine patients with vein of Galen malforma- date from which patients were at risk for hemorrhages.
tions. The patients ranged in age from 4 to 72 years of age. Gamma surgery of CMs appears to have a histologic
Among these patients, there were three with Yasargil Type I, effect on them, which is not evident on imaging studies. In
one with Type II, two with type III, and three with type IV a case reported earlier,29 a gamma surgery treated CM fol-
malformations. Prior embolization had failed in four of lowed for 5 years showed no change on MRI studies. Histo-
the cases. Three of the vein of Galen malformations were logic examination following surgical removal of the lesion
treated twice with radiosurgery. Follow-up angiograms were showed it to be partially obliterated (Fig. 5-12).
obtained in eight of the patients treated.86 Four malforma- A total of 23 patients have been treated by us for CMs
tions were completely obliterated (Fig. 5-11). Another one between 1985 and 1996, 22 of which are available for follow-
seems to be obliterated but definitive confirmation could up evaluation.91 Maximum treatment dose varied from 11 to
not be obtained as the patient refused a final angiogram. 60 Gy (mean 33 Gy). Peripheral dose varied from 9 to 35 Gy
Another patient has some residual fistula not in the initial (mean 18 Gy). Nine symptomatic hemorrhages occurred in
radiosurgical treatment field and has been retreated. Two this group after therapy for an annual incidence of 8%. Four
other patients had marked reduction of flow through their of these patients were subsequently operated upon. Six
malformations. patients suffered neurologic decline secondary to radiation-
induced changes, five of which were permanent. Two
Cavernous Malformations patients subsequently underwent surgery. Thus the per-
The success of treating AVMs prompted the treatment of manent radiation-induced complication rate is 22%, nearly
cavernous malformations (CMs) with the gamma knife. 12 times higher than expected for a similarly treated group
Their tendency to be small in size, with the lack of inter- of AVM patients. The high incidence of post-treatment hem-
vening normal brain tissue and relatively low rate of clini- orrhage and radiation-induced complications is greater
cally significant hemorrhage made CMs a natural target for than the expected morbidity from an untreated group. For
the gamma knife. The rate of hemorrhage for cavernomas this reason the routine use of the gamma knife in the treat-
is widely disparate in the neurosurgical literature reported ment of CMs cannot be supported at this time.
as between 0.1% and 32%.87-90 This is largely due to seman- There have been observations in literature that dem-
tic differences in defining a hemorrhage with some authors onstrate a protective effect of gamma surgery on the
counting the presence of a hemosiderin ring on MRI as rate of hemorrhage in these lesions. Based on 38 cases,
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 63

A B

C D

FIGURE 5-11  Gamma surgery for


a vein of Galen malformation.
A-P (A) and lateral (B) vertebral
angiograms show direct shunting
of blood into the primitive precur-
sor (promesencephalic vein) of the
vein of Galen. C and D, Stereo-
tactic angiogram obtained at the
time of treatment. E and F, Control
angiography obtained 1 year later
demonstrate cure of the malforma-
tion. (Courtesy of Hernan Bunge,
E F MD, Clinica del Sol, Buenos Aires,
Argentina.)

Kondziolka et al.92 maintain that radiosurgery offers benefit


to these patients. They reported that 6 patients (15%) had
significant reduction in size with a 13% hemorrhage rate;
10 of the patients (26%) developed neurologic deficits, 2 of
these underwent surgery and succumbed to the illness. The
rate of complications reported by them in the face of the fact
that only 15% of the patients in this series had any reduction
in the size of the lesion does not, in our opinion, constitute
grounds for justifying radiosurgery for CMs. Furthermore,
their contention that the complications reported by us may
in part be due to the high doses used in treatment does not
get support from their statistics with a lower dose. These 38
patients were a part of a later report on 47 patients from the
same authors detailing the outcome. They found a postra-
diosurgery annual hemorrhage rate of 8.8%, which is high
when compared to the risk reported by the same authors at
FIGURE 5-12  Hematoxylin and eosin stained histologic section of a cav- 0.6% to 4.5%, even if the difference is not statistically signifi-
ernous malformation that was treated with gamma surgery. Because cant. They chose, however, to compare their postradiosur-
no change was observed on serial MRI examinations over 5 years, the
lesion was excised. Except for a single persistent capillary channel, the
gery hemorrhage rates with the preradiosurgery rate in the
malformation was obliterated. same subjects, making the assumption that the rate could
64 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

be based on an epoch starting from first observation or first slice volumes. The error of this method was determined by
hemorrhage. This is fallacious since the malformation was comparing various hand-partitioned volumes with volumes
present before the presenting hemorrhage and most likely estimated using polyhedrons to approximate the regions of
from birth. Recomputed on this basis the preradiosurgery interest on each slice. The average relative error is strongly
annual bleed rate comes to 5.9%, which is more congruent dependent on the number of axial slices obtained through
with expected natural history. Once again the incidence of the object of interest and is fairly independent of the size of
hemorrhages postradiosurgery seems spuriously higher. the object itself. For objects varying in volume from 0.1 to 10
During the past decade, gamma knife has been widely cc, the average relative errors per number of slices through
used in some centers to treat CMs. Since the lesions can- the object have been computed as follows: 3% for 7 slices,
not be precisely visualized by any imaging studies, the out- 4% for 6 slices, 6% for 5 slices, 11% for 4 slices, and 21% for 3
come of radiosurgery was universally evaluated based on slices. Volumetric estimation based on 1 or 2 slices through
the hemorrhage rate before and after radiosurgery using the region of interest produces unacceptable average rela-
the same group of patients as control. There are method- tive errors of more than 40%. We now require all follow-up
ological flaws in such study design. As been demonstrated studies to be performed with a slice thickness of 3 mm with
in publications,93 patients with previous hemorrhages tend zero overlap or gap between adjacent slices. Such a proto-
to bleed more often. By calculating the clustering number col generally helps ensure the acquisition of 3 or more slices
of hemorrhages in the short period of follow-up time, which through the region of interest. Even though the technique of
was prematurely terminated by radiosurgery prompted by volume estimation has an acceptable level of accuracy, we
the hemorrhage, the preradiosurgical hemorrhage rate prefer to ignore changes of less than 15%.
was erroneously high ranging from 17% to 36%.64,88,94-96
The hemorrhage rate after gamma surgery is these series Pituitary Adenomas
ranged from 2% to 4%, which seems to be significantly low The efficacy of radiation in the treatment of pituitary adeno-
compared to the preradiosurgical bleeding rate but actu- mas was well-documented before gamma surgery was used
ally is not much different while comparing to the number for this disease.100,101 Reduced fractionation techniques
reported in series studying natural course of CMs. Of note, had been shown to have effectiveness in the treatment of
the complications in these series remained to be high. Cushing’s disease and were the impetus for the use of radio-
surgery. MRI has replaced less exact invasive localization
Developmental Venous Anomalies procedures such as cisternography and CT in the planning
The natural history of developmental venous anomalies of gamma surgery in patients with pituitary adenomas.
(previously named venous angiomas) is benign97 and There still remain difficulties with the use of gamma sur-
clearly not a surgical lesion. Prior to clear elucidation of this gery. The peripheral dose that can be delivered for mac-
prognosis, 19 patients were treated for this entity by us.98 roadenomas is limited if the optic apparatus is in proximity
One patient was cured and three were partially obliterated. with the tumor. Localization of microadenomas can be dif-
Three patients suffered radionecrosis, and one had symp- ficult with even the best MRI examinations (e.g., a fat sup-
tomatic edema. One patient with radionecrosis underwent pression MRI protocol) and amelioration of hypersecretory
subsequent debridement. A 5% cure incidence with a 30% syndromes is delayed.
complication incidence for a benign entity is unacceptable. One of the best indications for gamma surgery of secre-
tory or nonsecretory pituitary adenomas is residual tumor
TUMORS that is not removable with microsurgical techniques (i.e.,
Treatment of tumors with gamma surgery introduces a new tumors within the cavernous sinus). If it is known before
approach to the evaluation of the endpoint of the treatment. microsurgery that the cavernous sinus is involved and a
Unlike microsurgery no actual debulking of tissue occurs, debulking procedure is considered, then every effort to
and, in the short term, there are no visible changes. How- clear the tumor away from the optic nerves and chiasm
ever, in the long term, the tumors often shrink, and some should be made in order to make gamma surgery postop-
even disappear entirely on follow-up neuroimaging stud- eratively more effective. A suprasellar approach should be
ies. Success is therefore established by a pattern of reduc- considered if there is doubt that this can be accomplished
ing tumor size over serial follow-up studies or the lack of through a trans-sphenoidal approach. There is some diffi-
growth. With benign tumors, the natural history may be one culty in differentiating residual tumor from postoperative
of no growth for many years. As such, longer follow-up is changes on MRI. A thorough operative note concerning any
necessary to ascertain whether gamma surgery affords true foreign material or grafts left behind is important, as well as
tumor volume control in slow growing tumors. a high-quality preoperative scan for comparison.
In an attempt to eliminate some of the subjectivity of Another indication for gamma surgery is persistence
naked eye observations and the obvious fallacy resulting or recurrence of elevated hormone levels after micro-
from the estimation of a three dimensional object on the surgery. In the presence of residual or recurrent tumor
basis of three linear measurements in orthogonal planes, that is not readily amenable to further extirpation, either
we have developed software that allows estimation of lesion because of its location or the inability to localize the
volume based on MRI or CT.99 The procedure involves scan- tumor within the sella, gamma surgery can be applied.
ning the study into a computer program and outlining the Tumor within the cavernous sinus can be treated. Diffi-
pathology in each slice. The computer then measures the culty in localizing the tumor usually requires radiosur-
area within the contour and calculates a volume based on gical targeting of all the contents within the sella, and
slice thickness, the process is repeated for each slice and such an approach carries a fair risk of postradiosurgical
the total volume calculated by integrating the individual hormonal insufficiency.102 If the patient has a secretory
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 65

microadenoma but the symptomatology is not urgent and there have been a wide range of outcomes with regard to
microsurgery is for some reason not considered, then hormonal normalization of secretory adenomas. The varied
gamma surgery can be used as the primary therapy. outcome results for hormonal normalization may arise from
In preparation for treatment with high-dose, nar- the following reasons:105 early studies utilized CT rather
row beam radiation, many centers have recommended than more precise MRI for dose planning;106 different crite-
a temporary cessation of antisecretory medications in ria for defining an endocrinologic cure have been applied
the peritreatment time period. In 2000, Landolt et  al. first in various studies and there is little consensus even within
reported a significantly lower hormone normalization rate the neuro-endocrinologic community for precise defin-
in acromegalic patients who were receiving antisecretory ing criteria107; and many studies had short or intermediate
medications at the time of radiosurgery.103 Since then, this follow-up periods and may not have been long enough to
same group as well as others has documented a counter- observe patients with an endocrinologic recurrence follow-
productive effect of antisecretory medications on the rate ing an initial remission.
of hormonal normalization following gamma surgery.32,104
The degree to which and the mechanism by which antise- Nonsecretory Tumors
cretory medications lower hormonal normalization rates is We have treated 100 patients with nonsecretory pituitary
unknown, but Landolt et al. have hypothesized that these tumors, 90 of which have imaging and endocrinologic follow-
drugs lower the tumor’s metabolic rate and decrease their up of a minimum of 6 months and an average of 45 months108
radiosensitivity.105,106 Moreover, the optimal time period to (Tables 5-2 and 5-3). Of these, 59 (65.6%) had a decrease in
hold antisecretory medications in conjunction with gamma the volume of their tumors (Fig. 5-13) and 24 (26.7%) had
surgery is not clear. Landolt and Lomax recommend that no change in the size. In seven (7.8%) patients, the tumors
dopamine agonists be withheld 2 months prior to the pro- increased in size. Of note, among 61 tumors involving the
cedure.104 For acromegalics, they recommend altering anti- cavernous sinus, 39 shrank, 17 remained unchanged, and
secretory medication administration as early as 4 months five increased in size. The minimal effective peripheral dose
prior to radiosurgery and completely halting all antisecre- was 12 Gy; peripheral doses greater than 20 Gy did not seem
tory medications 2 weeks prior to radiosurgery.103 Although to provide additional benefit. In 61 patients with residual
many centers have incorporated such methodology into pituitary function at the time of gamma surgery, new hor-
their treatment regimen, the potential risk and benefits of mone deficiency occurred in 12 patients (20%).
halting antisecretory medication administration should be
weighed. The functional adenoma may be more likely to Growth Hormone–Secreting Tumors (Table 5-4)
respond to gamma surgery. However, in the absence of anti- We have performed gamma knife procedures on 137
secretory medication control, it may also enlarge thereby patients with growth hormone secreting adenomas (Table
risking adjacent structures (e.g., the optic apparatus), 5-4). Follow-up of at least 18 months was available for 95 of
necessitating a lower prescription dose, and making effec- these patients. There was normalization of IGF-1 in 53% of
tive treatment more difficult. cases at an average time of 30 months after radiosurgery.
Most centers have observed effective growth control of Three patients developed recurrence of their acromegaly
pituitary adenomas following gamma surgery. However, after initial remission, with a mean time to recurrence of

Table 5-2  Gamma Surgery for Pituitary Adenomas Outcomes at University of Virginia
TUMOR SIZE
Tumor Type Patient No. Decreased (%) Unchanged (%) Increased (%) Endocrine Remission (%)
Nonsecretory 90a 66 27 7 n/a
Acromegaly 90a/95b 92 6 2 53
Prolactinomas 23a/28b 46 43 11 26
Cushing’s 67a/90b 80 14 6 53
Nelson’s 22a/15b 55 46 9 20
aNumbers of patients available for imaging evaluation.
bNumbers of patients available for endocrinologic evaluation.

Table 5-3  Imaging Outcomes of Radiosurgery for Nonsecretory Pituitary Adenomas


TUMOR SIZE (%)
Peripheral New Hormone Visual
Author Year Patient No. F/U (Months) Dose (Gy) Decreased Unchanged Increased Deficit (%) ­Complication (%)
Pollock et al.170 2008 62 44.9 16 60 37 3 25 0
Mingione et al. 108 2006 90 44.9 18.5 65.6 26.7 7.8 25 0
Iwai et al.171 2005 34 59.8 14 58.1 29 12.9 6.5 0
Losa et al.172 2004 54 41.1 16.6 96.1 NR 3.9 9.6 0
Sheehan et al.173 2002 42 31.2 16 42.9 54.8 2.4 0 4.8

F/U, follow-up; NR, not reported.


66 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

A B
FIGURE 5-13  Nonsecretory pituitary adenoma treated with gamma surgery following three microsurgical resections. Sagittal T1-weighted MRI of a
nonsecretory pituitary adenoma in a 34-year-old man (A), demonstrating marked reduction at 30 months after radiosurgery (B). Patient recovered
his visual acuity and had resolution of his visual field defect, and returned to his job as a policeman.

Table 5-4  Hormone and Imaging Outcome of Radiosurgery for Growth Hormone–Secreting Pituitary Adenomas
IGF-1 TUMOR VOLUME CHANGE (%) New Visual
Patient F/U Peripheral Normalization Hormone Complication
Author Year No. (Months) Dose (Gy) (%)a Decreased Unchanged Increased Deficit (%) (%)
Jagannathan 2008 95 57 22 53 92 6 2 34 4
Losa et al.174 2008 83 69 21.5 60.2 45.8 51.8 2.4 8.5 0
Vik-Mo et al.175 2007 53 66 26.5 58 41.5b 47.2b 0 23 3.8
Pollock et al.176 2007 46 63 20 50 70 30 0 33 0
Jezkova et al.177 2006 96 53.7 32 50 62.3 37.7 0 27.1 0
Voges et al.c178 2006 64 54.3 15.3 49.8 23.4 73.5 3.1 12.3 1.4
Castinetti et al.179 2005 82 49.5 12-40 40 NR NR NR 17.1 0
Attanasio 2003 30 46 20 23 58 42 0 6.7 0

F/U, follow-up; IGF-1, insulin-like growth factor-1; NR, not reported.


aIncludes patients on and off medications.
bTumor volume unavailable for six patients.
cLinac radiosurgery.

42 months. New endocrinologic deficiencies developed in Prolactin-Secreting Tumors


34% of patients, with hypothyroidism and low testosterone Prolactinomas are usually well-controlled by dopamine
levels being the most common new endocrinopathies. agonists (Table 5-5). Nonetheless, this medication occa-
In five patients the tumors could not be identified on sionally fails to achieve remission and is not tolerated by
MRI and the whole sella was targeted. Of the remaining 90 all patients. Alternative for these patients not responding
tumors treated with gamma surgery, a decrease in tumor size to medical therapy is surgery. Patients who are refrac-
was seen after 83 (92%) gamma procedures. Tumor growth tory to medical and/or surgical therapy may be treated
was seen after 2 (2%) procedures. No change in tumor with gamma surgery. Of the 37 prolactin secreting tumors
volume was seen after 5 (6%) procedures. Four patients treated by us at the Lars Leksell gamma knife center,109 28
developed the new-onset of visual acuity deficits; three of have imaging follow-up of 1 year or more. Thirteen (46%)
these patients had received prior conventional fractionated had a decrease in the size, 12 (43%) were unchanged and
radiation therapy and their vision recovered following a three (11%) were increased. Excluding patients with normal
short course of steroids. One patient developed deteriora- prolactin level before gamma surgery and those with nor-
tion in visual fields secondary to tumor growth. His vision mal level at the last follow-up while still receiving dopamine
continued to deteriorate in spite of repeat trans-sphenoidal agonists, endocrine follow-up was available for 23 patients.
surgery. One patient developed temporal lobe epilepsy 15 There was remission (serum prolactin level <20 ng/ml) in
months following radiosurgery with MRI showing temporal 26% of cases. New onset endocrine deficiency developed
enhancement. She is free of seizure with normal MRI scans in 29% of patients. Two patients had new onset extraocu-
and off antiepileptics 45 months after gamma surgery. No lar movement problems; one developed an oculomotor
instance of ophthamoplegia occurred in any patients. and the other an abducens nerve palsy. In both cases, the
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 67

Table 5-5  Hormone and Imaging Outcome of Radiosurgery for Prolactin-Secreting Pituitary Adenomas
TUMOR VOLUME CHANGE (%) New Visual
Patient F/U Peripheral Hormone Hormone Complication
Author Year No. (Months) Dose (Gy) Remission Decreased Unchanged Increased Deficit (%) (%)
Pouratian et al.109 2006 23 58 18.6 24 46 43 11 28 7
Choi et al.180 2003 21 42.5 28.5 24 50 50 0 0 0
Pan et al.181 2000 128 33 31.5 52 57.8 40.6 1.6 NR 0
Landolt and Lomax104 2000 20 29 25 25 NR NR NR NR 5
Mokry et al.182 1999 21 31 14 21 NR NR NR NR NR
Levy et al.183 1991 20 12 NR 60 NR NR NR NR NR

F/U, follow-up; NR, not reported.

Table 5-6  Hormone and Imaging Outcome of Radiosurgery for ACTH-Secreting Pituitary Adenomas
24-Hour UFC TUMOR VOLUME CHANGE (%) New Visual
Patient F/U Peripheral Normaliza- Hormone Complication
Author Year No. (Months) Dose (Gy) tion (%) Decreased Unchanged Increased Deficit (%) (%)a
Jagannathan et al.110 2007 90 41.3 23 54 92 3 5 22 5.6
Castinetti et al.184 2007 40 54.7 29.5 42.5 NR NR NR 15 0
Kobayashi et al.185 2002 20 63.6 28.7 35b 85 15 0 NR NR
Hoybye et al.186 2001 18 204 60–100c 83 NR NR NR 69 0
Levy et al.183 1991 64 NR NR 86 NR NR NR NR NR

ACTH, adrenocorticotropic hormone; F/U, follow-up; NR, not reported; UFC, urine-free cortisol.
aVisual field defect or CN 3, 4, 6 palsy.
bACTH <50 pg/ml; cortisol <10 mg/dl.
cRange of maximal doses.

cavernous sinus was involved and both cases received a parasellar area was seen in three patients but only one had
prescription dose of 25 Gy. symptoms attributable to these changes.
The results of 35 patients treated at the Karolinska Insti-
ACTH-Secreting Tumors tute have been reported.111 Of the 29 patients that had fol-
A total of 107 patients with Cushing’s disease underwent low-up of up to 9 years, 22 (76%) had normalization of their
gamma surgery at our institution (Table 5-6). Seventeen endocrine abnormalities, 10 within 1 year and the remain-
patients who had less than 12 months follow-up were der within 3.
excluded, leaving 90 patients evaluable.110 All but one
patient had undergone previous trans-sphenoidal opera- Nelson’s Syndrome
tions. Of note, in 23 patients in which no tumor can be Patients with an ACTH-secreting pituitary tumor may
identified on planning MRI, the entire sellar content and require a bilateral adrenalectomy to treat their Cushing’s
adjacent cavernous sinuses were targeted. The mean pre- disease when surgical extirpation and radiosurgery for the
scription dose of gamma surgery was 23 Gy (range 8–30 pituitary tumor failed to normalize hormonal production
Gy). Of 67 patients with visible tumors, imaging follow- (Table 5-7). Approximately one third of these patients will
up demonstrated a decrease in the size of the tumor in experience Nelson’s syndrome, namely, enlargement of
62 cases (92%), no change in 2 (3%), and an increase in residual pituitary adenoma, developing hyperpigmentation
size in 3 (5%). However since the hypercortisolism defines and/or having an elevated level of serum ACTH. At the Lars
the dangerous character of the ACTH-secreting tumor, the Leksell center, we have performed gamma surgery on 23
control of endocrine abnormalities is the true measure of Nelson’s patients. Five patients had previously received con-
tumor control. Normal 24-hour, urine-free cortisol levels ventional fractionated radiation therapy, and two patients
were achieved in 49 patients (44%), at an average time of 13 had received prior gamma surgery for Cushing’s disease.
months post-treatment (range 2–67 months). Ten patients Median prescription dose to the tumor margin was 25 Gy
who achieved remission after gamma surgery suffered a (range 4–30 Gy). Twenty two patients had imaging follow-
recurrence. Seven of these patients had repeat gamma up and the mean imaging follow-up was 20 months (range
knife procedures, with three patients achieving another 125–124 months). Fifteen patients had elevated ACTH level
remission. New endocrine deficiencies developed in before gamma surgery and follow-up ACTH level was avail-
20 patients (22%), with hypothyroidism being the most com- able. The mean endocrine follow-up was 50 months (range
monly found new endocrinopathy. Five patients developed 13–166 months). Tumors decreased in 12 (55%) patients,
new-onset ophthalmoplegia (four of them with visual acu- remained unchanged in 8 (36%), and increased in 2 (9%).
ity deficits). One of them had received prior conventional ACTH levels decreased in 10 patients (67%) with a median
fractionated radiation therapy, three had two gamma knife decrease of 75% (range 29%–93%). Three patients (31%)
surgeries, and one had fractionated radiotherapy and sub- achieved normal ACTH levels with a mean time to remission
sequently two gamma procedures. Evidence of radiation- of 9.4 months postradiosurgery. New endocrinopathies were
induced changes presenting as increased enhancement of seen in 4 out of 10 patients with residual pituitary function
68 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

before gamma knife procedures, growth hormone defi- Gamma surgery as an adjunct to microsurgical resection
ciency being the most common new hormonal deficit. One has been used in lieu of radiation therapy, or in addition to
patient suffered from a permanent oculomotor nerve palsy. it, at several centers. The instillation of radioisotopes (e.g.,
It is worth noting that there is a wide variation in both the P32) into large, nonloculated cystic components of the
rates of endocrinologic cure and hypopituitarism follow- tumor and gamma surgery for the solid portion is the treat-
ing gamma surgery. The difference in cure rates between ment policy for craniopharyngiomas at our center.
modern radiosurgical series is likely due to the definition We treated 37 craniopharyngiomas in 35 patients. The
of cure employed and the length of follow-up. However, prescription doses ranged from 6 to 25 Gy (mean 13.3 Gy).
the discrepancy in the reported rates of hypopituitarism is The follow-up ranged between 8 and 212 months with
more likely a function of the degree to which there is rigor- a mean of 62.5 months. Four tumors increased in size. A
ous endocrinologic follow-up testing. decrease in the solid component of the tumor was seen in
29 (Fig. 5-14) and no change was seen in 4. However, of
Craniopharyngiomas the patients whose solid tumors decreased or remained
Craniopharyngiomas are very difficult tumors to treat. unchanged, 10 developed new or enlarged cystic compo-
Their benign histology is misleading. The near impossibility nent with 4 of them requiring further surgical resection and
to resect completely and usual location in and about the 4 receiving intracavitary P32 instillation. In total, 23 patients
hypothalamus make them difficult to cure. Microsurgery, improved or remained stable clinically. Twelve deteriorated
intracystic instillation of radioisotopes, radiation therapy, and 10 of them died from complications of disease or sur-
and now radiosurgery have all been used. Long-term evalu- geries. The mean 5-year survival rate was 71%.
ation of patients with craniopharyngiomas is available after Several other series have been reported in the use
various treatment protocols.112,113 The general consensus is of gamma surgery in the treatment of craniopharyngio-
that as complete a surgical resection as possible, without mas117,118 with results similar to ours. As larger series with
creating significant morbidity, should be performed; this is longer follow-up become available it is likely that gamma
followed by radiation therapy and gives reasonable long- surgery will either take the place of less discriminate radia-
term survival. The ill effects on children after receiving frac- tion therapy, or be a useful adjunct to it.
tionated brain irradiation are well-known.114,115 Good results
with resection alone have been achieved but only in the Meningiomas
hands of a few neurosurgeons. Even so, long-term results of Meningiomas are usually benign, circumscribed tumors
children with subtotal resection followed by radiation ther- that arise from the coverings of the central nervous sys-
apy has been shown to be superior to complete resection tem and therefore tend to be superficial. Because of these
alone116 and the deficits incurred with aggressive surgery attributes microsurgical extirpation of the entire tumor as
can be considerable. well as any involved meninges is the treatment of choice.

Table 5-7  Hormone and Imaging Outcome of Radiosurgery for Nelson’s Syndrome
Hormone TUMOR VOLUME CHANGE (%) New Visual
F/U Peripheral Remission Hormone Complication
Author Year Patient n (Months) Dose (Gy) (%) Decreased Unchanged Increased Deficit (%) (%)
Mauerman et al.187 2007 23 20/50a 25 20 54.5 36.4 9.2 40 4
Vogesb178 2006 9 63/47a 15.3 16.7 44.4 44.4 11.2 NR NR
Pollock and 2002 11 37 20 24 82c 18 9 27
Young188
aMean imaging follow-up/mean endocrine follow-up.
bLinac radiosurgery.
cTumor under control.
F/U, follow-up; NR, not reported.

FIGURE 5-14  Reduction in size of


craniopharyngioma treated with
gamma surgery. Residual cranio-
pharyngioma following microsur-
gery treated with the gamma knife.
Contrast-enhanced T1-weighted
images before (A) and 4 months
after treatment (B). Marked reduc-
tion in tumor size. Patient has a
normal neurologic examination
and endocrine profile.

A B
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 69

Unfortunately many meningiomas do not have one or more tumors. This allows treatment to include the vascular sup-
of the mentioned attributes. Aggressive, locally invasive ply when ideal treatment is not possible because of radia-
tumors, especially those invading or involving critical or tion dose constraints imposed by the treatment volume
difficult to control neural or vascular structures and those or proximity of the tumor to the optic apparatus. Recently
at the skull base can be problematic in their complete we have used MRA source images instead of angiograms
removal. The use of radiation to lower the recurrence rate to conduct treatment planning. Using MRI, the group from
following microsurgical removal of meningiomas was Heidelberg proved that radiation occluded small nutrient
shown to be beneficial.118-120 Recurrence rates were found vessels of meningiomas providing the rationale for the treat-
to be dramatically decreased, and for patients with residual ment we have used since 1976.
tumor following surgery the progression of tumor growth The primary therapy for meningiomas is microsurgery.
was significantly decreased. The advantage of histologic diagnosis, debulking and rea-
We have treated 750 meningiomas at the Lars Leksell sonable chance of cure secures surgical extirpation as the
center since 1989. The most recent evaluation of our mate- procedure of choice for this tumor. The tumors most ame-
rial was for 206 patients with a follow-up of 1 to 6 years. nable to gamma surgery treatment are less than 10 to 15 cm3
Tumor volume ranged from 1 to 32 cm3. These patients in volume. The ability of gamma surgery to effectively treat
received an average of 38 Gy maximum dose (range 20–60 small tumors with low morbidity argues strongly, however,
Gy) and an average peripheral dose of 14 Gy (range 10–20 for minimizing morbidity during open procedures. The
Gy). There were 142 patients treated for residual tumor and option to treat residual tumor in critical or hard to reach
64 treated with gamma surgery primarily. Imaging follow- locations should temper the ambition of total surgical
up was available for 151 patients. Of the evaluated patients removal. This is especially true in locations where complete
94 (63%) showed a decrease in the volume of their tumor meningeal resection is impossible and thus the chance of
greater than 15%. No change in size was seen in 40 (26%) recurrence is high.
and an increase in size in 17 (11%).
Tumors within the parasellar compartment, which is a Vestibular Schwannomas
part of the extradural neural axis compartment, can be dif- Historically and incorrectly referred to as an acoustic neu-
ficult to remove with microsurgery without significant mor- roma, we prefer the designation of vestibular schwannoma,
bidity.121,122 Residual tumor attached to still patent vascular which recognizes the anatomic and histologic origins of
or critical neural structures can be targeted with gamma these tumors.123 There may be no other intracranial neu-
surgery and allows less radical microsurgical resection and ropathology about which the proper treatment arouses as
a lower incidence of morbidity. much controversy as the vestibular schwannoma. Neuro-
We have recently reviewed the central skull base menin- surgeons cite the series of surgeons with enormous experi-
giomas involving the sellar-parasellar space in 138 patients. ence removing these tumors to justify suboccipital removal,
There were 107 females (78%) and 31 (22%) males. The mean while otolaryngologists sacrifice the inner ear during the
age was 54 years (range 19–85). Mean tumor volume at the translabyrinthine approach in an attempt to better expose
time of radiosurgery was 7.5 cm3 (range 0.2–55 cm3). Eighty- and preserve the facial nerve. Radiosurgery’s proponents
four patients had prior microsurgery with partial resection cite excellent tumor control and low morbidity but must
of the tumor. Fifty-four had an upfront gamma procedure. acknowledge that although the tumor often shrinks, it is
In our assessment, the gamma treatment was optimal in still there. Therefore it is in the best interest of our patients
109 (79%) and nonoptimal in 29 cases (21%). We defined that long-term outcome in patients treated with these three
nonoptimal treatment as follows: the part of the tumor close modalities be thoroughly evaluated.
to the optic apparatus did not receive the desired prescrip- The first vestibular schwannomas treated with the
tion dose, typically because there was no distance between gamma knife were by Leksell and Steiner in 1969.124 Since
the tumor and the visual pathways. The mean prescription then more than 36,843 have been treated around the world
dose used in this series was 13.7 Gy (range 4.8–30 Gy). through 2006. The indications for gamma surgery for this
The mean maximum dose was 34.2 Gy (range 16–60 Gy). tumor vary. Some physicians advocate gamma surgery in
The mean MRI follow-up was 82.4 months (range 24– medically high risk patients, patients who refuse microsur-
216 months). Sixty-six tumors (48%) shrank (Fig. 5-15), 52 gery, and in patients with postoperative residual tumors.
(38%) remained unchanged and 20 (14%) increased in However, others advocate gamma surgery as the treatment
size. Fourteen patients developed new or deteriorated cra- of choice in nearly all cases of vestibular schwannomas.
nial nerve deficits; 11 due to tumor progress and 3 in spite The usefulness of irradiation in the postoperative period
of good tumor control. There was no mortality. Young age, was shown by Wallner in 1987 where external beam irra-
optimal treatment, and smaller tumor size were correlated diation lowered the recurrence rate from 46 to 6% in Bold-
with better outcome. The tumor progression–free survival at rey’s surgical series at the University of California at San
5 years was 95.4% and at 10 years was 71%. ­Francisco.125 By then, gamma surgery was already being
We have long-term follow-up of 10 to 21 years for 31 widely applied to this disease under many circumstances.
meningiomas treated with the gamma knife. Two thirds of The fact is that for a number of reasons few neurosurgeons
these tumors have either shrunk significantly or remained acquire the necessary competency to satisfactorily extir-
stable, and among these were cases where only the vascu- pate these tumors. This situation may change if a method to
lar supply for the tumor was targeted (Fig. 5-16). This has improve the acquisition of skills required for extirpation of
resulted in significant tumor shrinkage and lasting effect these lesions is found.
even in the long term. Our practice has been to obtain a The advent of MRI has made planning for gamma pro-
stereotactic angiogram prior to gamma surgery for large cedures much more exact. With a high-quality MRI scan
70 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

A C

B D
FIGURE 5-15  Large left parasellar meningioma residual following microsurgery visualized on postcontrast, T1-weighted axial (A) and coronal (B)
MRI. MRI obtained 6 months following gamma surgery shows that the tumor has disappeared (C and D). Repeated control MRI examinations at 5
years show no recurrence of the tumor.

and a relatively small tumor, the seventh cranial nerve can At the Lars Leksell center, we have treated 470 patients
occasionally be visualized and carefully excluded from the with vestibular schwannomas. A total of 153 of these
treatment field. The trigeminal nerve can nearly always be patients with more than 12 months of follow-up have been
identified except with the largest tumors, which in most reported.126 Radiosurgery was the primary treatment for 96
cases should not be treated primarily with gamma surgery. of such patients and was the adjutant (following microsur-
Small collimators are used to better match the isodose gery) in 57. The volume of the treated tumors ranged from
configuration to the size and shape of the tumor. We have 0.02 to 18.3 cm3.
had no brain stem–related complications. Previously we Of the patients treated primarily with gamma surgery
used minimum peripheral doses up to 20 Gy and maximum a decrease in tumor size was seen in 81% (78 patients),
doses up to 70 Gy. Presently, we use a margin dose of 11 to no change in 12%, and an increase in size in 6%. Among
13 Gy at the 30% to 50% isodose curve. The incidence of those 78 patients with a decrease in the size of their
cranial nerve palsies rose considerably at the higher doses tumors, the decrease was greater than 50% in 20 patients.
without significant improvement in the degree of tumor It is our policy to not consider decreases in volume of less
control. than 15% as significant. This is true of all tumors that we
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 71

A B

FIGURE 5-16  Long-term result of


gamma surgery for meningioma.
CT scans of a right parasellar
meningioma treated with radiation
to the nutrient vessels as defined
by a CT and angiogram (A and B,
respectively). The original size of
the tumor is depicted in the pre–
gamma surgery axial CT (C), and
the last follow-up at 18 years after
gamma surgery is shown (D). The
C D tumor has substantially decreased
in size.

treat. Imaging follow-up for these patients ranged from 1 the first patient, the facial paresis occurred 6 months after
to 10 years. the gamma surgery. Unnecessary surgery was performed
Of the 57 patients treated with gamma surgery after without asking for our advice and the facial nerve was cut
microsurgery, a decrease in tumor size was seen in 65%, during surgery. Another patient recovered completely in
no change in 25%, and an increase in size in 10%. Among six weeks, and the third has nearly completely recovered
the 37 patients with a decrease in tumor size, the decrease at 10 months. Of the patients with useful hearing prior to
was greater than 50% in 12 patients. The outcome in terms gamma surgery, 58% retained their hearing following radio-
of postradiosurgical volume reduction in patients who had surgery. The majority of hearing changes were observed at
prior microsurgery is worse than those who were primarily the 2-year checkup, and additional auditory changes were
treated with gamma surgery. This difference is likely a result observed as late as eight years postradiosurgery.
of the increased difficulty with accurate targeting in those Other centers report similar rates of tumor control (i.e.,
who have undergone prior microsurgery. Of note, although with no change or decrease in the size of the tumor) seen in
our experience with treating large vestibular schwannomas 89% to 100% of patients.127-129
is small (n = 19), we have observed a 95% tumor control rate Evaluation of the material from the Karolinska group
in these following gamma surgery. included evaluation of radiographic changes besides
In our patients, there were five with transient changes size.130 The most common change was loss of central
in trigeminal sensation and three with facial paresis. In enhancement within the tumor on either contrasted MRI or
72 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

CT studies. This occurred in 70% of patients and typically can be problematic. Gamma surgery can also be used as
was observed within 6 to 12 months of treatment. How- an adjunct to surgical resection. The incidence of residual
ever, these changes were reversible. Another change that postoperative tumor is unfortunately not uncommon after
was observed and that we have often seen is a transient “total” surgical resections and care is often taken when the
increase in the size of the tumor during the first 6 months tumor abuts eloquent brain so as not to leave neurologic
after gamma surgery. This is commonly seen in tumors that deficit even at the expense of incomplete gross tumor resec-
then regress to their original size or smaller (Fig. 5-17). tion. In these cases, gamma surgery can be used to treat the
We have not seen an instance of cerebellar edema or residual tumor. Whole or focal radiation therapy has been
hydrocephalus requiring spinal fluid diversion following used to lower the recurrence rate after these surgical thera-
gamma surgery for vestibular schwannomas, but both of pies have been undertaken.
these have been reported elsewhere.130,131
Low-Grade Astrocytomas
Astrocytomas We treated 21 pilocytic tumors, 2 subependymal giant cell
The treatment of astrocytomas, whether low or high grade, astrocytomas (Grade II), and 26 Grade II astrocytomas with
is largely defined by the ability to effectively reduce the gamma surgery between 1989 and 2003 at the Lars Leksell
tumor burden as much as possible and to lessen the rate center. The median treatment volume was 2.4 cm3 with a
of recurrence. Except in the case of pilocytic astrocytoma range of 0.5 to 36.0 cm3. The median prescription dose was
cure is rare. Classically the goal of reducing tumor bur- 15 Gy. The mean clinical follow-up was 63 months. Median
den is obtained by gross total resection with a margin of clinical progression-free survival was 44 months (range
“normal” brain when possible and postoperative radiation 0–118 months). The 5-year clinical progression-free survival
in the case of more malignant tumors. The indication for was 41%. Eight patients died of disease progression. No
radiation therapy for intermediate grade tumors, chemo- information on the cause of the death was available for one
therapy, repeat surgical debulking, and other therapies patient. The duration of imaging follow-up was 59 months
is dependent on several factors, many of which are not (range 2–118 months). Median imaging progression-free sur-
clearly defined. Into this cornucopia of choices, gamma vival was 37 months (range 0–80 months). Five-year, imag-
surgery has been introduced. Intellectually, we have diffi- ing progression-free survival was 37%. At the last imaging
culty accepting the application of a focused technique for follow-up, 37 tumors decreased or remained unchanged
an infiltrative process. Nevertheless, recent results showing and 12 tumors increased in size. Three patients experienced
improved survival indicate that this negative attitude may transitory neurologic deficits associated with increased T2
be inappropriate. signal on MRI.
In the case of low-grade tumors, gamma surgery can be Yen et al. reported on a series of 20 patients with brain-
used in place of surgical resection when the tumor is in an stem gliomas presenting with clinical or imaging progres-
inaccessible location (e.g., brain stem) or when the patient sion treated with gamma surgery.132 Sixteen tumors were
opts for this alternative. Their small size and relative circum- located in the midbrain, four in the pons and one in the
scription make planning straightforward, and fairly good medulla oblongata. The mean tumor volume at the time of
results have been obtained. gamma surgery was 2.5 cm3. Tissue diagnosis was available
For high-grade tumors, gamma surgery may be employed in only 10 cases (50%). The cases without histology were
in several ways. If the tumor is small and in an inacces- treated based upon appearance on imaging as well-defined
sible location (e.g., thalamus), gamma surgery is used to small tumors. Mean prescription dose was 15 Gy (range
treat the tumor primarily. Focal or whole brain irradiation 10–18 Gy). The tumor disappeared in 4 patients (20%)
is also used as an adjunct therapy. The incidence of radio- (Fig. 5-18) and shrank in 12 patients (60%) after a minimal
necrosis is relatively high when aggressive protocols are of 12 months of follow-up (mean follow-up 78 months).
used and differentiating recurrence from this phenomenon Transitory extrapyramidal symptoms and fluctuating times

A B C
FIGURE 5-17  A right vestibular schwannoma with a volume of 9.3 cm3 shown on a postcontrast, T1-weighted axial MRI prior to gamma surgery
(A). Same lesion 6 months after treatment shows central nonenhancement and no change in size (B). At 36 months after treatment, the lesion is
again homogeneously enhancing and is significantly smaller (69%) (C). Control MRI examinations for 6 years show that lesion has remained stable.
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 73

of consciousness occurred in one patient. Tumor progres- residual tumor based upon the neuroimaging studies. It
sion occurred in four patients. One of these four patients seems clear that no single treatment modality in the neuro-
required a ventriculoperitoneal shunt for hydrocephalus, oncology armamentarium is a magic bullet for such tumors,
two experienced neurologic deterioration, and one died of and, as such, this multimodality approach to high-grade
tumor progression. gliomas is prudent.
We have treated 56 malignant astrocytomas. Our expe-
High-Grade Astrocytomas rience has been similar to other reported series133-135 with
From an intellectual standpoint, it is difficult to understand the majority of patients showing initial decrease in size or
how a patient with a highly invasive and diffuse tumor like remaining stable for a period of time (Fig. 5-19); however,
a high-grade glioma can benefit from such a focused treat- recurrence and progression is the rule with these tumors
ment as gamma surgery. However, when coupled with che- and no therapy is curative. Because of the differences in his-
motherapy and fractionated radiation therapy, the gamma tology and the wide variety of therapies and protocols avail-
knife can be used to treat the largest concentration of the able for these tumors it is difficult to judge the benefit of

A B
FIGURE 5-18  A pilocytic astrocytoma shown on a postcontrast, T1-weighted sagittal MRI image (A). Annual control MRI examinations were obtained
and the latest made 9 years following gamma surgery is shown (B).

A B
FIGURE 5-19  Postcontrast, T1-weighted axial MRI demonstrating a right parietal glioblastoma multiforme and associated cyst on postcontrast,
T1-weighted axial MRI (A). Same patient 11 months after gamma surgery shows complete radiographic disappearance of lesion (B).
74 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

gamma surgery. Although our group and Nwokedi et  al.136 hemorrhage in the tumor 1 year after gamma surgery and
have observed a statistically significant prolongation of life the tumor had decreased significantly at the last follow-
expectancy in the group of patients undergoing aggressive up. This patient had a new tumor at some distance of the
multi-modality treatment (e.g., including some or all of the successfully treated one. Four patients were asymptomatic
following: radical tumor debulking, radiation therapy, che- during the follow-up period and a patient with hemiparesis
motherapy, and gamma surgery), it remains to be seen if caused by a previous transcortical resection was stable. A
these findings will be borne out in larger, better controlled patient died of sepsis due to a shunt infection.
studies. The limit of the benefit that radiation can contrib-
ute to the treatment of these lesions seems to have been Chordoma
reached, hence it may be stated that the dose escalation Skull base chordomas are a rare neoplasm arising from the
with the gamma knife in the treatment protocol of this dis- remnants of notochord. Although histologically benign, these
ease will change only marginally the clinical outcome. It is tumors are locally invasive and present significant manage-
also conceivable that targeting tumor angiogenesis and find- ment challenges. There is consensus that surgical debulk-
ing ways to induce apoptosis will have some impact on the ing should be performed. Proton radiotherapy has been the
management of these cases. mainstay of treatment for recurrent or residual tumors.142,143
Fifteen patients (8 males and 7 females) had undergone
Neurocytomas gamma surgery between 1990 and 2007 at Lars Leksell center.
Central neurocytomas were described by Hassoun et al. in The median age was 46 years (range 13–80). Twelve patients
1982.137 According to Brandes et al., 210 cases were reported had undergone tumor resection. Mean tumor volume was
in the literature.138 The histology, biological behavior and 5.8 cm3 (range 1.03–15.6 cm3).The tumors were treated with
clinical course of central neurocytomas may vary from a mean prescription dose of 12.7 Gy (range 12–20 Gy) and a
benign to more aggressive patterns.139 Surgical resec- mean maximal dose of 36.7 Gy (range 28–50 Gy).
tion is the first choice of treatment. Rades and Fehlhauer Imaging follow-up was available for all patients with a
compared 108 and 74 patients who underwent complete median time of 88 months (range 8–167), and clinical follow-
or incomplete resection.140 At 5 years tumor control rates up was available for 11 patients with a median of 70 months
were 85% and 46%, respectively. If the surgical resection (range 8–132). At the last follow-up, tumor control was
is not total, the residual tumor should be irradiated. The achieved in five out of 15 patients (33.3%) after initial GKS
5-year tumor control rate with postoperative radiotherapy (Fig. 5-21). Actuarial 5- and 10-year tumor control rates after
increased from 46% to 83% after incomplete resection but one gamma surgery was 42.6% and 34%, respectively. Three
radiotherapy did not seem to improve survival rate.140 patients who underwent a second gamma surgery achieved
With the advent of radiosurgery, it was used as upfront good tumor control. Actuarial 5- and 10-year tumor control
or adjunct therapy following surgery. We used the gamma rates after one or more gamma procedures improved to 50.3%.
knife in 7 patients with a total of 9 neurocytomas.141 The Symptomatic progression was seen in 75% of the patients.
mean tumor volume at the time of the gamma procedures For the management of intracranial chordoma, surgery as
ranged from 1.4 to 19.8 cm3 (mean 6.0 cm3). A mean pre- radical as possible is the main treatment alternative—a goal
scription dose of 16 Gy (range 13–20 Gy) was used. After a frequently not achieved and some forms of radiation have
mean follow-up period of 60 months, 4 tumors disappeared to be used as an adjunct. Chordoma is relatively radioresis-
and 5 shrank significantly (Fig. 5-20). One patient had a tant and respond best to high doses of fractionated proton

A B
FIGURE 5-20  Gamma surgery for central neurocytoma. T1-weighted, contrast-enhanced MRI reveals a moderately enhancing neurocytoma
­spanning both lateral ventricles (A). The last follow-up image obtained 14 years following gamma surgery shows that the tumor decreased in size
significantly with only some residual tissue in the septum pellucidum (B).
5  •  Gamma Knife Surgery for Cerebral Vascular Malformations and Tumors 75

radiotherapy. The physical and biological properties of the tumor. Similarly with gamma surgery only the solid portion
proton—it carries higher kinetic energy and as they slow of these tumors were targeted. We treated 16 hemangioblas-
down a higher release of energy (Bragg peak)—make it an tomas with the gamma procedure. Five of them had von Hip-
excellent source of radiation for chordomas. Amichetti et al. pel-Lindau disease. The mean prescription dose was 15 Gy.
in a review article presented the current data on the treatment The patients were followed for an average of 21 months. In 12
of skull base chordomas with proton beam and compared patients (75%), the solid component of the tumor targeted did
the outcomes to those obtained with fractionated photon decrease in size. In 4 patients, it remained unchanged. It was
radiation, ion therapy, fractionated stereotactic photon ther- not uncommon, however, for the cystic portion of the tumor
apy, and radiosurgery.142 With proton therapy, doses above to grow larger regardless of the behavior of the solid portion.
70 cobalt Gray equivalent can be applied safely, achieving During the follow-up, 6 of 16 patients (42%) required surgi-
local control rates at 3 years of 67.4% to 87.5%, at 5 years of cal drainage for expanding cysts. Although several patients
46% to 73%, and at 10 years of 54%. The estimated overall sur- responded well, the high incidence of second, open proce-
vival rates are 66.7% to 80.5% at 5 years and 54% at 10 years. dures indicates that the microsurgical removal of hemangio-
blastomas is in most cases the initial procedure of choice.
Chondromas and Chondrosarcomas
These are rare tumors in the skull base. We have treated Hemangiopericytomas
four chondromas and eight chondrosarcomas with gamma Hemangiopericytomas are tumors of mesenchymal origin.
surgery. More than 50% shrinkage was observed in two They are recognized for their aggressive clinical behavior,
cases of chondrosarcomas and three tumors shrank 25% high recurrence rates, and tendency for distant metastases
to 50%. None progressed at follow-up, ranging from 1 to 5 even after a gross total resection. Initial treatment is usu-
years (median 3.5 years). ally resection. Upon recurrence, adjuvant treatment is fre-
Muthukumar et  al. treated 15 patients (nine with chor- quently used. Chemotherapy has provided only marginal
domas and six with chondrosarcomas) with gamma sur- benefit.145 Radiosurgery or fractionated radiotherapy has
gery and reported their results with an average follow-up been used as alternatives.
of 4 years. Four of their patients had died; only two deaths Between 1989 and 2008, we treated 28 recurrent or resid-
were related to progression of disease and both of these ual hemangiopericytomas in 21 patients with gamma sur-
had progression outside of the treated area. Only one of the gery. The median age was 47 years (range 31–61 years). Eight
surviving 11 had tumor progression, and five had shrunk.144 patients had prior fractionated radiotherapy. The mean pre-
Gamma surgery seems to be a reasonable treatment alterna- scription and maximum radiosurgical doses to the tumors
tive for these tumors, but longer follow-up and larger series were 17 and 40 Gy, respectively. Thirteen tumors had under-
are required before definitive statements can be made. gone repeat gamma surgery. The median follow-up period
was 68 months (range 2–138 months). At the last follow-up,
Hemangioblastomas local tumor control was demonstrated in 10 of 21 patients
The gold standard treatment for hemangioblastomas is the (47.6%). Of the 28 tumors treated, 8 decreased in size on
surgical resection of the solid component of the tumor. It is follow-up imaging (28.6%), 5 remained unchanged (17.9%),
not necessary to resect, if present, the cystic portion of the and 15 ultimately progressed (53.6%). The progression free

A B
FIGURE 5-21  Gamma surgery for chordoma. A 45-year-old male with chordoma was treated with gamma surgery. The size of the tumor progres-
sively decreased. However, after 5 years, recurrence occurred. At the time of retreatment with gamma surgery, the tumor measured 3 cm3 on
enhanced, T1-weighted MRI (A). It shrank progressively and, after close to 9 years, measured 0.1 cm3 (B).
76 Section One  •  SURGICAL MANAGEMENT OF BRAIN AND SKULL BASE TUMORS

survival rates were 90%, 60%, and 29% at 1, 3, and 5 years dose of 18 to 22 Gy. These doses are adjusted down if whole
after initial gamma surgery. The progression free survival brain irradiation has been given previously. The reduction of
rate improved to 95%, 72%, and 72% at 1, 3, and 5 years after dose in the instance of tumors that appear after whole brain
one or multiple gamma surgery. The 5-year survival rate irradiation is possibly not necessary or desirable. In a study
after radiosurgery was 81%. In 4 (19%) of 21 patients, extra- comparing the efficacy of surgery plus whole brain radio-
cranial metastases developed. therapy with radiosurgery alone in the treatment of solitary
brain metastases less than or equal to 3.5 cm in diameter,
Metastatic Tumors local tumor control and 1-year death rates did not statisti-
Surgical extirpation of a solitary brain metastasis has been cally differ between the two groups.146 In a large, multi-insti-
shown to significantly prolong survival if the primary disease tutional study, the omission of upfront fractionated radiation
is controlled. Likewise whole brain irradiation has been show therapy did not compromise the overall length of survival
to be of benefit for some tumor types. These conclusions and in brain metastasis patients who had undergone radiosur-
the well-defined limits on neuroimaging studies of most met- gery.147 Radiosurgery even appears to be efficacious for
astatic lesions make them very amenable to gamma surgery. treating traditionally relatively “radioresistant” brain metas-
Because of this as well as the high incidence of these lesions, tases such as melanoma and renal cell carcinoma.
the treatment of metastatic tumors is presently the most fre- We have treated more than 1,000 patients for metastatic
quent indication for gamma surgery worldwide. tumors to the brain. Evaluation of our series demonstrated
Except for solitary lesions causing mass effect, the treat- an 81% to 97% control rate of treated lesions (disappeared,
ment of metastatic brain tumors is primarily palliative. In the shrank, or did not change) and a median survival of 8 to
instance of solitary metastasis the occurrence of long-term 14 months. The usual cause of death was systemic disease.
survival is not unheard of; however, in general the guiding
philosophy is palliation, reversal of neurologic deficits and LUNG CARCINOMA
maintenance of quality of life. There has been some disagree- Lung carcinoma is the leading cause of death from can-
ment regarding the total number and volume of tumors that cer and the most common source of brain metastases
can be treated with gamma surgery in the instance of mul- (Table  5-8). Depending on the actual histologic subtypes,
tiple metastases. Our general guideline is not to treat more lung carcinoma metastasizes intracranially between 13%
than five if that is known to be the case. We have treated and 54% of the time. The overall frequency of brain metas-
more but usually when additional lesions were discovered tasis in patients with lung carcinoma is approximately 32%
on the treatment MRI. With the gamma knife model C, if and between 54% and 64% of patients with lung carcinoma
metastatic deposits are located very far from one another metastatic to the brain harbor or eventually develop multiple
in space the ability to treat them all with the same frame lesions.148,149 Treatment options include symptomatic medi-
placement may be difficult due to the limitation of the space cal management with corticosteroids and whole-brain radia-
within the treatment helmet. Such consideration makes tion therapy, which lead to a median survival of 3 to 6 months.
frame placement for widely separated metastases a chal- Patient with small cell lung cancer developed metastases
lenge at times. The large radiation space within the gamma quite early and adjuvant chemotherapy has also become
knife model Perfexion basically eliminates this concern. well-accepted for the treatment of extracranial disease in
Most reports regarding gamma surgery for metastatic small cell lung cancer. We have treated 903 metastases in
tumors report a 7- to 15-month survival following treatment. 262 patients with lung carcinoma. The median survival was
Local tumor control rates range from 71% to 98.5%. The his- 15.4 months. Age of less than 65 years, a Karnofs