3D NEUROANATOMY – Intrinsic brain anatomy and surgical approaches

THURSDAY 5th MODULE

1: Surface Surgical Anatomy. – Phylogenetic evolution of the human brain. – The cerebral lobes. – Craniometric points of the skull. – Brain surface functional understanding through intraoperative mapping.

MODULE 2: The Cerebral Substance (I). – The white matter of the human brain. – Lateral dorsal & ventral tracts. – How I do it: awake surgery. – Technical adjuncts for glioma surgery. – How I do it: endoscopic assisted glioma surgery.

SURGICAL STATION 1: Hands-On. – Intrinsic brain tumor resection on a 3D printed model.

SURGICAL STATION 2: Break-out Session. – The case for discussion: INSULAR GLIOMA.

SURGICAL STATION 3: Quiz Session. – Sulco-gyral organization and cortical 3D understanding based on real cases.

Ischemic Stroke Management Medical Interventional and Surgical Management

Ischemic Stroke Management Medical Interventional and Surgical Management

by Alejandro Spiotta (Author), Roberto Crosa Erroyzarena (Author)

List Price: $129.99

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A complete guide to improving stroke treatment and patient outcomes from international experts!

Of the more than 795,000 estimated strokes that occur annually in the U.S., 87% are ischemic due to blockages, while the remaining 13% are hemorrhagic associated with spontaneous bleeding in the brain. Ischemic Stroke Management: Medical, Interventional and Surgical Management by esteemed neurosurgeons Alejandro Spiotta, Roberto Crosa, and an impressive group of international contributors details evidence-based medical, interventional, and neurosurgical treatment of ischemic stroke.

Twelve chapters cover complete management of ischemic stroke, from symptom manifestation to interventions in the ER, OR, and NICU. The first chapters cover stroke epidemiology, intravenous thrombolysis in stroke, and the crucial role stroke centers play in ensuring timely treatment of this devastating disease. Subsequent chapters discuss diagnostic imaging techniques in acute ischemic stroke, neurosurgical interventions for hemorrhagic and ischemic stroke, and neuroanesthesia considerations.

Key Features

With contributions from South America to Europe, North America to Asia, authors share diverse experiences treating stroke patients, delivering a unique international perspective

Endovascular neurosurgery ischemic stroke approaches and discussion of scientific evidence

Mechanical thrombectomy utilizing Catch, Trevo, and Solitaire stent retrievers and the evolution of direct clot aspiration approaches

Special topics include neurocritical care of acute ischemic stroke, pediatric stroke, and emerging state-of-the-art techniques

Truly global viewpoints encompassed in this unique book make it a must-read for trainee and veteran neurosurgeons and interventional neuroradiologists across the world. This resource is also an essential bookshelf addition for medical centers worldwide that treat stroke patients.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Chronic Subdural Hematoma Surgical Technique

Chronic Subdural Hematoma Surgical Technique

Till 1970s, craniotomy was the most commonly used method. Burr hole trephination for chronic subdural hematoma became the most preferred method from 1980s. In 1977Twist drill craniotomy for chronic subdural hematoma was introduced. Closed system drainage after a Burr hole (BH) or a Twist drill (TD) became the most frequently used surgical method 1).

Pre-operative evaluation of radiological features of CSDHs is crucial in determining the right indication for minimally invasive drainage. Minimally invasive treatments of CSH may reduce the use of anaesthetic drugs and worsening of pre-existing neurodegenerative disorders 2).

The duration of procedure was significantly more in Burr-Hole Craniostomy BHC than in Twist-Drill Craniostomy TDC. In postoperative outcome, there was no significant difference in the GCS score, motor power improvement, motor power deterioration, overall clinical improvement, and improvement in CT scans of both the groups. Postoperative residue requiring reoperation was significantly more in TDC group. There was no significant difference in the development acute SDH, reoperation rate, complications, death, and hospital stay in both the groups. Avoiding the complications of general anesthesia and giving the equal postoperative improvement and complications of BHC, the TDC is considered as an effective alternative to the BHC in the surgical management of CSDH 3)

Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For chronic subdural hematoma recurrences, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space 4).


Chronic subdural hematoma treatment in the elderly include observation, operative burr holes or craniotomy, and bedside twist drill drainage. The decision on which technique to use should be determined by weighing the comorbidities and symptoms of the patient with the potential risks and benefits.

Chronic subdural hematoma are ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care.

Originally, CSDHs were treated by open craniotomy 5) 6) 7) 8). Later burr hole trephination (BHT) was adopted because it was less invasive with lower morbidity and recurrence rates when compared with standard craniotomy 9) 10) 11) 12) 13) 14).

The traditional methods include evacuation via a burr hole with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation or craniotomy, with subdural drain or without drain placement.

Minicraniotomy (MC) emerged as an attractive alternative to BHT as it allows better visualisation of the subdural cavity, enabling better haemostasis and resection of membranes.

Although bedside twist drill evacuation may avoid operating room costs and anesthetic complications in an elderly patient population and allow earlier anticoagulation resumption treatment if necessary, there is also a risk of morbidity if uncontrolled bleeding is encountered or the patient is unable to tolerate the bedside procedure. However, bedside twist drill craniostomy is a reasonable and effective option for the treatment of subacute/chronic SDH in patients who may not be optimal surgical candidates 15).


Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial) 16).

Burr hole trephination for chronic subdural hematoma

Twist drill craniotomy for chronic subdural hematoma

Subdural drain for chronic subdural hematoma

Subdural evacuating port system for chronic subdural hematoma

Subgaleal drain for chronic subdural hematoma

Craniotomy for chronic subdural hematoma

Neuroendoscopy

References

1) , 4)

Lee KS. How to Treat Chronic Subdural Hematoma? Past and Now. J Korean Neurosurg Soc. 2019 Mar;62(2):144-152. doi: 10.3340/jkns.2018.0156. Epub 2018 Nov 30. PubMed PMID: 30486622; PubMed Central PMCID: PMC6411568.
2)

Certo F, Maione M, Altieri R, Garozzo M, Toccaceli G, Peschillo S, Barbagallo GMV. Pros and cons of a minimally invasive percutaneous subdural drainage system for evacuation of chronic subdural hematoma under local anesthesia. Clin Neurol Neurosurg. 2019 Oct 10;187:105559. doi: 10.1016/j.clineuro.2019.105559. [Epub ahead of print] PubMed PMID: 31639631.
3)

Thavara BD, Kidangan GS, Rajagopalawarrier B. Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma. Asian J Neurosurg. 2019 Apr-Jun;14(2):513-521. doi: 10.4103/ajns.AJNS_37_19. PubMed PMID: 31143272; PubMed Central PMCID: PMC6516027.
5)

Ernestus R, Beldzinski P, Lanfermann H, Klug N. Chronic subdural hematoma: surgical treatment and outcome in 104 patients. Surg Neurol 1997;48:220–5.
6)

McKissock W, Richardson A, Bloom WH. Subdural hematoma: a review of 389 cases. Lancet 1960;1:1365–9.
7)

Tyson G et al. The role of craniectomy in the treatment of chronic subdural hematomas. J Neurosurg 1980;52:776–81.
8)

Putnam IJ, Cushing H. Chronic subdural hematoma. Its pathology, its relation to pachymeningitis hemorrhagica, and its surgical treatment. Arch Surg 1925;11:329–93.
9)

Chronic Almenawer S et al. Subdural hematoma management: a systematic review and meta-analysis of 34829 patients. Ann Surg 2014;259(3):449–57.
10)

Lee J, Ebel H, Ernestus R, Klug N. Various surgical treatments of chronic subdural hematoma and outcome in 172 patients: is membranectomy necessary? Surg Neurol 2004;61:523–5528.
11)

Ducruet A et al. The surgical management of chronic subdural hematoma. Neurosurg Rev 2012;35:155–69.
12)

Leroy H et al. Predictors of functional outcomes and recurrence of chronic subdural. J Clin Neurosci 2015;22:1895–900.
13)

Regan J, Worley E, Shelburne C, Pullarkat R, Burr Watson J. Hole Washout versus craniotomy for chronic subdural hematoma: patient outcome and cost analysis. PLoS One 2015;10(1):1–8.
14)

Mondorf Y, Abu-Owaimer M, Gaab M, Oertel J. Chronic subdural hematoma – Craniotomy versus burr hole trephination. Br J Neurosurg 2009;23(6):612–6.
15)

Garber S, McCaffrey J, Quigley EP, MacDonald JD. Bedside Treatment of Chronic Subdural Hematoma: Using Radiographic Characteristics to Revisit the Twist Drill. J Neurol Surg A Cent Eur Neurosurg. 2016 Jan 25. [Epub ahead of print] PubMed PMID: 26807616.
16)

Agrawal A, Pacheco-Hernandez A, Moscote-Salazar LR. Letter: Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial). Neurosurgery. 2019 Aug 6. pii: nyz289. doi: 10.1093/neuros/nyz289. [Epub ahead of print] PubMed PMID: 31387117.

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