Modern neurosurgical practice

MODERN NEUROSURGICAL

PRACTICE

MICHAEL THOMAS D.O.

EDUCATIONAL REQUIREMENTS

FUNCTIONAL NEUROANATOMY NEUROPHYSIOLOGY NEUROPATHOLOGY NEUROPHARMACOLOGY NEUROANESTHESIOLOGY NEURORADIOLOGY NEUROONOCOLOGY NEUROTRAUMA PEDIATRIC NEUROSURGERY

TERMINOLOGY

CRANIOTOMY- REMOVAL AND REPLACEMENT OF PART OF CRANIUM

CRANIECTOMY- REMOVAL W/O REPLACEMENT OF PART OF CRANIUM

LAMINOTOMY- REMOVAL OF PART OF LAMINA

LAMINECTOMY- COMPLETE REMOVAL OF LAMINA

BONE FLAP- THAT REGION OF CRANIUM REMOVED

SURGICAL MICROSCOPE

LEICA OH3

MICROSCOPE TECHNOLOGY

FLORESCENCE TECHNOLOGY FOR NEUROVASCULAR SURGERY

FLORESCENCE TECHNOLOGY

BRAIN LAB NEURONAVIGATION

INTEGRATION WITH STEREOTACTIC NAVIGATION

MICROSCOPE TECHNOLOGY

TENSOR FIBER TRACT IMAGE

BRAIN LAB INTRAOPERATIVE MRI

BRAIN LAB WITH FUNCTIONAL MRI MAPPING

BRAIN LAB MAPPING AND FIBER TRACKING

FUNCTIONAL MRI

BRAIN LAB 3D RECONSTRUCTED IMAGE

NEUROENDOSCOPY

VENTRICULAR ENDOSCOPY – PRIMARILY USED TO TREAT INTRAVENTRICULAR TUMORS AND HYDROCEPHALUS

MAY BE USED TO ASSIST WITH DIFFICULT AND LIMITED OPERATIVE EXPOSURES -IE; ANEUYSM SURGERY, PITUITARY SURGERY

ASSISTANCE WITH SPINAL SURGERY

ENDOSCOPE USED WITH NEURONAVIGATION

HYDROCEPHALUS

OBSTRUCTIVE-BLOCKAGE WITHIN VENTRICULAR CSF PATHWAYS

COMMUNICATING- BLOCKAGE OF ABSORBTION AT ARACHNOID VILLI

OBSTRUCTIVE HYDROCEPHALUS

AQUEDUCTAL STENOSIS INTAVENTRICULAR TUMORS-IE; COLLOID

CYSTS,DERMOIDS, SUBEPYNDYMOMAS. PINEAL TUMORS, CERREBELLAR MASSES, CEREBELLAR STROKES/HEMORRHAGE, BRAINSTEM TUMORS

4th VENTRICLE IS USUALLY NORMAL SIZE OR SMALL

HYDROCEPHALUS - CLINICAL PRESENTATION

GAIT DISTURBANCE HEAD ACHE MEMORY DISTURBANCE LETHARGY URINARY INCONTINANCE

AQUEDUCTAL STENOSIS

SUPRACEREBELLARARACHNOID CYST

AQUEDUCT OF SYLVIUS

4th VENTRICLE (NORMAL SIZE)

AQUEDUCTAL STENOSIS

CORONAL MRI-OBSTRUCTIVE HYDROCEPHALUS

PINEAL TUMOR

BRAINSTEM GLIOMA

ASTROCYTOMA

COLLOID CYST

3rd VENTRICULAR COLLOID CYST

colloid

TREATMENT OF HYDROCEPHALUS

CSF DIVERSION – NORMAL SIZE VENTRICLES HAS 25 CC’s OF CSF – TOTAL PRODUCTION OF CSF IS 500 -750 CC’s PER DAY

OBSTRUCTIVE HYDRO-ENDOSCOPIC 3RD VENTRICULOSTOMY OR AQUEDUCTAL DILATATION AND STENTING. IF THIS FAILS

THEN VP SHUNT COMMUNICATING HYDROCEPHALUS-

VENTRICULOPERITONEAL SHUNT (VENTRICULOATRIAL , VENTRICULOPLEURAL)

ENDOSCOPIC VIEW OF 3RD VENTRICULOSTOMY FORMATION

ENDOSCOPIC VIEW OF OSTOMY AND PREPONTINE CISTERN

3rd VENTRICAL EXPLORATION

BRAIN TUMORS

MULTIPLE TYPES DEPENDING ON EMBRYOLOGICAL ORIGIN -ie; Astrocytoma derived from glial tissue origin

METASTASTATIC(secondary) BRAIN TUMORS MOST COMMON

ASTROCYTOMA MOST COMMON PRIMARY BRAIN TUMOR

BRAIN TUMOR CLINICAL PRESENTATION

HEAD ACHES SEIZURES NAUSEA/VOMITING MENTAL STATUS CHANGES GAIT DISTURBANCE VISUAL DISTURBANCE NEUROLOGICAL DEFICIT DEPENDING ON

LOCATION CEREBRAL HEMORRHAGE BRAIN HERNIATION

BRAIN TUMOR DIFFERENCIAL DIAGNOSIS

CEREBRAL ABCESS STROKE PSEUDOTUMOR CEREBRI CEREBRITIS (PRE-ABCESS STAGE) ARTERIAL-VENOUS MALFORMATION MS HYDROCEPHALUS

BRAIN TUMOR WORK UP AND INITIAL TREATMENT

DEXAMETHASONE- INITIAL 10 MG IV X 1 THEN FOLLOWED WITH 4-6 MG IV/PO q 6 hrs

OBTAIN CT OR MRI WITH AND WITH OUT CONTRAST

IF MASS IS PRESENT THEN RULE OUT ABCESS vs METASTATIC DISEASE

IF ORIGIN OF TUMOR CANT BE DISCOVERED THEN CEREBRAL BIOPSY AND POSSIBLY RESECTION IS INDICATED

FALX MENINGIOMA

MENINGIOMA

ASTROCYTOMA

ANAPLASTIC ASTROCYTOMA

ANAPLASTIC ASTROCYTOMA HISTOPATHOLOGY

PILOCYTIC ASTROCYTOMA

GLIOBLASTOMA MULTIFORME

GLIOBLASTOMA MULTIFORME

GBM HISTOPATHOLOGY

SUBEPENDYMAL GIANT CELL ASTROCYTOMA

FRONTAL CRANIOTOMY

EXPOSURE OF RIGHT FRONTAL LOBE

PARTIAL FRONTAL LOBECTOMY

FALX

PREMOTORCORTEX

SUPERIORSAGITALSINUS

LATERAL VIEW ANTERIOR FRONTAL LOBECTOMY

FALX CEREBRI

CORONAL SUTRE

TEMPORALIS MUSCLE

TRANSVENTRICULAR COLLOID CYST REMOVAL

SKULL BASE MENINGIOMA

SAGITAL CORONAL AXIAL

SKULL BASE MENINGIOMA – POST OP MRI

STRUCTURES OF THE CAVERNOUS SINUS

P

S

PITUITARY

SPHENOID SINUS

PITUITARY MACROADENOMA

PITUITARY ADENOMA CLINICAL PRESENTATION

HEADACHE BITEMPERAL HEMIANOPSIA APOPLEXY(RARE) SECRETING vs NON-SECRETING ENDOCRENOPATHIES –Cushings(ACTH)

ACROMEGALY(GH),PANHYPOPITUITARY FREQUENTLY HAVE ELEVATED

PROLACTIN LEVELS-(STALK EFFECT vs PROLACTINOMA SECRETING ADENOMA

PITUITARY SURGERY

MOST COMMON APPROACH IS TRANSSPHENOIDAL

GOALS OF SURGERY 1) PRESERVE VISION 2) CORRECT ENDOCRENOPATHY

CAVERNOUS SINUS INVASION WILL REQUIRE POST OPERATIVE STEREOTACTIC RADIOSURGERY ,CONTINUED MEDICAL MANAGEMENT, OR BOTH

CRANIOTOMY IS RARELY INDICATED

TRIGEMINAL NEUARALGIA ETIOLOGY

REDUNDANT SUPERIOR CEREBELLAR ARTERY COMPRESSION

SUPERIOR PETROSAL VEIN COMPRESSION

POSTERIOR FOSSA TUMOR MULTIPLE SCLEROSIS (bilateral TN)

TRIGEMINAL NEURALGIA(AKA tic douloureux) PATHOPHYSIOLOGY

SEVERE PAROXYSMAL LANCINATING PAIN LASTING ONLY A FEW SECONDS OFTEN TRIGGERED BY SENSORY STIMULI

CONFINED TO THE DISTRIBUTION OF ONE OR MORE DIVISIONS OF THE TRIGEMINAL NERVE ON ONE SIDE OF THE FACE

DUE TO EPHAPTIC TRANSMISSION IN TRIGEMINAL NERVE FROM LARGE DIAMETER MYLENATED A FIBERS TO POORLY MYLENATED A-DELTA AND C NOCICEPTIVE FIBERS

EPHAPTIC - conduction of nerve impulse across point of lateral contact rather than at synapse

VENTRAL BRAIN/POSTERIOR FOSSA

RIGHT CEREBELLOPONTINE ANGLE

TRIGENINAL NEURALGIA - TX OPTIONS

MEDICAL- TEGRETOL, NEURONTIN, DILANTIN PERCUTANEOUS RADIOFREQUENCY

RHIZOTOMY PERCUTANEOUS GLYCEROL INJECTION PERCUTANEOUS TRIGEMINAL BALLON

COMPRESSION MICROVASCULAR TRIGEMINAL

DECOMPRESSION STEREOTACTIC RADIOSURGERY

TRIGEMINAL NEURALGIA MICROVASCULAR DECOMPRESSION

CN VII+VIII A.I.C.A. SUP. PET. V. CN V S.C.A.

FLOCCULUS

CEREBELLUM

PONS

CN IV

PONTOMEDULLAY JUNCTION

DURA

CEREBELLUM

SPINALCORD TUMORS: CLASSIFICATION

EXTRADURAL-arise outside cord in vertebral body and epidural tissue(metastatic tumors most common)

INTRADURAL EXTRAMEDULLARY-arise from leptomeninges or nerve roots. ie; meningiomas and neurofibromas

INTRAMEDULLARY- primary and secondary tumors that destroy tracts and grey matter

INTRADURAL EXTRAMEDULLARY TUMOR

TUMOR

CONUS

CAUDAEQUINA EPENDYMOMA

CERVICAL MEDULLARY ANGIOMA

SYRINGOMYELIA

ARNOLD CHIARI MALFORMATION

INTRAMEDULLARY MASS IDIOPATHIC HYDROCEPHALUS

ETIOLOGIES

INTRAMEDULLARY ASTROCYTOMA

MEDULLOBASTOMA

MEDULLOBLASTOMA HISTOPATHOLOGY

INTRADURAL EXTRAMEDULLARY

T-1 WEIGHTED SAGITAL IMAGE OF A NEUROFIBROMA

CONTRAST ENHANCED T1 WEIGHTED AXIAL IMAGE OF NEUROFIBROMA

SPINAL CORD

C-6 SCHWANNOMA RESECTION

C-6 NEUROFIBROMA RESECTION

SUBDURAL HEMATOMA

POST OP CRANIOTOMY

SUBARACHNOID HEMORRHAGE

ANEURYSMAL SUBARACHNOID HEMORRAGE SEVERE SUDDEN ONSET HEAD ACHE MAY CAUSE ACUTE HYDROCEPHALUS HUNT HESS GRADING SCALE 0-5 HIGH GRADE PTS REQUIRE VENTRICULOSTOMY 4 PERCENT RERUPTURE RATE WITHIN 24 HR REQUIRES ANGIOGRAM MAY PRESENT WITH NO NEURO DEFICIT TO FOCAL DEFICIT

TO COMA 3rd OF PATIENTS DON’T EVEN MAKE IT TO HOSPITAL VASOSPASM CLINICALLY EFFECTS 30% NO SOONER THAN

DAY 3 ,USUALLY AROUND DAY6-8 ICP MANAGEMENT

MANAGEMENT OF ANEURYSMS

ANGIOGRAM TO DEFINE ANEURYSM ANATOMY IF GRADE 3 OR LOWER SURGICALLY CLIP OR

COIL VENTRICULOSTOMY FOR HYDROCEPHALUS CALCIUM CHANNEL BLOCKER (NIMODIPINE)-

HELPS PREVENT VASOSPASM STEROIDS (DEXAMETHASONE) ANALGESIA TRIPLE “H” THERAPY

TRIPLE “H” THERAPY

VASOSPASM TREATMENT

HYPER VOLEMIA HYPERTENSION HEMODILUTION

EARLY SURGERYCANT TREAT SAFELY WITHOUT SECURING ANEURYSM

CAROTID BIFERCATION ANEURYSM

CT ANGIOGRAM

BASILAR ANEURYSM

POSTERIOR CEREBRAL ARTERY

CTA BASILAR ANEURYSM

OCCIPITAL AVM

NEUROSURGICAL HORIZONS

GENE THERAPY STEM CELL IMPLANTS IMMUNOTHERAPY NANOTECHNOLOGY ROBOTICS MOORE’S LAW NEURO - CYBERTECHNOLOGY