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BackgroundMultiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques.MethodsA literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used.ResultsThirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD −2.06, P < 0.001; incontinence, MD −1.17, P = 0.007) and intermediate term (stool frequency, MD −0.81, P = 0.021; incontinence MD −0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012).ConclusionBecause of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.

Background: Ultrasound (US) including power Doppler (PD) are increasingly being used to evaluate joint involvement in rheumatoid arthritis (RA). Aim of this study was to evaluate joint involvement in RA by US including PD and gray scale imaging and its comparison with conventional radiographic changes and correlation with disease activity parameters. Methods: Patients with RA of less than 3.5 years disease duration were subjected to detailed clinical examination and laboratory investigations. After X-ray imaging (posterior-anterior view) of both hand joints, PD and gray scale US examination of 14 joints of both hands was performed and mean cumulative flow signal score (CFS) was calculated. Disease activity score (DAS28) was also calculated for each patient. Results: Out of total 57 patients evaluated, 54 had abnormal findings on US as compared to only 17 having radiographic abnormalities. US could detect erosions in 29 patients including all of the fourteen patients who had radiographically detectable erosions. On US evaluation, radiocarpal joint was involved most frequently. The mean CFS was 1.17 ± 1.64 in patients who were in remission (DAS28 5.1). The difference in CFS among these groups was statistically significant (P < 0.01). In 5 out of 12 patients with DAS28

Background Vertebrobasilar insufficiency resulting from embolism, atherosclerosis, or arterial dissection has long been a challenge for successful management and outcomes. The main treatment options include medical therapy, angioplasty and stenting, and surgical revascularization. Unlike cardiac or peripheral vascular revascularization, large randomized trials with cerebrorevascularization have not revealed favorable outcomes. In patients who have failed maximal medical therapy, and having persistent debilitating symptomology, cerebral revascularization may still be a viable option. Methods We report 3 patients who presented with symptoms of vertebrobasilar ischemia. The diagnosis was verified by computerized tomographic arteriography and digital subtraction angiography. Results These patients subsequently underwent revascularization with a radial artery graft. We also present a comprehensive review of the literature of treatment for vertebrobasilar insufficiency. Conclusions Surgical revascularization should be considered in the posterior circulation in the rare subset of patients with VBI, who remain symptomatic despite having a protracted course of maximal medical therapy with large- and medium-sized vessel occlusions and poor collateral circulation.

Use of living donor has expanded the pool of potential transplant recipients. We have outlined here the indications, contraindications, donor workup and surgical technique of modified right liver graft retrieval, recipient hepatectomy, benching and recipient implantation in brief.

Aneurysmal subarachnoid hemorrhage (SAH) remains an important health issue in the United States. Despite recent improvements in the diagnosis and treatment of cerebral aneurysms, the mortality rate following aneurysm rupture. In those patients who survive, up to 50% are left severely disabled. The goal of preventing the hemorrhage or re-hemorrhage can only be achieved by successfully excluding the aneurysm from the circulation. This article is a comprehensive review by contemporary vascular neurosurgeons and interventional neuroradiolgists on the modern management of cerebral aneurysms.

BACKGROUND The management of basilar apex (BX) aneurysms remains problematic. OBJECTIVE We quantified the surgical exposure of the BX through the opticocarotid window (OCW) and the carotid-oculomotor window (COW), before and after mobilization of the internal carotid artery and division of the posterior communicating artery (PCoA). METHODS Eleven silicone-injected cadaveric heads were dissected bilaterally. The surgical dissection was divided into 4 major steps: (1) supraorbital modified orbitozygomatic craniotomy, (2) mobilization of the internal carotid artery after drilling out the anterior clinoid process intradurally and cutting the distal dural ring, (3) drilling out the posterior clinoid process and dorsum sellae, and (4) dividing the PCoA from the posterior third portion of the vessel. A frameless navigation system was used to quantify the surgical exposure area of the BX through the OCW and COW. RESULTS The total surgical area increased significantly from steps 1 to 4 (P < .001) in both OCW and COW groups. Overall, there was a larger total surgical area obtained in the COW compared with the OCW (P = .010). ICA mobilization increased the surgical area for temporary (P < .001) and permanent (P < .003) clip application in both windows. The division of PCoA significantly increased the overall surgical area for permanent clip application (P < .003). Compared with the OCW, the COW had a significantly increased change in the area for permanent clip application in the low-lying group (P = .03). CONCLUSION When approaching the BX via the pterion route, the appropriate surgical step and window should be selected according to characteristics of the PCoA and height of the BX.

We quantified the effects on anatomical cadaver dissection of a balloon-inflation tumor model positioned in the parasellar region and approached through an orbitozygomatic (OZ) craniotomy. A modified supraorbital OZ was performed bilaterally on 5 silicon-injected cadaver heads. Ten predetermined anatomical points assigned using a frameless stereotactic device were used to measure the working area of exposure, degree of surgical freedom, and horizontal and vertical angles of attack to specific target points before and after inflation of a balloon catheter mimicking a parasellar tumor. Balloon inflation displaced the central anatomical structures (pituitary stalk, lamina terminalis, anterior chiasm, and internal carotid artery [ICA]-posterior communicating artery and ICA-A1 junctions) by 14-51% (p ≤ .05). With tumor simulation, the vertical angle of attack increased by 67% (p .01), while the area of exposure increased by 83% (p .01) and surgical freedom increased by 58% (p .01). This tumor model also significantly displaced central anatomical sella-associated structures. Compared to a normal anatomical configuration, the tumor simulation (balloon) opened surgical corridors (especially vertical) and acted as a natural retractor, widening the angle of access to the infundibular apex-hypothalamic junction. Although this model cannot exactly mimic a tumor mass in a patient, the effects of tumor compression and sequential displacement of important structures can be combined into and then assessed in a cadaveric neurosurgical anatomical scenario for training and research.

Objective The extent of the far-lateral approach (FLA) has not yet been quantified for the region of the vertebral and posterior inferior cerebellar arteries (VA-PICA). We quantitatively analyzed six main sequential steps of the FLA. Methods A modified small FLA (msFLA) and a classic large FLA (clFLA) were performed sequentially on both sides of five cadaveric heads. A frameless navigational system was used to quantify the angle of attack for the origin (T1) and lateral medullary segment (T2) of the PICA and the surgical area of exposure above and below the vagus nerve (cranial nerve [CN] X). Results The total area of exposure above CN X increased significantly (p 0.05) from the msFLA to the clFLA. However, the surgical exposure area below CN X did not change (p 0.05). C1 hemilaminectomy increased (p 0.05) the vertical angle of attack, and drilling the posteromedial third of the occipital condyle increased (p 0.05) the horizontal angle of attack to the origin of the PICA. Conclusions For the VA-PICA region, the msFLA offered a similar practical surgical working area and similar angles of attack when compared with the clFLA. The FLA should be tailored based on the location, size, and pathology of lesions and on the exposure required for effective surgical treatment.

Background: The risk of developing immediate postoperative seizures in patients undergoing supratentorial brain tumor surgery without anti-epileptic drug (AED) prophylaxis is 15-20%. Patients who present with pre-operative seizures and patients with supratentorial meningioma or supratentorial low grade gliomas are at significantly higher risk. There is little data on the efficacy of levetiracetam as a prophylactic AED in the immediate postoperative period (within 7 days of surgery) in these patients. Methods: We conducted a retrospective chart review of 165 adult patients classified as higher risk for postoperative seizures who underwent brain tumor resection at Duke University Hospital between time May 2010 and December 2011. All patients had received levetiracetam monotherapy in doses of 1000-3000 mg/day in the immediate postoperative period. Results: We identified 165 patients with following tumor locations: Frontal 83 (50.3%), Temporal 37 (22.4%), Parietal 30 (18.2%), Occipital 2 (1.2%) and 13 (7.8%) with single lesions involving more than one lobe. Histology revealed: Glioma 98 (59.4%), Meningioma 57 (34.5%) and Brain Metastases 6 (3.6%). Preoperatively, 88/165 (53.3%) patients had presented with seizures. 12/165 patients (7.3%) developed clinical seizures (generalized 10, partial 2) in the immediate post-operative period. Other than somnolence in 7 patients (4.2%), no major side-effects were noted. Conclusions: The incidence of seizures was significantly lower in patients treated with levetiracetam (7.3%) when compared with the expected (15-20%) rate without AED prophylaxis based on the previous literature. Levetiracetam appears effective and safe for seizure prevention in patients undergoing brain tumor resection and who are at significantly higher risk of developing post-operative seizures. These findings warrant confirmation in a prospective randomized trial.

Background: Oculomotor nerve palsy (OMNP) is a well-recognized complication of posterior communicating artery (PCOM) aneurysms. Only a few comparative studies have assessed the effect of clipping versus coiling on recovery from OMNP in PCOM aneurysms. A retrospective review and meta-analysis was conducted to assess the relationship between PCOM aneurysm treatment and OMNP. Materials and Methods: Medical records of all patients presenting between January 2000 and February 2013 with intracranial aneurysm were searched. All patients with OMNP secondary to PCOM aneurysm were included for analysis. Patients undergoing surgical clipping or endovascular coiling were compared with respect to complete resolution of OMNP after aneurysm surgery (i.e., primary outcome). A meta-analysis of published studies of OMNP associated with PCOM aneurysm was performed after a MEDLINE search. Results: Seventeen patients with OMNP secondary to PCOM aneurysms met the inclusion criteria. Surgical clipping (seven of eight patients, or 87.5%) resulted in greater complete resolution of OMNP compared with endovascular coiling (four of nine patients, or 44.4%), P = 0.13. A meta-analysis of similar studies revealed that complete resolution of OMNP was more commonly associated with surgical clipping (36 of 43 patients, or 83.7%) than with endovascular coiling (29 of 55 patients, or 52.7%), yielding an adjusted odds ratio (OR) of 6.04 [confidence interval (CI) =1.88-19.45, P = 0.003]. Multivariate analysis found that the degree of pre-operative OMNP (OR = 0.07, CI = 0.02-0.28, P = 0.001) and surgical clipping (OR = 6.37, CI = 1.73-23.42, P = 0.005) were significant factors that affected the complete recovery of OMNP. Conclusion: Complete recovery of OMNP with PCOM aneurysms is more commonly associated with surgical clipping than with endovascular coiling. Also, the degree of pre-operative OMNP and the treatment modality are significant factors that affect the complete recovery of OMNP.

Study Design: A cadaveric study to determine the accuracy of percutaneous screw placement in the thoracic spine using standard fluoroscopic guidance. Summary of Background Data: While use of percutaneous pedicle screws in the lumbar spine has increased rapidly, its acceptance in the thoracic spine has been slower. As indications for pedicle screw fixation increase in the thoracic spine so will the need to perform accurate and safe placement of percutaneous screws with or without image navigation. To date, no study has determined the accuracy of percutaneous thoracic pedicle screw placement without use of stereotactic imaging guidance. Materials and Methods: Eighty-six thoracic pedicle screw placements were performed in four cadaveric thoracic spines from T1 to T12. At each level, Ferguson anterior-posterior fluoroscopy was used to localize the pedicle and define the entry point. Screw placement was attempted unless the borders of the pedicle could not be delineated solely using intraoperative fluoroscopic guidance. The cadavers were assessed using pre- and postprocedural computed tomography (CT) scans as well as dissected and visually inspected in order to determine the medial breach rate. Results: Ninety pedicles were attempted and 86 screws were placed. CT analysis of screw placement accuracy revealed that only one screw (1.2%) breached the medial aspect of the pedicle by more than 2 mm. A total of four screws (4.7%) were found to have breached medially by visual inspection (three Grade 1 and one Grade 2). One (1.2%) lateral breach was greater than 2 mm and no screw violated the neural foramen. The correlation coefficient of pedicle screw violations and pedicle diameter was found to be 0.96. Conclusions: This cadaveric study shows that percutaneous pedicle screw placement can be performed in the thoracic spine without a significant increase in the pedicle breach rate as compared with standard open techniques. A small percentage (4.4%) of pedicles, especially high in the thoracic spine, may not be safely visualized.

Background: Mechanical thrombectomy devices are gaining popularity in large vessel occlusions where chemical thrombolysis is usually futile. MERCI, Multi-MERCI, Penumbra and SWIFT trails have elevated the status of mechanical thrombectomy from being a complementary treatment modality to mainstream stroke intervention. The aim of this study was to compare our immediate recanalization rates with available mechanical devices. Materials and Methods: A retrospective review from March 2009 to August 2012 was performed on patients who underwent mechanical thrombectomy for large vessel occlusion. Cases where IATPA and/or balloon angioplasty was performed without mechanical thrombectomy were excluded from the study. Recanalization rates were assessed immediately post-procedure by follow-up angiography. TICI scores were used to quantify the extent of recanalization and the residual clot burden. Results: Twenty two procedures were performed on 20 patients using Merci (MER):5; Penumbra (PEN):11; Solitaire-FR (SOL):6. Two patients underwent intervention using both Merci and Penumbra devices. The M:F ratio was 1.2:1. The most common vascular territory involved was the right MCA (9/20) followed by left MCA (5/20), left ICA (2/20), basilar (3/20) and vertebral arteries (1/20). The average door to needle time was 210 minutes [MER: 184.4; PEN: 249.2; SOL: 162]. Additional procedures were performed in 63.4% (14/22) of the patients [MER: 80% (4/5); PEN: 72.7% (8/11) and SOL: 33.3% (2/6)]. Vasospasm was observed in MER: 20% (1/5); PEN: 9.1% (1/11); SOL: 0% (0/6)]. Complete recanalization was achieved in 59.1% (13/22) [MER: 40% (2/5); PEN: 45.5% (5/11); SOL: 100% (6/6)]. The rate of complete recanalization was statistically significant for the Solitaire group vs. the MERCI group ( P=0.0062) as well as the Penumbra group (0.0025). The average pre-procedure TICI was 0.4 [MER: 0.6; PEN: 0.3; SOL: 0.3], while the average post-procedure TICI was 2.5 [MER: 2.4; PEN: 2.3; SOL: 3.0]. Conclusions: The study reveals a higher rate of angiographic recanalization using the Solitaire-FR device, requiring a lesser number of passes and other associated procedures as compared to MERCI and Penumbra. Thus, Stentrievers (Solitaire-FR) are advantageous in faster device delivery and quick flow restoration. However, future prospective randomized large trials are required to confirm these early results.

Background: The proximal superior cerebellar artery (pSCA) is often considered a perforator-free area. Precise anatomical knowledge of this region clarifies the pathophysiology underlying posterior fossa ischemic syndromes and helps avoid treatment-related complications. Objective: To anatomically evaluate perforating branches arising from the pSCA and the upper basilar artery (BA). Methods: Forty-four SCAs from 20 cadaveric heads were examined to determine patterns of the pSCA; its morphometry for medial and lateral branches; and frequency, number, diameter, distribution, and vascular territory of perforators arising from the pSCA and rostral BA. Results: SCA arose as a single trunk in 36 sides (90%): mean diameter at origin was 1.38 mm; mean length was 14.± 6 7.9 mm. Ninety-nine pSCA perforator branches were present in 82% of specimens (mean, 2.3 ± 1.6; range, 0-7 perforators/side). Of these, 59% were direct, belonging to the interpeduncular group in 85% of cases; 28% were short circumflex, belonging to lateral and medial pontine group; and 13% were long circumflex, reaching the medullary perforation zone (basal cerebellar group). Median distance to the first perforator was 2.0 mm (range, 0.1–15 mm). There were 132 perforator branches in the last centimeter of the BA. Conclusion: The pSCA should not be regarded as a perforator-free area. Although the pSCA territories likely overlap with the posterior cerebral artery, BA, and anterior inferior cerebellar artery, the pSCA segment cannot be surgically manipulated with impunity.

During the 1930s, white matter tracts began to assume relevance for neurosurgery, especially after Cajal's work. In many reviews of white matter neurobiology, the seminal contributions of Josef Klingler (1888-1963) and their neurological applications have been overlooked. In 1934 at the University of Basel under Eugen Ludwig, Klingler developed a new method of dissection based on a freezing technique for brain tissue that eloquently revealed the white matter tracts. Klingler worked with anatomists, surgeons, and other scientists, and his models and dissections of white matter tracts remain arguably the most elegant ever created. He stressed 3-dimensional anatomic relationships and laid the foundation for defining mesial temporal, limbic, insular, and thalamic fiber and functional relationships and contributed to the potential of stereotactic neurosurgery. Around 1947, Klingler was part of a Swiss-German group that independently performed the first stereotactic thalamotomies, basing their targeting and logic on Klingler's white matter studies, describing various applications of stereotaxy and showing Klingler's work integrated into a craniocerebral topographic system for targeting with external localization of eloquent brain structures and stimulation of deep thalamic nuclei. Klingler's work has received renewed interest because it is applicable for correlating the results of the fiber-mapping paradigms from diffusion tensor imaging to actual anatomic evidence. Although others have described white matter tracts, none have had as much practical impact on neuroscience as Klinger's work. More importantly, Josef Klingler was an encouraging mentor, influencing neurosurgeons, neuroscientists, and brain imaging for more than three quarters of a century.

BACKGROUND The transciliary supraorbital approach (TCSO) provides an anterior view for visualizing sellar, parasellar, and suprasellar structures. Whether an orbital osteotomy adds to this exposure has not been quantified. OBJECTIVE We quantitatively evaluated the TCSO and benefits of an additional orbital osteotomy for exposing common sites of anterior circulation aneurysms. METHODS Under image guidance, TCSO and orbital osteotomy were performed on 10 sides of 5 cadaver heads to quantify exposures of 4 surgical targets: (1) the junction of the anterior cerebral and anterior communicating arteries (ACoA); (2) the internal carotid artery (ICA) at the level of the posterior communicating artery (PCoA); (3) the bifurcation of the ICA; and (4) the middle cerebral artery (MCA) bifurcation. Horizontal and vertical angles of attack and surgical freedom for instrument manipulation were measured before and after the orbital rim and roof were removed. RESULTS An orbital osteotomy significantly increased surgical freedom to the ACoA (from 471.15 +/- 182.14 mm2 to 683.35 +/- 283.78 mm2, P = .021); PCoA (from 746.58 +/- 242.78 mm2 to 966.23 +/- 360.22 mm2, P = .007); ICA bifurcation (from 616.08 +/- 310.95 mm2 to 922.38 +/- 374.88 mm2, P = .002); and MCA bifurcation (from 1160.77 +/- 412.03 mm2 to 1597.71 +/- 733.18 mm2, P = .004). There were no significant differences in horizontal angles of attack. The vertical angles of attack were significantly greater after orbital osteotomy, principally with the ACoA and ICA bifurcation as targets. CONCLUSION TCSO combined with orbital osteotomy improves exposure. Removing the orbital rim and roof increases the area for instrument use and improves the vertical angle of attack to common sites in the anterior circulation involving aneurysms.

Spontaneous transvaginal bowel evisceration is a rare surgical emergency with only a few cases reported and particularly postmenopausal, posthysterectomy, multiparous elderly women are considered to be at higher risk for development of bowel evisceration. It is difficult to manage such a patient for any surgeon and poses significant challenges especially intraoperatively. Here, we report a case of vaginal vault rupture with small bowel evisceration through the vagina in a known case of uterine prolapse and highlight the risk factors, clinical presentation, and treatment options for this rare surgical emergency.

In contrast to the well-developed neurosurgical and ophthalmological literature, the literature on manifestations of the trigeminocardiac reflex (TCR) during neurointerventions has been reported in a total of only 16 cases. All of the cases involved the use of Onyx® as the embolic agent, with its solvent, dimethyl sulfoxide (DMSO), the likely responsible ingredient. These reports involved the embolization of arteriovenous fistulae or nasal tumors, with injection of the internal maxillary artery, the middle meningeal artery, the inferior petrosal sinus, or the cavernous sinus. Although there has been no clear demonstration that DMSO can act as a trigeminal excitatory agonist, clinical experience, as well as the chemical similarity of DMSO to organic vaporous solvents which are known to act that way, suggests that this is the likely mechanism. All cases of the TCR discussed in the neurointerventional literature responded immediately to atropine, with no permanent sequelae. It is recommended that both neurointerventionalists and anesthesiologists performing the aforementioned procedures be prepared for the possibility of episodes of the TCR.

1. Non Malignant Brain Tumors.- 2. Malignant Brain Tumors.- 3. Pituitary Tumors.- 4. Pediatric Brain Tumors.- 5. Congenital Neurosurgical Problems.- 6. Hydrocephalus.- 7. Chiari Syndrome.- 8. Brain Aneurysms.- 9. Brain Arteriovenous Malformations.- 10. Moya Moya Disease.- 11. Medical Management of a Stroke.- 12. Neuro-Interventional Management of a Stroke.- 13. Symptoms and Signs to Look for After a Spinal Cord surgery.- 14. Evaltuation of Spinal Alignment.- 15. Herniated Discs of the Spine.- 16. Spinal Fusions.- 17. Spinal Tumors.- 18. Epilepsy

Cryptococcal spinal arachnoiditis occurs in patients with meningitis and usually when they are immunocompromised. Spinal symptoms in cryptococcosis are rare and a very exceptional entity in the immunocompetent population. We present a young immunocompetent male who developed progressively increasing paraparesis due to primary cryptococcal arachnoiditis, who showed significant improvement after antifungal therapy. Although extremely rare, spinal arachnoiditis in an immunocompetent individual can be caused due to cryptococcus, as in our case. This case illustrates and emphasizes the necessity for an exhaustive and complete investigation, with a high index of suspicion for fungal etiology in patients presenting with spinal arachnoiditis or other disabling, progressive spinal cord syndromes of unknown etiology. Awareness of this presentation is necessary to avoid delay in diagnosis and management of this potentially curable condition.

We present a case of tongue necrosis due to intraoperative pressure injury. A laryngeal mask airway with adhesive electrodes was inserted into the oropharynx, over an endotracheal tube, to facilitate glossopharyngeal nerve monitoring during craniotomy for a cerebellopontine angle tumor. The case, mechanisms of injury, and modifications to our current practice are discussed.

The laser is a less-invasive method compared with the conventional techniques because it produces little cell destruction and less bleeding due to its hemostatic properties and requires the patient a reduced number of sessions and less chairside time for the most applications.

Introduction: Carotid-cavernous fistulas (CCFs) are arteriovenous fistulas (AVFs) between the carotid artery or its branches and the adjacent cavernous sinus. The purpose of this report is to present a case of recurrent indirect CCF presenting 47 years after previous operative trapping of the ICA for traumatic direct CCF, the longest reported recurrence to date. Methods: A spontaneous recurrence of indirect carotid-cavernous fistula presented 47 years following initial surgical trapping of the internal carotid artery for traumatic direct carotid-cavernous fistula. Results: The patient was successfully treated with an orbitozygomatic extended middle cranial fossa approach for direct petrous internal carotid artery clip ligation after failure of percutaneous embolization techniques. Conclusions: CCFs can be difficult entities to treat, requiring extensive knowledge and experience with both potential endovascular and surgical options. In addition, recurrences are not uncommon and may present remotely from initial treatment and with different anatomical configurations. This also represents, to our knowledge, the first case reported that required direct petrous carotid ligation to treat the fistula after all endovascular and standard approaches were attempted or not plausible. Clinicians must be aware of these possibilities and ensure close follow-up to guarantee long-term occlusion.

Microscope integrated Near infra red Indocyanine green video angiography (NIR ICG VA) has been frequently used in cerebrovascular surgery. It is believed to be a simple and reliable method with acquisition of real time high spatial resolution images. The aim of this review article was to evaluate the efficacy of intra operative Indocyanine green video angiography (ICG VA) in Aneurysm, brain arteriovenous malformations (AVM) and extracranial-intracranial (EC-IC) bypass surgeries and also to analyze its limitations. Intra operative imaging is a very useful tool in guiding surgery; thus, avoiding surgical morbidity. Now-a-days, many cerebrovascular units are using ICG VA rather than Doppler and intra operative DSA in most of their aneurysm surgeries, and surgeons are incorporating this technique for AVM and in EC-IC bypass surgeries too. This article is an overview of the beneficial effects of ICG VA in cerebrovascular surgery and will also point out its limitations in various circumstances. Intra operative ICG VA gives high resolution, real time images of arterial, capillary, and venous flow of cerebral vasculature. Although it gives adequate information about the clipped neck, parent/branching artery and perforator involvement, it has some limitations like viewing the neck residuals located behind the aneurysm, thick walled atherosclerotic vessels, and thrombosed aneurysms. In AVM surgery, it is useful in detecting the residual nidus in diffuse type AVM, but cannot be relied in deep seated AVMs and it gives exact information about the anastomosis site in EC-IC bypass, thus, avoiding early bypass graft failure. NIR ICG VA is a simple, reliable, and quick method to pick up subtle findings in cerebrovascular procedures. But in selected cases of aneurysms, endoscopy and intra operative Digital substraction angiography (DSA) may be helpful, whereas in deep seated AVMs, navigation may be required as an adjunct to confirm intra operative findings.

Previously considered the domain of the otolaryngologists, the endoscopy is now a common part of the armamentarium of a neurosurgeon. Neuroendoscopy or endoscope-assisted microsurgery is now being used in almost all routine procedures performed in the neurosurgical operating room. Hands-on training has become essential to learn the basics of neuroendoscopy, even for neurosurgeons well accustomed to the use of microscopes. To decrease the slope of the learning curve of residents during their training and reduce complications of procedures, most neurosurgery training programs around the world have incorporated laboratory or dissection programs in their curricula. Preconference workshops held during annual meetings are also an excellent tool to aid in the transition of surgeons from being a resident under the umbrella of an attending neurosurgeon to being a neurosurgeon able to operate independently and with confidence. In this "tech-savvy era," various cadaver or synthetic models are readily available for endoscopy training in a virtually simulated environment. In accord with the results of a surveys conducted by individual groups and societies, the authors firmly believe that incorporation of endoscopy in the neurosurgical curriculum would add a new dimension to the existing protocol. There is an urgent need for dedicated endoscopy training programs similar to postresidency fellowships in addition to translational research and establishment of dedicated societies to formulate guidelines for such research and monitor its progress.

INTRODUCTION Restrictions in elective surgery and large group gatherings as well as changes in faculty and resident schedules during the COVID-19 pandemic has led to rapid evolvement of the training curriculum for neurosurgical trainees While necessary, these changes may have significant impact on the training of neurosurgery residents METHODS A survey assessing changes to resident clinical and educational workload and their sentiment about how these changes may affect their careers was distributed electronically to neurosurgery residents in the United States and Canada RESULTS One hundred ninety-seven resident responses were collected between April 17, 2020 and April 30, 2020 The survey respondents were spread over 29 states and Canada and were evenly spread across all residency levels (P = 619) Nearly 82% reported that the inpatient and outpatient volumes were either greatly (44 0%) or moderately (37 8%) reduced Greater than 91% reported a significant reduction in work hours and a significant increase in resident didactics (P < 001) Nearly all residents surveyed (98 5%) reported that their program had converted to electronic platforms for their didactic lectures, and there was a significant increase in the time residents spent in didactic lectures Residents reported converting the majority of their time outside of neurosurgery clinical responsibilities into watching remote didactic lectures, conducting research, and preparing for board examinations, while nearly 14% of trainees spent at least a portion of that time providing COVID-19 medical care Senior residents were more likely to express concern about their educational experience as well as their future career prospects CONCLUSION Universally, residents have experienced reduced work hours and operative case volumes Programs have adapted by increasing didactic time and using electronic platforms The findings suggest that senior residents may feel the effects more than their junior counterparts This may require more acute attention from faculty with respect to preparing senior residents for moving on to fellowship or ultimate job It is possible that this remarkable time period will prompt a critical re-appraisal of the pre-COVID-19 adequacy of educational content in our training programs, and that enhanced educational efforts driven by this pandemic may be lasting

The transoral (TO) approach to the craniocervical junction provides similar access to the periclival and subaxial spine compared with the extraoral anterolateral prevascular (EAP) approach, but the additional exposure gained by the EAP approach has not been quantified. This study quantitatively compared the two surgical exposures.Ten silicon-injected fixed cadaver heads were used for the TO approach and another 5 heads (10 sides) were dissected for the EAP approach. For the TO approach, mouth opening was standardized to 5.5 cm using a Spetzler-Sonntag retractor, and the soft palate was split 1.5 cm to access the periclival area. A frameless stereotactic device was used to calculate the lengths, angles, and areas of surgical exposure for different anatomic targets.The vertical working length on the dura progressively increased 61% (336 ± 26 mm to 539 ± 16 mm [mean ± standard deviation]; P0.001), and the vertical working angle increased 23% (98 ± 3 degrees to 121 ± 5 degrees; P0.0) using the TO versus the EAP approach. In the TO approach, the bilateral average horizontal working length on the C1 arch was less on the ipsilateral side than for the EAP approach (11 ± 1 mm vs. 17 ± 1 mm, 61%; P0.01). The mean periclival and subaxial exposures were 546 ± 72 mm(2) and 932 ± 70 mm(2) with the TO approach and 874 ± 75 mm(2) and 1644 ± 107 mm(2) with the EAP approach (mean increases 62% and 77%, respectively; both P0.001).Both the TO and EAP approaches improved surgical exposure, but the EAP approach provides more significant and consistent gains to the anterolateral periclival and subaxial areas.

Background The lower cranial nerves must be identified to avoid iatrogenic injury during skull base and high cervical approaches. Prompt recognition of these structures using basic landmarks could reduce surgical time and morbidity. Methods The anterior triangle of the neck was dissected in 30 cadaveric head sides. The most superficial segments of the glossopharyngeal, vagus and its superior laryngeal nerves, accessory, and hypoglossal nerves were exposed and designated into smaller anatomic triangles. The midpoint of each nerve segment inside the triangles was correlated to the angle of the mandible (AM), mastoid tip (MT), and bifurcation of the common carotid artery. Results A triangle bounded by the styloglossus muscle, external carotid artery, and facial artery housed the glossopharyngeal nerve. This nerve segment was 0.06 ± 0.71 cm posterior to the AM and 2.50 ± 0.59 cm inferior to the MT. The vagus nerve ran inside the carotid sheath posterior to internal carotid artery and common carotid artery bifurcation in 48.3% of specimens. A triangle formed by the posterior belly of digastric muscle, sternocleidomastoid muscle, and internal jugular vein housed the accessory nerve, 1.90 ± 0.60 cm posterior to the AM and 2.30 ± 0.57 cm inferior to the MT. A triangle outlined by the posterior belly of digastric muscle, internal jugular vein, and common facial vein housed the hypoglossal nerve, which was 0.82 ± 0.84 cm posterior to the AM and 3.64 ± 0.70 cm inferior to the MT. Conclusions Comprehensible landmarks can be defined to help expose the lower cranial nerves to avoid injury to this complex region.

AComA aneurysms are most commonly found at the A1-A2 junction on the dominant side. The angle of the arteries at the bifurcation and the direction of blood flow are factors of hemodynamic stress in the apical region where these aneurysms often develop. They exist at the bifurcation of dominant A1, A2 and AComA and usually point in the direction away from the dominant A1. They are more prone to rupture and demonstrate the highest incidence of post-operative morbidity among anterior circulation aneurysms. Consideration of aneurysm morphology may be used to guide approaches in AComA aneurysms. Resection of the gyrus rectus in combination with a pterional approach was popularized by Yasargil and it became the standard for treatment or exposure of AComA aneurysms, although other skull base approaches are also widely used. Clip selection is of extreme importance and the preservation of blood flow to the perforators should be emphasized. Adequate dissection and exposure of the entire "H" complex prior to clipping is the key to a successful outcome. Separating the perforators from the neck or dome of the artery and preserving the parent vessel presents a substantial challenge to the surgeon when the aneurysm is behind the parent artery, making it difficult to achieve a good outcome.

To determine factors that help decide the side of approach for anterior communicating artery (AComA) aneurysms, based on a prospective study.Between January 2004 and January 2006, 93 cases with AComA aneurysms were treated through pterional approach. They were classified as Type I, II (IIa, IIb), III and IV, based on the various projections and size of aneurysm. The principle for the choice of operative side was designed based on the type of aneurysm and the A2 fork orientation (the interrelations between the plane of bilateral A2, AComA, and mid-saggital plane).There were 55 aneurysms of Type I, 10 of Type IIa, 14 of Type IIb, 12 of Type III, and 2 of Type IV. In Types I and IIa, the side posteriorly placed to A2 was chosen for the approach. In Type IIb, the side of the dominant A1 was selected. In Type III, the side anteriorly placed to A2 was chosen. Type IV aneurysms were difficult to handle even if approached from the dominant A1. There were 11 cases treated from the side of non-dominant A1. The overall outcome in the treatment of AComA aneurysms were considered excellent in 90.8% of cases according to the Glasgow Outcome Scale, with complete occlusion of aneurysms and complete patency of parent or perforating arteries.Applying three-dimensional computed tomography and magnetic resonance angiography, we classified AComA aneurysms as four types and undertook surgical clipping from the chosen side of approach, according to the type of aneurysm and the A2 fork orientation. The selective side of approach on the basis of individual decision-making has led to favourable outcomes.

Within a few months of Wilhelm Conrad Röntgen's discovery of x-rays in 1895, Fedor Krause acquired an x-ray apparatus and began to use it in his daily interactions with patients and for diagnosis. He was the first neurosurgeon to use x-rays methodically and systematically. In 1908 Krause published the first volume of text on neurosurgery, Chirurgie des Gehirns und Rückenmarks (Surgery of the Brain and Spinal Cord), which was translated into English in 1909. The second volume followed in 1911. This was the first published multivolume text totally devoted to neurosurgery. Although Krause excelled in and promoted neurosurgery, he believed that surgeons should excel at general surgery. Importantly, Krause was inclined to adopt technology that he believed could be helpful in surgery. His 1908 text was the first neurosurgical text to contain a specific chapter on x-rays (“Radiographie”) that showed roentgenograms of neurosurgical procedures and pathology. After the revolutionary discovery of x-rays by Röntgen, many prominent neurosurgeons seemed pessimistic about the use of x-rays for anything more than trauma or fractures. Krause immediately seized on its use to guide and monitor ventricular drainage and especially for the diagnosis of tumors of the skull base. The x-ray images contained in Krause's “Radiographie” chapter provide a seminal view into the adoption of new technology and the development of neurosurgical technique and are part of neurosurgery's heritage.