Neurosurgery
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Biography Historical Article
W. W. Keen: America's pioneer neurological surgeon.
The contributions of William Williams Keen to the development of neurological surgery were greater than those of any other American surgeon in the last quarter of the 19th century. His close association with S. Weir Mitchell, the father of American neurology, spanned more than 50 years. ⋯ He made contributions to the surgical treatment of hydrocephalus, craniostenosis, torticollis, trigeminal neuralgia, and nervous system trauma. Keen's surgical texts provided an important foundation for Cushing, Frazier, and those that followed. Showered with honors as America's dean of surgery, Keen lived to see the many specialties evolve.
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Case Reports
Arteriovenous malformations of the superior cerebellar artery: excision via an occipital transtentorial approach.
Arteriovenous malformations (AVMs) of the superior cerebellar artery (SCA) are unusual and difficult lesions to treat, representing less than half of all AVMs located in the posterior fossa. Traditional approaches for surgical extirpation include the subtemporal transtentorial and suboccipital supracerebellar routes. ⋯ Exposure of the AVM from above and in the midline provides superior visualization of the deep veins, the SCA arborization in the retrocollicular space, and the rostral cerebellum, without exposing the temporal lobe and the 4th nerve to surgical trauma in a narrow, confined space. Superior cerebellar AVMs that arise from the caudal branch of the SCA on the superolateral aspect of the hemisphere are more easily handled by standard suboccipital methods.
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Because controversy exists regarding continued use of the seated position for neurosurgical procedures, this prospective (1981-1983) and retrospective (1972-1981) analysis of 554 seated patients was done to establish the incidence and severity of venous air embolism (VAE) related to type of surgical procedure and anesthetic technique; to examine the impact of specific monitoring practices on detection, morbidity, and mortality; and to establish the incidence of other complications related to the seated position (hypotension, quadriplegia, and arterial air embolism (AAE)). The overall morbidity and mortality related to the seated position was 1% (2 VAE, 1 AAE, 2 hypotension, 1 myocardial infarction) and 0.9% (1 VAE, 1 AAE, 2 hypotension, 1 quadriplegia), respectively. ⋯ The seated position is safe in experienced hands if appropriate surgical and anesthetic skills are exercised in patient selection and management. Caution is advised in patients with atherosclerotic cardiovascular disease, severe hypertension, cervical stenosis, and right to left intracardiac shunts.
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The microsurgical anatomy of the superficial cortical veins was examined in 20 cerebral hemispheres. The superficial cortical veins are divided into three groups based on whether they drain the lateral, medial, or inferior surface of the hemisphere. The veins on the three surfaces are further subdivided on the basis of the lobe and cortical area that they drain. ⋯ The tentorial group drains the lateral surface of the temporal lobe and the basal surface of the temporal and occipital lobes. The falcine group drains an area that includes the cingulate and parahippocampal gyri and approximates the cortical parts of the limbic lobe of the brain. The relationship of these veins to the venous lacunae was also examined.
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With a patient in the concorde position, lying prone with the head flexed and tilted laterally, higher than the heart, it is possible to use both the occipital transtentorial and infratentorial supracerebellar approaches without changing the patient's position. We report the successful treatment with this combined approach of an arteriovenous malformation in the upper vermis supplied by the superior cerebellar artery.