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Ramamurthi and Tandon’s Textbook of Neurosurgery (3 Volumes)
Prakash Narain Tandon, Ravi Ramamurthi
SECTION 1: HISTORY
1:
Evolution of Neurosurgical Techniques
INTRODUCTION
Medical Practice in Ancient India
Medical Education in Ancient India
Medical Ethics in Ancient India
NEUROSURGICAL TECHNIQUES IN ANTIQUITY
Neurosurgery in Ancient India
Trephining in Neolithic Period
The Edwin Smith Surgical Papyrus
Hippocrates and Neurosurgery (460–377 BC)
Neurosurgical Techniques in the Medieval Period (500–1500 AD)
Neurosurgical Techniques in the Renaissance (1500–1700 AD)
Neurosurgical Techniques in the Pre-Listerian Period (1700–1846 AD)
Neurosurgical Techniques in the Pre-Horsley Period (1846–1890 AD)
DEVELOPMENT OF CONTEMPORARY NEUROSURGICAL TECHNIQUES
The Development of Techniques for CSF Access and Analysis
Development of Neuroradiology
Patient Positioning
Surgical Gloves
Craniotomy
Suction and Irrigation
Brain Retractors
HAEMOSTASIS
Scalp Haemostasis
Cerebral Haemostasis
Thermal Methods
Mechanical and Chemical Methods
OPERATING MICROSCOPE IN NEUROSURGERY
DEVELOPMENT OF NEUROSURGICAL TECHNIQUES IN SURGERY FOR BRAIN TUMOURS
Gliomas
Meningiomas
Pineal Tumours
Acoustic Tumours
Pituitary Tumours
Trans-sphenoidal Surgery
Transcranial Surgery
Spinal Cord Tumours
CEREBROVASCULAR SURGERY
SURGERY FOR EPILEPSY
SURGERY FOR MOVEMENT DISORDERS
SURGERY FOR INTRACTABLE PAIN
SURGERY FOR TRIGEMINAL NEURALGIA
PSYCHOSURGERY
STEREOTACTIC SURGERY
ENDOSCOPIC NEUROSURGERY
DEVELOPMENT OF HIGH SPEED DRILLS
ACKNOWLEDGEMENT
2:
History of Microneurosurgery
DEVELOPMENT OF VARIOUS MICRONEUROSURGICAL TECHNIQUES
Aneurysms
Arteriovenous Malformations
Arteriovenous Fistulas
Occlusive Cerebrovascular Surgery
Peripheral Nerve Surgery
SECTION 2: DIAGNOSTICS
3:
Electrodiagnosis
MUSCLE AND NERVE ELECTROPHYSIOLOGIC STUDIES
Nerve Conduction Studies
Definition of Related Terms
Types of Neuropathy
Technical Limitation while Interpreting Nerve Conduction Study (NCS)
Important Points to Remember
Electromyography
Electromyography Findings
Insertional Activity
Spontaneous Activity
Normal
Abnormal
Causes
Causes
Motor Unit Action Potentials
Characteristics of Activation Pattern of Motor Unit Action Potentials
Recruitment
Electrodiagnostic Findings in Nerve Injury
Timing of the Test is Important
Neuropraxia
EDX
Axonotmesis
EDX
Neurotmesis
EVOKED POTENTIALS
Sensory Evoked Potentials
Somatosensory-Evoked Potentials
Methodology1
Role of Somatosensory-Evoked Potential in Neurosurgical Diseases
Intra-Operative Monitoring
Abnormality Criteria
Somatosensory-Evoked Potentials (SSEPs) in Peripheral Nerve Trauma
Brainstem Auditory-Evoked Potentials
Brainstem Auditory-Evoked Potential Wave Generators
Intra-Operative Brainstem Auditory-Evoked Potential Monitoring
Visual Evoked Potentials
ELECTROPHYSIOLOGY FOR SOME CLINICAL CONDITIONS OF INTEREST TO NEUROSURGEONS
Carpal Tunnel Syndrome
Electrophysiology
Electrodiagnostic Grading of Carpal Tunnel Syndrome
Electrophysiological Findings
Sensory Latency
Distal Motor Latency
Post-Operative Changes
Criteria for the Electrodiagnostic Evaluation of Unilateral Neurogenic Thoracic Outlet Syndrome61
Details Regarding the Above Criteria
Acoustic Neuroma
ELECTROENCEPHALOGRAPHY
How Can Electroencephalography Help in Epilepsy?47
Diagnosis of Epilepsy
Management of Epilepsy
Minimum Technical Standards
Advantages
Disadvantages
Standardising Electroencephalography Recording, Lab Infrastructure and Electroencephalography Reporting
Patient Information
Documentation during Recording
Recording
Display
Electrode Nomenclature
Montages to Be Used?
Bipolar Derivation
Common Reference Derivation
Common Average Reference Derivation
Sensitivity and Specificity of the Electroencephalography
Role of Brain Mapping
Activation Procedures
Hyperventilation
Photic Stimulation
Sleep Deprivation
Clinical Significance of Interictal Epileptiform Discharges
Epileptiform Discharges in Non-Epileptic Subjects
Epileptiform Discharge in the First and Serial Electroencephalograms
Ictal Video-Electroencephalography (Long-Term Monitoring)
Indications for Video-Electroencephalography Monitoring
Diagnosis
Classification/Characterisation
Quantification
Partial Seizures
Generalised Seizures
Can Electroencephalography Help in the Prognosis of Epilepsy?
Classification of Epilepsy
First Seizure
Anti-Epileptic Drug Withdrawal
Summary
ELECTROCORTICOGRAPHY
Potential Advantages of Electrocorticography
CONCLUSION
4:
Intracranial Pressure
HISTORY
ANATOMY AND PHYSIOLOGY
VOLUME-PRESSURE RELATIONSHIP
PATHOLOGY OF INCREASED INTRACRANIAL PRESSURE
INTRACRANIAL PRESSURE MONITORING
Epidural Monitoring
Subarachnoid and Subdural Devices
Parenchymal Monitoring
Intraventricular Monitoring
Lumbar Monitoring
5:
Neuro-Ophthalmology
THE NORMAL FIELD OF VISION
THE NORMAL VISUAL PATHWAY
ASSESSMENT OF VISUAL FIELD
INTERPRETATION OF VISUAL FIELD
Terminologies
VISUAL FIELD DEFECTS
Retina
Anatomy
Organisation of Retinal Nerve Fibre Layer
Fields Defects
Optic Nerve
Anatomy
Organisation
Field Defects
The Chiasma
Anatomy
Organisation
Clinical Features
Field Defects
Optic Tract and Lateral Geniculate Body
Anatomy
Organisation
Clinical Features
Field Defects
Optic Radiations
Anatomy
Organisation
Clinical Features of Temporal Lobe Involvement
Clinical Features of Parietal Lobe Involvement
Field Defects
Visual Cortex
Anatomy
Organisation
Clinical Features
Fields Defects
SPECIAL VISUAL FIELD DEFECTS
Baring of Blind Spot
Pseudobitemporal Hemianopia
Binasal Hemianopia
CONCLUSION
6:
Neuro-Otology
QUANTITATIVE TESTS FOR VESTIBULAR FUNCTION
Electronystagmography
Electro-Oculography
Video-Oculography/Videonystagmography
Gaze Nystagmus
DYNAMIC TESTING
Saccade Testing
Smooth Pursuit
Optokinetic Testing
Caloric Testing
Interpretation
Rotatory Chair
Shortcomings of Conventional Vestibular Function Tests
Vestibular Evoked Myogenic Potentials
Computerised Dynamic Posturography
Cranio-Corpography
INVESTIGATIONS FOR THE AUDITORY SYSTEM
Puretone Audiogram
Impedance Audiometry
ELECTROPHYSIOLOGICAL TESTS
Otoacoustic Emissions
Electrocochleography
Procedure
Clinical Applications
Auditory Brainstem Response
Clinical Applications
Neuro-otological Applications
Assessing Neurological Disorders
Auditory Steady State Response
Middle and Long Latency Evoked Potentials
Editorial Comments
Vestibular Function Test in Unconscious Patients
References Used
COCHLEAR IMPLANTS
History of Implants
Components
Selection Criteria
Contraindications
Pre-Operative Evaluation
Surgery of Cochlear Implantation
Electrophysiologic Testing or Neural Response Telemetry
Post-Operative Care
Complications of Cochlear Implantation
The Future
AUDITORY BRAINSTEM IMPLANTATION
Components
Indications for Auditory Brainstem Implant
Pre-Operative Evaluation
Auditory Brainstem Implant Surgery
Auditory Midbrain Implants
CONCLUDING REMARKS
7:
Neuroendocrinology
INTRODUCTION
PROLACTIN
GROWTH HORMONE
ADRENOCORTICOTROPIC HORMONE AND CORTISOL
Urinary-free Cortisol Excretion Rate
Tests for Hypocortisolism
Morning Plasma Cortisol Level (Between 8 am and 9 am)
THYROID
Newer Methods
Index Methods
Indexes Using a Thyroid Hormone Binding Ratio or “Uptake” Test
Ligand Assays
GONADOTROPINS
Gonadotropin-releasing Hormone Stimulation Test
Gonadotropin-releasing Hormone Analogue Stimulation Tests
The Buserelin Stimulation Test
ANTIDIURETIC HORMONE (VASOPRESSIN)
8:
Intra-Operative Monitoring
CHOOSING AN INTRA-OPERATIVE MONITORING MACHINE
HARDWARE
SOFTWARE
RECORDING ELECTRODES
BIPOLAR AND MONOPOLAR ELECTRICAL STIMULATION
VISUAL EVOKED POTENTIAL
BRAINSTEM AUDITORY EVOKED POTENTIAL
SOMATOSENSORY EVOKED POTENTIAL MONITORING
MOTOR EVOKED POTENTIAL
MOTOR NUCLEI AND NERVE STIMULATION
MAPPING ELOQUENT AREAS
INTRACRANIAL MONITORING USING ELECTROENCEPHALOGRAPHY
INTRA-OPERATIVE ELECTROMYOGRAPHY
INTRA-OPERATIVE DOPPLER ULTRASONOGRAPHY AND ULTRASOUND ANGIOGRAPHY
NEURONAVIGATION
NAVIGATED BLOOD FLOW IMAGING
FLUORESCENCE-GUIDED RESECTION
INTRA-OPERATIVE MAGNETIC RESONANCE IMAGING IN NEUROSURGERY
INTRA-OPERATIVE MONITORING OF CEREBRAL BLOOD FLOW BY LASER SPECKLE CONTRAST ANALYSIS
WIRELESS INSTANTANEOUS NEUROTRANSMITTER CONCENTRATION SYSTEM
INTRA-OPERATIVE ELECTROCORTICOGRAPHY
9:
Conventional Radiology
PLAIN X-RAY OF THE SKULL
Posteroanterior View
Fronto-Occipital
Caldwell View
Towne's View
Submento-Vertical View
Intracranial Calcification
Increased Vascularity
Localised Areas of Bony Erosion or Sclerosis
Raised Intracranial Pressure
Craniostenosis syn. Craniosynostosis
Microcephaly
“Hemiatrophy” of the Skull
Platybasia and Basilar Invagination
Sellar and Parasellar Neoplasms
IMAGING OF THE SPINE
Plain X-rays
10:
Basic Principles of CT Scan and MRI Scan
INTRODUCTION
BASIC PHYSICS
TYPES OF SCANNING TECHNIQUES
Axial (Sequential) Scanning
Helical (Spiral) Scanning
COMPUTED TOMOGRAPHY TERMINOLOGIES
Pixel and Voxel
Hounsfield Unit or Computed Tomography Number
WINDOW LEVEL AND WINDOW WIDTH
SLICE THICKNESS
PITCH
IMAGE POST PROCESSING
COMPUTED TOMOGRAPHY CONTRAST MEDIA
ADVANTAGES AND CLINICAL USE OF COMPUTED TOMOGRAPHY
DISADVANTAGES OF COMPUTED TOMOGRAPHY
BASIC PRINCIPLES OF MAGNETIC RESONANCE IMAGING
Radiofrequency Field
Free Induction Decay
T1 and T2 Relaxation
Repetition Time
Echo Time
Slice Orientation
Slice Position
INSTRUMENTATION
The Magnet
Superconducting Magnets
Resistive Magnets
Permanent Magnets
Magnetic Field Gradients
Radiofrequency System
Transmitter and Receiver Coils
COMMONLY USED PULSE SEQUENCES
Spin-Echo Pulse Sequence
Gradient Echo Imaging
Inversion Recovery Imaging
MAGNETIC RESONANCE CONTRAST
Safety
MAGNETIC RESONANCE ANGIOGRAPHY
Techniques of Magnetic Resonance Angiography
Time-of-Flight Magnetic Resonance Angiogram
Phase Contrast Magnetic Resonance Angiogram
Advantages of phase contrast magnetic resonance angiogram:
Disadvantages of phase contrast magnetic resonance angiogram:
Contrast-Enhanced Magnetic Resonance Angiography
Advantages:
NEWER ADVANCED MAGNETIC RESONANCE IMAGING TECHNIQUES
Diffusion-Weighted Imaging
Applications
Lesions Bright on Diffusion Images
Functional Imaging
Magnetic Resonance Spectroscopy
Indications
11:
Radiology: Intracranial Tumours
IMAGING MODALITIES
APPROACH TO BRAIN TUMOURS
ADVANCED NEUROIMAGING OF BRAIN TUMOURS
Perfusion Imaging
Spectroscopy
Functional Magnetic Resonance Imaging
Diffusion Weighted Imaging and Diffusion Tensor Imaging
Susceptibility Weighted Imaging
SPECIFIC TUMOURS
Glioma
Oligodendrogliomas
Glioma Tumour Evaluation to Differentiate Low and High Grade Tumours
Evaluating Peri-tumoural Region to Differentiate Metastases from Primary Tumour
Gangliogliomas
Meningioma
Choroid Plexus Papillomas
Central Neurocytomas
Chordomas
Craniopharyngiomas
Dermoids and Epidermoids
Ependymomas
Germ Cell Tumours
Hemangioblastomas
Lymphoma
Paragangliomas
Metastases
Pituitary Adenomas
Medulloblastomas/Primitive Neuroectodermal Tumours
Rathke's Cleft Cysts
Schwannoma
TUMOUR-MIMICKING LESIONS
POST-SURGICAL IMAGING
RADIATION NECROSIS VERSUS TUMOUR RECURRENCE
12:
Radiology: Intracranial Infections
INTRODUCTION
PYOGENIC INFECTIONS
Cerebritis
Cerebral Abscesses
Septic Embolism and Mycotic Abscesses
Meningitis
Complications
Subdural Collections
Hydrocephalus
Empyema
Epidural Empyema
Subdural Empyema
Pyogenic Ventriculitis
MYCOBACTERIUM TUBERCULOSIS INFECTION
Tuberculous Meningitis
Tuberculomas
Tuberculous Abscess
NEUROCYSTICERCOSIS
NEUROBRUCELLOSIS
ANTHRAX MENINGOENCEPHALITIS
VIRAL INFECTIONS OF THE BRAIN
Herpes Simplex 1 Encephalitis
Japanese Encephalitis
Rabies Encephalitis
Creutzfeldt-Jakob-Disease
Acute Disseminated Encephalomyelitis
Subacute Sclerosing Panencephalitis
FUNGAL INFECTIONS
Cryptococcus Neoformans
Candidiasis
Aspergillus Infection
Mucormycosis
CONCLUSION
ACKNOWLEDGEMENT
SECTION 3: CONGENITAL
13:
Embryology: Skull and Vertebral Column
DEVELOPMENT OF THE VERTEBRAL COLUMN
Regional Variations in the Development of the Vertebral Column
Cervical
Thoracic
Lumbar
Sacrum
Molecular Basis of Vertebral Column Development
Hox Genes
Hox Codes
Pax Genes
Sonic Hedgehog Gene
Msx1 and Msx2
Development of the Skull
Vault of the Skull
Base of the Skull
Molecular Biology of Skull Development
Fibroblast Growth Factor Receptors
Msx Genes
TWIST Gene
Transforming Growth Factors (TGFs)
14:
Embryology: Brain and Spinal Cord
INTRODUCTION
DEVELOPMENT OF THE CENTRAL NERVOUS SYSTEM
The Embryonic Disc
Gastrulation and the Trilaminar Embryonic Disc
Development of the Notochord
Formation of the Neural Tube
Neurulation
Development of the Brain
Flexures of the Brain
The Hindbrain
Myelencephalon
Metencephalon
Development of the Cerebellum
Mesencephalon
Diencephalon
Telencephalon
Histogenesis of the Neural Tube
Neural Crest and its Differentiation
Development of the Spinal Cord
Canalisation of the Tail Bud
Regression
Development of the Meninges
Molecular Basis of Brain Development
Molecular Regulation of Neural Induction
Homeobox Genes (Hox Genes)
Sonic Hedgehog Gene
Otx, Emx, LIM 1 and EN Genes
Molecular Regulation of Cortical Development
Molecular Regulation of Spinal Cord Development
Post-natal Growth of the Brain
15:
Congenital Malformations of Cerebrum
DEVELOPMENT AND PATHOGENESIS
Commissural Agenesis
Malformation of Cortical Development
Cellular Multiplication
Cellular Differentiation
Cellular Migration
Cellular Organisation
Schizencephaly
CONCEPTS, CAUSES AND CLASSIFICATION
Molecular Genetics
STRUCTURAL IMAGING
FUNCTIONAL IMAGING
CLINICO-RADIOLOGICAL FEATURES
Megalencephaly
Hydrocephaly
Lissencephaly
Classical Lissencephaly or Type 1
Cobblestone Lissencephaly or Type 2
Walnut Type Lissencephaly or Type 3
Holoprosencephaly
Agenesis of Corpus Callosum
Schizencephaly
Pachygyria
Polymicrogyria
HETEROTOPIAS
Band Heterotopia or Double Cortex Syndrome
Subependymal Heterotopias
Focal Cortical Dysplasia
MANAGEMENT
PROGNOSIS
16:
Encephalocoeles
DEFINITION AND HISTORICAL ASPECTS ON ENCEPHALOCOELES
INCIDENCE OF ENCEPHALOCOELES
EMBRYOLOGY
CLASSIFICATION OF ENCEPHALOCOELES
ASSOCIATED PATHOLOGY
CLINICAL PRESENTATION
ANTERIOR ENCEPHALOCOELES
Nasofrontal Type
Nasoethmoid Type
Naso-orbital Type
Trans-sphenoid Encephalocoeles
RARE CLINICAL FEATURES
Investigations
MANAGEMENT
Prognosis in Patients with Occipital Encephalocoeles
Encephalocoeles through the Cranial Vault
Temporal and Parietal Encephalocoeles
TREATMENT
Treatment of Trans-sphenoid Encephalocoele
Treatment of Anterior Encephalocoeles
Prognosis in Patients with Anterior Encephalocoeles
17:
Intracranial Arachnoid Cysts
INTRODUCTION
EMBRYOLOGY AND ANATOMY
PATHOGENESIS OF CYST EXPANSION
PATHOLOGY
Macroscopic Appearances
Microscopic Appearances
Normal Arachnoid Mater
Light Microscopic Features
Transmission Electron Microscopic Features
Arachnoid Cyst
Light Microscopic Features
Transmission Electron Microscopic Features
Immunohistochemical Findings of Arachnoid Cysts
NATURAL HISTORY
INTRACRANIAL CYSTS
Clinical Features
Incidence and Distribution
Manifestations—General
Manifestations—Specific
Sylvian Fissure Cysts
Suprasellar Cysts
Posterior Cranial Fossa Cysts
Parasagittal and Interhemispheric Cysts
Pineal and Quadrigeminal Cistern Region Cysts
Convexity Cysts
Intraventricular and Intradiploic Cysts
Radiology
Plain Skiagrams
Sonography
Computerised Tomography Scan
Magnetic Resonance Imaging
Management
Craniotomy and Fenestration
Shunting
Endoscopic Surgery
SPINAL CYSTS
Introduction
Embryology
Clinical Features
Radiology
Treatment
18:
Craniofacial Deformities (Craniostenosis)
HISTORY/INTRODUCTION
NORMAL CALVARIAL GROWTH
Endochondral Ossification
Intramembranous Ossification and Sutural Growth
Remodelling
Displacement
INCIDENCE, AETIOLOGY AND PATHOGENESIS OF PREMATURE CRANIOSYNOSTOSIS
CLASSIFICATION AND TERMINOLOGY
RADIOLOGY
TREATMENT OF CRANIOSYNOSTOSIS
SURGICAL INCISIONS AND PROCEDURES
COMPLICATIONS OF SURGICAL TREATMENT
Intra-Operative Stage
Early Post-Operative Stage
Late Post-Operative Stage
19:
Spinal Dysraphic States
INTRODUCTION
PREVALENCE
EMBRYOLOGY
AETIOLOGY
SYMPTOMATOLOGY
ASSESSMENT
PRENATAL DIAGNOSIS
RADIOLOGICAL ASSESSMENT
MANAGEMENT
SURGICAL TREATMENT
PATIENT SELECTION
SURGICAL TECHNIQUE
TETHERED CORD SYNDROME
Embryogenesis
Pathogenesis
Clinical Features
Symptoms
Neurological Examination
Indication for Treatment
The Principles of Surgery
Retethering
Lipomyelomeningocele
Surgical Technique
Myelocystocele
SPLIT CORD MALFORMATIONS
Surgical Technique
COMPOUND OR COMPOSITE SPLIT CORD MALFORMATION
DERMAL SINUS
SYNDROMES OF THE TETHERED CORD
TETHERED CORD SYNDROME IN ADULTS
NEUROGENIC BLADDER WITH CONUS AT NORMAL POSITION
20:
Hydrocephalus
INTRODUCTION
HISTORY14,59
EMBRYOLOGY
CEREBROSPINAL FLUID PRODUCTION AND ABSORPTION
AETIOLOGY AND PATHOPHYSIOLOGY OF HYDROCEPHALUS
CLASSIFICATION
CLINICAL FEATURES
INVESTIGATIONS
Computerised Tomography and Magnetic Resonance Imaging
Volumetric Measurements
Electrophysiology
Natural History
TREATMENT
Medical Management
Indian Shunt Systems
Endoscopic Treatment
Complications of Shunts
INTELLECTUAL OUTCOME15,22,37,40,49,51,54,55,58,61,64
SPECIAL TYPES OF HYDROCEPHALUS
Post-Haemorrhagic
Meningomyelocoele
Aqueduct Stenosis
Dandy Walker Syndrome
Post-Meningitic
Subarachnoid Haemorrhage
Normal Pressure Hydrocephalus
Hydrocephalus and Venous Hypertension
Arrested Hydrocephalus
Multiloculated Hydrocephalus
Hydrocephalus Ex-vacuo
21:
Endoscopic Management of Hydrocephalus
INTRODUCTION
NORMAL ENDOSCOPIC ANATOMY
APPROACH
Lateral Ventricles
Third Ventricle
Aqueduct and Fourth Ventricle
INSTRUMENTATION
Rigid Endoscope
Fibreoptic Endoscopes
Rigid Fibrescope
STABILISATION AND GUIDING DEVICES
Stereotactic Guidance
Additional/Supplementary Instrument
ENDOSCOPIC PROCEDURES FOR OBSTRUCTIVE HYDROCEPHALUS
Third Ventriculostomy
Patient Selection
Operative Procedure
Complications
Assessment of Effectiveness
Success Rates
Age and Outcome
Aetiology and Outcome
Myelomeningocoele with Hydrocephalus
Chiari Malformation and Hydrocephalus
Fourth Ventricular Outlet Obstruction
Obstructive Hydrocephalus Due to Tumours
Dandy-Walker Malformation
Aqueductal Reconstruction
Technique
Complications
Success Rates
Choroid Plexus Coagulation
Multiloculated Hydrocephalus
Septum Pellucidotomy
Intraventricular Shunt Catheter Placement and Removal of Dislocated Shunt
22:
Normal Pressure Hydrocephalus
INTRODUCTION
INCIDENCE
AETIOLOGY
Increased Venous Resistance
Tissue Distortion
Interstitial Fluid Pressure Increase
Watershed Ischaemia
Vasoactive Metabolites
Vascular Disease
CRITERIA FOR DIAGNOSIS
CLINICAL FEATURES OF IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS
Gait Abnormality
Cognitive Deficits
Urinary Incontinence
Differential Diagnosis of Normal Pressure Hydrocephalus
Diagnosis
Computed Tomography
Nuclear or Computed Tomography Cisternography
Magnetic Resonance Imaging
Magnetic Resonance Cerebrospinal Fluid Flow Studies
Cerebral Perfusion
Cerebral Metabolism
Transcranial Doppler Ultrasonography
Tap Test
Measurement of Cerebrospinal Fluid Opening Pressure
Continuous Intracranial Pressure Monitoring
Controlled Continuous Lumbar Drainage
Impedence of Flow Offered by Cerebrospinal Fluid Absorption Pathways
SURGICAL MANAGEMENT OF IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS
Patient Selection
Current Recommendations of the iNPH Guidelines for iNPH Diagnosis and Use of Supplemental Prognostic iNPH Tests for Identifying Shunt Responsive Patients
Type of Shunt
Valve Selection
Clinical Scales for Assessing Outcome
Management of Patients Who Fail to Improve or Those Who Deteriorate Clinically Following Shunt Placement
Subdural Fluid Collection Following Cerebrospinal Fluid Diversion
Unchanged or Increased Ventricular Size
23:
Bony Anomalies of the Craniovertebral Junction
INTRODUCTION
EMBRYOLOGICAL ANATOMY OF CRANIOVERTEBRAL JUNCTION
CLASSIFICATION
Malformations of the Occipital Bone
Basilar Invagination and Platybasia
Malformations of Atlas
Atlas Assimilation
Aplasia and Hypoplasia of the Anterior and Posterior Arches of Atlas
Congenital Anomalies of Atlantoaxial Joint
Atlantoaxial Rotatory Fixation
Os Odontoideum
Ossiculum Terminale
Syndromic Abnormalities of Craniovertebral Junction
Mucopolysaccharidoses
Down's Syndrome
Grisel's Syndrome
Clinical Symptomatology
Investigations
Surgical Management
CONCLUSION
24:
Syringomyelia
INTRODUCTION
TERMINOLOGY AND CLASSIFICATION
AETIOPATHOGENESIS
Mechanism of Syrinx Formation
Syringomyelia Associated with CV Junction Anomaly
Syringomyelia Related to Primary Spinal Abnormalities
Mechanism of Syrinx Propagation
SYMPTOMATOLOGY
Symptoms Predominantly Due to Central Spinal Cord Cavitation
IMAGING
NATURAL HISTORY
MANAGEMENT
SELECTION OF PATIENTS FOR SURGERY
Surgical Management of Syringomyelia Associated with Craniovertebral Junction Anomalies
Management of Syringomyelia Related to Primary Spinal Abnormalities
Results of Surgery
CAUSES OF SURGICAL FAILURE AND THEIR PREVENTION
SECTION 4: HEAD INJURIES
25:
Epidemiology of Head Injury
INTRODUCTION
TYPE OF INJURY AND DISABILITY
AETIOLOGY OF HEAD INJURY AND AGE DISTRIBUTION
GENDER AND HEAD INJURY
REASONS FOR ROAD ACCIDENTS IN INDIA
FINANCIAL IMPLICATION OF HEAD INJURY
CONCLUSION
ACKNOWLEDGEMENT
26:
Biomechanics of Head Injury
INTRODUCTION
TYPES OF MECHANICAL FORCES
Dynamic Loading
Impact Loading
Impulsive Loading
Static Loading
MECHANISM OF SPECIFIC INJURIES
Concussion and Sports Injuries
Contrecoup Contusions
Subdural Haematoma
Diffuse Axonal Injury
Shaken Baby Syndrome
FUTURE RESEARCH
CONCLUSION
27:
Pathology
INTRODUCTION
CAUSES OF BRAIN DAMAGE—TRAUMATIC BRAIN INJURY
Focal Brain Injury
Contusions
Intracranial Haemorrhage
Diffuse (Multifocal) Brain Damage
Diffuse Vascular Injury
Features of Raised Intracranial Pressure and Brain Swelling
Ischaemic Brain Damage
Diffuse Axonal Injury
PATHOLOGY OF TRAUMATIC HEAD INJURY IN CHILDREN
OTHER AREAS
Brainstem114,175,178,180
Primary Brainstem Injury
Secondary Brainstem Injury
Hypothalamus
Pituitary
Cranial Nerves
CELLULAR/MOLECULAR RESPONSE TO BRAIN INJURY
Inflammation and Cytokines
Hypersensitivity of Traumatised Brain to Secondary Cerebral Ischaemia
Ionic Events and Role of Excitatory Amino Acids in Traumatic Brain Injury
Role of Apolipoprotein E in the Outcome of Head Injury
Ethanol Potentiation of Central Nervous System Trauma
USE OF MRI IN ASSESSING THE TRAUMATIC BRAIN INJURY
Neuropathology of Post-Traumatic Sequelae
INTRODUCTION
CLASSIFICATION OF SPINAL CORD INJURIES
Mechanisms of Closed Injuries
Flexion and Deflexion Injuries
Compression Injuries
Rotation Injuries
Combined Mechanisms
Types of Cord Lesions in Closed Injury
Primary Traumatic Lesions
PATHOPHYSIOLOGY OF ACUTE SPINAL CORD INJURIES
Systemic Effects
Neurogenic Shock
Local Effects
Damage to the Microcirculation
Biochemical Changes
Electrolyte Shifts
STRATEGIES FOR TREATMENT OF SPINAL CORD INJURY
28:
Concussion Brain
INTRODUCTION
MECHANISM
PATHOGENESIS AND PROPOSED THEORIES
PATHOPHYSIOLOGY
CLINICAL PICTURE
STRUCTURAL AND FUNCTIONAL IMAGING
CUMULATIVE EFFECTS
SECOND IMPACT SYNDROME
RECOVERY TIME
GRADING SCALES
TREATMENT
29:
Cerebral Contusions
INTRODUCTION
CONTUSION
Pathology
LACERATION
Clinical Features
Frontal Lobe Injury
Sensorimotor Contusion
Cerebellar Injury
Hypothalamic Injury
Radiology
Management
Prognostic Factors
Outcome
Temporal Lobe Contusion
30:
Diffuse Axonal Injury
INTRODUCTION
PATHOPHYSIOLOGY
PATHOLOGY OF TRAUMATIC DIFFUSED AXONAL INJURY
INCIDENCE OF TRAUMATIC DIFFUSED AXONAL INJURY
CLINICAL PRESENTATION
DIAGNOSTIC STUDIES
Conventional Radiography
Computed Tomography Scan
Magnetic Resonance Imaging
DIFFERENTIAL DIAGNOSIS
MANAGEMENT OF TRAUMATIC DIFFUSE AXONAL INJURY
PROGNOSIS
CONCLUSION
31:
Fat Embolism
INTRODUCTION
AETIOLOGY
Traumatic Factors
Non-Traumatic Factors
Diseases
Drugs
PATHOPHYSIOLOGY
CLINICAL FEATURES OF FAT EMBOLISM SYNDROME
NEUROLOGICAL ABNORMALITIES
DIAGNOSIS
Gurd and Wilson's Criteria12
Lindeque et al. Criteria18
Laboratory Tests
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
Prevention
Treatment of Established Fat Embolism Syndrome
PROGNOSIS
ACKNOWLEDGEMENTS
32:
Paediatric Head Injuries
INTRODUCTION
GROWTH AND DEVELOPMENT
CLINICAL ASPECTS
Evaluation and Management of the Injured Child
Injuries in the Various Age Groups
Head Injuries in Haemophiliacs
SPECIFIC INJURIES AND PROBLEMS
CRITICAL CARE
Indications for Admission to the ICU
Neurosurgical Indications
Non-neurosurgical Indications
Care in the ICU
Monitoring in ICU
Managing in the ICU
General
Barbiturates
Diuretic
Ventilatory Support
Surgical Measures
Hypo/Hyperthermia
Seizures
Complications
SUMMARY
OUTCOME
CONCLUSION
33:
Clinical Assessment of a Head Injured Patient
INTRODUCTION
CONSCIOUS LEVEL
GENERAL EXAMINATION
CLINICAL HISTORY
GENERAL PHYSICAL EXAMINATION
NEUROLOGICAL ASSESSMENT
Pupillary Status and Optic Nerve Function
Eye Movements
Other Cranial Nerves
Motor Examination and Reflexes
SENSORY AND LOCAL EXAMINATION
BRAIN DEATH
SUMMARY
34:
Fluid and Electrolyte Balance in Head Injury
INTRODUCTION
GENERAL CONSIDERATIONS
Head Injury Patients
Normal Homeostatic Mechanisms
BASIC PHYSIOPATHOLOGICAL FACTS
Water Distribution in the Body
Sodium Distribution in the Body
Osmolarity of the ECF
Osmoreceptors
Hypovolaemia
Antidiuretic Hormone
Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP)
Serum Osmolality and Osmolarity
Loss of Fluid and Electrolytes
MAIN CLINICOPATHOLOGICAL CATEGORIES
HYPONATRAEMIA
Maintenance of Volume in Hyponatraemic States
Aetiopathogenesis
Differential Diagnosis
Hyperosmotic Hyponatraemia
Isosmotic Hyponatraemia
Hyposmotic Hyponatraemia
Common Hyponatraemic States in Head Injury Patients
Syndrome of Inappropriate ADH Secretion
Cerebral Salt Wasting Syndrome
Management2,5,12,19,20,27,33,35,41
SIADH19,20,33,41
Cerebral Salt Wasting Syndrome2,3,5,10,21,24,25,27,36,42,45
HYPERNATRAEMIA
Common Hypernatraemic States
Aetiopathogenesis2,4–6,11,15,17,22,27,30,35,37,39
Differential Diagnosis5,7,11–13,15,27,30,35,39,42
Diabetes Insipidus5,7,11–13,22,30,35,39,42
Clinical Manifestations
Diagnostic Tests1,5,28,29,30,35,39
Management1,2,5,7,11,12–14,22,25,30,39,42
CONCLUSION
35:
Scalp Injuries
INTRODUCTION
Historical Aspects
ANATOMY
DESCRIPTION OF SCALP INJURIES
Caput Succedaenum
Cephal-Haematoma
Abrasion
Age of the Abrasion
Contusion (Bruise)
Age of the Contusion
Laceration
Split Lacerations
Stretch Lacerations
Avulsion
Thermal Injury
Electrical Burns
Grading of Electrical Burns
Chemical Burns
Radiation Injury
MANAGEMENT
Resuscitation
Initial Evaluation of Scalp Injury
Aims of Management of Scalp Injury
Assessment
Assessment of the Scalp Injury Includes the Following
Surgical Principles in Treating Scalp Injuries
Surgical Planning and Execution
Reconstructive Ladder: Options for Covering the Scalp Defect
Free Skin Grafts
Split Skin Graft
Techniques of Flap Transfer
Flap Theory
Local Flaps
Local Scalp Flaps with Galeal Scoring
Medium-Sized Defects (6–8 cm)
Orticochea Flap Techniques
Large Defects (8–10 cm)
Pericranial Flaps and Overlying Skin Grafts or Local Flaps
Muscular Flaps
Rotation Flaps
Calvarial Reconstruction
Materials Used for Calvarial Reconstruction
Dural Closure and Intradural Repair
Tissue Expansion
Replantation
Omental Transfer
Complications of Scalp Injuries
FUTURE PERSPECTIVES
Scalp Transplantation
Foetal Tissue Healing
ACKNOWLEDGEMENTS
36:
Acute Subdural Haematomas
INTRODUCTION
AETIOPATHOGENESIS
CLINICAL SPECTRUM
IMAGING FEATURES
SURGICAL MANAGEMENT
OUTCOME
37:
Extradural Haematomas
INTRODUCTION
EPIDEMIOLOGY
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
DIAGNOSIS
MANAGEMENT
POSTERIOR FOSSA EDH (PFEDH)
MORBIDITY AND MORTALITY
CONCLUSION
38:
Traumatic Intracerebral Haematomas
CLASSIFICATION
INCIDENCE
INTRACEREBRAL HAEMORRHAGE
Immediate Intracerebral Haemorrhages
Cortical and Subcortical Haemorrhage
Petechial Haemorrhages
Massive Traumatic Intracerebral Haematoma
Delayed Intracerebral Haemorrhage
Stage of Initial Compression
Stage of Anaemia and Neuronal Paralysis
Stage of Irreversible Neuronal Failure
CLINICAL FEATURES
Conscious Level
Early Detection
Volumetric Measurement of Intracerebral Haematoma6
REGIONAL CEREBRAL BLOOD FLOW (rCBF) MEASUREMENT
GUIDELINES FOR THE TREATMENT OF TRAUMATIC ICH5
Treatment Strategies-Timing and Methods
OUTCOME
PREVENTION OF TRAUMATIC ICH
39:
Traumatic Brainstem Haematomas
HISTORY
INCIDENCE
MECHANISM OF INJURY
CLINICAL PRESENTATION
Cold Caloric Response (Vestibulo-Ocular Reflex)
Brainstem Auditory Evoked Response
RADIOLOGY
TREATMENT
Outcome in Patients with Traumatic BSH
CONCLUSION
40:
Complications and Sequelae of Head Injuries
INTRODUCTION
POST-TRAUMATIC AMNESIA
Evaluation of Post-Traumatic Amnesia
POST-TRAUMATIC (POST-CONCUSSION) SYNDROME
Pathophysiology
Clinical Profile and Evaluation
Treatment
NEUROBEHAVIOURAL SEQUELAE
Cognitive Impairment
Generalised Intellectual Impairment
Focal Cognitive Impairment
Recovery of Intellectual Function
Personality Change
Personality Change with Brain Damage
Personality Change without Brain Damage
Psychoses
Neuroses/Neurotic Disability
Memory Impairment
Neurobehavioural Sequelae in Children
Boxing Injuries
Pathology of Traumatic Brain Injury
Treatment of Neurobehavioural Sequelae
POST-TRAUMATIC EPILEPSY
Definition
Incidence
Pathophysiology
Early Post-Traumatic Epilepsy
Late Post-Traumatic Epilepsy
Prophylaxis and Treatment
41:
Cranioplasty
INTRODUCTION
AETIOLOGY OF THE CRANIAL DEFECT
CRANIOPLASTIC MATERIAL
PRESERVATION OF AUTOGRAFTS
NEED FOR RECONSTRUCTION
CRITICAL SIZE OF DEFECT THAT REQUIRES CRANIOPLASTY
ANATOMY OF THE DEFECT
TIMING OF RECONSTRUCTION
IMPORTANCE OF ADEQUATE SKIN COVER
CHOICE OF MATERIAL FOR CRANIOPLASTY
ALLOPLASTIC MATERIAL
FIXATION
CASE EXAMPLES
Case 1: Small Defect Frontal Region (Burr Holes)
Case 2: Sliding Bone Flap
Case 3: Large Defect with Skin Deficiency
Case 4: Large Defect in the Frontoparietal Region
Case 5: Depressed Frontal Bone Fracture, Use of Autogenous Bone and HA
42:
Maxillofacial Injuries
INTRODUCTION
GENERAL PRINCIPLES
CLINICAL EVALUATION OF FACIAL INJURIES
IMAGING
SOFT TISSUE INJURIES
FRACTURE OF THE MANDIBLE
Investigations
Management
MAXILLARY FRACTURES
FRACTURES OF THE ZYGOMA
NASAL FRACTURES
NASO-ORBITO-ETHMOID/FRONTO-ORBITO-ETHMOID FRACTURES
PAN-FACIAL FRACTURES
PAEDIATRIC FACIAL INJURIES
43:
Traumatic CSF Fistulae
CEREBROSPINAL FLUID RHINORRHOEA
Pathophysiology
Diagnosis
Investigations
Computerised Tomography Scan
Radionuclide Cisternography
Magnetic Resonance Imaging
Treatment
Indications for Surgery
CEREBROSPINAL FLUID OTORRHOEA
TRAUMATIC PNEUMOCEPHALUS
Treatment
44:
Missile Injuries of the Brain
HISTORICAL PERSPECTIVE
APPLIED BALLISTICS
Missiles
Energy Transfer
PHYSICAL EFFECTS OF MISSILE WOUNDING
PATHOPHYSIOLOGY
Effect on ICP and Cerebral Perfusion
Mechanism of Brain Injury
EVALUATION AND INITIAL MANAGEMENT
Imaging
Skull Radiograph
Computed Tomography
Carotid Angiography
OPERATIVE MANAGEMENT
PROBLEM OF RETAINED INTRACRANIAL FRAGMENTS
Infection (Fig. 6)
Epilepsy
Migration
ADJUNCTS TO OPERATIVE MANAGEMENT
Anticonvulsants
Management of Raised Intracranial Pressure
Antibiotics
CONCLUSIONS
45:
Endocrine Abnormalities following Traumatic Brain Injuries
INTRODUCTION
SCREENING FOR TRAUMATIC BRAIN INJURY-INDUCED HYPOPITUITARISM
Who Should Screen Patients?
Screening
WHO SHOULD UNDERGO IMMEDIATE HORMONAL REPLACEMENT?
WHO SHOULD UNDERGO FURTHER FOLLOW-UP BEFORE HORMONE REPLACEMENT?
PATHOGENESIS OF ENDOCRINAL ABNORMALITIES
CLINICAL SIGNS AND SYMPTOMS OF HYPOPITUITARISM
Endocrinological Symptoms of Hypopituitarism in Traumatic Brain Injury
INVESTIGATIONS
Routine Baseline Screening Tests
Provocative Testing
TREATMENT OF HYPOPITUITARISM
CONCLUSIONS
46:
Optic Nerve Injury
INTRODUCTION
ANATOMICAL AND PATHOLOGICAL CONSIDERATIONS
PATHOLOGY
Introduction
Optic Nerve Injury
Anterior Marginal Tear
Anterior Optic Nerve Injury
Posterior Optic Nerve Injury
PATHOPHYSIOLOGY OF OPTIC NERVE INJURY
PATHOLOGICAL ANATOMY
CLINICAL FEATURES
Fundus Finding
Field Defects in Optic Nerve Injury
INVESTIGATIONS
Role of Visual Evoked Potentials
Flash Visual Evoked Potential
TREATMENT OF OPTIC NERVE INJURY
Medical Management
Indications for Surgery
Optic Nerve Decompression
Endoscopic Optic Nerve Decompression
Surgical Technique for Optic Nerve Decompression
INTERNATIONAL OPTIC NERVE TRAUMA STUDY
OUTCOME AND FACTORS INFLUENCING OUTCOME
CHIASMAL INJURY
Pathological Types of Chiasmal Injuries
Pathogenesis
Clinical Findings
Diagnosis
Treatment
Visual Outcome in Chiasmal Injury
Injury to Posterior Visual Pathway
CONCLUSION
SECTION 5: SPINAL INJURIES
47:
Assessment and Emergency Management of Acute Spinal Injuries
INTRODUCTION
INITIAL TRAUMA EVALUATION
Suspicion of Injury to the Spine
PREADMISSION SPINE IMMOBILISATION
TRANSPORT OF SPINAL INJURED PATIENT
EVALUATION AND TRIAGE
CLINICAL EVALUATION
SPINAL INJURY GRADING SYSTEMS
Frankel Grading System
ASIA Score
SPINAL SHOCK
SPINAL CORD NEUROPRAXIA
WHIPLASH INJURIES
Incomplete Injury
Complete Injury
SPINAL INJURY SYNDROMES
BELL'S CRUCIATE PARALYSIS SYNDROME
ANTERIOR CORD SYNDROME
POSTERIOR CORD SYNDROME
BROWN SEQUARD SYNDROME29
CONUS MEDULLARIS SYNDROME
CAUDA EQUINA SYNDROME
CENTRAL CORD SYNDROME
SPINAL INSTABILITY
Degrees of Instability
RADIOLOGICAL ASSESSMENT
X-Rays
Cross Table Lateral View
Computerised Tomography
CT Myelogram
CT Angiogram
Magnetic Resonance Imaging
Dynamic Imaging
SPINAL SCREENING
CLASSIFICATION AND A BRIEF OVERVEIW OF SPINAL TRAUMA
OCCIPITOCERVICAL DISLOCATION
OCCIPITAL CONDYLE FRACTURES
ATLAS FRACTURES
AXIS (C-2) FRACTURES70,90
Odontoid Fractures
Traumatic Spondylolisthesis of the Axis
Miscellaneous C-2 Fractures
ATLANTOAXIAL DISLOCATION
Atlantoaxial Rotatory Instability
Atlanto-Dens Instability
OS ODONTOIDEUM
COMBINATION FRACTURES OF C1–C2
SUBAXIAL CERVICAL SPINE TRAUMA (C3-T1)100,151
Flexion Injuries
Extension Injuries
Thoracolumbar Injuries
Sacral Injuries
Intensive Care Management of Spinal Injuries
Cardiovascular
RESPIRATION
AUTONOMIC SYSTEM MANAGEMENT
NUTRITION IN SPINAL INJURY PATIENTS
MEDICAL AND PHARMACOLOGIC
METHYLPREDNISOLONE
TRACTION
Applying Traction
Extension Traction
Neutral Traction
Flexion Traction
ORTHOTIC DEVICES IN SPINE TRAUMA
Halo
Minerva Jacket
Soft Cervical Collar
Philadelphia Collar
Yale Brace
SURGERY
PAEDIATRIC SPINE INJURIES
Spinal Cord Injury without Radiographic Abnormality120
Geriatric Spine Injuries
Deep Vein Thrombosis44
Vertebral Artery Injury
Double Noncontiguous Spinal Injuries
Neglected Spinal Injuries
OUTCOME SCORES
FUTURE GOALS
RECOMMENDED READING
48:
Biomechanics of the Spine
INTRODUCTION
HISTORICAL BACKGROUND
BIOMECHANICAL TERMINOLOGY
Scalar
Vector
Force Vector or Load Vector
Cartesian Co-ordinate System
Deformation
Strain
Stiffness
Biomechanical Load Deflection Response
Coupling
Instantaneous Axis of Rotation
Range of Movement
Relaxation
Creep
Elastic Deformation
Plastic Deformation
Break Point
Hysteresis
Kyphosis
Junghans Motion Segment
Bending Movement
BIOMECHANICAL TESTING METHODS
In vivo Testing
In vitro Testing
Mathematical Model Testing (Finite Element Analysis)
Biomechanical Tests can be Dynamic and Static
ROLE OF IMAGING IN BIOMECHANICS
Radiography
Computed Tomography
Magnetic Resonance Imaging
BRIEF NORMAL ANATOMY OF THE SPINE
Curvatures of the Vertebral Column
Vertebral Body
Facet Joints
Pedicles
Intervertebral Discs
Annulus Fibrosus
Nucleus Pulposus
Spinal Canal
Ligaments
Anterior Longitudinal Ligament
Posterior Longitudinal Ligament
Ligamentum Flavum
Capsular Ligaments
Interspinous and Supraspinous Ligaments
SPECIAL REGIONAL ANATOMY
Craniovertebral Junction
Sub-Axial Cervical Spine
Cervicodorsal Junction
Thoracic Spine
Thoracolumbar Junction
Lumbar Spine
Lumbosacral Junction
SPINAL STABILITY AND INSTABILITY
NEURAL CONTROL
ROLE OF THE MUSCULATURE
DEFINITION OF CLINICAL INSTABILITY OF WHITE AND PANJABI
Acute
Chronic
THEORY OF LOUIS
TWO COLUMN THEORY OF HOLDSWORTH
THREE COLUMN THEORY OF DENIS
EVANS FLAGPOLE CONCEPT
WHITESIDE'S CONSTRUCTION CRANE ANALOG OF THE SPINE
BIOMECHANICS AND AXIAL TRACTION
BIOMECHANICS OF TRAUMA
APPLIED BIOMECHANICS
BIOMECHANICS OF SPINE DEFORMITY
BIOMECHANICS OF CORD INJURY
BIOMECHANICS OF BONE GRAFTS
BIOMECHANICS OF SPINAL IMPLANTS
FUTURE OF BIOMECHANICS
RECOMMENDED READING
49:
Injuries of the Craniovertebral Junction and Upper Cervical Spine
INTRODUCTION
SURGICAL ANATOMY
CLINICAL FEATURES
OCCIPITOCERVICAL DISSOCIATION
OCCIPITOCERVICAL INSTABILITY
CONDYLAR FRACTURES
ATLAS FRACTURES
Classification of Atlas Fractures
Clinical Presentation
Diagnosis
Treatment and Results
RUPTURE OF TRANSVERSE LIGAMENT
ODONTOID FRACTURES
Treatment
TRAUMATIC SPONDYLOLISTHESIS (HANGMAN'S FRACTURE)
OPTIONS OF SURGICAL PROCEDURES FOR CRANIOVERTEBRAL JUNCTION TRAUMA
Posterior Fusion Techniques
Wiring Techniques
Gallie's Technique
Brooks’ and Jenkin's Technique
Dickman and Sonntag
Interlaminar Clamps
Jeanneret and Magerl Transarticular Screw Technique
Goel and Laheri/Harms and Melcher Fixation
Crossed C2 Intralaminar Screws
Occipitocervical Lateral Mass Polyaxial Rod and Screw Placement
Anterior Fusion Techniques
Odontoid Screw Fixation
Anterior Atlantoaxial Facet Screw Fixation
SUMMARY
50:
Injuries of the Subaxial Cervical Spine
INTRODUCTION
HISTORICAL BACKGROUND
Posterior Era
Anterior Era
ANATOMICAL CORRELATES OF THE SUBAXIAL CERVICAL SPINE
MECHANISMS AND TYPES OF INJURY
CLASSIFICATION OF SUBAXIAL CERVICAL SPINE INJURIES
Flexion Injuries
Flexion-Compression Injuries
Flexion-Distraction Injuries
Vertical Compression Injuries
Extension Injuries
MANAGEMENT
Intensive Care and Initial Management
Steroids
Venous Thromboprophylaxis
EXAMINATION
INVESTIGATIONS (IMAGING OF THE SUBAXIAL CERVICAL SPINE IN TRAUMA)
Static X-Rays
Dynamic X-Rays: Flexion Extension Views
Computerised Tomography
Magnetic Resonance Imaging
TREATMENT
CONSERVATIVE
Axial Controlled Traction
Halo
Surgery
GUIDELINES
Subaxial Cervical Facet Dislocation Injuries
Subaxial Cervical Injuries Excluding Facet Dislocation Injuries
Unilateral Locked Facets
LATERAL MASS FRACTURES
Spondyloptosis
Burst Fractures
Laminar Fractures
Management
Anterior Instrumentation
Posterior Instrumentation
POST-TRAUMATIC DISC
Combined Anterior and Posterior Approaches
Circumferential Fusion
Instrumentation
OUTCOME
Functional Outcome Assessment
COMPLICATIONS
Carotid Artery Injury
Vertebral Artery Injury
Injury to the Spinal Cord and Roots
Injury to the Recurrent Laryngeal Nerve
Injury to the Sympathetic Trunk
Distraction Injury
PAEDIATRIC SUBAXIAL SPINE INJURIES
GERIATRIC SUBAXIAL SPINE INJURIES
DELAYED SUBAXIAL SPINE INSTABILITY
FUTURE TRENDS AND PREVENTIVE NEUROSURGERY
51:
Whiplash Injury
MECHANISM AND PATHOLOGY
CLINICAL PROFILE
IMAGING
Cervical Spine Radiographs
Magnetic Resonance Imaging
MANAGEMENT
52:
Thoracic and Thoracolumbar Injuries
INTRODUCTION
EPIDEMIOLOGY AND AETIOLOGY
CLASSIFICATION
ASSOCIATED INJURIES
PREDISPOSING FACTORS
CLINICAL FEATURES AND ASSESSMENT
IMAGING
Plain Radiography
Computerised Tomography Scanning
Magnetic Resonance Imaging
CONCEPT OF INSTABILITY
MANAGEMENT
Triage Care
Non-Surgical Management
Surgical Management
Goals of Surgery
Controversy over Decompression and Timing of Surgery in Patients with Neurological Deficits
Controversy over the Treatment of Burst Fractures without Neurological Deficit
Available Options for Surgery
Decision Making
OPEN SPINE INJURIES
CONCLUSION
ACKNOWLEDGEMENT
53:
Lumbar and Lumbosacral Injuries
CLASSIFICATION
CLINICAL FEATURES
DIAGNOSTIC TESTS
MANAGEMENT
54:
Penetrating Injuries of the Spine
INTRODUCTION
LOCATION OF WOUND
APPLIED BALLISTICS
The Missiles
Energy Transfer
Physical Effects of Missile Wounding
Missiles and Mechanism of Injury
Illustrative Cases
APPROACH TO A PATIENT WITH MISSILE INJURIES OF THE SPINE
Imaging
Plain Radiography
Myelography
Computed Tomography
Magnetic Resonance Imaging
Controversies and Evolution of Treatment Philosophy
Surgical versus Conservative Management
Intraspinal Fragment
Associated Injuries and Spinal Cord Decompression
Cauda Equina Injury
Spine Stabilisation
CURRENT MANAGEMENT
Wound Debridement
Operative Management for Missile Injuries of the Spine
Post-Operative Management
Prevention of Deep Vein Thrombosis
SEQUELAE
Pain
Delayed Neurological Deterioration
Lead Toxicity
Mode of Injury
APPROACH
Neurological Presentation
Imaging
Surgical Approach
SECTION 6: PERIPHERAL NERVE
55:
Anatomy and Physiology of the Peripheral Nerve
NEURON
Classification
On the Basis of Processes
On the Basis of Function
Structure
Cell Body
Dendrites
Axons
Schwann Cells
NERVES
Histology of a Nerve Fibre
Endoneurium
Perineurium
Epineurium
Basic Nerve Physiology
Excitation and Conduction
Resting Membrane Potential
Latent Period
Action Potential
All or None Law
Ionic Basis of Excitation and Conduction
Ionic Basis of the Resting Membrane Potential
Ionic Fluxes During Action Potential
Neuromuscular Junction
Peripheral Nerve Transection
Seddon's Classification of Nerve Injury
Sunderland Classification of Nerve Injury
Neurotrophic Factors
56:
General Principles of Management of Peripheral Nerve Injuries
INTRODUCTION
ANATOMY
PATHOPHYSIOLOGY OF NERVE INJURY
NERVE REGENERATION
CLASSIFICATION SYSTEMS FOR PERIPHERAL NERVE INJURY
PATHOGENESIS OF PERIPHERAL NERVE INJURIES
Open Injuries
Laceration Injuries
Gunshot Wounds
Iatrogenic Injuries
Closed Injuries
Stretch Injuries
Crush Injuries
Ischaemic/Compressive Injuries
Electrical/Thermal Injuries
CLINICAL AND ELECTROPHYSIOLOGICAL EVALUATION
RADIOLOGICAL EVALUATION
MANAGEMENT OF PERIPHERAL NERVE INJURIES
PRINCIPLES OF SURGICAL NERVE REPAIR
Exposure of the Healthy Nerve Proximal and Distal to the Site of Injury
Intra-operative Electrophysiological Evaluation
Intra-operative Microscopic Examination by Quick (Frozen) Section
Fascicular Microsuture Technique
Technical Pearls
Avoidance of Tension
Using a Minimal Number of Sutures
Maximising the Number of Motor Fibres Available for Repair
Matching the Graft to Recipient Nerve Fascicles
POST-OPERATIVE MANAGEMENT
Immobilisation
Follow-up Electrodiagnostic Studies
Prognosis and Reasons for Failure
57:
Surgical Anatomy and Management of Brachial Plexus Injuries
INTRODUCTION
SURGICAL ANATOMY
CLASSIFICATIONS
Anatomical
CLINICAL EXAMINATION
DIAGNOSTIC STUDIES
Imaging Studies
Magnetic Resonance Imaging
Neurophysiological Examination
Electromyography
Sensory Nerve Action Potentials
Somatosensory Evoked Potentials
MANAGEMENT
Surgical Exploration
Techniques
Direct Nerve Repair
Neurolysis
Nerve Grafting
Nerve Crossing
Direct Neurotisation8
FUNCTIONAL FREE MUSCLE TRANSFER
Doi Procedures4,5
First Stage
Second Stage
OBSTETRICAL BRACHIAL PLEXUS PALSY
PROGNOSIS
FUTURE
58:
Management of Injuries to Specific Peripheral Nerve
GENERAL CONSIDERATIONS
Introduction
Anatomy
Mechanisms of Nerve Injuries
Open Injuries
Closed Injuries
Miscellaneous Injuries
Grading of Nerve Injuries
Evaluation of Nerve Injury
Philosophy of Management
Closed Injuries
Treatment Options
Sutureless Repair
Nerve Grafts
Post-Operative Management
59:
Entrapment Syndromes
INTRODUCTION
TRAUMATIC AND ENTRAPMENT NEUROPATHIES18
Carpal Tunnel Syndrome
Aetiology
Associated Disorders
Epidemiology
Clinical Manifestations
Prevention
Differential Diagnosis
Diagnostic Workup
Management
Prognosis and Complications
Median Nerve Entrapment at Other Sites
Ulnar Entrapment at the Elbow
Aetiology
Prevention
Differential Diagnosis
Management
Ulnar Entrapment at Other Regions
Prognosis
Radial Nerve Entrapment
Aetiology
Management
Sciatic Neuropathy
Piriformis Syndrome
Aetiology
Management
Peroneal Neuropathy
Diagnosis
Management
Tibial Neuropathy
Proximal Tibial Nerve
Distal Tibial and Plantar Nerves
Digital Neuropathies (Morton Neuromas)
Sural Neuropathy
Thoracic Outlet Syndrome
Clinical Manifestations
Aetiology
Differential Diagnosis
Diagnostic Workup
Management
Meralgia Paraesthetica
SECTION 7: INFECTIONS
60:
Brain Abscess
INTRODUCTION
INCIDENCE
HISTORY
AETIOPATHOGENESIS
In Association with Contiguous Suppurative Focus
Otogenic Abscess
Paranasal Sinus Infection
Periodontal Infection
Bacterial Meningitis
Post-Traumatic
Metastatic Abscess
Cryptogenic
Miscellaneous Causes of Brain Abscess
Post-Operative Abscess
MICROBIOLOGY OF BRAIN ABSCESS
PATHOGENESIS OF DEVELOPMENT OF BRAIN ABSCESS AND CAPSULE FORMATION
Early Cerebritis Stage (1st to 3rd Day)
Late Cerebritis Stage (4th to 9th Day)
Early Capsule Formation (10th to 13th Day)
Late Capsule Formation (14th Day and Beyond)
CLINICAL FEATURES
LABORATORY INVESTIGATIONS
RADIOLOGICAL INVESTIGATIONS
X-Ray Skull
Computed Tomography
Magnetic Resonance Imaging
Magnetic Resonance Spectroscopy
Diffusion Weighted Imaging
TREATMENT
Medical Treatment
Surgical Treatment
Management of Multiple Abscesses
Role of Corticosteroids
COMPLICATIONS
Epilepsy
OUTCOME AND PROGNOSIS
61:
Scalp and Skull Infections
SCALP LACERATIONS
POST-OPERATIVE SCALP INFECTION
CRANIOTOMY AND SCALP INFECTION
DEEP BRAIN STIMULATION AND SCALP INFECTION
PIN SITE SCALP INFECTION
OTHERS
Diagnosis
Management
SKULL OSTEOMYELITIS
Pathogenesis
Pathogens
Clinical Features
Investigation
Management
62:
Subdural Empyema
INTRODUCTION
IMAGING
MICROBIOLOGY
MANAGEMENT
63:
Spinal Epidural and Intramedullary Abscess
SPINAL EPIDURAL ABSCESS
Relevant Anatomy and Pathophysiology
Epidemiology
Clinical Features
Diagnosis
Laboratory Investigations
Imaging
Treatment
Outcome
SPINAL INTRAMEDULLARY ABSCESSES
Pathogenesis
Clinical Features
Management
Outcome
SPINAL INTRAMEDULLARY TUBERCULOMAS
64:
Tuberculosis of the Central Nervous System
INTRODUCTION
HISTORY
PATHOGENESIS
CENTRAL NERVOUS SYSTEM TUBERCULOSIS
INTRACRANIAL TUBERCULOMAS
Incidence
Pathology
Tuberculoma En Plaque
Tuberculous Abscess
Cystic Tuberculoma
Multiple Grape-like Tuberculomas
Microtuberculomas
Calcified Tuberculoma
Tuberculous Encephalopathy with an “Inconsequential” Tuberculoma
Microscopy
Clinical Features
Age and Sex
Sites
Symptoms and Signs
Investigations
Computerised Tomography
Magnetic Resonance Imaging
Magnetic Resonance Spectroscopy
Stereotactic Biopsy
Treatment
Multi-Drug Resistant Tuberculosis
Role of BCG
Surgical Treatment
65:
Tuberculous Meningitis
INCIDENCE
AETIOPATHOGENESIS
EARLY DIAGNOSIS
LABORATORY INVESTIGATIONS
LATE DIAGNOSIS AND COMPLICATIONS
Acute Stage of the Disease
Raised Intracranial Pressure Pathogenesis
Diagnosis and Treatment
Subacute and Chronic Stage of the Disease
Tuberculous Endarteritis
Involvement of Large Arteries
Tuberculomas and Tuberculous Abscess
Basal Meningitis
Hydrocephalus
Clinical Picture
Investigations
Treatment
Results
SEQUELAE OF THE DISEASE
Optochiasmal Arachnoiditis
Malnourishment
Endocrine Signs
Tuberculous Spinal Arachnoiditis
Incidence
Pathology
Clinical Features
Magnetic Resonance Findings
Treatment
66:
Tuberculosis of the Spine
HISTORY
INCIDENCE
PATHOLOGY AND PATHOGENESIS
Route of Infection
Types of Lesions
Neurological Involvement
Pathology
CLINICAL PRESENTATION
Associated Lesions
Neurological Deficit
IMAGING
Plain X-rays
Magnetic Resonance Imaging
Radioisotope Bone Scans
TREATMENT
Evolution of Treatment
Posterior Fusion
Antibiotic Therapy
Conservative Therapy
Bed Rest or Ambulation
Excisional Therapy and Grafting
Bone Grafting
Instrumentation
Factors Influencing Results
Surgery for Paraplegia
Conservative Approach Justified
RECENT TRENDS IN THE MANAGEMENT OF SPINAL TUBERCULOSIS
Late Onset Paraplegia
Correction of Kyphosis
Indications of Surgical Therapy
CRANIOVERTEBRAL TUBERCULOSIS
Treatment
67:
Surgery for Leprosy
INTRODUCTION
HISTORICAL REVIEW
EPIDEMIOLOGY
PATHOLOGY OF NERVE INVOLVEMENT
Common Sites
Entry of Bacilli into the Nerve and Establishment of Neuritis
Nerve Damage in Reactions
Type I Reaction (Reversal or Upgrading Reaction)
Type II Reaction (Erythema Nodosum Leprosum)
Nerve Abscess
CLINICAL FEATURES OF NEURITIS
DIFFERENTIAL DIAGNOSIS
TREATMENT
Medical
Treatment of Acute Neuritis
Surgical Decompression
Indications for Decompression
Ulnar Nerve Procedure
Median Nerve
Radial Nerve
Common Peroneal Nerve
Posterior Tibial Nerve
PARALYTIC DEFORMITIES
Hand
DYNAMIC TENDON TRANSFER
General Principles
Claw Hand
Foot Drop
Facial Palsy
Tarsorrhaphy
Kuhnt-Szymanowsky Procedure
Dynamic Transfer
MISCELLANEOUS SURGICAL CONDITIONS
Contractures
Trophic Foot Ulcer
Facial Deformities
Gynaecomastia
68:
Cysticercosis
INTRODUCTION
LIFE CYCLE AND PATHOGENESIS
Life Cycle
The Adult Worm
Disposition of Gravids
The Larval Stage (Intermediate Host-Pig)
Ingestion of Larvae by Humans
Humans are Accidental Intermediate Host
Pathogenesis
Stages of Involution of Cysticerci
Pathologic Changes in the Central Nervous System
Parenchymatous
Meningeal
Intraventricular and Subarachnoid
Spinal
EPIDEMIOLOGY
Neurocysticercosis in Developing Countries
Cysticercosis in India
CLINICAL MANIFESTATIONS
RADIOLOGICAL INVESTIGATIONS
DIAGNOSIS
Absolute Criteria
Histological Demonstration of the Parasite from Biopsy of a Brain or Spinal Cord Lesion
Cystic Lesions Showing the Scolex on CT or MRI
Direct Visualisation of Subretinal Parasites by Funduscopic Examination
Major Criteria
Lesions Highly Suggestive of NSS on Neuroimaging Studies
Positive Serum Enzyme-Linked Immunoelectrotransfer Blot Assay (EITB) for the Detection of Antibodies to T. Solium Glycoprotein Antigens
Spontaneously Resolving Small Single Enhancing Lesions
Resolution of Intracranial Cystic Lesions after Therapy with Albendazole or Praziquantel
Minor Criteria
Lesions Compatible with NCC on Neuroimaging Studies
Clinical Manifestations Suggestive of Neurocysticercosis
Positive CSF Enzyme-Linked Immunosorbent Assay (ELISA) for Detection of Anticysticercal Antibodies or Cysticercal Antigens
Cysticercosis Outside the Central Nervous System
Epidemiologic Criteria
TREATMENT
Medical Treatment
Symptomatic Medical Therapy
Surgery
Endoscopic Excision
Spinal Neurocysticercosis
Shunt
PREVENTION AND CONTROL
69:
Hydatid Disease
PARASITOLOGY
EPIDEMIOLOGY
CEREBRAL ECHINOCOCCOSIS
Incidence
Pathology
Clinical Features
Diagnosis
Treatment
HYDATID DISEASE OF THE CRANIUM
Clinical Features
Diagnosis
Treatment
70:
Other Parasitic Infestations of the Brain
COENEUROSIS CEREBRALIS
SCHISTOSOMIASIS (BILHARZIASIS)
PARASITOLOGY
Route of Involvement
CEREBRAL SCHISTOSOMIASIS
Schistosoma Japonicum
Schistosoma Mansoni and Schistosoma Haematoma
Treatment
SPINAL SCHISTOSOMIASIS
Treatment
PARAGONIMIASIS
Diagnosis
STRONGYLOIDIASIS
Diagnosis
Treatment
TRICHINOSIS
Treatment
CEREBRAL SPARGANOSIS MANSONI
VISCERAL AND OCULAR LARVA MIGRANS
71:
Spinal Hydatidosis
LIFE CYCLE AND SPINAL IMPLANTATION
INCIDENCE
PATHOGENESIS AND PATHOLOGY
CLINICAL FEATURES
IMAGING
Plain Radiographs
Magnetic Resonance Imaging
Computed Tomography
SEROLOGICAL DIAGNOSIS
SURGICAL MANAGEMENT
MEDICAL MANAGEMENT
PERCUTANEOUS ASPIRATION, INJECTION, REASPIRATION (PAIR)
PREVENTION OF ECHINOCOCCOSIS
72:
Fungal Infections
GENERAL CONSIDERATIONS
CLASSIFICATION
Pseudo Mycetes
Septate Mycetes
Non-Septate Mycetes
Fungi Like Bacteria109
PATHOGENESIS
Pathogenic Fungi
Opportunistic Fungi
Meningitis
Meningoencephalitis
Brain Abscesses/Infarction/Haemorrhages
CLINICAL FEATURES
Meningeal Syndromes
Space Occupying Lesions
Rhinocerebral Syndrome
Stroke Syndromes
Skull Base Syndromes
Spinal Syndromes
DIAGNOSIS
Evidence of Fungal Infection in the Central Nervous System
Cerebrospinal Fluid Examination
Imaging Techniques
Biopsy
Evidence of Fungal Infections Elsewhere in the Host
Evidence of Immunological Compromise
TREATMENT
Non-Specific Measures
Specific Measures
Antifungals can be classified as:
Surgical Management
PROGNOSIS
Poor Prognostic Factors
CRYPTOCOCCOSIS
Cerebral Cryptococcosis
Pathology
Spinal Cryptococcosis
Pathology
Diagnosis
Treatment
ASPERGILLOSIS
NORTH AMERICAN BLASTOMYCOSIS
NOCARDIOSIS
COCCIDIOIDOMYCOSIS
CANDIDIASIS
MUCORMYCOSIS
PSEUDOALLESCHERIA BOYDII
73:
Viral Infections
HERPES SIMPLEX ENCEPHALITIS
HERPES ZOSTER (VARICELLA ZOSTER)
RAMSAY HUNT SYNDROME
REYE'S SYNDROME
CREUTZFELDT-JAKOB DISEASE
POLYOMA VIRUS
RABIES VIRUS
ENTEROVIRUS CENTRAL NERVOUS SYSTEM INFECTIONS
H1N1 VIRUS
EPSTEIN-BARR VIRUS
CYTOMEGALOVIRUS
HUMAN HERPES VIRUS 6
JAPANESE ENCEPHALITIS
74:
AIDS and the Neurosurgeon
HISTORICAL PERSPECTIVE
THE VIRUS
PATHOGENESIS
CLINICAL FEATURES7,19,25,35,37,44
NEUROLOGICAL MANIFESTATIONS OF ACQUIRED IMMUNODEFICIENCY SYNDROME
PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA
PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY
TOXOPLASMOSIS
MENINGITIS
Cryptococcal Meningitis
Carcinomatous Meningitis
Aseptic Meningitis
TUBERCULAR INFECTION
AIDS ENCEPHALOPATHY AND AIDS DEMENTIA COMPLEX
HIV MYELOPATHY
PERIPHERAL NERVOUS SYSTEM
CEREBROVASCULAR DISEASE
OTHER UNCOMMON NEUROLOGICAL PRESENTATIONS
DIAGNOSIS OF HIV
MANAGEMENT OF INTRACRANIAL LESIONS
BIOPSY IN AIDS
RISKS IN HEALTH PROFESSIONALS
ADDITIONAL PRECAUTIONS WHEN CARING FOR KNOWN HIV POSITIVE AND HIGH-RISK PATIENTS
TRANSMISSION FROM HEALTH WORKERS TO PATIENTS
PRECAUTIONS FOR INFECTED HEALTH WORKERS
INVASIVE PROCEDURES TO BE AVOIDED BY E-ANTIGEN OR HIV POSITIVE HEALTH WORKERS
SECTION 8: VASCULAR DISORDERS
75:
Subarachnoid Haemorrhage
INTRODUCTION
EPIDEMIOLOGY
AETIOLOGY
CLINICAL FEATURES
Grading of Clinical Status
MISDIAGNOSIS OF SUBARACHNOID HAEMORRHAGE
INVESTIGATIONS
Computed Tomography Brain
Lumbar Puncture
Angiography
Computed Tomography Angiography and Magnetic Resonance Angiography
MANAGEMENT OF SUBARACHNOID HAEMORRHAGE
Acute Management
Prevention of Rebleed
PATIENT OUTCOME FOLLOWING SUBARACHNOID HAEMORRHAGE
PERIMESENCEPHALIC SUBARACHNOID HAEMORRHAGE
CONCLUSION
76:
General Principles of Management of Intracranial Aneurysms
INTRODUCTION
GENETICS
CLINICAL FEATURES OF RUPTURED ANEURYSMS
CLINICAL PRESENTATION OF UNRUPTURED ANEURYSMS
DIAGNOSIS
Computed Tomography Angiography
Four-Dimensional Computed Tomography Angiography
Technique
Magnetic Resonance Angiography
Intra-Arterial Digital Subtraction Angiography
LOCATION OF INTRACRANIAL ANEURYSMS
AGE AND SEX DISTRIBUTION
MANAGEMENT OF ANEURYSMS
ANEURYSMS IN NEONATES AND CHILDREN
Intracranial Aneurysms in Neonates
Diagnosis
Treatment
Complications
Outcome
Intracranial Aneurysms in Children
Treatment
ANEURYSMS IN THE EIGHTH AND NINTH DECADE
FUSIFORM ANEURYSM
Pathogenesis
Treatment of Fusiform Aneurysms
MANAGEMENT OF RUPTURED ANEURYSMS
Surgical Principles
Positioning and Craniotomy
Further Steps
MANAGEMENT OF COMPLEX ANEURYSMS
TRAUMATIC INTRACRANIAL ANEURYSMS
Pathogenesis
Clinical Presentation
POST-OPERATIVE MANAGEMENT OF INTRACRANIAL ANEURYSMS
77:
Vasospasm and Its Management
INTRODUCTION
BRIEF HISTORICAL OVERVIEW OF VASOSPASM
INCIDENCE
CHRONOLOGY
Immediate or Acute Vasospasm
Early Spasm
Late Vasospasm
RISK FACTORS FOR DEVELOPING VASOSPASM
SITE OF OCCURRENCE
CLASSIFICATION AND GRADING OF VASOSPASM
Classification According to Size of Vessel
Small Vessel Spasm
Large Vessel Spasm
Grading According to Severity
Fisher Grading System
EXPERIMENTAL MODELS FOR STUDYING VASOSPASM
Two-Haemorrhage Model
Perforation Model
Prechiasmatic SAH Model
Primate Model
Cultured Cells
Computational and Mathematical Models
AETIOPATHOGENESIS OF VASOSPASM
Is Vasospasm Protective?
BIOLOGY OF CEREBRAL BLOOD VESSELS
Genetics and Pathophysiology of Vasospasm at the Molecular Level
Red Blood Cells, Components and Other Spasmogens
VASCULOPATHY
TRAUMA OF MANIPULATION OF THE ARTERIES
HYPOTHALAMUS
SYMPATHETIC PLEXUS
Role of Nitric Oxide in Vasospasm
APOPTOSIS AND VASOSPASM
CASCADE OF EVENTS BEFORE AND AFTER VASOSPASM
EARLY BRAIN INJURY
CLINICAL FEATURES OF VASOSPASM
INVESTIGATIONS
Cerebral Blood Flow Studies
Electroencephalography
Transcranial Doppler
Lindegaard Index
Angiography
Computerised Tomography
Computerised Tomography-Angiography
Single-Photon Emission Computed Tomography
Xenon-Computed Tomography Scan
Perfusion Computed Tomography-Scan
Magnetic Resonance Imaging
Magnetic Resonance-Angiography
Positron Emission Tomography Scan
TREATMENT
Initial Intensive Care Unit Management
Triple-H Therapy
Induced Hypertension, Hypervolaemia, Haemodilution
Induced Hypertension
PHARMACOLOGICAL PREVENTION OF VASOSPASM
Calcium Channel Blockers
Nimodipine
Nicardipine
Free Radical Scavengers
Endothelin
Nitric Oxide
Vasoconstriction due to Deficiency of Endothelial Nitric Oxide
Recombinant Tissue Plasminogen Activator
Papaverine
Intra-arterial Papaverine
Statins
Miscellaneous
TIMING OF SURGERY IN RELATION TO VASOSPASM
SURGERY
Interventional Neurosurgery
Cerebrospinal Fluid Drainage
OUTCOME
Preventive Neurosurgery—The Future
CONCLUSION
78:
Cerebral Protection
INTRODUCTION
PATHOPHYSIOLOGY OF INJURY TO THE CENTRAL NERVOUS SYSTEM
Intracellular Calcium Accumulation
Excessive Activation of Excitatory Amino Acid Receptors
Voltage-Gated Calcium Channels
Other Sources of Intracellular Calcium
Lipid Peroxidation
Role of Oxygen-Free Radicals
PROTECTIVE MECHANISM AGAINST OXYGEN-FREE RADICALS
MODALITIES OF CEREBRAL PROTECTION
PHARMACOLOGICAL THERAPIES
Barbiturates
Isoflurane
Etomidate
Calcium Entry Blockers
Classification of Calcium Entry Blockers
Mechanism of Protection by Calcium Entry Blockers
Diuretics
Mannitol
Furosemide
Steroids
Phenytoin
Perfluorochemical Blood Substitutes
Sendai Cocktail
Excitotoxic Antagonists
Antioxidants/Free Radical Scavengers
NON-PHARMACOLOGICAL THERAPIES
Hypothermia
Mechanism of Protection by Hypothermia
Recommended Limits of Total Circulatory Arrest under Deep Hypothermia
Systemic Effects of Deep Hypothermia
Hyperventilation
Hypertension, Hypervolaemia and Haemodilution (Triple H Therapy)
Hypertension
Hypervolaemia
Haemodilution
Agents for Volume Expansion
Induced Hypotension
Relative Contraindications to Induced Hypotension
Complications of Induced Hypotension
Agents for Induced Hypotension90
Electrophysiological Monitoring
79:
Paraclinoid Aneurysms
INTRODUCTION
NEUROANATOMY
Paraclinoid Internal Carotid Artery
Review of Classification Schemes
Classification of Paraclinoid Aneurysms
Carotico-ophthalmic Aneurysms
Ventral or Posterior Wall Aneurysms
Superior Hypophyseal Aneurysms
Siphon or Transitional Aneurysms
Clinical Presentation
SPECIAL RADIOLOGICAL CONSIDERATIONS
THERAPEUTIC OPTIONS
Clip Alone
Ligature and Clip
Trapping of the ICA with or without Extracranial-Intracranial Bypass
Circumferential Wrapping
Cardiopulmonary Bypass with Profound Hypothermia and Circulatory Arrest
Endovascular Treatment
Progression of Thrombosis
Refilling
Surgical Considerations
Craniotomy
Proximal Control
Untethering of the Optic Nerve
Anterior Clinoidectomy
Dural Ring Division
Dissection
Clipping
Accessing Bilateral Carotico-ophthalmic Aneurysms via the Same Approach
Precautions during Surgery
Prevention of Optic Nerve Injury
Avoidance of Cerebrospinal Fluid Rhinorrhoea
Avoidance of Arterial Lumen Compromise during Aneurysm Clipping
Outcome
80:
Internal Carotid Bifurcation Aneurysms
INTRODUCTION
ANATOMY
PRE-OPERATIVE EVALUATION
Position and Skin Incision
INTRA-OPERATIVE RUPTURE
TEMPORARY CLIPPING3,12,21,23,34
GIANT ANEURYSMS17,31
COMPLICATIONS
Endovascular Treatment
ACKNOWLEDGEMENT
81:
Anterior Communicating Artery Aneurysms
INTRODUCTION
INCIDENCE
AETIOLOGY
SURGICAL MILESTONES IN THE MANAGEMENT OF ANTERIOR COMMUNICATING ARTERY ANEURYSMS
MICROSURGICAL ANATOMY OF ANTERIOR COMMUNICATING ARTERY COMPLEX
Anterior Cerebral Artery
ANTERIOR COMMUNICATING ARTERY COMPLEX
Supreme Anterior Communicating Artery
CLINICAL FEATURES
The “ACoA Syndrome”
Neuropsychological Symptoms
Visual Symptoms
Endocrinological Symptoms
Hydrocephalus
INVESTIGATIONS
Conventional Angiography
Computerised Tomography
3D Computerised Tomography Angiography
Magnetic Resonance Imaging and Magnetic Resonance Angiography
CLIPPING AND COILING DEBATE IN THE MANAGEMENT OF ANTERIOR COMMUNICATING ARTERY ANEURYSMS
SURGICAL TECHNIQUE
PRE-OPERATIVE MEASURES
APPROACHES TO ANTERIOR COMMUNICATING ARTERY ANEURYSMS
Side of Approach
The Subfrontal Modified Gyrus Rectus Approach
Pterional Craniotomy
Anterior Interhemispheric Approach
The Basal Interhemispheric Approach
Midline Trephine Approach
Other Skull Base Approaches
Orbitopterional Approach
Orbitocranial Approach
Supraorbital Keyhole Minicraniotomy
Endoscopic Assisted Microneurosurgery
GIANT ANTERIOR COMMUNICATING ARTERY ANEURYSMS
FUSIFORM ANTERIOR COMMUNICATING ARTERY ANEURYSMS
BLISTER-LIKE ANTERIOR COMMUNICATING ARTERY ANEURYSMS
KISSING ANTERIOR COMMUNICATING ARTERY ANEURYSMS
COMPLICATIONS
Intra-Operative Rupture
Injury to Arterial Branches and Perforators
Hydrocephalus
Electrolyte Disturbance
Brain Retraction Injury
Neuropsychological Sequelae
Others
OUTCOMES
82:
Distal Anterior Cerebral Artery Aneurysm
INTRODUCTION
MICROSURGICAL ANATOMY
CLINICAL CHARACTERISTICS
INVESTIGATIONS
SURGICAL CONSIDERATIONS
83:
Middle Cerebral Artery Aneurysms
CLINICAL FEATURES
Intracerebral Haematoma
INVESTIGATIONS
4D Computed Tomography Angiography
TREATMENT
Anatomy15,31,43,47,68,73
Sylvian Fissure15,73
Middle Cerebral Artery10,15,31,47
Branches for ECIC Bypass
Variants
Surgical Techniques3–5,8–10,14,17,25,31,32,40,45–47,50,58,60–62,66,70–73
Proximal Trans-Sylvian Approach8,10,14,31,40,72
Distal Trans-Sylvian Approach40,45
Superior Temporal Gyrus Approach17,40
Intra-Operative Rupture
Single-Stage Approach for Bilateral Middle Cerebral Artery Aneurysms32
Intra-Operative Microvascular Doppler
Indocyanine Green Chorioangiography Angiography
Giant Aneurysms10,49,59,60
Neuroprotection13,37
Temporary Clipping21,53,64,65
Outcome
M1 Segment Aneurysms2,10,11,16,18,20,52,69
Mini-Craniotomy Approaches9,12,28
Dissecting Aneurysms27,41,42
Distal Middle Cerebral Artery Aneurysms1,24,35,57
ACKNOWLEDGEMENTS
84:
Posterior Circulation Aneurysms
INTRODUCTION
MICROSURGICAL ANATOMY
Vertebral Artery (VA)42
Posterior Inferior Cerebellar Artery (PICA)19,28
Basilar Artery36
Posterior Cerebral Artery (PCA)56
Superior Cerebellar Artery (SCA)23
Anterior Inferior Cerebellar Artery (AICA)20
Perforating Vessels29
INCIDENCE
CLINICAL PRESENTATION
DIAGNOSTIC STUDIES
SURGICAL MANAGEMENT
SUBTEMPORAL APPROACH
PTERIONAL-TRANS-SYLVIAN APPROACH
ORBITOZYGOMATIC AND EXTENDED ORBITOZYGOMATIC APPROACH
TRANSPETROSAL APPROACH
FAR LATERAL APPROACH
ALTERNATIVE SURGICAL STRATEGIES
ENDOVASCULAR MANAGEMENT
ENDOVASCULAR OBLITERATION
MANAGEMENT OF GIANT POSTERIOR CIRCULATION ANEURYSMS (Figs 9A to C and 10A to C)
CONCLUSION
85:
Giant Aneurysms
INTRODUCTION
PATHOLOGY
CLINICAL PRESENTATION
RADIOLOGICAL EVALUATION
Skull Radiographs and Bone Windows of Computed Tomographic (CT) Scans
Computed Tomography
Magnetic Resonance Imaging (MRI)
Digital Subtraction Angiography (DSA)
AIM OF SURGICAL TREATMENT18
SURGICAL TREATMENT
Special Considerations for Giant Aneurysms
Surgical Technique
Adjuvant Techniques
Long-Term Outcome
86:
Incidental Intracranial Aneurysms
POPULATION AT RISK
ISUIA STUDY AND CONTROVERSIES
SHOULD WE SCREEN FOR INCIDENTAL ANEURYSMS
MANAGEMENT ISSUES
FACTORS ASSOCIATED WITH SURGICAL OUTCOME
ENDOVASCULAR TREATMENT
MANAGEMENT GUIDELINES FOR INCIDENTAL ANEURYSMS
THE AMERICAN HEART ASSOCIATION GUIDELINES
ADVANCES
CONCLUSION
87:
Multiple Intracranial Aneurysms
INCIDENCE
RISK FACTORS FOR MULTIPLE INTRACRANIAL ANEURYSMS
Hypertension
Gender
Arteriovenous Malformation
Familial Aneurysms
Connective Tissue Disease and Congenital Disorders
Sickle Cell Disease
Smoking
ANEURYSM DISTRIBUTION
INSTITUTIONAL EXPERIENCE
ILLUSTRATIVE CASE
PREDICTION OF RUPTURE SITE
TREATMENT
OUTCOME
CONCLUSION
88:
Infectious Intracranial Aneurysms
HISTORY
AETIOPATHOGENESIS
CLINICAL FEATURES
RADIOLOGICAL FEATURES
MANAGEMENT ALGORITHM
BACTERIAL ANEURYSMS
Therapy
FUNGAL INFECTIONS
VIRAL INFECTIONS
89:
Intracavernous Aneurysms
INTRODUCTION
CLINICAL FEATURES
Cranial Neuropathy
Pain
Subarachnoid Haemorrhage
Epistaxis13,22,24
Transient Ischaemic Attacks
INVESTIGATIONS
TREATMENT
Indications for Treatment
METHODS OF TREATMENT
Endovascular Technique3,4,26
Surgical Treatment
Direct Surgical Methods
Indirect Surgical Methods
Proximal Internal Carotid Artery Occlusion
Trapping
External Carotid-Internal Carotid Bypass16–30
Indications
PRE-OPERATIVE EVALUATION
ANAESTHESIA
SUPERFICIAL TEMPORAL ARTERY TO MIDDLE CEREBRAL ARTERY ANASTOMOSIS
Technique
Donor (Superficial Temporal Artery Dissection)
Intracranial Exposure
Internal Carotid Artery or External Carotid Artery-Middle Cerebral Artery Bypass Using a Graft
Anastomosis
Closure
POST-OPERATIVE MANAGEMENT
COMPLICATIONS
GRAFT PROBLEMS17,23
Graft Failure23
Early Graft Occlusion
Subacute Graft Occlusion
Delayed or Late Graft Occlusion
Treatment of Graft Occlusion
SUMMARY
90:
Contemporary Endovascular Treatment of Intracranial Aneurysms
INTRODUCTION AND HISTORICAL BACKGROUND
INDICATIONS FOR ANEURYSM COILING4,19,23,26
LIMITATIONS OF ENDOVASCULAR TREATMENT
STEPS OF ENDOVASCULAR COILING
POST-PROCEDURE MANAGEMENT
FOLLOW-UP
EQUIPMENT AND DISPOSABLE MATERIAL
DRUGS USED DURING THE PROCEDURE
DRUGS USED IN ADVERSE EVENTS
TREATMENT OF VASOSPASM
SPECIAL CONSIDERATIONS IN ENDOVASCULAR ANEURYSM TREATMENT
Dissecting Aneurysms
Giant Aneurysms
Mycotic (Infective) Aneurysms
BALLOON REMODELLING CATHETERS
COATED/BIOACTIVE COILS
Matrix
Hydrocoils
NEWER ADVANCES
Stent Grafts
Oynx
COMPLICATIONS
Perforation
Thromboembolism
Device Related Issues
RECANALISATION/RECURRENCE
CONCLUSION
91:
Vascular Malformations of the Brain
INTRODUCTION
CLASSIFICATION
ARTERIOVENOUS MALFORMATIONS
Aetiopathogenesis
Incidence
Location
Pathology
Natural History
Clinical Features
Haemorrhage
Seizures
Focal Neurological Deficits
Other Features
Cardiovascular Effects
Haematological Effects
HAEMODYNAMICS OF ARTERIOVENOUS MALFORMATION
INVESTIGATIONS
CAUSES FOR ANGIOGRAPHICALLY OCCULT ARTERIOVENOUS MALFORMATIONS
GRADING OF ARTERIOVENOUS MALFORMATIONS
92:
Surgical Management of Cerebral AVMS
CONSIDERATIONS IN THE TREATMENT OF AVM
Factors Related to the Patient
Factors Related to the AVM
Experience of the Neurosurgical Team
SURGERY
Principles of Surgical Treatment
AVMs Associated with Aneurysms
Haemodynamic Changes after Removal of an AVM
Post-Operative Complications
Normal Perfusion Pressure Breakthrough Syndrome
Occlusive Hyperaemia
Post-Operative Seizures
Results of Surgery
EMBOLISATION
Pre-Radiosurgical Embolisation
Palliative Embolisation
RADIATION THERAPY
ELECTROTHROMBOSIS AND CRYOSURGERY
SPECIAL CONSIDERATIONS
Pregnant Patients
Recommendations
Paediatric Lesions
93:
Embolisation of Intracranial Vascular Malformation
INVESTIGATIONS
INDICATIONS FOR TREATMENT
CONTRAINDICATIONS
EMBOLISATION
Technique
Curative Embolisation by Injecting Glue or Absolute Alcohol
Selecting Sections Judiciously for Pre-SRS Embolisation
COMPLICATIONS
Technical Complications
Neurological Complications
CONCLUSION
94:
Stereotactic Radiosurgery for Cerebral AVMS
HISTORY
INTRODUCTION TO STEREOTACTIC RADIOSURGERY
DECISION-MAKING IN RADIOSURGERY
RADIOBIOLOGICAL EFFECTS OF STEREOTACTIC RADIOSURGERY ON ARTERIOVENOUS MALFORMATIONS
CLINICAL PRESENTATION
Investigations
STEREOTACTIC RADIOSURGERY FOR CEREBRAL ARTERIOVENOUS MALFORMATIONS: THE PROCEDURE
Step 1—Fixing the Frame
Step 2—Computerised Tomography or Magnetic Resonance Imaging Data Acquisition
Step 3—Angiographic Data Acquisition
Step 4—Treatment Planning
Step 5—Treatment
Procedure Related Complications
Follow-Up
Embolisation Prior to Stereotactic Radiosurgery for Arteriovenous Malformations
Location
Outcome
Causes of Treatment Failure
Complications
LARGE ARTERIOVENOUS MALFORMATION
95:
Vein of Galen Malformations
ANATOMICAL CONSIDERATIONS AND CLASSIFICATION
CLINICAL FEATURES
Neonates
Infants
Older Children and Adults
DIAGNOSTIC INVESTIGATIONS
Brain Imaging
Cerebral Angiography
Other Investigations
TREATMENT
Medical Treatment
Interventional Strategies
Treatment of Hydrocephalus
Endovascular Treatment
Surgical Treatment
Radiosurgery
OUTCOME
96:
Cavernomas of the Brain
INCIDENCE
AETIOPATHOGENESIS
PATHOLOGY
CLINICAL PRESENTATION
Seizures
Haemorrhage
Focal Neurological Deficit
Incidental
IMAGING
Computerised Tomography
Magnetic Resonance Imaging
Angiography
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
SURGERY
Supratentorial Cavernous Malformations
Surgical Strategies for Epilepsy
Infratentorial Cavernous Malformations
OBSERVATION
RADIOSURGERY
97:
Other Vascular Malformations of the Brain
VENOUS ANGIOMA
Pathology
Natural History and Clinical Features
Investigations
Management
CAPILLARY TELANGIECTASIAS
Clinical Presentation
Investigations
Management
Hereditary Haemorrhagic Telangiectasia (Osler-Weber-Rendu Disease)
Genetics
Diagnosis
Treatment
Genetic Counselling
CRYPTIC ARTERIOVENOUS MALFORMATIONS
98:
Carotid Cavernous Fistula
INTRODUCTION
HISTORICAL
ANATOMY OF THE CAVERNOUS SINUS
Arteries
Veins
CLASSIFICATION
SYMPTOMS AND SIGNS
INVESTIGATIONS
TREATMENT
Endovascular Therapy
Surgical Approaches
Radiosurgery
Prognosis and Complications
99:
Dural Arteriovenous Malformations
INTRODUCTION
EMBRYOLOGY AND PATHOPHYSIOLOGY
AETIOLOGY
NATURAL HISTORY
CLASSIFICATION
CLINICAL FEATURES
INVESTIGATIONS
MANAGEMENT
100:
Embolisation of Spinal Vascular Malformation
CLASSIFICATION OF SPINAL VASCULAR MALFORMATIONS5,53,63
VASCULAR SUPPLY OF THE SPINAL CORD6,57
CLINICAL PRESENTATION
INVESTIGATIONS
Myelography
Computerised Tomography Scan
Magnetic Resonance Imaging
Magnetic Resonance Angiography
Digital Subtraction Angiography
TREATMENT
Indications for Treatment
Technique8,13,18,56,64
Spinal Cord AVM19,32,62
Dural AVF
Spinal Cord AVF10,61
Complications
Follow-Up
CONCLUSION
101:
Spontaneous Intracerebral Haemorrhage
INTRODUCTION
RISK FACTORS
EMERGENCY DIAGNOSIS AND ASSESSMENT OF ICH AND ITS CAUSES
Diagnosis
PATHOPHYSIOLOGY
Early Haematoma Growth
Perihaematomal Brain Injury
PROGNOSIS
MANAGEMENT
Airway
Blood Pressure
Management of ICP
Haemostatic Therapy
Reversal of Anticoagulation
Fluids
Anticonvulsant Therapy
Fever Control
Management of Glucose
Nutrition
Deep Venous Thrombosis Prophylaxis
Anticoagulation after ICH
Recommendations for the Management of ICH Related to Coagulation and Fibrinolysis4
SURGICAL MANAGEMENT
Minimally Invasive Surgery
Endoscopic Aspiration
Thrombolytic Therapy and Aspiration of Clots
Decompressive Craniotomy
Timing of Surgery4
102:
Surgery for Stroke
CLINICAL FEATURES
Carotid Territory
Vertebro-Basilar Territory
Investigations
SURGERY FOR STROKE PREVENTION
Direct Revascularisation Procedures
Carotid Territory
Surgical Risk Factors
Surgical Technique
Intra-operative Monitoring
Procedure
Complications
Extracranial to Intracranial (EC-IC) Bypass
Technique
Vertebro-basilar Territory
Indirect Revascularisation Procedures
SURGERY IN ACUTE STROKE
Pathophysiology
Management71
Cerebral Infarct
Medical Therapy
Surgical Therapy
Cerebellar Infarcts
Revascularisation Procedures
Haemorrhagic Stroke
Investigations
Pathophysiology
Management
Newer Techniques
Outcome
Pontine and Midbrain Haematomas
Cerebral Venous Thrombosis
Paediatric Stroke
SURGERY IN STROKE REHABILITATION
CONCLUSION
SECTION 9: TUMOURS OF THE SPINE AND SPINAL CORD
103:
Clinical Features and Diagnosis
HISTORICAL BACKGROUND
CLASSIFICATION
TUMOURS OF THE SPINAL CORD
Primary Extradural Tumours
Intradural Extramedullary
Intramedullary Tumours
TUMOURS OF THE VERTEBRAL COLUMN
Intraspinal Extension of Paravertebral Tumours
PATHOPHYSIOLOGY OF CORD COMPRESSION
SYMPTOMS AND SIGNS OF SPINAL COMPRESSION
Involvement of the Posterior Root
Involvement of the Anterior Nerve Root and Anterior Horns
Segmental Involvement
Involvement of the Long Sensory Tracts
Sensory Disturbances
MRC Classification of Sensory Nerve Dysfunction23
Motor Disturbance
Sphincter Disturbances
Bowel Function
Disturbances of Autonomic Functions
Skeletal Symptoms and Signs
CLINICAL FEATURES OF TUMOURS AT DIFFERENT LEVELS
Dorsal Lesions
Upper Lumbar Segments
Epiconus Syndrome
Conus Syndrome
Cauda Equina Syndrome
Differentiation between Extramedullary (Intradural) and Intramedullary Tumours
ALIGNMENT OF CORD SEGMENTS AND VERTEBRAE
DIFFERENTIAL DIAGNOSIS
FUNCTIONAL SCORES IN SPINAL CORD DISEASE
McCormick Classification
Nurick's Grading for Cervical Myelopathy
Frankel's Grading
104:
Vertebral Tumours
BENIGN TUMOURS OF THE SPINE
Clinical Presentation
Investigations
Treatment
Osteoid Osteoma
Osteoblastoma
Osteochondroma
Giant Cell Tumour
Eosinophilic Granuloma
Aneurysmal Bone Cyst
Haemangioma
PRIMARY MALIGNANT TUMOURS OF THE SPINE
Chordomas
Osteosarcoma
Chondrosarcoma
Ewing's Sarcoma
Plasmacytoma
Multiple Myeloma
Lymphoma
Metastatic Tumours of the Spine
PATHOGENESIS
CLINICAL PRESENTATION
Frenkel's Classification
RADIOLOGICAL EVALUATION
MANAGEMENT
Surgical Management
Anterior Approaches
105:
Spinal Schwannomas and Meningiomas
INTRODUCTION
HISTORICAL CONSIDERATION
CLASSIFICATION AND TERMINOLOGY
Epidemiology
Incidence
Histopathology
GENETIC ASPECTS
CLINICAL SYMPTOMS AND SIGNS
DIAGNOSTIC IMAGING
Treatment
Pre-operative Preparation
Operative Procedure
Outcome and Prognosis
106:
Intramedullary Tumours
INTRODUCTION
HISTORY
AETIOPATHOLOGY
HISTOLOGICAL SUBTYPES
Astrocytomas
Ependymomas
Haemangioblastomas
Lipomas
Metastases
Miscellaneous Lesions
CLINICAL FEATURES—SYMPTOMS
Pain
Motor Function
Sensory Abnormalities
Autonomic Dysfunction
Spinal Deformity
CLINICAL EXAMINATION
INVESTIGATIONS
Imaging
Angiography
MANAGEMENT
Rationale of Treatment
Surgical Management
Pre-operative Management
SPECIAL INSTRUMENTS/TECHNOLOGY
Evoked Potential Recordings
Ultrasonic Aspirator
Laser
Tissue Vapouriser
Intra-operative Ultrasound (iUSG)
SURGICAL STEPS
Positioning
Bone Removal
Durotomy
Myelotomy
Ependymomas
Astrocytomas
Haemangioblastomas
Lipomas
Intramedullary Metastases
Closure
POST-OPERATIVE MANAGEMENT
POST-OPERATIVE COMPLICATIONS
Neurological Deficit
Wound Dehiscence
Spinal Deformities
ADJUNCTIVE TREATMENT
PROGNOSIS
THE AIIMS EXPERIENCE
CONCLUSION
107:
Congenital Tumours of the Spine
EPIDERMOID AND DERMOID CYSTS
SACROCOCCYGEAL TERATOMA
LIPOMA
NEURENTERIC CYST
ARACHNOID CYST
MISCELLANEOUS LESIONS
Cavernous Malformation
Angiolipoma
Astrocytoma
108:
Paediatric Spinal Tumours
HISTORICAL OVERVIEW
EPIDEMIOLOGY
PATHOLOGY
CLASSIFICATION
CLINICAL PRESENTATION
LABORATORY INVESTIGATIONS
Imaging
THERAPEUTIC CONSIDERATIONS
Surgery
Extradural Tumours
Primary Bone Tumours
Osteoid Osteoma and Osteoblastoma
Osteochondroma and Osteogenic Sarcoma
Aneurysmal Bone Cysts
Eosinophilic Granuloma
Malignant Tumours
Neuroblastomas
Ewing's Sarcoma
Intradural Extramedullary Tumours
Intermedullary Tumours
EVOKED POTENTIAL MONITORING
COMPLICATIONS
Post-operative Spinal Deformity
ADJUVANT THERAPY
SECTION 10: DISC DISEASE AND OTHER SPINAL PATHOLOGIES
109:
Pathophysiology of Disc Degeneration
INTRODUCTION
ANATOMY OF INTERVERTEBRAL DISC
Nucleus Pulposus
Annulus Fibrosus
End Plates
Blood Supply
Nerve Supply
Ligaments
PHYSIOLOGY OF INTERVERTEBRAL DISC
Nutrition and Metabolism
Biomechanics
Ageing Changes
DEGENERATIVE DISC DISEASE
Structural Changes
Biochemical Changes
Vascular Changes
Inflammatory Changes
Cause of Pain
Experimental Models
AETIOLOGY OF DEGENERATIVE DISC DISEASE
Mechanical Load Injury
Genetic Factors
DISC REGENERATION
Pharmacotherapy
Cell Based Therapy
Gene Therapy
Other Methods
CLINICAL CORRELATIONS
IMAGING CORRELATIONS
CONCLUSION
110:
Cervical Disc Disease and Spondylosis—Clinical Features and Diagnosis
INTRODUCTION
IMAGING EVALUATION
Neurophysiologic Studies
111:
Cervical Disc Disease and Spondylosis Management
MEDICAL MANAGEMENT OF CERVICAL SPONDYLOSIS
SURGICAL MANAGEMENT OF CERVICAL DISC DISEASE AND SPONDYLOSIS
ANTERIOR APPROACH
Anterior Cervical Discectomy
Technique of Anterior Cervical Discectomy
Results of Anterior Cervical Discectomy
Complications of Anterior Cervical Discectomy
Anterior Cervical Discectomy with Fusion
Fusion of the Cervical Spine
Techniques of Anterior Spinal Fusion
Bone Grafts and Other Materials Used for Fusion
Instrumented Fusion
Dynamic Fusion
Partial Median Corpectomy and Grafting
POSTERIOR APPROACH
Cervical Laminectomy
Foraminotomy
112:
Cervical Ossification of Posterior Longitudinal Ligament
INTRODUCTION
INCIDENCE AND PREVALENCE
AETIOPATHOGENESIS
Genetics
Growth Factors and Cytokines
PATHOLOGY
CLASSIFICATION OF OSSIFICATION OF THE POSTERIOR LONGITUDINAL LIGAMENT
MICROSURGICAL ANATOMY OF POSTERIOR LONGITUDINAL LIGAMENT
CLINICAL PRESENTATION AND NATURAL HISTORY
MANAGEMENT
Radiodiagnosis
Plain X-rays
COMPUTED TOMOGRAPHY (CT) SCAN AND CT MYELOGRAPHY
Magnetic Resonance Imaging
TREATMENT
Conservative
Operative
Selection of Surgical Procedure
Surgical Technique
Complications
Graft Extrusion
OUTCOME
113:
Thoracic Disc Prolapse
INTRODUCTION
PATHOLOGY
CLINICAL FEATURES
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
TREATMENT
Surgical Management
Complications
Outcome of Surgery
Conservative Management
114:
Lumbar Disc Disease
INTRODUCTION
HISTORICAL PERSPECTIVES
ANATOMY AND BIOMECHANICS OF THE LUMBAR INTERVERTEBRAL DISC
PATHOPHYSIOLOGY OF DEGENERATIVE DISC DISEASE7,13
CLINICAL FEATURES
Symptoms
Signs
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
Radiographs of the Lumbar Spine
Myelography
Computerised Tomography
Magnetic Resonance Imaging
Discography14,17
Electromyogram/Nerve Conduction
MANAGEMENT
Conservative Management
Microdiscectomy
Surgical Outcomes
Minimally Invasive Spinal Surgery16
Chemonucleolysis
Percutaneous Nucleotomy
Percutaneous Laser Assisted Discectomy
Intradisc Electrothermal Coagulation
CONTROVERSIES IN MANAGEMENT
RECURRENT DISC HERNIATION15
RECENT ADVANCES
Artificial Disc Technology1
Stem Cell Therapy6
CONCLUSION
115:
Lumbar Canal Stenosis
NORMAL ANATOMY
PATHOPHYSIOLOGY
SPINAL CLAUDICATION SYNDROME
Neurogenic Compression Theory
Vascular Compression Theory
CLINICAL PRESENTATION
IMAGING STUDIES
CT Myelography
MANAGEMENT
Laminotomy or Laminectomy
Decompression and Spinal Fusion
116:
Spondylolisthesis
TERMINOLOGY
CLASSIFICATION AND AETIOLOGY
Isthmic Spondylolisthesis
Degenerative Spondylolisthesis
Dysplastic Spondylolisthesis
Traumatic and Pathological Spondylolisthesis
GRADING
CLINICAL FEATURES AND THEIR BASIS
INVESTIGATIONS
Plain Radiographs
Computerised Tomography Scan
Magnetic Resonance Imaging
Discography
MANAGEMENT
Conservative Management
Surgical Management
Decompression
Reduction
Fusion
Instrumentation
Surgical Techniques
CONCLUSION
117:
Skeletal Fluorosis
INTRODUCTION
METABOLISM OF FLUORIDE
Sources of Fluoride
Foods
Water and Beverages
Air
Total Daily Fluoride Intake
ABSORPTION OF FLUORIDES
DISTRIBUTION OF FLUORIDES
EXCRETION OF FLUORIDES
Faeces
Urinary
Sweat
Other Routes
CLINICAL FEATURES
Dental Fluorosis
Pre-Skeletal Stage
Skeletal Fluorosis
Endemic Genu Valgum
NEUROLOGICAL MANIFESTATIONS OF SKELETAL FLUOROSIS
Myelopathy
Radiculopathy
Cranial Nerve Lesions
Peripheral Neuropathies
Cerebral Ischaemia
LABORATORY INVESTIGATIONS
General
Electrophysiological Studies
Fluoride Estimations
Urine Fluoride Estimation
Serum Fluoride Estimation
Bone Fluoride Estimation
Bone Biopsy
Pulmonary Function Tests
Scintigraphic Studies
Radiology of Fluorosis
Computed Tomography
Magnetic Resonance Imaging
Myelography
PATHOLOGY OF FLUOROSIS
Gross Changes in the Skeleton
Histopathology of Bones
Muscle Pathology
Nerve Pathology
Spinal Cord Studies
DIFFERENTIAL DIAGNOSIS
TREATMENT OF FLUOROSIS
Prevention
Prevention of Endemic Fluorosis
Prevention of Industrial Fluorosis
Medical Therapy
Surgical Management of Skeletal Fluorosis with Neurological Manifestations
118:
Osteoporosis
INTRODUCTION
DEFINITION
AETIOLOGY
CLINICAL FEATURES
INVESTIGATIONS
Plain Radiography
Computerised Tomography Scan
Magnetic Resonance Imaging
Radionuclide Imaging
Quantitative Assessment of Bone Mineral Density
Quantitative Computerised Tomography
Quantitative Ultrasonography
Assessment of Bone Turnover
TREATMENT
Medical Treatment
General Measures
Conservative Management of Vertebral Compression Fracture
Percutaneous Intervention for Osteoporotic Vertebral Compression Fracture
Indications
Mechanism of Pain Relief
Contraindications
Technique
Approach
Cement Injection
Technique of Kyphoplasty
Results
Complications
Concerns
Surgery for Osteoporotic Compression Fractures
Instrumentation in Osteoporotic Spine
Interbody Fusion in Osteoporotic Spine
SUMMARY
SECTION 11: PATHOLOGY OF INTRACRANIAL TUMOURS
119:
Classification of Tumours of the Nervous System
CLASSIFICATION
GRADING OF CENTRAL NERVOUS SYSTEM TUMOURS
Significance of Grading
Predictive Value of Tumour Grades
Grading of Astrocytomas
ASTROCYTIC TUMOURS
Circumscribed Astrocytic Tumours
Pilocytic Astrocytoma (WHO Grade I)
Pilomyxoid Astrocytoma (WHO Grade II)
Pleomorphic Xanthoastrocytoma (WHO Grade II)
Subependymal Giant Cell Astrocytoma (WHO Grade I)
Diffusely Infiltrating Astrocytic Tumours
Diffuse Astrocytoma (WHO Grade II)
Anaplastic Astrocytoma (WHO Grade III)
Glioblastoma (WHO Grade IV)
Biology/Molecular Genetics/Predictive and Prognostic Factors
Molecular Genetics
Parameters of Invasiveness
Tumour Angiogenesis
Gene Expression Profiles in Glioblastomas
Prognostic and Predictive Factors
Giant Cell Glioblastoma
Gliosarcoma
Gliomatosis Cerebri
Oligodendroglioma
Oligoastrocytoma
EPENDYMAL TUMOURS
Ependymoma (WHO Grade II)
Incidence and Localisation
Clinical Features and Neuroimaging
Histopathology
Histological Variants
Predictive and Prognostic Factors
Anaplastic Ependymoma (WHO Grade III)
Subependymoma (WHO Grade I)
120:
Pathogenesis of Tumours of the Nervous System
MOLECULAR PATHOGENESIS OF GLIOMAS
Tumour Oncogenes
Growth Factors
Epidermal Growth Factor (EGF)
Vascular Endothelial Growth Factor (VEGF)
Tumour Angiogenesis Factor (TAF)
Other Growth Factors in Gliomas
The 12q Amplicon Including CDK4 and MDM2
Tumour Suppressor Genes (TSG)
Retinoblastoma (Rb) Gene
p53
p16
LOH-10
LOH-22q and 19q, 13.2–13.3
Genetic instability
HEREDITARY SYNDROMES
ONCOGENIC VIRUSES
Simian Virus-40 (SV-40)
Historical Evidence
JC Virus
Adenovirus 12
EFFECT OF RADIATION
Radio Frequency (RF) Radiation
CHEMICAL CARCINOGENS
IMMUNODEFICIENCY STATUS
HORMONAL FACTORS
TRAUMA
ACKNOWLEDGEMENTS
121:
Germ Cell Tumours of the Central Nervous System
CLINICAL FEATURES AND LOCALISATION
IMAGING FEATURES
PATHOLOGY
Germinoma
Teratoma
Mature Teratoma
Immature Teratoma
Teratoma with Malignant Transformation
Yolk Sac Tumour
Choriocarcinoma
Embryonal Carcinoma
HISTOGENESIS
PROGNOSTIC AND PREDICTIVE FACTORS
122:
Embryonal Tumours of the Central Nervous System
MEDULLOBLASTOMAS
Clinical Features
Imaging
Histopathology
Classic Medulloblastomas
Desmoplastic/Nodular Medulloblastomas
Medulloblastomas with Extensive Nodularity
Anaplastic Medulloblastomas
Large Cell Medulloblastomas
Melanocytic Medulloblastomas
Medullomyoblastomas
Molecular Genetics
Non-random Chromosomal Abnormalities
Abnormalities in Signal Transduction Pathways
Altered Neural Transcription Factors
Molecular Differences between the Different Medulloblastoma Variants
Treatment and Prognosis
Risk Stratification in Medulloblastomas (Prognostic Factors)
Clinical Factors
Histopathological Factors
Molecular, Cytogenetic Factors and Signalling Pathway Markers
Loss of 17p/Isochromosome 17q
C-myc and N-myc Amplification
Gene Profiling
TrkC Expression
ErbB2 Expression
Wingless (WNT/WG) Pathway
ATYPICAL TERATOID/RHABDOID TUMOUR
Clinical Features
Imaging
Histopathology
Histogenesis and Molecular Genetics
Treatment and Prognosis
CENTRAL NERVOUS SYSTEM PRIMITIVE NEUROECTODERMAL TUMOURS
Supratentorial Primitive Neuroectodermal Tumour
Clinical Features
Imaging
Histopathology
Histogenesis and Genetics
Outcome and Prognosis
Medulloepithelioma
Clinical Features
Histopathology
Genetics
Outcome and Prognosis
Ependymoblastoma
Clinical Features
Histopathology
Histogenesis
Prognosis
ACKNOWLEDGEMENT
123:
Tumours of Meninges
MENINGIOMA
Primary Melanocytic Lesions
Other Neoplasms Related to the Meninges
Age and Gender
Site
Clinical Features and Associations
Radiological Features
Gross Pathology
Microscopy
Meningothelial Meningioma
Fibroblastic Meningioma
Transitional Meningioma
Psammomatous Meningioma
Angiomatous Meningioma
Microcystic Meningioma
Secretory Meningioma
Lymphoplasmacyte Rich Meningioma
Metaplastic Meningioma
Clear Cell Meningioma (WHO Grade II)
Atypical Meningioma (WHO Grade II)
Chordoid Meningioma (WHO Grade II)
Papillary Meningioma (WHO Grade III)
Rhabdoid Meningioma (WHO Grade III)
Anaplastic Meningioma (WHO Grade III)
Immunohistochemistry
Molecular Genetics
Proliferation
Recurrent Meningiomas
Hormone Receptors
Treatment and Prognosis
HAEMANGIOPERICYTOMA
Definition and Grading
Incidence
Age and Gender
Location
Gross and Microscopic Features
Immunohistochemistry
Genetic Susceptibility, Cytogenetics and Molecular Genetics
Treatment and Prognosis
SOLITARY FIBROUS TUMOUR
HAEMANGIOPERICYTOMA AND SOLITARY FIBROUS TUMOUR—CURRENT CONCEPT
HAEMANGIOBLASTOMA
Location
Age and Gender
Clinical Manifestations
Neuroimaging
Pathogenesis
Gross Pathology
Microscopy
Prognosis
124:
Pituitary Tumours, Sellar and Suprasellar Lesions
INTRODUCTION
PITUITARY ADENOMA8,55
Radiographic Features
Gross
Microscopic Features
Differential Diagnosis
Normal Adenohypophysis
Metastatic Carcinoma
ADENOMAS OF SPECIFIC CELL TYPE21
Growth Hormone Cell Adenoma
Prolactin Cell Adenoma (Prolactinoma)
Adenomas Producing Growth Hormone and Prolactin36
Mixed Growth Hormone Cell-Prolactin Cell Adenoma
Mammosomatotroph Cell Adenoma
Acidophil Stem Cell Adenoma13
Adrenocorticotropic Hormone Cell Adenomas
Adenomas of Cushing's Disease
Adenomas of Nelson's Syndrome
Silent Corticotroph Cell Adenomas
Glycoprotein Adenomas
Gonadotroph Cell Adenoma
Thyrotroph Cell Adenoma
Plurihormonal Adenomas
Silent Adenoma, Subtype III
Null Cell Adenomas
INVASION AND MALIGNANCY IN PITUITARY ADENOMAS
Invasive Adenoma
Atypical Adenoma
Pituitary Carcinoma
Pituitary Apoplexy
MARKERS OF BIOLOGICAL BEHAVIOUR OF PITUITARY ADENOMAS
DNA Analysis
Proliferation Markers
p53 Tumour Suppressor Gene
Apoptosis
Angiogenesis
Growth Factors
MOLECULAR PATHOLOGY: ONCOGENES AND TUMOUR SUPPRESSOR GENES29
CRANIOPHARYNGIOMA4
Clinical Features
Histological Subtypes
1. Adamantinomatous
Gross
Microscopic Features
Behaviour
Differential Diagnosis
2. Papillary Craniopharyngioma
Gross
Microscopic Features
Behaviour
Differential Diagnosis
PITUICYTOMA AND GRANULAR CELL TUMOUR4,8
Gross
Microscopic Features
Granular Cell Tumour
Pituicytomas
Immunohistochemistry
Ultrastructural Features
Differential Diagnosis
Pilocytic Astrocytoma
Behaviour
SPINDLE CELL ONCOCYTOMA OF THE ADENOHYPOPHYSIS7
Microscopic Features
Immunoreactivity
Prognosis
POST-IRRADIATION SARCOMA4,8
Microscopic Features
Behaviour
NON-NEOPLASTIC LESIONS OF THE SELLA TURCICA4
Rathke's Cleft Cyst
Microscopic Features
Behaviour
Empty Sella Syndrome15,46
Giant Cell Granuloma4
Clinical Features
Gross
Microscopic Features
Behaviour
Differential Diagnosis
Lymphocytic Hypophysitis1,4,33,51
Clinical Features
Radiographic Features
Gross
Microscopic Features
Treatment
Pituitary Hyperplasia4,12
Microscopic Features
Growth Hormone Cell Hyperplasia
Prolactin Cell Hyperplasia
Corticotroph Hyperplasia
Gonadotroph Hyperplasia
Thyrotroph Hyperplasia
125:
Lymphomas and Metastatic Tumours of Nervous System
LYMPHOMAS OF THE CENTRAL NERVOUS SYSTEM
PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA
Epidemiology
Predisposing Conditions
Age and Gender
Clinical Presentation
Pathogenesis
Non-AIDS Related Molecular Pathology
Gross Pathology
Histology
Diagnosis
Cerebrospinal Fluid Examination
Role of Stereotactic Brain Biopsy
Prognostic Markers
Spinal Cord Compression Due to Haematological Malignancies
Non-Hodgkin's Lymphoma
Hodgkin's Lymphoma
Multiple Myeloma and Solitary Plasmacytomas
METASTATIC TUMOURS OF THE CENTRAL NERVOUS SYSTEM
Epidemiology
Pathogenesis
Spread of the Tumours
Tumours Metastasising to Brain
Diagnosis
Prognostic Factors
Acknowledgement
126:
Cerebral Oedema in Relation to Neoplasias of Nervous System
BLOOD-BRAIN BARRIER
Anatomy of Blood-Brain Barrier
CEREBROSPINAL FLUID AND HYDROCEPHALUS
AQUAPORINS IN THE BRAIN
CEREBRAL OEDEMA
Cytotoxic Oedema
Vasogenic Oedema
Hydrostatic Oedema
Osmotic Oedema
Hydrocephalic Extracellular Oedema
Brain Oedema Following Trauma
BRAIN TUMOURS AND OEDEMA
SECONDARY EFFECTS OF CEREBRAL OEDEMA-RAISED INTRACRANIAL PRESSURE
Papilloedema
Intracranial Herniations
127:
Tumour Markers in Tumours of Nervous System
USES OF TUMOUR MARKERS
CHOICE OF TUMOUR MARKERS
CLASSIFICATION OF TUMOUR MARKERS
USE OF TUMOUR MARKERS DETECTED IN SERUM/CSF
Oncofoetal Proteins
TUMOUR MARKERS IN CELLS/TISSUES (IMMUNOHISTOCHEMICAL MARKERS)
Use of Oncofoetal Markers5,8
Types of Tumour Markers in Cells/Tissues15,16,34,36
Tumour Markers for Diagnostic Use
Tumour Markers Useful for Prognostic Evaluation
Cell Proliferation Markers
Molecular Genetic Markers
Genetic/Molecular Markers for Prediction of Response to Treatment
Temozolamide (TMZ): O6-Alkylguanine-DNA Alkyltransferase (AGT)
Microarray Based Expression Profiling for Prognostication of Glial Tumours
128:
Tumours of Cranial and Peripheral Nerves
SCHWANNOMA
Syndromic Associations
Incidence and Site
Gross Pathology
Conventional Schwannomas
Ancient Schwannomas
Cellular Schwannomas
Melanotic Schwannoma
Plexiform Schwannoma
Immunohistochemistry
Ultrastructure
Syndromic Association
NEUROFIBROMA
Histological Features
Atypical Neurofibroma
Cellular Neurofibroma
Cell Biology
Prognosis
PERINEURIOMA
MALIGNANT PERIPHERAL NERVE SHEATH TUMOURS
Predisposing Factors
Incidence and Localisation
Histopathology
Prognosis
KEY POINTS
129:
Tumours of the Choroid Plexus
INCIDENCE
SITE
AETIOLOGY
Association with SV 40 Virus
Role of p53
Aicardi Syndrome
CLINICAL FEATURES
NEUROIMAGING
PATHOLOGY
Macroscopy
Microscopy
Atypical CPP
Choroid Plexus Carcinoma
IMMUNOHISTOCHEMISTRY
DIFFERENTIAL DIAGNOSIS
PROGNOSIS
130:
Pineal Parenchymal Tumours
PINEOCYTOMA (WHO GRADE I)
Clinical Features and Localisation
Imaging Features on Computerised Tomography Scan
Pathology
PINEAL PARENCHYMAL TUMOUR OF INTERMEDIATE DIFFERENTIATION (PPT-ID; WHO GRADE II/III)
Clinical Features and Localisation
Pathology
PINEOBLASTOMA (GRADE IV)
Prognostic and Predictive Factors
Clinical Features and Localisation
Imaging Features
Pathology
HISTOGENESIS OF PINEAL PARENCHYMAL NEOPLASMS
PROGNOSTIC AND PREDICTIVE FACTORS OF PINEAL PARENCHYMAL NEOPLASMS
PAPILLARY TUMOUR OF THE PINEAL REGION
131:
Neuronal and Mixed Neuronal Glial Tumours
GANGLIOGLIOMA AND GANGLIOCYTOMA
Neuroimaging
Histopathology
Treatment and Prognosis
LHERMITTE-DUCLOS DISEASE/DYSPLASTIC GANGLIOCYTOMA OF THE CEREBELLUM
Histopathology
DESMOPLASTIC INFANTILE GANGLIOGLIOMA/ASTROCYTOMA
Clinical Features
Neuroimaging
Histopathology
CENTRAL NEUROCYTOMA AND EXTRAVENTRICULAR NEUROCYTOMA
Clinical Features
Imaging
Histopathology
Histogenesis
Treatment and Prognosis
EXTRAVENTRICULAR NEUROCYTOMA
Clinical Features
Histopathology
Treatment and Prognosis
CEREBELLAR LIPONEUROCYTOMA
Clinical Features
Neuroimaging
Histopathology
Histogenesis
Treatment and Prognosis
PAPILLARY GLIONEURONAL TUMOUR
Clinical Features
Neuroimaging
Histopathology
Histogenesis
Treatment and Prognosis
ROSETTE FORMING GLIONEURAL TUMOUR OF THE FOURTH VENTRICLE
Clinical Features
Histopathology
Histogenesis
Treatment and Prognosis
DYSEMBRYOPLASTIC NEUROEPITHELIAL TUMOUR
Clinical Features
Neuroimaging
Pathology
Simple Form
Complex Form
Histogenesis
Treatment and Prognosis
SPINAL PARAGANGLIOMA
Clinical Features
Neuroimaging
Histopathology
Histogenesis
Treatment and Prognosis
SECTION 12A: CRANIAL AND INTRACRANIAL TUMOURS
132:
Clinical Features of Intracranial Tumours
INTRODUCTION
IMPORTANCE OF CLINICAL ASSESSMENT
RAISED INTRACRANIAL PRESSURE—PATHOGENESIS
EFFECTS OF RAISED INTRACRANIAL PRESSURE ON VARIOUS STRUCTURES
SIGNS AND SYMPTOMS OF RAISED INTRACRANIAL PRESSURE
Headache
Localised Tenderness of the Skull
Vomiting
Vertigo
Visual Changes28,77
Papilloedema
Optic Atrophy
Abducens Palsy
Proptosis
Disturbance of Higher Functions
Systemic Changes
Signs of Interference with Local Functions
Epilepsy and Brain Tumour
Regional Signs
Subfrontal Tumours
Frontal Lobe Tumours
Tumours in the Sensorimotor Region
Parietal Lobe Tumours
Temporal Lobe Lesion
Occipital Lobe Lesions
Lesions Near the Falx
Lesions of the Corpus Callosum
Assessment of Lobar and Higher Cognitive Functions—Brief Outline
Frontal Lobe Dysfunction
Parietal Lobe Dysfunction
Temporal Lobe
Lateral Ventricle Tumours
Lesions Involving the Basal Ganglia
Middle Cranial Fossa Lesions
Midline Lesions of the Brain
Posterior Third Ventricle Tumours
Tumours Involving the Hypothalamus
Lesions of the Midbrain
Tumours of the Posterior Fossa
Posterior Midline Lesions
Cerebellar Hemisphere Lesions
Cerebellopontine Angle Tumours
Prepontine or Clival Tumours
Intrinsic Lesions of the Brainstem
Tumours of the Fourth Ventricle
Tumours at the Craniovertebral Junction
Neighbourhood Signs
Herniation
Subfalcine Herniation
Tentorial Herniation
Cerebellar Herniation (Tonsillar Herniation)
Retrograde Tentorial Herniation
Distant Signs
False Localising Signs
133:
Supratentorial Astrocytomas
INTRODUCTION
HISTORY
INCIDENCE
Overall Incidence
Frequency of Subtypes
Age and Incidence
Gender and Incidence
Other Epidemiological Factors
PATHOLOGY
Location of Gliomas
Gross Pathology
Spread
Extracranial Metastases
CLASSIFICATION AND GRADING
MICROSCOPIC PATHOLOGY
Types of Specimens
Histological Variants
Pilocytic Astrocytoma
Protoplasmic Astrocytoma
Subependymal Giant Cell Astrocytoma
Desmoplastic Infantile Astrocytoma
Angiocentric Glioma
Pilomyxoid Astrocytoma
Chordoid Glioma
Pleomorphic Xanthoastrocytoma
Gliofibroma
Gemistocytic Astrocytoma
Giant Cell Glioblastoma
Gliomatosis Cerebri
Gliosarcoma
AETIOLOGY AND PATHOGENESIS
Radiation Therapy Induced Gliomas
Hereditary Syndromes and Glioma
Cytokinetic Studies and Labelling Index
Genetic Abnormalities in Non-Syndromic Glioma
Role of Growth Factors
Role of Stem Cells
Role of Environmental Factors
Glioma Models
CLINICAL FEATURES
Duration and Progression
Raised Intracranial Pressure
Epileptic Seizure
Focal Neurological Dysfunction
Cognitive Dysfunction
Uncommon Presentations
INVESTIGATIONS
Imaging
Low-Grade Astrocytomas
Anaplastic Astrocytoma
Glioblastoma Multiforme
Recent Trends in Imaging
Proton Magnetic Resonance Spectroscopy
Perfusion and Diffusion Magnetic Resonance
Positron Emission Tomography
Serum and Cerebrospinal Fluid Markers
TREATMENT
Goals of Therapy
Biopsy
Need for Biopsy
Indications for Biopsy
Accuracy
Rationale of Biopsy
Technical Issues
Safety and Risks
Tumour Removal
Differences Between Radical Cancer Surgery Elsewhere and in the Brain
Impact of Maximal Tumour Removal on Survival
Strategies to Maximise the Resection
Risks of Aggressive Resection
Strategies to Minimise the Risk to Neurological Function in Glioma Surgery
Technical Aspects of Glioma Resection
Low-Grade Gliomas
Observation
Biopsy
Resection
Radiotherapy
External Radiotherapy
Brachytherapy
Risks of Radiotherapy
Stereotactic Radiosurgery
Chemotherapy
Temozolomide
PROGNOSIS
RECURRENCES
Clinical Features of Recurrence
Imaging of Recurrence
Treatment of Recurrence
Re-operation
Radiosurgery
Chemotherapy
EMERGING THERAPIES
Molecularly Targeted Therapies
Convection Enhanced Delivery
Gene Therapy
Other Drugs
Immunotherapy
ACKNOWLEDGEMENT
134:
Cerebellar Astrocytomas
INTRODUCTION
INCIDENCE
PATHOLOGY
Gross Pathology
Microscopic Pathology
Malignant Astrocytomas
Other Histological Types
Tumour Biology
CLINICAL PRESENTATION
NEURORADIOLOGY
MANAGEMENT
Surgery
Goal
Approach
Exposure
Tumour Excision
Closure
Complications
Adjuvant Therapies
PROGNOSIS
135:
Brainstem Gliomas
INTRODUCTION
CLASSIFICATION
PATHOLOGY
Diffuse
Focal
Cervicomedullary Tumours
Cystic Tumours
Exophytic Tumours
Tectal Plate Gliomas
CLINICAL FEATURES
NEURORADIOLOGY
MANAGEMENT
Mapping of the Cranial Nerve Nuclei
Intra-Operative Motor Nucleus Mapping
Continuous Intra-Operative Electromyographic Monitoring
Surgical Approaches
Management of Diffuse Tumours
CONCLUSION
136:
Hypothalamic-Optic Nerve Gliomas
INTRODUCTION
INCIDENCE
PATHOLOGY
Macroscopic Appearance
Microscopic Pathology
CLINICAL FEATURES
Visual Dysfunction
Proptosis
Hypothalamic Dysfunction
Symptoms of Increased Intracranial Pressure
INVESTIGATIONS
MANAGEMENT
Observation
Surgery
Chemotherapy
Radiotherapy
PROGNOSIS
CONCLUSION
137:
Oligodendrogliomas
INTRODUCTION
CLASSIFICATION
INCIDENCE AND SITE
PATHOLOGY
Gross Morphological Features
Microscopic Features
Ultrastructural Features
Immunohistochemistry
Cytogenetic and Molecular Studies
AGE AND SEX
CLINICAL FEATURES
RADIOLOGY
DIFFERENTIAL DIAGNOSIS
TREATMENT
General Management Plan
Surgical Management
Radiation Therapy
Chemotherapy
PROGNOSIS
138:
Ependymomas
DEFINITION
INCIDENCE
ORIGIN
LOCATION
CLINICAL PROFILE
Intraspinal Ependymomas
PATHOLOGY
IMAGING
MANAGEMENT
Adjunctive Therapy
Radiotherapy
ANAPLASTIC EPENDYMOMA
PROGNOSIS
MYXOPAPILLARY EPENDYMOMA
Presentation
Management
Histopathology
Prognosis
EXTRANEURAL EPENDYMOMAS
PARASACRAL EPENDYMOMAS
INTRA-ABDOMINAL EPENDYMOMAS
ACKNOWLEDGEMENT
139:
Medulloblastomas
PATHOLOGY
GROSS APPEARANCE
HISTOLOGY
MOLECULAR GENETICS
CLINICAL FEATURES
INVESTIGATIONS
STAGING
PROGNOSTIC FACTORS
Age
Histology
Glial Differentiation
ERB-B2 Expression
MANAGEMENT
SURGERY
Microsurgical Anatomy
Surgical Strategies
Management of Hydrocephalus
Definitive Surgery
Peri-operative Complications and their Management
Air Embolism
Pressure Sores
Delayed Anaesthetic Arousal
Pseudobulbar Palsy
Cerebellar Mutism
Aseptic Meningitis
Stress Ulcers
Post-Operative Pseudomeningocoele
Cervical Spine Instability
RADIATION THERAPY
Historical Perspective
CHEMOTHERAPY
Management Strategies
High-Risk Disease
Average Risk Disease
Infant Medulloblastoma
Relapsed Medulloblastoma
Chemoradiotherapy Sequelae
Neurocognitive Decline
Neuroendocrinologic Dysfunction
Newer Chemotherapeutic Agents
CONCLUSION
140:
Metastatic Brain Tumours
DEFINITION
INCIDENCE OF BRAIN METASTASIS
FACTORS GOVERNING THE METASTATIC PROCESS
CLASSIFICATION DEPENDING ON SITE OF ORIGIN89
Skull and Dura
Leptomeninges
Parenchyma
PATHOPHYSIOLOGY
Pagets Seed and Soil Theory
MOLECULAR BIOLOGY OF BRAIN METASTASIS
MOLECULAR GENETICS OF NON-SMALL CELL LUNG CANCER
MOLECULAR GENETICS OF BREAST CARCINOMA
MOLECULAR GENETICS USING REAL TIME IMAGING
PATHOLOGY
Histopathology
Immunohistochemistry
CLINICAL FEATURES
INVESTIGATIONS
Computerised Tomography
Magnetic Resonance Imaging
Magnetic Resonance Spectroscopy
Positron Emission Tomography
Whole-Body Magnetic Resonance Imaging
DIFFERENTIAL DIAGNOSIS
TREATMENT
Medical Management
Surgery
Chemotherapeutic Regimen
Stereotactic Radiosurgery
PROGNOSIS
Prognostic Factors Associated with Better Survival
Lung Metastasis to Brain
Breast Metastasis to the Brain
Germ Cell Tumour Metastasis to the Brain
Renal Metastasis to the Brain
Melanoma Metastasis to the Brain
RECENT ADVANCES
MULTIPLE METASTASES
RECURRENCE OF BRAIN METASTASIS
MENINGEAL CARCINOMATOSIS
Aetiopathogenesis
Clinical Features
Investigations
Cerebrospinal Fluid Analysis
Computerised Tomography/Magnetic Resonance Imaging
Meningeal Biopsy
Treatment
Recent Advances
CARCINOMATOUS ENCEPHALOPATHY
141:
Radiation Therapy for Malignant Brain Tumours
INTRODUCTION
RADIOTHERAPY TECHNIQUES
Stereotactic Radiosurgery
Stereotactic Radiotherapy
TREATMENT OF INDIVIDUAL TUMOURS
Gliomas
High-Grade Gliomas (Anaplastic Astrocytoma, Glioblastoma Multiforme)
Dose of Radiotherapy
Volume of Irradiation
Role of Chemoradiation
Brachytherapy
Low-Grade Gliomas
Brainstem Gliomas
Ependymomas
Medulloblastoma
Primary Central Nervous System Lymphoma
142:
Adjuvant Therapies for Malignant Brain Tumours
CHEMOTHERAPY
Blood-Brain Barrier
Tumour Heterogeneity
Drug-Drug Interaction7
Tumour Resistance7
Chemotherapeutic Agents
Newly Diagnosed Glioblastoma
Treatment of Recurrent Gliomas
Anaplastic Astrocytomas
Anaplastic Oligodendroglioma
Low Grade Gliomas
IMMUNOTHERAPY
CLASSIFICATION
Antibody-Guided Therapy
Vaccination
GENE THERAPY
ACKNOWLEDGEMENT
143:
Colloid Cyst
INTRODUCTION
REGIONAL EMBRYOLOGY OF THIRD VENTRICLE
INCIDENCE
Incidental Colloid Cyst
PATHOLOGY
LOCATION
CLINICAL FEATURES
INVESTIGATIONS
DIFFERENTIAL DIAGNOSIS
TREATMENT
144:
Choroid Plexus Tumours
HISTORY
CLINICAL COURSE
INVESTIGATIONS
TREATMENT
145:
Pineal Region Tumours: Clinical Features and Management
INTRODUCTION
PATHOLOGY
SYMPTOMS AND SIGNS
NEUROIMAGING
TUMOUR MARKERS
MANAGEMENT
SURGICAL APPROACHES
Surgical Anatomy
Endoscopic Approach
Indications
Technique
Complications
Stereotactic Approach
Indications
Technique
Complications
Microsurgical Approaches
Indications
Infratentorial Supracerebellar Approach
Technique
Complications
Occipital Transtentorial Approach
Technique
Complications
STEREOTACTIC RADIOSURGERY
RADIOTHERAPY
CHEMOTHERAPY
PROGNOSIS
146:
Pituitary Tumours Overview
INTRODUCTION
HISTORICAL
ANATOMY OF THE PITUITARY GLAND AND ITS SURROUNDINGS
Embryology
Pituitary Gland
Blood Supply
Sella Turcica
Diaphragma Sella
Sphenoid Sinuses
Carotid Arteries
Optic Chiasm
SYMPTOMS AND SIGNS
Effect on Neighbouring Structures
Headache
Ocular Palsies and Ptosis
Fifth Nerve Involvement
Hypothalamic Involvement
Hydrocephalus
Psychological Changes
Endocrine
147:
Prolactinomas
INTRODUCTION
SIGNS AND SYMPTOMS
ENDOCRINOLOGY
MANAGEMENT
Pergolide
Cabergoline
Quinagolide
Surgery
148:
Growth Hormone Secreting Adenomas
PATHOGENESIS
CLINICAL FEATURES
SYSTEMIC CHANGES
TREATMENT
Surgery
Medical Treatment
Somatostatin Analogues (Octreotide, Lanreotide and Pasireotide)
Dopamine Agonists (Bromocriptine, Quinagolide, and Cabergoline)
Growth Hormone Receptor Antagonists
Radiotherapy
149:
Cushing's Disease and Syndrome
INTRODUCTION
NORMAL HYPOTHALAMIC-PITUITARY-ADRENAL AXIS
AETIOPATHOLOGY
CLINICAL FEATURES
ENDOCRINE EVALUATION
Confirmation of Cushing's Syndrome
Twenty-four Hour Urine Free Cortisol Excretion
One Milligram Overnight Dexamethasone Suppression Test
Midnight Plasma Cortisol or Salivary Cortisol Level Determination
Establish ACTH-Dependent versus ACTH-Independent
Cushing's Disease versus Ectopic ACTH Syndrome
High Dose Dexamethasone Suppression Test
DIAGNOSTIC EVALUATION
Magnetic Resonance Imaging
Inferior Petrosal Sinus Sampling
MANAGEMENT
150:
Other Secreting Adenomas of the Pituitary
INTRODUCTION
PHYSIOLOGY OF THE PITUITARY THYROID AXIS
PATHOLOGY
CLINICAL PRESENTATION
EVALUATION
DYNAMIC TESTING
RADIOLOGICAL DIAGNOSIS
THERAPY
Medical Treatment
Criteria of Cure
CONCLUSION
151:
Non-Functioning Pituitary Adenomas
INTRODUCTION
PATHOLOGY
CLASSIFICATION OF PITUITARY ADENOMAS12,42
IMMUNOHISTOCHEMISTRY
CLINICAL PROFILE
ENDOCRINE DIAGNOSIS
IMAGING
TREATMENT
SURGERY
Transcranial Surgery
Complications of Surgery
RADIATION
FOLLOW-UP
OUTCOME
RECOVERY OF PITUITARY FUNCTION FOLLOWING MANAGEMENT OF NON-FUNCTIONING ADENOMAS
152:
Pituitary Apoplexy
INCIDENCE
PATHOGENESIS
CLINICAL FEATURES
INVESTIGATIONS
MANAGEMENT
153:
Giant Invasive Pituitary Adenomas
INTRODUCTION
EXTENSION
INVASION
MOLECULAR BIOLOGY
CLINICAL PRESENTATION
INVESTIGATION
TREATMENT
RADIATION
154:
Perioperative Endocrine Management
INTRODUCTION
PRE-OPERATIVE ASSESSMENT
Pituitary-Thyroid Axis
Pituitary-Adrenal Axis
Serum Prolactin
Growth Hormone—IGF-1 Axis
Pituitary-Gonadal Axis
Vasopressin
Pre-Operative Management
EARLY POST-OPERATIVE EVALUATION/MANAGEMENT (1–2 WEEKS)
General Principles of Pituitary Function Assessment
Diabetes Insipidus
Hyponatraemia
Pituitary Adrenal Insufficiency
Functioning Tumours
LATE POST-OPERATIVE EVALUATION/MANAGEMENT (AFTER ONE MONTH)
Pituitary-Adrenal Axis
Chronic DI/SIADH
Pituitary-Thyroid Axis
Pituitary-Gonadal/Prolactin Axis
Pituitary-Growth Hormone Axis
CONCLUSION
155:
Empty Sella Syndrome
PATHOGENESIS
Congenital Factors
Suprasellar Factors
Intrasellar Factors
Systemic Factors
Hypertension
Obesity
PRIMARY EMPTY SELLA
Symptoms and Signs
Radiology
SECONDARY EMPTY SELLA
Treatment
156:
Diencephalic Syndrome
DIENCEPHALON
DIENCEPHALIC SYNDROME
Clinical Features
Pathophysiology
Pathology
MANAGEMENT
Imaging Studies
Endocrine Assessment
Treatment
157:
Other Tumours of the Sellar Region
INTRODUCTION
PITUITARY CARCINOMA
Pathology
Clinical Features
Radiological Features
Treatment
Chemotherapy
GRANULAR CELL TUMOURS
NEUROHYPOPHYSEAL GLIOMAS
GERM CELL TUMOURS
Pathology
Clinical Features
Radiological Features
Treatment
CHORDOMAS
Pathology
Clinical Features
Radiological Features
Treatment
METASTATIC TUMOURS TO THE SELLAR REGION
RATHKE'S CLEFT CYST
Pathology
Clinical Presentation
Radiological Features
Treatment
HAMARTOMAS, CHORISTOMAS AND GANGLIOCYTOMAS OF THE SELLAR REGION
Hypothalamic Hamartomas
Pathology
Clinical Features
Radiological Features
Treatment
Intrasellar Choristomas (Gangliocytomas)
TUMOUR-LIKE CONDITIONS
Pituitary Abscess
Aetiology of Pituitary Abscess
LYMPHOCYTIC HYPOPHYSITIS
Pathology
Clinical Presentation
Radiological Features
Treatment
MUCOCOELE
SARCOIDOSIS
HISTIOCYTOSIS X (LANGERHAN'S CELL HISTIOCYTOSIS)
CAVERNOUS ANGIOMA OF CAVERNOUS SINUS6,28,37
MISCELLANEOUS TUMOURS
Schwannomas
Giant Cell Tumours of the Sphenoid
Paragangliomas
Glomangiomas
Lipomas
Primary Melanoma
Angiofibroma
Esthesioneuroblastoma
Fibrous Dysplasia
158:
Craniopharyngioma
INTRODUCTION
HISTORICAL PERSPECTIVE
PATHOLOGY
Other Epithelial Cysts in the Suprasellar Region
INCIDENCE
CLINICAL FEATURES
Endocrine Manifestations
IMAGING
TREATMENT
Aims of Treatment
Pre-Operative Evaluation and Management
Dilemmas in Management Decisions
Surgical Management
Associated Hydrocephalus
Operative Approaches
Radical Surgery Versus Conservative Surgery and Radiation
Radiotherapy
Surgical Technique
Complications
Other Treatment Modalities
Cyst Aspiration
Intracavitary Bleomycin Injection
Intracavitary Irradiation
Stereotactic Radiosurgery
Stereotactic Radiotherapy
Treatment Summary
Recurrent Tumours
Salvageability
Quality of Life
Complications
Radical surgery
Limited surgery plus irradiation
Ommaya reservoir with intracystic instillation
Stereotactic radiosurgery
Radiation or SRT
SECTION 12B: CRANIAL AND INTRACRANIAL TUMOURS
159:
Dermoids and Epidermoids
EPIDERMOIDS
History
Pathogenesis
Location
Pathology
Incidence
Clinical Features
Radiological Findings
Computed Tomography Scan
Magnetic Resonance Imaging
Treatment
Complications
DERMOIDS
Incidence
Location
Pathology
Clinical Features
Radiological Findings
Treatment
160:
Teratomas
INCIDENCE
PATHOGENESIS
PATHOLOGY
CLINICAL FEATURES
IMAGING
TREATMENT
161:
Acoustic Schwannomas
INTRODUCTION
HISTORY
EPIDEMIOLOGY
Age and Sex Distribution
Racial and Geographic Distribution
Tumour Syndromes and Genetic Factors
Natural History
SURGICAL ANATOMY
PATHOLOGICAL ANATOMY
PATHOLOGY
Microscopic Features
CLINICAL FEATURES
Auditory
Vestibular
Facial Nerve
Other Cranial Nerves
Cerebellar
Brainstem
Raised Intracranial Pressure
Headache
Papilloedema
INVESTIGATIONS
Neuro-Otological Workup
Clinical Testing of the Auditory System
Specialised Testing
Imaging
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
Observation
Surgery
The Middle Fossa Approach
The Translabyrinthine Approach
The Retromastoid Suboccipital Approach
The Retrolabyrinthine Approach
The Transcanal Approach
The Suboccipital Translabyrinthine Approach
The Subtemporal Transtentorial Approach
Endoscopy
Post-Operative Complications
Results
Facial Nerve Preservation
Hearing Preservation
Radiosurgery
Fractionated Stereotactic Radiotherapy
Subtotal Removal and Tumour Recurrence
CYSTIC VESTIBULAR SCHWANNOMA
BILATERAL ACOUSTIC NEUROFIBROMAS
NEURAL PROSTHESIS IN RESTORING HEARING
162:
Trigeminal Schwannomas
INTRODUCTION
SURGICAL ANATOMY
SURGICAL PATHOLOGY
Clinical Presentation
Radiological Diagnosis
Plain X-Rays
Computed Tomography Scans
Magnetic Resonance Imaging (MRI)
Cerebral Angiography
SURGICAL TECHNIQUES
POST-OPERATIVE COURSE
ROLE OF RADIOSURGERY
AIIMS EXPERIENCE26
163:
Jugular Foramen Lesions
INTRODUCTION
ANATOMICAL CONSIDERATIONS
PATHOLOGY
CLINICAL MANIFESTATIONS
NEUROIMAGING
SURGICAL APPROACHES
Major Groups
Lateral Approaches
Anterior Approaches
Posterior Approaches
Suboccipital Retrosigmoid Approach
Suboccipital Transcondylar Approach
Supracondylar Approach
Juxtacondylar Approach
Petro-Occipital Trans-Sigmoid (POTS) Approach
Infratemporal Fossa Approach Type A5
Modifications of This Approach
Modified Transcochlear Approach6,22
Type A Modified Transcochlear Approach
POST-OPERATIVE COMPLICATIONS
ACKNOWLEDGEMENTS
164:
Other Intracranial Schwannomas
INTRODUCTION
FACIAL NERVE SCHWANNOMAS
Clinical Presentation
Diagnosis
Management
Surgical Approach
LOWER CRANIAL NERVE SCHWANNOMAS
Clinical Presentation
Diagnosis
Management
Surgical Approach
SCHWANNOMAS OF THE OCULAR MOTOR NERVES
Clinical Presentation
Diagnosis
Management
165:
Phakomatoses
INTRODUCTION
NEUROFIBROMATOSIS
Neurofibromatosis-1
Neurofibromatosis-2
TUBEROSE SCLEROSIS
Clinical Manifestations
Skin Manifestations
Nervous System Manifestations
VON HIPPEL-LINDAU DISEASE
NEUROCUTANEOUS ANGIOMATOSIS
Ataxia Telangiectasia
Sturge-Weber Syndrome
Klippel-Trenaunay-Weber Syndrome
Osler-Weber-Rendu Syndrome or Hereditary Haemorrhagic Telangiectasia
Fabry's Disease
Wyburn-Mason Syndrome
Phakomatosis Pigmentovascularis/Speckled Lentiginous Nevus Syndrome
166:
Convexity Meningiomas
INTRODUCTION
INCIDENCE
LOCATION
CLINICAL FEATURES
ANTERIOR CONVEXITY MENINGIOMAS
MEDIAN CONVEXITY MENINGIOMAS
POSTERIOR CONVEXITY MENINGIOMAS
TEMPORAL CONVEXITY MENINGIOMAS
IMAGING
X-rays
Computed Tomography
Magnetic Resonance Imaging
Electroencephalogram
Angiography
DIFFERENTIAL DIAGNOSIS
SURGICAL MANAGEMENT
Pre-Operative Protocol
Scalp Incision
Post-Operative Care and Complications
PROGNOSIS
RECURRENCE
LONG-TERM OUTCOME
167:
Parasagittal and Falx Meningiomas
CLINICAL FEATURES
IMAGING
TREATMENT
PROGNOSIS
168:
Olfactory Groove Meningioma
INTRODUCTION
ANATOMY
CLINICAL FEATURES
RADIOLOGY
SURGICAL MANAGEMENT
Complications
Result
INTRODUCTION
ANATOMY
CLINICAL FEATURES
RADIOLOGY
SURGICAL MANAGEMENT
Other Surgical Approaches
Results
ADJUVANT THERAPIES
169:
Sphenoidal Wing Meningiomas
INTRODUCTION
CLINICAL PRESENTATION
Inner Third Sphenoid Wing Meningiomas
Middle Third or Alar Meningiomas
External Third or Pterional Meningiomas
NEURORADIOLOGY
TREATMENT
Surgical Treatment
Pterional Meningiomas
Inner and Middle Third Meningiomas
Surgical Complications
Results
GAMMA KNIFE SURGERY FOR MENINGIOMAS OF THE SPHENOIDAL WING
MEDIAL SPHENOID WING OR CLINOIDAL MENINGIOMAS
170:
Tentorial Meningiomas
INTRODUCTION
RELEVANT MICROSURGICAL ANATOMY
Tentorium
Dural Venous Sinuses
Blood Supply of the Tentorium
CLASSIFICATION (Fig. 1)
SIGNS AND SYMPTOMS
INVESTIGATIONS
Computed Tomography and Magnetic Resonance Imaging
Angiography with Tumour Embolisation
SURGICAL APPROACHES
PRIMARY TENTORIAL MENINGIOMAS
Tentorial Free Edge
Tentorial Leaf and Lateral and Posterior Tentorial Attached Margin
Falcotentorial
Torcular Meningioma
Complex Tentorial Meningioma
Parasellar and Cavernous Meningioma
Cerebellopontine Angle Meningioma
Petroclival Meningioma
Pineal Meningioma
Basal Approaches to Tentorial Meningiomas
Resection of Venous Sinuses to Achieve Complete Tumour Excision
SURGICAL RESULTS
Considerations in Elderly Patients
STEREOTACTIC RADIOSURGERY
CONCLUSION
171:
Posterior Fossa Meningiomas
INTRODUCTION
EPIDEMIOLOGY
AETIOPATHOGENESIS INCLUDING MOLECULAR BIOLOGY
CLASSIFICATION
PATHOLOGY
CLINICAL FEATURES
Type I
Type II
Type III
Type IV or the Petroclival Meningiomas
Type V
Type VI or the Unclassified Posterior Fossa Meningiomas
DIAGNOSTIC RADIOLOGY
DIAGNOSTIC CHALLENGES
TREATMENT
SURGICAL TREATMENT
General Principles
Pre-Operative Embolisation
Tumour Resection
Closure
Surgical Approaches Used by Tumour Location (Tables 2 to 8)
Type I Posterior Fossa Meningiomas
Type II Posterior Fossa Meningiomas
Type III Posterior Fossa Meningiomas
Type IV Posterior Fossa Meningiomas
Type V Posterior Fossa Meningiomas
Type VI Posterior Fossa Meningiomas
RADIATION TREATMENT
Fractionated External Beam Radiation
Stereotactic Radiosurgery
OTHER TREATMENTS
RESULTS AND PROGNOSIS
CONCLUSION
EDITORIAL COMMENT
172:
Petroclival Meningiomas
INTRODUCTION
NATURAL HISTORY
CLINICAL FEATURES
NEURORADIOLOGICAL EVALUATION
OPERATIVE DETAILS
Surgical Approaches
Adjunctive Procedures
Tumour Characteristics
Post-Operative Radiotherapy
Surgical Complications
Follow-Up and Survival
Long-Term Disabilities
Recurrence and Progression
CONCLUSION
173:
Foramen Magnum Meningiomas
INTRODUCTION
TUMOURS AT THE FORAMEN MAGNUM
GENERAL PERI-OPERATIVE CLINICAL EVALUATION AND NEUROPHYSIOLOGICAL MONITORING
THE POSTERIOR/POSTEROLATERAL SUBOCCIPITAL APPROACH
TRANSORAL/TRANSPHARYNGEAL APPROACH
THE EXTREME LATERAL TRANSCONDYLAR APPROACH
EXTENDED ENDOSCOPIC ENDONASAL APPROACHES TO SKULL BASE
Approach
RADIOSURGERY
CONCLUSION
174:
Intraventricular Meningiomas
INTRODUCTION
ORIGIN
PATHOLOGY AND CLINICAL COURSE
HISTOPATHOLOGY
IMAGING
SURGICAL MANAGEMENT
Lateral Ventricular Tumours
Third Ventricular Tumour
Fourth Ventricular Tumour
Results
Lateral Ventricular Tumours
Third Ventricular Tumours
Fourth Ventricular Tumours
CONCLUSION
175:
Haemangioblastomas
HISTORY13,39,40,44,59,78
GENETICS6,7,29,30,74
INCIDENCE
PATHOLOGY
Macroscopic Features
Microscopic Features
SYMPTOMS AND SIGNS29,32,45,53–55
INVESTIGATIONS
TREATMENT AND RESULTS
176:
Primary Central Nervous System Lymphomas
INTRODUCTION
CLINICAL FEATURES
PATHOLOGY
DIAGNOSTIC TESTS
Imaging Radiology
Cerebrospinal Fluid Examination
Vitreous Fluid Examination
Systemic Evaluation
RESPONSE TO CORTICOSTEROIDS
PROGNOSTIC FACTORS
MANAGEMENT AND THERAPY
Immunocompetent Individuals
Corticosteroids
Surgery
Radiotherapy
Chemotherapy
Commonly Used Drugs to Treat PCNSL
Systemic Lymphoma Protocols
Methotrexate Based Protocols
THE INDIAN SCENARIO
177:
Intracranial Melanomas and Other Tumours
INTRODUCTION
PRIMARY PIGMENTED LESIONS
Localised Melanocytic Neoplasms—Benign Melanocytomas and Malignant Melanomas
Clinical Presentation
Differential Diagnosis
Radiological Features
Histopathology
Management
Prognosis
Diffuse Melanocytic Neoplasms
Neurocutaneous Melanosis
Secondary Malignant Melanoma
Indications
Contraindications
Other Pigmented CNS Lesions
Melanotic Medulloblastoma
Melanotic Cerebral Astrocytoma
Melanotic Choroid Plexus Papilloma
178:
Benign Intracranial Tension
PATHOPHYSIOLOGY
INFANTILE PRESENTATION OF BIH
AETIOLOGY
CLINICAL DESCRIPTION
CT AND MR STUDIES
DIFFERENTIAL DIAGNOSIS
TREATMENT
OPTIC NERVE SHEATH DECOMPRESSION
RESULTS
179:
Tumours of the Cranial Vault
ANATOMICAL CONSIDERATIONS
Classification
DIAGNOSTIC EVALUATION
Plain Skull Films
Computed Tomography
Magnetic Resonance Imaging
Cerebral Angiography
MANAGEMENT
Operative Treatment
Radiation Therapy
Chemotherapy
PRIMARY TUMOURS OF THE SKULL91
Benign Tumours
Osteoma
Haemangiomas
Giant Cell Tumours (Osteoclastoma)
Epidermoid and Dermoid Tumours
Chondroma
Other Benign Tumours
Malignant Tumours
Chondrosarcoma and Osteogenic Sarcomas
Osteogenic Sarcoma
Fibrosarcoma
Ameloblastic Fibrosarcoma
Malignant Fibrous Histiocytoma
Chordoma
Ewing's Sarcoma
Other Malignant Tumours
TUMOURS INVOLVING THE SKULL BY DIRECT EXTENSION
CONDITIONS SIMULATING SKULL NEOPLASMS
Osteomyelitis
Traumatic Conditions
Cephal Haematoma
Leptomeningeal Cyst (Growing Fracture of the Skull)
Vascular Diseases
Vascular Impressions in the Skull
Sinus Pericranii
Histiocytosis X
Sarcoidosis
Osteitis Deformans (Paget's Disease)
Fibrous Dysplasia
Hyperparathyroidism
Mucocoele
Neuroectodermal Dysplasias
Haemolytic Anaemias
Hyperostosis Frontalis Interna
Petrous Apex Cholesterol Granuloma
SECTION 13: SKULL BASE SURGERY
180:
Clival Chordomas
INTRODUCTION
NATURAL HISTORY
PATHOLOGICAL FEATURES
CLINICAL FEATURES
IMAGING FEATURES
PRINCIPLES OF SURGICAL MANAGEMENT
Surgical Approach
Tumour Resection
Reconstruction of the Skull Base and Potential Complications
RADIATION TREATMENT
CONTEMPORARY CASE SERIES AND SURVIVAL
ILLUSTRATIVE CASES
181:
Trans-facial Transmaxillary Approaches to Anterior Skull Base
INTRODUCTION
HISTORY
INDICATIONS
SURGICAL ANATOMY1,23,25
PRE-OPERATIVE EVALUATION
ANAESTHESIA
PATIENT POSITIONING
OPERATIVE TECHNIQUE
Classification of Transfacial Transmaxillary Approaches
Medial
Medial Maxillectomy
Medial Mini-Facial Translocation15
Lateral
Total Maxillectomy
Standard Facial Translocation
Extended Osteoplastic Maxillotomy
Combined (Medial and Lateral)
Medial Extended Facial Translocation (Le Fort I)15
Medial and Inferior Extended Facial Translocation15
Bilateral
Bilateral Facial Translocation15
Extended Transfacial Subcranial Approach24
Facial Degloving16
Transmaxillary Approaches of Beals and Joganic3
POST-OPERATIVE MANAGEMENT
COMPLICATIONS
182:
Approaches to the Lateral Skull Base
INTRODUCTION
IDEAL APPROACH
SURGICAL CONSIDERATIONS
Operative Technique
Bone Work
SURGICAL APPROACHES TO LATERAL SKULL BASE
Anterior Subtemporal Approaches
Transtemporal Approaches
Petrous Apex
Mobilisation of the Intrapetrous Carotid Artery
Facial Nerve
Mobilisation of the Facial Nerve
Approaches Preserving Hearing
Approaches Involving Sacrifice of Hearing
Approaches Involving Mobilisation of the Facial Nerve
Extended Middle Fossa Approach27
Operative Technique
Basal Extension of Lateral Subtemporal Craniotomy
Operative Technique
Middle Fossa Sub-Gasserian Ganglion Approach29
Operative Technique
Infratemporal Fossa Interdural Approach28
Operative Technique
Presigmoid Approach
Retrosigmoid Approach
Surgical Technique
Transcondylar Transclival Approach
Supracondylar Infrajugular Bulb Keyhole Approach to Anterior Medullary Lesions32
Operative Technique
Splitting of the Temporalis Muscle33
Anatomical and Technical Considerations
Tentorial Dural Flap26
Operative Technique
SELECTION OF APPROACHES
Petroclival Meningiomas
Trigeminal Schwannomas
Foramen Magnum Meningiomas
Clival Chordoma
183:
Transpharyngeal Approach to the Cranio Vertebral Junction
INTRODUCTION
ASSESSMENT OF NUTRITIONAL STATUS
Dental Hygiene
Assessment of Co-morbidities
Oropharyngeal Cultures
DECISION TREE FOR TREATMENT OF CRANIOCERVICAL JUNCTION ABNORMALITIES
PRE-OPERATIVE CERVICAL TRACTION
OPERATIVE TECHNIQUE OF THE TRANSORAL-TRANSPALATOPHARYNGEAL APPROACH TO THE VENTRAL CRANIOCERVICAL BORDER
SPECIAL CIRCUMSTANCES
Transpalatal Route
Median Glossotomy Combined with Transoral-Transpalatopharyngeal Approach
Intradural Extension for Tumour and Repair of Cerebrospinal Fluid Leak
POST-OPERATIVE MANAGEMENT
PREVENTION AND MANAGEMENT OF COMPLICATIONS
184:
Reconstruction of the Skull Convexity and Base
INTRODUCTION
HISTORY
ANATOMICAL CONSIDERATIONS
SURGICAL CONSIDERATIONS
Reconstruction of Bone Defects
Flaps
Vascularised Osteomyoplastic Flap9
Pericranium Based Bone Flaps9,10
Long Vascular Pedicle Composite Cranial Flap14
Use of Bone Dust and Debris
Reconstruction of Skull Base with Free Bone Flap
Suturing of Bone Pieces
Subgaleal Preservation of Bone Flaps15
Reconstruction of Dural and Soft Tissue Defects
Fat and Free Muscle As a Packing Material
Lyophilised Dura, Gelfoam® and Fascia Lata
Use of Pericranial and Galeal Flaps
Use of Rotation of Muscle Flap
Extended Vascularised Temporalis Muscle-Fascia Flap11
Extended Subgaleal Fascia-Pericranial Temporalis Flap12
Temporalis Muscle and Temporoparietal Fascia
Myocutaneous Flaps
Free Tissue Transfer/Free Flaps
Multilayer Reconstruction of Middle Fossa Base
Anterior Cranial Base Reconstruction
Multilayer Reconstruction of the Anterior Cranial Fossa Floor21
Use of Outer Layer of Dura As a Pedicled Flap16
Tenting Scalp Stitches8
185:
Orbital Tumours
INTRODUCTION
GROSS SURGICAL ANATOMY
Bony Orbit
Periorbita
Extraconal Orbit
Intraconal Orbit
Globe
TYPES AND INCIDENCE OF ORBITAL TUMOURS
CLINICAL FEATURES OF ORBITAL TUMOURS
Proptosis
Optic Neuropathy
Ocular Motor Nerve Paresis
Pain
Pupillary Abnormalities
Chemosis and Bruit
INVESTIGATIONS
Plain X-ray
Computed Tomography Scan
High Resolution Magnetic Resonance Imaging Scan
Angiography
Ultrasonography
MANAGEMENT OF ORBITAL TUMOURS
Principles in the Treatment of Orbital Tumours
History of Surgical Approaches to the Orbit
Extracranial Approach
Lateral Orbitotomy
Transcranial Approach
Other Approaches
Various Areas in the Orbit may be Approached in the Following Manner
Surgical Approaches
Lateral Orbitotomy
Subfrontal Approach
Fronto-orbito-zygomatic Craniotomy
Fronto-temporal-orbito-zygomatic Craniotomy
DIFFERENT ORBITAL TUMOURS
Neurofibroma
Meningioma
Cavernous Haemangioma
Lymphangioma
Optic Nerve Glioma
Lacrimal Gland Tumours
Fibrous Dysplasia
Dermoid and Epidermoid Cysts
Osteoma
Mucocoele
Metastatic Tumours
Vascular Lesions
Venous Varix
Arteriovenous Malformations
Intraorbital Ophthalmic Artery Aneurysms
Pseudotumours
RESULTS
ACKNOWLEDGEMENT
SECTION 14: STEREOTAXY
186:
Stereotaxy: General Principles
PRINCIPLES AND TECHNIQUES
STIMULATION AND DEPTH RECORDING
METHODS OF MAKING THE LESION
Temporary Lesions
Chemical Lesions
Electrolytic Lesions
Cold Lesions (Cryogenic Lesions)
Mechanical Lesions
STEREOTAXIC BIOPSY
Biopsy Instrumentation
POST-OPERATIVE STUDY OF THE SITE OF THE LESION
ASPIRATION OF CYSTS AND HAEMATOMAS
STEREOTACTIC CRANIOTOMY
CHRONIC IMPLANTATION
STEREOTACTIC ANGIOGRAPHY
TECHNIQUE USING THE LEKSELL'S APPARATUS
COSMAN-ROBERTS-WELLS SYSTEM
PHANTOM INSTRUMENTS
TWO MACHINE STEREOTAXY
STEREOTACTIC EXTERNAL BEAM RADIATION THERAPY
General Concepts
Clinical Applications
FRAMELESS STEREOTAXY
SPINAL STEREOTAXIC SURGERY
187:
Stereotaxy: Brain Tumours
INTRODUCTION
STEREOTACTIC BIOPSY
Procedure
Results
STEREOTACTIC ASPIRATION
STEREOTACTIC BRACHYTHERAPY
STEREOTACTIC CRANIOTOMY
STEREOTACTIC ENDOSCOPY
188:
Involuntary Movements: Anatomy and Pathophysiology
INTRODUCTION
MAJOR BASAL GANGLIA PATHWAYS
Connections of the Basal Ganglia
Striatal Afferents
Striatal Efferents
Pallidal Afferent
Pallidal Efferent
Subthalamic Nucleus
Substantia Nigra
FUNCTIONAL ORGANISATION OF THE BASAL GANGLIA AND OTHER PATHWAYS
ACKNOWLEDGEMENT
189:
Stereotaxy for Parkinson's Disease
PHYSIOLOGICAL BASIS OF THE TARGET
SELECTION OF PATIENTS
PRE-OPERATIVE WORK-UP
PALLIDOTOMY/PALLIDAL STIMULATION
Results
Author's Personal Series of Pallidotomy
Complications
Discussion
SUBTHALAMIC NUCLEUS STIMULATION/LESION
Surgical Procedure
Results
Off Medication Evaluation
On Medication Evaluation
Adverse Events
Discussion
Future Therapies
190:
Surgery for Movement Disorders
INTRODUCTION
HISTORY OF MOVEMENT DISORDER SURGERY IN INDIA
HISTORY OF MOVEMENT DISORDER SURGERY—WORLD (EXCLUDING INDIA)
TREMORS
Parkinsonian Tremor
Essential Tremor
Post-Traumatic and Post-Hemiplegic Tremor
Multiple Sclerosis Tremors
The Vim Target
DYSTONIA
Indications for Surgical Treatment of Dystonia
Surgical Options in Dystonia
Results
COMPLICATIONS
Pallidotomy Complications
Thalamotomy Complications
SURGERY FOR MOVEMENT DISORDERS: FUTURE DIRECTIONS
191:
Gamma Knife Radiosurgery
HISTORY
MEDICAL PHYSICS
Dose-Volume Histogram
Conformity Indices
RADIOBIOLOGY
DOSE SELECTION
PROCEDURE
Basic Principles
Specific Steps
Frame Fixation
Imaging
Cross-Registration
Planning
Manual/Automatic Positioning
ADVANTAGES OF GAMMA KNIFE RADIOSURGERY
Current Uses
Review of Literature
GUIDELINES AND SUCCESS RATES
Vestibular Schwannomas
Meningiomas
Pituitary Adenomas
Non-functioning Tumours
Cushing's Disease
Acromegaly
Chordomas and Chondrosarcomas
Glomus Jugulare
Haemangioblastomas
Gliomas
Pilocytic Astrocytomas
Low-Grade Gliomas
Malignant Gliomas
Metastases
Current Recommendations
Vascular
Arteriovenous Malformations
Cavernomas
Functional
Trigeminal Neuralgia
Movement Disorders and Epilepsy Surgery
COMPLICATIONS AND SIDE EFFECTS
Acute Complications: Post Gamma Knife Headache a New Syndrome?
Radiation Myelitis
Cyst Formation
Hydrocephalus
Second Malignancy
PLATFORMS DELIVERING STEREOTACTIC RADIOSURGERY
Leksell Gamma Knife™
Rotating Gamma System
LINAC Based Radiosurgery
Charged Particle Radiosurgery
EVOLVING INDICATIONS AND FUTURE TRENDS
192:
Psychosurgery
HISTORY OF PSYCHOSURGERY
LIMBIC SYSTEM ANATOMY—NEWER PERSPECTIVES
Concept of Thalamocortical Dysrhythmias97
Amygdala
Structure of the Amygdala
Connections of the Amygdala
Nucleus Accumbens
HYPOTHALAMUS
Physiology
Early Psychosurgery
Choice of Target
CLASSIFICATION OF PSYCHIATRIC DISORDERS3—AN OUTLINE
AN OVERVIEW OF THE COMMON PSYCHIATRIC MALADIES AMENABLE TO PSYCHOSURGERY (NEUROANATOMY AND CLINICAL FEATURES)91
Obsessive Compulsive Disorder (OCD)
Neuropathologic Circuitry
Depression
Sexual Disorders and Drug Addiction
IMAGING IN PSYCHIATRY
Indications for Surgery
PROCEDURES USED IN MODERN PSYCHOSURGERY
Cingulotomy
Anatomical Considerations
Technique of Cingulotomy (As was Used by Profs. Balasubramaniam V and Ramamurthi B)
Results
Subcaudate Tractotomy
Indications
Target
Results
Transient Complications Seen in Patients
Anterior Capsulotomy
Target
Side Effects
Limbic Leucotomy
Limbic Leucotomy is the Procedure of Choice in the Treatment of Intractable OCD26
Dorsomedian Thalamotomy
Amygdalotomy
Aetiology of Behaviour Disturbance
Selection of Cases
Selection of Targets
Unilateral or Bilateral Operations
One-stage or Two-stages
Amygdala First or Hypothalamus First
Assessment
Surgical Technique for Amygdalotomy (As Used by Balasubramaniam and Ramamurthi)
Results
Hypothalamotomy (Surgical Technique as Described by the Senior Author)
Determining the Co-ordinates
Depth Recording
Verification of Electrode Placement
Making the Lesion
Post-operative Complications
Thalamolaminotomy71,90
Results of Hypothalamotomy and Other Sedative Neurosurgical Procedures
OUTCOME MEASUREMENTS IN PSYCHOSURGERY
NEWER MODALITIES OF TREATMENT IN PSYCHOSURGERY
Vagal Nerve Stimulation
Transcranial Magnetic Stimulation (TMS)
ETHICS OF FUNCTIONAL NEUROSURGERY75
APPENDIX 1: THE YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)
The Severity Rating Test
Obsession Rating Scale (Item Range of Severity)
Compulsion Rating Scale
APPENDIX 2: ITEM HAMILTON RATING SCALE FOR DEPRESSION
193:
Neural Transplantation and Stem Cell
HISTORICAL BACKGROUND
EMBRYONIC STEM CELLS
DEFINITIONS
Stem Cells
Embryonal Stem Cells
Totipotent Cells
Pluripotent Cells
Neural Stem Cells
Progenitor Cells
SOURCES OF STEM CELLS
Adult Neural Stem Cells
Non-Neural Adult Stem Cells
Induced Pluripotent Stem Cells
NINE MYTHS ABOUT STEM CELLS
Myth 1: Stem Cells are Immortal
Myth 2: Asymmetric Divisions are Required to Define Stem Cell
Myth 3: Adult Stem Cells are like Foetal Cells, only Better
Myth 4: Cells Similar to Embryonic Stem Cells Exist in Adult Tissue
Myth 5: Stem Cells are more Plastic than Other Cells
Myth 6: The most Primitive Stem Cell for a Tissue or Organ is the Best Stem Cell to Use
Myth 7: Stem Cells can Home and Migrate to Sites of Injury
Myth 8: Stem Cells do not Provoke an Immune Response
Myth 9: Therapy will be Straight-forward and will Mimic Strategies used in Bone Marrow Therapy
OTHER USES OF STEM CELLS
EXPANSION OF HAEMATOPOIETIC STEM CELLS
STEM CELL RESEARCH IN INDIA
ACKNOWLEDGEMENT
SECTION 15: PAIN
194:
Pain: Anatomy and Physiology
INTRODUCTION
DEFINITIONS OF PAIN
ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS
Peripheral Receptors
Sensory Nerve Fibres
Nociceptors
C Polymodal Nociceptor70
Visceral Pain
ORGANISATION OF THE SPINAL CORD
Lamina I
Lamina II (Substantia Gelatinosa of Rolando)
Laminae III-V
Laminae VI and VII
Laminae VIII-X
PAIN PATHWAYS IN THE SPINAL CORD
Dorsolateral Tract of Lissauer
Spinothalamic Tract
Spinoreticular Tract
Spinomesencephalic Tract
Spino-Cervical Tract
Dorsolateral Posterior Synaptic Pathway
Propriospinal Multisynaptic Ascending System
Dorsal Root Entry Zone86
Trigeminal Nerve and its Nuclei
The Thalamus (Table 4)
Summary of the Neurophysiology of the Thalamus89
NEUROPHARMACOLOGY OF PAIN
Towards the Understanding of Pain—Pain Models
The Biophysical Model of Pain
The Gate Control Theory of Pain
Neuromatrix Theory of Pain63
CHRONIC PAIN SYNDROMES
Pain in Peripheral Nerve Lesions
Cerebral Areas for Pain Perception
Mechanisms of Central Pain4,70
Thalamic Pain Syndromes (Dejerine and Roussy)
Congenital Indifference to Pain (Pain Asymbolia)
Summary of Physiological Principles
Physiological Classification of Pain91
Mechanisms of Chronic Pain
CHRONIC REGIONAL PAIN SYNDROME
Pathophysiology of Chronic Regional Pain Syndrome
Diagnostic Criteria for Chronic Regional Pain Syndrome
Clinical Signs and Symptoms
Lab Results
Interpretation
Scores
Clinical Correlates in Pain
Hyperalgesia
Grading of Pain
Psychological Issues in Pain Management
Alternative and Complementary Treatment in Pain
QiGong
Tai-Chi
Traditional Indian Systems of Medicine100
Biostimulation
Multidisciplinary Approach to the Management of Chronic Pain
195:
Surgery for Intractable Pain
TREATMENT
DRUGS
Non-Narcotic Analgesic Drugs
Acetaminophen (Official Generic Name: Paracetamol)
Salicylates
Non-Steroidal Anti-inflammatory Drugs
Phenothiazines
Phenytoin
Carbamazepine
Oxcarbazepine
Gabapentin
Benzodiazepines
Tricyclic Antidepressants
Pregabalin
Narcotics
Opioids in Cancer Pain
Spinal Delivery of Opioids
Anaesthetic Measures
Peripheral Nerve Block
Spinal Neurolysis (Subarachnoid, Subdural and Epidural)
SURGICAL PROCEDURES
Peripheral Neurectomy
Posterior Root
Section (Rhizotomy)
Selective Rhizotomy (Rhiziditomy)
Percutaneous Radiofrequency Rhizotomy
Dorsal Root Entry Zone Lesions
Chemical Rhizotomy
Sympathectomy for Visceral Pain
Operations on the Spinal Cord
Spinothalamic Tractotomy-Anterolateral Cordotomy
Percutaneous Cervical Cordotomy
Commissural Myelotomy
Medullary and Mesencephalic Tractotomy
Thalamus: Stereotaxic Thalamotomy
Hypothalamotomy
Sensory Cortex Ablation
Frontal Lobes
Cingulumotomy
Hypophysectomy
Intracranial Neurostimulation for Pain Control
Motor Cortex Stimulation for Neuropathic Pain Syndromes
Deep Brain Stimulation
Afferent Stimulation for Abolition of Pain
Dorsal Column Stimulation
Focal Brain Stimulation
Hypnosis
Outcome Assessment
CHRONIC PAIN SYNDROMES
Deafferentation Pain Syndromes
Clinical Syndromes of Deafferentation Pain
Peripheral Nerve and Root
Spinal Cord
Brainstem
Thalamus
Cortex
Treatment
Phantom Limb and Stump Pain
Acute Pain Following Amputation
Mechanisms of Pain in Chronic Stump and Phantom Limb Pain
Blood Flow
Voluntary Muscle Spasm
Psychological Factors
Treatment
POST-HERPETIC NEURALGIA
Natural History and Epidemiology
Prevention of Post-Herpetic Neuralgia
Treatment
Medical Treatment
Surgical Treatment
PAIN IN MULTIPLE SCLEROSIS
PAIN SYNDROMES WITH CANCER
196:
Trigeminal Neuralgia
HISTORY
INCIDENCE
CLINICAL FEATURES
PATHOLOGY
PATHOGENESIS
IMAGING
TREATMENT
Emergency Room Management
Medical Therapy
Surgical Procedures
Peripheral Procedures
Percutaneous Retrogasserian Glycerol Rhizolysis
Technique of Percutaneous Retrogasserian Glycerol Rhizolysis
Results of Percutaneous Retrogasserian Glycerol Rhizolysis
Percutaneous Radiofrequency Thermocoagulation (PRFTC)
Technique of Percutaneous Radiofrequency Thermocoagulation
Results of Percutaneous Radiofrequency Thermocoagulation
Percutaneous Trigeminal Balloon Compression (PTBC)
Technique of Percutaneous Trigeminal Balloon Compression
Results of Percutaneous Trigeminal Balloon Compression
Comparison of the Three Percutaneous Ablative Techniques
Microvascular Decompression
Partial Sensory Rhizotomy
Radiosurgery
CONCLUSION
197:
Glossopharyngeal and Other Cranial Neuralgia
INTRODUCTION
CLINICAL FEATURES
CAUSES
EPIDEMIOLOGY
EXAMINATION
DIAGNOSIS
TREATMENT
Medical Management
Surgical Management
Microvascular Decompression
Other Ablative Procedures
Complications
GENICULATE NEURALGIA
PERSISTENT IDIOPATHIC FACIAL PAIN
TOLOSA-HUNT SYNDROME (PAINFUL OPHTHALMOPLEGIA)
OCCIPITAL NEURALGIA
COSTEN'S SYNDROME
READER'S SYNDROME
198:
Microvascular Decompression
HISTORY
PATHOPHYSIOLOGY
TRIGEMINAL NEURALGIA
Selection of Patients
Investigations
Anatomy of the Trigeminal Nerve in the Cerebellopontine Angle
Surgical Procedure
Results
HEMIFACIAL SPASM
Selection of Patients
Anatomy of the Facial Nerve in the Cerebellopontine Angle
Surgical Technique
Results
ESSENTIAL HYPERTENSION
GLOSSOPHARYNGEAL NEURALGIA
ENDOSCOPE IN MICROVASCULAR DECOMPRESSION
RADIOSURGERY VERSUS MICROVASCULAR DECOMPRESSION
SECTION 16: EPILEPSY
199:
Epilepsy: Overview
INTRODUCTION
DEFINITIONS
MAGNITUDE OF THE PROBLEM
BASIC MECHANISMS OF EPILEPTOGENESIS
CLASSIFICATION OF SEIZURES AND EPILEPSIES
GENETICS OF EPILEPSIES
NATURAL HISTORY OF EPILEPSIES
Initial Unprovoked Seizure
Natural History of Treated Epilepsies
Natural History of Untreated Epilepsies
Chronic Epilepsy
Determinants of Natural History of Epilepsies
Refractory Epilepsies
Mechanisms of Pharmacoresistance
Comprehensive Epilepsy programme
DIFFERENTIAL DIAGNOSIS OF EPILEPSIES
INVESTIGATION OF EPILEPSIES
Electroencephalography
Video-EEG Telemetry
Neuroimaging
Invasive Video-EEG Monitoring
NEUROPATHOLOGY OF EPILEPSIES
TREATMENT OF EPILEPSIES
Emerging and Alternative Treatment for Epilepsy
Vagus Nerve Stimulation
Ketogenic Diet
Yoga
COMMUNITY AWARENESS AND ATTITUDE TOWARDS EPILEPSY
PROBLEMS ASSOCIATED WITH LONG-STANDING EPILEPSY
Sudden Unexplained Death in Epilepsy
Psychiatric Disorders
Quality of Life Outcome
SUMMARY
200:
Epilepsy: Medical Management
INTRODUCTION
NEWLY DIAGNOSED EPILEPSY
SEIZURE RECURRENCE ON MONOTHERAPY
CONTROLLED ON POLYTHERAPY
POORLY CONTROLLED ON POLYTHERAPY
SPECIAL CLINICAL SITUATIONS
LONG-ACTING ANTIEPILEPTIC DRUG FORMULATIONS
ROLE OF SERUM ANTIEPILEPTIC DRUG LEVEL MONITORING
A PRACTICAL GUIDE FOR ANTIEPILEPTIC DRUG WITHDRAWAL
CONCLUSION
201:
Surgery for Epilepsy: General Principles
INTRODUCTION
Definitions
Magnitude of the Problem
HISTORICAL PERSPECTIVE
PHYSIOLOGY
Cellular Mechanisms
Seizure Generation
Seizure Classification
PATHOLOGY
Mesial Temporal Lobe Epilepsy
Neocortical Epilepsy
Developmental Lesions
Developmental Tumours
Vascular Malformations
Brain Trauma
SURGICALLY REMEDIABLE LESIONAL EPILEPSY SYNDROMES
PRE-SURGICAL EVALUATION
Objectives of Pre-surgical Evaluation
Candidates for Pre-surgical Evaluation
Pre-surgical Evaluation
NEUROIMAGING
Non-invasive Electroencephalography
Neuropsychological Assessment
Intracarotid Amobarbital (Wada) Test
Functional Magnetic Resonance Imaging
Invasive Electroencephalography
Cortical Stimulation Mapping
Awake Craniotomy
Electrocorticography
Neuronavigation
SURGICAL PROCEDURES
Lesionectomy
Lobar/Cortical Resections
Frontal Lobe Resections
Central Resections
Parietal and Occipital Resections
Multilobar Resections
Hemispherectomy
Corpus Callosotomy
Multiple Subpial Transections
Radiosurgery
Neurostimulation
Vagal Nerve Stimulation
Deep Brain Stimulation
Stereotactic Surgery
COMPLICATIONS
OUTCOME ASSESSMENT
Seizure Outcome
Resurgery
CONCLUSION
ACKNOWLEDGMENTS
202:
Surgery for Temporal Epilepsy
INTRODUCTION
HISTORICAL PERSPECTIVE
PATHOLOGY
MEDICAL REFRACTORINESS
PRE-SURGICAL EVALUATION
Non-invasive Evaluation
Seizure Semiology, Lateralisation and Localisation
Magnetic Resonance Imaging
Neuropsychological Evaluation
Functional Imaging in Temporal Lobe Epilepsy
Invasive Evaluation
SURGICAL TREATMENT
Surgical Approaches
Anterior Temporal Lobectomy
Selective Amygdalohippocampectomy
Lesional Temporal Lobe Epilepsy
Stereotactic Procedures
Alternate Surgical Procedures
Complications
OUTCOME ASSESSMENT
Seizure Outcome
Surgical Failures
Determinants of Post-Operative Seizure Outcome
Quality of Life Outcome
Economics
CONCLUSION
ACKNOWLEDGEMENTS
SECTION 17: CEREBRAL PALSY
203:
Stereotaxy for Cerebral Palsy
HISTORICAL ASPECTS
DEFINITION
AETIOLOGY
CLINICAL FEATURES
Disorders of Tone
Abnormal Movements
TREATMENT
Criteria for Selection of Cases for Stereotaxic Surgery
Pre-operative Assessment
Electromyographic Studies
Psychometric Assessment
Timing of the Operation
Pathophysiology and Choice of the Target
Rigidity
Rigidospasticity and Spasticity
Sensory-induced Dystonia
Dyskinesias
Infantile Hemiplegia with Athetosis
Ipsilateral Relief
Location of the Target during Surgery
Method of Making the Lesion
Post-operative Assessment
Later Additions to the Management of Cerebral Palsy
Our Experience
204:
Surgery for Spasticity
INTRODUCTION
MECHANISM OF GENERATION OF SPASTICITY AND BASIS OF ACTION OF VARIOUS PROCEDURES10
Suprasegmental Control
Segmental Control
TREATMENT PROTOCOL
Physical Methods
Selection of Cases
Detection of Non-progression of Neurological Deficits
Detection of Harmful Spasticity
Detection of Resistant Spasticity
Detection of Probable Safety and Usefulness of the Procedure
Detection and Discussion of Goals
Neuro-interventional Procedures
Ideal Method
CLASSIFICATION
Anatomical Classification
Control Pathways
Location
Physiological Classification
Non-ablative Segmental (Spinal Circuit) Procedures
Peripheral Procedures
Central Procedures
Non-ablative Supra-segmental Procedures—Central Procedures
Neural-stimulation
Ablative Segmental (Spinal Circuit) Procedures
Peripheral Proceduress
Procedure
Results
Indications and Specific Selection Criteria and Goals
Results22,23,51,52,57,58,59
Spasticity and Spasms
Motor Functions
Side Effects
Central Procedure
SECTION 18: MISCELLANEOUS
205:
Anaesthesia for Neurosurgery
CEREBRAL PHYSIOLOGY
CEREBRAL BLOOD FLOW AND ITS REGULATION
METABOLIC CONTROL
AUTO-REGULATION
CARBON DIOXIDE
OXYGEN
NEUROGENIC CONTROL
CEREBRAL PERFUSION PRESSURE
Rosner Concept or Edinburgh Concept
Lund Concept
INTRACRANIAL PRESSURE
PHARMACOLOGY OF ANAESTHETIC DRUGS
Inhalational Agents
Halothane
Enflurane
Isoflurane (Blood Gas Solubility 1.4 and MAC 1.2%)
Sevoflurane (MAC 1.7–2% and a Low Blood Gas Solubility 0.6)
Desflurane (MAC 5–10% and Blood Gas Solubility, 0.4%)
Nitrous Oxide
Hypnotics
Barbiturates
Etomidate
Propofol
Ketamine
Narcotics
Fentanyl
Pethidine
Alfentanil
Sufentanil
Remifentanil
Neuromuscular Blocking Drugs
Suxamethonium
Pancuronium
Vecuronium
Atracurium
Mivacurium
Rocuronium
Choice of Anaesthetic
GENERAL ANAESTHESIA: AN OVERVIEW
Pre-operative Evaluation
History and Physical Examination
Premedication
General Anaesthesia for Neurosurgical Procedures
Tight Brain during Surgery
Emergence from Anaesthesia
ANAESTHETIC CONSIDERATIONS FOR DIFFERENT TYPES OF NEUROSURGICAL SITUATIONS
Intracranial Tumours where ICP is a Concern
Posterior Fossa Surgery
Aneurysmal Subarachnoid Haemorrhage
Spinal Surgery
Paediatric Neuroanaesthesia
Post-operative and Intensive Care
Mechanical Ventilation
Sedation and Analgesia
Haemodynamic Management
Management of Disorders of Sodium Concentration
Hyponatraemia (Na+ ≤135)
Hypernatraemia
206:
Positioning in Neurosurgery
POSITIONING FOR NEUROSURGERY
Cranial Procedures
Supine Position
Prone Position
Lateral Decubitus Position
Sitting Position2
Spinal Procedures
Craniovertebral Junction
Cervical Spine
Thoracic Spine
Lumbar and Sacral Spine
Peripheral Nerves
207:
Operation Theatre for Neurosurgery
EVOLUTION OF THE NEUROSURGICAL OPERATING ROOM
GENERAL PRINCIPLES OF PRE-OPERATIVE CARE AND OPERATING THEATRE USE-WHO GUIDELINES12
Infection Prevention in the Operation Theatre
Pre-Operative Care and Patient Preparation
Pre-Operative Processes
Pre-Operative Showering
Pre-Operative Hair Removal
Patient Skin Preparation in the Operating Theatre
Antiseptics for Preparation of the Skin and Hands
Principles to Maximise Antibiotic Benefit Pre-Operatively
Pre-Operative Skin Preparation of Operation Theatre Personnel
Tips for Scrubbing
Protective Clothing for Use in the Operation Theatre
Environment and Infrastructure of a Modern Neurosurgical Operating Theatre
Layout of the Operation Theatre
Zoned Operation Theatre
Temperature and Humidity
Ideal Ventilation System: Air Supply and Exhaust
Design Features
Environmental Cleaning and Maintenance of the OT
Microbial Sampling
Theatre Sterile Services Unit
Neurosurgical Operating Room
Mayfield Frame
Sugita Frame
Brain Suite: (Integrated Operating Room with the Intra-Operative MRI)
Equipment and Theatre Set-Up
The Future
208:
Basic Neurosurgical Instruments
INTRODUCTION
HEAD FIXATION SYSTEM
OPERATING TABLE
MICROSURGICAL OPERATING CHAIRS
INSTRUMENT TABLE
RETRACTOR SYSTEMS
Self-Retaining Brain Retractor System
FIBRE OPTIC LIGHT SOURCE WITH HEADLIGHT
Suction
COAGULATION FORCEPS
SCISSORS
Forceps
MICRODISSECTORS AND RING CURETTES
Needle Holders and Sutures
Cup Forceps and Biopsy Forceps
ANEURYSM CLIPS AND APPLICATORS
NEUROSURGICAL DRILLS
High Speed Drills
Ultrasonic Bone Curette
KERRISON'S PUNCHES AND RONGEURS
EQUIPMENT FOR ENDOSCOPE ASSISTED MICROSURGERY
COAXIAL MICROSURGICAL INSTRUMENTS
OPERATING MICROSCOPES
CONCLUSIONS
209:
Navigation in Brain and Spinal Surgery
INTRODUCTION
HISTORY
GENERAL PRINCIPLES
ELEMENTS OF STEREOTAXIS
Brain in a Geometric (Cartesian) System
Reference Points
Stereotactic Frame
Applications
Frame-based Systems
Stereotactic Biopsy
Technique
Indications7
Contraindications
Basic Steps
Frameless Stereotaxy (Interactive Image Guided Surgery)
Imaging
Disadvantages
Uses
BRAIN SUITE: (INTRA-OPERATIVE MAGNETIC RESONANCE IMAGING AND REAL-TIME NEURO-NAVIGATION)
NAVIGATION IN SPINE SURGERY
Clinical Applications of Spinal Navigation
Technique
Pitfalls of Image Guided Surgery
210:
Endoscopy in Brain Tumour Surgery
INTRODUCTION
EARLY HISTORY
DECLINE OF NEUROENDOSCOPY—ADVENT OF VENTRICULAR SHUNTS AND MICRONEUROSURGERY
REDISCOVERY OF NEUROENDOSCOPY
New Lens Type
Invention of Charged Couple Devices
Fibreoptics
USES IN NEURO-ONCOLOGY
Instruments
IMAGE-GUIDED ENDOSCOPY
Ventriculoscopy
Neuroendoscopic Biopsy
Endoscopic Fenestrations of Intracranial Cysts
Middle Fossa Cyst
Suprasellar Cysts
Endoscopic Resection of Intraventricular Tumours
Colloid Cyst
Endoscopy-Assisted Microneurosurgery
Endoscopic Pituitary Surgery
Microscopic Adenomectomy versus Pure Endoscopic Adenomectomy
Microscopic Adenomectomy
Pure Endoscopic Adenomectomy
Endoscopy Assisted Surgery for Skull Base Lesions
Robot-Assisted Neuroendoscopy
CONCLUSION
211:
Orthotics
INTRODUCTION
FUNCTIONS
BIOMECHANICS
Movements of the Spine
Balanced Horizontal Forces
Fluid Compression
Traction
Sleeve Principle
Skeletal Fixation
NOMENCLATURE
Corset and Belts
Corsets
Belts
Orthoses
Cervical Orthoses
Thoraco-Lumbar Orthoses
Lumbo-Sacral Orthoses (LSO)
Thoraco-Lumbo-Sacral Orthoses
Cervical Thoraco-Lumbo-Sacral Orthoses
Boston Orthosis, Miami Orthosis and Under Arm Plastic Body Jacket
Turnbuckle and Hinged Orthosis
17Halo Head Cervico Thoraco-Lumbo-Orthosis (HCTLO)
MECHANISM OF ACTION
ORTHOTIC MANAGEMENT OF SPECIFIC PROBLEMS
Low Back Pain
Minimal Symptoms (Mild)
Less Severe Symptoms (Sub-acute)
Severe Symptoms (Acute)
Spinal Deformities
Scoliosis
Endpoint Control
Curve Correction
Kyphosis
Lordosis
Spinal Surgery
Pre-Operative
Post-Operative
Disc Surgery without Fusion
Fractures
Mechanisms of Action of Spinal Orthoses
Orthoses for Thoraco-Lumbar Injury
Osteoporosis and Multiple Vertebral Compression Fractures
Inflammatory Spinal Arthritis
Juvenile Spinal Osteochondritis (Scheuermann's Disease)
Infectious Disorders of Spine
Osteomyelitis and Tuberculosis
Tumours of the Spine
Paralytic Disorders
Poliomyelitis and Dystrophies Involving the Trunk
Paraplegia
Spina Bifida
Spondylolisthesis
Congenital (Developmental) Spondylolisthesis
Degenerative Spondylolisthesis
Cervical Conditions
Sprains
Torticolis
Cervical Spondylosis and Cervical Spondylitis
Fracture Dislocation
Post-Operative Orthosis
Post-Operative TLSO
POSITIVE EFFECTS OF SPINAL ORTHOSES
NEGATIVE EFFECTS OF SPINAL ORTHOSES
Weakness and Atrophy
Contracture
Psychological Dependence
Aggravation of Symptoms
CHECKOUT OF SPINAL ORTHOSIS
PAEDIATRIC SPINAL ORTHOSES
Cervical Spine
Thoracic Spine
LONG-TERM USE OF ORTHOSES
RECENT ADVANCES
BRACE CARE
DOs:
DON'Ts:
ACKNOWLEDGEMENT
212:
Principles of Physiotherapy
INTRODUCTION
PHYSIOTHERAPY IN INTENSIVE CARE
Treatment Techniques
FUNCTIONAL REHABILITATION
Sensory Stimulation and Arousal Therapy
Constraint Induced Therapy
Soft Tissue Flexibility
INDEX
TOC
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