Modern neurosurgical practice

MICHAEL THOMAS D.O.

EDUCATIONAL REQUIREMENTS FUNCTIONAL NEUROANATOMY  NEUROPHYSIOLOGY  NEUROPATHOLOGY  NEUROPHARMACOLOGY  NEUROANESTHESIOLOGY  NEURORADIOLOGY  NEUROONOCOLOGY  NEUROTRAUMA  PEDIATRIC NEUROSURGERY 

TERMINOLOGY      CRANIOTOMY- REMOVAL AND REPLACEMENT OF PART OF CRANIUM CRANIECTOMY- REMOVAL W/O REPLACEMENT OF PART OF CRANIUM LAMINOTOMY- REMOVAL OF PART OF LAMINA LAMINECTOMY- COMPLETE REMOVAL OF LAMINA BONE FLAP- THAT REGION OF CRANIUM REMOVED

SURGICAL MICROSCOPE LEICA OH3

MICROSCOPE TECHNOLOGY FLORESCENCE TECHNOLOGY FOR NEUROVASCULAR SURGERY

FLORESCENCE TECHNOLOGY

BRAIN LAB NEURONAVIGATION

MICROSCOPE TECHNOLOGY INTEGRATION WITH STEREOTACTIC NAVIGATION

TENSOR FIBER TRACT IMAGE

BRAIN LAB INTRAOPERATIVE MRI

BRAIN LAB WITH FUNCTIONAL MRI MAPPING

BRAIN LAB MAPPING AND FIBER TRACKING

FUNCTIONAL MRI

BRAIN LAB 3D RECONSTRUCTED IMAGE

NEUROENDOSCOPY    VENTRICULAR ENDOSCOPY – PRIMARILY USED TO TREAT INTRAVENTRICULAR TUMORS AND HYDROCEPHALUS MAY BE USED TO ASSIST WITH DIFFICULT AND LIMITED OPERATIVE EXPOSURES -IE; ANEUYSM SURGERY, PITUITARY SURGERY ASSISTANCE WITH SPINAL SURGERY

ENDOSCOPE USED WITH NEURONAVIGATION

HYDROCEPHALUS OBSTRUCTIVE-BLOCKAGE WITHIN VENTRICULAR CSF PATHWAYS  COMMUNICATING- BLOCKAGE OF ABSORBTION AT ARACHNOID VILLI 

OBSTRUCTIVE HYDROCEPHALUS AQUEDUCTAL STENOSIS  INTAVENTRICULAR TUMORS-IE; COLLOID CYSTS,DERMOIDS, SUBEPYNDYMOMAS. PINEAL TUMORS, CERREBELLAR MASSES, CEREBELLAR STROKES/HEMORRHAGE, BRAINSTEM TUMORS  4th VENTRICLE IS USUALLY NORMAL SIZE OR SMALL 

HYDROCEPHALUS - CLINICAL PRESENTATION  GAIT DISTURBANCE  HEAD ACHE  MEMORY DISTURBANCE  LETHARGY  URINARY INCONTINANCE

AQUEDUCTAL STENOSIS SUPRACEREBELLAR ARACHNOID CYST AQUEDUCT OF SYLVIUS 4th VENTRICLE (NORMAL SIZE)

AQUEDUCTAL STENOSIS CORONAL MRIOBSTRUCTIVE HYDROCEPHALUS

PINEAL TUMOR

BRAINSTEM GLIOMA ASTROCYTOMA

COLLOID CYST

3rd VENTRICULAR COLLOID CYST  colloid

TREATMENT OF HYDROCEPHALUS    CSF DIVERSION – NORMAL SIZE VENTRICLES HAS 25 CC’s OF CSF – TOTAL PRODUCTION OF CSF IS 500 -750 CC’s PER DAY OBSTRUCTIVE HYDRO-ENDOSCOPIC 3RD VENTRICULOSTOMY OR AQUEDUCTAL DILATATION AND STENTING. IF THIS FAILS THEN VP SHUNT COMMUNICATING HYDROCEPHALUSVENTRICULOPERITONEAL SHUNT (VENTRICULOATRIAL , VENTRICULOPLEURAL)

ENDOSCOPIC VIEW OF 3RD VENTRICULOSTOMY FORMATION

ENDOSCOPIC VIEW OF OSTOMY AND PREPONTINE CISTERN

3rd VENTRICAL EXPLORATION

BRAIN TUMORS MULTIPLE TYPES DEPENDING ON EMBRYOLOGICAL ORIGIN -ie; Astrocytoma derived from glial tissue origin  METASTASTATIC(secondary) BRAIN TUMORS MOST COMMON  ASTROCYTOMA MOST COMMON PRIMARY BRAIN TUMOR 

BRAIN TUMOR CLINICAL PRESENTATION HEAD ACHES SEIZURES NAUSEA/VOMITING MENTAL STATUS CHANGES GAIT DISTURBANCE VISUAL DISTURBANCE NEUROLOGICAL DEFICIT DEPENDING ON LOCATION  CEREBRAL HEMORRHAGE  BRAIN HERNIATION       

BRAIN TUMOR DIFFERENCIAL DIAGNOSIS CEREBRAL ABCESS  STROKE  PSEUDOTUMOR CEREBRI  CEREBRITIS (PRE-ABCESS STAGE)  ARTERIAL-VENOUS MALFORMATION  MS  HYDROCEPHALUS 

BRAIN TUMOR WORK UP AND INITIAL TREATMENT     DEXAMETHASONE- INITIAL 10 MG IV X 1 THEN FOLLOWED WITH 4-6 MG IV/PO q 6 hrs OBTAIN CT OR MRI WITH AND WITH OUT CONTRAST IF MASS IS PRESENT THEN RULE OUT ABCESS vs METASTATIC DISEASE IF ORIGIN OF TUMOR CANT BE DISCOVERED THEN CEREBRAL BIOPSY AND POSSIBLY RESECTION IS INDICATED

FALX MENINGIOMA

MENINGIOMA

ASTROCYTOMA

ANAPLASTIC ASTROCYTOMA

ANAPLASTIC ASTROCYTOMA HISTOPATHOLOGY

PILOCYTIC ASTROCYTOMA

GLIOBLASTOMA MULTIFORME

GLIOBLASTOMA MULTIFORME

GBM HISTOPATHOLOGY

SUBEPENDYMAL GIANT CELL ASTROCYTOMA

FRONTAL CRANIOTOMY

EXPOSURE OF RIGHT FRONTAL LOBE

PARTIAL FRONTAL LOBECTOMY FALX SUPERIOR SAGITAL SINUS PREMOTOR CORTEX

LATERAL VIEW ANTERIOR FRONTAL LOBECTOMY FALX CEREBRI CORONAL SUTRE TEMPORALIS MUSCLE

TRANSVENTRICULAR COLLOID CYST REMOVAL

SKULL BASE MENINGIOMA SAGITAL CORONAL AXIAL

SKULL BASE MENINGIOMA – POST OP MRI

STRUCTURES OF THE CAVERNOUS SINUS PITUITARY P SPHENOID SINUS S

PITUITARY MACROADENOMA

PITUITARY ADENOMA CLINICAL PRESENTATION HEADACHE  BITEMPERAL HEMIANOPSIA  APOPLEXY(RARE)  SECRETING vs NON-SECRETING  ENDOCRENOPATHIES –Cushings(ACTH) ACROMEGALY(GH),PANHYPOPITUITARY  FREQUENTLY HAVE ELEVATED PROLACTIN LEVELS-(STALK EFFECT vs PROLACTINOMA SECRETING ADENOMA 

PITUITARY SURGERY MOST COMMON APPROACH IS TRANSSPHENOIDAL  GOALS OF SURGERY 1) PRESERVE VISION 2) CORRECT ENDOCRENOPATHY  CAVERNOUS SINUS INVASION WILL REQUIRE POST OPERATIVE STEREOTACTIC RADIOSURGERY ,CONTINUED MEDICAL MANAGEMENT, OR BOTH  CRANIOTOMY IS RARELY INDICATED 

TRIGEMINAL NEUARALGIA ETIOLOGY REDUNDANT SUPERIOR CEREBELLAR ARTERY COMPRESSION  SUPERIOR PETROSAL VEIN COMPRESSION  POSTERIOR FOSSA TUMOR  MULTIPLE SCLEROSIS (bilateral TN) 

TRIGEMINAL NEURALGIA(AKA tic douloureux) PATHOPHYSIOLOGY    SEVERE PAROXYSMAL LANCINATING PAIN LASTING ONLY A FEW SECONDS OFTEN TRIGGERED BY SENSORY STIMULI CONFINED TO THE DISTRIBUTION OF ONE OR MORE DIVISIONS OF THE TRIGEMINAL NERVE ON ONE SIDE OF THE FACE DUE TO EPHAPTIC TRANSMISSION IN TRIGEMINAL NERVE FROM LARGE DIAMETER MYLENATED A FIBERS TO POORLY MYLENATED A-DELTA AND C NOCICEPTIVE FIBERS EPHAPTIC - conduction of nerve impulse across point of lateral contact rather than at synapse

VENTRAL BRAIN/POSTERIOR FOSSA

RIGHT CEREBELLOPONTINE ANGLE

TRIGENINAL NEURALGIA - TX OPTIONS       MEDICAL- TEGRETOL, NEURONTIN, DILANTIN PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY PERCUTANEOUS GLYCEROL INJECTION PERCUTANEOUS TRIGEMINAL BALLON COMPRESSION MICROVASCULAR TRIGEMINAL DECOMPRESSION STEREOTACTIC RADIOSURGERY

TRIGEMINAL NEURALGIA MICROVASCULAR DECOMPRESSION

CN VII+VIII A.I.C.A. SUP. PET. V. CN V S.C.A. CEREBELLUM FLOCCULUS PONS CN IV

PONTOMEDULLAY JUNCTION DURA CEREBELLUM

SPINALCORD TUMORS: CLASSIFICATION EXTRADURAL-arise outside cord in vertebral body and epidural tissue(metastatic tumors most common)  INTRADURAL EXTRAMEDULLARY-arise from leptomeninges or nerve roots. ie; meningiomas and neurofibromas  INTRAMEDULLARY- primary and secondary tumors that destroy tracts and grey matter 

INTRADURAL EXTRAMEDULLARY TUMOR CONUS TUMOR

CAUDAEQUINA EPENDYMOMA

CERVICAL MEDULLARY ANGIOMA

SYRINGOMYELIA ETIOLOGIES     ARNOLD CHIARI MALFORMATION INTRAMEDULLARY MASS IDIOPATHIC HYDROCEPHALUS

INTRAMEDULLARY ASTROCYTOMA

MEDULLOBASTOMA

MEDULLOBLASTOMA HISTOPATHOLOGY

INTRADURAL EXTRAMEDULLARY T-1 WEIGHTED SAGITAL IMAGE OF A NEUROFIBROMA

CONTRAST ENHANCED T1 WEIGHTED AXIAL IMAGE OF NEUROFIBROMA SPINAL CORD

C-6 SCHWANNOMA RESECTION

C-6 NEUROFIBROMA RESECTION

SUBDURAL HEMATOMA

POST OP CRANIOTOMY

SUBARACHNOID HEMORRHAGE

ANEURYSMAL SUBARACHNOID HEMORRAGE SEVERE SUDDEN ONSET HEAD ACHE MAY CAUSE ACUTE HYDROCEPHALUS  HUNT HESS GRADING SCALE 0-5  HIGH GRADE PTS REQUIRE VENTRICULOSTOMY  4 PERCENT RERUPTURE RATE WITHIN 24 HR  REQUIRES ANGIOGRAM  MAY PRESENT WITH NO NEURO DEFICIT TO FOCAL DEFICIT TO COMA  3rd OF PATIENTS DON’T EVEN MAKE IT TO HOSPITAL  VASOSPASM CLINICALLY EFFECTS 30% NO SOONER THAN DAY 3 ,USUALLY AROUND DAY6-8  ICP MANAGEMENT  

MANAGEMENT OF ANEURYSMS        ANGIOGRAM TO DEFINE ANEURYSM ANATOMY IF GRADE 3 OR LOWER SURGICALLY CLIP OR COIL VENTRICULOSTOMY FOR HYDROCEPHALUS CALCIUM CHANNEL BLOCKER (NIMODIPINE)HELPS PREVENT VASOSPASM STEROIDS (DEXAMETHASONE) ANALGESIA TRIPLE “H” THERAPY

VASOSPASM TREATMENT EARLY SURGERY CANT TREAT SAFELY WITHOUT SECURING ANEURYSM TRIPLE “H” THERAPY  HYPER VOLEMIA  HYPERTENSION  HEMODILUTION

CAROTID BIFERCATION ANEURYSM CT ANGIOGRAM

BASILAR ANEURYSM POSTERIOR CEREBRAL ARTERY

CTA BASILAR ANEURYSM

OCCIPITAL AVM

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