دانلود کتاب Youmans and Winn Neurological Surgery: 4 - Volume Set, 8th Edition

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How to Use Youmans & Winn Neurological Surgery Copyright Copyright Copyright Copyright DEDICATION Editor-in-Chief Section Editors Contributors Foreword Note by Editor-in-Chief Preface 1 - History Historical Overview of Neurosurgery Neurosurgery in the Prehistoric Period Ancient Egyptian Neurosurgery Classical Period: Greek and Byzantine Neurosurgery Hippocratic School Herophilus of Chalcedon Aulus Aurelius Cornelius Celsus Galen of Pergamon Paulus Aegineta (Paul of Aegina) Islamic/Arabic Medicine: Prescholastic Period Middle ages: the age of Medieval Medical Scholasticism Origins of Neurosurgical Practice in the Renaissance Surgeons of the Insurgency: Seventeenth Century Eighteenth Century: an Enlightened Period for Neurosurgery Nineteenth Century: Incunabula Period of Modern Neurosurgery Further Advances in Neurosurgery: Twentieth Century Concluding Thoughts Charles Babbage and the Concept of the Computer Wilhelm Röntgen and the X-Ray Computed Tomography 2 - Surgical Anatomy of the Brain INTRODUCTION CEREBRUM Lateral Surface: Neural Structures Superficial Anatomy ?Frontal Lobe. The two main sulci are the superior and the inferior frontal sulci, which are anteroposteriorly oriented and exte... ?Parietal Lobe. The parietal lobe is limited anteriorly by the central sulcus, medially by the interhemispheric fissure, inferol... ?Temporal Lobe. The temporal lobe is limited superiorly by the posterior ramus of the sylvian fissure and posteriorly by the tem... ?Occipital Lobe. The occipital lobe is located behind the lateral parietotemporal line and is composed of irregular convolutions... ?Sylvian Fissure. The sylvian fissure is the space between the frontal, parietal, and temporal opercula, and the insula; the syl... ?Insula. The insula has the shape of a pyramid with its apex directed inferiorly and presents an anterior surface and a lateral ... ?Foramen of Monro. The foramen of Monro communicates the lateral ventricle to the third ventricle. It usually presents a crescen... Internal Capsule ?Corpus Callosum. The corpus callosum (“tough body”) is the largest transverse commissure connecting the cerebral hemispheres. I... ?Optic Radiation. The optic radiation is a bundle of fibers that extend from the lateral geniculate body to the visual area in t... ?Fornix. The fornix is a C-shaped structure that wraps around the thalamus in the wall of the lateral ventricle. The initial por... Basal Ganglia. Although macroscopically fused and gathered into a “core” that is covered laterally by the insula, the basal gang... ?Thalamus. The thalamus (inner chamber) is located at the center of the lateral ventricle. Each lateral ventricle wraps around t... ?Hippocampus. The hippocampus occupies the medial part of the floor of the temporal horn and is divided into three parts: the he... ?Amygdala. The amygdala (“almond”) and the hippocampus (“sea horse”) constitute the core of the limbic system. The temporal amyg... ?Choroidal Fissure. The choroidal fissure is a cleft located between the thalamus and the fornix. It is the site of attachment o... Third Ventricle Lateral Surface: Arterial Relationships Lateral Surface: Venous Relationships Basal Surface: Neural Relationships Anterior Perforated Substance Basal Surface: Arterial Relationships Basal Surface: Venous Relationships Medial Surface: Neural Relationships Medial Surface: Arterial Relationships Medial Surface: Venous Relationships Central Core Arachnoid Membrane Gray Matter and White Matter White Matter of the Cerebrum POSTERIOR FOSSA Osseous Landmarks Muscles of the Occipital and Suboccipital Regions “Rule of Three” Brainstem Cerebellum Petrosal Surface of the Cerebellum and Fourth Ventricle Tentorial Surface of the Cerebellum and Fourth Ventricle Suboccipital Surface of the Cerebellum and Fourth Ventricle Veins of the Posterior Fossa Arteries of the Posterior Fossa Cerebellopontine Angle Region Anatomic-Angiographic Correlation 3 - Surgical Anatomy of the Skull Base The Far Lateral Approach Surgical Targets Bone Anatomy Surgical Anatomy of the Skull Base Surgical Anatomy Positioning Skin Incision Muscular Layer Craniotomy Dural Opening Intradural Anatomy The Retrosigmoid Approach Surgical Targets Bone Anatomy Surgical Anatomy Positioning Skin Incision Muscular Layer Craniotomy Dural Opening Intradural Anatomy The Transpetrosal Approaches Surgical Targets Bone Anatomy Surgical Anatomy Positioning Skin Incision Muscular Layer Craniectomy Dural Opening Intradural Anatomy The Orbitozygomatic Approach Surgical Targets Bone Anatomy Surgical Anatomy Positioning Skin Incision Muscular Layer Craniotomy Dural Opening Intradural Anatomy The Endoscopic Endonasal Approach Surgical Targets Bone Anatomy Surgical Anatomy 4 - Surgical Anatomy of the Spine Cervical Region Thoracic Region Lumbosacral Region Vertebral Structures Surgical Anatomy of the Spine Vertebral Body Vertebral Arch Pedicle. The pedicles create the narrow, anterior portions of the vertebral arch. They are short, thick, and rounded, and they a... Lamina. The laminae are continuous with the pedicles. They are flattened from anterior to posterior and form the broad posterior... Spinous Process. The spinous process of each vertebra projects posteriorly and often inferiorly from the laminae, especially in ... Transverse Process. The transverse processes project laterally from the junction of the pedicle and lamina. Like the spinous pro... Superior and Inferior Articular Processes. The superior articular processes (or zygapophyses) also arise from the pediculolamina... Vertebral Foramen. The vertebral foramen is the opening within each vertebra that is bounded by the VB, the left and right pedic... Relationship Between Vertebrae Three-joint Complex Facet Joint Intervertebral Disk. There are 32 IVDs, which account for one-third of the spine’s height. On one hand, IVDs act as structures t... Uncovertebral Joint Spinal Canal Intervertebral Foramina Spinal Cord Arterial Supply of the Spinal Cord Anterior Spinal Artery. At the level of the foramen magnum, before the VA converges to the basilar artery, one branch from each ... Posterior Spinal Artery. The posterior spinal arteries appear in pairs and arise from the VA or posterior inferior cerebellar ar... Radicular Artery. The anterior and posterior radicular arteries run along with the anterior and posterior roots of the spinal ne... Muscles Associated With the Spine Dorsal Musculature Superficial Muscles. These muscles originate from spinous processes and terminate at the bones of upper extremities, the superio... Deep Muscles. Deep muscles of the back are well developed and extend longitudinally from the sacrum to the base of the skull. Th... First Layer. The first-layer muscles include the splenius capitis and splenius cervicis, which expand from the ligamentum nuchae... Second Layer. The second-layer muscles include the iliocostalis, longissimus, and spinalis. Together these muscles form a column... Third Layer. There is also a group of short muscles associated with the transverse and spinous processes of the vertebral column... Anterolateral Muscles. In the superficial layer of the cervical region, the sternocleidomastoid muscle is involved in neck flexi... Cervical Region Osseous Anatomy Occipital Bone Atlas Axis Subaxial Cervical Vertebrae Vertebra Prominens Ligaments of the Cervical Spine Ligaments of the Upper Cervical Spine Tectorial Membrane. The tectorial membrane is the superior continuation of the PLL. It begins by attaching to the posterior aspe... Cruciform Ligament. The cruciform ligament is a cross-shaped ligament that serves as the major stabilizer of the atlanto-axial c... Alar Ligaments. The left and right alar ligaments are thick, wing-shaped stabilizers that run from the posterolateral aspect of ... Anterior Atlanto-occipital Membrane. The anterior atlanto-occipital membrane is the continuation of the ALL and is located in fr... Apical Ligament of the Odontoid Process. The apical ligament of the odontoid process runs from the posterosuperior surface of th... Posterior Longitudinal Ligament. The PLL projects caudad to the tectorial membrane, which is its superior continuation (see Fig.... Ligamenta Flava. The ligamenta flava are paired ligaments that run between the laminae of adjacent vertebrae with C1–C2 superior... Interspinous Ligaments. The interspinous ligaments are a series of ligaments that course between the spinous processes of each p... Ligamentum Nuchae. The ligamentum nuchae is a flat, membranous structure that runs in a sagittal plane from the inion to the pro... Cervical Intervertebral Disks Neural Structures of the Cervical Region Vascular Structures of the Cervical Spine Vertebral Artery Major Arteries of the Anterior Neck Mayor Veins of the Anterior Neck Thoracic Region Osseous Anatomy Typical Thoracic Vertebra, Ribs, and Sternum Transitional Thoracic Vertebrae Ligaments Interspinous Ligament Supraspinous Ligament Thoracic Intervertebral Disks Neural Structures of the Thoracic Spine Vascular Structures of the Thoracic Spine Posterior Intercostal Arteries Anterior Intercostal Arteries Intercostal Venous Drainage System Lumbar Region Osseous Anatomy Vertebral Bodies Pedicles Transverse Processes Accessory Processes Superior Articular Processes Inferior Articular Processes Zygaphophysial Joints Laminae Vertebral Foramina Spinous Processes Intervertebral Foramen Ligaments of the Lumbar Region Anterior Longitudinal Ligament and Posterior Longitudinal Ligament Ligamenta Flava Lumbar Interspinous and Supraspinous Ligaments Iliolumbar Ligaments Lumbar Intervertebral Disks Nerves of the Lumbar Region Dorsal and Ventral Roots and Spinal Nerves Anterior Primary Division of the Lumbar Plexus Vessels of the Abdomen Related to the Spine Abdominal Aorta and its Branches Veins of the Abdomen 5 - Precision Medicine in Neurosurgery Introduction Cancer Clinical Application Drug Discovery and Selection Nanoparticles and Drug Delivery Neurosurgeons in Targeted Therapy Intraoperative Guidance and Imaging Adaptive Hybrid Surgery Subspecialty Implications Cerebrovascular Neurosurgery Trauma Spine Functional Neurosurgery Epilepsy Pediatrics Outlook: Clinical Integration into Neurosurgical Practice Conclusion 6 - Improving Patient Safety Epidemiology of Patient Safety Adverse Events and Errors Systems Thinking Tools for Improving Patient Safety Finding Errors and Complications Preventing Specific Errors and Complications Wrong-Site Surgery and Checklists Surgical Site Infections Volume-Outcome Relationships ERAS Pathways Artificial Intelligence in Neurosurgery Conclusion 7 - Neuroanesthesia: Preoperative Evaluation General Preanesthetic Evaluation Medical History American Society of Anesthesiologists Perioperative Brain Health Initiative and Cognitive Assessment of Geriatric Patients General Physical Examination Assessment of System Functions Frailty Assessment Neurological System Respiratory System Cardiovascular System Gastrointestinal System Renal System Hematologic System Endocrine System Laboratory Investigations Consideration of Specific Neurological Disorders Specific Neurosurgical Categories Intracranial Tumors Aneurysmal Subarachnoid Hemorrhage. The most important aspect of preoperative evaluation of patients with intracranial aneurysms... Arteriovenous Malformations. Treatment options for patients with intracranial AVMs include surgical resection, endovascular embo... Posterior Fossa Procedures Traumatic Brain Injury Spine Surgery Epilepsy Disorders and Movement Disorders Neuroradiology Conclusion 8 - Preoperative Assessment by Navigated Transcranial Magnetic Stimulation Basic Principles of nTMS, nTMS Motor and Language Mapping, and Safety Considerations General Motor Function Language Safety Navigated Transcranial Magnetic Stimulation Motor Mapping nTMS Mapping and nTMS-Based DTI Fiber Tracking of Motor Pathways and Their Clinical Use Risk Stratification by Means of nTMS via Corticospinal Excitability in Motor and Language Area–Related Surgery nTMS Language Mapping nTMS Data and Tractography of Language Networks General Aspects Diffusion Tensor Imaging nTMS Language Mapping and Its Clinical Use Special Aspects Integration of Functional Data in the Clinical Workflow Arteriovenous Malformations Radiotherapy Potentials and Limitations 9 - CLASSIFICATION SYSTEMS IN NEUROSURGERY History and Philosophy Classification Systems in Neurosurgery Modern Statistical Methods, Technology, and Applications Methods of Meta-Classification Criteria for Evaluating Classification Systems Validity Consistency Quantification METHODS OF CLASSIFYING NEUROSURGICAL CLASSIFICATION SYSTEMS CLASSIFICATION OF NEUROSURGICAL CLASSIFICATION SYSTEMS FUTURE DIRECTIONS IN CLASSIFYING CLASSIFICATION SYSTEMS IN NEUROSURGERY 10 - Computed Tomography and Magnetic Resonance Imaging of the Brain COMPUTED TOMOGRAPHY OF THE BRAIN History and Fundamentals Computed Tomographic Angiography Perfusion Computed Tomography MAGNETIC RESONANCE IMAGING OF THE BRAIN Physics and Techniques of Magnetic Resonance Imaging History Creating the Signal. To begin, the sample is immersed in a strong, constant magnetic field. A magnet that creates the field may ... Detecting the Signal. To detect the magnetic resonance signal, an RF coil is placed as shown in Fig. 10.12. This may be the same... Physics: Localizing the Signal. Up to this point, the sample has been polarized and excited and a signal detected, but the locat... The Origin of Image Contrast. The intensity of a voxel in an image arises from three principal factors. The first is the number ... Spin Echo Gadolinium Contrast Fast Spin Echo Imaging Inversion Recovery Gradient Echo Echo Planar Imaging Diffusion-Weighted Imaging Perfusion-Weighted Imaging Spectroscopy Functional Magnetic Resonance Imaging Diffusion Tensor Imaging Diffusion Tensor Imaging Display. There are three principal methods of displaying DTI data. The first and simplest is a fraction... Limitations of Diffusion Tensor Imaging. DTI is based on an EPI sequence. The EPI sequence is acutely susceptible to magnetic fi... Clinical Magnetic Resonance Imaging Introduction Tailored Magnetic Resonance Imaging. There are many different ways to perform a brain MRI examination. For patients in whom clin... Nonglial Neoplasms. According to the most recent 2016 WHO revised classification of CNS tumors, beyond the 5 “glial” neoplasm gr... Meningiomas. Meningiomas are the most common nonglial primary brain neoplasm. They occur at any age and in both sexes but are us... Pituitary Adenomas. Pituitary adenoma is one of the more common primary neoplasms encountered in adults. The tumors may be secre... Metastatic Neoplasms. MRI with gadolinium enhancement is the most sensitive imaging technique for evaluating CNS metastasis. MRI... Schwannomas. Intracranial schwannomas arise from the Schwann cells that envelop the cranial nerves as they exit the intracranial... Embryonal Tumors. Classifications of embryonal tumors (ETs) have undergone changes over the past 20 years in previous versions o... Infections Stroke and Vascular Diseases Trauma Vascular Malformations Seizure and Epilepsy 11 - Radiology of the Spine Radiography Computed Tomographic Imaging Radiology of the Spine Myelography Magnetic Resonance Imaging Dynamic Imaging Neurography Cerebrospinal Fluid Perfusion Imaging Artifacts and Contraindications Spinal Angiography Ultrasonography Thermography, Diskography, and Computed Tomographic Diskography Nuclear Medicine Examinations Indications for Imaging and Imaging Findings Degenerative Disk Disease, Including Back Pain Degenerative Disk Changes Degenerative Marrow Changes Degenerative Facet and Ligamentous Changes Alignment Abnormalities Disk Herniation Spinal Stenosis Significance of Imaging Findings and When to Image Metastatic Disease Infection Trauma Computed Tomography Radiography Magnetic Resonance Imaging Postoperative Imaging Magnetic Resonance Imaging Computed Tomography Radiography Congenital Abnormalities Vascular Disorders Vascular Malformations of the Spine and Spinal Cord Systematic Approach to Interpreting Imaging Examination Scout Images and Paravertebral Soft Tissues Marrow and Extradural Evaluation Extradural Evaluation Marrow Imaging Normal Marrow Appearance. MRI can help directly evaluate the marrow of the spine and can reveal abnormalities more quickly than ... Approach to Marrow Abnormalities. The osseous structures should be relatively uniform in signal attenuation on CT imaging and in... Benign Versus Pathologic Compression Fracture. Distinguishing between benign and malignant compression fractures on images is of... Multiple Myeloma. Multiple myeloma is an important differential consideration in patients with abnormal marrow signal intensity.... Hemangiomas. On conventional radiographs, hemangiomas demonstrate coarse vertical bony trabeculae. On axial CT images, these les... Chordomas. Chordomas typically appear on conventional radiographs as radiolucent lesions or heterogeneous destructive masses, us... Other Primary Bone Neoplasms. Other primary tumors of bone such as osteoid osteomas (eFig. 11.29), osteoblastomas, aneurysmal bo... Intradural Extramedullary Disease Meningiomas Schwannomas Dermoid and Epidermoid Tumors Myxopapillary Ependymoma Leptomeningeal Disease/Enhancing Nerve Roots Cysts Spinal Cord Herniation Intramedullary Disease and Tumors Demyelination/Acute Transverse Myelitis Primary Spinal Cord Tumors Spinal Cord Syrinx 12 - Physiologic Evaluation of the Brain With Magnetic Resonance Imaging Physiologic Evaluation of the Brain With Magnetic Resonance Imaging Diffusion-Weighted Imaging Physics Clinical Uses and Applications Pitfalls and Limitations Diffusion Tensor Imaging and Tractography Physics Clinical Uses and Applications Pitfalls and Limitations Magnetic Resonance Angiography Physics Clinical Uses and Applications Stroke Intracranial Aneurysms Vascular Malformations Intracranial Venous System and Venous Sinus Thrombosis Pitfalls and Limitations Phase-Contrast Magnetic Resonance Imaging of Cerebrospinal Fluid Flow Physics Clinical Uses and Applications Normal Cerebrospinal Fluid Flow Abnormal Flow of Cerebrospinal Fluid Pitfalls and Limitations Perfusion- and Permeability-Weighted Imaging Overview of Arterial Spin Labeling Physics of Arterial Spin Labeling Clinical Applications Cerebrovascular Disease Vascular Territory Mapping “Stress Test” Arteriovenous Malformation and Fistula Neoplasm Neurodegenerative Disease Epilepsy Psychiatric and Other Neurologic Disorders Mild Traumatic Brain Injury Pitfalls and Limitations Physics of Contrast-enhanced Perfusion Clinical Uses and Applications Pitfalls and Limitations Functional Magnetic Resonance Imaging Physics Clinical Uses and Applications Pitfalls and Limitations Vessel Wall Imaging Technique Clinical Uses Aneurysm Non-aneurysmal Vascular Pathologies Pitfalls and Limitations Proton Magnetic Resonance Spectroscopy Physics Clinical Uses and Applications Pitfalls and Limitations Magnetic Resonance Elastography Physics Clinical Uses and Applications Tumors Normal-pressure Hydrocephalus Dementia Pitfalls and Limitations Combined Positron Emission Tomography/Magnetic Resonance Imaging Clinical Uses and Applications Neuro-oncology Epilepsy Stroke Pitfalls and Limitations Introduction to Volumetric and Simulation Magnetic Resonance Imaging 13 - Molecular Imaging of the Brain with Positron Emission Tomography Molecular Imaging of the Brain with Positron Emission Tomography Basic Principles of Positron Emission Tomography Imaging The Cyclotron and Radiopharmaceutical Production The Pet Scanner and Brain-Imaging Principles Tracer Kinetic Models Pet Imaging for the Assessment of Neurological Disease Movement Disorders Huntington Disease Parkinsonian Syndromes Essential Tremor Dementia Psychiatric Diseases Epilepsy and Seizure Disorders Brain Tumors Brain Injury Migraines Chronic Pain Conclusion 14 - Diffusion Tensor Imaging Diffusion Tensor Imaging ? INTRODUCTION HISTORY OF THE INVENTION OF DIFFUSION TENSOR IMAGING THE BASIS OF DIFFUSION ANISOTROPY IMAGING Physics Underlying the Image Signal in Nuclear Magnetic Resonance Use of Location Gradients to Create a Magnetic Resonance Image Diffusion-Weighted Magnetic Resonance Imaging Diffusion Anisotropy Imaging: Tensor and Vector Techniques The Method of Tractography THE BASES OF FRACTIONAL ANISOTROPY AND TRACTOGRAPHY IN BRAIN EVALUATION Analyzing the Structure of the Voxel Carrying Out the Tractography CONNECTOMICS AND CONSTRAINED SPHERICAL DECONVOLUTION Mapping the Human Connectome CLINICAL APPLICATIONS Tractographic Guidance for Intracranial Resective Surgery Improved Access to Functional Stimulation and Lesion Sites Localization of Occult Stroke and Prognostic Evaluation After Cerebrovascular Accident Evaluation of Closed Head Injury General Cognitive Losses Memory Function Deterioration Emotional Behavioral Dysfunction Visual Disturbances Central Vertigo Tremor Chronic Traumatic Encephalopathy SPINAL CORD DIFFUSION TENSOR IMAGING PERIPHERAL NERVE DIFFUSION TENSOR IMAGING 15 - Neuro-ophthalmology Neuro-ophthalmology From the eye to the Visual Cortex: The Afferent Visual System History Examination Anatomy and Disorders of the Afferent Visual System Anterior Segment Ocular and Retinal Disorders Papilledema Pseudopapilledema Anterior Ischemic Optic Neuropathy Optic Neuritis Compressive and Infiltrative Optic Neuropathies Metabolic Optic Neuropathies Hereditary Optic Neuropathies Traumatic Optic Neuropathy Optic Chiasm Retrochiasmal Visual Pathways Ocular Motility and the Pupil: The Efferent Visual System Ocular Motor Anatomy and Pathophysiology Ocular Motor History and Examination Disorders of the Ocular Motor System Neuromuscular Junction: Ocular Myasthenia Gravis Cranial Nerve: Third (Oculomotor) Nerve Cranial Nerve: Fourth (Trochlear) Nerve Cranial Nerve: Sixth (Abducens) Nerve Cranial Nerve: Multiple Supranuclear, Internuclear, and Cerebellar Eye Movements in Coma Symptomatic Treatment of Diplopia The Pupil Determining the Abnormal Pupil The Abnormally Large Pupil The Abnormally Small Pupil Conclusion 16 - Neurotology Neurotology Anatomy of the Inner Ear The Cochlear System Physiology of Hearing Transformer Mechanism of the Tympanum Transmission in the Labyrinth Measures of Auditory System Function Subjective Measures of Hearing Tuning Forks Bone Conduction. The primary audiologic tests used to distinguish conductive from sensorineural hearing loss are the comparative... Masking. When a patient has a substantial difference in hearing sensitivity between the two ears, it is necessary to rule out th... Speech Audiometry Speech Recognition Threshold. Traditionally, the SRT is measured with the use of spondaic words: that is, two-syllable words in ... Speech Recognition Measures. Measurement of speech recognition at suprathreshold levels is conducted with standardized lists of ... Objective Measures of Auditory System Function Immittance Studies Tympanometry. Tympanometry provides evidence of the relative change in impedance (or its reciprocal, admittance) with a change i... Acoustic Reflex. The acoustic reflex is the reflexive contraction of the stapedius muscle on delivery of an acoustic stimulus. T... Auditory Brainstem Evoked Response Measures Auditory Neuropathy. Results from auditory evoked potential recordings combined with those from otoacoustic emission (OAE) testi... Electrically Auditory Evoked Potentials With Cochlear Implant Users. Auditory evoked potentials elicited electrically have been ... Otoacoustic Emission Measures Measures of Auditory System Function: Summary The Vestibular System Anatomy Physiology Tests of Vestibular Function Spontaneous Nystagmus Labyrinthine Fistula Test Positional Tests Objective Measurement of Vestibular Function Videonystagmography/Electronystagmography Bithermal Caloric Test. The bithermal caloric test is most suitable for identifying unilateral lesions of the peripheral vestibu... Gaze Test. In the gaze test, eye movements are monitored as the patient fixates while gazing 30 degrees rightward, 30 degrees le... Positional Test. The purpose of the positional test is to determine whether different head positions induce or modify the vestib... Hallpike Maneuver. The patient is subjected to the Hallpike maneuver, as described previously, while infrared video eye recordin... Saccade Test. The purpose of the saccade test is to detect abnormalities in saccadic eye movement. The horizontal eye movements ... Pursuit Tests. Two tests of pursuit—smooth pursuit and the optokinetic test—are commonly performed in the VNG/ENG examination. I... Rotational Tests Visual-Vestibular Interaction Vestibular Evoked Myogenic Potentials Differential Diagnosis of Vertigo Differentiating Between Peripheral and Central Lesions Vertigo of Peripheral Origin Benign Paroxysmal Positional Vertigo. Benign paroxysmal positional vertigo (i.e., benign positional vertigo) is the most common ... Ménière Disease. Ménière disease (i.e., endolymphatic hydrops) is an idiopathic condition of the membranous labyrinth that is ch... Differential Diagnosis. The most difficult lesion to distinguish from Ménière disease, at least in its early stages, is an acous... Secondary Endolymphatic Hydrops. Endolymphatic hydrops with associated vertiginous symptoms may also occur in patients with otos... Vestibular Neuronitis. Vestibular neuronitis is characterized by a sudden onset of sustained and severe vertigo that worsens wit... Third Window Syndrome. SSCD was first described by Ostrowski and colleagues in 199763; however, it was Minor who first character... Posttraumatic Vertigo. Trauma to the temporal bone—common even with minor head injury70—such as temporal bone fractures, labyrin... Drug-induced Ototoxicity. Peripheral vestibular dysfunction after toxic injury to the inner ear is produced by a group of ototox... Vertigo of Central Origin Brainstem Lesions. Primary brainstem tumors, such as gliomas, usually grow slowly, infiltrate the brainstem nuclei and fiber tra... Multiple Sclerosis. Vertigo is the initial symptom in approximately 5% of patients with multiple sclerosis and is reported somet... Migraine. Migraine has long been considered a vascular disorder whereby vasodilation is responsible for the headache, and vasoco... Vascular Accidents. Vascular occlusion of the ipsilateral vertebral artery results in a lateral medullary infarction (i.e., Wall... Vertebrobasilar Insufficiency. Approximately one-third of transient ischemic attacks (TIAs) involve the territories of the verte... Tumors of the Posterior Cranial Fossa. Tumors of the posterior cranial fossa can give rise to marked and persistent disequilibri... Indications for Vestibular Neurectomy Indications for Cochlear and Auditory Brainstem Implantation 17 - Neurourology Neurourology Urologic Anatomy and Physiology Evaluation of Neurourologic Disorders History Additional History Physical Examination Neurourologic Examination Laboratory Testing Radiologic Studies Upper Urinary Tract Imaging Lower Urinary Tract Imaging Urodynamic Testing of the Lower Urinary Tract Cystometry. The filling cystometrogram analyzes the filling and storage function of the bladder. Two catheters, one transurethra... Pressure-Flow Studies and Uroflowmetry. The pressure-flow component of urodynamics assesses the voiding phase of the micturition... Electromyography. Sphincter EMG is used to record bioelec­tric potentials generated by the striated sphincter complex during bla... Neurourologic Diseases Suprapontine Lesions Cerebrovascular Disease Brain Tumors Normal Pressure Hydrocephalus Supraspinal Neurodegenerative Disorders Spinal Lesions Spinal Cord Injury Spinal Shock Suprasacral Cord Injury Spinal Stenosis Neurospinal Dysraphism Disease at or Distal to the Sacral Spinal Cord Sacral Spinal Cord Injury Disk Disease Radical Pelvic Surgery Treatment of Neurourologic Diseases Failure to Store Urine (Incontinence) Management of Detrusor Overactivity or Impaired Compliance External Collecting Devices Medications. In the treatment of neurogenic detrusor overactivity and poor bladder compliance, first-line therapy often includes... Intravesical Botulinum Neurotoxin A Sacral Neuromodulation. Patients refractory to medical treat­ment may benefit from sacral neuromodulation techniques, which use ... Augmentation Cystoplasty. Patients with intractable neuro­genic detrusor overactivity may be candidates for physical enlargement... Management of Outlet Deficiency Conservative Measures Injectable Bulking Agents. Injection of urethral bulking agents is used to increase resistance within the urethra or at the blad... Sling Procedures. Management of outlet failure secondary to low bladder neck and urethral pressure can be overcome with increase... Artificial Urinary Sphincters. Implantation of an artificial urinary sphincter can be performed at the level of the bladder neck... Bladder Neck Closure. Failure of more conservative therapy or devastation of the bladder outlet from a chronic indwelling cathet... Urinary Diversion. Urinary diversion is useful to establish independence from caregivers for patients who are unable to catheter... Failure to Empty Urine (Retention) Indwelling Catheters. A Foley catheter or suprapubic cystostomy tube can be useful in the management of detrusor areflexia and i... Voiding with the Credé and Valsalva Maneuvers. Some patients with detrusor areflexia do not require intermittent catheterization... Cholinergic Agonists. Bethanechol is a cholinergic agonist that may be expected to improve bladder contractility. Unfortunately,... Sacral Neuromodulation. The use of sacral neuromodulation, mentioned previously for refractory detrusor overactivity, has shown ... Urinary Diversion. Patients who are unable to empty their bladders are at increased risk for infection, upper urinary tract inju... Management of Detrusor–External Sphincter Dyssynergia External Sphincterotomy. Surgical transurethral endoscopic incision of the external urethral sphincter can be used to manage mal... Urethral Stenting. Prosthetic stent placement across the external sphincter can produce an effect similar to that of sphincterot... Botulinum Neurotoxin A Injection. Direct injection of BoNT type A into the external sphincter can provide a minimally invasive a... Management of Detrusor–Internal Sphincter Dyssynergia 18 - Coagulation for the Neurosurgeon Basic Science of Coagulation Hemostasis and Coagulation Coagulation Cascade Cell-based Model of Coagulation Platelet Activation Antiplatelet Drugs Cyclooxygenase-1 Inhibitors Phosphodiesterase Inhibitors Adenosine Diphosphate Receptor (P2Y12) Inhibitors Glycoprotein IIb/IIIa Inhibitors Anticoagulant Drugs Heparin and Heparinoids Factor Xa Inhibitors Direct Thrombin Inhibitors Vitamin K–dependent Clotting Factor Inhibitors Future Perspectives Developing Antithrombotic Drugs with Reversal Agents Intraoperative Hemostasis Chitosan Nanoparticulate Agents 19 - The Microbiome and the Central Nervous System 20 - Peripheral Venous Disease in the Neurosurgery Patient Introduction Epidemiology Diagnosis and Diagnostic Techniques Preoperative Deep Venous Thrombosis Screening Inpatient Prophylaxis Inpatient Treatment Follow-Up For Untreated Extremity Deep Venous Thrombosis Outpatient Management 21 - Surgical Planning Preoperative Evaluation Neuroimaging and Other Technologies Anesthesia General Determination of Surgical Approach Considerations for Cranial Procedures Cranial Tumor Cases Operative Planning for Cerebrovascular Cases Planning of Spine Procedures Conclusion 22 - Avoidance of Complications in Neurosurgery Avoidance of Complications in Neurosurgery Complications Related to Patient Positioning Supine Positioning Prone Positioning Lateral Positioning Intraoperative Monitoring Cranial Fixation Complications Dependent Edema Catastrophic Medical Complications Intraoperative Venous Air Embolism Deep Venous Thrombosis and Pulmonary Embolism Hemorrhagic and Transfusion-Related Issues Wound Complications Risk Factors Related to Anatomy or Technique in Specific Surgical Procedures Cranial Surgery Postoperative Seizures Postoperative Edema and Increased Intracranial Pressure Posterior Fossa Craniotomy. Infratentorial craniotomies carry many of the same risks as do supratentorial craniotomies. However,... Transsphenoidal Surgery. Transsphenoidal surgery is commonly used to reach tumors in the sellar region. This procedure can be pe... Cranial Base Surgery. Cranial base lesions represent a heterogeneous group of pathologies associated with the cranial base bony ... Complications of Stereotactic Brain Surgery Stereotactic Radiosurgery Robotics, Augmented Reality, and Artificial Intelligence Spine Surgery Cerebrospinal Fluid Leak or Pseudomeningocele Formation Instrumentation-Related Risks Complications of Bracing and Halo Use Anterior Cervical Approach Posterior Cervical Approach Thoracic Spinal Procedures Anterior Lumbar Procedures Posterior Lumbar Procedures Pedicle Screw Fixation Facet Screw Fixation Conclusion 23 - Incisions and Closures Principles of Wound Healing Hemostasis Inflammatory Phase Proliferative Phase Maturation and Remodeling Phase Special Considerations in Wound Healing Antibiotic Therapy Surgical Anatomy Angiosomes Wound Closure and Scalp Reconstruction Incision Suture Selection The Reconstructive Ladder Healing by Secondary Intention Primary Closure Skin Graft Tissue Expansion Local Flaps Pedicled Flaps Free Tissue Transfer Algorithm Conclusion 24 - Positioning for Cranial Surgery Positioning for Cranial Surgery General Considerations and Guidelines Pterional (Frontotemporal) Craniotomy Temporal, Subtemporal, and Middle Fossa Approaches Midline Parasagittal Approach Posterior Parasagittal Approach Lateral Suboccipital Approach Far-lateral Position Midline Suboccipital Approach Sitting Position Transsphenoidal Approach Conclusion 25 - Positioning for Spine Surgery 26 - Positioning for Peripheral Nerve Surgery Positioning for Peripheral Nerve Surgery Anatomy, Positioning, and Surgical Exposure Upper Extremity Positioning. For an anterior approach to the brachial plexus, the patient is placed in the supine position with a bolster under ... Surgical Exposure. Exposure of the brachial plexus anteriorly may be divided into the supraclavicular and infraclavicular approa... Surgical Exposure. The sulcus between the biceps brachii and the triceps muscles is located, palpated, and traced proximally to ... Surgical Exposure. The incision is made on the posterolateral aspect of the arm. An incision in a line connecting the acromion a... Surgical Exposure. The incision begins 3 to 4 cm proximal to the elbow flexion crease in the interval between the biceps brachii... Surgical Exposure. Exposure of the nerve within the cubital tunnel begins with a skin incision 5 cm proximal to the medial epico... Lower Extremity Positioning. After intubation and induction of general endotracheal anesthesia in the patient on a stretcher, the patient is pla... Surgical Exposure. The surgeon makes a curvilinear incision in the shape of a reverse question mark. The stem of the question ma... Surgical Exposure. The skin incision is laid out so that the proximal end is just superior to the popliteal fossa. In the mediol... Surgical Exposure. The patient is in the prone position with the midline marked. The incision begins at the midline and extends ... Surgical Exposure. The incision runs in a curvilinear manner, in a radius approximately 2 to 3 cm around the posterior aspect of... 27 - Surgical Simulation Surgical Simulation Simulation NeuroVR Simulator Simbionix Arthro Mentor Surgical Theater Planner and Surgical Navigation Advanced Platform Immersive Touch Simulation System Physical Simulation and Three-Dimensional Printing Mixed Simulation Other Applications of Neurosurgical Simulation Multidisciplinary Conferences and Education Patient Education, Engagement and Satisfaction Social Media Simulation Throughout the Patient Pipeline The Future of Neurosurgical Simulation Conclusion 28 - Robotics in Cranial Neurosurgery Robotics in Cranial Neurosurgery Robotic Systems in Current Use in Cranial Neurosurgery Stereotactic Radiosurgery Trajectory-Finding Robotic Systems Robotic Micromanipulators with Image Guidance for Tissue Ablation Dexterous Neurosurgical Robotics Advanced Robotic Surgical Systems Used Primarily in Other Specialties Principles of Robotics Relevant to Surgery Limitations of Current Neurosurgical Robotic Systems Future Directions and Needs For Future Systems 29 - Spinal Robotic Surgery Spinal Robotic Surgery History Decompression Pedicle Screw Interbody Intraoperative Navigation Genesis of Robotics and Surgery Early Robot Development Robotics and Spinal Surgery Evolution of Intraoperative Navigation First-generation Spinal Robots Pedicle Screw Placement Accuracy Efficiency and Workflow Robotic Limitations Future Directions Conclusions 30 - Augmented Reality as an Aid in Neurosurgery Introduction Prerequisites Overview of Current Systems Current Applications Augmented Reality in Craniotomy Planning Augmented Reality in Neuro-oncologic Surgery ?Intra-axial Lesions (Video 30.2) Skull Base Surgery Augmented Reality in Cerebrovascular Surgery Augmented Reality in Spinal Procedures Current Limitations and Future Development Registration and Tracking of the Surgical Field Visualization of the Augmented Rendering Future Applications Conclusion 31 - Visualization and Optics in Neurosurgery Our Understanding of Vision Augmentation of Vision The Operating Microscope New Technologies for Surgical Visualization High Dynamic Range Imaging Focus Stacking Visual Annotation The Visual Record The Visual Record in Neurosurgery Microneurosurgical Anatomy Moving Pictures Future Directions 32 - Microscope Integration and Heads-Up Display in Brain Surgery What Does Augmented reality Add to Neurosurgery What is Augmented Reality Implementation Preoperative Preparation Scan Acquisition Parameters Surgical Planning Adjudication and Model Modification Practice Microscope Integration Registration Intraoperative Adjustments Errors Registration Errors Segmentation Errors Role in Surgical Education Areas for Further Improvement Inattention Blindness Conclusions 33 - Brain Retraction Principles of Retractor-Based Surgery and Avoidance of Retractor Injury Patient Factors Surgical Anatomy Positioning the Patient Brain Retraction Toward Exploration of the Brain The Early Methods Handheld Brain Retractors Modifications of the Handheld Retractor Self-Retaining Retractors Soft Tissue–Mounted Retractors Skull-Mounted Retractors Table-Mounted Retractors Headrest-Mounted Retractors Maximization of Bony Exposure Dissection Corridors Adjuvant Techniques Fluid Diversion Neuronavigation Technical Aspects of Brain Retraction Retractor Positioning Retraction Systems Altering Pressure Light and Magnification Retraction Injuries Incidence of Retraction Injury Pathophysiologic Mechanisms of Retraction Injury Cerebral Blood Flow Mechanical Disruption and Damage Detecting Retraction Injury Future Directions Simulation Twenty-First Century Brain Retraction Spoon Retractors Balloon Retraction Revisiting Sponge Retraction Tubular Retractor Systems and Endoscopy: Minimal Invasion of the Brain Parenchyma Retractorless Brain Surgery: Toward a More Dynamic Neurosurgeon Conclusion 34 - Advantages and Limitations of Cranial Endoscopy History of Endoscopy Endoscopic Instrumentation and General Principles Endoscopy and Hydrocephalus Endoscopy and Intraventricular Lesion Resection Endoscopy and Arachnoid Cysts Endoscopy for Intracerebral Hematoma Evacuation Endoscopy and the Skull Base Endoscopy and Craniosynostosis Endoscope-Assisted Microneurosurgery Limitations of use of the Endoscope in Intracranial Surgery Conclusion 35 - Principles of Neurocritical Care Neurocritical Considerations in Ischemic Stroke Blood Pressure Glucose Control Temperature Nutrition and Hydration Cardiac Monitoring Antiplatelet Therapy Anticoagulants Infection Treatment of Acute Neurological Complications Cerebral Edema Hemorrhagic Transformation Seizures Neurocritical Considerations in Intracerebral Hemorrhage Reversal of Coagulopathy Blood Pressure Control Surgical Management Treatment of Complications Seizures Medical Complications Neurocritical Considerations in Aneurysmal Subarachnoid Hemorrhage General Considerations Rehemorrhage Hydrocephalus and Intracranial Pressure Hyponatremia Vasospasm Seizures Cardiac Abnormalities Neurocritical Considerations in Spinal Cord Injury Hemodynamics Pulmonary Considerations Pharmacologic Therapy Hypothermia Critical Care Bedside Procedures Intubation Arterial Line Placement Central Venous Catheterization External Ventricular Drain Placement Intracranial Pressure Monitor Placement Lumbar Drain 36 - The Neurosurgical Intensive Care Unit and the Unique Role of the Neurosurgeon History of the Neuro-Icu and Harvey Cushing’s Contributions Evaluation of the Neuro-Icu Patient The Role of the Icu in the Care of Neurosurgery Patients Elements of Neuro-Icu Care Neurocritical Care Training Models Of Neuro-Icu Care Conclusion 37 - Intracranial Pressure Monitoring Historical Perspective General Principles and Standard of Intracranial Pressure Monitoring Technology Current Intracranial Pressure Monitoring Technology (FIG. 37.1) External Ventricular Drain Venue of External Ventricular Drain Placement Extended Tunneling Prophylactic Catheter Exchange Prophylactic Antibiotic Use Antibiotic-Impregnated Catheter Silver-Impregnated Catheters Fiberoptic Intracranial Pressure Monitor Miniature Strain Gauge Spiegelberg Parenchymal Transducer Hummingbird Synergy Telemetric Intracranial Pressure Monitoring Emerging Technology Compliance Monitor Noninvasive Intracranial Pressure Monitoring Pediatric Intracranial Pressure Monitoring Conclusion 38 - The Geriatric Patient: Age-Related Pathophysiologic Changes and Anesthesia Considerations Age-Related Pathophysiologic Changes and Anesthesia Considerations Age-Related Pathophysiologic Changes Cardiovascular System Respiratory System Renal System Gastrointestinal and Hepatic Systems Musculoskeletal System Central Nervous System Preoperative Considerations Intraoperative Considerations General Considerations Craniotomy for Tumor Degenerative Spinal Disease Stroke and Cerebrovascular Disease Movement Disorders Postoperative CONSIDERATIONS in the Elderly 39 - Brain Tumor Management in the Geriatric Patient Introduction Meningioma Introduction and Natural History in Elderly People Surgical Resection Stereotactic Radiosurgery Risk Stratification CLASS Algorithm SKALE Grading System Charlson Comorbidity Index Clinical Radiological Grading System The Geriatric Scoring System Glioblastoma Multiforme Genetic Markers in Elderly Patients With Glioblastoma Multiforme Surgical Intervention Radiotherapy for Elderly Patients With Glioblastoma Multiforme Systemic Therapy Temozolomide Bevacizumab Immunotherapy Conclusion Brain Metastases Epilogue 40 - Traumatic Brain Injury in the Geriatric Patient Preexisting Conditions, Frailty, and Polypharmacy Preexisting Conditions Traumatic Brain Injury in the Geriatric Patient Frailty Polypharmacy Acute Diagnostic and Management Considerations Clinical Assessment Neuroimaging Emerging Blood-based Biomarkers Anticoagulants Antiplatelet Agents Hemodynamic Targets and Neuromonitoring Operative Interventions Seizure Prophylaxis Geriatric Traumatic Brain Injury Guidelines Palliative Care Discharge Planning Discharge Considerations Rehabilitation Preventing Reinjury Outcomes Outcome Prediction Mortality Functional Outcome Long-Term Neurobehavioral Outcomes Epilepsy Psychiatric Disturbances Cognitive Outcomes Neurodegenerative Diseases Conclusions 41 - Genetics of Idiopathic Normal Pressure Hydrocephalus Genetics of Idiopathic Normal Pressure Hydrocephalus Pathology of iNPH Reports of Familial iNPH Evidence for iNPH-associated Genetic Defects Discussion 42 - Production and Flow of Cerebrospinal Fluid Production and Flow of Cerebrospinal Fluid Different fluid-forming capabilities: choroid plexus vs. Brain capillaries Cerebrospinal Fluid Ion Homeostasis Intricate Fluid Balance Among Central Nervous System Compartments Variations in cerebrospinal fluid production: normal vs. Disease Mechanisms of Cerebrospinal Fluid Formation by the Choroid Plexus Sodium Chloride Bicarbonate Water Volume Transmission or Bulk Flow of Cerebrospinal Fluid Neurohumoral Regulation of Cerebrospinal Fluid Formation Rate Neurohumoral Ligands/Receptors Pharmacologic Inhibition of Cerebrospinal Fluid Formation Lower Cerebrospinal Fluid Formation Rate in Hydrocephalus Flow Directionality of Cerebrospinal Fluid Impact of Cerebrospinal Fluid Flow on Brain Functions Magnetic Resonance Imaging of Cerebrospinal Fluid Hydrodynamics vs. Hemodynamics Regionally Interrupted Cerebrospinal Fluid Flow in Normal Pressure Hydrocephalus Sylvian Aqueduct Basal Cisterns Cortical Subarachnoid Space Cerebrospinal Fluid Flow Reversal in Idiopathic Normal Pressure Hydrocephalus Cerebrospinal Fluid Stroke Volume Issues in Idiopathic Normal Pressure Hydrocephalus Dwindling Cerebrospinal Fluid Turnover Rate in Aging, Normal Pressure Hydrocephalus, and Alzheimer Disease Altered Cerebrospinal Fluid and Barrier Clearance Systems in Aging and Neurodegeneration Blood-CSF Barrier and Blood-Brain Barrier Reabsorptive Transporters Cerebrospinal Fluid Sink Action Glymphatic Interstitial Fluid–Cerebrospinal Fluid Drainage Translational Neuroscience to Fortify Cerebrospinal Fluid–Brain Dynamics in Older Adult Patients 43 - Clinical Evaluation of Hydrocephalus in Adults Classification of the Adult Hydrocephalus Continuum Transition Hydrocephalus Acquired Hydrocephalus Unrecognized Congenital Hydrocephalus Suspected Idiopathic Normal Pressure Hydrocephalus Idiopathic Normal Pressure Hydrocephalus History and Physical Examination Gait and Balance Cognition Bladder Control Blood Laboratory Assessment Neuroimaging Diagnostic Criteria Tests Based on Cerebrospinal Fluid Circulatory Physiology Large-volume Cerebrospinal Fluid Tap Test External Lumbar Drainage Cerebrospinal Fluid Infusion Test Cerebrospinal Fluid Biomarkers Treatment Options and Outcomes Perioperative Optimization Conclusion 44 - Shunting Valve Design and Terminology The Differential-Pressure Valve Adjustable (“Programmable”) Valves Antisiphon, Flow-Restricting, and Gravitational Devices Managing Shunt Overdrainage and Underdrainage Overdrainage Underdrainage Valve Selection Shunt Configuration Cerebrospinal Fluid Access Distal Site Infection Avoidance Shunt Allergies Miscellaneous Conditions and Clinical Challenges High Protein Concentration or Cell Count in the Cerebrospinal Fluid The Patient Undergoing Anticoagulation or Antiplatelet Therapy The Hemicraniectomy Patient Shunt Operations Associated With Other Procedures Continuity Care of the Pediatric Hydrocephalus Into Adulthood Role of Endoscopic Third Ventriculoscopy 45 - The Role of Endoscopic Third Ventriculostomy: A Critical Review Comparison of Adult and Pediatric Hydrocephalus Epidemiology Patient Selection and Outcomes for Endoscopic Third Ventriculostomy Pediatric Hydrocephalus Adult Hydrocephalus Endoscopic Third Ventriculostomy for Unrecognized Congenital Hydrocephalus Endoscopic Third Ventriculostomy for Acquired Hydrocephalus (Usually Noncommunicating) Endoscopic Third Ventriculostomy in Normal-Pressure Hydrocephalus Secondary Endoscopic Third Ventriculostomy After Shunt Malfunction With an Underlying Diagnosis of Obstructive Hydrocephalus Imaging Prior to Endoscopic Third Ventriculostomy Postoperative Radiologic Imaging and Outcome Assessment Operative Technique for Endoscopic Third Ventriculostomy Operating Suite Operative Techniques Anatomic Considerations Third Ventricular Floor Fenestration Endoscopic Third Ventriculostomy and Choroid Plexus Cauterization Closure and Postoperative Issues Complications of Endoscopic Third Ventriculostomy Repeated Endoscopic Third Ventriculostomy After Primary Failure Conclusion 46 - Pathophysiology of Chronic Subdural Hematomas Definitions Epidemiology Cause Pathology Pathogenesis Recurrent Hemorrhage, Fibrinolysis, Inflammation, and Angiogenesis Osmotic and Oncotic (Colloid Osmotic) Pressures Appearance on Computed Tomography and Magnetic Resonance Imaging Natural History and Recurrence After Surgery Conclusion 47 - Medical and Surgical Management of Chronic Subdural Hematomas Introduction and Epidemiology Pathogenesis Clinical Presentation Diagnosis Management Preoperative Optimization Correction of Coagulopathy and Thrombopathy Adjuvant Treatments Conservative Management Surgical Intervention Anesthesia. Usually general anesthesia is used, but the procedure may be performed with local anesthesia ?Technique (Video 47.2). The patient is placed supine on a horseshoe headrest and the head and shoulders are tilted to the contr... Discussion. The series by Markwalder et al. in 1981 brought BHC into prominence as a first-line alternative to craniotomy for th... Anesthesia. Local anesthesia is used Technique. TDC may be performed at the bedside on the ward or in the neurocritical care unit. After injection of local anesthesi... Discussion. The technique was first report by Tabaddor and Shulman, who found it to be superior to BHC and craniotomy in their c... Anesthesia. General anesthesia is used Technique. The patient is placed supine with the head resting on a horseshoe headrest. The head and shoulders are tilted roughly... Discussion. Historically craniotomies were associated with significant morbidity and mortality. In modern practice, large cranio... Anesthesia Outcomes Postoperative Care Follow-up Complications and Prognosis Future Research Areas Conclusion 48 - Systemic and Central Nervous System Changes During Pregnancy Introduction Systemic Physiologic Changes in Pregnancy Hematologic Changes Cardiovascular System Physical Examination Electrocardiogram Heart Intravascular Volumes During Labor. Cardiac output is further increased by 15% in the first stage and 50% in the second stage. Uterine contractions le... After Delivery. Cardiac output increases 60% to 80% immediately owing to relief of the IVC obstruction and contraction of the ut... Venous System Pulmonary System Renal System Metabolism Musculoskeletal System Low Back Pain and Spine Disorders Pregnancy-Related Carpal Tunnel Syndrome Bell Palsy Maternal Neuroendocrine Alterations and Pituitary Tumors During Pregnancy Changes in the Pituitary Gland in Pregnancy Prolactinoma. Here we focus on prolactinomas in the pregnant patient. Chapter 175 should be consulted for an in-depth review of ... Corticotropin. Corticotropin-releasing hormone (CRH) levels increase in pregnancy from approximately 10 pg/mL to 50 pg/mL at ter... Cushing Disease. Cushing syndrome refers to the clinical manifestations induced by chronic exposure to excess glucocorticoids Growth Hormone. Maternal serum growth hormone (GH) levels begin to increase at about 10 weeks of pregnancy, plateau at around 28... Acromegaly. Acromegaly is the second most common pituitary adenoma seen in pregnancy after prolactinomas.77 Patients with acrome... Thyroid-Stimulating Hormone. Thyroxine (T4) production by follicular cells of the thyroid gland is under the control of hypothal... Thyrotropinoma/TSHomas. TSH-secreting tumors are rare and account for only 1% of all pituitary tumors.97 Most TSHomas secrete ex... Gonadotropins. Gonadotrophs constitute 7% to 15% of anterior pituitary cell numbers and decrease during pregnancy and normalize ... Gonadotroph Adenomas. Sixty-four percent of all nonfunctional pituitary adenomas are gonadotroph adenomas, which usually present... Nonfunctioning Adenoma. Nonfunctioning pituitary adenomas (NFPAs) are benign tumors that do not secrete any hormones and therefo... Lymphocytic Hypophysitis/Autoimmune Hypophysitis. Lymphocytic hypophysitis is a rare but important cause of hypopituitarism.149 ... Diabetes Insipidus of Pregnancy. Two types of transient diabetes insipidus in pregnancy are caused by the enzyme vasopressinase ... Sheehan Syndrome. The physiologic increased pituitary size during pregnancy and the low-flow and low-pressure portal circulation... Pseudotumor Cerebri. See Chapter 189 for further information 49 - Neuroanesthesia During Pregnancy Physiologic Changes of Pregnancy Relevant to Neuroanesthesia Cardiovascular System Pulmonary System and Airway Neuroanesthesia During Pregnancy Hematology Gastrointestinal, Hepatic, Endocrine Systems Renal System Nervous System Anesthetic Considerations Related to the Physiology of Pregnancy Positioning Induction and Airway Management Maintenance of Maternal and Fetal Well-Being Under Anesthesia Emergence Cardiopulmonary Resuscitation in Pregnancy Perioperative Neuroanesthesia Drugs and Pregnancy Specific Neurosurgical Procedures During Pregnancy Intracranial Procedures Intracranial Hemorrhage Intracranial Neoplasm Traumatic Brain Injury Spine Surgery Interventional Radiology Procedures Timing of Neurosurgery and Perioperative Fetal Monitoring Timing of Surgery Fetal Monitoring Recommendations Conclusion 50 - Vascular Lesions During Pregnancy Overview Evaluation Vascular Lesions During Pregnancy Vascular Disorders During Pregnancy Arterial Occlusion Venous Occlusion Postpartum Cerebral Angiopathy Aneurysmal Subarachnoid Hemorrhage Epidemiology Pathophysiology Management Outcomes Arteriovenous Malformations Management Other Vascular Lesions Metastatic Choriocarcinoma Postpartum Cerebral Vasospasm Carotid-Cavernous Fistula Pituitary Apoplexy Intracerebral Hemorrhage Moyamoya Disease Conclusion 51 - Brain Tumors During Pregnancy Neuroimaging in Pregnancy Neuroanesthesia in Pregnancy Neuroanesthesia for the Pregnant Woman Requiring Craniotomy Newborn Delivery in Patients With Cranial Lesions Pituitary Tumors Glial Tumors Diagnosis Treatment Meningiomas Diagnosis Treatment Other Tumors Conclusion 52 - Basic Science of Central Nervous System Infections Basic Science of Central Nervous System Infections Routes of central nervous system infection, or “it’s not whom you know, it’s how you get there” Role of the Blood-Brain Barrier In Central Nervous System Infections Escherichia coli at the Blood-Brain Barrier Interface Innate Immunity in the Central Nervous System Microglia: Ramón y Cajal’s “Third Element” Astrocytes: Stellar Actors in Central Nervous System Immunopathogenesis Matrix metalloproteinases: “you can’t have your cake and eat it too!” Brain Edema and Neurotoxicity: Consequences of Central Nervous System Infection Brain Edema and Central Nervous System Infections Viruses Invading the Central Nervous System Bacterial Infections of the Central Nervous System Neurotoxicity Human Immunodeficiency Virus–Associated Neurotoxicity Neurotoxicity and Bacterial Meningitis Brain Abscess: Pus in the Parenchyma Cerebrospinal Fluid Shunt Infections: The Role of Biofilms 54 - Postoperative Infections of the Spine Incidence Noninstrumented Spinal Procedures Instrumented Spinal Procedures Infectious Risk Factors Patient-Specific Factors Surgery-Specific Factors Disease-Specific Factors Clinical Findings Evaluation Imaging Diagnosis Plain Radiographs and Computed Tomography Nuclear Medicine Magnetic Resonance Imaging Bacteriologic Studies Treatment Nonoperative Treatment Surgical Débridement Treatment of Infections in the Intrathecal Pump and Spinal Cord Stimulator Wound Vacuum-Assisted Closure Irrigation-Suction Technique Other Surgical Techniques Antibiotic Therapy Prevention Preoperative Factors Intraoperative Factors Vancomycin Powder Postoperative Factors 55 - The Use and Misuse of Antibiotics in Neurosurgery The Importance of Antibiotics in Neurosurgery Risks of Antibiotic Administration General Principles of Antibiotic Use The Blood-Brain and Blood–Cerebrospinal Fluid Barriers Pharmacokinetics of Antibiotic Delivery Central Nervous System Toxicity of Antibiotic Therapy Surgical Site Infection Risk Reduction Systemic Antibiotic Prophylaxis Clean and Clean-Contaminated Neurosurgical Procedures External Ventricular Drains Cerebrospinal Fluid Fistula Prophylaxis in Spine Surgery Topical Antibiotic Prophylaxis Cerebrospinal Fluid Shunt Prophylaxis Antibiotic Treatment for Neurosurgical Infections Soft Tissue Infections Necrotizing Soft Tissue Infections Meningitis and Ventriculitis Cranial Subdural Empyema Brain Abscess Cerebrospinal Fluid Shunt Infections Infection With Spinal Instrumentation Vertebral Osteomyelitis and Discitis Osteomyelitis of the Skull Surgical Care Improvement Project Measures Conclusion 56 - Brain Abscess Brain Abscess Epidemiology and Pathogenesis Etiology Clinical Findings and Diagnosis Management Cranial Subdural Empyema and Epidural Abscess Epidemiology and Etiology Clinical Findings and Diagnosis Management Brain Abscess Brain Abscess Epidemiology Incidence and Risk Factors Pathogenesis Etiology Bacteria Fungi Experimental Models of Infection Initiation of Infection Stages of Infection Host Defense Mechanisms Clinical Findings Diagnosis Management Bacterial Brain Abscess Nocardial Brain Abscess Fungal Brain Abscess Adjunctive Therapy Outcome Cranial Subdural Empyema and Epidural Abscess Epidemiology and Etiology Clinical Findings Cranial Subdural Empyema Cranial Epidural Abscess Diagnosis Management Outcome 57 - Meningitis and Encephalitis Meningitis and Encephalitis Bacterial Meningitis Community-Acquired Bacterial Meningitis Bacterial Pathogens Streptococcus pneumoniae Neisseria Meningitidis Haemophilus Influenzae Listeria monocytogenes Streptococcus agalactiae (Group B Streptococcus) Pathogenesis and Pathophysiology Clinical Findings Diagnosis Cerebrospinal Fluid Studies Serum Inflammatory Markers Latex Agglutination Test Clinical Models Blood Cultures Polymerase Chain Reaction Analysis Radiologic Studies Treatment Health Care–Associated Ventriculitis and Meningitis Microbiology of Health Care–Associated Ventriculitis and Meningitis Postcraniotomy Meningitis External Ventricular Drain–Induced Meningitis Lumbar Drain–Induced Meningitis Posttraumatic Meningitis Recurrent Bacterial Meningitis Bacterial Encephalitis Aseptic Meningitis and Encephalitis Viral Meningitis and Encephalitis Diagnosis Viral Pathogens Enteroviruses Arboviruses West Nile Virus. A flavivirus, West Nile virus is the most common insect-borne cause of viral encephalitis in the United States.... St. Louis Encephalitis Virus. St. Louis encephalitis is also caused by a flavivirus, and the spectrum of clinical presentation r... Eastern Equine Encephalitis Virus. Eastern equine encephalitis (EEE) virus is a member of the Togaviridae family. It is the most... Herpes Simplex Virus Human Herpesvirus 6. HHV-6 causes exanthem subitum (sixth disease) in childhood, and rare cases of HHV-6 encephalopathy have bee... Cytomegalovirus. CMV is transmitted via bodily secretions and occasionally via blood transfusions or transplanted organs.197 Fol... Epstein-Barr Virus. Classically, primary Epstein-Barr virus (EBV) infection manifests as infectious mononucleosis. EBV infection... Measles Virus Rabies Virus Lymphocytic Choriomeningitis Virus Respiratory Viruses SARS-CoV-2 (COVID 19). The prevalence of neurological manifestations in patients with SARS-CoV-2 vary widely between 3.5% and 84... Autoimmune Encephalitis Treatment Mycobacteria (Tuberculous Meningitis) Fungal Meningitis Cryptococcal Meningitis Candidal Meningitis Coccidioidal Meningitis Blastomycosis Spirochetes Treponema pallidum (Syphilis) Borrelia burgdorferi (Lyme Disease) Protozoa Primary Amebic Meningoencephalitis Toxoplasma gondii Chemical Meningitis 58 - Neurological Manifestations of HIV and AIDS Neurological Manifestations of HIV and AIDS HIV Infection of the Nervous System Acute Retroviral Syndrome HIV-Associated Neurocognitive Disorders CD8+ Encephalitis in HIV Tumefactive Demyelination in HIV Myelopathy HIV-Associated Stroke HIV-Associated Neuropathy HIV-Associated Myopathy Infection Toxoplasmosis Fungal Infections Mycobacterial Infections Viral Infections Progressive Multifocal Leukoencephalopathy Cytomegalovirus Treponema pallidum and Bartonella Species AIDS-Related Malignancies Primary Central Nervous System Lymphoma Other AIDS-Related Malignancies HIV Treatment–Related Neurotoxic Effects Conclusion 59 - Parasitic Infections Protozoal Central Nervous System Infections Malaria Toxoplasmosis Trypanosomiasis Free-living Amebae Amebiasis by Entamoeba histolytica Helminthic Central Nervous System Infections Cysticercosis Echinococcosis (Hydatid Disease) Paragonimiasis Schistosomiasis (Schistosoma mansoni, hematobium, and japonicum) Toxocariasis (Toxocara canis and cati) Parasitic Infections Protozoal Infections Malaria Clinical Manifestations Diagnosis Pathology Treatment Toxoplasmosis Clinical Manifestations Diagnosis Pathology Treatment African Trypanosomiasis Clinical Manifestations Diagnosis Pathology Treatment American Trypanosomiasis Clinical Manifestations Diagnosis Pathology Treatment Free-Living Amebae Clinical Manifestations Diagnosis Pathology Treatment Amebiasis by Entamoeba histolytica Helminthic Infections Cysticercosis Clinical Manifestations Diagnosis Pathology Treatment Echinococcosis (Hydatid Disease) Diagnosis. On neuroimaging studies, cystic hydatid disease is characterized by a large nonenhancing vesicle that is well demarca... Pathology. E. granulosus cysts are large, spherical, and well demarcated from surrounding tissue.100 Within the CNS, these cysts... Treatment. Current therapy for hydatid disease of the CNS is largely empirical, and experience is limited to anecdotal cases and... Cystic Hydatid Disease of the Brain. Most hydatid cysts of the brain are removed with the Dowling technique, which consists of h... Cystic Hydatid Disease of the Spine. The surgical approach to patients with spinal hydatid disease usually includes a combinatio... Diagnosis. On neuroimaging studies, alveolar hydatid disease is characterized by multiple lesions surrounded by edema, with ring... Pathology. E. multilocularis cysts are small, group in clusters, elicit a severe inflammatory reaction from the host, and tend t... Treatment. Alveolar hydatid disease is invasive, and total surgical removal usually requires resection of adjacent tissue. This ... Paragonimiasis Clinical Manifestations Diagnosis Pathology Treatment Schistosomiasis (Schistosoma mansoni, hematobium, and japonicum) Toxocariasis (Toxocara canis and cati) 60 - Surgical Risk of Blood-Borne Transmissible Disease Hepatitis Hepatitis B Infection Hepatitis C Human Immunodeficiency Virus Prevention of Occupational Infection Personal Protective Barriers Technical Considerations Response to Exposure The Infected Surgeon Legal Issues PERTAINING TO THE UNITED STATES Future Considerations 62 - Optogenetics and CLARITYa Anchor 3030 Optogenetics and CLARITY Optogenetics Opsins Diverse Optogenetic Tools for Neural Control Animal Models Outlook Optical Calcium Sensors Small-Molecule Calcium Reporters Genetically Encoded Calcium Indicators Optical Signal Readout Outlook Enhanced Histologic Examination with Transparent Tissue: CLARITY Development of Clearing Techniques Development of Large-Volume Staining Imaging Methods and Data Management Clinical Applications and Development Outlook Conclusion and Outlook 63 - Neuroembryology Classical Neuroembryology Developmental Organization: Stages, Genes, and Regulatory Factors Gastrulation Induction Neurulation Segmentation and Regionalization Patterning of the Neural Tube Transcription Factors and Homeoboxes Developmental Gene Families of the Central Nervous System Function of Retinoic Acid Axonal Pathfinding Flexures and Sulci of the Brain Neocortical Maturation Olfactory System Development Developmental Patterns and Disorders Holoprosencephaly Neuronogenesis Normal Proliferation of Neuroblasts Disorders of Neuronogenesis Neuroblast Migration Normal Development Disorders of Neuroblast Migration Synaptogenesis Myelination Cellular Dysmorphogenesis Associated With Defective Genetic Cascades Conclusion 64 - Stem Cell Biology in the Central Nervous System Stem Cells and Progenitors Neurogenesis: Location and Function The Subventricular Zone The Subgranular Zone Neurogenesis in Other Areas of the Brain Regulation of Neurogenesis Astrocytes as Stem Cells Functional Significance of Neurogenesis Gliogenesis NG2+ Cells PDGFR-α A2B5 Astrocyte Precursor Cells Neural Stem Cells in the Spinal Cord Stem Cell and Progenitor Response to Injury Evidence for Adult Human Neurogenesis Stem Cells and Cancer Stem Cell–Based Therapies Stimulation of Endogenous Mechanisms of Repair Transplantation of Stem Cells Stem Cell Imaging Cell Engineering Conclusion 65 - Neurons and Neuroglia Neurons and Neuroglia Neurons Neuronal Function Sensory Neurons Mechanical Receptors Chemical Receptors Physical Receptors Effector Neurons Motor Neurons Neurosecretory Cells Neuronal Organization Neuronal Structure Dendritic Structure Cell Body Structure Axonal Structure Synaptic Structure The Cell Biology of Neuronal Death Neurodegenerative Diseases Neuroglia Astrocytes Radial Glia White Matter Astrocytes Gray Matter Astrocytes Reactive Astrocytes Oligodendrocytes Schwann Cells Microglia Turnover of Microglia Oligodendrocyte Progenitor Cells Oligodendrocyte Progenitor Cells in Development Oligodendrocyte Progenitor Cells in Adult Brain Oligodendrocyte Progenitor Cells and Glial Neoplasms Distribution of Microglia and Oligodendrocyte Progenitor Cells Ependymal Cells Transplantation Therapies Toward the Molecular Identity at a Single Cell Level 67 - Cellular and Molecular Responses in the Peripheral and Central Nervous System Following Axonal Injury ? Cellular and Molecular Responses in the Peripheral and Central Nervous System Following Axonal Injury Axonal Pathway and Regeneration in the Peripheral Nervous System Central Nervous System Response to Injury Opportunities For Intervention Cellular and Molecular Responses in the Peripheral and Central Nervous Systems Peripheral Nervous System Response to Injury Cell Body Survival Cell-intrinsic Mechanisms of Axonal Degeneration The Peripheral Nerve System Axonal Pathway Extracellular Matrix Proteins Cellular and Molecular Response in the Peripheral Nervous System Cytokines Axonal Regeneration in the Peripheral Nervous System Central Nervous System Response to Axonal Injury Opportunities for Intervention Promoting Regeneration and Restoration of Function Conclusion 69 - Physiology of the Cerebrospinal Fluid and Intracranial Pressure Physiology of the Cerebrospinal Fluid and Intracranial Pressure Historical Considerations General Physiology of Intracranial Pressure General Physiology of the Cerebrospinal Fluid Steady-State Intracranial Pressure and Cerebrospinal Fluid Dynamics Non–Steady-State Dynamics Effects of Elevated Intracranial Pressure Intracranial Pressure Monitoring Physiology of Intracranial Hypertension Therapy VCSF VBLOOD VBRAIN VOTHER Multimodal Application of Intracranial Hypertension Therapy 70 - Cerebral Edema Cerebral Edema Cerebral Fluid Homeostasis Monroe-Kellie Doctrine Blood-Brain Barrier Glymphatic System Pathophysiology of Cerebral Edema General Features Vasogenic Edema Pathophysiology Peritumoral Edema Peritumoral Edema to Cyst Formation Cytotoxic Edema Pathophysiology Ischemia-Related Cytotoxic Edema Interstitial (Hydrostatic) Edema Pathophysiology Osmotic Edema Pathophysiology Imaging of Cerebral Edema General Computed Tomography Magnetic Resonance Imaging Management of Cerebral Edema Guidelines for Management of Cerebral Edema Vasogenic Edema Medical Management Surgical Management Cytotoxic Edema Medical Management Surgical Management Interstitial Edema Medical Management Surgical Management Osmotic Edema Medical Management Conclusion 71 - Extracellular Fluid Movement and Clearance in the Brain: The Glymphatic Pathway Basic Principals Governing Interstitial Fluid Movement in the Brain Diffusion and Bulk Flow The Extracellular Space Bulk Flow in the Extracellular Space Role of Astrocytes in Fluid Movement Through the Extracellular Space Physiology of Interstitial Fluid Movement Blood−Cerebrospinal Fluid Interactions Ventricular Cerebrospinal Fluid–Interstitial Fluid Exchange Perivascular Pathways for Cerebrospinal Fluid−Interstitial Fluid Exchange Clinical Implications of Glymphatic Pathway Function Developmental Considerations Alzheimer Disease and Diseases of Protein Aggregation Cerebral Edema Hydrocephalus Subarachnoid Hemorrhage Neuroinflammation and Glial Injury Intrathecal, Intraventricular, and Intraparenchymal Delivery of Medications Drug Delivery to the Cerebrospinal Fluid Intraparenchymal Drug Delivery Conclusion 72 - Altered Consciousness A Brief Taxonomy Coma Vegetative State Minimally Conscious State Akinetic Mutism An Organizing Strategy to Assess Disorders of Consciousness Based on Anatomic and Physiologic Considerations A Guide to Formulating Prognosis in Patients With Disorders of Consciousness Emerging Role of Neuroimaging in Altered Consciousness: Opportunities and Limitations Cognitive Motor Dissociation Conclusion 73 - Neuropsychological Testing Neuropsychological Testing Clinical Assessment Clinical Interventions Computerized Neuropsychological Assessment Quantifying Recovery of Function After Brain Surgery Prediction of Performance in Real-Life Circumstances Treatment Trials Advances in Cognitive Neuroscience Discussion and Future Directions 74 - Biosensors in Neurosurgery: Wearable and Implantable Devices for Monitoring Biosensors in Neurosurgery: Wearable and Implantable Devices for Monitoring Introduction Intracranial Pressure Monitoring Invasive Intracranial Pressure Monitoring Noninvasive Intracranial Pressure Monitoring Body Fluid Composition Intraoperative Monitoring Electrophysiology Movement Disorders Gait Analysis Balance Analysis Kinesis Other Uses Electrical Activity Electroencephalography Bispectral Index Electrocorticography Fluid Dynamics Implantable Blood Pressure Monitoring Devices Fluid Flow in Shunts Conclusion 75 - Artificial Intelligence and Big Data in Neurosurgery This chapter provides a basis for neurosurgeons who are developing an interest in artificial intelligence (AI) and Big Data. Fir... Artificial Intelligence and Big Data: a Historical Overview AI Techniques Why Neurosurgery is Suitable for AI and Big Data Applications Diagnosis Radiologic Imaging Tissue Analysis Free Text (Natural Language Processing) Longitudinal Trends in Monitoring Devices Intraoperative Assisted Diagnosis Treatment Robotic Surgery Augmented Reality Surgery Follow-Up Outcomes Prediction Digital Monitoring Training Simulators and Virtual Reality Limits and Risks Future Directions 76 - Neurosurgical Epidemiology, Research, and Biostatistics Neurosurgical Epidemiology, Research, and Biostatistics Introduction Diagnostic and Screening Tests Validity Bayesian Approach Reliability Intrasubject Variation Intraobserver Variation Interobserver Variation Determining Causation Study Designs Case Reports and Case Series Cross-Sectional Studies Cohort Studies Case-Control Studies Literature Reviews and Systematic Reviews Control of Confounding Variables Exclusion Standardization Stratification Matching Modeling Randomization Evaluating Interventions Randomized Clinical Trials Determination of the Population to Be Studied Measurements of Baseline Factors Allocation Maneuver Measuring Outcomes Analyzing Results Reporting Results Meta-analysis Biostatistics Hypothesis Testing Confidence Intervals Ventriculoperitoneal Shunt Ventriculopleural Shunt Comparison Testing Regression Analyses Events Over Time/Survival Analysis Conclusion 77 - Electrophysiologic Properties of the Mammalian Central Nervous System Electrophysiologic Properties of the Mammalian Central Nervous System Introduction Electrical Properties of Mammalian Cells Ion Channels in Neurons and Glia Genesis of Fast Sodium Action Potentials and Properties of Sodium Channels Calcium Action Potentials and Calcium Channels Repolarization of Action Potentials and Maintenance of Resting Membrane Potential: Potassium Channels Glial Ion Channels and Glutamate Release Expression of Ion Currents in Different Neuronal Populations Ion Channelopathies Intercellular Communication: Electrical and Chemical Synaptic Transmission Electrical Synaptic Transmission Chemical Synaptic Transmission Deep Brain Stimulation: Electrophysiologic Mechanisms and Recent Advancements Maintenance of Extracellular Homeostasis Epilepsy: Effects of Brain Homeostasis Deregulation Epilepsy: Contributions and Consequences Epilepsy: Involvement of Glymphatic Drainage Electrophysiologic Monitoring and Recording in Neurosurgery Electroencephalography, Stereo-electroencephalography, and Electrocorticography Magnetoencephalography Single-unit and Multiunit Recording Transforming Electrophysiologic Recordings Into Functional Output: Brain-computer Interface 79 - Malformations of Cortical Development Malformations of Cortical Development Classification of Malformations of Cortical Development Disorders of Cellular Proliferation Disorders of Neuroblast Migration Disorders of Cortical Organization Focal Cortical Dysplasias Surgery for Malformations of Cortical Development Conclusion 80 - Diagnosis and Classification of Seizures and Epilepsy Approach to New-Onset Seizure Initial Diagnostic Approach and Differential Diagnosis Was the Event a Seizure History. Obtaining a reliable history regarding episodes associated with altered mental status or loss of consciousness can be c... Symptoms at Onset of the Event. Focal symptoms such as illogical speech, automatisms, head or body version, or unilateral rhythm... Description of the Event. A report of “shaking” by a witness is often not helpful. In a landmark German study, syncopal events w... Postictal Symptoms. Postictal confusion is strongly predictive of epilepsy. Quick recovery of orientation after an episode of lo... Physical Examination. The diagnosis of seizures may be supported or refuted by clinical findings, some of which are outlined in ... Tongue Bite. Tongue biting can be reported in epileptic seizures, syncope, and PNES. Lateral tongue bite has been reported as 10... Self-Injury. Injuries related to seizures (e.g., lacerations, bruises, thoracolumbar compression fractures, posterior shoulder d... Incontinence. Although patients are commonly asked about incontinence, a pooled analysis of the data from the current literature... Skin Examination. Skin examination is helpful to asses for any signs of trauma after a seizure. Rarely, identification of a neur... Cardiac. Identification of an arrhythmia, heart murmur, bradycardia, tachycardia, or orthostatic hypotension can help elucidate ... Was the Seizure Provoked or Unprovoked Provoked Seizure. The most common reasons for a provoked seizure include the following20 Acute Symptomatic Seizures. By definition, acute symptomatic seizures occur within 7 days of a precipitating symptomatic insult,... Does the Patient Have Epilepsy and What Type Unprovoked Seizure. In one-half of patients presenting with a first unprovoked seizure, prior seizures are detected on history, ... Remote Symptomatic Seizure. A remote symptomatic seizure is defined as a seizure that occurs at least 7 days after a neurologic ... Seizures Associated with an Epilepsy Syndrome. Epilepsy syndromes are a group of epilepsies presenting with a cluster of electro... Initial Investigations Diagnostic Testing Electroencephalography Neuroimaging Epilepsy Surgery for New-Onset Epilepsy Seizure and Epilepsy Classification Principles of Seizure and Epilepsy Classification Seizure Classification Example Epilepsy Classification Epilepsy Type Epilepsy Syndrome Epilepsy Etiology Comorbidities Conclusions 81 - Antiseizure Medications: Principles of Clinical Use Overview of AED History, Mechanism, and Efficacy Mechanisms Antiepileptic Drug Efficacy When to Start Antiepileptic Drug Therapy Seizures and Resultant Epilepsy Status Epilepticus Electrographic Seizures When Seizures or Epilepsy Diagnoses Are Unclear When Antiepileptic Drugs Are Not Useful Antiepileptic Drug Selection Antiepileptic Drug Monotherapy Specific Antiepileptic Drug Concerns in Common Neurosurgical Practice Parenteral Antiepileptic Drugs Antiepileptic Drug Polytherapy Special Considerations for Antiepileptic Drugs and Women When and How to Stop Antiepileptic Drug Therapy Antiepileptic Drug Use Coordination With Neurologists Conclusion 82 - Electroencephalography in Outpatient, Epilepsy Monitoring Unit, and Intensive Care Unit Settings Introduction Clinical Application and Value Historical Development Electroencephalography in Outpatients Routine Electroencephalography Long-Term Multihour and Ambulatory Electroencephalography Electroencephalography in the Epilepsy Monitoring Unit Clarification of Diagnosis and Event Characterization Clinical Assessment of Seizures and Spells Seizure/Syndrome Classification Seizure Quantification and Burden Assessment Medication Adjustment Differentiation Between Seizures and Side Effects Presurgical Evaluation Anticipated Course of Treatment for Medical and Presurgical Evaluation Tapering and Withdrawing Antiseizure Medications Sleep Deprivation Exercise Hyperventilation Photic Stimulation The Electroencephalogram in Epilepsy Interictal Recording: Epileptiform Discharges Ictal Recording: Ictal Patterns Electroencephalography in Focal Epilepsies Temporal Lobe Epilepsy Electroencephalography in Mesial Temporal Lobe Epilepsy. Mesial temporal lobe epilepsy (MTLE) is characterized by focal seizures... Electroencephalography in Neocortical Temporal Lobe Epilepsy. NTLE is more heterogeneous in terms of etiologies and electroclini... Electroencephalography in Frontal Lobe Epilepsy Electroencephalography in Parietal Lobe Epilepsy Parietal Epilepsy in Occipital Lobe Epilepsy Electroencephalography in Generalized Epilepsy Electroencephalography in the Intensive Care Unit Setting Application and Value Electroencephalography-Related Infrastructure in Intensive Care Units Detection of Nonconvulsive Seizures and Nonconvulsive Status Epilepticus Convulsive Status Epilepticus Nonconvulsive Seizures and Nonconvulsive Status Epilepticus Etiology Diagnosis Treatment of Status Epilepticus and Nonconvulsive Seizures Topics of Special Interest Traumatic Brain Injury Subarachnoid Hemorrhage Intracranial Hemorrhage Acute Ischemic Stroke Hypoxic-Ischemic Injury and Post–Cardiac Arrest Syndrome Electroencephalography and Prognostication in Post–Cardiac Arrest Syndrome Infectious and Noninfectious Encephalopathies Detection of Ischemia Ischemia Detection in Subarachanoid Hemorrhage. In patients with high-grade SAH, DCI may not be detected through changes in the ... Ischemia Detection in Acute Ischemic Stroke. Secondary ischemia after AIS may occur in many patients, depending on the stroke su... Periodic Discharges Scalp Electroencephalography for Multimodal Monitoring Devices Cortical Spreading Depolarization Conclusion and Future Directions 83 - Evaluation of Patients for Epilepsy Surgery Goals of Presurgical Evaluation of Patients With Epilepsy Clinical Approach and Techniques Used in the Presurgical Evaluation Clinical Approach Necessary Techniques for the Localization of the Epileptogenic Zone High-Resolution Magnetic Resonance Imaging Scalp Video-Electroencephalographic Monitoring Patient Management Conference and the Presurgical Hypothesis Additional Diagnostic Testing Invasive Evaluation Techniques in Presurgical Evaluation Rationale Indications for Invasive Evaluation Choice of Invasive Method Subdural Grid Implantation Method. The first prolonged intracranial recordings were reported in 1939 by Penfield and colleagues.... Principles of and Indications for Placement of Subdural Electrodes. The objective of extraoperative recordings with the SDG meth... Stereo-Electroencephalography Method. The SEEG method was developed in France by Jean Talairach and Jean Bancaud during the 1950... Principles and Technique of Implantation. The development of an SEEG implantation plan requires the formulation of a specific an... Indications for Electrode Placement. In addition to the general indications for invasive monitoring, specific indications may gi... Conclusion 84 - Magnetic Resonance Imaging for Epilepsy Surgery Indications Epilepsy Protocol Optional Sequences Structural Cerebral Abnormalities Identified with Magnetic Resonance Imaging Hippocampal Sclerosis Malformations of Cortical Development Group I Group II Group III Mild Malformations of Cortical Development. Krsek and colleagues33 described the imaging characteristics in a group of patients ... Focal Cortical Dysplasia Age and Imaging of Focal Cortical Dysplasia Tumors Vascular Malformations Transient Changes on Magnetic Resonance Imaging in Relation to Seizures Structural Magnetic Resonance Imaging and Cognition in Epilepsy Functional Imaging Functional Magnetic Resonance Imaging Motor Function Language Electroencephalography–Functional Magnetic Resonance Imaging Diffusion-Weighted Imaging Magnetic Resonance Spectroscopy Multimodality Imaging in Epilepsy Surgery Principles of Multimodality Application to Epilepsy Surgery Current Practice Barriers to Widespread Adoption Organizational Infrastructure Accuracy Validity Future Directions Interventional Magnetic Resonance Imaging Conclusion 85 - Single-Photon Emission Computed Tomography in Epilepsy Surgery Evaluation ICTAL Single-Photon Emission Computed Tomography ICTAL and Interictal Single-Photon Emission Computed Tomography SISCOM Statistical Parameter Mapping Statiscom Limitations of Single-Photon Emission Computed Tomography Outcome Procedures Associated With Single-Photon Emission Computed Tomography 86 - Magnetoencephalography/Magnetic Source Imaging Magnetoencephalography Principles Brief Overview of Clinical Magnetoencephalography Role of Magnetoencephalography in Epilepsy Surgery Applications of Magnetoencephalography in Functional Mapping in Neurosurgery Somatosensory Mapping Motor Mapping Language Mapping Visual Cortex Mapping Auditory Cortex Mapping Multimodal Integration of Magnetoencephalography With Other Diagnostic Tests FUTURE DIRECTIONS IN CLINICAL MAGNETOENCEPHALOGRAPHY Conclusion 87 - Wada Testing Procedures Pre-Wada Procedures Wada Procedure: Cognitive Testing Interpretation of Wada Testing Results Language Memory Pass Versus Fail Memory Asymmetry Anesthetic Agents and Dosages Safety Wada Testing in Children Perfusion Patterns Reliability Validity Changes in the Use of Wada Testing and Possible Alternatives Functional Neuroimaging Language Memory Closing Comments 88 - Preoperative Functional Localization Principles and Limitations of Functional Magnetic Resonance Imaging Language Lateralization Localization and Prediction of Language Outcome After Surgery Memory Processes Lateralization of Memory Functions Localization of Memory Functions Prediction of Memory Outcome After Epilepsy Surgery Postoperative Memory Network Plasticity Future Directions for Language and Memory Functional Magnetic Resonance Imaging Motor Functional Magnetic Resonance Imaging Sensory Functional Magnetic Resonance Imaging Interpretation in a Clinical Context Vision Diffusion and Tractography Tractography Conclusions 89 - Intracranial Monitoring with Subdural Grids and Strips History Generators For Electroencephalographic Signals Recording Technology Limitations of Scalp Electroencephalography Advantages of Subdural Electrodes Types of Subdural Electrodes Surgical Placement Postoperative Care and Imaging for Localization Clinical Use of Subdural Electrodes Indications for Subdural Electrodes (Figs. 89.3 and 89.4) Hypothesis-Guided Grid Placement Comparison With Depth Electrodes Ictal Direct Current Shift Recordings Ictal and Interictal High-Frequency Oscillation Recordings Patient Outcomes Following Subdural Electrode Placement Cortical Stimulation For Localization of Eloquent Cortex Background and Purposes of Cortical Stimulation Stimulation and Testing Procedure Safety and Complications of Subdural Electrodes Research Applications of Subdural Electrodes Cortical Evoked Potentials in Response to ­Single-Pulse Electrical Stimulation Cortical Stimulation to Inhibit Seizures Functional Mapping by Using Evoked and Induced Activities Conclusions 90 - Intracranial Monitoring: Stereo-electroencephalography Recording Brief Historical Perspective of Stereotactic Epilepsy Surgery Developing The Hypotheses and Implantation Planning Seeg Implantation Patterns Temporal Epilepsies Explorations Frontal-Parietal Explorations Rolandic Explorations Visual System and Posterior Temporal-Parietal-Occipital Areas Technical Nuances Orthogonal (Cartesian) Versus Oblique (Non-Cartesian) Implantations Hodologic Reasons Volume of Exploration Reasons SEEG-Guided Resection Reasons Safety and Accuracy Reasons Posterior Orbito-frontal Areas Dorsal Frontal and Parietal Areas Skull Defects Preventing Orthogonal Trajectories Insula Seeg-Guided Resections: General Considerations Clinical Scenarios: Seeg Implantation Planning and Resections in the “Nonlesional Scenario” Seeg Implantation Planning and Resections in the “Lesional Scenario” Conclusions 91 - Intraoperative Electrocorticography and Strategy in Tailored Lesionectomies History of Lesionectomy and Electrocorticography Indications for Intraoperative Electrocorticography and Technique Anesthetic Protocols for Effective Electrocorticography Application of Electrocorticography to Functional Mapping Focal Resection for Epilepsy Utilization of Electrocorticography with Lesional Epilepsy Focal Cortical Dysplasias Cavernous Malformations Low-grade Gliomas Polymicrogyria Tuberous Sclerosis Complex Nonlesional Epilepsy Conclusions 92 - Intraoperative Mapping and Monitoring for Cortical Resection Anatomic Considerations Indications Intraoperative Mapping and Monitoring for Cortical Resection Preoperative Functional Imaging Preoperative Preparations Patient Selection Equipment Anesthetic Considerations Surgical Positioning Considerations During the Craniotomy Intraoperative Stimulation Mapping Somatosensory Evoked Potential Recordings Electrocorticography Sensorimotor Stimulation Language Mapping Subcortical Stimulation Mapping Pitfalls of Stimulation Mapping Surgical Pearls Postoperative Considerations 93 - Investigation of Human Cognition in Epilepsy Surgery Patients Subjects Investigation of Human Cognition in Epilepsy Surgery Patients Electrodes Implantation Surgery Verification of Electrode Placement Recording of Electrical Activity Electrical Stimulation Concurrent Transcranial Magnetic Stimulation and Intracranial Electroencephalography Recording Cooling Measurement of Physiologic Phenomena Cognitive Task Design Cognitive Studies Cognitive Studies in the Ventromedial Prefrontal Cortex Investigation of Emotion Representation Investigation of Expectation of Reward and Punishment Cognitive Studies in the Medial Temporal Lobe Cognitive Studies in the Anterior Temporal Lobe Cognitive Studies of the Superior Temporal Cortex Distributed Processing Enables Cognition Conclusion 94A - Anteromedial Temporal Lobectomy Historical Perspective Preoperative Evaluation Surgical Decision Making General Anatomy Important Vasculature Language Localization Visual Fibers Anterior Temporal Lesions Extent of Lateral Resection Extent of Medial Resection Neuropsychological Testing Surgical Technique Craniotomy Lateral Temporal Resection Ventricular Exposure Amygdalar Resection Hippocampal Resection Postoperative Follow-Up Surgical Complications Outcomes 94B - Selective Amygdalohippocampectomy Selective Approaches for Mesial Temporal Epilepsy Technique for Subtemporal Selective Amygdalohippocampectomy Evidence for Selective Approaches 95 - Resections for Extratemporal Epilepsy Introduction Frontal Lobe Epilepsy Semiology and Diagnostic Work-up Surgical Management Outcomes Occipital Lobe Epilepsy Semiology and Diagnostic Work-up Surgical Management Outcomes Parietal Lobe Epilepsy Semiology and Diagnostic Work-up Surgical Management Outcomes Insular and Perisylvian Epilepsy Semiology and Diagnostic Work-up Surgical Management Outcomes Perirolandic Epilepsy Semiology and Diagnostic Work-up Surgical Management Outcomes Conclusion 96 - Palliative Procedures for Drug-Resistant Epilepsy Corpus Callosotomy History Patient Selection Operative Procedure Preoperative Imaging Anesthesia and Positioning Surgical Technique Results Complications Illustrative Cases Conclusion Multiple Subpial Transections History Patient Selection Operative Procedure Transections Pathology, Imaging, and Complications Pathology Radiology and Functional Imaging Complications Seizure Outcome Illustrative Case Conclusion Topectomy Presurgical Evaluation Extracranial Electroencephalography. Scalp EEG provides critical information about the location and size of the epileptogenic ar... Neuroimaging. MRI is the imaging modality of choice in patients with intractable epilepsy. It provides visualization of focal dy... Neuropsychological Testing. Neuropsychological examinations contain a personality inventory and tests of memory, language functi... Invasive Electroencephalography. When an epileptogenic focus is not clearly lateralized or is poorly localized, invasive EEG mon... Surgical Topectomy Procedure General Principles Based on Anatomic Considerations Preoperative Care and Anesthesia Intraoperative Electrocorticography Surgical Technique Surgical Outcome Illustrative Case Conclusion 97 - Radiosurgical Treatment for Epilepsy Radiosurgery as a Neuromodulation Therapy Preclinical Evidence Clinical Evidence Medial Temporal Lobe Epilepsy Dose Target Patient Selection Histologic Evaluation After Radiosurgical Treatment of Medial Temporal Lobe Epilepsy Antiepileptic Radiosurgery Mechanism Current Indications Summary Hypothalamic Hamartomas Surgery and Minimally Invasive Approaches Radiosurgery Topologic Classification and Treatment Strategy Effect of Gamma Knife Radiosurgery on Behavior and Cognitive Functions Limits of Radiosurgery for Hypothalamic Hamartoma Cavernous Malformations Target Definition Dose Selection Management Strategy Bleeding Risk Prognostic Factors Pathologic Response and Associated Risks Radiosurgical Corpus Callosotomy Callosotomy Techniques Gamma Knife Callosotomy Indications Extent of Callosotomy Dose Prescription 98 - Laser Interstitial Thermal Therapy in Epilepsy Development of Interstitial Thermal Therapy and Magnetic Resonance Imaging Guidance Laser Interstitial Thermal Therapy in Epilepsy Applications to Medically Intractable Epilepsy Mesial Temporal Lobe Epilepsy Focal Cortical Dysplasia, Insular Epilepsy, and Tuberous Sclerosis Hypothalamic Hamartomas Periventricular Nodular Heterotopia Cerebral Cavernous Malformations Corpus Callosotomy Conclusions 99 - Hemispheric Disconnection Procedures Development Less Resection—More Disconnection Indications, Patient Selection, and Timing Hemispheric Disconnection Procedures Etiology of Hemispheric Epilepsies Hemimegalencephaly Sturge-Weber Syndrome Rasmussen Encephalitis Indications Timing Contraindications to Hemispheric Disconnective Approaches Presurgical Evaluation Goals of Surgery Side Effects and Complications Surgical Techniques Hemispheric Deafferentation Techniques Transsylvian Keyhole Technique Vertical Parasagittal Hemispherotomy Combined Resection-Deafferentation Techniques Alternative Classic Techniques Postoperative Management Choice of Surgical Procedure Outcome and Factors of Influence Effect of Surgical Technique Long-term Outcome Cognition and Behavior Complications Conclusion 100 - Electrical Stimulation for Epilepsy (VNS, DBS, and RNS) Mechanisms of Action of Electrical Neuromodulation Electrical Stimulation for Epilepsy (VNS, DBS, and RNS) Targets For Electrical Stimulation in Epilepsy Vagus Nerve Stimulation Cerebellum Hippocampus Subthalamic Nucleus and Substantia Nigra Centromedian Nucleus of the Thalamus Anterior Nucleus of the Thalamus Nucleus Accumbens Responsive Neurostimulation Conclusion and Future Directions 101 - Epilepsy Surgery: Outcomes and Complications Epilepsy Surgery: Outcomes and Complications Basic Principles and Pitfalls of Outcomes Assessment For Epilepsy Surgery Resective or Ablative Surgery Temporal Lobe Epilepsy Surgery Early Versus Late Surgical Failures. More than half of the postoperative seizure recurrences start within 6 postoperative months... Running Down Phenomenon. The running down phenomenon is the late remission of postsurgical seizures. It occurs in 3.2% to 20% of... Duration of Epilepsy. A long history of seizures correlated with worse outcome in multiple studies on univariate analysis.31,69,... Age at Surgery. Most studies found no correlation between age at surgery and seizure outcome,7,8,10,46 although one longitudinal... Absence of Secondarily Generalized Tonic-Clonic Seizures. The poor prognostic significance of secondarily generalized tonic-clon... Low-Baseline Seizure Frequency. A lower seizure burden is correlated with more favorable seizure outcomes after TLE surgery. The... Nuclear Imaging. Unilateral temporal hypometabolism on fluorodeoxyglucose–positron emission tomography (FDG-PET) is a good predi... Invasive Electroencephalography. Depth electrode evaluations have traditionally been used to clarify lateralization of the epile... Surgical Approaches and Complications of Surgery for Temporal Lobe Epilepsy Impact of Cortical and Hippocampal Resection on Seizure Outcomes Utility of Intraoperative Electrocorticography Laser Interstitial Thermal Therapy and Stereotactic Laser Ablation Global Memory Deficits. Global amnesia is a rare but disabling complication of temporal lobe surgery. Two patients with global a... Material-Specific Memory Deficits. Reported material-specific memory deficits include loss of short-term verbal and nonverbal me... Memory Outcomes After Selective Amygdalohippocampectomy Memory Outcomes After Laser Interstitial Thermal Therapy Language Outcomes After Dominant-Hemisphere Temporal Lobe Resections Surgical Complications of Temporal Lobe Resection Impact of Temporal Lobe Resection on Epilepsy-Related Mortality Temporal Lobe Surgery for Lesional Epilepsy Frontal Lobe Epilepsy Surgery Rate and Stability of Postoperative Seizure Freedom Predictors of Seizure Recurrence Magnetic Resonance Imaging in Frontal Lobe Epilepsy and Seizure Outcome Extent of Resection and Seizure Outcome Subhemispheric Disconnection Techniques Posterior Cortex Surgery Rate and Stability of Postoperative Seizure Freedom Predictors of Seizure Recurrence Extratemporal Epilepsy: Surgical Approaches and Complications Seizure Outcomes Complications of Extratemporal Resection Extratemporal Lesional Epilepsy Hypothalamic Hamartomas Surgery for Cerebellar Seizures Resective or Ablative Surgery for Catastrophic Epilepsies Hemispherectomy Disconnection Surgery Multiple Subpial Transection Corpus Callosotomy Complications of Diagnostic Procedures Intracarotid Amytal Procedure (Wada Test) Invasive Monitoring: Depth Electrodes Subdural Strip Electrodes Subdural Grid Electrodes Stereo-electroencephalographic Monitoring Psychiatric Outcomes After Epilepsy Surgery Cost-Effectiveness of Surgical Treatment Neuromodulation for Epilepsy Vagus Nerve Stimulation Deep Brain Stimulation Responsive Neurostimulation Stereotactic Radiosurgery Radiosurgery for Hypothalamic Hamartomas Radiosurgery for Supratentorial Tumors Radiosurgery for Arteriovenous Malformations Radiosurgery for Cavernous Malformations Radiosurgery for Mesial Temporal Lobe Epilepsy 102 - Anatomy and Synaptic Connectivity of the Basal Ganglia Anatomy and Synaptic Connectivity of the Basal Ganglia Functional Circuitry of the Basal Ganglia The Striatum: An Entrance to the Basal Ganglia Circuitry Cellular Organization of the Striatum Glutamatergic Projections to the Striatum Corticostriatal Projections Thalamostriatal Projections Thalamostriatal Projections From the Caudal Intralaminar Nuclei. In primates, the centromedian (CM) and parafascicular (PF) nucl... Thalamostriatal Projections From Other Thalamic Nuclei. The CM/PF complex is not the only source of thalamostriatal projections.... Synaptic Organization and Prevalence of Thalamostriatal and Corticostriatal Terminals. Characterization of the connectivity of t... The Thalamostriatal System: A Potential Route of Cerebellar Outflow to the Striatum For many years, the circuits to and from the... Electrophysiologic Effects of Thalamostriatal Projections on Striatal Neurons. Electrical stimulation of the CM nucleus, in vivo... Potential Roles of the CM/PF-Striatal Systems in Cognition. Our knowledge about the roles of the thalamostriatal systems in the ... Centromedian Nuclei and Parafascicular Nuclei Degeneration in Parkinson and Other Diseases. Postmortem studies of patients’ brai... Dopaminergic Projections to the Striatum Dopaminergic Cell Groups Nigrostriatal Dopaminergic System. Based on various tract-tracing studies in monkeys, the following pattern emerged for organiza... Extrastriatal Dopaminergic Systems Direct and Indirect Pathways of the Basal Ganglia The Traditional Model of Basal Ganglia Circuitry The External Globus Pallidus: More Than a Relay Nucleus in the Indirect Pathway The Hyperdirect Corticosubthalamic System Anatomy of the Corticosubthalamic System Potential Roles of the Corticosubthalamic System The Pedunculopontine Nucleus as an Integrative Component of the Basal Ganglia Cellular Organization and Connectivity of the Pedunclulopontine Nucleus The Pedunculopontine Nucleus as a Target for Functional Deep Brain Stimulation in Movement Disorders Basal Ganglia Output to the Thalamus and Brainstem Efferent Projections of the Globus Pallidus Pars Interna The Pallidothalamic Projection The Pallidotegmental Projection The Pallidohabenular Projection Efferent Projections of the Substantia Nigra Reticulata The Nigrothalamic Projection The Nigrotegmental Projection The Nigrocollicular Projection The Nigroreticular Projection Conclusion 103 - Rationale for Surgical Interventions in Movement Disorders Relevant Anatomic and Physiologic Features of Brain Motor Systems Rationale for Surgical Interventions in Movement Disorders Movement Disorders: Clinical Characteristics, Medical Treatment, and the Role of Surgery Parkinson Disease Clinical Indications for Surgical Therapy of Parkinson Disease Pathophysiology of Parkinson Disease Dystonia Clinical Indications for Surgical Therapy of Dystonia Pathophysiology of Dystonia Role of Basal Ganglia Dysfunction in Dystonia. It is well known that dystonia may occur in patients with specific lesions involv... Cerebellar Involvement in Dystonia. The involvement of cerebellar circuits in dystonia145 is supported by animal experimentation... Involvement of Cortex in Dystonia. There is evidence for altered function in movement-related cortical areas in subjects with dy... Essential Tremor Pathophysiology of Essential Tremor Surgical Treatment of Movement Disorders Targets Physiologic Effects of Neurosurgical Interventions Surgical Treatment of Early Parkinson Disease On-Demand Stimulation Conclusion 104 - Neuropathology of Movement Disorders Neuropathology of Movement Disorders Functional Anatomy of Basal Ganglia Cortico–Basal Ganglia–Thalamocortical Circuits Classification of Movement Disorders α-Synucleinopathies Hypokinetic-Rigid Movement Disorders Lewy Body–Associated Disorders Lewy Bodies Pathobiologic Role of Lewy Bodies Sporadic Parkinson Disease Neuropathology of Parkinson Disease Development of α-Synuclein/Lewy Body–Related Pathology Parkinson Disease—A Multiorgan Disorder Lewy Body Pathology Staging Incidental Lewy Body Disease. The term incidental Lewy body disease is used when LBs are found in the nervous system in subjects... New Guidelines for Lewy Pathology. A new unifying system for LB disorders correlates with nigrostriatal degeneration, cognitive ... Neuronal Vulnerability Lesion Patterns in Clinical Subtypes of Parkinson Disease Motor Complications, Dyskinesia, and Freezing Pathology of Cognitive Impairment in Parkinson Disease Genetic Forms of Parkinson Disease Dementia With Lewy Bodies Neuropathology Dementia With Lewy Bodies Versus Parkinson Disease Dementia Etiopathogenesis of Lewy Body Disease Multiple System Atrophy Neuropathology and Molecular Pathology Tauopathies Progressive Supranuclear Palsy Neuropathology Corticobasal Degeneration Neuropathology Postencephalitic Parkinsonism Pick Disease Frontotemporal Dementia With Parkinsonism Linked to Chromosome 17 Guamanian and Other Forms of Western Pacific Parkinsonism Secondary Parkinsonism Vascular Parkinsonism (Pseudoparkinsonism) Drug- and Toxin-Related Parkinsonism Other Lesions Causing Parkinsonism Hyperkinetic Movement Disorders Chorea Huntington Disease Huntington Disease–like Syndromes. Approximately 1% of patients with an HDL phenotype have no mutation of the HTT gene; among th... Benign Hereditary Chorea. This rare AutD disease is clinically and genetically heterogeneous. Heterozygous point mutations or de... Sporadic (Nonhereditary) Chorea Paroxysmal Dyskinesias Hereditary Striatal Necrosis Dentatorubral-Pallidoluysian Atrophy Machado-Joseph Disease Progressive Pallidal Degenerations Neurodegeneration With Brain Iron Accumulation Neuroferritinopathy. Neuroferritinopathy (previously NBIA 2, currently NBIA 3), a rare AutD disease caused by mutations in the f... Neuronal Intranuclear Inclusion Disease and Basophilic Inclusion Body Disease Wilson Disease (Hepatolenticular Degeneration) Menkes Disease. This X-linked recessive multisystem disorder is due to mutations of the ATP7A gene, which encodes a copper-trans... Myoclonic and Startle Syndromes Ballism and Hemiballism Dystonias Tic Disorders Tremor Syndromes Conclusion 106 - Patient Selection Criteria for Deep Brain Stimulation in Movement Disorders General Selection Process Neurological Evaluation Neurosurgical Evaluation Neurocognitive and Psychiatric Evaluation Neuroimaging Medical Clearance Specific Indications For Deep Brain Stimulation Parkinson Disease Selection Criteria Diagnosis. DBS therapy should be considered only for patients with a confirmed diagnosis of idiopathic PD. Although idiopathic P... Disease Severity and Duration. Although it is not considered a predictor of DBS outcome, the duration of parkinsonism should be ... Response to Levodopa. A sustained preoperative response to levodopa not only provides support for the diagnosis of idiopathic PD... Age. The role of age as an outcome predictor for DBS is somewhat controversial.32,42 Some authors consider advanced age (in part... Cognitive Status. The patient’s cognitive status should be assessed with an appropriate battery of neuropsychological tests.15 P... Psychiatric Comorbid Conditions. In select patients, a psychiatric evaluation may be performed to assess the presence of untreat... Globus Pallidus Interna. A number of studies have shown that bilateral GPi stimulation is safe and effective for the management ... Subthalamic Nucleus. The clinical efficacy of STN-DBS in reducing PD symptoms has been reported by numerous investigators and va... Caudal Zona Incerta. In recent years, there has been growing interest in the caudal zona incerta (cZI) as a target for treating ... Pedunculopontine Nucleus. Thus far the literature on the efficacy of pedunculopontine nucleus stimulation in PD is mixed, and ou... Dystonia Classification Treatment Target Selection Essential Tremor Selection Criteria Target Selection Complex Tremor Syndromes Selection Criteria Cerebellar Tremor. Cerebellar tremor is characterized by a coarse action tremor, generally less than 5 Hz, and is occasionally a... Holmes Tremor. Also known as “rubral tremor” or midbrain tremor, HT is an irregular, low-frequency rest and intention tremor tha... Thalamic Tremor. TT is characterized by variable degrees of dystonia, athetosis, chorea, and action tremor and is occasionally a... Orthostatic Tremor. Described as a quivering tremor of the legs and trunk during standing accompanied by a sensation of unsteadi... Target Selection Gilles de la Tourette Syndrome Selection Criteria Target Selection Huntington Chorea and Other Choreas Selection Criteria Target Selection 107 - Functional Imaging in Movement Disorders Anchor 131 Molecular Imaging MRI Of Blood Oxygen Level–Dependent Signals Potential Confounders in Interpretation of Functional Neuroimaging Applications to Movement Disorders Diagnostic Accuracy Exploration of Structure-Function Relationships New DBS Target Selection Restorative Therapeutic Targeting Conclusion 108 - Neuroimaging in Stereotactic Functional Neurosurgery Image-Guided Surgery Magnetic Resonance Connectivity and Imaging of Brain Activity Image-Verified Surgery Safety of Magnetic Resonance Imaging in Patients with Implanted Deep Brain Stimulation Hardware Gamma Knife and Magnetic Resonance–Guided Focused Ultrasonography Conclusion 109 - Surgical Management of Tremor Pathophysiology and Circuitries of Tremor Surgical Management of Tremor History of Stereotactic Surgery for Tremor Contemporary Surgery for Tremor Targets Subthalamic Nucleus Ventral Intermediate Nucleus Posterior Subthalamic Area Caudal Zona Incerta Globus Pallidus Internus Imaging and Targeting Subthalamic Nucleus Ventral Intermediate Nucleus Caudal Zona Incerta. As stated earlier, recent experience in DBS for tremor, corroborating prior experience in ablative lesions ... Intraoperative Exploration of the Target in View of Deep Brain Stimulation Ablative Procedures Radiofrequency Thalamotomy Gamma Knife Thalamotomy MR-guided Focused Ultrasound Thalamotomy MRI-guided Laser Interstitial Thermal Therapy Results of Surgery on Tremor Parkinsonian Tremor Essential Tremor Dystonic Tremor Other Forms of Tremor 111 - Deep Brain Stimulation for Parkinson Disease Anatomy and Physiology of Targets Deep Brain Stimulation for Parkinson Disease Patient Selection Indications Contraindications Target Selection Factors Patient Symptomatology Surgeon’s Experience Alternative Target: Ventralis Intermedius Nucleus Unilateral Versus Bilateral Versus Staged Stimulator Implantation Selection of Surgical Technique Awake Surgical Technique Preoperative Imaging Operation Globus Pallidus Interna. The approximate coordinates used for initial GPi targeting are as follows: 2 mm anterior, 5 mm inferior... Trajectory. The approximate initial trajectory for both STN and GPi stimulation is 60 degrees from the AC-PC line in the sagitta... Positioning and Exposure Microelectrode Recording Deep Brain Stimulation Lead Implantation and Macrostimulation Closure and Pulse Generator Placement Asleep Interventional Magnetic Resonance Imaging Surgical Technique Results Complications Future Directions 112 - Deep Brain Stimulation for Dystonia Diagnosis and Classification of Dystonia Pathophysiology Medical Therapy for Dystonia Surgical Therapy for Dystonia The Deep Brain Stimulation Procedure Patient Selection Surgical Procedure Stereotactic Technique Anatomic Targeting Microelectrode Recording Deep Brain Stimulation Surgery in Children Macroelectrode Stimulation Implantation of the Pulse Generator Programming the Device Clinical Results Generalized Dystonia Pallidal Deep Brain Stimulation for Cervical Dystonia Indicators of Deep Brain Stimulation Response Stimulation Frequency Longevity of Response Primary Craniocervical Dystonia (Meige Syndrome) Secondary Dystonia Complications of Deep Brain Stimulation Therapy Alternative Targets for Deep Brain Stimulation in Dystonia Conclusion 114 - Complication Avoidance in Deep Brain Stimulation Surgery Procedure-Related Complications Death Neurological Deficit Intracerebral Hemorrhage Subdural Hematoma Cerebral Venous Infarction Ischemic Stroke Perioperative Confusion Venous Air Embolism Poorly Positioned Electrodes Seizure Aborted Procedures Cerebrospinal Fluid Leak Medical Complications Parkinsonism-Hyperpyrexia Syndrome Dystonic Crisis Hardware-Related Complications Lead/Extension Wire Fracture Lead Tip Migration Lead Tip Gliosis Brain Edema Surrounding Implanted Deep Brain Stimulation Leads Intraparenchymal Cyst Twiddler’s Syndrome Bowstringing Discomfort or Poor Cosmesis at the Pulse Generator Site Pulse Generator Malfunction Pulse Generator Migration General Hardware Complications Magnetic Resonance Imaging–Related Complications Infection Stimulation-Related Complications Internal Globus Pallidus Ventral Intermediate Nucleus of the Thalamus Subthalamic Nucleus Avoiding Complications Preoperative Evaluation Anesthetic Considerations Operative Measures Conclusion 115 - Neurophysiologic Monitoring for Movement Disorder Surgery Neurophysiologic Monitoring for Movement Disorder Surgery General Overview of Surgery Microelectrode Techniques Local Field Potentials General Stereotactic Technique Internal Globus Pallidus Procedures Ventrolateral Intramedial Nucleus Procedures Subthalamic Nucleus Procedures Data Analysis Conclusion 116 - Emerging and Experimental Neurosurgical Treatments for Parkinson’s Disease Emerging and Experimental Neurosurgical Treatments for Parkinson’s Disease Scientific Background Refinements in the Understanding of Mechanisms and Anatomic Targets for Electrical Stimulation Advances in Neurostimulation Technology for Deep Brain Stimulation Adaptive or Closed-loop Deep Brain Stimulation Directional Leads Improved Analysis Software and Automation of Device Programming Patient-Facing Interfaces Wireless Software Upgrades Wireless Recharging Magnetic Resonance Imaging Compatibility Image-Guided Ultrasound Lesioning Techniques for the Treatment of Parkinson’s Disease Transplantation of Fetal Neurons for the Treatment of Parkinson’s Disease Stem Cell Therapies for Parkinson’s Disease Progress in Gene Therapy for the Treatment of Parkinson’s Disease Conclusions 118 - Selective Peripheral Denervation for Cervical Dystonia Selective Peripheral Denervation for Cervical Dystonia Evolution of Surgical Techniques Selective Peripheral Denervation: Indications and Patient Selection Operative Techniques Denervation of the Sternocleidomastoid Muscle Posterior Ramisectomy Myotomy and Partial Myectomy Technique Variants and Combined Techniques Clinical Outcome: Results and Side Effects Future Concepts 119 - Thalamotomy for Focal Hand Dystonia Thalamotomy for Focal Hand Dystonia Diagnosis of Focal Hand Dystonia Rating of Focal Hand Dystonia eAppendix 119.1 Writer’s Cramp Rating Scale (WCRS) Part A: Writing Movement Score Part B: Writing Speed eAppendix 119.2 Indication for Surgery Surgical Technique eAPPENDIX 119.3 Arm Dystonia Disability Scale (ADDS) Results Complications Surgical Anatomy of the Ventro-oral Nucleus Discussion Conclusion 120 - History and Ethical Considerations in Functional Neurosurgery The Early Days of Functional Neurosurgery: Psychosurgery A History of Surgery for Movement Disorders A History of Stereotactic Neurosurgery Ethical Considerations in Functional Neurosurgery Informed Consent Beneficence and Nonmaleficence Respect for Autonomy Privacy Justice Conclusions 121 - Surgery for Tourette Syndrome Pathophysiology Diagnostics Treatment Noninvasive Treatment Options Surgical Treatment Lesions Deep Brain Stimulation Thalamus Globus Pallidus Internus Globus Pallidus Externus Internal Capsule/Nucleus Accumbens Subthalamic Nucleus Patient Selection and Ethical Considerations Surgical Technique Conclusions And Future Directions 122 - Surgery for Obsessive-Compulsive Disorder Introduction History of Psychosurgery Neural Circuits and Pathophysiology Patient Selection, and Team Approach Surgical Management of Obsessive-Compulsive Disorder Stereotactic Ablation Procedures Anterior Cingulotomy Stereotactic Anterior Capsulotomy Stereotactic Subcaudate Tractotomy Stereotactic Limbic Leucotomy High-Intensity Focused Ultrasound Lesioning Therapeutic Option Deep Brain Stimulation Anterior Limb of Internal Capsule Ventral Capsule and Ventral Striatum Bed Nucleus of the Stria Terminalis Nucleus Accumbens Subthalamic Nucleus Inferior Thalamic Peduncle Globus Pallidus Interna Vagus Nerve Stimulation Conclusion 123 - Surgery for Major Depressive Disorder Diagnosis and Treatment Circuitry of Mood and Depression Surgery for Major Depressive Disorder Nucleus Accumbens Subcallosal Cingulate Cortex Anterior Limb of the Internal Capsule Medial Forebrain Bundle The Ablative Experience Anterior Cingulotomy Subcaudate Tractotomy Limbic Leucotomy Anterior Capsulotomy Deep Brain Stimulation Subcallosal Cingulate Cortex Nucleus Accumbens/Ventral Striatum Inferior Thalamic Peduncle and Habenula Medial Forebrain Bundle Future Directions 124 - Surgery for Anorexia Nervosa Severe and Enduring Anorexia Nervosa Etiopathology and Neurocircuitry of Anorexia Nervosa Surgery for Anorexia Nervosa Genetics of Anorexia Nervosa Structural Alterations in Anorexia Nervosa Functional Alterations in Anorexia Nervosa Endophenotypes and Related Functional Brain Areas Serotonergic System and Emotion in Anorexia Nervosa Dopaminergic System and Reward in Anorexia Nervosa Other Neurocircuitries Implicated in Anorexia Nervosa Perspective Nonsurgical Management of Anorexia Nervosa Surgical Management of Anorexia Nervosa Overview Deep Brain Stimulation Stereotactic Ablation The Choice Between Deep Brain Stimulation and Stereotactic Ablation Grading of Anorexia Nervosa and Surgical Options Grading of Anorexia Nervosa According to Clinical Features Selection of Surgical Treatment Indications and Patient Selection Criteria Treatment History Clinical Indications Exclusion Criteria Perioperative Patient Management Preoperative Management Intraoperative Management Postoperative Management Adverse Events Associated with Surgery for Anorexia Nervosa Ablation-related Complications Deep Brain Stimulation–related Complications Other Postoperative Complications Conclusion and Perspective 125 - Surgery and Neuroscience of Addiction Epidemiology of Addiction Methods for Circuit Mapping in Animal Models of Addiction Optogenetics Chemogenetics Magnetogenetics Sonogenetics Animal Models of Addiction Cocaine Drug Self-Administration Cocaine-induced Locomotor Activity Conditioned Place Preference Alcohol Opiates Biologic and Anatomic Pathways Mediating Addictive Responses in the Brain Anatomy of Addiction Dopamine Signaling and DARPP-32 DeltaFosB p11 Neurosurgical Interventions for Addiction Summary 126 - Lesioning Surgery for Spasticity Peripheral Neurotomies Surgical Principles Preoperative Motor Blocks Anesthesia Electrophysiologic Mapping Sectioning Surgical Techniques Surgery on the Lower Limb Hamstring Neurotomy for the Knee. Hamstring neurotomy (Fig. 126.5) is indicated to counterflex deformity of the knees. Branches ... Tibial Neurotomy for the Foot. Tibial neurotomy (Fig. 126.6) is for the equinovarus spastic foot, with or without dystonic claw ... Anterior Tibial Neurotomy for the Extensor Hallucis. This procedure is indicated for permanent extension of the hallux (“forced”... Femoral Neurotomy for the Quadriceps. Femoral neurotomy (Fig. 126.7) is indicated to treat excessive spasticity of the quadricep... Musculocutaneous Neurotomy for the Elbow. Neurotomy of the musculocutaneous nerve (Fig. 126.8) is indicated for spasticity of th... Median Neurotomy for the Wrist and Fingers. Neurotomy of the median nerve (Fig. 126.9) is indicated for spasticity of the forear... Ulnar Neurotomy for the Wrist and Fingers. Neurotomy of the ulnar nerve (Fig. 126.10) is also indicated for spasticity of the wr... Complications and Recurrence of Symptoms Surgery on the Spinal Roots, Dorsal Root Entry Zone, and Spinal Cord History Surgical Techniques Dorsal Rhizotomies Lesioning at the Dorsal Root Entry Zone Orthopedic Surgery Other Methods Patient Selection Treating Spasticity in Adults Treating Spasticity in Children Conclusion 127 - Management of Spasticity by Central Nervous System Infusion Techniques Physiologic Basis of Spasticity Management of Spasticity by Central Nervous System Infusion Techniques Mechanisms Underlying Reflex Function Ia Monosynaptic Connection Ia Excitatory Polysynaptic Pathways Reciprocal Ia Inhibition Group II Pathways Decreased Recurrent Inhibition Alpha Motoneuron Hyperexcitability Gamma Motoneuron Hyperactivity Decreased Ib Inhibition Summary of Mechanisms Why Do Spinal Circuits Malfunction Abnormal Descending Control Local Changes at the Spinal Level Changes in Muscle Fiber and Connective Tissue Measurement of Spasticity Clinical Evaluation Passive Quantifiable Evaluations Active Quantifiable Evaluations Measurement of Spasms Treatment of Spasticity Intrathecal Baclofen Physiologic Effects of Baclofen Kinetics and Distribution of Intrathecal Baclofen Efficacy of Intrathecal Baclofen for Spinal Spasticity Drug Side Effects Delivery Systems Patient Selection 128 - Treatment of Intractable Vertigo Classification of Vestibular Disorders Nonsurgical Management of Vertigo Surgical Management of Intractable Vertigo Conclusion Treatment of Intractable Vertigo Classification of Vestibular Disorders Central Vestibular Disorders Vertebrobasilar Insufficiency Migrainous Vertigo Tumors Paraneoplastic Syndromes Demyelinating Disorders Peripheral Vestibular Disorders Benign Paroxysmal Positional Vertigo Meniere Disease Labyrinthitis Vestibular Neuritis Perilymphatic Fistula Superior Semicircular Canal Dehiscence Syndrome Trauma Nonsurgical Management of Vertigo Vestibular Rehabilitation Canalith Repositioning Maneuvers Pharmacologic Therapy Surgical Management of Intractable Vertigo Surgery for Benign Paroxysmal Positional Vertigo Singular Neurectomy Posterior Semicircular Canal Occlusion Surgery for Superior Semicircular Canal Dehiscence Syndrome Surgery for Perilymphatic Fistula Surgery for Meniere Disease Intratympanic Injection of Dexamethasone and Gentamicin Meniett Device Endolymphatic Sac Surgery Endolymphatic Duct Blockage Vestibular Ablative Surgery Considerations for Ablative Surgery. Careful selection of patients for vestibular ablative surgery is absolutely central to secu... Labyrinthectomy.Although labyrinthectomy was commonly used for treating suppurative labyrinthitis in the late 1800s, the first l... Vestibular Nerve Section. The first sectioning of the eighth cranial nerve in a patient with vertigo was performed by Parry in t... Middle Fossa Vestibular Neurectomy. In the 1960s, House proposed an extradural approach to the internal auditory canal in which ... Retrolabyrinthine Vestibular Neurectomy. In light of the technical difficulties associated with MFVN, a posterior fossa approach... Retrosigmoid Vestibular Neurectomy. Dandy and McKenzie developed RSVN in the 1930s. The procedure entails a posterior fossa cran... Combined Retrosigmoid–Internal Auditory Canal/Retrolabyrinthine Vestibular Neurectomy. In the late 1980s, Silverstein and collea... Endoscopically Assisted Vestibular Neurectomy. Endoscopic selective vestibular neurectomy is one of the latest additions to the ... 129 - Motor Cortex Stimulation for Pain and Movement Disorders Introduction Methods: Surgical and Cortical Mapping Technique Discussion Clinical Results 130 - Deep Brain Stimulation for Obesity Anatomy Lateral Hypothalamus Ventromedial Hypothalamus Nucleus Accumbens Deep Brain Stimulation Theory Animal Studies Lateral Hypothalamus Ventromedial Hypothalamus Nucleus Accumbens Human Studies Ethics of Deep Brain Stimulation for Obesity Summary 131 - Deep Brain Stimulation for Alzheimer Disease Introduction History of Surgical Intervention for Alzheimer Disease Pathologic Process in Alzheimer Disease Functional Disconnection of Structurally Preserved Brain Regions Surgical Trials in Alzheimer Disease Deep Brain Stimulation of the Fornix Surgical Technique of Fornix Deep Brain Stimulation Rationale for Fornix Neuromodulation in Alzheimer Disease Recruiting the Functionally Disconnected Regions. The rationale for fornix-DBS in AD is to activate dysfunctional memory network... Preclinical Studies of Neuromodulation of Memory Network in Rodents. Hescham and associates38 performed bilateral fornix-DBS in ... Potential Mechanisms Underlying the Effect of Fornix–Deep Brain Stimulation Cerebral Activation. In the phase 1 trial of fornix-DBS, the topography of cerebral activation was studied with standardized low... Effect on Hippocampal Oscillations. The electrical stimulation of memory networks may also influence hippocampal oscillations, e... Deep Brain Stimulation of the Nucleus Basalis of Meynert Deep Brain Stimulation of the Nucleus Basalis of Meynert for Other Types of Dementias Conclusion and Future Directions 132 - Neuroprosthetics Interface Modalities Electroencephalography Intraparenchymal Electrodes Electrocorticography Spinal Cord Stimulation Peripheral Nerve Interfaces Somatosensory Speech Stroke Cochlear Implant Industry Involvement Conclusion 133 - Brain Tumors: An Overview of Current Histopathologic and Genetic Classifications Astrocytomas Diffuse Astrocytomas Circumscribed Astrocytomas Oligodendroglial Tumors Ependymal Tumors Choroid Plexus Tumors Other Neuroepithelial Tumors Neuronal and Mixed Neuronal-Glial Tumors Pineal Region Tumors Germ Cell Tumors Embryonal Tumors Tumors of the Meninges Tumors of the Sellar Region (Excluding Pituitary Adenoma) Lymphoma Metastatic Tumors of the Central Nervous System Intraoperative Consultation (Frozen Section) in Neuro-Oncology 134 - Brain Tumor Immunology and Immunotherapy Introduction to Brain Tumor Immunology and Immunotherapy Antigen-Driven Therapies Peptide Vaccines Heat Shock Proteins and Dendritic Cells Chimeric Antigen Receptor T Cells Immune-Checkpoint Inhibitors Nonreplicative Viral Therapies Oncolytic Viruses Adenoviruses Poliovirus Summary 135 - Brain Tumor Stem Cells: Francesco DiMeco, Alessandro Perin, Donatella Sgubin, and Alfredo Quiñones-Hinojosa The Neurosphere Assay and the Discovery of Adult Neurogenesis Development of the Brain Tumor Stem Cell Hypothesis Markers for Neural Stem Cells and Brain Tumor Stem Cells Brain Tumor Stem Cell of Origin Molecular Pathways Altered in Brain Tumor Stem Cells Clinical Implications and Future Directions Conclusion 136 - Molecular Genetics and the Development of Targets for Glioma Therapy Detecting Molecular Alterations in Cancer Molecular Genetics and the Development of Targets for Glioma Therapy Polymerase Chain Reaction DNA Sequencing Whole-genome DNA Sequencing Next-generation Platforms for Whole-genome DNA Sequencing. To improve the speed and accuracy of DNA sequencing, new technologies... Whole-exome Sequencing RNA Sequencing Single-cell RNA Sequencing Chromatin Immunoprecipitation Sequencing Fluorescence in Situ Hybridization Comparative Genomic Hybridization Assays and Copy Number Alterations Single Nucleotide Polymorphism Genotyping Assays Gene Expression Assays: Complementary DNA Arrays, MicroRNA Arrays, and Proteomics Whole-genome Methylation Profiling Glioma Analysis Using Molecular Tools The Cancer Genome Atlas and Repository for Molecular Brain Neoplasia Data Results From Human Glioma Analysis Copy Number Alterations Somatic Mutations Neurofibromatosis 1. Somatic mutations to the loci coding NF1, the gene for neurofibromatosis 1, were detected in 23% of tumor s... Phosphatidylinositol 3-Kinase. Members of the phosphatidylinositol-3-kinase (PI3K) gene complex, such as PI3K catalytic alpha (P... Retinoblastoma. Tumor analyses demonstrated that 77% of GBMs have alterations in the retinoblastoma gene (RB1) tumor suppressor ... TP53. Finally, the most common event that resulted in inactivation of the p53 pathway was alternative reading frame (ARF) deleti... Genomic Alteration–driven Clonal Evolution During Treatment Oncoscape: Visualizing Molecular Information During Clinical Decision Making Models for Evaluating Molecular Alterations in Glioma In Vitro Models DNA Construction and Gene Expression in Vitro Transfection and Transduction Patient-specific Glioma Organoids In Vivo Models Transgenic Mice Knockout Mice Somatic Cell Gene Transfer Bilateral Tumor Model for Abscopal Response Targeted Therapy for Glioma: Progress and Failures Receptor Tyrosine Kinase Inhibitor Therapies O6-Methylguanine-DNA Methyltransferase and Temozolomide Metabolism and IDH1 Mutations Genome Editing Clinical Research: Designing Effective Clinical Trials Based on Molecular Targets in Gliomas Conclusion 137 - The Genetic Origins of Brain Cancers Clonal Expansion of Malignant Tumors Inherited Mutations and Familial Syndromes The Genetic Origins of Brain Cancers Tumor Suppressors, Oncogenes, and Mutator Genes Different Types of DNA Mutations and Alterations The Spectrum of Mutations That Underlie Brain Cancers Glioblastomas Other Gliomas Medulloblastomas Perspectives in Brain Tumor Genomics and Genetics 139 - Basic Science of Brain Metastases Diagnosis of Brain Metastases Cancer Type and Propensity of Brain Metastasis Lung Cancer Breast Cancer Melanoma Theories of Metastasis The Paget Seed and Soil Hypothesis Cloned Evolution Theory Versus Cancer Stem Cell Theory Epithelial-Mesenchymal Transition Theory Anatomic Avenues for Dissemination Seeding Through the Blood-Brain Barrier Seeding Through the Cerebrospinal Fluid Barrier and the Blood–Cerebrospinal Fluid Barrier Pachymeningeal Seeding Post–Neurosurgical Resection Spinal Metastasis Barriers to Entry Role of Neural Input in Tumorigenesis and Metastasis The Role of Semaphorins in Tumorigenesis Neurotransmitters/Neurotrophins and Cancer Progression Molecular Considerations for Metastasis Role of Microenvironment in Metastatic Niche Formation Microglial Contribution to Brain Metastasis Tumor-induced Changes to the Microenvironment Tumor Dormancy Preparation for Flight Brain Colonization and Tumor Outgrowth Therapeutic Perspectives in Brain Metastases Classical Approaches Use of Immunotherapy in Treating Brain Metastasis 140 - Angiogenesis and Brain Tumors: Scientific Principles, Current Therapy, and Future Directions Angiogenesis and Brain Tumors: Scientific Principles, Current Therapy, and Future Directions Historical Perspective Angiotherapy: A Novel Approach To Glioma Therapy Mechanisms of Tumor Angiogenesis Angiogenic Switch Normalization Hypothesis and the Normalization Window Vascular Niche and Glioma Progenitor/Stem Cells Enhanced Immune Surveillance and Tumor Immunity Reduction of Vasogenic Edema, Radioprotection, and Radiosensitization Clinical Experience With the Use of Bevacizumab Bevacizumab Resistance and Glioma Recurrence The Role of Anti-Vegf Therapy For Other CNS Tumors Recurrent Oligodendrogliomas Acoustic Neuromas Meningiomas Pituitary Adenomas and Carcinomas Brain Metastases Pediatric Brain Tumors Current Trends and Future Directions Conclusion Online Resources of Angiogenesis in Brain Tumors 141 - Delivery of Therapy to Brain Tumors: Problems and Potentials The Blood-Brain Barrier Delivery of Therapy to Brain Tumors: Problems and Potentials The Blood-Tumor Barrier The Blood–Cerebrospinal Fluid Barrier Drug Modifications For Enhanced Drug Delivery to Brain Tumors Lipophilic Analogues Prodrugs Antibody- and Gene-directed Enzyme Prodrug Therapy Receptor- and Vector-mediated Drug Targeting Barrier Disruption Barrier Disruption Strategies for Enhancing Drug Delivery Osmotic Disruption of the Blood-Brain Barrier Biochemical Disruption of the Blood-Brain Barrier Ultrasound-mediated Disruption of the Blood-Brain Barrier Hyperthermia-induced Blood-Brain Barrier Disruption Direct Delivery to the Brain Methods for Direct Delivery of Drugs to the Brain Parenchyma Implanted Polymers Intracavitary Delivery Systems Convection-enhanced Delivery Novel Devices Designed to Optimize Convection-enhanced Delivery Other Approaches For Enhancing Drug Delivery to the Brain Intraventricular/Intrathecal Drug Delivery Intra-arterial Therapy Liposomal Drug Encapsulation Nanoparticulate Systems Magnetic Microspheres Conclusion 142 - Epidemiology of Brain Tumors Descriptive Epidemiology Survival and Prognostic Factors for Glioma and Meningioma Glioma Meningioma Genetic Risk Factors Glioma Meningioma Telomere Biology Environmental and Developmental Risk Factors in Glioma and Meningioma Ionizing Radiation Allergic Conditions and Associated Immunologic Factors Other Environmental Factors Conclusion 143 - Clinical Features: Neurology of Brain Tumor and Paraneoplastic Disorders Basis for Neurological Dysfunction in Patients with Malignancies of the Nervous Systems Presenting Symptoms of Central Nervous System Malignancies Headaches Seizures Cognitive Dysfunction Psychological, Behavioral and Psychiatric Symptoms Focal Symptoms of Brain Tumors and Treatment Effects Motor Dysfunction Vision Changes Hearing Impairment Speech and Language Disturbances Gait Disturbance Patient-Reported Symptoms as End Points for Clinical Trials Paraneoplastic Syndromes Paraneoplastic Cerebellar Degeneration Limbic Encephalitis and Encephalomyelitis Subacute Sensory Neuronopathy Opsoclonus and Myoclonus Lambert-Eaton Myasthenic Syndrome Polymyositis and Dermatomyositis Summary and Conclusion 144 - Radiologic Features of Central Nervous System Tumors Mass Effect Tumor Locations: Intra-Axial Versus Extra-Axial Brain Tumors Radiologic Features of Central Nervous System Tumors Lesional and Perilesional Imaging Features of Brain Tumors Tumor Permeability Perilesional Edema Tumor Vascularity Tumor Cellularity Tumor Necrosis Tumor-Associated Cysts Calcifications Metabolic Imaging of Tumor by Magnetic Resonance Spectroscopy Positron Emission Tomography Imaging Characteristics of Brain Tumors Based on Anatomic Location Extra-Axial Masses Meningioma Schwannoma Pineal Region Tumors Tumors of Germ Cell Origin Pineal Cell Tumors Sellar and Suprasellar Lesions Intraventricular Masses Choroid Plexus Papilloma Ependymoma Subependymomas Neurocytomas Other Intraventricular Lesions Intra-Axial Neoplasms Infiltrating Gliomas Astrocytic Tumors Oligodendroglioma Brainstem Glioma Pilocytic Astrocytoma Lymphoma Metastasis Glioneuronal Tumors. Glioneuronal tumors contain neoplastic cells arising from neuronal elements with varying degrees of astrocy... Pleomorphic Xanthoastrocytoma. Pleomorphic xantho­as­trocytomas are commonly located in the cortical locations of the frontal an... Primitive Neuroectodermal Tumors. The PNET cell line (formerly medulloblastomas, ependymoblastomas, pineoblastomas, and primary ... Atypical Teratoid/Rhabdoid Tumors. Atypical teratoid/rhabdoid tumors (ATRTs) occur predominantly in very young children (prescho... Dysembryoplastic Neuroepithelial Tumors. DNETs are hypodense on CT images, hypointense on T1-weighted images, and hyperintense o... Desmoplastic Infantile Ganglioglioma. As its name implies, DIG is usually seen in the first 2 years of life. The tumors typicall... Subependymal Giant Cell Astrocytomas. Subependymal giant cell astrocytomas almost always occur in the setting of tuberous sclero... Presurgical Planning Blood Oxygen Level–Dependent Functional MRI Diffusion Tensor Imaging and Tractography Postoperative Imaging Therapeutic Monitoring Radiation Injury Tumor Progression Versus Radiation Necrosis or Pseudoprogression Conclusion 145 - Endovascular Techniques for Tumor Embolization Background and Indications Rationale and Evidence Principles and Techniques Embolic Agents Liquid Embolics Sclerosing Agents Particulates Coils General Rules When Using Embolic Agents Anatomic Considerations Timing Complication Avoidance Indications for Tumor Embolization Meningioma Other Tumors of the Skull and Face Presurgical Artery Deconstruction Spinal Tumor Embolization Endovascular Delivery of Chemotherapy Conclusion 146 - Genetic Syndromes of Brain Tumors Neurofibromatosis Type 1 Clinical Criteria Central Nervous System Tumors Management of NF1 Brain Tumors Neurofibromatosis Type 2 Clinical Criteria Central Nervous System Tumors Management Tuberous Sclerosis COMPLEX Central Nervous System Tumors Management Von Hippel-Lindau Disease Central Nervous System Tumors Management Li-Fraumeni Syndrome Cowden Disease Conclusion 147 - Principles of Chemotherapy Introduction Basic Concepts Cellular Kinetics Tumor Kinetics Mechanisms of Drug Resistance Concepts in Chemotherapy Dose Intensification Adjuvant Chemotherapy Neoadjuvant Chemotherapy Combination Chemotherapy Delivery of Chemotherapy to the Brain Factors Influencing Drug Delivery Approaches to Overcome Barriers Methods to Increase Drug Delivery Methods to Circumvent the Blood-Brain Barrier Chemotherapeutic Agents in Central Nervous System Tumors Alkylating Agents Antimetabolites Topoisomerase Inhibitors Microtubule Agents Conclusion 148 - Brain Tumor Outcome Studies: Design and Interpretation Brain Tumor Outcome Studies: Design and Interpretation Defining the Patient Population Age Histology Composite Baseline Risk Scores: Recursive Partitioning Analysis and Others Other Factors Describing Treatment: Extent of Resection Describing Outcomes of Brain Tumor Therapy: End Point Choices and Definitions End Points for Cancer Studies Survival, Operative Mortality, and Disease-Specific Mortality Progression-Free Survival, Time to Progression, and Time to Treatment Failure Other Time-Dependent End Points Quality of Life, Functional Status, and Measures of Symptoms Tumor Response Rate Special Considerations in Specific Phases of Drug or Technology Testing Early Phase of Development Studies (Phase 1, Phase 2, Phase 0) Phase 3 Clinical Trials Special Considerations in Specific Types of Brain Tumor Study Design Extent of Surgical Resection as a Prognostic Factor for Survival Studies on Technological Adjuncts for Improving Extent of Resection Analysis of Survival in Recurrent Tumor Studies Cause-Specific Survival in Metastatic Tumor Studies Health Services Research: Volume-Outcome and Disparities Studies 149 - Neurocognition in Brain Tumor Patients Cognitive Function in Brain Tumor Patients Cognition as a Major Outcome Measure Cognitive Function as a Predictor of Survival Cognition as a Component of Quality-of-Life Assessment Methodology for Assessing Cognitive Function Specific Causes of Cognitive Dysfunction in Brain Tumor Patients Tumor Effect Treatment Effect Surgery Radiation Therapy Corticosteroids. Dexamethasone is the most common cortico­steroid prescribed to patients with brain tumors and is associated wit... Chemotherapy. The potential detrimental effects of chemo­ther­apy on concentration and short-term memory have been described in ... Cognitive Preservation in Brain Tumor Patients Surgical Approaches for Cognitive Preservation Advanced Radiotherapy Techniques Medical Treatment for Cognitive Impairment Specific Types of Tumors and Cognitive Impairment Glioblastoma Low-Grade Glioma Brain Metastases Summary 151 - Basic Principles of Cranial Surgery for Brain Tumors Basic Principles of Cranial Surgery for Brain Tumors Preoperative Evaluation And Management Preoperative Imaging Interpretation Timing of Surgery Surgical Planning: Imaging Studies Surgical Preparation Positioning Incision Craniotomies Frontotemporal Parieto-occipital Parasagittal Midline Cerebellar Lateral Cerebellar Tumor Removal Postoperative Care Conclusion 152 - Basic Principles of Skull Base Surgery History of Endoscopic Skull Base Surgery Basic Principles of Skull Base Surgery Overview of Skull Base Surgery Preoperative Surgical Planning Preoperative Neurological Examination Preoperative Risk Evaluation and Preparation Preoperative Imaging Computed Tomography and Magnetic Resonance Imaging Preoperative Angiography Surgery Timing Operative Considerations and Approach Selection Approach Selection Pterional Approach Subfrontal Approach Transpetrosal Approaches Retrosigmoid Suboccipital Approach Transsphenoidal Endoscopic Approach Anesthetic Considerations Airway Positioning Neuroprotection and Neuromonitoring Considerations Tumor Resection The Role of Spinal Fluid Diversion in Skull Base Surgery Intraoperative Navigation and Intraoperative Magnetic Resonance Imaging Neuroendoscopy Extent of Surgical Resection and Role of Radiation Therapy Complication Avoidance and Management Reconstruction Strategies Local Flaps Pedicled Myocutaneous Flaps Free Flap Transfers Spinal Fluid Leak Repair Venous Injury and Reconstruction 153 - Risks of Intrinsic Brain Tumor Surgery and Avoidance of Complications Defining a Complication Classification Schemes Patient Selection and Avoidance of Complications Neurological Complications Minimally Invasive Stereotactic Biopsy Procedures for High-Risk Tumor Patients Inadvertent Injury to Functionally Relevant Normal Brain Structures Brain Edema Injury to Vascular Structures Postoperative Hematomas Regional Complications Systemic Complications Mortality Associated With Brain Tumor Surgery Conclusion 154 - Surgical Navigation for Brain Tumors Historical Aspects Surgical Navigation for Brain Tumors Role of Neuronavigation in Brain Tumor Surgery Craniotomy Minimal and Optimal Access Craniotomies Relationship to Critical Brain and Preservation of Function Use of Diffusion Tensor Imaging in Tumor Resection Use of Functional Magnetic Resonance Imaging in Tumor Resection Guidance to Subcortical Lesions Robotic Neurosurgery Brain Shift and its Impact on Neuronavigation Intraoperative Ultrasonography in Tumor Resection Use of Intraoperative Magnetic Resonance Imaging in Tumor Resection Role of Neuronavigation in Laser Interstitial Thermal Therapy Role of Neuronavigation in Fluorescence-guided Resection How it Works Imaging and Fiducials Registration Tracking Display Patient Head Movement Nuances in Using Navigation for Intraoperative Resection Control Future Applications 155 - Endoscopic Approaches to Brain Tumors General Principles of Neuroendoscopy Endoscope-Assisted Surgery in Transcranial Approaches Endoscopic Endonasal Approaches to Sellar and Skull Base Tumors Endoscopic Management of Intraventricular Tumors Conclusion 156 - Awake Craniotomy and Intraoperative Mapping Preoperative Mapping of Function Neuropsychological Assessment Awake Intraoperative Mapping Techniques Neuroanesthesia Sensorimotor Mapping Functional Magnetic Resonance Imaging Magnetoencephalography Transcranial Magnetic Stimulation Diffusion Tensor Imaging Supplementary Motor Area Language Visual Pathways Spatial Cognition Calculation Judgment Mentalization Neural Plasticity Functional Outcomes Conclusions 157A - Intraoperative Magnetic Resonance Imaging Pediatric Brain Tumors Downsides Intraoperative Magnetic Resonance Imaging Future Directions 157B - Fluorescence-guided Brain Tumor Surgery Fluorescence-guided Brain Tumor Surgery Fluorophores and Glioma Fluorescence-Guided Surgery 5-Aminolevulinc Acid 5- Aminolevulinic Acid for High-grade Gliomas 5-Aminolevulinic Acid for Recurrent High-grade Gliomas 5-Aminolevulinic Acid for Low-grade Gliomas Fluorescein Fluorescein Fluorescence-guided Surgery for High-grade Gliomas Limitations of Fluorescein Fluorescence-guided Surgery Indocyanine Green Limitations of Indocyanine Green Fluorescence-guided Surgery Fluorescence-Guided Surgery for Nonglial Tumors Meningioma Cerebral Metastasis Pediatric Brain Tumors Pituitary Adenomas and Vestibular Schwannomas Spinal Cord Intramedullary Tumors Primary Central Nervous System Lymphomas and Stereotactic Biopsy Targeted Fluorophores BLZ-100 Fluorescence-Guided Surgery Tumor-Targeted Alkylphosphocholine Analogues Fluorescence-Guided Surgery Cetuximab-IRDye 800 EC17 and OTL38 Fluorescence Visualization Technologies Wide-field Surgical Microscopy Wide-field Fluorescence Endoscopy Quantitative Spectroscopy Probe-based Confocal Microscopy Conclusions and Future Directions 158 - Low-Grade Gliomas: Diffuse Astrocytoma and Oligodendroglioma Introduction and Epidemiology Clinical Presentation Conventional and Emerging Neuroimaging Histologic Features of Diffuse Low-Grade Gliomas Diffuse Astrocytoma Oligodendroglioma Immunohistochemical Assessment of Diffuse Low-Grade Gliomas Molecular Pathogenesis and Integrated Diagnosis of Diffuse Low-Grade Gliomas Diffuse Astrocytoma, IDH-mutant (WHO Grade II) Oligodendroglioma, IDH-Mutant and 1p/19q Co-deleted (WHO Grade II) Diffuse Astrocytic Glioma, IDH Wild-type, With Molecular Features of Glioblastoma (cIMPACT-NOW Recommendation as Grade IV Design... Diffuse Midline Glioma, H3 K27M-mutant (WHO Grade IV) Diffuse Glioma, MYB/MYBL1-Altered (No Grade Designation Yet) Management and Survival Surgical Resection Chemotherapy Radiotherapy Conclusion 159 - Malignant Gliomas: Anaplastic Astrocytoma, Glioblastoma, Gliosarcoma, and Anaplastic Oligodendroglioma Introduction Malignant Astrocytomas Epidemiology Anaplastic Astrocytoma and Glioblastoma Gliosarcoma Clinical Manifestations Anaplastic Astrocytoma and Glioblastoma Gliosarcoma Histopathology and Molecular Biology Anaplastic Astrocytoma and Glioblastoma Role of Stem Cells in Pathogenesis and Resistance to Therapy The 2016 World Health Organization CNS Classification Gliosarcoma Neuroimaging Studies Anaplastic Astrocytoma and Glioblastoma Gliosarcomas Management General Medical Management Surgery Influence of Extent of Resection on Clinical Outcomes. To date, there have been four systematic reviews of the influence of the ... Radiation Therapy and Chemotherapy for Anaplastic Astrocytoma and Glioblastoma Gliosarcoma Patient Outcome and Survival Gliomatosis Cerebri Anaplastic Oligodendrogliomas Epidemiology Clinical Manifestations Histopathology Neuroimaging Management Surgery Radiation Therapy Chemotherapy Summary of Management Patient Outcome and Survival Prognostic Factors Controversies and Future Directions for Anaplastic Oligodendroglioma Midline Gliomas Epidemiology Clinical Manifestations Neuroimaging Histopathology Management Patient Outcome and Survival Future Directions for Malignant Gliomas 160 - Radiologic and Clinical Criteria of Treatment Response Radiologic and Clinical Criteria of Treatment Response Findings in the Imaging of Brain Tumors are Nonspecific The Response Assessment in Neuro-Oncology Criteria Drugs Interfering With Contrast Uptake on Imaging Imaging Nonenhancing Tumors Postsurgical Imaging Clinical Assessment of Tumor Response and Nonsurvival End Points Some Practical Considerations on Brain Tumor Outcome Assessment 161 - Unusual Gliomas Subependymal Giant Cell Astrocytoma Clinical Presentation and History Imaging Pathology Management and Outcome Angiocentric Glioma Clinical Presentation and History Imaging Pathology Management and Outcome Astroblastoma Clinical Presentation and History Imaging Pathology Management and Outcome Pilomyxoid Astrocytoma Clinical Presentation and History Imaging Pathology Management and Outcome Pleomorphic Xanthoastrocytoma Clinical Presentation and History Imaging Pathology Management and Outcome Ganglioglioma Clinical Presentation and History Imaging Pathology Management and Outcome Papillary Tumor of the Pineal Region Clinical Presentation and History Imaging Pathology Management and Outcome Dysembryoplastic Neuroepithelial Tumor Clinical Presentation and History Imaging Pathology Management and Outcome Chordoid Glioma of the Third Ventricle Clinical Presentation and History Imaging Pathology Management and Outcome Papillary Glioneuronal Tumor Clinical Presentation and History Imaging Pathology Management and Outcome Diffuse Leptomeningeal Glioneuronal Tumor Clinical Presentation and History Imaging Pathology Management and Outcome Conclusion 162 - Local Therapies for Gliomas Introduction Local Therapies for Gliomas Blood-Brain Barrier Disruption General Features Technologic Application Advantages and Limitations Clinical Application Selective Intra-arterial Chemotherapeutic Delivery General Features Technologic Application Advantages and Limitations Clinical Application Intrathecal and Intraventricular Administration General Features Technologic Application Advantages and Limitations Clinical Applications Drug-Impregnated Biopolymers General Features Technologic Application Advantages and Limitations Clinical Applications Convection-Enhanced Delivery General Features Technologic Application Advantages and Limitations Clinical Applications Direct Injection General Properties Technologic Application Advantages and Limitations Clinical Application Other Techniques Hyperthermia Conclusion 163 - Central Nervous System Embryonal Tumors Incidence Pathology Central Nervous System Embryonal Tumors Clinical Evaluation Signs and Symptoms Radiographic Evaluation Treatment Management of Hydrocephalus Tumor Removal Complications Outcomes and Adjuvant Therapy Conclusion 164 - Pineal Tumors Anatomy Pineal Tumors Pathology Clinical Features Initial Symptoms Diagnosis Tumor Markers Treatment Management of Hydrocephalus Tissue Diagnosis: Biopsy Versus Open Resection Surgical Techniques Stereotactic Procedures Endoscopic Biopsy Open Surgical Procedure Considerations Patient Positioning Sitting Position Lateral and Three-Quarter Prone Position Prone Position Operative Approaches Supracerebellar Infratentorial Approach Lateral Supracerebellar Infratentorial Interhemispheric Transcallosal Approach Occipital Transtentorial Approach Transcortical Transventricular Approach Postoperative Care Complications Surgical Outcome Postoperative Workup Outcomes and Follow-Up Care Based on Pathology Benign Pineal Region Tumors Glial Tumors Papillary Tumor of the Pineal Region Pineal Parenchymal Tumors Germ Cell Tumors Conclusion 165 - Medulloblastomas in Adults Clinical Presentation Diagnostic Investigations Histologic and Molecular Classification Medulloblastomas in Adults Staging and Risk Stratification Treatment Surgery Radiation Therapy Chemotherapy Prognosis and Follow-up Future Perspectives 166 - Intracranial Ependymomas in Adults Introduction Pathology and Molecular Characteristics Clinical Presentation Imaging Staging Treatment Surgical Treatment Radiation Therapy and Chemotherapy Prognosis 167 - Hemangioblastomas Imaging Findings Clinical Findings Peritumoral Cyst Formation Hemangioblastomas Von Hippel-Lindau Disease Natural History General Pregnancy Pathologic Findings Pathogenesis Management Von Hippel-Lindau Disease–Related Versus Sporadic Hemangioblastomas Screening for von Hippel-Lindau Disease Systemic Therapy Surgical Resection Preoperative Embolization Radiation Therapy Surgical Technique Cerebellar Hemangioblastomas Spinal Cord Hemangioblastomas Brainstem Hemangioblastomas Conclusion 168 - Primary Central Nervous System Lymphomas Introduction Epidemiology Pathobiology Clinical Manifestations Diagnosis Treatment Newly Diagnosed Primary Central Nervous System Lymphoma Elderly Patients With Primary Central Nervous System Lymphoma Refractory and Relapsed Primary Central Nervous System Lymphoma Neurotoxicity Monitoring and Follow-Up 169 - Metastatic Brain Tumors Pathophysiology of Brain Metastases Epidemiology Lung Cancer Breast Cancer Melanoma Other Histologies Treatment Modalities Whole-Brain Radiation Therapy Patient Parameters and Prognostic Factors Whole-Brain Radiotherapy Dose-Fractionation Schemes Altered Fractionation Schemes Radiation Sensitizers Prophylactic Cranial Irradiation for Small Cell Lung Cancer Complications of Whole-Brain Radiotherapy Hippocampal-Avoidance Whole-Brain Radiotherapy Surgical Resection Patient Selection and Prognostic Factors Radiographically Determined Features Tumor Number Tumor Size Tumor Location Histology Clinical Assessment Surgical Techniques Cortical Mapping Metastasis Anatomy Surgical Approaches Reoperation for Recurrent Metastases Outcome and Prognosis with Surgery Studies Including Primary Tumors with Different Histologies Perioperative Mortality Postoperative Morbidity Survival Lung Cancer Breast Cancer Melanoma Renal Cell Carcinoma Colorectal Carcinoma Stereotactic Radiotherapy Stereotactic Radiosurgery vs. Conventional surgery Stereotactic Radiosurgery Plus Whole-Brain Radiotherapy Postoperative Radiotherapy Novel Therapies Alternating Electric Field Therapy Laser Interstitial Thermal Therapy Metastases From Renal Cell Carcinoma, Melanoma, and Sarcoma Leptomeningeal Disease Reirradiation Chemotherapy Lung Cancer Breast Cancer Melanoma Current Recommendations Conclusion 170 - Ventricular Tumors Clinical Presentation Ventricular Tumors Diagnostic Studies Surgical Anatomy Lateral Ventricle Third Ventricle Fourth Ventricle Indications for Surgery Surgical Planning Surgical Adjuncts Surgery of the Lateral Ventricle Principles Surgical Approaches Anterior Interhemispheric Transcallosal Approach Posterior Interhemispheric Transcallosal Approach Posterior Interhemispheric Transcingulate and Transprecuneus Approach Transfrontal Approach Transparietal Approach Anterior Temporal Neocortical Resection Anterior Temporal Approach Posterior Temporal Approach Supracerebellar Transtentorial Approach Transsylvian Approach Occipital Transcortical Resection Surgery of the Third Ventricle Principles Surgical Approaches Transnasal Transsphehnoidal Endoscopic Approach Subfrontal Approach Transfrontal Approach Anterior Interhemispheric Transcallosal Approach Transforaminal Technique. The transforaminal approach takes advantage of a widened foramen of Monro to allow for tumor debulking... Transchoroidal Technique. As mentioned earlier, the transforaminal technique may be coupled with a transchoroidal approach to th... Subchoroidal Technique. The subchoroidal approach to the third ventricle is similar to the transchoroidal route, except that the... Interforniceal Approach Posterior Interhemispheric Transcallosal Approach Posterior Interhemispheric Retrocallosal/Occipital Transtentorial Approach Infratentorial Supracerebellar Approach Cranio-orbital Approach Surgery of the Fourth Ventricle Principles Telovelar Approach Intraventricular Tumor Pathology Ependymomas Subependymomas Central Neurocytomas Pilocytic Astrocytomas Choroid Plexus Tumors Meningiomas Epidermoid Cysts Dermoid Cysts 171 - Colloid Cysts of the Third Ventricle Histogenesis Natural History of Colloid Cysts Symptomatic Colloid Cyst Risk Factors Colloid Cysts of the Third Ventricle Acute Neurological Decline Possible Hypothalamic Dysfunction Colloid Cyst Risk Score Neuroimaging for Colloid Cysts Cyst Location Imaging Characteristics Diagnostic Algorithm Surgical Decision Making Timing of Surgery Hyperacute Management Surgical Anatomy Veins Fornix Velum Interpositum Surgical Approaches Shunting Microsurgical Resection Endoscopic Resection Conversion From Endoscopic to Open Resection Port-Based Microsurgical Resection Cyst Aspiration Complications and Pitfalls 172 - Meningiomas Historical Background Epidemiology Pathology High-Grade Meningiomas Multiple Meningiomas Collision Tumors Immunohistochemistry and Molecular Diagnostics Genetic Aspects Meningiomas and Receptors Etiology Trauma Viruses Irradiation Other Associations Radiology Observation for Meningiomas Surgical Therapy and Tumor Recurrence Embolization Radiation Therapy Medical Management Meningiomas by Location and their Surgical Management Convexity Meningiomas Parasagittal Meningiomas Falcine Meningiomas Intraventricular Meningiomas Tentorial Meningiomas Olfactory Groove Meningiomas Tuberculum Sellae Meningiomas Supraorbital Approach Patient Position. The patient is placed supine with the head and trunk elevated 20 degrees. The head is fixed in a Mayfield clam... Craniotomy Technique. A curvilinear scalp incision is made extending from 1 cm anterior to the tragus to the contralateral super... Sphenoid Wing and Clinoidal Meningiomas Cavernous Sinus Meningiomas Meningiomas of the Optic Nerve and Orbit Cranio-Orbital Zygomatic Approach Patient Position. The patient is placed supine. The head is rotated 30 to 40 degrees to the side opposite the lesion’s location ... Craniotomy Technique. A curvilinear incision is made behind the hairline, extending from the zygomatic arch on the ipsilateral s... Posterior Fossa Meningiomas Cerebellopontine Angle Meningiomas Petroclival Meningiomas Anterior Petrosal Approach Patient Position. The patient’s head is rotated approximately 30 to 40 degrees to the side contralateral to the tumor’s location... Craniotomy Technique. A preauricular, curvilinear incision is made starting at the inferior margin of the root of the zygoma, an... Posterior Petrosal Approach and Extended Petrosal Approach Patient Position. The patient is placed in the supine position on the operating table. The table is flexed approximately 20 degr... Craniotomy Technique. The incision starts at the zygoma, anterior to the tragus, and is carried to approximately 2 to 3 cm above... Jugular Foramen Meningiomas Foramen Magnum Meningiomas Craniotomy Technique. The skin is incised behind the ear in a curvilinear fashion two fingerbreadths behind the mastoid. The cur... Closure and Reconstruction. Skull base approaches require especially meticulous closure. CSF leaks must be avoided by achieving ... Basal Meningiomas 173 - Mesenchymal Nonmeningothelial Tumors Epidemiology Solitary Fibrous Tumor/Hemangiopericytoma Epidemiology Classification and Histopathology Clinical Manifestations Evaluation Treatment Metastasis Recurrence and Survival Chondrosarcoma Classification and Histopathology Evaluation Management Fibrosarcoma Angiosarcoma Rhabdomyosarcoma Malignant Fibrous Histiocytoma Primary Meningeal Osteosarcoma Hemangioblastoma Other Sarcomas Conclusion 174 - Vestibular Schwannomas Introduction Historical Perspective Natural History and Epidemiology Neurofibromatosis 2 Histopathology Clinical Presentation and Diagnosis Clinical Presentation Radiologic Assessment Preoperative Imaging Computed Tomography. There is often erosion and widening of the IAM on CT scans, which leads to an asymmetrical appearance. The ... Magnetic Resonance Imaging. On T1-weighted images, two-thirds of VS cases are slightly hypointense and one-third are isointense ... Differential Diagnosis. Other masses commonly found in the CPA include meningiomas and epidermoid cysts. Although meningioma has... Preoperative Planning Management of the Asymptomatic Patient Intraoperative Neuromonitoring Cranial Nerve VII Monitoring Cranial Nerve VIII Monitoring Brainstem Auditory Evoked Responses Direct Cochlear Nerve Action Potential Monitoring Surgical Approaches Retrosigmoid Approach Technique Middle Cranial Fossa Approach Technique Translabyrinthine Approach Technique89,90 Radiosurgery, Radiotherapy, and Adaptive Hybrid Surgery Complications and Their Management Facial Nerve Injury Cochlear Nerve Injury Cerebrospinal Fluid Leaks Vascular Complications Hydrocephalus Headache Conclusion 175 - Pituitary Tumors: Functioning and Nonfunctioning Epidemiology Embryology, Morphology, and Anatomy of the Normal Pituitary Gland Classification of Pituitary Tumors Clinical and Endocrinologic Classification Pathologic Classification Genetic Features Imaging Classification Clinical Presentation General Considerations Hormonal Excess States Pituitary Insufficiency Mass Effect Pituitary Apoplexy Incidentalomas Evaluation and Diagnosis Anatomic Diagnosis Endocrine Evaluation Surgical Management Historical Considerations Indications and Goals of Surgery Preoperative Evaluation Transsphenoidal Approaches Operative Setup Patient Preparation Nasal Phase Sphenoidal Phase Sellar Phase Closure Transcranial Approaches Frontotemporal Approach and Variations Subfrontal Approach Postoperative Care and Follow-up Complications of Pituitary Surgery Sinonasal Complications Visual Compromise Vascular Injury Cerebrospinal Fluid Rhinorrhea Pituitary Dysfunction Hypothalamic Injury Radiotherapy Specific Considerations for Pituitary Adenoma Subtypes Prolactinoma Clinical Presentation Laboratory Evaluation Treatment Options Medical Therapy. Prolactinomas can be controlled medically with the use of dopamine agonists. These agents bind D2 receptors and... Operative Management. Several indications exist for the surgical management of prolactinomas (Box 175.6). One of the clearest is... Remission and Postoperative Recurrence Growth Hormone–Secreting Pituitary Adenomas Clinical Features Endocrine Diagnosis Treatment Options Pharmacologic Therapy Somatostatin Analogues. The discovery of somatotropin release–inhibiting factor (SRIF) in hypothalamic extract in 1970 led to th... Dopamine Agonists. Dopamine agonists have been used as both primary and adjuvant treatment for acromegaly, with modest response.... Growth Hormone Receptor Antagonists. Pegvisomant, a GH receptor antagonist, acts directly on the peripheral target, unlike somat... Surgery Defining Endocrinologic Remission and Reported Rates of Endocrine Remission Radiotherapy Tumor Recurrence Corticotroph Adenomas: Cushing Syndrome, Cushing Disease, and Nelson Syndrome Cushing Syndrome Cushing Disease Clinical Features. Patients with corticotroph adenomas most frequently present with endocrinopathy; less common are symptoms ref... Laboratory Evaluation. In contrast with other pituitary tumors, for which imaging studies are of primary diagnostic importance, ... Establishing Hypercortisolemia. Measurement of free cortisol in a 24-hour urine specimen is a sensitive first step in verifying ... Differentiating Adrenocorticotropic Hormone–Dependent from Adrenocorticotropic Hormone–Independent Causes of Hypercortisolemia. ... Differentiating Cushing Disease from Ectopic Adrenocorticotropic Hormone States. The secretory activity of corticotroph adenomas... Imaging. The diagnosis of a corticotroph adenoma is established by endocrine investigations; imaging studies, although essential... Surgery. Once it is established that the cause of hypercortisolemia is a corticotroph adenoma, surgery remains the first-choice ... Radiotherapy. For patients unresponsive to sellar exploration, the most effective next step is some form of radiotherapy. Remiss... Medical Therapy. Pharmacologic therapy is the least attractive therapeutic option for corticotroph adenomas. Although an armamen... Bilateral Adrenalectomy. Total bilateral adrenalectomy followed by lifelong glucocorticoid and mineralocorticoid replacement is ... Nelson Syndrome Crooke Cell Adenoma Thyrotroph Pituitary Adenomas Clinically Nonfunctioning Pituitary Tumors Functional Gonadotrophs Pituitary Carcinoma Conclusion 176 - Craniopharyngiomas in Adults Craniopharyngioma Classification, Clinical Presentation, and Imaging Characteristics Craniopharyngiomas in Adults Goals of Treatment Approach Selection Conclusions 177 - Epidermoid, Dermoid, and Neurenteric Cysts Introduction Epidermoid Cysts Clinical Findings Imaging Treatment Pathology Case Presentation Dermoid Cysts Imaging Treatment Pathology Case Presentation Neurenteric Cysts Clinical Findings Imaging Treatment Pathology Case Presentation Conclusion 178 - Endoscopic Endonasal Surgery for Skull Base Tumors Endoscopic Endonasal Corridors Endoscopic Endonasal Approaches Transcribriform and Fovea Ethmoidalis Approaches Transsellar Approach Transplanum Transtuberculum Approach Transcavernous Approach Transclival Approach Transodontoid Approach Transpterygoid Approach Different Pathologies Treated with Endoscopic Approaches Pituitary Adenoma (Suprasellar, Cavernous Sinus) Meningioma (Tuberculum Sella, Planum Sphenoidale, Olfactory Groove) Craniopharyngioma Chordoma Chondrosarcoma Trigeminal Schwannoma Esthesioneuroblastoma Juvenile Angiofibroma Reconstruction of the Skull Base Defect Associated Complications and Management 179 - Overview of Skull Base Tumors Classification Epidemiology Meningiomas Therapeutic Plan Surgical Considerations Pituitary Adenomas Therapeutic Plan Surgical Considerations Craniopharyngiomas Therapeutic Plan Surgical Considerations Schwannomas Therapeutic Plan Surgical Considerations Epidermoid and Dermoid Therapeutic Plan Surgical Considerations Chordomas and Chondrosarcomas Therapeutic Plan Surgical Considerations Paraganglioma (Chemodectomas or Glomus Tumors) Therapeutic Plan Surgical Considerations Skull Base Metastases Therapeutic Plan Conclusion 180 - Chordomas and Chondrosarcomas Introduction Epidemiology and Predictors of Survival Surgical Evaluation Chordoma Pathology and Histologic Origin Imaging and Work-up Drawing Connections: Similarities Between Chordoma and Chondrosarcoma Molecular Pathophysiology of Chordoma Differential Diagnosis Treatment Surgery Radiation Differentiating Between Chordoma and Notochordal Rest Skull Base/Clival Lesions. Lesions should be completely resected, as prior studies have demonstrated total resection to provide ... Mobile Spine. En bloc, R0 resection is the preferred means of treating lesions of the mobile spine.65,66,92 Unlike in skull base... Sacrum. Lesions of the sacrum are the most amenable to oncologic (R0) surgical resection owing the lack of vital organs within t... Chemotherapy Selecting a Modality: The Differences Between Particle Therapy and Photon Therapy. For more than a century, radiation therapy ha... Recurrent Disease and Nonsurgical Lesions Future Progress Chondrosarcoma Pathology and Histologic Origin Molecular Pathology Imaging and Work-up Molecular Pathogenesis of Chondrosarcoma Differential Diagnosis Treatment Conclusion 181 - Head and Neck Paragangliomas Nomenclature General Overview Topography World Health Organization Classification Historical Background Identification of the Lesion Sites of Origin Classification and Surgical Removal of Temporal Paragangliomas (Jugular Paragangliomas and Tympanic Paragangliomas) Classification and Surgical Removal of Cervical Paragangliomas (Carotid Paragangliomas, Vagal Paragangliomas, and Laryngeal Para... Embolization Radiation Treatment Radiotherapy Radiosurgery Tumor Characteristics Origin Genetic Aspects Incidence and Prevalence Pathogenesis Histopathology Growth and Metastases Functionality Typical Aspects According to Origin, Clinical Signs, and Symptoms Carotid Paragangliomas Tympanic Paragangliomas Jugular Paragangliomas Vagal Paragangliomas Laryngeal Paragangliomas Diagnosis Treatment Embolization Embolization With Polyvinyl Alcohol Particles Glues Occlusion or Stenting of Large Vessels Surgery Jugular Paragangliomas Carotid Paragangliomas Surgical Approaches Extracranial Skull Base Approaches Transcervical Approach Radiotherapy External Beam Radiotherapy Stereotactic Radiosurgery Wait and Scan Multidisciplinary Treatment Conclusion 182 - Neoplasms of the Paranasal Sinuses Pathogenesis Pathologic Features Diagnostic Evaluation Classification Treatment Principles Surgical Management Craniofacial Resection Endoscopic Transcribriform Resection Transmaxillary Maxillary Neurectomy Orbitectomy Lateral Approaches Complications Endoscopic Surgery Adjuvant Therapies Outcome Conclusion 183 - Esthesioneuroblastoma Pathology Esthesioneuroblastoma Presentation Patient Evaluation Treatment Surgical Resection Surgery With Adjuvant Therapies Endoscopic Resection Radiotherapy Chemotherapy Surgical Technique Complications Outcomes Summary 184 - Trigeminal Schwannomas Tumor Biology, Pathology, and Pathogenesis Pathologic Anatomy and Classification Schemes Trigeminal Schwannomas Clinical Findings Diagnostic Imaging Surgical Treatment Role of Radiosurgery and Radiotherapy Outcome Summary 185 - Juvenile Nasopharyngeal Angiofibromas Juvenile Nasopharyngeal Angiofibromas Introduction and Epidemiology Histology Pathogenesis Patterns of Growth Diagnostic Studies Staging Treatment Options Surgery Choice of Surgical Approach Open Surgery. Open surgical techniques can be classified according to the following scheme (see Table 185.3). Surgical approach ... Transpalatal Approach. Prior to the advent of endoscopy, early versions of the transpalatal approach were preferred for access i... Other Anterior Approaches. Le Fort I maxillotomy is another popular anterior approach that offers exposure of the medial nasal s... Infratemporal Fossa Approach. Tumors with extensive intracranial penetration and/or penetration of the dura require an infratemp... Endoscopic and Endoscopically Assisted Approaches. Since first described in the treatment of JNA,73 endoscopy has gradually beco... Radiotherapy Surveillance and Recurrent or Residual Tumors Conclusion 186 - Tumors of the Orbit Clinical Manifestations Surgical Anatomy Surgical Approaches (“Around the Clock”) Lateral Corridors External Approaches Fronto-orbital Temporal and Pterional Transcranial Approaches Eyebrow Fronto-orbital (Supraorbital) Approach and Eyelid (Transorbital) Approach Lateral Microsurgical Approach and Lateral Orbitotomy Medial Corridors External Approaches: Anterior Medial Micro-Orbitotomy and Transconjunctival Approach Endoscopic Endonasal Approaches Medial-Inferior Extraconal Approach Transmaxillary Extraconal Approach Medial Intraconal Approach Complications and Their Management Choice of Approach Conclusion 188 - Scalp Tumors Keratoses Seborrheic Keratoses Actinic Keratosis Keratoacanthomas Scalp Tumors Nonmelanoma Skin Cancers Basal Cell Carcinoma Squamous Cell Carcinoma Staging and Treatment for Basal Cell Carcinoma and Squamous Cell Carcinoma Nevi Melanoma Soft Tissue Lesions Lesions of Vascular Tissue Hemangioma Arteriovenous Malformation Angiosarcoma Lesions of Nervous Tissue Adnexal Tumors Dural Involvement Reconstruction Radiation Therapy 189 - Pseudotumor Cerebri Epidemiology Symptoms and Signs Diagnosis Neuroimaging Cerebrospinal Fluid Examination Secondary Pseudotumor Cerebri Complications Pathophysiology Monitoring Treatment Treatment Related to Obesity Medical Treatment For Headache. There are many medications that may be helpful for patients in whom headache is the main problem, although some of... For Increased Intracranial Pressure. Carbonic anhydrase, present in the choroid plexus, has a major role in the secretion of CSF... Lumbar Puncture Surgery Cerebrospinal Fluid Diversion Procedures. In the past, most neurosurgeons preferred to perform lumboperitoneal shunting for pati... ?Optic Nerve Sheath Fenestration. ONSF (also called optic nerve sheath decompression) is a procedure in which the optic nerve ju... Venous Sinus Stenting. As noted earlier, occlusion of the cerebral venous sinuses can produce increased ICP and papilledema. How... Special Circumstances Pregnancy Fulminant Pseudotumor Cerebri Prognosis 190 - Sarcoidosis, Tuberculosis, and Demyelinating Disease Clinical Approach Imaging Sarcoidosis Tuberculosis Demyelinating Disease 191 - Anatomy and Physiology of Pain Sensory Transmission of Pain-Related Information Descending Modulation of Pain Anatomy and Physiology of Pain Primary Afferent Nociceptors Dorsal Horn and Ascending Pathways Role of Dorsal Column Pathway in Visceral Pain Supraspinal Nociceptive Targets Thalamus Lateral Thalamic Nuclei Ventral Caudal Nucleus Ventral Posterior Inferior Nucleus and the Posterior Part of the Ventral Medial Nucleus Medial Thalamic Nuclei Intralaminar Nuclei Brainstem Cortical Processing Primary Somatosensory Cortex Secondary Somatosensory Cortex Insula Anterior Cingulate Cortex Prefrontal Cortex Sensitization of Ascending Pain Transmission Pathways Descending Modulatory Systems Descending Modulation and the Periaqueductal Gray Matter/Rostral Ventromedial Medulla System Bidirectional Control Neural Basis for Bidirectional Control Recruitment of the Periaqueductal Gray Matter/Rostral Ventromedial Medulla Modulatory System Activation by Noxious Inputs: A Positive Feedback Loop Stress Contribution to Chronic Pain States Descending Modulation in Humans: Evidence from Imaging Studies Conclusion 192 - Molecular Basis of Nociception Pain Sensitization Molecular Basis of Nociception Activation of Primary Afferents Pain-promoting Substances Released With Tissue Injury Detection and Transduction of Tissue Injury Nociception in Other Tissues Peripheral Sensitization Modulation of Primary Afferent Firing Transmission of Pain Signals to the Central Nervous System Central Mechanisms of Sensitization Acknowledgments 193 - Approach to the Patient With Chronic Pain Introduction Before the Patient’s Arrival The Initial Visit Obtaining a History General Aspects Pain History and Onset Pain Characteristics Pain Treatment History Medical and Surgical History Family History Social and Psychological History Physical and Neurological Examinations Formulating a Treatment Plan 194 - Pharmacologic Treatment of Pain Introduction Pathophysiology Pharmacologic Treatment of Pain Pharmacologic Treatment of Pain Nonsteroidal Antiinflammatory Drugs Acetaminophen Antidepressants Antiepileptics Opioids Current Practices With Opioids, and Their Consequences. Prescriptions for opioids quadrupled in the United States between 1999 a... Mechanistic Approach to Pain Medication Selection Neuropathic Pain Acute Pain Acute Pain in Children. Identifying pain in children can be challenging because children often cannot express their pain and can... Chronic Pain Cancer Pain Conclusion 195 - Management of Pain by Percutaneous Anesthetic Injections and Neurolysis Considerations for Diagnostic and Therapeutic Injections Diagnostic Injections Therapeutic Injections Limitations of Neural Blockade and Therapeutic Injection Imaging Guidance and Anatomic Considerations Fluoroscopy Ultrasonography Common Blocks and Technique for Neural Blockade Epidural and Selective Nerve Root Injections Rationale for Epidural Steroid Injections Indications, Contraindications, and Limitations Injection Technique and Anatomic Approach Interlaminar Versus Transforaminal Approach Technique: Midline Interlaminar and Caudal Technique: Transforaminal Outcomes and Adverse Events Facet Joint Injections and Medial Branch Nerve Procedures Introduction and Neuroanatomy Rationale and Indications for Diagnostic Medial Branch Blocks Diagnostic Injections Versus Denervation Radiofrequency Denervation Technique Outcomes, Risks, and Efficacy Sacroiliac Joint Injections and Radiofrequency Ablations Sympathetic Nerve Blocks Rationale for Sympathetic Blockade Anatomic Approaches for Common Sympathetic Blocks Sphenopalatine Ganglion Block Stellate Ganglion Block Thoracic Sympathetic Block Celiac Plexus and Splanchnic Nerve Block Lumbar Sympathetic Blocks Other Anesthetic Techniques Trigger Point Injections Botox Injections for Chronic Migraines Minimally Invasive Treatment of Neurogenic Claudication with Interspinous Implants Conclusion 196 - Evidence-Based Approach to the Treatment of Facial Pain The Benefit of Evidence-Based Medicine Implementation of Evidence-Based Medicine in Surgery for Facial Pain Other Trial Options Conclusion 197 - Trigeminal Neuralgia: Diagnosis and Nonoperative Management Introduction Diagnostic Criteria and Classification Ancillary Diagnostic Testing: Imaging and Quantitative Sensory Testing Differential Diagnosis Epidemiology and Risk Factors Etiology Nonoperative Management Timing of Surgical Consultation Conclusion 198 - Percutaneous Procedures for Trigeminal Neuralgia Historical Development Of Percutaneous Procedures For Trigeminal Neuralgia Trigeminal Anatomy Diagnosis Diagnostic Tools Surgical Treatment Percutaneous Preoperative Considerations Patient Selection Preoperative Patient Preparation Percutaneous Surgical Procedures Radiofrequency Rhizotomy Glycerol Rhizotomy Balloon Compression Postoperative Management Radiosurgery Results And Complications Special Considerations Multiple Sclerosis Recurrent Treatment Conclusion 199 - Stereotactic Radiosurgery for Trigeminal Neuralgia Introduction Historical Perspective of Gamma Knife in Trigeminal Neuralgia Rationale of Radiosurgery For Trigeminal Neuralgia Factors Related to Favorable Outcomes of Radiosurgery Radiosurgical Targeting Imaging Target Selection Dose Selection Clinical and Radiologic Follow-Up After Radiosurgery Pain Control After Radiosurgery Adverse Radiation Effects Recurrence and Re-Treatment Comparison of Radiosurgery and Open Surgery For Trigeminal Neuralgia Future of Stereotactic Radiosurgery For Trigeminal Neuralgia Conclusions 200 - Microvascular Decompression for Trigeminal Neuralgia History Pathophysiology Microvascular Decompression for Trigeminal Neuralgia Alternative Treatments Patient Selection and Classification of Facial Pain Preoperative Imaging Operative Technique Postoperative Care Complications Results Other Neurovascular Facial Pain Syndromes Glossopharyngeal Neuralgia Geniculate Neuralgia (Nervus Intermedius Neuralgia) Conclusion 201 - Neurosurgical Management of Intractable Pain Neurosurgical Management of Intractable Pain Prelude to Surgical Treatment Patient Selection for Surgical Pain Therapies Neurosurgical Therapies for Intractable Pain Augmentative Therapies Neuroablative Therapies Peripheral Procedures Spinal Procedures Supraspinal Intracranial Techniques Conclusion 202 - Evidence-based Neurostimulation for Pain Spinal Cord Stimulation Deep Brain Stimulation Motor Cortex Stimulation Peripheral Nerve Stimulation Conclusion 203 - Peripheral Nerve Stimulation for Neuropathic Pain Indications Technique Peripheral Nerve Stimulation for Neuropathic Pain Outcome Dorsal Root Ganglion Stimulation Advances and Future Direction 204 - Spinal Cord Stimulation Introduction Mechanism of Action Gate Theory Neurotransmitters Functional Imaging Dorsal Root Ganglion Stimulation Summary of Mechanisms Indications and Outcomes Failed Back Surgery Syndrome Chronic Pain and Opioids Complex Regional Pain Syndrome Ischemic Pain Psychological Screening Spinal Cord Stimulation Leads Early Lead Configurations Modern-Day Lead Types Laminectomy Versus Percutaneous Placement Generators Constant Current Versus Constant Voltage Patient Programmers Stimulation Parameters Conventional Stimulation Parameters High-Frequency Stimulation Burst Stimulation Surgical Technique Electrode Placement Awake Versus Asleep Placement Generator Placement Complications Cautions and Contraindications Compatibility With Magnetic Resonance Imaging New Directions 205 - Evidence Base for Destructive Procedures Results Rhizotomy Rhizotomy for Truncal or Extremity Neuralgias and Lumbar Facet Syndrome Rhizotomy for Chronic Discogenic Back Pain Rhizotomy for Cervical Pain Rhizotomy for Trigeminal Neuralgia Neurectomy for Trigeminal Neuralgia Rhizotomy and Neurectomy for Cluster Headache and Facial Pain Rhizotomy for Cancer Pain Ganglionectomy Ganglionectomy for Lumbar and Cervical Radicular Pain Ganglionectomy for Occipital Neuralgia Ganglionectomy for Pain of Other Etiologies DREZ Lesions Trigeminal Tractotomy for Facial Pain Cordotomy Myelotomy Mesencephalotomy Thalamotomy Cingulotomy Sympathectomy Discussion Conclusion 206 - Dorsal Rhizotomy and Dorsal Root Ganglionectomy Indications for Dorsal Rhizotomy and Ganglionectomy Cancer Pain Noncancer Pain Surgical Technique Cervical Ganglionectomy and Dorsal Rhizotomy Thoracic Ganglionectomy and Dorsal Rhizotomy Ganglionectomy at Lumbosacral Region and Sacral Rhizotomy Conclusion 207 - Diagnosis and Management of Painful Neuromas Pathophysiology Clinical Presentation Diagnosis Treatment Prevention Of Secondary Neuroma Poor Surgical Candidates Future Directions 208 - Dorsal Root Entry Zone Lesions for Pain Rationale Indications Cancer Pain Root Avulsion Pain (Brachial and Lumbosacral Plexus) Spinal Cord Injury Pain Other Pain Indications Hyperspastic States Technique How to Avoid Complications Conclusion 209 - Percutaneous Cordotomy and Trigeminal Tractotomy for Pain History And Introduction Cordotomy Indications Technique Equipment Procedure. Thirty minutes prior to the procedure, a lumbar injection of 12 cc of Omnipaque 300 mg/mL is performed. Patients are ... Clinical. Usually cord penetration produces pain in the area to be ablated. Electric stimulation of the target also reproduces t... Macrostimulation. The electrodes used for lesioning allow for stimulation of the spinothalamic tract in both sensory and motor f... Results Complications Future of Cordotomy Trigeminal Tractotomy-Nucleotomy Indications for Trigeminal Tractotomy-Nucleotomy Technique Equipment Preoperative Preparation Surgical Positioning Imaging and Data Acquisition Needle Placement Clinical. Usually cord penetration produces pain in the area that is to be ablated. Electrical stimulation also produces sensati... Macrostimulation. The electrodes used for lesioning allow stimulation of the spinothalamic tract (the target) in both sensory an... Lesion Making. If patients are awake, creation of the lesion is painful and lower temperature over longer periods has been advoc... Results Conclusion 210 - Neuroanesthesia in Children Preoperative Evaluation and Preparation Intraoperative Management Induction of Anesthesia Airway Management Maintenance of Anesthesia Local Anesthesia Vascular Access Monitoring Thermal Homeostasis Positioning Emergence From Anesthesia Postoperative Management Conclusion 211 - Neurocritical Care in Children Neurological Assessment in the Pediatric Intensive Care Unit Airway Management and Respiratory Failure Stroke in Children Stroke in Children With Sickle Cell Disease Stroke: Anticoagulation and Supportive Therapy Fluids, Electrolytes, and Nutrition Intracranial Hypertension Seizures Infections Prevention of Secondary Insults to the Brain The Diagnosis of Brain Death in Children Conclusion eAppendix 211.1: Postoperative Protocol for Diabetes Insipidus Background Indications Diagnostic Criteria for Postoperative Diabetes Insipidus Monitoring (eTable 211.1) Treatment Goals of Treatment Vasopressin Infusion Titration If Patient Is Able to Drink If Urine Output Replacement Is Indicated Criteria for Transition to Oral Desmopressin Differential Diagnoses Diabetes Insipidus (Other than Postoperative DI) Syndrome of Inappropriate Antidiuretic Hormone Secretion Cerebral Salt Wasting Syndrome 212 - Neuroembryology and Molecular Genetics of the Brain Early Embryonic Development and Induction Early Brain Induction Defects of Brain Induction: Hesx1 and Septo-optic Dysplasia Neurulation Defects of Cranial Neurulation: Anencephaly Segmentation Secondary Organizers Rhombencephalon/Hindbrain Isthmic Organizer Defects of Isthmic Organizer Activity: Brainstem and Cerebellar Malformations (Including Dandy-Walker Malformation) Rhombic Lip Cerebellum Correlation of Cerebellar Development and Neoplasia: Posterior Fossa Medulloblastoma Prosencephalon Defect of Telencephalon Development: Holoprosencephaly Diecephalon Defects of Diencephalon Organizer Development Cerebral Cortex Malformations of Cortical Development: Lissencephaly and Cortical Dysplasias Embryonic Ventricular System Development of Ependymal Cells Development of Choroid Plexus Hydrocephalus Caused by Aqueductal Stenosis 213 - Cranial Dysraphisms: Encephaloceles, Meningoceles, and Cranial Dermal Sinus Tracts Introduction Nosology Classification and Nomenclature Sincipital Encephaloceles Anterior Fontanelle Lesions Temporal Encephaloceles Lateral Encephaloceles Parietal Encephaloceles Occipital Encephaloceles Embryology Epidemiology Genetics Pathologic Features Diagnosis Management Mode of Delivery Encephaloceles and Hydrocephalus Anesthetic Considerations Goals of Surgery Posterior Encephaloceles: Surgical Technique Chiari Type III and Cervical Encephaloceles Anterior Encephaloceles Temporal Encephaloceles Prognosis Conclusion Cranial Meningoceles Cranial Dermal Sinus Tracts Introduction Embryology Epidemiology Genetics Diagnosis Association With Dermoid and Epidermoid Cysts and Intracranial Abscesses Management Goals of Surgery Occipital Nasal Prognosis Conclusion 214 - Dandy-Walker Syndrome History and Embryology Terminology and Differential Diagnosis Clinical Features Treatment Prognosis Conclusion 215 - Arachnoid Cysts in Childhood Arachnoid Cysts in Childhood Clinical Presentation Imaging Supratentorial Arachnoid Cysts Infratentorial Arachnoid Cysts Conclusion 216 - Chiari Malformations History Terminology Chiari I Malformation Chiari II Malformation Chiari III Malformation Chiari IV Malformation Chiari 0 Malformation Chiari 1.5 Malformation Signs and Symptoms Chiari I Malformation Chiari II Malformation Diagnostic Studies Imaging Chiari I Malformation Chiari II Malformation Cerebrospinal Fluid Flow Studies and Cine-Mode Magnetic Resonance Imaging Electrophysiologic Studies Pathophysiology Chiari I Malformation Chiari II Malformation Syringohydromyelia Treatment Chiari I Malformation Chiari II Malformation Complications Results and Prognosis Chiari I Malformation Chiari II Malformation Follow-Up Chiari I Malformation Chiari II Malformation Controversial Topics Occiput-to-Spine Fusion or C1–C2 Fusion, With or Without Anterior Decompression Tethered Cord Release Chiari Decompression in Ehlers-Danlos Syndrome Need for Dural Opening Arachnoid Opening Dural Closure Open Versus Endoscopic Approaches Syrinx Management Extent of Bony Decompression Arachnoiditis and Subsequent Syringomyelia Conclusion 217 - Craniopagus Twins Introduction Historical Perspective Classification and Demographics ? Surgical Separation Risk Stratification Preoperative Assessment Surgical Techniques Soft Tissue Preparation and Incision Planning Brain and Vascular Separation Surgery Wound Closure and Reconstruction Innovations Risks and Complications Inoperable Craniopagus Craniopagus Twins With Conjoined Brain Bridge Effect of Cultural Views on Craniopagus Management Conclusion 218 - Molecular Genetics and Principles of Craniosynostosis Suture Morphogenesis Syndromic Craniosynostosis Inheritance Patterns in Syndromic Craniosynostosis Molecular Genetics of Syndromic Craniosynostosis Genetic Testing in Craniosynostosis Muenke Syndrome Apert Syndrome Pfeiffer Syndrome Crouzon Syndrome Jackson-Weiss Syndrome Saethre-Chotzen Syndrome Nonsyndromic Craniosynostosis Sagittal and Metopic Craniosynostosis Coronal Craniosynostosis ERF-Related Craniosynostosis Value of Molecular Genetics to the Craniofacial Surgeon Conclusion 219 - Nonsyndromic Craniosynostosis: Introduction and Single-Suture Synostosis Nonsyndromic and Syndromic Craniosynostosis Diagnosis Operative Timing and Approaches Neurocognitive Considerations Etiology of Neurocognitive Disabilities Effect of Surgical Technique and Timing Operative Treatment Metopic Synostosis Operative Technique Unilateral Coronal Synostosis Operative Technique Bilateral Coronal Synostosis Operative Technique Sagittal Synostosis Operative Technique Lambdoid Synostosis Operative Technique Operative Complications Philosophy of Treatment 220 - Syndromic Craniosynostosis Syndromic Craniosynostosis Craniofacial Syndromes and Genetics Apert Syndrome Crouzon Syndrome Pfeiffer Syndrome Muenke Syndrome Saethre-Chozen Syndrome Craniofrontonasal Dysplasia Carpenter Syndrome Other Syndromes Problems and Functional Complications Intracranial Pressure/Craniocerebral Disproportion Hydrocephalus Chiari Elevated Venous Pressure/Anomalous Venous Drainage Visual Function/Corneal Exposure Airway Anomalies Associated Brain Malformations Intellectual Function Hand and Extremity Anomalies Other Extracranial Anomalies Operative Management Preoperative Workup Airway Assessment/Sleep Study Imaging Plain Radiographs. Plain radiographs is an attractive initial option in children with abnormal head shape because of its relativ... Computed Tomography. High-resolution CT with three-dimensional (3D) reconstruction is historically the gold standard,87,100 with... Magnetic Resonance Imaging. Use of MRI reduces radiation risk and provides excellent visualization of the brain anatomy and pote... Operative Management of the Child With Syndromic Craniosynostosis Early Suturectomy or Craniectomy Fronto-orbital Advancement Posterior Vault Distraction Osteogenesis Spring-assisted Cranioplasty Cranial Vault Expansion Midfacial Advancement Intraoperative Planning Anesthesia/Transfusion/Intraoperative Complication Avoidance Positioning Incision Planning Bone Defects and Bone Fixation Postoperative Care and Follow-up Conclusion 221 - Endoscopic Treatment of Craniosynostosis Endoscopic Treatment of Craniosynostosis Instrumentation Surgical Helmet Anesthesia Sagittal Surgical Procedure Results Coronal Surgical Procedure Results Metopic Surgical Procedure Results Lambdoid Surgical Procedure Results Nonsyndromic Multiple Suture Synostosis Conclusion Literature Review 222 - Nonsynostotic Plagiocephaly History Scope and Impact Incidence Pathogenesis and Pathology Evaluation of the Infant With Plagiocephaly Treatment Conclusion 223 - Hydrocephalus in Children: Etiology and Overall Management Etiology Congenital Hydrocephalus Associated with Myelomeningocele Arachnoid Cyst Genetics and Cellular Mechanisms Acquired Post-hemorrhagic Hydrocephalus Hydrocephalus Associated With Brain Tumors Post-traumatic Hydrocephalus Presentation Patients Presenting in Utero Patients Presenting in Infancy Older Children Diagnostic Studies Management Follow-Up The Child With Suspected Shunt Malfunction The Child With a Shunt and Chronic Headache The Child With a Shunt and Fever Long-Term Monitoring The Child With Hydrocephalus Growing Into Adulthood Long-Term Outcome 224 - Infantile Post-hemorrhagic Hydrocephalus Intraventricular Hemorrhage in Preterm Infants Terminology Epidemiology Pathophysiology of Germinal Matrix Hemorrhage and Post-hemorrhagic Infarction Clinical Presentation and Diagnostic Evaluation Treatment Options Nonsurgical Treatment Timing of Surgical Interventions Temporary Surgical Interventions Permanent Cerebrospinal Fluid Diversion Procedures Shunt Technique Endoscopic Third Ventriculostomy Complications Infection Malfunction in Temporary Shunts Other Complications Neurological Outcome and Comorbidities Intraventricular Hemorrhage in Term Infants Epidemiology Pathophysiology Clinical Presentation Treatment Neurological Outcome and Comorbidities Infant Postinfectious Hydrocephalus Infant Posttraumatic Hydrocephalus 225 - Cerebrospinal Fluid Disorders and Transitional Neurosurgery Cerebrospinal Fluid Disorders and Transitional Neurosurgery Evolving Cerebral Fluid System Concepts Cerebrospinal Fluid Bulk Flow Model Cerebrospinal Fluid Production Cerebrospinal Fluid Absorption Arachnoid Villi Lymphatic System Cerebrospinal Fluid Drainage Lymphatic System and Solute Clearance Parenchymal Capillary Exchange Cerebrospinal Fluid Movement Cerebrospinal Fluid Content The Cerebral Fluid System: A Complex System Transitional Hydrocephalus and Cerebral Fluid System Disorders of Young Adults Transitional Neurosurgical Care Management Challenges and Strategies in the Adult With Congenital Hydrocephalus and Other Cerebral Fluid System Disorders Adult-Onset Congenital Hydrocephalus Slit Ventricle Syndrome Management of Slit Ventricle Syndrome Prevention Strategies Idiopathic Intracranial Hypertension Intracranial Hypotension and Cerebrospinal Fluid Leak Arachnoid Cysts and Dandy Walker Malformation Arachnoid Cysts Dandy-Walker Malformation Chiari Malformations Chiari Malformation as a Cerebral Fluid System Disorder Acquired Chiari Malformation. A form fruste of Chiari I malformation has been well described in the context of lumbar CSF draina... Idiopathic Chiari I Malformation. Idiopathic Chiari I malformation is diagnosed when there is no apparent cause of tonsillar ect... Cerebrospinal Fluid Flow Dysregulation at the Cervicomedullary Junction Chiari and Other Cerebral Fluid System Disorders Idiopathic Intracranial Hypertension. As described previously in this chapter and in Chapters 42 and 69, IIH is known to occur i... Hydrocephalus. Hydrocephalus is another common comorbidity seen with Chiari I malformation.342 The prevalence of hydrocephalus i... Chiari-Associated Syringomyelia. The relationship between crowding at the cervicomedullary junction resulting in restriction of ... Summary Syringomyelia Conclusion 226 - Experimental Hydrocephalus Experimental Hydrocephalus Experimental Models Animal Models of Acquired Obstructive and Communicating Hydrocephalus Animal Models of Congenital and Transgenic Hydrocephalus Modeling Biomechanical Properties in Hydrocephalus In Vitro Models in Experimental Hydrocephalus Pathophysiologic Mechanisms and Treatment Possibilities Gliosis and Neuroinflammation Biomechanical Properties of Hydrocephalic Brains Cerebrospinal Fluid Absorption: Lymphatic, Glymphatic, Arachnoid, Microvascular Neurodevelopmental Effects on Neurogenesis and Neural Progenitors Conclusion 227 - Ventricular Shunting Procedures History Components of Shunt Systems Ventricular and Distal Catheter Choices Valve Choices Fixed Differential Pressure Valves Anti-siphon Devices. The problem of shunt overdrainage spurred the development of ASDs over 40 years ago.81 ASDs are coupled (i.... Gravitational Devices. Gravitational devices similarly offer an avenue to prevent overdrainage, although their mechanism differs... Flow-Regulating Valves Programmable Differential Pressure Valves Choosing a Valve Shunt Surgery General Principles Infection Avoidance Postoperative Considerations Ventricular Access Frontal (Coronal) Approach Occipitoparietal Approach Technical Considerations Complications Ventriculoperitoneal Shunts Indications Specific Complications Operative Technique Cranial and Abdominal Exposure. The patient is positioned supine and bolstered so that the mastoid, clavicle, and xiphoid are co... Abdominal Access. Abdominal access may be obtained by (1) minilaparotomy, (2) laparoscopic-assisted method, or (3) trocar method... Minilaparotomy. Minilaparotomy (i.e., open technique) is the traditional method. A transverse incision is made superolateral to ... Laparoscopic-Assisted Method. With laparoscopic VP shunt insertion,222-225 a general surgeon typically performs the abdominal po... Trocar Method. A small incision is made superior and lateral to the umbilicus. The abdominal skin is pulled anteriorly with two ... Subcutaneous Tunneling. A subgaleal pocket for the shunt valve is dissected around the cranial incision. Tunneling is usually pe... Ventricular Access, Shunt Assembly and Testing, and Closure. The peritoneal catheter is connected to the shunt valve and tightly... Ventriculoatrial Shunts Indications Specific Complications Operative Technique Cranial and Cervical Exposure and Subcutaneous Tunneling. The patient is positioned supine. The cranial exposure is done in the ... Venous Access. The patient is placed in the Trendelenburg position with the head rotated to the contralateral side. Unless contr... Percutaneous Approach. In the percutaneous approach253-255 the distal catheter can be placed into the atrium by a modified Seldi... Open Approach. The common facial vein (CFV) and IJV are dissected. A purse-string suture is placed on the anterior wall of the I... Catheter Position. Optimal catheter placement is verified by intraoperative fluoroscopy; the preferred position of the tip is mi... Ventricular Access, Shunt Assembly and Testing, and Closure. The operating table is returned to the neutral position. The ventri... Ventriculopleural Shunts Indications Specific Complications Operative Technique Cranial and Thoracic Exposure, Subcutaneous Tunneling, Ventricular Access, and Shunt Assembly and Testing. The patient is placed... Pleural Access. Pleural access can be achieved by (1) thoracotomy (i.e., open technique), (2) thoracoscopic-assisted method, or ... Thoracotomy. In this open method,260,262 working from the thoracic incision (see earlier), the subcutaneous fat, deep fascia, an... Thoracoscopic-Assisted Method. In the thoracoscopic-assisted method,264,265 a general surgeon typically performs the chest part ... Trocar Method. In the trocar method,266 the subcutaneous tissues are taken down to the level of the intercostal muscles. A split... Closure. The catheter is fed into the pleural cavity directly or through the peel-away or trocar sheath in the open, thoracoscop... Ventriculosubgaleal Shunts Indications Specific Complications Operative Technique Ventricular Reservoirs Indications Specific Complications Operative Technique Outcomes of Ventricular Shunting Shunt Failure Quality of Life Conclusion 228 - Neuroendoscopy Neuroendoscopy History Indications Hydrocephalus Endoscopic Third Ventriculostomy Endoscopic Aqueductoplasty Septostomy, Foraminoplasty, and Complex Hydrocephalus Ventricular Tumors and Cysts Pineal Region Tumors Colloid Cysts Arachnoid Cysts Suprasellar Cysts Pineal Cysts Intraventricular Hemorrhage Conclusion 229 - Cerebrospinal Fluid Devices Introduction History of Cerebrospinal Fluid Shunt Devices Cerebrospinal Fluid Shunt Hydrodynamics Pressure Flow and Resistance Cerebrospinal Fluid Devices Proximal and Distal Shunt Catheters Shunt Valves Fixed Differential Pressure Valves Flow-Regulated Valves Programmable Valves Valve Design Trials Conclusion 230 - Management and Prevention of Shunt Infections Features of Shunt Infections Rates of Infection Timing of Shunt Infections Risk Factors Age Previous Revisions Gastrostomy Tubes Hydrocephalus Etiology Surgical Factors Evaluating Infections Signs and Symptoms Diagnostic Imaging Laboratory Evaluation Causative Agents Treatment Surgical Intervention Antibiotic Therapy Outcomes of Infection and Treatment Preventive Measures Antibiotic-Impregnated Catheters Conclusion 231 - Genetics of Pediatric Brain Tumors Introduction Definitions Pediatric Gliomas Pediatric High-Grade Glioma Midline and Hemispheric Pediatric High-Grade Gliomas Diffuse Intrinsic Pontine Glioma Pediatric Low-Grade Glioma Diffuse Astrocytoma. WHO grade II DAs arise in supratentorial locations in the midline as well as the cerebral hemispheres, with... Pleomorphic Xanthoastrocytoma. PXAs are hemispheric WHO grade II tumors that display more aggressive clinical behavior than othe... Oligodendroglioma. Oligodendrogliomas are rare tumors in the pediatric population, accounting for approximately 1% of brain tumo... Subependymal Giant Cell Tumors. SGCTs are the most common brain tumors in patients affected by tuberous sclerosis complex. This ... Dysembryoplastic Neuroepithelial Tumors. DNETs are also epileptogenic lesions that typically occur in the temporal lobe. Distinc... Desmoplastic Infantile Astrocytomas/Ganglioglioma. DIAs and desmoplastic infantile gangliogliomas (DIGs) are rare benign intracr... Other Mixed Glioneuronal Tumors. Several other rare mixed glioneuronal entities have also been shown to have highly recurrent dr... Embryonal Tumors Medulloblastoma Atypical Teratoid Rhabdoid Tumors Embryonal Tumor With Multilayered Rosettes Other Embryonal Tumors Ependymal Tumors Posterior Fossa Ependymoma Supratentorial Ependymoma Spinal Ependymoma Germ Cell Tumors of the Central Nervous System Other Pediatric Central Nervous System Tumors Craniopharyngioma Choroid Plexus Tumors Pineoblastoma Hemangioblastoma Vestibular Schwannoma–Acoustic Neuroma Conclusion 232 - General Approaches and Considerations for Pediatric Brain Tumors General Approaches and Considerations for Pediatric Brain Tumors Epidemiology Clinical Features Classification Oncogenic Factors Molecular Factors Diagnostic Evaluation Treatment Preoperative Considerations Intraoperative Considerations Postoperative Considerations End of Therapy 233 - Optic Pathway Hypothalamic Gliomas ? Background Clinical Presentation Radiologic Imaging Chemotherapy Radiotherapy Management of Tumor-Related Hydrocephalus Tumor Biopsy Neurosurgery for Pure Optic Nerve Tumors (Anterior Intraorbital Portion) Treatment of Diffuse or Multifocal Optic Pathway Gliomas Neurosurgery to Debulk Chiasmatic or Hypothalamic Tumors Surgical Approach Neurosurgical Adjuncts and Advances Functional Outcome Conclusion 234 - Thalamic Tumors Surgical Anatomy Arterial Supply Thalamic Tumors Growth Patterns Presentation Clinical Presentation Radiographic Presentation Histopathology Molecular Drivers H3K27M Mutation RAF Mutations/Fusions IDH1 Mutations Treatment Surgical Decision Making Biopsy Open Resection Anterior Interhemispheric Transcallosal Approach Posterior Interhemispheric Transcallosal Approach Transcortical Parietooccipital Approach Supracerebellar Infratentorial Approach Adjuvant Treatment Outcomes Future Directions 235 - Choroid Plexus Tumors Epidemiology Pathology Gross Appearance Classification and Histopathology Immunohistochemistry Genetics and Molecular Biology Clinical Features Diagnostic Imaging Treatment Management of Hydrocephalus Preoperative Considerations Operative Treatment Special Considerations in the Pediatric Population Choroid Plexus Carcinoma and Atypical Choroid Plexus Papilloma Surgical Considerations Adjuvant Therapy Outcomes Conclusion 236 - Pediatric Craniopharyngiomas Introduction Epidemiology Histopathology Biologic Characteristics of ACP CTNNB1 Mutation and β-Catenin Accumulation The MAPK/ERK and EGFR Pathways The Programmed Cell Death Pathway: PD-1/PD-L1 Imaging Preoperative Evaluation Postoperative Evaluation Clinical Presentation and Evaluation Surgical Management Preoperative Considerations Operative Approaches Transnasal Endoscopic Approach Transventricular Neuroendoscopy Craniotomy Surgical Outcomes Radiation Therapy Stereotactic Radiosurgery Intracystic Therapy Intracavitary Bleomycin Intracavitary Interferon Intracavitary Irradiation Recurrent Craniopharyngiomas Conclusion 237 - Pediatric Supratentorial Hemispheric Tumors Background Clinical Presentation Low-Grade Tumors Low-grade Gliomas Glioneuronal Tumors High-Grade Tumors High-grade Gliomas Ependymomas Embryonal Tumor With Multilayered Rosettes Atypical Teratoid/Rhabdoid Tumors Conclusion 238 - Ependymomas Ependymomas Clinical Overview Prognostic Factors Extent of Resection Histologic Grade and Molecular Classification Age at Diagnosis Location Pathology Hereditary Tumor Syndromes Cancer Genetics Stem Cell Biology Ependymoma Variants Neuroimaging Initial Surgery Surgery For Residual or Recurrent Tumor Surgical Technique Treatment of Hydrocephalus Radiotherapy Chemotherapy Conclusion 239 - Medulloblastomas in Children Historical Perspective Epidemiology Pathology Gross Microscopic Genetics and Molecular Subgroups of Medulloblastoma WNT Medulloblastoma SHH Medulloblastoma Group 3 Medulloblastoma Group 4 Medulloblastoma Proposed Group 3 and Group 4 Medulloblastoma Subtypes Subtype III. Subtype III also has a median age at onset of 5 years, frequent metastasis (56%), and high male predominance (3.6:1... Subtype IV. This subtype occurs frequently in infants, with a median age of 3 years at diagnosis, has a male-to-female ratio of ... Subtype VIII. Subtype VIII tumors are the most common (25% of all Group 3 and Group 4 tumors). They occur in children, adolescen... Subtype V. This methylation subtype arises in childhood and adolescence with a 2.4:1 male predominance. Classic histology is mos... Subtype VII. Subtype VII tumors can occur in infancy through adulthood, but most commonly occur in childhood and twice as freque... Molecular Classification of Medulloblastoma and Genomic Testing Clinical Presentation Diagnostic Imaging Radiographic Correlates of Medulloblastoma Subgroups Staging and Prognostic Factors Histologic Classification and Prognosis Molecular Subgroups and Medulloblastoma Prognosis Treatment Surgery Management of Hydrocephalus Surgical Resection Technique Postoperative Complications Radiation Therapy Historical Perspective Risk-Adapted Therapeutic Strategies Alternative Radiation Technologies Radiation Strategies in Infants and Young Children Side Effects and Late Toxicities of Radiation Therapy Molecular Subgroups and Risk-Adapted Therapy Chemotherapy Average-Risk Children High-Risk Children Infants and Young Children Adverse Effects of Chemotherapy Novel Therapies Surveillance Imaging and Disease Prognosis Quality of Life in Medulloblastoma Survivors Future Directions 240 - Cerebellar Astrocytomas Molecular Biology and Etiology Cerebellar Astrocytomas Pathology Patient Characteristics Epidemiology Clinical Findings Imaging Features Surgical and Perioperative Management Adjuvant Therapy Complications Risk for Recurrence Surveillance Quality of Life Conclusion 241 - Brainstem Gliomas Advancement in Imaging Technologies and Intraoperative Facilities Brainstem Gliomas Focal Brainstem Glioma Clinical Presentation Imaging Studies Differential Diagnosis Biology and Pathology Management and Prognosis Surgical Intervention Midbrain. Most of the upper midbrain tumors, such as tectal gliomas, are usually associated with obstructive hydrocephalus. Ther... Pons. The midline suboccipital craniotomy is the most common approach for dorsally located tumors of the pons and the medulla.1 ... Medulla and Upper Cervical Spine. For intrinsic tumors of the medulla, a midline suboccipital craniotomy with removal of the dor... Chemotherapy BRAF Inhibitors Radiation Therapy Diffuse Intrinsic Pontine Glioma Clinical Presentation Imaging Studies Biology and Pathology Management and Prognosis Steroids Biopsy Radiotherapy Chemotherapy Conclusion 242 - Intracranial Germ Cell Tumors Epidemiology and Classification Molecular Pathogenesis Presentation Diagnostic Evaluation Surgical Management Adjuvant Therapy Germinomas Nongerminomatous Germ Cell Tumors Teratoma Conclusions 243 - Neurocutaneous Tumor Syndromes Epidemiology, Natural History, and Genetics Diagnosis Clinical Features and Management Neurocutaneous Tumor Syndromes Type 2 Neurofibromatosis Epidemiology, Natural History, and Genetics Diagnosis and Screening Clinical Features and Management Tuberous Sclerosis Complex Epidemiology Genetics Diagnosis Central Nervous System Manifestations Von Hippel-Lindau Disease Genetics and Pathogenesis Diagnosis and Screening Clinical Manifestations 244 - Pediatric Intraventricular and Periventricular Tumors Surgical Management Strategies Cerebrospinal Fluid Diversion Pediatric Intraventricular and Periventricular Tumors Microsurgical Approaches to Tumors of the Lateral and Third Ventricles Approaches to the Frontal Horn, Foramen of Monro, and Body of the Lateral Ventricle Anterior Transcortical Approach Anterior Interhemispheric Transcallosal Approach Approaches to the Atrium and Temporal Horn of the Lateral Ventricle Posterior Interhemispheric Transcingular Approach Intraparietal Sulcus/Transcortical Superior Parietal Lobule Approach Transsylvian/Transsylvian Translimen Insula Approach Occipitotemporal Sulcus Approach Open Approaches to the Anterior Third Ventricle Subfrontal Translamina Terminalis Approach Interforniceal Approach Transforaminal Approach Transchoroidal Approach Approaches to the Posterior Third Ventricle, Pineal Region, and Rostral Mesencephalon Posterior Interhemispheric Transsplenial Approach Infratentorial Supracerebellar Approach Occipital Transtentorial Approach Anterior Third Ventricular Approaches Revisited in the Endoscopic Era Endoscopic Tumor Biopsy Endoscopic Septal Fenestration Endoscopic Tumor Removal Endoscopic Tumor Cyst Fenestration Complications Associated With Endoscopic Surgery Intraventricular Tumor Subtypes Classified by Surgically Relevant Anatomic Regions Tumors of the Lateral Ventricle Subependymal Giant Cell Astrocytoma Central Neurocytoma Choroid Plexus Tumors Meningioma Tumors of the Anterior Third Ventricle Craniopharyngioma Tumors of the Posterior Third Ventricle, Pineal Region, and Rostral Mesencephalon Pinealoblastoma Pineocytoma Pineal Parenchymal Tumor of Intermediate Differentiation Teratoma Germ Cell Tumors Tectal Tumors Involving the Third Ventricle Tumors of the Fourth Ventricle Ependymoma Medulloblastoma Epidermoid Cyst Tumors With Multiple Possible Intraventricular or Periventricular Locations Low-Grade Gliomas Infrequent Tumors Conclusion 245 - Skull Lesions in Children Inclusion Cysts Langerhans Cell Histiocytosis Fibrous Dysplasia Juvenile Ossifying Fibromas Intraosseous Lipomas of the Skull 246 - Moyamoya Disease in Children Epidemiology Associated Conditions Pathophysiology Genetics Clinical Findings Ischemic Symptoms Hemorrhage Headache and Other Symptoms Natural History and Prognosis Diagnosis Computed Tomography Magnetic Resonance Imaging Angiography Other Diagnostic Techniques Screening and Genetic Testing Treatment Medical Therapy Surgery Indications and Timing Surgical Approaches Indirect Revascularization Anesthetic Management Perioperative Care Acute Symptoms Follow-up Conclusion 247 - Vein of Galen Aneurysmal Malformation Choroidal Vein of Galen Aneurysmal Malformation Mural Vein of Galen Aneurysmal Malformation Vein of Galen Aneurysmal Dilation Pial Arteriovenous Malformation With Vein of Galen Aneurysmal Dilation Vein of Galen Aneurysmal Malformation Dural Arteriovenous Malformation With Vein of Galen Aneurysmal Dilation Vein of Galen Varix Embryology Genetic Cause of Vein of Galen Aneurysmal Malformation Angioarchitecture of Vein of Galen Aneurysmal Malformation Clinical Manifestations Cardiac Failure Umbilical Catheterization and Early Treatment Strategy Hydrodynamic Disorder Melting Brain Syndrome Treatment Indication and Goal of Treatment Pretherapeutic Evaluation Endovascular Treatment Development of Dural Shunting Dural Sinus Occlusion and Endovascular Treatment Surgical Treatment Stereotactic Radiotherapy Treatment Results Follow-Up Conclusion 249 - Pediatric Arteriovenous Malformations Pediatric Arteriovenous Malformations Pathology Presentation Location Natural history Mortality Diagnostic Decision Making Therapeutic Decision Making Surgery Stereotactic Radiosurgery Embolization Multimodal Treatment Recurrence Special Considerations Conclusion 250 - Management of Head Injury: Special Considerations in Children Types of Head Injury Initial Evaluation Management of Traumatic Brain Injury Mild Traumatic Brain Injury Moderate and Severe Traumatic Brain Injury Surgical Indications and Preoperative Considerations Skull Fracture Placement of Intracranial Pressure Monitors and External Ventricular Drains Hematoma Evacuation Decompressive Craniectomy Cranioplasty Intensive Care Unit Management Physiology Medical Treatment of Intracranial Hypertension Hyperosmolar Therapy Hyperventilation Sedation and Paralysis Barbiturate Coma Seizures Temperature and Hypothermia Outcomes Conclusion 251 - Inflicted Trauma (Child Abuse) Inflicted Trauma (Child Abuse) Physical Abuse in Older Children Management of Head Injuries from Child Abuse Acute Subdural Hematoma Extracerebral Fluid Collections Ex Vacuo Cerebrospinal Fluid Collections Spinal Injury Caused by Child Abuse Outcome of Head Injuries From Child Abuse Prevention Medicolegal Considerations in Child Abuse Physician Responsibility and Liability The Physician as a Witness Preparing for Court Testimony Legal and Social Outcomes of Child Physical Abuse 252 - Growing Skull Fractures History and Pathogenesis Epidemiology Classification Evaluation, Diagnosis, and Treatment Treatment Conclusion 253 - Neonatal Brain Injury Hypoxia-Ischemia and Neonatal Encephalopathy Neonatal Seizures Intracranial Hemorrhage in Newborns Germinal Matrix and Intraventricular Hemorrhage of Prematurity Pathophysiology Presentation, Evaluation, and Treatment Traumatic Intracranial Hemorrhage in Newborns Pathophysiology Presentation, Evaluation, and Treatment Conclusion 254 - Birth Brachial Plexus Injury Birth Brachial Plexus Injury Pathophysiology nAtural History Clinical Presentation Patient Evaluation Surgical Treatment Exposure of Brachial Plexus Resection of Neuromas Repair Procedures Complications Postoperative Care Surgical Outcome Conclusion 255 - Myelomeningocele and Myelocystocele Myelomeningocele History Anatomy, Embryology, and Pathogenesis Cervical Myelomeningocele Epidemiology and Etiology Nutritional Deficiencies Antiepileptics and Other Risk Factors Associated Chromosomal Abnormalities Diagnosis Maternal Serum α-Fetoprotein High-Resolution Fetal Ultrasonography Magnetic Resonance Imaging Amniocentesis Prognosis and Prenatal Counseling Cognitive Development Motor Function Urinary and Fecal Continence Risk in Siblings Perinatal Management In Utero Repair Delivery Neurosurgical Evaluation Renal Plastic Surgery Surgery: Myelomeningocele Repair Timing Preparation and Positioning Hydrocephalus Operative Technique Large Defects Kyphosis Postoperative Management Complications and Long-Term Follow-up Early Complications Hydrocephalus Chiari II Malformation Tethered Spinal Cord Hydrosyringomyelia Orthopedics Latex Allergy Long-Term Follow-up Myelocystocele History Anatomy, Embryology, and Pathogenesis Epidemiology and Etiology Diagnosis Prognosis and Prenatal Counseling Perinatal Management Surgery: Myelocystocele Repair Timing Operative Technique Complications and Long-Term Follow-up 256 - Fetal Surgery for Myelomeningocele Fetal Surgery for Myelomeningocele Management of Myelomeningocele Study After the Management of Myelomeningocele Study Benefits of Fetal Surgery Risks of Fetal Surgery Prenatal Counseling for Fetal Surgery Surgical Technique Innovations and What Lies Ahead 257 - Lipomyelomeningocele Embryology Lipomyelomeningocele Epidemiology Patient Presentation Cutaneous Signs Symptoms Evaluation Prenatal Diagnosis Ultrasonography Plain Radiographs Magnetic Resonance Imaging Computed Tomography Urodynamics Surgical Treatment Indications Operative Technique Intraoperative Electrophysiology Complications Outcomes Conclusion 258 - Split Spinal Cord Epidemiology of Split Cord Malformations Embryogenesis Signs and Symptoms Imaging Surgical Management Outcomes Conclusion 259 - Tethered Spinal Cord: Fatty Filum Terminale, Meningocele Manqué, and Dermal Sinus Tracts Embryologic Overview Imaging Considerations Tethered Spinal Cord: Fatty Filum Terminale, Meningocele Manqué, and Dermal Sinus Tracts Fatty Filum Terminale Symptoms Treatment Meningocele Manqué Symptoms Treatment Dermal Sinus Tracts Symptoms Radiology and Treatment Conclusion 260 - Developmental Anomalies of the Craniovertebral Junction and Surgical Management Introduction Anatomy of the Craniovertebral Junction Bone-Ligament Complex Blood Supply Lymphatic Drainage Embryology and Development of Craniovertebral Junction Disorders Implications of Craniovertebral Abnormalities Biomechanics Biomechanical Comparison of Cervical Orthoses Classification of Craniovertebral Junction Abnormalities Epidemiology Clinical Presentation Neurodiagnostic Imaging Treatment Developmental Abnormalities Affecting the Craniovertebral Region Grisel Syndrome Down Syndrome Proatlas Segmentation Failures or Manifestations of Occipital Vertebrae Assimilation of the Atlas and Klippel-Feil Syndrome Basilar Invagination Anomalies of the Odontoid Process Aplasia-Hypoplasia of the Dens Os Odontoideum Basilar Impression and Bone-Softening Disorders Skeletal Dysplasias Mucopolysaccharidosis 261 - Achondroplasia and Other Dwarfisms Genetics And Epidemiology Clinical Manifestations Evaluation And Diagnosis Cervicomedullary Compression Clinical Findings and Pathology Evaluation Indications for Surgery Hydrocephalus Clinical Findings and Pathology Evaluation Indications for Surgery Spinal Stenosis Clinical Findings and Pathology Evaluation Indications for Surgery Operative Management Cervicomedullary Compression Spinal Stenosis Outcome Craniocervical Decompression Spinal Decompression Spinal Restenosis in Achondroplasia Conclusion 262 - Surgical Management of the Pediatric Subaxial Cervical Spine Biomechanics Normal Kinematics Determinants of Stability Surgical Management of the Pediatric Subaxial Cervical Spine Clinical Presentation of Subaxial Cervical Spine Disorders Common Pathologic Conditions Congenital Abnormalities Neoplastic and Other Acquired Conditions Epidemiology Klippel-Feil Syndrome and Klippel-Feil Variant Vater/Vacterl Association Management of Subaxial Cervical Spine Lesions Nonoperative Management External Orthoses Diagnostic Imaging Eosinophilic Granuloma Osteoid Osteoma and Osteoblastoma Treatment Surgical Management Anterior Cervical Approach ?Approach. The anterior cervical approach can be used to gain access to the spine anywhere from the body of C2 to at least T1, a... Implants. No spinal implants have been approved by the US Food and Drug Administration for use in the subaxial cervical spine in... Disk Arthroplasty. Disk arthroplasty has been explored in the treatment of adult patients with surgical disk herniation.64,65 Th... Absorbable Plates. Absorbable plates have been studied in a limited fashion in both adult and pediatric patients.66,67 In the pe... Cervical Anterolateral Approach Posterior Cervical Approach Bone Graft Materials Postoperative Follow-Up 263 - Tumors of the Spine, Spinal Canal, and Spinal Cord in Children Introduction Epidemiology Intramedullary Spinal Cord Tumors Intradural Extramedullary Tumors Extradural Tumors Spinal Column Tumors Pathology Intramedullary Spinal Cord Tumors Intradural Extramedullary Tumors Extradural Tumors Spinal Column Tumors Presentation Diagnostic Evaluation Intramedullary Spinal Cord Tumors Intradural Extramedullary Tumors Inclusion Cysts Extradural Tumors Spine Tumors Treatment: Surgery Intramedullary Spinal Cord Tumors Intradural Extramedullary Tumors Extradural Tumors Spinal Column Tumors Treatment: Alternative and Adjuvant Therapeutics Intramedullary Spinal Cord Tumors Intradural Extramedullary Tumors Extradural Tumors Spinal Column Tumors Malignant Tumors Complications Outcomes Intramedullary Spinal Cord Tumors Intradural Extramedullary Tumors Extradural Tumors Spinal Column Tumors Benign Tumors Malignant Tumors Conclusion 264 - Introduction to Spinal Deformities in Children History and Physical Examination in Pediatric Spinal Deformities Radiographic Assessment of Pediatric Spinal Deformity Plain Films Magnetic Resonance Imaging Computed Tomography Ultrasonography Etiology and Classification of Pediatric Spinal Deformities Infantile Idiopathic Scoliosis Juvenile Idiopathic Scoliosis Adolescent Idiopathic Scoliosis Neuromuscular Scoliosis Congenital Scoliosis Scheuermann Kyphosis Treatment of Scoliosis in the Growing Spine Long-Term Consequences of Fusion in Skeletally Immature Children Spondylolysis Spondylolisthesis Surgical Adjuncts Future Research Conclusion 265 - Thoracolumbar Spinal Disorders in Pediatric Patients Imaging Evaluation Thoracolumbar Spinal Disorders in Pediatric Patients Principles of Management Congenital Disorders Congenital Scoliosis Congenital Kyphosis Congenital Lordosis Congenital Stenosis Spinal Dysraphism Diastematomyelia Epidermoids, Dermoids, and Dermal Sinus Tracts Tethered Cord Neuromuscular Disorders Cerebral Palsy Neuromuscular Dystrophies and Myopathies Myelomeningocele Spinal Cord Injury and Paralytic Deformity Idiopathic Scoliosis Nonoperative Management Surgical Management (Nonfusion) Surgical Management (Fusion) Surgical Treatment by Lenke Curve Types Lenke 1: Single Thoracic Curve Lenke 2: Double Thoracic Curve Lenke 3: Double Major Curve Lenke 4: Triple Major Curve Lenke 5: Thoracolumbar/Lumbar Curve Lenke 6: Thoracolumbar/Lumbar and Main Thoracic Curves Surgical Fusion for Lenke Curves Selective Fusion and Long-Term Outcomes Data for Idiopathic Scoliosis Evolution of Scoliosis Surgery and Potential Strategies to Reduce Complications Intraoperative Image Navigation Intraoperative Neuromonitoring Use of Antifibrinolytics Conclusion Pediatric Vertebral Column and Spinal Cord Injuries Pediatric Vertebral Column and Spinal Cord Injuries Introduction Epidemiology Anatomic Considerations Cervical Pseudosubluxation History and Physical Examination Immobilization Medical Management Steroids Venous Thromboembolism Imaging X-Ray Computed Tomography Scans Magnetic Resonance Imaging “Clearing” the Cervical Spine Cervical Spine Injuries Atlantooccipital Dislocation Diagnosis Treatment Atlantoaxial Rotatory Subluxation Diagnosis Treatment C1 Anterior Subluxation Diagnosis Treatment Fracture of the Odontoid Synchondrosis Diagnosis Treatment Diagnosis Treatment Subaxial Cervical Spine Injuries Teardrop Fractures Unilateral or Bilateral Locked Facets Sciwora Diagnosis Treatment Thoracolumbar Spinal Column Injuries Compression and Transverse Process Fractures Treatment Hyperflexion/Distraction Injuries and the “Seat Belt Syndrome” Diagnosis Treatment Burst Fractures and Fracture-Dislocations Treatment Vertebral End Plate Fractures and Traumatic Disk Herniations Surgical Treatment Of Spinal Column Injuries Rehabilitation Future Directions Summary 267 - Pediatric Epilepsy Surgery Epilepsy and the Developing Brain The Path to Pediatric Epilepsy Surgery Epilepsy Classification: Modern Approaches Presurgical Evaluation Surgical Approaches: Diagnostic and/or Therapeutic Stereo-Electroencephalography Grid, Strip, and Depth Electrodes Focal Resection/Ablation Hemispherotomy and Disconnections Callosotomy Vagus Nerve Stimulation Deep Brain Stimulation Responsive Neurostimulation Conclusion 268 - Clinical Features and Management of Cerebral Palsy Diagnosis and Classification Associated Impairments Neurological and Developmental Comorbidities Sensation Communication Epilepsy Cognition and Behavior Secondary Conditions and Other Health Impairments Gastrointestinal Renal Improving Mobility and Motor Function (“I Want to Walk”): how do we Help Them Physical and Occupational Therapy Management of Hypertonia and Spasticity in Cerebral Palsy Oral Medications Baclofen Tizanidine Diazepam Dantrolene Sodium Gabapentin Focal Spasticity Botulinum Toxin Serial Casting Phenol and Alcohol Multisegmental and Generalized Spasticity Selective Dorsal Rhizotomy (see Chapter 270) Intrathecal Baclofen (see Chapter 269) Orthopedic Surgery Dystonia and Mixed Movement Disorders in Cerebral Palsy Conclusion 269 - Intrathecal Baclofen Therapy for Cerebral Palsy Anchor 66 Introduction Patient Selection Screening Tests Pump and Catheter Implantation Dosing Outcomes In Intrathecal Baclofen Therapy Complications of Intrathecal Baclofen Therapy Approach to the Patient with Baclofen Overdose Approach to the Patient in Baclofen Withdrawal Future Directions Conclusions 270 - Selective Dorsal Rhizotomy for Spastic Cerebral Palsy Harmful Effects of Cerebral Palsy Spasticity Indications for Selective Dorsal Rhizotomy Contraindications for Selective Dorsal Rhizotomy Preoperative Evaluation ?Surgical Technique (see Video 270.1) St. Louis children’s hospital experience 271 - Pathophysiology of Surgical Nerve Disorders Introduction and Overview Grading of Peripheral Nerve Injuries Mechanisms of Nerve Injuries Direct Nerve Injury (Trauma) Neuroma-in-Continuity (Stretch, Traction, and Contusion). Medium- to high-energy forces applied to nerves can result in a combin... Avulsion Injury. Brachial plexus injury is a common disorder resulting from a stretch mechanism. Stretch or traction injuries to... Compartment Syndromes. Severe crush injury, burns, skeletal fracture with vascular compromise, and anticoagulant administration ... Nerve Injuries Caused by Injections. Injection injury is usually iatrogenic injury caused by a needle placed into or close to a ... Indirect Nerve Injury (Complex Nerve Injuries) Electrical Thermal Irradiation Neurobiology of Peripheral Nerve Injury Regenerative Response After Nerve Injury Initial Phase of Regeneration Role of Schwann Cells in Axonal Regeneration Experimental Paradigms and Assessment of Axonal Regeneration Later Events: Neuronal Attrition and Misdirection After Nerve Injury Chronic Schwann Cell Denervation Chronic Neuronal Axotomy Misdirection of Regenerating Axons Pathophysiologic Basis of Surgical Management for Nerve Injuries Conclusion and Future Directions 272 - Peripheral Nerve Examination, Evaluation, and Biopsy Setting Obtaining the Medical History Characteristic Aspects of Nerve Pain Subtypes Sensory Loss Patient Description of Motor Deficits Risk Factors for Repetitive Strain, Entrapment, and Medical Neuropathies Physical Examination General Inspection Orthopedic Assessment Motor Examination Sensibility Testing Autonomic Testing Reflex Tests Peripheral Nerve Examination Diagnostic Confirmation Electrodiagnostics in the Diagnostic Paradigm Nerve Imaging With Magnetic Resonance Neurography, Computed Tomography, Positron Emission Tomography, and Ultrasound Ongoing Reassessment Nerve Biopsy Conclusion 273 - Peripheral Neuropathies Introduction Anatomy and Physiology of Peripheral Nerves Clinical Evaluation of Peripheral Neuropathy Electrodiagnostic Evaluation Laboratory, Radiologic, and Other Studies in Peripheral Neuropathy Metabolic Neuropathies Diabetic and Metabolic Peripheral Neuropathy Chronic Renal Failure Immune-Mediated Neuropathies Acute Inflammatory Demyelinating Polyneuropathy Chronic Inflammatory Demyelinating Polyradiculoneuropathy Chronic Inflammatory Demyelinating Polyradiculoneuropathy Variants Plasma Cell Dyscrasias and Monoclonal Gammopathy of Uncertain Significance Neuropathies of Vasculitis Hereditary Neuropathies Charcot-Marie-Tooth Disease (Hereditary Motor Sensory Neuropathy) Other Inherited Neuropathies Infectious Neuropathies Environmental and Toxic Neuropathies Vitamin and Mineral Deficiencies Toxic Neuropathies Critical Illness Neuropathy Skin and Peripheral Nerve Biopsy Conclusion Electromyography Nerve Conduction Studies Monitoring of Neural Function: Electromyography, Nerve Conduction, and Evoked Potentials Other Peripheral Neurodiagnostics Combined Central and Peripheral Tests Common Clinical Disorders Surgical Applications General Use of Intraoperative Neurodiagnostic Monitoring 275 - Imaging for Peripheral Nerve Disorders Technical Aspects of Magnetic Resonance Neurography Diffusion-Based Tractographic Techniques T2-based Neurography The Physiologic Foundation of T2-based Neurography Optimizing Performance of the Main Magnet of Magnetic Resonance Imaging Spatial Resolution and Signal-to-Noise Performance Phased-Array Coils Intravenous Gadolinium Contrast Agent Image Plane Orientation Nerve Image Reconstruction, Three-Dimensional Reconstruction, and Partial Volume Averaging Conspicuity and Maximum-intensity Projection Images Dynamic Three-dimensional Analysis Classes of Image Findings Imaging in the Setting of Nerve Entrapment and Pain Image Findings in Brachial Plexus Studies Thoracic Outlet Syndromes Brachial Plexus Neuritis Lumbar Foraminal Pathology Magnetic Resonance Neurography in the Pelvis Distal Entrapments Nerve Adhesions Reflex Sympathetic Dystrophy Nerve Trauma Obstetric Injury to the Brachial Plexus Follow-up of Nerve-Grafting Procedures Nerve Tumors Magnetic Resonance Findings in Systemic Neuropathies Diagnosis of Diseases Affecting Muscle Imaging of Denervated Muscle Muscle Magnetic Resonance Imaging in the Setting of Nerve Injury Myopathic and Neuropathic Effects on Muscle Image Patterns Conclusion 276 - Distal Entrapment Syndromes: Carpal Tunnel, Cubital Tunnel, Peroneal, and Tarsal Tunnel Median Nerve Anatomy Clinical Findings Diagnostic Evaluation Conservative Treatment Surgical Techniques Open Technique Endoscopic Techniques Ultrasound-guided Techniques Ulnar Nerve Anatomy Clinical Findings Diagnostic Evaluation Conservative Treatment Operative Treatment Common Peroneal Nerve Anatomy Clinical Findings Diagnostic Evaluation Conservative Treatment Operative Treatment Posterior Tibial Nerve Anatomy Clinical Findings Diagnostic Evaluation Conservative Treatment Surgical Treatment Double Crush Syndrome 277 - Brachial Plexus Nerve Entrapments and Thoracic Outlet Syndromes Subcategorization in the Definition of Thoracic Outlet Syndrome Neurogenic, Vascular, and Nonspecific Thoracic Outlet Syndrome Brachial Plexus Nerve Entrapment Syndromes Clinical Presentation Physical Examination Findings Diagnostic Imaging in Thoracic Outlet Syndrome Scalene Syndrome and Other Proximal Entrapments Entrapments in the Midplexus Involvement of the Axillary Nerve and Distal Plexus Imaging Diagnosis of Plexitis Summary of Diagnostic Imaging Approaches Image-Guided Injections of the Scalene Muscles and Distal Plexus Conclusion Neuroplasty Surgery for Thoracic Outlet Syndromes Neuroplasty Approaches Procedure for Supraclavicular Approach Procedure for Transaxillary Approach for Neuroplasty of the Distal Plexus and Axillary Nerve First Rib Resection Image Diagnosis and Surgical Outcomes Outcome Studies Review 278 - Piriformis Syndrome, Obturator Internus Syndrome, Pudendal Nerve Entrapment, and Other Pelvic Entrapments Distinguishing Among Spinal Versus Pelvis Peripheral Nerve Etiologies by Physical Examination Nerve Entrapments of the Posterior Pelvis: Superior Gluteal Nerve and Sciatic Entrapment by the Piriformis Muscle Diagnosis and Management of Pelvic Sciatic Syndromes Physical Examination Findings in Pelvic Sciatic Nerve Entrapment Syndromes Neurography Results for Sciatica of Nondisk Origin Open MRI–Guided Injections for Piriformis Syndrome Minimal Access Surgery for Pelvic Entrapment of the Sciatic Nerve Nerve Entrapments of the Lower Pelvis: Entrapments of the Pudendal Nerve and the Nerve to the Obturator Internus Diagnosis and Management of Pudendal Syndromes Presentation Physical Examination Findings Management With Open MRI–Guided Injections Surgical Management of Pudendal Nerve Entrapment Nerve Entrapments of the Anterior Pelvis: Ilioinguinal, Femoral, Obturator, and Lateral Femoral Cutaneous Nerves 279 - Techniques in Nerve Reconstruction and Repair Functional Anatomy Pathologic Principles and Surgical Indications General Considerration for Surgery and Operative Principles Nerve Repair Technique Epineurial Repair Fascicular Repair Grouped Fascicular Repair End-to-Side Repair Nerve Grafting Nerve Graft Harvesting Techniques Nerve Tube Repair Postoperative Care Envisioning of Prospects for How to Improve Results of Nerve Repair Conclusion 280 - Nerve Transfers Nerve Transfers Spinal Accessory Transfer Contralateral C7 Transfer Other Commonly Used Transfers Conclusion 281 - Management of Acute Peripheral Nerve Injuries Pathophysiology of Nerve Injuries Management of Acute Nerve Injuries According to the Biomechanical Classification Overall Approach to Management of Acute Nerve Injuries Management of Acute Peripheral Nerve Injuries Management of Type A Injuries Transection Stretch, Traction, and Contusion With or Without a Lesion-in-Continuity Avulsion Compartment Syndromes Management of Type C Acute Nerve Injuries Electrical Nerve Injuries Thermal Injuries Irradiation Injuries Injection Injuries Approach to Intraoperative Management of Acute Nerve Injuries: Microsurgery Intraoperative Nerve Action Potential The Role of Tissue Engineering: Nerve Conduits The Role of Electrical Stimulation Conclusion 282 - Early Management of Brachial Plexus Injuries Early Management of Brachial Plexus Injuries Introduction Anatomy Pathophysiology and Classification Brachial Plexus Injuries in Adults Clinical Assessment Associated Injuries Preoperative Ancillary Investigations Therapy and Management Infraclavicular Exposure. An incision is made over the deltoid-pectoral groove. The pectoralis major muscle can be divided at it... Posterior Exposure. A posterior approach to the BP has been described by Kline and is indicated in well selected cases to expose... Nerve Transfer. In a nerve transfer, a functioning donor nerve is divided and the proximal end is coapted to the denervated dist... Triceps Nerve Branch. Functional restoration of shoulder abduc­tion can be achieved by transferring a nerve branch of the radial... Fascicles of the Ulnar and Median Nerve. Transfer of a single fascicle of the ulnar nerve to the biceps innervation was describe... Contralateral C7. Gu et al. first proposed using the entire contralateral C7 nerve for transfer in 1986, a rather radical approa... Novel Nerve Transfer Techniques Clinical Outcome of Brachial Plexus Surgery in Adults Birth-Related Brachial Plexus Injuries Timing of and Selection for Surgery Clinical Outcome After Nerve Surgical Treatment of Birth-Related Brachial Plexus Injury Shoulder Function Elbow Flexion Hand Function 283 - Secondary Procedures for Brachial Plexus Injuries Tendon Transfer General Principles Tissue Equilibrium Pain Control Availability Muscle Strength Excursion Direction Synergy Tension Tendon Transfer for Shoulder Function Transfer of the Trapezius Latissimus Dorsi and Teres Major Transfer Tendon Transfer for Elbow Flexion Steindler Procedure Pectoralis Major Transfer Latissimus Dorsi Transfer Tendon Transfer for Elbow Extension Tendon Transfer for Wrist Stabilization Tendon Transfer for the Hand Functioning Free Muscle Transfer Functioning Free Muscle Transfer for Elbow Function Functioning Free Muscle Transfer for Prehensile Function Double Functioning Free Muscle Transfer Arthrodesis Tenodesis Corrective Osteotomy Amputation/Prostheses Rehabilitation Cortical Reorganization and Training Muscle Stimulation Splinting Pain Management Conclusion 284 - Nerve Injuries of the Lower Extremity Epidemiology Lumbosacral Plexus Injuries Obturator Nerve Femoral Nerve Surgery Results Lateral Femoral Cutaneous Nerve Sciatic Nerve and Other Nerves of the Posterior Pelvis Surgery Results Peroneal Nerve Surgery Results Posterior Tibial Nerve Surgery Results Conclusion 285 - Benign and Malignant Tumors of the Peripheral Nerve Benign Tumors of Neural Sheath Origin Schwannoma Surgical Approach Neurofibroma Surgical Approach Surgical Outcome Perineurioma Benign Tumors of Non–Neural Sheath Origin Desmoid Tumors Ganglion Cysts Myoblastoma or Granular Cell Tumor Lymphangiomas Lipomas Meningiomas Radiation-Induced Brachial Plexus Lesions (Actinic Plexitis) Malignant Peripheral Nerve Sheath Tumors Epidemiology and Risk Factors Diagnosis Imaging Treatment Radiotherapy Chemotherapy Pathology Prognosis 286 - Avoiding Iatrogenic Injury Affecting Nerves and Treatment of Consequent Symptoms Neurological Symptoms After Nerve Injury Iatrogenic Nerve Injuries Nerve Injuries Associated With Surgical Positioning and Preparation Iatrogenic Injury of Nerves During Procedures or Surgery on Nonneural Tissues Preventable or Unpredictable Known or Common Nerve Injuries of a Nearby Nerve Iatrogenic Injury of Peripheral Nerves During Spine Surgery Iatrogenic Injury During Peripheral Nerve Surgery and Complication Avoidance Conclusion 287 - Neuroelectronic Systems Patient Population Targeted Muscle Reinnervation Surgery Bionic Reconstruction Surgery Intermediate Rehabilitation Postoperative Rehabilitation Implantable Neuroelectronic Interfaces Conclusion 288 - Peripheral Nerve Surgery for Central Nervous System Disorders Peripheral Nerve Surgery for Central Nervous System Disorders Spinal Cord Injury Background Upper Motor Neuron Versus Lower Motor Neuron Injury Cervical Spinal Cord Injury Lower Spinal Cord Injury Spasticity Dystonia Contralateral Nerve Transfers for Spastic Hemiplegia Potential Role for Nerve Transfers in Acute Flaccid Myelitis Potential Role for Nerve Transfers in Brainstem Lesions Conclusion 289 - Peripheral Nerve Treatments for Central and Autonomic Disorders Eagle Syndrome: Entrapment of the Glossopharyngeal Nerve Associated With an Elongated or Ossified Cranial Styloid Process Peripheral Nerve Treatments for Central and Autonomic Disorders Headache Syndromes Treatable by Nerve Decompression Treatment of the Celiac and Splanchnic Plexus for Management of Upper Abdominal Pain and Gastrointestinal Dysmotility Syndromes Treatment of the Superior Hypogastric Plexus and Inferior Hypogastric Plexus Decompression of the Inferior Hypogastric (Impar) Ganglion for Treatment of Urogenital Pain and Dysfunction 290 - General and Historical Considerations of Radiotherapy and Radiosurgery The Beginning The Search for Energy and Penetration Emergence of Radiobiology and Limitation of Radiation Injury Imaging and Targeting Computational Advances The Organization of Clinical Investigation and Practice Robotic Positioning and Automated Collimation Brachytherapy Stereotactic Radiosurgery Intensity-Modulated Radiotherapy and Volumetric Modulated Arc Therapy Particulate and Other Novel Radiation Systems Exporting Radiosurgery from Brain to Body Conclusion 291 - Radiobiology of Radiotherapy and Radiosurgery Types of Therapeutic Radiation X-Rays: External Beam Radiotherapy Gamma Rays: Gamma Knife Radiosurgery Radiobiology of Radiotherapy and Radiosurgery Heavy-Ion Particles: Protons and Carbon Ions Electrons Brachytherapy Linear Energy Transfer and Relative Biologic Effectiveness Direct and Indirect Effects of Radiation Effects of Ionizing Radiation Time Scale Cellular and Subcellular Effects Early and Late Effects of Radiation in Normal Tissue Functional Organization of Tissue Therapeutic Ratio Models of Cell Survival Conventional Radiation Target Theory Linear Quadratic Theory Stereotactic Radiosurgery and Stereotactic Radiotherapy Classic Descriptions of DNA Damage Repair Fractionation The Five Rs of Radiobiology Repair: Basic Molecular Mechanisms of DNA Damage and Repair Single-Stranded and Double-Stranded Break Repair Chromosomal Alterations Cell Cycle and Redistribution Cell Cycle Redistribution Reoxygenation Repopulation Radiosensitivity Radiobiologic Considerations for Different Radiation Techniques Three-Dimensional Conformal Radiation Therapy Intensity-Modulated Radiotherapy and Arc Therapy Image-Guided Radiotherapy Stereotactic Radiosurgery and Stereotactic Radiotherapy Conclusion 292 - Radiation Therapy Techniques Radiation Modalities Two-Dimensional And Three-Dimensional Techniques Conventionally Fractionated Radiotherapy Whole-Brain Radiotherapy Versus Partial-Brain Radiotherapy Intensity-Modulated Radiotherapy Stereotactic And Image-Guided Radiotherapy Stereotactic Radiosurgery Hypofractionated Stereotactic Radiotherapy Charged-Particle Therapy Brachytherapy 293 - Radiosurgery Technique History of Radiosurgery Radiation Sources for Radiosurgery Photon-Based Radiosurgery Particle Radiation Radiosurgical Devices Gamma Knife Linear Accelerator–Based Radiosurgery Proton Radiosurgery Summary The Gamma Knife Radiosurgical Procedure Stereotactic Frame Placement Custom Mask Creation and Reference Cone Beam Computed Tomography Frame Adaptor and Frame Cap Fitting Check Stereotactic Brain Imaging With Magnetic Resonance Imaging, Computed Tomography, Angiography, or Any Combination of These Modali... Coregistration of Images Treatment Planning Dose Prescription and Fractionation Selection Dose Limitations to Critical Structures: Value of Shielding and Plugging Technique Stereotactic Delivery of Radiation to the Target Volume Inside the Collimator System Removal of the Stereotactic Guiding Device The Linear Accelerator–Based Radiosurgical Procedure Immobilizing the Target of Radiation Dosimetry: Prescribing to a Target Volume Methods of Conformality in Available in LINAC Devices Frameless Radiosurgery and the Spine Proton Beam Radiosurgery Conclusion 294 - Radiology of Radiation Techniques Introduction Vestibular Schwannoma Preoperative Imaging Postoperative Imaging Complications Meningioma Preoperative Imaging Postoperative Imaging Complications Arteriovenous Malformation Preoperative Imaging Postoperative Imaging Complications Intracranial Metastasis Preoperative Imaging Postoperative Imaging Complications 295 - Combining Ionizing Radiation and Systemic Therapies for Treatment of Brain Metastases Introduction Cytotoxic Chemotherapy And Radiation Targeted Therapy And Radiation Breast Cancer Melanoma Lung Cancer Immunotherapy And Radiation CTLA-4 Inhibitors (Ipilimumab) PD-1/PD-L1 Inhibitors Recommendations 296 - Fractionated Radiotherapy for Brain Tumors Radiobiology Radiation Delivery: Technical Issues Treatment Setup Three-Dimensional Planning and Treatment Conventional External-Beam Radiotherapy Fractionated Stereotactic Radiotherapy Charged Particles Clinical Applications Brain Metastases Medical Management Radiotherapy Fractionation Trials Dose-Response Relationship Prognostic Factor Analysis Role of Adjuvant Whole-Brain Radiotherapy Radiation Sensitizers Side Effects of Whole-Brain Radiotherapy Prophylactic Cranial Irradiation Reirradiation of Brain Metastases Future Directions Primary Central Nervous System Neoplasms Gliomas Glioblastomas Utility of Radiation Therapy. Although retrospective analysis demonstrates that nearly gross total resection (>98%) of GBM leads... Radiation Target Volume Recurrence Patterns. Despite the recognized benefit of adjuvant RT in improving the durability of local control, most patients w... Radiation Dose Chemotherapy. The use of chemotherapy for GBM is discussed extensively elsewhere, but the utility of adjuvant chemotherapy in co... Sensitizer Trials. One of the identifying pathologic features of GBM is tumor necrosis. Viable cells exist between the necrotic,... Particle Beam Radiotherapy. Because of the grim prognosis and relative lack of success to date with dose escalation and radiosen... Prognostic Factor Analysis. The RTOG used an RPA to analyze survival in 1578 patients entered in three RTOG malignant glioma tri... Anaplastic (WHO Grade III) Gliomas Low-Grade Gliomas Meningiomas Benign Meningiomas Optic Nerve Sheath Meningiomas. Management of optic nerve sheath meningiomas (ONSMs) is almost exclusively nonsurgical. These ra... Atypical (WHO Grade II) Meningiomas Malignant (WHO Grade III) Meningiomas Recurrent Meningiomas Juxtaposing SRS for Meningiomas Versus FSRT Proton Therapy for Meningiomas Hemangiopericytomas Intracranial Schwannomas Primary Central Nervous System Lymphomas Pituitary Adenomas Prolactinomas Cushing Disease Nelson Syndrome Acromegaly Nonfunctioning Adenomas Primitive Neuroectodermal Tumors Germ Cell Neoplasms Craniopharyngiomas Chordomas Chondrosarcomas Complications 297 - Fractionated Radiotherapy for Spine Tumors Radiation Tolerance of the Spinal Cord Radiotherapy Techniques Intramedullary Tumors Astrocytoma Radiotherapy Dose and Techniques Ependymoma Radiotherapy Dose and Techniques Extramedullary Tumors Meningioma Nerve Sheath Tumor Extradural Tumors Tumors of the Vertebral Column: Metastatic Treatment: Cord Compression Treatment: Uncomplicated Bone Metastases Treatment: Retreatment after Prior Radiotherapy Radiation Dose and Volumes Tumors of the Vertebral Column: Primary Chordoma Radiotherapy Dose and Techniques. Based on treatment guidelines for proton therapy, doses of at least 70 to 80 GyE to the GTV ar... Chondrosarcoma Radiotherapy Dose and Techniques. Radiotherapy target delineation is similar to that for chordomas. Because they appear to be sl... Osteosarcoma Ewing Sarcoma Radiotherapy Dose and Techniques. Ewing sarcoma is a chemotherapy-sensitive tumor and often shows dramatic responses to therapy.... Conclusion 298 - Radiosurgery for Malignant Intracranial Tumors Radiosurgery for Brain Metastases Whole-Brain Radiotherapy Versus Stereotactic Radiosurgery Alone Clinical Outcomes of Stereotactic Radiosurgery Alone Tumor Control Overall Survival New Distant Lesions Prevention of Neurological Death and Preservation of Neurological Function Untoward Effects Levels I and II Evidence for Stereotactic Radiosurgery Efficacy for Brain Metastases Summary of Radiosurgery for Brain Metastases Radiosurgery for Primary Malignant Tumors Glioblastoma and Anaplastic Gliomas Good Indications for Stereotactic Radiosurgery Alone Tumor Size Karnofsky Performance Scale Score of 70 or Better Leptomeningeal Dissemination Cumulative Intracranial Tumor Volume Tumor Number Ependymoma Complications Summary of Radiosurgery for Primary Malignant Tumors Brainstem Glioma Medulloblastoma 299 - Radiosurgery for Benign Intracranial Tumors Introduction History Definition Radiobiology Topologic Differential Effect Long-Term Complications Vestibular Schwannomas Comparison With Microsurgery Efficacy of Radiosurgery Preservation of Hearing Preservation of Facial Nerve Wait and See Versus Stereotactic Radiosurgery in Small Koos Stage I Tumors Large Vestibular Schwannomas: Combined Microsurgical and Radiosurgical Treatment Meningiomas Rational for Radiosurgery Patient Selection Technical Considerations Results Histopathology Clinical Evaluation Tumor Response Tumor Control Functional Outcome Special Situations Large Tumors Histology Pituitary Tumors Growth Hormone–Secreting Pituitary Adenomas Adrenocorticotropic Hormone–Secreting Pituitary Adenomas (Cushing Disease) Prolactin-Secreting Pituitary Adenomas Antitumor Effects Hypopituitarism Optic Nerve Neuropathy Other Potential Adverse Effects Conventional Radiotherapy Conclusion Other Benign Tumors Nonvestibular Schwannomas Craniopharyngiomas Gliomas Hemangioblastomas Glomus Tumors Future Indications Conclusion 300 - Radiosurgery for Intracranial Vascular Malformations 301 - Radiosurgery for Functional Disorders Radiosurgery for Functional Disorders Movement Disorders Psychiatric Disorders Summary 302 - Radiosurgery for Benign Spine Tumors and Spinal Vascular Malformations Arteriovenous Malformations Spinal Hemangioblastomas Intradural Extramedullary Tumors, Meningiomas, and Nerve Sheath Tumors Conclusion 303 - Radiosurgery for Malignant Axial Spine Tumors Introduction Limitations of Conventional External Beam Radiation Therapy The Development of Spine Radiosurgery Technique Outcomes of Spine Radiosurgery Radiosurgery as Neoadjuvant and Definitive Therapy Radosurgery as A Postsurgical Adjuvant Treatment Radiosurgery in the Setting of Reirradiation Radiosurgery Combined with Percutaneous and Minimally Invasive Techniques Radiosurgery for High-Grade Spinal Cord Compression Complications of Spine Radiosurgery Conclusion 304 - Spinal Anatomy Atlantoaxial Spine and Craniospinal Articulation Subaxial Cervical Spine Thoracic Spine Lumbar Spine Sacrum Further Ligamentous Anatomy Nervous Anatomy: The Spinal Cord and Spinal Nerves Gross Anatomy and Spinal Nerves Selected Gray Matter Nuclei and Rexed Laminae Spinal Cord Tracts Vascular Anatomy Vertebral Arteries Arterial Supply Venous Drainage 305 - Spinal Imaging Spinal Imaging Imaging Modalities Magnetic Resonance Imaging Advances in Magnetic Resonance Imaging of the Spine Diffusion-Weighted Imaging Diffusion Tensor Imaging Perfusion Magnetic Resonance Imaging Susceptibility-Weighted Imaging Functional Magnetic Resonance Imaging Phase-Contrast Magnetic Resonance Imaging Magnetic Resonance Spectroscopy Evaluation of Disk Degeneration Magnetic Resonance Angiography Computed Tomography Plain Radiographs Myelography Nuclear Scans Ultrasound Clinical Considerations Evaluation of Back Pain Postoperative Imaging Spine Deformity Conclusion 306 - Spinal Biomechanics and Basics of Spinal Instrumentation Normal Anatomy Spinal Biomechanics and Basics of Spinal Instrumentation Degenerative Pathophysiology Iatrogenic Causes of Spinal Instability Energy Transfer and Pain Spinal Alignment and Pelvic Parameters Radiographic Evaluation Spinal Alignment Parameters Pelvic Parameters Kinematics and Kinetics Implant Properties Understanding the Difference Between Implant Stiffness and Strength Importance of Implant Material and Other Factors Importance of Patient Characteristics Importance of Construct Demands Other Clinical Considerations Motion Preservation Devices Conclusion 307 - Disk Degeneration and Regeneration Nucleus Pulposus Anulus Fibrosus Disk Degeneration and Regeneration Intervertebral Disk Degeneration Epidemiology Etiology Pathogenesis Regeneration Tissue Engineering Scaffold for Three-Dimensional Constructs Molecular Therapy Cell-Based Therapy Advantages of Cell-Based Therapy. Cell-based therapy usually necessitates the culture of a therapeutic cell population prior to ... Progenitor Cells. Like MSCs, notochordal cells are also known to have the potential to differentiate into nucleus pulposus cells... Regeneration Under Dynamic Microenvironment Cell-Seeded Scaffolds Gene Therapy Conclusion 308 - Pathophysiology and Treatment of Spinal Cord Injury Phases of Spinal Cord Injury Primary Injury Pathophysiology and Treatment of Spinal Cord Injury Secondary Injury Cell Death and Apoptosis Spinal Cord Ischemia Excitotoxicity and Ionic Dysregulation Mitochondrial Dysfunction Free Radicals and Lipid Peroxidation Neuroinflammation Barriers to Regeneration Myelin and Extracellular Matrix Inhibitors Glial Scarring Endogenous Neural Stem/Progenitor Cells Classification of Spinal Cord Injury Syndrome Classification Severity Classification Scales for Specific Outcome Measures Quality of Life Locomotor Function Upper Limb Function Treatment Strategies Initial Assessment and Stabilization Neurogenic Shock and Spinal Shock Spinal Cord Decompression Methylprednisolone Emerging Therapies Neuroprotective Strategies Minocycline Riluzole Magnesium/Polyethylene Glycol Fibroblast Growth Factor Analogue SUN13837 Hypothermia Cerebrospinal Fluid Drainage Neuroregenerative Strategies Targeting Myelin-Associated Inhibitors of Regeneration ATI-355 Cethrin. A toxin produced by Clostridium botulinum, C3 transferase is a specific inhibitor of the GTPase Rho34 through which all... Elezanumab (Anti–Repulsive Guidance Molecule a Antibody). Repulsive guidance molecule a (RGMa) is an inhibitory molecule that is... Cellular Therapies Granulocyte Colony-Stimulating Factor. Granulocyte colony-stimulating factor (G-CSF) drives the differentiation, proliferation, ... Activated Autologous Macrophages (ProCord). The ProCord trials are noteworthy for being the first human trials of cellular trans... Schwann Cells. Schwann cells, the myelinating cells of the PNS, hold significant regenerative capacity. The ability to harvest t... Olfactory Ensheathing Cells. Olfactory ensheathing cells (OECs) are specialized glia of the olfactory system that accompany rege... Mesenchymal Stem Cells. Mesenchymal stem cells (MSCs) are multipotent progenitor cells found in several tissues including bone m... Neural Stem Cells. Although endogenous neural stem cells exist within the spinal cord, they remain insufficient for adequate reg... Oligodendrocyte Progenitor Cells. Oligodendrocyte progenitor cells (OPCs) primarily differentiate into oligodendrocytes but also... Neuromodulatory and Neurorehabilitation Strategies Conclusion 309 - Electrophysiologic Studies and Monitoring Evidence For Neuromonitoring Somatosensory Evoked Potentials Motor Evoked Potentials Muscle Motor Evoked Potentials Direct Waves Electromyography Lateral Monitoring Anesthetic Considerations and Troubleshooting Conclusion Acknowledgments 310 - Bone Metabolism and Osteoporosis Regulators of Bone Homeostasis Calcium Bone Metabolism and Osteoporosis Vitamin D Parathyroid Hormone Diagnosis of Osteoporosis Types of Osteoporosis Criteria for Osteoporosis Screening and Risk Assessment Prevention and Treatment Calcium and Vitamin D Supplementation Bisphosphonates Recombinant Parathyroid Hormone Estrogen and Selective Estrogen Receptor Modulators Calcitonin Receptor Activator of Nuclear Factor κB Ligand Inhibitor Important Secondary Causes of Osteoporosis and Associated Treatment Options Chemotherapy-induced Osteoporosis Radiation-induced Osteoporosis Glucocorticoids Effect of Osteoporosis on Surgical Implications and Treatment Options Looking Ahead: What’s Next for Osteoporosis Treatments Conclusion 311 - Differential Diagnosis of Spinal Disease Differential Diagnosis of Spinal Disease Clinical Presentation Pain Mechanical Pain Degenerative Spinal Disorders Deformity Inflammatory Disorders Oncologic Causes Infectious Causes Acute Localized Pain Traumatic Injury Idiopathic Causes Metabolic Causes Oncologic Causes Inflammatory Lesions Radicular Pain Degenerative Causes Peripheral Entrapment Musculoskeletal Causes Shoulder. Commonly, C5 radiculopathy causes pain that radiates to the shoulder and may be similar to the pain associated with in... Hip. Degenerative hip and spine disorders are common, and their rates increase with age; thus the odds of both occurring in the ... Knee. Knee pain should be distinguished from L3 root disorders. The distinguishing characteristic of pain originating in the kne... Myofascial Trigger Point Pain Vascular Causes Deformity Traumatic Causes Inflammatory and Infectious Causes Oncologic Causes Neurological Deficit Vascular Causes Traumatic Injury Inflammatory Causes Infectious Causes Degenerative Diseases Oncologic Causes Metabolic Disorders Congenital Malformations Psychogenic Causes 312 - Nonsurgical and Postsurgical Management of Low Back Pain Epidemiology of Low Back Pain Pathophysiology of Low Back Pain Nonoperative Management of Lower Back Pain Nonpharmacologic Treatment Pharmacologic Treatment Acetaminophen Nonsteroidal Anti-inflammatory Drugs Opioids Antiepileptics Antidepressants Skeletal Muscle Relaxants Interventional Procedures Facet Joint Injection Epidural Steroid Injection Sacroiliac Intra-articular Injection Radiofrequency Neurolysis Spinal Cord Stimulators Trigger Point Injections Postoperative Pain Management in Spine Surgery Parenteral Analgesics Epidural Anesthesia Intrathecal Analgesia Conclusions 313 - Complication Avoidance in Spine Surgery ? Introduction Infection Venous Thromboembolism Vision Loss Spinal Cord Injury and Other Neurologic Injury Approach-Specific Complications Anterior Cervical Fusion Anterior Lumbar Surgery Lateral Lumbar Surgery Conclusion 314 - Predictive Analytics in the Treatment of Spinal Disorders Potential Applications for Spinal Disorders Predictive Analytics in the Treatment of Spinal Disorders Machine Learning Methodology: Strengths, Limitations, and Pitfalls Developing Novel Indices for Predictive Utility Overview of Predictive Models for Spine Surgery Predictive Models for General Spinal Disorders Predictive Models for Adult Spinal Deformity Surgery Advanced Uses of Machine Learning and Artificial Intelligence for Adult Spinal Deformity Novel Directions and Future Uses of Machine Learning Conclusion 315 - Evaluation and Treatment of Cervical Disk Herniations Historical Background Anatomy and Pathophysiology Epidemiology Clinical Findings Axial Neck Pain Cervical Radiculopathy Myelopathy Diagnostic Studies Plain Radiographs Magnetic Resonance Imaging Computed Tomography Neurophysiologic Studies Interventional Techniques: Diskography Conservative Management Axial Neck Pain Radiculopathy Myelopathy Operative Management Planning for Surgical Treatment Anterior Approach for Cervical Disk Herniation Anesthesia and Positioning Exposure Anterior Cervical Discectomy and Corpectomy Arthroplasty Fusion Anterior Cervical Instrumentation Posterior Approach for Cervical Degenerative Disease Indications for Surgical Treatment Anesthesia and Positioning Exposure Foraminotomy/Discectomy Laminectomy/Laminoplasty Cervical Posterior Segmental Instrumentation Conclusion 316 - Evaluation and Treatment of Ossification of the Posterior Longitudinal Ligament Pathophysiology Evaluation and Treatment of Ossification of the Posterior Longitudinal Ligament Mechanism: Histologic Analysis Pathologic Features of Spinal Cord Lesions Caused by Ossification of the Posterior Longitudinal Ligament Pathologic Changes in Gray Matter Pathologic Changes in White Matter Mechanism of Spinal Cord Damage Clinical Manifestations Diagnostic Imaging Natural History and Progression Treatment and Decision Making Conservative Treatment Decisions on Surgical Treatment Dural Ossification Cervical Lordosis, the K-line Concept, and T1 Slope Anterior Corpectomy. Anterior approaches to the cervical spine are well-established tools in the treatment of cervical myelopath... Anterior Osteotomy Techniques Surgery-related Outcomes, Complications, and Fusion Rate Complications. The most common intraoperative complication of the anterior procedure for OPLL is durotomy with CSF leakage, whic... Conclusion 317 - Evaluation and Treatment of Thoracic Disk Herniation Epidemiology Symptoms Radiographic Analysis Conservative Management Operative Management Indications Preoperative Considerations Fusion/Instrumentation Giant Calcified Thoracic Disk Herniations Surgical Techniques Posterior Approach Posterolateral Approach Open Anterior Thoracotomy Thoracoscopic Approach Lateral Retropleural Approach Summary 318 - Evaluation and Treatment of Lumbar Disk Disease Clinical Evaluation History Physical Examination Imaging Therapy Nonsurgical Interventions Surgical Interventions Conclusion 319 - Cervical, Thoracic, and Lumbar Stenosis Etiology and Classification Clinical Presentation Radiologic Imaging Cervical, Thoracic, and Lumbar Stenosis Natural History Surgical Management Thoracic Spinal Stenosis Etiology Clinical Presentation Radiologic Imaging Natural History Surgical Management Lumbar Spinal Stenosis Etiology Clinical Presentation Radiologic Imaging Natural History Nonoperative Management Surgical Management Surgical Techniques Bilateral Decompression Through Bilateral or Unilateral Laminotomy Minimally Invasive Decompression of Stenosis Postoperative Rehabilitation Surgical Outcomes Impact of Surgical Approach Predictors of Outcome Surgical Complications Role of Fusion in LSS With Concurrent Low-Grade Spondylolisthesis Stenosis Associated With Synovial Cysts Tandem Stenosis 320 - Evaluation and Treatment of Degenerative Lumbar Spondylolisthesis Biomechanics Natural History Evaluation and Treatment of Degenerative Lumbar Spondylolisthesis Evaluation Clinical Assessment Radiologic Evaluation Grading Treatment Conservative Treatment Comparisons of Surgical and Nonsurgical Treatment Surgical Options Decompression Without Fusion Noninstrumented Fusion Instrumented Fusion Minimally Invasive Approaches for Lumbar Fusion Reduction of Spondylolisthesis Conclusion 321 - Evaluation and Treatment of Degenerative Cervical Myelopathy Introduction Epidemiology Pathophysiology Spinal Column Spinal Cord Stretch-Associated Injury Evaluation Clinical Evaluation Imaging Advanced Quantitative Imaging Electrophysiology Natural History Nonoperative Treatment Operative Treatment Anterior Approaches Posterior Approaches Alternative Procedures Treatment Outcomes Efficacy of Operative Treatment Clinical Predictors of Outcome 322 - Evaluation and Treatment of Spinal Epidural Abscess Introduction Clinical Presentation Risk Factors and Causative Organisms Work-up Management and Outcomes Medical Versus Surgical Management Surgical Approach Complications Discussion 323 - Treatment of Pyogenic Spondylodiscitis Introduction Presentation and Diagnosis Nonoperative Treatment Operative Treatment Conclusions 324 - Evaluation and Treatment of Fungal and Tubercular Infections of the Spine Evaluation and Treatment of Fungal and Tubercular Infections of the Spine Historical Background Epidemiology and Pathology of Spinal Tuberculosis Epidemiology Pathophysiology Epidemiology and Pathology of Fungal Infections Clinical Features of Spinal Tuberculosis Tubercular Abscess Spinal Deformity Neurological Deficit Atypical Presentations Pediatric Spinal Tuberculosis Diagnosis of Spinal Tuberculosis Diagnostic Work-up Imaging Studies Laboratory Investigations Clinical Features and Diagnosis of Fungal Infections Management of Spinal Tuberculosis Medical Treatment Drug-Resistant Tuberculosis Surgical Treatment Anterior Surgery Posterior Surgery Combined Anterior and Posterior Surgery Minimally Invasive Surgery Surgery for Healed Tuberculosis Treatment of Fungal Infections of Spine Conclusions 325 - Evaluation and Treatment of Benign Tumors of the Axial Skeleton Clinical Features Evaluation Histopathologic Diagnosis Diagnosis and Management by Histology Aneurysmal Bone Cyst Hemangiomas Osteoid Osteoma and Osteoblastoma Enchondroma/Chondroma Osteochondroma Chondroblastoma Giant Cell Tumor Chemotherapy and Radiotherapy Surgical Management Conclusion 326 - Evaluation and Treatment of Primary Malignant Tumors of the Axial Skeleton Evaluation and Treatment of Primary Malignant Tumors of the Axial Skeleton Epidemiology and Clinical Presentation Approach to Primary Tumors of the Spine Radiologic Assessment Standard Radiographs Computed Tomography Magnetic Resonance Imaging Bone Scan Fluorodeoxyglucose–Positron Emission Tomography/Computed Tomography Angiography Obtaining a Diagnosis Oncologic Staging Enneking Classification Surgical Margins Weinstein-Boriani-Biagini Classification Surgical Planning Malignant Primary Spinal Tumors Chordoma Chondrosarcoma Osteosarcoma Ewing Sarcoma Conclusion 327 - Evaluation and Treatment of Benign Intradural Extramedullary Tumors Epidemiology Evaluation and Treatment of Benign Intradural Extramedullary Tumors Imaging Presentation and Indications for Surgery Surgery in Syndromic Patients Surgical Considerations Electrophysiology Approaches Cervical Approaches Thoracolumbar Approaches Lumbosacral Approaches Choice of Approach Minimally Invasive Approaches Need for Spinal Fusion Surgery For Intradural Nerve Sheath Tumors Surgery for Dumbbell Tumors and Extradural Nerve Sheath Tumors Surgery for Spinal Meningiomas Surgery for Tumors of the Filum Terminale Adjuvant Therapy and Radiosurgery Outcomes Conclusion 328 - Evaluation and Treatment of Metastatic Spinal Lesions Epidemiology Clinical Presentation Management Clinical Tools for the Management of Spinal Metastasis Systemic Therapy: Chemotherapy and Hormonal Therapy Radiotherapy Asymptomatic Spinal Metastasis Uncomplicated Symptomatic Spinal Metastasis Metastatic Epidural Spinal Cord Compression Nonsurgical Treatment Radiotherapy and Surgical Treatment Surgical Advancements Conclusion 329 - Evaluation and Treatment of Malignant PrimarySpinal Tumors Introduction Malignant Astrocytomas: Anaplastic Astrocytomas and Spinal Glioblastoma Multiforme Anaplastic Ependymomas Rare Malignant Intradural Intramedullary Tumors: Anaplastic Oligodendrogliomas and Anaplastic Gangliogliomas Spinal Malignant Peripheral Nerve Sheath Tumors Malignant Meningioma Primary Spinal Cord Melanoma Conclusion 330 - Evaluation and Treatment of Rheumatoid Arthritis and Inflammatory Spinal Diseases Epidemiology Pathophysiology Specific to Spinal Ligaments Clinical Features Assessment Imaging Modern Medical Treatment Indications for Surgical Intervention 331 - Evaluation and Treatment of Ankylosing Spondylitis and Diffuse Idiopathic Skeletal Hyperostosis Ankylosing Spondylitis Diffuse Idiopathic Skeletal Hyperostosis Clinical Features And Diagnosis Ankylosing Spondylitis Diffuse Idiopathic Skeletal Hyperostosis Imaging Ankylosing Spondylitis Diffuse Idiopathic Skeletal Hyperostosis Pathophysiology Ankylosing Spondylitis Diffuse Idiopathic Skeletal Hyperostosis Primary Management Trauma Management Surgical Management 332 - Adult Congenital Malformations of the Thoracic and Lumbar Spine Epidemiology and Associated Disorders Imaging Embryology Embryogenesis Neurogenesis Skeletogenesis Congenital Scoliosis Congenital Kyphosis and Lordosis Congenital Thoracolumbar Stenosis Spondylolysis and Spondylolisthesis Sacral Agenesis and Caudal Regression Syndrome Sacrococcygeal Teratoma Spinal Dysraphism Lipomyelomeningocele Intradural Lipoma Diastematomyelia and Diplomyelia Neurenteric Cyst Terminal Myelocystocele Dermal Sinus Tract Dermoids and Epidermoids Fatty Filum Terminale Meningocele Manqué Conclusion 333 - Adult Tethered Cord Syndrome Incidence and Epidemiology Developmental Considerations Pathophysiology of Tethered Cord Syndrome Symptomatology and Clinical Presentation Etiology Fatty and Thickened Filum Terminale Meningocele Manqué Dermal Sinus Tracts Treatment Conclusions 334 - Adult Syringomyelia Pathophysiology and Classification Adult Syringomyelia Symptomatology and Clinical Presentation Radiologic Evaluation Specific Etiologies of Adult Syringomyelia Posttraumatic Syringomyelia Arachnoiditis Treatment Conclusion 335 - Evaluation and Classification of Spinal Instability Definition of Spinal Instability Anatomy and Biomechanics of Spinal Stability Anatomy Vertebrae Intervertebral Disk Spinal Ligaments Spinal Cord Biomechanics of Spinal Instability Assessment of Spinal Instability Clinical Assessment Radiographic Assessment Plain Radiography Multidetector Computed Tomography Magnetic Resonance Imaging Assessment of Instability in the Pediatric Population Classification of Spinal Instability History of Spinal Injury Classification Column Models of Spinal Stability The Checklist Approach Subaxial and Thoracolumbar Injury Classification and Severity Scoring Systems Assessment and Classification of Instability at the Craniocervical Junction Specific Craniocervical Lesions Delayed Posttraumatic Instability 336 - Medical Management of Spinal Cord Injury Pathophysiology Initial Care and Assessment of Acute Spinal Cord Injury Immobilization Clinical Assessment Medical Imaging Critical Care Management of Acute Spinal Cord Injury Effects of Spinal Cord Injury on Respiratory Function Airway Management Bradycardia and Cardiac Arrhythmias Neurogenic Shock Principles of Surgical Management Pharmacotherapy Corticosteroids GM-1 Ganglioside Emerging Therapies Neuroprotective Agents Minocycline Riluzole VX-210 (Cethrin) Magnesium–Polyethylene Glycol Granulocyte Colony-Stimulating Factor Fibroblast Growth Factor Stem Cell Replacement Therapy Therapeutic Hypothermia Cerebrospinal Fluid Drainage Management of Subacute Complications Cardiovascular Complications Orthostatic Hypotension Autonomic Dysreflexia Respiratory Complications Venous Thromboembolism Decubitus Ulcers Gastrointestinal Complications and Nutrition Prognosis Conclusion 337 - Prognosis in Spinal Trauma Mortality in Spinal Trauma Neurology in Spinal Trauma Instability and Deformity Cranial Cervical Junction Atlas Injuries Axis Fracture Odontoid Fracture Subaxial Cervical Spine Fracture Thoracolumbar Fracture Other Comorbidities Relevant to Spinal Trauma Osteoporosis Ankylosis of the Spine Patient-reported Outcome Score Conclusion 338 - Classification and Treatment of O–C1 Craniocervical Injuries Isolated Ligament Injuries Anatomy and Biomechanics Occipitoatlantal Dislocation Mechanism of Lesion Diagnosis and Classification Treatment Transverse Ligament Injuries Isolated Osseous Injuries Anatomy and Mechanism of Lesions Occipital Condyle Fractures Diagnosis and Classification Treatment Isolated Atlas Fractures Diagnosis and Classification Treatment 339 - Evaluation and Treatment of C2 (Axis) Fractures and Instability Anatomy Of C2 Common C2 Fractures Odontoid Fractures Type I Odontoid Fractures Type II Odontoid Fractures Nonsurgical Management. Healing rates of type II odontoid fractures may be considered less than acceptable with nonsurgical ther... Surgical Management. As noted earlier, Grauer et al.9 revised the classification scheme of type II odontoid fractures to help de... Type III Odontoid Fractures Evaluation of C2 Fractures Treatment of Odontoid Fractures Anterior Odontoid Screw Fixation. This surgical technique can be used for acute type II and type III odontoid fractures (Fig. 33... Transarticular Screw Placement for C2 Fractures (Magerl Technique). This is a feasible surgical approach when anterior C2 screw ... Posterior C1–2 Screw-Rod Fixation (Harms Technique). The drawbacks of transarticular screw placement were described earlier and ... Complications of C2 Fracture Treatment Odontoid Fractures in Elderly Patients Outcome and Prognosis Hangman’s Fracture Miscellaneous C2 Fractures Conclusion 340 - Evaluation, Classification, and Treatment of Subaxial Cervical (C3–C7) Injuries Incidence Age Distribution Anatomy and Biomechanics Posterior Ligamentous Complex and Facet Anatomy Evaluation Spinal Cord Injury Classification Injury Subtypes Compression Injuries Tension Band Injuries Translational Injuries Facet Injuries Treatment Nonoperative Treatment Operative Treatment Compression Injuries (AO Type A) Tension Band Injuries (AO Type B) Translational Injuries (AO Type C) Vascular Injuries Conclusion 341 - Evaluation and Treatment of Cervicothoracic Junction Injuries Evaluation and Treatment of Cervicothoracic Junction Injuries Injuries Types of Injuries Compression Injury Distraction Injury Rotational-Translational Injury Discoligamentous Complex Injury Clay Shoveler’s Fracture Treatment Surgical Approaches Anterior Approaches Lateral Approach Posterior Approaches Construct Design Cadaveric Studies Segmental Instrumentation Construct Failure Conclusion 342 - Evaluation and Management of Athletic Injuries of the Cervical Spine Background Classification of Athletic Spinal Injuries Type I Spinal Injury Type II Spinal Injury Type III Spinal Injury Etiologic Forces Compression Hyperflexion Hyperextension Injury Location Upper Cervical Spine Injury Subaxial Cervical Spine Injury Traumatic Intervertebral Disk Herniation Return-to-Play Criteria Following Cervical Spine Injury Cervical Spine Fractures/Ligamentous Instability Spinal Stenosis and Transient Quadriparesis Stingers Intervertebral Disk Herniation Spear Tackler’s Spine Malformations Postoperative Considerations Conclusion 343 - Evaluation, Classification, and Treatment of Thoracolumbar Spine Injuries Classification Schemes in Thoracic and Lumbar Spine Injuries Anatomy Posterior Ligamentous Complex Termination of the Conus Medullaris Initial Assessment and Evaluation Initial Clinical Evaluation and Secondary Survey Imaging Timing of Imaging in Acute Traumatic Spinal Cord Injury Radiography and Computed Tomography Magnetic Resonance Imaging Assessment of the Posterior Ligamentous Complex Classifications Denis Classification Load-Sharing Classification Magerl Classification System Thoracolumbar Injury Classification and Severity Score Updated Aospine Thoracolumbar Spine Injury Classification System Operative Versus Nonoperative Management Anterior, Posterior, or Combined Approach Conclusion 344 - Evaluation and Treatment of Osteoporotic Fractures (Cement Augmentation) Epidemiology Bone Cement Reinforcement Definitions and Terminology Height Restoration Indication For Treatment and Patient Selection Personality of Fracture (Good Versus Bad) Assessment and Treatment Algorithm Indications for Cement Reinforcement (Vertebroplasty, Kyphoplasty)60 Contraindications to Percutaneous Cement Reinforcement Treatment Modalities For Osteoporotic Vertebral Fractures Conservative Treatment Surgical Treatment Preoperative Planning Surgical Procedure Placement of the Filling Cannula or Working Portal. This can be either transpedicular or parapedicular, depending on the patient... Cement Preparation. Several cement formulas currently available on the market are specially designed for vertebroplasty. They ha... Cement Injection. Low-viscosity cement should not be injected. Also, many injection tools on the market are not well designed an... Complex Fractures Requiring Surgical Stabilization Controversies Complications and Their Avoidance Misplacement of the Cannulas Cement Leakage Adjacent Fractures Mechanical Failure Infection 345 - Rehabilitation of Acute Spinal Cord Injury Introduction Prediction of Outcomes in sci Rehabilitation Outcome Prediction of Lower Extremity Function Rehabilitation of Motor Function Outcome Prediction of Upper Extremity Function Rehabilitation of Upper Limb Function Bladder and Sexual Dysfunction Neurogenic Bowel Dysfunction Diagnosis and Management of Bowel Dysfunction Sci-Associated Secondary Conditions Pain Spasticity Decubital Ulcers Autonomic Systemic Dysfunction Outlook of Advanced Interventions in Rehabilitation Transcutaneous Spinal Cord Stimulation Epidural Spinal Cord Stimulation Cortical Neurostimulation Deep Brain Stimulation Stem Cells in Human Spinal Cord Injury Conclusion 346 - Classification of Spinal Deformity Introduction Adolescent Idiopathic Scoliosis Classification Historical Adolescent Idiopathic Scoliosis Classification Systems Lenke Classification of Adolescent Idiopathic Scoliosis PUMC Classification of Adolescent Idiopathic Scoliosis Adult Spinal Deformity Classifications History of Adult Spinal Deformity Classifications Scoliosis Research Society–Schwab Classification of Adult Spinal Deformity Other Adult Spinal Disorder Classifications Conclusion 347 - Evaluation of Spinal Alignment Introduction Sagittal Alignment: A Slope To Slope Concept Pelvic Parameters From Pelvis to Lumbar Thoracic Kyphosis Cervical Curvature Upper Cervical and Horizontal Gaze Global Alignment Global Deformity (T1-Pelvic Angle, Spino-Sacral Angle, and Spino-Pelvic Angle) Truncal Inclination (Sagittal Vertical Axis and T1 Spino-Pelvic Inclination) Clinical Relevance of Parameters Pelvic and Lumbar Parameters Global Alignment Systematic Approach to Investigate Sagittal Alignment Identify Drivers of Malalignment Analysis of Compensatory Mechanisms Global Alignment and Gaze Assessment Case Presentations Conclusion 348 - Evaluation and Treatment of Cervical Deformity Etiology and Epidemiology Evaluation and Treatment of Cervical Deformity Evaluation Clinical Assessment Radiologic Assessment Treatment Indications for Treatment Surgical Treatment Outcomes Conclusion 349 - Evaluation and Treatment of Adolescent Idiopathic Scoliosis Etiology Evaluation and Treatment of Adolescent Idiopathic Scoliosis Natural History Evaluation History Physical Examination Imaging Classification Treatment Observation Bracing Surgical Treatment Surgical Approach Postoperative Care/Outcomes Complications Conclusion 350 - Evaluation and Treatment of Scheuermann Kyphosis Etiology Evaluation Evaluation and Treatment of Scheuermann Kyphosis Nonsurgical Management Physical Rehabilitation Bracing Surgical Approaches Posterior Approach Anterior-Posterior Approach Outcomes Nonsurgical, Conservative Measures Surgery Conclusions 351 - Evaluation and Treatment of Adult Scoliosis and Sagittal Plane Deformity Evolutionary Basis for Spinal Deformity: Bipedalism and the Perils of Erect Posture History of Spinal Deformity and Its Treatments Pathophysiology and Progressive Deformity Risk Factors and Natural History Updating Dubousset’s Cone of Economy Prevalence and Presentation Clinical Evaluation: History and Physical Examination Radiographic Evaluation Classifications Thoracolumbar Spine Deformity Nonoperative Management Indications for Surgery Surgical Planning and Treatment Reemphasizing the Importance of Coronal Correction for Adult Spinal Deformity Defining the Role of Minimally Invasive Surgery Surgical Treatment of Adult Cervical Spine Deformity Outcomes Complications Strategies to Reduce Complication Rates and Improve Safety Neurophysiologic Monitoring Reducing Proximal Junction Kyphosis/Proximal Junction Failure Reducing Intraoperative Blood Loss Reducing Rod Fractures Reducing Surgical Site Infections Predictive Analytics and Risk Stratification Conclusion 352 - Evaluation and Treatment of Proximal Junctional Kyphosis Prevention Strategies Soft Tissue Preservation Upper Instrumented Vertebra Selection and Spinopelvic Correction Evaluation and Treatment of Proximal Junctional Kyphosis Hook Fixation Cement Augmentation Ligament Augmentation Terminal Rod Contouring Summary of Prevention Strategies Evaluation And Treatment Representative Cases Case 1: Lower Thoracic UIV Case 2: Upper Thoracic UIV 353 - Treatment of High-Grade Spondylolisthesis Epidemiology Pathophysiology and Etiology Risk Factors for Progression Clinical Presentation Classification System for Spondylolisthesis: History and Current Status Treatment Strategy for High-Grade Spondylolisthesis Radiologic Evaluation Natural History of High-grade Spondylolisthesis Indications for Surgery: When to Operate Adult versus Pediatric High-grade Spondylolisthesis Surgery for High-grade Spondylolisthesis: Is There a Consensus Reduction or No Reduction Anterior Column Support: Is It Beneficial Surgery for High-Grade Spondylolisthesis Basic Surgical Tenets Surgical Options Posterior in Situ Fusion Posterior Reduction of Spondylolisthesis, Decompression, and Instrumented Posterolateral Fusion Posterior Reduction of Spondylolisthesis, Decompression, and Circumferential Fusion Transsacral Fusion for Anterior Column Support Supplemented With Posterolateral Instrumented Fusion With No Attempt at Reduction... Spondylectomy for Spondyloptosis Complications Emerging Outcomes Research Conclusion 354 - Bone Graft Options, Graft Substitutes, and Harvest Techniques Bone Healing Overview Bone Graft Considerations for Spinal Fusion Bone Graft Options, Graft Substitutes, and Harvest Techniques Types of Bone Graft Autograft Autograft Harvest Techniques Local Harvest Spine Autograft Posterior Iliac Crest Autograft Harvest Technique Anterior Iliac Crest Autograft Harvest Technique Rib Autograft Harvest Technique Fibula Autograft Harvest Technique Allograft Synthetics Calcium Phosphate Salts Bone Morphogenetic Proteins Algorithm for Selection of Bone Graft Arthrodesis Technique Conclusion 355 - Cervical Arthroplasty Indications Techniques Cervical Arthroplasty Outcomes Adjacent Segment Disease Heterotopic Ossification Conclusion 356 - Lumbar Disk Arthroplasty History Lumbar Disk Arthroplasty Implant Design Biomechanics Materials Clinical Outcomes Charité prodisc L activL Cost-Effectiveness Patient Selection Surgical Technique Postoperative Management Complications Conclusion 357 - Occiput, C1, and C2 Instrumentation Occiput, C1, and C2 Instrumentation Craniovertebral Instability Atlantoaxial Dislocation Three-Dimensional Models Atlantoaxial Facetal Dislocation: Concept of Central or Axial Atlantoaxial Instability Horizontal Facetal Instability Type 1 Facetal Instability Type 2 Facetal Instability Type 3 Facetal Instability Lateral Atlantoaxial Facetal Dislocation Rotatory Atlantoaxial Dislocation Vertical Mobile Atlantoaxial Dislocation Acute and Chronic Mobile and Reducible Atlantoaxial Dislocation (Fig. 357.8) Atlantoaxial Instability Related to Syndromic Conditions Anatomy of the Lateral Masses of Atlas and Axis and Their Vertebral Artery Relationship11,12 Surgery for Atlantoaxial Dislocation Atlantoaxial Fixation Techniques Midline Methods of Fixation Brooks–Jenkins Fusion. Brooks–Jenkins fusion was first described in 1978. Doubled 20-gauge wires are passed bilaterally under th... Sonntag’s Modification of Gallie Fusion. In 1991 Dickman and colleagues described the use of C1–C2 wiring technique, which avoid... Occipitocervical Fixation Lateral Mass Fixation Procedures ?Operative Technique for Goel’s Lateral Mass Plate (or Rod) and Screw (Monoaxial or Polyaxial) Fixation8,22 (Fig. 357.9 and Vide... Alternative Sites of C2 Screw Insertion Insertion of the C2 Screws in the Inferior Facet. In cases in which the screw insertion in the superior facet of axis is not pos... Insertion of Screws Into Lamina, Spinolaminar Junction, and Spinous Process for Fixing the Axial End of the Implant. Goel first ... Vertebral Artery Mobilization. A “high-riding” vertebral artery has been frequently identified to pose difficulties in C2 screw ... Surgical Handling of Vertebral Artery Injury. The most dreaded complication of the procedure is injury to the vertebral artery. ... C2 Ganglion Sectioning. In 1994 Goel first described the possibility and safety of sectioning of the C2 ganglion for exposure of... C2 Neurinomas.. Neurinomas in the C2 region are relatively common and arise from the ganglion. These tumors have a special locat... Postoperative Care. The patients are mobilized as soon as possible and advised to wear a hard cervical collar for 3 months. Neck... Double Insurance Fixation. Double insurance fixation is an alternative method of atlantoaxial fixation that combines the transar... Joint Jamming Technique. Jamming of spiked spacers within the atlantoaxial joints can provide a satisfactory method of atlantoax... Irreducible or Fixed Atlantoaxial Dislocation Basilar Invagination Historical Perspective and Pathogenesis Evolution of Understanding Stage 1 Stage 2 Stage 3 Clinical Features Reversibility of Musculoskeletal and Neural Alterations Goel’s Clinical Grading System Radiologic Criteria for Basilar Invagination Chamberlain Line McRae Line of the Foramen Magnum41 Wackenheims Clival Line Platybasia Omega Angle Brainstem Girth Distance Between Odontoid Tip and the Pontomedullary Junction Neck Size (see Fig. 357.18) Surgical Management Atlantoaxial Fixation for Both Group A and Group B Basilar Invagination Group B Basilar Invagination (see Fig. 357.17). Because atlantoaxial instability is the nodal point of pathogenesis, atlantoaxia... Role of Foramen Magnum Decompression. As our experience in the subject is growing, it appears that atlantoaxial stabilization is... Chiari Formation and Syringomyelia Idiopathic Syringomyelia Os Odontoideum Central Atlantoaxial Dislocation in Association with Cervical Myelopathy Related to Multisegmental Cervical Spondylosis, Ossific... Conclusion 358 - Anterior Cervical Instrumentation History Biomechanics Indications for Anterior Cervical Screw-Plate Fixation Operative Technique Preoperative Considerations Preoperative Preparation and Positioning Skin Incision Soft Tissue Dissection and Exposure of the Vertebral Column Discectomy With or Without Corpectomy Bone Grafting and Plate Fixation Enhancing the Natural Capacity for Bone Healing Iatrogenic Impediments to Fusion Biology Optimizing the Fusion and Hardware Construct Closure Complications Orthoses and Postoperative Follow-Up Evolution of Screw-Plate Systems Conclusion 359 - Posterior Subaxial and Cervicothoracic Instrumentation Anatomy/Exposure Techniques of Instrumentation Posterior Subaxial and Cervicothoracic Instrumentation Interspinous Wiring The Bohlman Triple-Wiring Technique The Dewar Technique Sublaminar Wiring (Cabling) Techniques Lateral Mass Screw Fixation Transpedicular Screws Laminar Screws Laminar Hooks Cervicothoracic Junction Other Fixation Techniques Biomechanical Considerations Conclusion 360 - Anterior Thoracic Instrumentation Introduction Historical Perspective: History of Anterior Spinal Surgery Indications for Anterior Thoracic Spine Surgery General Statement Infection Trauma Tumor Degenerative Conditions Deformity Surgical Approach Manubrial Split for C7 to T4 Open Thoracotomy for T2 to T8 Diaphragm Split to Approach the Thoracolumbar Junction Thoracoscopic Approach Biomechanical Considerations Instrumentations Constructs Dual-Rod Constructs Screw-Plate Constructs Cages Complications Approach Related Instrument or Fusion Related Methods to Avoid Complications Conclusion 361 - Anterior and Lateral Lumbar Instrumentation Surgical Approaches Minimally Invasive Transpsoas Approach Indications Degenerative Disease and Deformity Surgery Anatomic Considerations Surgical Technique (L1–L5) Preoperative Planning Positioning Procedure Limitations Complications Mini-Open Anterolateral Approach for Corpectomies Indications Surgical Technique Complications Anterior Lumbar Interbody Fusion Indications Surgical Techniques Retroperitoneal Approach (L3–S1) Transperitoneal Approach Discectomy Interbody Fusion Instrumentation Complications Single-Position Lumbar Instrumentation Conclusion 362 - Posterior Thoracic and Lumbar Instrumentation Posterior Thoracic and Lumbar Instrumentation Historical Overview of Posterior Thoracic and Lumbar Instrumentation Anatomic and Biomechanical Considerations for Pedicle Screw Insertion in the Thoracic and Lumbar Vertebrae Correct Level Determination in the Thoracic Spine Biomechanical Considerations Indications for Posterior Thoracic and Lumbar Instrumentation Unstable Fractures Requiring Surgical Stabilization Degenerative Disk Disease Deformities Spondylolisthesis with Lumbar Stenosis Lumbar Stenosis Following Decompression (Without Spondylolisthesis) Spinal Instability Due to Tumors or Infections Surgical Techniques for Posterior Thoracic and Lumbar Fixation Open Surgical Technique for Thoracic and Lumbar Pedicle Screw Fixation Posterior Fixation with Hook-Rod Instrumentation Laminar Hooks Pedicle Hooks Transverse Process Hooks Cemented Screws Transarticular Screws Cortical Bone Trajectory Screws Achieving Arthrodesis in the Thoracolumbar Spine “360” Instrumentation and Fusion in the Thoracolumbar Spine via a Posterior Approach Minimally Invasive Thoracolumbar Instrumentation Complications and Their Avoidance Pedicle Screw–Related Complications Hook-Related Complications Complications Related to the General Surgical Technique of Posterior Fixation and Fusion 363 - Posterior, Transforaminal, and Anterior Lumbar Interbody Fusion: Techniques and Instrumentation Indications Patient Selection Interbody Grafts Technique Posterior Lumbar Interbody Fusion Open Transforaminal Lumbar Interbody Fusion Minimally Invasive Transforaminal Lumbar Interbody Fusion Anterior Lumbar Interbody Fusion Complications Conclusion 364 - Image-Guided Spinal Navigation: Principles and Clinical Applications Introduction History of Spinal Navigation Principles of Image-Guided Spinal Navigation Spinal Navigation Techniques Clinical Applications and Results Conclusion 365 - Sacropelvic Fixation: Anterior and Posterior Options History Spinopelvic Anatomy Biomechanics Indications for Sacropelvic Fixation Supplementation of Long-Segment Constructs High-grade Spondylolisthesis After Sacrectomy for Sacral Tumors Discitis-Osteomyelitis Sacral Fractures Flat Back Deformity That Necessitates Osteotomies Correction of Pseudoarthrosis Correction of Pelvic Obliquity Substantial Osteoporosis in the Setting of Lumbosacral Fusion Degenerative Stenosis Caudal to Long-Segment Constructs Long-Term Outcomes Techniques for Pelvic Fixation General Principles Iliosacral Screws Transiliac Bar Iliac Screws S2 Alar-Iliac Screws Conclusion 366 - Spinal Osteotomies Introduction Preoperative Planning Osteotomy Indications Grade 1 Osteotomy (Partial Facet Joint Resection) Grade 2 Osteotomy (Complete Facet Joint Resection) Grade 3 Osteotomy Grade 4 Osteotomy (Pedicle, Partial Body, and Disk Resection) Grade 5 Osteotomy Grade 6 Osteotomy (Multiple Vertebral Body and Disk Resections) Complications Conclusion 367 - Evaluation, Indications, and Techniques of Revision Spine Surgery Initial Evaluation Evaluation, Indications, and Techniques of Revision Spine Surgery General Surgical Principles Postoperative Spinal Instability and Deformity Pseudarthrosis Postarthrodesis Adjacent Segment Degeneration and Disease Cervical Spine Revision Postlaminectomy Cervical Kyphosis Dorsal Approach Ventral Approach Pseudarthrosis Ventral Surgical Techniques Occipitocervical Junction. Operative management of pseudarthrosis occurring at the occipitocervical junction is challenging beca... Atlantoaxial Junction. Atlantoaxial pseudarthrosis is approached in a very similar fashion to occipitocervical fusions. Emphasis... Postarthrodesis Adjacent Segment Disease Lumbar Spine Revision Segmental Instability After Posterior Lumbar Decompression Pseudarthrosis Recurrent Lumbar Disk Herniation Postarthrodesis Adjacent Segment Disease Thoracic Spine Revision Pseudarthrosis Proximal Junctional Kyphosis Conclusion 368 - Minimally Invasive Decompression Techniques Background Instruments and Setup Minimally Invasive Lumbar Decompression Minimally Invasive Cervical Decompression Management of Dural Tears in Minimally Invasive Spine Surgery Unilateral Laminotomy for Bilateral Decompression Minimizing Postoperative Instability Balancing Tissue Trauma Decompression Adjacent to an Unstable Segment Tubular Versus Specular Retractors 369 - Minimally Invasive Lateral and Anterolateral Approaches to the Lumbar Spine Overview Approach Overview Difference in Interbody Graft Placement Degree of Indirect Decompression Risk for Subsidence Lateral Lumbar Interbody Fusion Patient Selection Surgical Technique Outcomes Complications Antepsoas or Anterior to the Psoas Technique Patient Selection Surgical Procedure Outcomes Complications Conclusion 370 - Minimally Invasive Transforaminal Lumbar Interbody Fusion and Posterior Approaches to Spine Introduction General Indications Evidence-Based Data Surgical Procedure Equipment Operating Room Setup and Positioning Surgical Technique Localization and Exposure Laminotomy/Facetectomy Interbody Fusion Pedicle Screw Fixation Outcomes Complications Future Directions Conclusions 371 - Endoscopic Approaches and Applications for Lumbar Spinal Procedures Nomenclature Endoscopic Instruments Working Channel Endoscope Tubular Retractor Endoscopic Tools Principles of Endoscopic Spine Surgery Transforaminal Endoscopic Lumbar Approaches Traditional Transforaminal Approach Background Indications Approach Planning Approach Visualize Target Area Identification of the Traversing Nerve Root and Resection of Disk Fragment Transforaminal Surgical Technique Modification Trans-pars Approach Trans–Superior Articular Process Approach Dorsolateral Approach Pearls and Pitfalls of Transforaminal Approaches Approach: G18 Versus Jamshidi Needle Approach: Rostrocaudal Inclination Trans–Superior Articular Process Bony Reaming Identification of Neural Structures Interlaminar Endoscopic Lumbar Approaches Background Indications Approach Planning Approach Visualize the Target Area Identify Neural Elements Resection of a Disk Sequester Interlaminar Technique Modifications Migrated Disk Fragments Unilateral Laminotomy for Bilateral Decompression Interlaminar Contralateral Endoscopic Lumbar Foraminotomy Pearls and Pitfalls of Interlaminar Approaches Choosing the Optimal Endoscope Inefficient Progression From Radiographic Imaging to Palpation Inefficient Progression From Palpation to Visualization Inability to Mobilize Neural Elements 372 - Minimally Invasive Spine Surgery for Adult Spinal Deformity: Principles and Applications Introduction Miss Versus Open Deformity Surgery Comparative Studies Between MISS and Open Deformity Surgery Ceiling Effects in MISS for Deformity Correction MISS as a Philosophy of Adult Spinal Deformity Care Decision Making: ISSG Minimally Invasive Spinal Deformity Surgery Algorithm Miss Posterior Approaches Troubleshooting in Percutaneous Pedicle Screw Insertion and Rod Passage Percutaneous Iliac Screw Insertion Multilevel Less Invasive Transforaminal Lumbar Interbody Fusion Mini-Open Pedicle Subtraction Osteotomy Miss Lateral Approaches Lateral Lumbar Interbody Fusion in Adult Spinal Deformity: The Convexity Versus Concavity Debate Complication Profile Unique to the Lateral Approach Hybrid Surgery: Combining MISS Lateral Interbodies With Open Posterior Techniques Anterior Column Realignment to Correct Severe Sagittal Deformity Comprehensive Anatomic Spinal Osteotomy and Anterior Column Realignment Classification Antepsoas Approaches, Oblique Lumbar Interbody Fusion, and Anterior Lumbar Interbody Fusion in the Lateral Position Circumferential MISS Protocols Miss Anterior Approaches Evolution of Mini-Open Anterior Lumbar Interbody Fusion and Role in Adult Spinal Deformity Hyperlordotic Anterior Lumbar Interbody Fusion Cages and Other Advances Minimizing Risk in Anterior Approaches Conclusions and Future Directions Predictive Analytics Modeling Planning Software, the Evolving Role of Navigation and Robotics, and Other Advances Enhanced Recovery After Surgery in the Deformity Realm Role of Endoscopy as an Ultra-MISS Tool in Adult Spinal Deformity 373 - Epidemiology of Traumatic Brain Injury ?Introduction The Effect of Traumatic Brain Injury From a Global Perspective Classification of Traumatic Brain Injury Prevalence of Traumatic Brain Injury Incidence of Traumatic Brain Injury Regional Variations in Incidence Rates Populations at Risk Mortality Rates Cause of Injury Limitations and Gaps In Knowledge of Epidemiology in Traumatic Brain Injury The Long and Winding Road of the Epidemiology of Traumatic Brain Injury 374 - Biomechanical Basis of Traumatic Brain Injury Biomechanical Basis of Traumatic Brain Injury Clinical Classification of Brain Injuries Biomechanical Mechanisms of Injury Types of Biomechanical Loading Tissue Properties and Responses to Loading Mechanistic Causes of Head Injuries Contact Injuries Local Contact Effects Remote Contact Effects Head Motion (Inertial) Injuries Types of Head Acceleration Determinants of Acceleration Injury Blast-Induced Brain Injuries Predominant Clinical Consequences of Injury Mechanisms Skull Fracture Linear Fracture Depressed Fracture Basilar Fracture Focal Brain Injury Epidural Hematoma Coup Contusions Contrecoup Contusions Intermediate Coup Contusions Intracerebral Hematoma Tissue Tear Hemorrhages Subdural Hematoma Diffuse Brain Injury Cerebral Concussion Diffuse Axonal Injury Conclusion 375 - Neuropathology of Traumatic Brain Injury Neuropathology of Traumatic Brain Injury Increased Intracranial Pressure and Herniation Brain Herniation Syndromes Cingulate Herniation Uncal Herniation Central Herniation Cerebellar Tonsillar Herniation Fungus Cerebri Cerebral Edema Cytotoxic Edema Vasogenic Edema Interstitial Edema Anatomic Structures Involved in Traumatic Brain Injury Scalp Skull Dura Epidural Hematoma Subdural Hematoma Acute Subdural Hematoma Chronic Subdural Hematoma Brain Parenchymal Injury Concussion Contusion Penetrating Brain Injury Traumatic Axonal Injury Cerebrovascular Damage Traumatic Intracerebral Hemorrhage Traumatic Intraventricular Hemorrhage Chronic Effects of Traumatic Brain Injury Chronic Traumatic Encephalopathy Catastrophic Injuries Conclusion 376 - Animal Models of Traumatic Brain Injury Animal Models of Traumatic Brain Injury Type of Injury Size, Age, and Species Outcome Measures Caveats and Conclusions 377 - Genetics of Traumatic Brain Injury Introduction Neurodegeneration Pathways Apolipoprotein E Brain-Derived Neurotrophic Factor Inflammatory Pathways Interleukin-1 Interleukin-6 Tumor Necrosis Factor-α Angiotensin-Converting Enzyme Oncogene Pathways B-Cell Lymphoma 2 Tumor Protein 53 Poly(Adenosine Diphosphate–Ribose) Polymerase-1 Neuroprotective Pathways Neprilysin Neuroglobin Neurotransmitter Pathways Dopamine D2 Receptor (DRD2) and ANKK1 Catechol O-Methyltransferase Solute Carrier Family 6, Member 4 Additional Neurotransmission Pathways Conclusion 378 - Neurochemical Pathomechanisms in Traumatic Brain Injury Primary and Secondary Brain Injury Relationship Between Mechanical Forces and Brain Injury Primary Injury: Molecular and Microscopic Aspects Focal Versus Diffuse Primary Brain Injury Diffuse Primary Brain Injury Focal Primary Brain Injury Damage to Cells/Tissue Neurons Axons Clinical Implications. Cyclosporine is a widely investigated immunosuppressive drug that has been shown to blunt traumatically i... Astrocytes Shear Effect on the Microvasculature Ion Channels Synapses Secondary Injury Processes Hypoxia-Ischemia Genesis of Ischemic Brain Damage After Severe Human Traumatic Brain Injury Infarction versus Selective Neuronal Loss Clinical Implications. Noting that historical strategies in managing severe TBI followed ICP-directed protocols (and therefore w... Ischemia and Associated Acidosis Clinical Implications. Acidosis and elevated lactate often accompany TBI and were targeted in a clinical study in which tris-(hy... Edema/Intracranial Pressure Elevation Excitotoxicity Clinical Implications Calcium Dysregulation Clinical Implications Cytoskeletal Proteolysis Clinical Implications Derangements in Brain Metabolism After Traumatic Brain Injury Clinical Implications Mitochondrial Permeability Transition Clinical Implications. Cyclophilin D (CyD) is a member of the cyclophilin protein family that plays a role in the folding of oth... DNA Damage Free Radical Formation Clinical Implications. Medical science has long endeavored to augment endogenous defenses from free radicals, which are overwhel... Cell Death Nomenclature of Cell Death Intrinsic Pathway of Caspase-Dependent Apoptosis Extrinsic Pathway of Caspase-Dependent Apoptosis Caspase-Independent Apoptosis Clinical Implications Neuroinflammation Targeting Inflammation as Therapy Modifiers of Response to Traumatic Brain Injury Age Genomics and Apolipoprotein E Gender Clinical Implications Conclusion 379 - Traumatic Brain Injury: Proteomic Biomarkers Clinical Basis for the Importance of Biomarkers in Traumatic Brain Injury Pathophysiology of Biomarkers for Traumatic Brain Injury Definition of a Biomarker Pathophysiology Methods of Biomarker Sampling Protein Biomarkers of Traumatic Brain Injury Axonal Injury Markers Glial Fibrillary Acidic Protein S-100B Myelin Basic Protein Neurofilament Polypeptides Neuronal Injury Markers Ubiquitin Carboxyl-Terminal Hydrolase Isoenzyme L1 Neuron-Specific Enolase αII-Spectrin Breakdown Products Neuroinflammation Markers Neurodegeneration Markers Cleaved-Tau Protein Amyloid-β Peptides Proteomic Approach to tbi Biomarker Analysis Conclusion 380 - Therapeutic Strategies for Repair and Regeneration Following Traumatic Brain Injury Therapeutic Strategies for Repair and Regeneration Following Traumatic Brain Injury The Injury Microenvironment: A Double-Edged Sword Inflammatory Mechanisms and Gliosis Neural Connectivity Gene and Protein Expression Endogenous Neurogenesis After Traumatic Brain Injury Subventricular Zone Neurogenesis After Trauma Migration of Subventricular Zone Neural Progenitor Cells to the Site of Injury Hippocampal Neurogenesis After Brain Trauma Cortical Neurogenesis After Brain Trauma Evidence for Functional Recovery Neuroimaging Effect of Environmental Stimulation Neurorehabilitation and Environmental Enrichment Developing Therapies for Functional Recovery After Traumatic Brain Injury Enhancing Neoneurogenesis After Brain Trauma Cell Transplantation Neuronal Progenitor Cell Grafts in Traumatic Brain Injury Models Induced Pluripotent Stem Cells in Traumatic Brain Injury Use of Biologic Scaffold Matrices to Enhance Recovery Possibility of Autologous Neural Stem Cell Transplantation Oligodendrocyte Replacement Gene Therapy Noninvasive Neurostimulation and Cortical Stimulation Deep Brain Stimulation Ethical Issues Conclusion 381 - International Initiatives to Advance Knowledgein Traumatic Brain Injury Generation of Evidence: Randomized Controlled Trials and Comparative Effectiveness Research International Initiatives to Advance Knowledgein Traumatic Brain Injury Large-Scale Collaborative Studies and Their Potential Global Initiatives and the Involvement of LMICs in TBI Research Global Neurosurgery: Collaborations With WHO and WFNS Initiatives Across the Chain of Trauma Care Conclusion 382 - Structural Neuroimaging of Traumatic Brain Injury Structural Neuroimaging of Traumatic Brain Injury Structural Neuroimaging: Modalities Conventional Radiography Computed Tomography Indications for Noncontrast Head Computed Tomography in Acute Mild Traumatic Brain Injury Noncontrast Head Computed Tomography Protocol for Traumatic Brain Injury Structural Magnetic Resonance Imaging Structural Brain Magnetic Resonance Imaging Protocol for Acute Traumatic Brain Injury Imaging Findings in Acute Traumatic Brain Injury Skull Fractures Epidural Hematoma Subdural Hematoma Subarachnoid Hemorrhage Brain Contusion Intracerebral Hemorrhage Dating of Blood Products Within the Brain Traumatic Axonal Injury and Diffuse Axonal Injury Cerebral Swelling, Brain Herniation, and Stroke Blunt Cerebrovascular Injury Conclusion 383 - Advanced Structural and Functional Imaging of Traumatic Brain Injury Types of Structural and Functional Imaging Techniques to Study Brain Connectivity After Traumatic Brain Injury Diffusion Tensor Imaging Functional Magnetic Resonance Imaging Seed-based Correlation Analysis Independent Component Analysis Graph Theory Structural Imaging Findings in Traumatic Brain Injury Functional Imaging Findings in Traumatic Brain Injury 385 - Sport-Related Concussion Definitions Epidemiology Concussion Diagnosis Signs and Symptoms of Concussion On-Field Assessment of Acute Concussion and Sideline Assessment Tools Adjuncts to the Clinical Assessment of Concussion Video Assessment of Clinical Signs of Concussion Neuropsychological Testing Advanced Neuroimaging Cerebrospinal Fluid and Serum-Based Biomarkers of Injury American Academy of Neurology Guideline Recommendations: Concussion Assessment Concussion Management American Academy of Neurology Guideline Recommendations for Concussion Management Outcomes Postconcussion Syndrome Cumulative Effects of Repetitive Mild Traumatic Brain Injury Suggested Readings eAppendix 385.1 eAppendix 385.2 386 - Initial Resuscitation, Prehospital Care, and Emergency Department Care in Traumatic Brain Injury Prehospital Management General Trauma Resuscitation and the Trauma Team Primary Survey A (Airway) B (Breathing) C (Circulation) D (Disability) E (Exposure) Secondary Survey and Neurological Assessment History Examination Coma Scales Radiographic Evaluation Computed Tomography Plain Radiographs Magnetic Resonance Imaging Cerebral Angiography Acute Trauma Management Moderate and Severe Traumatic Brain Injury Management Mild Traumatic Brain Injury Management Specialized Traumatic Brain Injury Management Conclusion 387 - Critical Care Management of Traumatic Brain Injury Epidemiology of Traumatic Brain Injury Traumatic Brain Injury Classification Pathophysiology of Traumatic Brain Injury Primary Brain Injury Diffuse Axonal Injury Hematomas/Contusions Secondary Brain Injury Traumatic Brain Swelling/Intracranial Hypertension Hypoperfusion and Outcome. CBF studies using the 133Xe method or the nitrous oxide saturation method have described the prognost... Vasospasm and Head Injury Outcome. The TCDB study reported the occurrence of traumatic subarachnoid hemorrhage in 39% of patient... Neurological Intensive Care Management of Traumatic Brain Injury Monitoring Neurological Status Neurological Intensive Care Unit Monitoring Management of and Therapeutic Approach to Severe Traumatic Brain Injury General Measures to Minimize Intracranial Hypertension/Improve Cerebral Perfusion Minimize Venous Outflow Resistance: Head Elevation, Head Position Treatment of Secondary Ischemic Processes: Cerebral Ischemia Treatment of Secondary Ischemic Processes: Intracranial Hypertension Hyperosmolar Therapy Decompressive Craniectomy Hypothermia Barbiturate Coma Treatment of Secondary Ischemic Processes: Intracranial Hemorrhage Treatment of Systemic Hypotension Treatment of Systemic Hypertension Treatment of Hypoxia Airway Protection/Controlled Ventilation Sedation/Analgesia Treatment of Fever Prevention of Seizures Treatment of Cerebral Vasospasm General Intensive Care Unit Management Treatment of Anemia Nutritional Support Management of Fluid and Electrolytes Hypernatremia–Diabetes Insipidus. Diabetes insipidus (DI) occurs when there are inadequate circulating quantities of antidiureti... Hyperglycemia. Hyperglycemia has been associated with a poor neurological outcome after TBI.236,237 Part of this association is ... Hypopituitarism Prevention of Hospital-Acquired Infections: Ventilator-Associated Pneumonia Prophylaxis for Thromboembolism Prophylaxis for Gastric Ulcers 388 - Invasive Physiologic Monitoring for Traumatic Brain Injury ? Introduction Intracranial Pressure Monitoring How Common Is Increased Intracranial Pressure in Severe Traumatic Brain Injury Patients Which Patients Should Undergo Intracranial Pressure Monitoring What Monitoring Device Should Be Used What Is the Threshold Above Which Interventions to Lower Intracranial Pressure Should Be Initiated Does Monitoring for and Treating Intracranial Pressure Elevation in a Systematic Manner Influence Outcome How to Treat Elevated Intracranial Pressure—A Tiered Therapy Approach Cerebral Perfusion Pressure Parameters Derived From Intracranial Pressure, Mean Arterial Pressure, Cerebral Perfusion Pressure, and the Intracranial Pressur... Monitoring of Intracranial Compliance and Elastance Multimodal Monitoring Monitoring Brain Oxygenation Jugular Venous Saturation and Arteriovenous Oxygen Content Difference Brain Tissue Oxygen Tension Cerebral Blood Flow Monitoring Thermal Diffusion Flowmetry Laser Doppler Flowmetry Cerebral Metabolic Monitoring: Cerebral Microdialysis Future Directions in Cerebral Monitoring: Bioinformatics Conclusion 389 - Noninvasive Neuromonitoring for Traumatic Brain Injury Basic Cerebral Ultrasonography in the Neuro-ICU Intracranial Hematomas and Acute Ischemic Stroke Hydrocephalus Midline Shift Optic Nerve Sheath Diameter Optical Pupillometry Noninvasive Intracranial Pressure Monitoring Imaging: Computed Tomography and Magnetic Resonance Imaging Tympanic Membrane Displacement Venous Ophthalmodynamometry Transcranial Doppler Ultrasound Tissue Resonance Analysis Tonometry Other Available Monitoring Techniques Near-Infrared Spectroscopy use in Traumatic Brain Injury NIRS-Measured Indices Continuous Wave Detection and Spatially Resolved Spectroscopy Extracranial Tissue Contamination and Limitations NIRS Applications in Traumatic Brain Injury Prehospital Care Traumatic Intracranial Hemorrhage Cerebral Tissue Oxygenation Monitoring and Intracranial Pressure Role of NIRS in Outcome Prediction Transcranial Doppler use in Traumatic Brain Injury Basic Principles Evaluation of Cerebral Autoregulation Pressure Reactivity Index Optimal Cerebral Perfusion Pressure Mean Flow Velocity Index Pulsatility Index and Plateau Waves in Traumatic Brain Injury Cerebral Vasospasm Transcranial Doppler and Outcome Prediction Conclusion 390 - Electrophysiologic Monitoring for Traumatic Brain Injury Introduction Methodology and Procedures for Electrophysiologic Monitoring Normal and Background Electrophysiology Seizures Why Monitor for Nonconvulsive Seizures After Acute Traumatic Brain Injury Potential Role for Intracranial Electroencephalography in Seizure Monitoring Effect of Seizures on Outcome and Indications for Antiepileptic Drug Treatment Spreading Depolarizations A Paradoxical Pathology The Spreading Depolarization Continuum in Brain Injury Spreading Depolarizations in Clinical Neurology Traumatic Brain Injury Clinical Application and Interpretation Treatments Conclusions 391 - Surgical Management of Traumatic Brain Injury Evaluation of Imaging Findings Surgical Management of Traumatic Brain Injury Medical Versus Surgical Treatment of Traumatic Brain Injury Perioperative Management of Traumatic Brain Injury Principles of Advanced Trauma Life Support and Traumatic Brain Injury Acute Neurological Deterioration Assessment and Reversal of Coagulation Abnormalities Intracranial Pressure Monitoring Surgical Technique for Insertion of Intracranial Pressure Monitor External Ventricular Drain Surgical Technique for Placement of External Ventricular Drain Exploratory bur Holes Surgical Technique for Exploratory Bur Holes Extradural Hematoma Surgical Technique for Extradural Hematoma Acute Subdural Hematoma Surgical Technique for Acute Subdural Hematoma Intraparenchymal Lesions Surgical Technique for Traumatic Intraparenchymal Lesions Posterior Fossa Hematoma Surgical Technique for Traumatic Posterior Fossa Hematoma Depressed Skull Fracture Surgical Technique for Depressed Skull Fracture Diffuse Brain Injury Surgical Technique for Decompressive Craniectomy 392 - Traumatic Brain Injury Care in Resource-Challenged Environments Epidemiology Traumatic Brain Injury Care in Resource-Challenged Environments Prehospital Care Emergency Care Surgical Care Exploratory Burr Holes Cranial Decompression as a Damage Control Approach Cisternostomy External Ventricular Drainage Advanced Medical Treatment (Surgical Wards, Intermediate Units, Intensive Care Units) Postacute Care 393 - Surgical Management and Prognosis of Penetrating Brain Injury Gunshot Wound to the Head Vital Signs Entrance and Exit Wounds Focal Neurological Deficit Level of Consciousness Management of Gunshot Wound to the Head Resuscitation Neuroimaging Considerations in Management of Penetrating Brain Injury Minimalism in Surgical Management of Penetrating Brain Injury Management of Penetrating Brain Injury With Significant Tissue Damage Management of Air Sinus Penetration Management of Vascular Complications in Penetrating Brain Injury Management of Cerebrospinal Fluid Leaks in PBI Intracranial Pressure Monitoring Decompressive Craniectomy Prophylactic Antibiotics Seizure Prophylaxis Prognosis Following Gunshot Wound to the Head 394 - Cranioplasty Cranioplasty Clinical Indications for Cranioplasty Timing of Cranioplasty Preoperative Management Cranioplasty Material Options Operative Technique Postoperative Care Complications After Cranioplasty Conclusion 395 - Surgical Considerations for Patients With Polytrauma Introduction Triaging Care of Patients With Polytrauma Evaluation of Patients with Traumatic Brain Injury and Multiple Injuries Rapid Identification and Triage of Extracranial Injuries Tracheobronchial Injuries Intrathoracic Injuries Cardiac Injuries Abdominal Hemorrhage Pelvic Trauma With Hemorrhage Mangled Extremities Musculoskeletal Injuries and Orthopedic Triage Considerations Damage Control Surgery for Life-Threatening Injuries Delayed Treatment of Non–Life-Threatening Injuries Until Stabilization of Traumatic Brain Injury Delayed Treatment of Thoracoabdominal Injuries Delayed Treatment of Musculoskeletal Injuries Concomitant Operative Management of Intracranial and Extracranial Injuries Traumatic Brain Injury with Associated Spinal Cord Injury Critical Care Considerations in Patients with Polytrauma Conclusion 396 - Blast-Induced Neurotrauma Blast-Induced Neurotrauma Blast-Brain Interaction Pathobiology of Blast-Induced Neurotrauma Phase Ia: Activation of Primary Brain Injury Mechanisms Phase Ib: Activation of the Autonomic Nervous System3 Phase Ic: Vascular Response Phase II: Early Activation of Secondary Brain Injury Mechanisms Phase III: Chronic Consequences of Blast-induced Neurotrauma Modifying Potential of Systemic Changes Caused by Blast Air Emboli Systemic Inflammation Blast-Induced Neurotrauma Versus Traumatic Brain Injury Diagnosis of Blast-Induced Neurotrauma Clinical Management of Severe Blast-Induced Neurotrauma Conclusion eAppendix 396.1: Blast-Induced Neurotrauma: A Presentation of Models and Outcomes for Functional Impairment in Blast-Induced Neu... Types and Mechanisms of Blast Injury Multiorgan Damage Caused by Single or Repeated Blast Exposures Blast Injury Models and Reproducing Symptoms of Human Blast-Induced Neurotrauma Using Experimental Models Blast-Induced Cerebral and Systemic Inflammation Contributing to Neurodegeneration Conclusion 397 - Indications and Techniques for Cranial Decompression After Traumatic Brain Injury Introduction Background Indications Technique Complications Outcomes Conclusion 398 - Craniofacial Injuries Functional Anatomy The Anterior Cranium The Facial Skeleton Craniofacial Injuries The Orbit The Paranasal Air Sinuses Frontal Sinuses Ethmoid Sinuses Sphenoid Sinuses Maxillary Sinuses Pathophysiology The Cranial Cavity The Brain Olfactory Nerve Optic Nerve The Globe and Orbit Oculomotor Nerves Other Cranial Nerves The Nerves of the Face Trigeminal Nerve Facial Nerve Mechanisms of Injury Frontal Impact Penetrating and Missile Wounds Crushing Injury Associated Injuries Initial Management Emergency Assessment and Resuscitation Specific Acute Problems With Craniofacial Injuries Airway Breathing Securing the Airway. Intubation may be very difficult and requires a highly experienced anesthetist. Endotracheal intubation is ... Circulation Clinical Assessment Neurological The Face Investigations Early Imaging Computed Tomography Angiography Later Imaging Standard Radiographic Projections Computed Tomography Three-Dimensional Computed Tomography Reconstructions. The acquired CT slices, usually axial, can be used to produce three-dimen... Magnetic Resonance Imaging Management Cranial Injury Priorities in Managing the Craniofacial Injury Orbital Injury Injury to the Globe Orbital Compartment Injury Optic Nerve Injury Sympathetic Ophthalmia Definitive Repair Priorities and Staging of Procedures Timing of Repair Surgical Principles Craniofacial Exposures The Bicoronal Scalp Flap Bone Grafting Rib Grafts. Rib grafts can be readily harvested through a submammary incision. The malleable ribs are useful within the orbit, f... Calvarial Grafts. Calvarial bone has the disadvantage of being more rigid than either iliac bone or rib. The outer table can be ... Other Donor Sites. The anterior surface of the tibia is no longer commonly used Vascularized Bone Grafts Cartilage Grafts Specific Fracture Patterns Fractures Involving the Frontal Sinus Naso-orbito-ethmoid Fractures Operative Management Fractures of the Zygoma Treatment Orbital Injury Fractures of the Mandible Maxillary Fracture Patterns Clinical Assessment Management Multiple and Panfacial Fractures Clinical Assessment Radiologic Assessment Treatment Sequence of Repair Sagittal Fractures of the Midface Infancy and Childhood General Principles Senescence Gunshot Wounds Management Timing of Repair Soft Tissue Injury Tattooed Foreign Matter Puncture Wounds Complications Dural Fistula Infection Vascular Injury Carotid-Cavernous Fistulas Clinical Assessment Internal Carotid Artery Injury Enteric Tubes Impairments and Disabilities Neuropsychological Chronic Facial Pain Anosmia 399 - Prognosis After Traumatic Brain Injury Approaches to Prognostic Analyses Methodologic Challenges in Prognostic Studies Study Design and Sample Size Predictors Missing Data Outcome Measures for Prognostic Studies in Traumatic Brain Injury Building Blocks for Prognostic Analysis Genetic Constitution Demographic Factors Clinical Severity Secondary Insults Structural Abnormalities Laboratory Parameters Mild Traumatic Brain Injury Prognostic Models Development of Prognostic Models Validation of Prognostic Models Application of Prognostic Models in Clinical Practice Illustration of Prognostic Models After Moderate and Severe Traumatic Brain Injury Future Directions 400 - Traumatic Cerebrospinal Fluid Fistulas Pathophysiology Blunt Injury Rhinorrhea Otorrhea/Otorhinorrhea Traumatic Cerebrospinal Fluid Fistulas Oculorhinorrhea Penetrating Injury Complications of Cerebrospinal Fluid Fistula Infection Intracranial Air (Pneumocephalus) Clinical Features History Examination Time of Onset of Leakage of Cerebrospinal Fluid After Trauma Early Onset Delayed Onset or Recurrence Very-Late-Onset Cerebrospinal Fluid Leakage or Infection High-Pressure and Low-Pressure Leaks Diagnostic Tests Medical Management Antibiotic Prophylaxis Conservative Care Surgical Management Timing of Surgery Open Repair Patient Positioning Middle Fossa Postoperative Care Endoscopic Repair Cribriform Plate/Anterior Skull Base Central Sphenoid Sinus, Posterior Ethmoid Sinus Lateral Sphenoid Sinus Frontal Sinus Site Preparation and Grafts Pediatric Cerebrospinal Fluid Leaks Cerebrospinal Fluid Shunting Conclusion 401 - Rehabilitation of Patients With Traumatic Brain Injury Rehabilitation of Patients With Traumatic Brain Injury Mechanisms of Recovery After Traumatic Brain Injury Prognosis and Recovery of Brain Injury Cognitive Dysfunction in Traumatic Brain Injury Fundamental Basis of Cognition Reaction Time Working Memory Unawareness of Deficits Major Domains of Cognition General Intelligence Memory Spatial Cognition Executive Functions Treatment of Cognitive Dysfunction Nonpharmacologic Therapy Errorless Learning. One form of task-specific training is errorless learning. In this method, the correct response is provided i... Metacognitive Training. In cases of TBI in which insight is impaired, metacognitive training may be beneficial.71 This technique... Physical Paradigms. Whereas the previously discussed therapeutics address cognitive impairment, physical paradigms also exist fo... Other Therapy Protocols. As for other nonpharmacologic therapies, there are several Cochrane protocols reviewing music therapy, ... Pharmacologic Therapy Amantadine. Evidence supports the use of amantadine, a dopamine receptor agonist and N-methyl-d-aspartate receptor antagonist, i... Methylphenidate. A Cochrane review indicated insufficient evidence to warrant the use of a monoaminergic agonist to improve reco... Atomoxetine. Atomoxetine is a potentially more convenient choice for treatment, as it is not a Schedule II medication under the ... Donepezil and Other Cholinergic Medications. The Neurobehavioral Guidelines Working Group convened to perform a systematic revie... Selective Serotonin Reuptake Inhibitors. Depression can confound cognitive impairment and as a result should be considered in th... Modafinil. Modafinil promotes wakefulness probably through interaction with the hypocretin (orexin) system to activate noradrene... Zolpidem. Zolpidem is a nonbenodiazepine drug that is highly selective for GABA receptors.116 Although introduced as a hypnotic ... Warnings. Although one class I study has suggested that valproate does not impair or improve cognitive function, many other medi... Agitation and Aggression Treatment Sleep Disturbance Assessment Treatment Depression Neuroanatomy Treatment Apathy Upper Motor Neuron Sequelae Spasticity Mechanisms Assessment Treatment Physical Modalities. Passive range-of-motion exercises reduce motion-triggered spasticity, whereas static stretching using splin... Medications. The most commonly used medications with clinical trials demonstrating their efficacy include baclofen, tizanidine, ... Chemical Blocks. Adverse side effects and limited antispasmodic activity interfere with the use of oral agents in up to 40% of p... Shock Wave Therapy. One new area of focus in the treatment of spasticity following neurological injury is the use of extracorpor... Surgical Intervention. Surgery can correct deformities induced by spasticity and improve function. This option tends to be reser... Bowel and Bladder Incontinence Bowel Incontinence Urinary Incontinence Dysphagia Mechanisms Counseling the Patient’s Family Assessment Treatment Outcomes General Supportive Measures Nutrition Venous Thromboembolism Prophylaxis in Traumatic Brain Injury Screening Prophylaxis Treatment Pain Syndromes Headache Definition Incidence Mechanisms Clinical Features Treatment Neuropathic Pain Mechanisms Clinical Presentation Treatment Peripheral Nerve Injury Complex Regional Pain Syndrome Etiology Diagnosis Treatment Pharmacotherapy. Modulation of pain pathways is an attractive target for pharmacotherapy. Patients are generally started on anal... Interventions. In patients unresponsive to pharmacotherapy, more invasive measures may need to be attempted. Historically the us... Specific Syndromes Posttraumatic Hydrocephalus Definition and Epidemiology Symptoms Investigations Treatment Heterotopic Ossification Clinical Features Pathogenesis Investigation Treatment Paroxysmal Sympathetic Hyperactivity Definition Incidence and Effects Mechanisms Diagnosis Treatment The Future of Rehabilitation 402 - Long-term Sequelae of Traumatic Brain Injury Introduction Functional Outcome Long-term Outcome After Moderate/Severe Traumatic Brain Injury Long-term Outcome After Mild Traumatic Brain Injury Longer-term Functional Outcome Longer-term Functional Outcome After Moderate/Severe Injury Longer-term Functional Outcome After Mild Traumatic Brain Injury Cognitive Outcomes After Traumatic Brain Injury Cognitive Outcome in the First Year After Moderate/Severe Traumatic Brain Injury Longer-term Cognitive Outcome After Moderate/Severe Traumatic Brain Injury Long-term Cognitive Outcome After Mild Traumatic Brain Injury Longer-term Cognitive Outcome After Mild Traumatic Brain Injury Psychological and Behavioral Sequelae of Traumatic Brain Injury Special Topics Impact of Multiple Traumatic Brain Injuries Neurogenerative Disease After Traumatic Brain Injury Mortality Risk After Moderate/Severe Traumatic Brain Injury Mortality Risk After Mild Traumatic Brain Injury Conclusions 403 - Cerebral Blood Flow and Metabolism and Cerebral Ischemia Cerebral Blood Flow and Metabolism and Cerebral Ischemia Cerebral Metabolism Overview Cerebral Metabolic Rate Energy Capture and Transfer Choice of Metabolic Substrates Metabolism of Glucose Glucose and Oxygen Delivery Energy Production From Glucose Other Metabolic Fates of Glucose Amino Acid and Neurotransmitter Synthesis Glycerol Synthesis Pentose Phosphate Pathway Storage as Glycogen Metabolic Contributions of Brain Structural Elements Neurons Astrocytes Blood-Brain Barrier Cerebral Blood Flow Hemodynamics Hemorheology Relationship Between Cerebral Blood Flow and Intracranial Pressure Regulation of Cerebral Blood Flow Eicosanoids. Eicosanoids are a diverse group of 20-carbon mediators that are ubiquitously produced by the regulated oxygenation ... Endothelium-Derived Hyperpolarizing Factor. Apart from NO and prostanoids, there is at least one other endothelium-dependent dil... Endothelins. The endothelium also produces a family of three 21–amino acid isopeptides known as endothelins. Of these, ET-1 is r... Adenosine. Adenosine is an endogenously produced purine nucleoside generated from the action of either 5′-nucleotidases on AMP o... Potassium Ions. Potassium ions (K+) are among the most potent vasodilatory signals in the brain. Evidence suggests that K+ is a ... Hydrogen Ions. The well-known vasodilatory action of CO2 is mediated mainly through the action of H+ on cerebral arteries.223 Th... Cerebral Autoregulation Mechanisms. The precise mechanism of cerebral autoregulation is not known. Proposed mechanisms include intrinsic changes in VSM ... Oxygen. Arterial oxygen is another important determinant of CVR and hence CBF. Elevated inspired oxygen concentrations elicit CV... Cerebral Neurovascular Coupling Mechanisms Clinical Measurement of Cerebral Blood Flow and Metabolism Historical Background Clinical Techniques Inert Nondiffusible Tracer Techniques Stable Xenon-Enhanced Computed Tomography. Xenon-enhanced CT relies on the inert, freely diffusible, and radiodense properties o... Computed Tomographic Perfusion Imaging. The basic principle underlying CTP imaging is that the standard iodinated contrast mater... Single-Photon Emission Computed Tomography Positron Emission Tomography Magnetic Resonance Imaging and Spectroscopy Cerebral Ischemia Global Versus Focal Cerebral Ischemia Flow Thresholds and the Origin of the Concept of the Penumbra Further Characterization of the Ischemic Penumbra Mechanisms of Ischemic Brain Injury Regulation of Cellular Calcium Depletion of Adenosine Triphosphate and Terminal Depolarization Acidosis Glutamate-Dependent and Glutamate-Independent Cellular Calcium Overload Activation of Inflammation Enhanced Activity of Free Radical Species DNA Damage Generation of Lipid Mediators Proteolysis by Calpains and Cathepsins Secondary Energy Failure Modes of Neuronal Death in Ischemia Apoptosis Mechanisms of Apoptosis. On transmission electron microscopy, there is a stereotypical morphologic progression of apoptosis that... Intrinsic Pathway: Mitochondrial Release of Proapoptotic Molecules. Mitochondria serve two seemingly contradictory intracellular... Extrinsic Pathway: Signaling Through Cell Surface Receptors. Stimulation of cell membrane death receptors belonging to the TNF r... Necrosis Mitochondrial Permeability Transition Pore–Dependent Necrosis. The MPTP is a multiprotein complex in the inner mitochondrial mem... Poly(ADP-Ribose) Polymerase–Dependent Necrosis. PARP has been implicated in necrosis following ischemic injury in many tissues, ... Autophagy Necroptosis Ferroptosis: Integrating the Many Ways to Die Intraoperative Cerebral Protection Conclusion 404 - Intraoperative Cerebral Protection Pathophysiology of Ischemic Injury Cerebral Blood Flow Ischemic Penumbra Energy Failure Cortical Spreading Depression Altered Calcium Homeostasis and Excitotoxicity Free Radicals and Oxidative Stress Free Fatty Acids Inflammatory Response Cell Death Integration of Cellular Injury Mechanisms Cerebroprotective Strategies for Focal Ischemia Limiting the Duration of Ischemia Augmentation of Cerebral Blood Flow Prevention of Iatrogenic Ischemia (Intraoperative Cerebral Blood Flow Monitoring) Reduction of Metabolic Activity Hypothermia Anesthesia (Barbiturates, Etomidate, and Propofol) Serum Glucose Modulation Cytoprotective Agents Calcium Channel Blockers Glutamate Antagonists Nitric Oxide Synthase Inhibitors Nicardipine Statins Endogenous Factors Other Cytoprotective Agents SUGGESTED SURGICAL PROTOCOL FOR VESSEL OCCLUSION Conclusion 405 - Acute Medical Management of Ischemic and Hemorrhagic Stroke Introduction Clinical Presentation Initial Workup Ischemic Stroke Hemorrhagic Stroke Conclusion 406 - Acute Surgical and Endovascular Management of Ischemic and Hemorrhagic Stroke Limitations of Medical Therapy Acute Surgical and Endovascular Management of Ischemic and Hemorrhagic Stroke Endovascular Therapy for Stroke Intra-arterial Thrombolysis Endovascular Thrombectomy Evidence Supporting Current Recommendations. First-generation MT devices were investigated between 2004 and 2012 in the Mechanic... Presence and Location of Occlusion. Endovascular therapy can be effective only if there is a documented large vessel occlusion. ... Quality of Recanalization. In addition to speed, the extent of recanalization is a predictor of good outcome. Among IMS III pati... Clot Retrieval Devices Systems of Care: Patient Selection, Transport, and Team Preparation Technical Aspects of Thrombectomy Operative Decompression Decompression for Malignant Cerebral Edema Strokectomy Posterior Fossa Decompression for Cerebellar Stroke Conclusion Hemorrhagic Stroke Pathophysiology Historical Perspectives Surgery for Intracranial Hemorrhage Supratentorial Craniotomy and Clot Evacuation Decompressive Craniectomy Minimally Invasive Treatment of Supratentorial Intracerebral Hemorrhage Surgical Treatment of Posterior Fossa Intracerebral Hemorrhage Management of Intraventricular Hemorrhage Conclusion 407 - Antiplatelet and Anticoagulation Therapy for Interventional and Microvascular Procedures and Patients Digital Subtraction Angiography: Antiplatelet and Anticoagulation Therapy as Prevention Aneurysm Embolization: Antiplatelet and Anticoagulation Therapy as Prevention And Rescue Aneurysm Embolization Devices and Techniques Primary Aneurysmal Coil Embolization Aneurysmal Stent-assisted Coil Embolization Flow-Diversion Aneurysmal Embolization Antiplatelet Testing in Aneurysmal Embolization Rescue and Prophylaxis Therapy During Neurointerventional Procedures Anticoagulation and Antiplatelet Therapy in Acute Aneurysm Rupture Carotid Disease: Antiplatelet and Anticoagulation in Stroke Prevention Carotid Artery Stenting Carotid Endarterectomy Intracranial Atherosclerotic Disease/Stenosis Conclusion 408 - Neuroanesthesia for Microvascular and Interventional Cerebrovascular Procedures General Principles Common Goals Optimal Brain Relaxation “Quiet” Operating Field Optimal Neurophysiologic Monitoring Environment Prompt Emergence From Anesthesia Microvascular Procedures Specific Considerations Cerebral Aneurysm/Arteriovenous Malformation Carotid Artery Disease Moyamoya Disease Endovascular Procedures for Ischemic Stroke General Anesthesia Versus Local Anesthesia/Conscious Sedation Other Considerations Final Considerations 409 - Vascular Access for Neuroendovascular Procedures Vascular Access for Neuroendovascular Procedures Transfemoral Approach Anatomy Outcomes and Complications Technique Transradial Approach Anatomy Outcomes Complications Technique Technical Nuances Distal Transradial Approach Anatomy Outcomes and Complications Technique Transbrachial Approach Technique Transcervical Approach Complications Technique Superior Ophthalmic Vein Approach Anatomy Complications Technique 410 - Diagnostic and Therapeutic Neurosonology Background and Principles of Ultrasonography History of Doppler Ultrasound B-Mode Ultrasonography Intraoperative Ultrasonography Duplex Ultrasonography Transcranial Doppler Ultrasonography Applications of Duplex Scanning in Cerebrovascular Disease Applications of Transcranial Doppler Imaging in Stroke and Cerebrovascular Disease Intracranial Stenosis Intracranial Hemodynamics Cerebral Autoregulation Positional Vertebral Artery Obstruction Intracranial Emboli Transcranial Doppler Applications in Neurosurgery and Neurocritical Care Effect of Vessel Narrowing From Subarachnoid Hemorrhage on Blood Flow Velocity Predictive Value of Transcranial Doppler Ultrasonography in Vasospasm Arteriovenous Malformations Detection of Intracranial Aneurysms Monitoring During Carotid Endarterectomy Posttraumatic Vasospasm Vascular Dissection Transcranial Doppler Findings With Increased Intracranial Pressure Transcranial Doppler as a Confirmatory Test for Brain Death Therapeutic Neurosonology Transcranial Sonothrombolysis for Acute Ischemic Stroke Magnetic Resonance–Guided Focused Ultrasonography Minimally Invasive Catheter-delivered Ultrasonography and Tissue Plasminogen Activator for Treatment of Intracerebral Hemorrhage... Conclusions 411 - Neurovascular Imaging Computed Tomography–Based Techniques Computed Tomographic Angiography Technique Acute Ischemia. The advantageous speed of CTA (newer postprocessing software can quickly and reliably provide reconstructions wi... Chronic Ischemia and Carotid Stenosis. CTA is increasingly being used as a stand-alone diagnostic test to identify carotid and i... Neurovascular Imaging Other. As software technology has improved, CTA has been used increasingly to diagnose other cerebral pathology, such as arterio... Computed Tomographic Perfusion Technique Clinical Application: Acute Stroke Single-Photon Emission Computed Tomography Technique Clinical Applications Magnetic Resonance Imaging–Based Techniques Magnetic Resonance Angiography Technique Time-of-Flight Imaging. TOF MRA is based on the principle known as flow-related enhancement (FRE). Briefly, MRI relies on the ap... Phase-Contrast Imaging. MRI takes into account both the magnitude of the signal and its phase. Phase differences can occur for m... Contrast-Enhanced Imaging. Unlike TOF and PC MRA, CE MRA does not rely on FRE or phase differences to create contrast. Instead, ... Magnetic Resonance Perfusion and Diffusion Imaging. Unlike the methods mentioned earlier, MR perfusion protocols offer an indire... Vessel Wall Imaging. In recent years, high-resolution MR-based vessel wall imaging (VWI) has emerged as a noninvasive modality f... Clinical Applications Cerebral Aneurysm. MRA offers a safe alternative to DSA (risk of permanent and transient neurological complication of unruptured... Aneurysm Screening and Pretreatment Evaluation. The prevalence of cerebral aneurysms is estimated to be 5%; however, in people w... Aneurysm Screening and Pretreatment Evaluation. Although there is still some controversy regarding the use of MRA for initial ev... Arteriovenous Malformations. AVMs are complex vascular lesions characterized by an abnormal tangle of high-flow arteries feeding... Dural Arteriovenous Fistulas. MRA typically has a limited role in the evaluation of dural arteriovenous fistulas.97 Although MRA... Extracranial Atherosclerotic Disease. MRA can prove useful in the evaluation of extracranial carotid atherosclerotic disease (Fi... Intracranial Atherosclerotic Disease. Modern MRA techniques have improved the visualization of intracranial vessels (Fig. 411.9)... Other. Other applications of MRA include visualization of dissections and dural sinus thrombosis with MR venography (MRV).118 In... Intraoperative Imaging Indocyanine Green–Based Videoangiography Intraoperative Angiography Intraoperative Magnetic Resonance Imaging 412 - Frontal Electroencephalography for Anesthetic Management in Neurosurgery Electroencephalography Frontal Electroencephalography for Anesthetic Management in Neurosurgery Clinical Uses of Frontal Electroencephalography Using Electroencephalography to Avoid Awareness With Recall Electroencephalography and Cognitive Outcomes Using Electroencephalography to Maximize Analgesia Future Directions Improving Emergence (Recovery of Consciousness) Optimizing Unconsciousness Detection Conclusions 413 - The Natural History and Medical Management of Carotid Occlusive Disease Pathologic Mechanisms of Atherosclerosis Clinical Manifestations of Carotid Atherosclerosis Natural History of Extracranial Carotid Disease Asymptomatic Carotid Disease Symptomatic Carotid Disease Medical Management of Extracranial Carotid Disease Risk Factor Treatment Hypertension Diabetes Mellitus Dyslipidemia Alcohol Consumption, Smoking, Obesity Antiplatelet Therapy Aspirin Adenosine Diphosphate Receptor Inhibitors Other Agents Surgical Management of Extracranial Carotid Disease 414 - Carotid Endarterectomy History Preoperative Evaluation Symptomatic Patients Asymptomatic Patients Surgical Indications and Decision Making Symptomatic Patients Asymptomatic Patients Contralateral Stenosis Carotid Artery Stenting Surgical Technique Preoperative Evaluation Anesthesia Positioning and Exposure High Bifurcation Exposure Endarterectomy Shunting Primary Closure of the Arteriotomy Patch Closure of the Arteriotomy Closure Postoperative Care Complications Conclusion 415 - Carotid Artery Angioplasty and Stenting Introduction Historical Perspective Carotid Endarterectomy Trials Carotid Artery Stenting Trials and Registries Indications for Carotid Artery Angioplasty and Stenting Procedural Technique Device and Procedure Selection Periprocedural Management Procedural Durability Complications and their Management Risk Stratification Complications Associated With Steps and Tools of Carotid Artery Angioplasty and Stenting Femoral Artery Access Aortic or Brachiocephalic Access Direct Carotid Access Guide Catheter Placement Embolic Protection Angioplasty Stent-Associated Complications Complications Related to Protection Device Capture Intracranial Complications Systemic Complications New Frontiers Nonatherosclerotic Carotid Artery Disease Dissection Fibromuscular Dysplasia Carotid Pseudoaneurysm and Aneurysm Acute Carotid Occlusion Intraluminal Thrombus Conclusion 416 - Blunt Cerebrovascular Injury ? Introduction Traumatic Cerebrovascular Injury as a Distinct Clinical Entity Epidemiology Pathophysiology Injury to Arterial Wall Cerebral Ischemia and Infarction Traumatic Aneurysms Risk Factors and Screening Protocols Presentation Imaging Computed Tomography Angiography of Head and Neck Injury Classification Management Antithrombotic Medications Observation Endovascular Therapy Choice of Management Strategy Prognosis Conclusion 418 - Extracranial Vertebral Artery Diseases Historical Background Clinical Presentation Anatomy of the Extracranial Vertebral Artery First Vertebral Artery Segment (V1) Second Vertebral Artery Segment (V2) Third Vertebral Artery Segment (V3) Pathophysiology of Extracranial Vertebral Artery Disease Atherosclerosis Dissection Spontaneous Traumatic Compression Subclavian Steal Syndrome Diagnostic Evaluation History and Physical Examination Routine Laboratory and Cardiac Testing Audiometric and Vestibular Tests Noninvasive Anatomic Imaging Techniques Cerebral Angiography Hemodynamic Evaluation Medical Management Atherosclerotic Disease Antiplatelet Therapy Statin Therapy Dissection Anticoagulation Therapy Thrombolysis Compression Endovascular Management Atherosclerotic Disease Dissection Compression Surgical Management Surgery of the First Vertebral Artery (V1) Segment Approach to the Proximal Vertebral Artery Transposition of Proximal Vertebral Artery to Common Carotid Artery Alternative Transpositions and Vein Graft to the Proximal Vertebral Artery Subclavian-Vertebral Endarterectomy Decompression of the Proximal Vertebral Artery Surgery of the Second Vertebral Artery (V2) Segment Approach to the Proximal V2 Segment (C6) Approach to the Middle V2 Segment (C2–C5) Approach to the Distal V2 Segment (C1–C2) Decompression of the V2 Segment Revascularization to the V2 Segment Using Transpositions Revascularization to the V2 Segment Using Vein Grafts Surgery of the Third Vertebral Artery (V3) Segment Approach to the V3 Segment Decompression of the V3 Segment Revascularization to the V3 Segment Conclusion 419 - Microsurgical Management of Intracranial Occlusion Disease Epidemiology Pathophysiology Natural History Risk Factors/Progression Radiographic Evaluation Patency of Vessels Perfusion Treatment Medical Management Microsurgical Treatment Operative Technique Flow-Assisted Surgical Technique Additional Techniques Outcomes Conclusion 420 - Endovascular Management of Intracranial Occlusion Disease Introduction Endovascular Techniques and Management Large Vessel Occlusion Intracranial Atherosclerotic Disease Conclusion 421 - Adult Moyamoya Angiopathy Pathophysiology and Etiology Adult Moyamoya Angiopathy Clinical Presentation Neuroimaging Treatment Surgical Treatment Direct Revascularization Procedures Using Microvascular Technique Indirect Bypass Techniques Perioperative Management Prognosis Conclusion 422 - Cerebral Venous and Sinus Thrombosis History and Clinical Significance Pathogenesis Incidence Clinical Presentation Diagnostic Evaluation Treatment Antithrombotics Systemic Thrombolytics Interventional Neuroradiology Surgery Treatment Guidelines Outcome Conclusion 423 - Nonlesional Spontaneous Intracerebral Hemorrhage Epidemiology and Prognosis Pathoetiology Hypertension Cerebral Amyloid Angiopathy Systemic Anticoagulation and Antiplatelet Therapy Drug Abuse Hematoma Location and Clinical Presentation Deep Hemispheric Hemorrhages (Putaminal, Capsular, Thalamic, and Caudate) Lobar Hemorrhage Cerebellar Hemorrhage Brainstem Hemorrhage Intraventricular Hemorrhage Medical Management Hypertension Blood Glucose Control Temperature Management Systemic Anticoagulation Antiplatelet Agents Intracranial Pressure Antiepileptic Medications Systemic Complications Surgical Management International Surgical Trial in Intracerebral Hemorrhage (STICH) STICH II Trial for Lobar Intracerebral Hemorrhage Without Intraventricular Hemorrhage Endoscopic and Minimally Invasive Evacuations Stereotactic Aspiration and Thrombolysis Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Trials... Clot Stability and Etiology Screening Catheter Trajectories Cannula Aspiration and Catheter Placement for Thrombolysis Outcome Decompressive Hemicraniectomy With or Without Hematoma Evacuation Management of Cerebellar Hematomas Open Surgical Technique Management of Intraventricular Hemorrhage Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) Trials Cerebrospinal Fluid Inflammation Versus Infection Following Intraventricular Hemorrhage Clot Stability and Etiology Screening Catheter Placement Other Ongoing Studies Conclusion 424 - Genetics of Intracranial Aneurysms Genetics of Intracranial Aneurysms Systemic Heritable Disorders Associated With Intracranial Aneurysms Autosomal Dominant Polycystic Kidney Disease Brain Small-Vessel Diseases Associated With Type 4 Collagenopathies Alagille Syndrome Disorders Associated With Familial Thoracic Aortic Aneurysms Loeys-Dietz Syndrome Ehlers-Danlos Syndrome Approaches to Study the Contribution of Genetic Factors to Intracranial Aneurysm Pathophysiology Inherited Susceptibility to Intracranial Aneurysms Genome-Wide Association Studies for Common Variants in the General Population Genome-Wide Association Studies of Intracranial Aneurysms Intracranial Aneurysm–Associated Genes Found in Genome-Wide Association Studies Resequencing for Identification of Rare Intracranial Aneurysm Variants Conclusion 425 - The Natural History of Cerebral Aneurysms Introduction Natural History of Unruptured Aneurysms Prevalence of Unruptured Aneurysms Risk Factors Associated With Prevalence Rupture Rate of Unruptured Aneurysms Predictive Methodologies: Phases, UIATS, and ELPASS Factors Associated With Rupture Age. Increasing age has long been recognized as a risk factor of hemorrhage. Weir170 in a comprehensive review of the literature... Systemic Hypertension. In the past, the role of hypertension in aneurysm formation and rupture was controversial, but more recen... Cigarette Smoking. Cigarette smoking has been statistically associated with occurrence of aSAH. In a multicenter study,182 prosp... Alcohol, Diabetes Mellitus, and Other Metabolic Factors. In addition to hypertension and smoking, alcohol, diabetes, and other m... Sentinel Headaches. Sentinel or “thunderclap” headaches are severe headaches of short duration (approximately 1 minute) first de... Genetic and Molecular Factors. As previously discussed (and extensively reviewed in Chapter 424), accumulating evidence supports... Aneurysm-Related Factors Size. Size is usually meant to be the largest dimension and is discussed as part of a more complex morphologic analysis later (s... Shape and Irregularity. Like size, the shape and irregularity of aneurysms have long been a focus of investigators attempting to... Aneurysm Location. The large ISUIA137 found that site was an independent variable in incidence of SAH with an intact aneurysm: b... Complex Morphology and Hemodynamic Factors Complex Morphology. These structural/anatomic factors include many different measurements and calculated values210,211 derived f... Hemodynamic Factors and Wall Stress. Similar to studies on the morphology of aneurysms, advances in invasive and noninvasive tec... Multiple Aneurysms Aneurysm Growth Symptomatic Aneurysms Inflammation Summary of the Natural History of Unruptured Aneurysms Natural History of Ruptured Intracranial Aneurysms Short-Term Outcome: Posthospitalization to 6 Months Patient-Related Factors Clinical Grade on Admission. Clinical grade as defined by Hunt and Hess254 on admission (Table 425.6) is strongly (P < .001) cor... Gender. The influence of gender on outcome after aSAH is unclear. Most studies, including population-based analyses, have not id... Age. Increased age is associated with outcome in conservatively treated patients in some studies. For example, Lagares and colle... Hypertension. The influence of systemic hypertension on outcome after SAH is unclear. This may be related to the elevation in bl... Time From Hemorrhage. Time from hemorrhage is also correlated with mortality.261,262 For patients seen immediately after their a... Molecular and Genetic Profiles. A variety of molecular factors have been investigated to determine if their presence is associat... Tobacco. Pobereskin264 surprisingly found smoking to be positively associated with survival after aSAH Aneurysm-Related Factors Aneurysm Location. Aneurysm location is associated with mortality, as indicated in Table 425.7.242 Thus mortality at 6 months in... Aneurysm Size. Surprisingly, analysis of the relationship between aneurysm size and outcome is relatively limited,262 although t... Rebleeding. Rebleeding is strongly correlated with mortality.18,22-24,242 The rate of rebleeding is highest during the first 24 ... Late Follow-up: After 6 Months Late Rebleeding Late Mortality Late Morbidity and Functional Recovery Late Epilepsy Summary of the Natural History of Ruptured Aneurysms 426 - Pathobiology of Intracranial Aneurysms Histology and Mechanisms of Aneurysm Wall Degeneration and Rupture Histology of Normal Intracranial Arteries and Aneurysms Proteolysis and Intracranial Aneurysms Apoptosis and Intracranial Aneurysms Inflammation and Intracranial Aneurysms Hemodynamic Stress and Intracranial Aneurysms Atherosclerosis and Intracranial Aneurysms Initiating Events and Genetic Analysis of Aneurysm Formation Transforming Growth Factor β Signaling in Intracranial Aneurysm Mechanotransduction in Intracranial Aneurysm CDKN2A/CDKN2B/CDKN2B-AS1 and Transcription Factor SOX17 in Intracranial Aneurysms THSD1, Focal Adhesions, and Cellular Adhesions Conclusion 427 - Surgical Decision Making for the Treatment of Intracranial Aneurysms Introduction Decision Making The Status of the Patient and Aneurysm Natural History Neuroradiologic Evaluation Unruptured and Ruptured Aneurysms: Impact on Decision Making The Unruptured Aneurysm Natural History Efficacy of Surgical Treatment for Unruptured Intracranial Aneurysms Surgical Risk for Unruptured Intracranial Aneurysms Factors That Are Associated With Surgical Outcome Which Patient With an Unruptured Intracranial Aneurysm Should Be Treated The Ruptured Aneurysm Aneurysm Rebleeding Timing of Aneurysm Obliteration The Poor-Grade Patient Intracerebral Hemorrhage Acute Intraventricular Hemorrhage and Hydrocephalus Ruptured Aneurysms and Early Vasospasm Surgical Complications After Open Microsurgery for Ruptured Aneurysms Institutional Considerations in Surgical Decision Making for Cerebral Aneurysms Where Should Patients With Intracranial Aneurysms Be Managed Training Special Circumstances Advanced Age Pregnancy Pediatric Aneurysms Infective Aneurysms Traumatic Intracranial Aneurysms Aneurysms and Arteriovenous Malformations Coexistent Carotid Artery Disease Fusiform Aneurysms Microaneurysms (Blister Aneurysms) Giant Aneurysms Cavernous Carotid Aneurysms The Residual or Recurrent Aneurysm Endovascular Aneurysm Occlusion Safety and Results of Endovascular Aneurysm Occlusion Long-Term Stability and the Implications of Residual Aneurysms Re-treatment of Recurrent (or Residual) Aneurysms Treated With Endovascular Techniques Which Aneurysm Can Be Successfully Occluded Using Endosaccular Coiling Techniques Endovascular Techniques After SAH What Is the Role of Endovascular Techniques for Unruptured Aneurysms Endovascular Techniques for Giant Aneurysms Collaboration and Comparison 428 - Perioperative Management of Subarachnoid Hemorrhage Definitions and Epidemiology Pathophysiology Intracranial Pressure Cerebral Blood Flow, Volume, and Metabolism Early Brain Injury and Delayed Cerebral Ischemia Patient Evaluation Clinical Grading Diagnosis Computed Tomography Lumbar Puncture Magnetic Resonance Imaging and Magnetic Resonance Angiography Catheter Digital Subtraction Angiography and Computed Tomographic Angiography General Management General Care Management of Blood Pressure Specific Complications of Subarachnoid Hemorrhage Rebleeding Hydrocephalus Intraventricular Hemorrhage and Increased Intracranial Pressure Intracerebral Hemorrhage Seizures Medical Complications Fever Anemia and Transfusion Blood Glucose Respiratory Complications Cardiovascular Complications Venous Thromboembolism Fluid and Electrolyte Disturbances Gastrointestinal Complications Postoperative Deterioration Special Considerations Follow-Up After Aneurysmal Subarachnoid Hemorrhage Recurrent Aneurysms and Subarachnoid Hemorrhage Outcome 429 - Open Versus Endovascular Treatment of Ruptured Aneurysms: 10-Year BRAT Report and Overview of Other Trials Introduction Barrow Ruptured Aneurysm Trial Study Design and Key Considerations 10-Year Report: Key Results and Interpretation International Subarachnoid Aneurysm Trial Study Design Results and Key Considerations Other Trials Summary and Future Directions 430 - Endovascular Approaches to Intracranial Aneurysms Principle 1: Create a Stable Construct Endovascular Approaches to Intracranial Aneurysms Principle 2: Balance Anticoagulation Principle 3: Promote Endothelialization Fundamental Tenets of Safe and Effective Constructs Tenet 1: Need for Treatment Tenet 2: Immediacy of Occlusion Tenet 3: Aneurysm Morphology, Location, and Patient-Specific Anatomy Tenet 4: Plan For The Unexpected Tenet 5: Choose the Simplest Option Among Equals Conclusion 431 - Endovascular Approaches to Narrow-necked Intracranial Aneurysms Indications for Treatment Narrow-Necked Aneurysms Technique of Primary Embolization The Balloon Microcatheter Endovascular Approaches to Cerebral Aneurysms Anterior Communicating Artery and Pericallosal Aneurysms Posterior Communicating Artery Aneurysms Ophthalmic and Cavernous Internal Carotid Artery Aneurysms Aneurysms of the Internal Carotid Artery Terminus and Middle Cerebral Artery Bifurcation Distal Vertebral (V4) and Posterior Inferior Cerebellar Artery Aneurysms Basilar Artery, Superior Cerebellar Artery, and Posterior Cerebral Artery Aneurysms Effect of Coils on Aneurysmal Hemodynamics Flow Diverters for Narrow-Necked Aneurysms Occlusion and RETREATMENT Rates Conclusion 433 - Endovascular Flow Diversion for Intracranial Aneurysms Flow Diversion Concepts Porosity, Density, Transition Zone, and Hemodynamics of Flow Diverters Types of Flow Diverters Silk Flow Diverter Pipeline Embolization Device Surpass Flow Re-Direction Endoluminal Device Use of Antiplatelet Therapy With Flow-Diversion Devices Use of Antiplatelet Therapy in the Ruptured Aneurysm Setting General Flow Diverter Procedural Principles Radiographic Assessment of Placement Potential Complications and Special Considerations In-Stent Thrombosis and Thromboembolism In-Stent Stenosis and Stent Migration Branch Vessel and Perforator Occlusions Delayed Intraparenchymal Ipsilateral Hemorrhage Perianeurysmal Brain Inflammation Delayed Aneurysm Rupture and Rate of Thrombosis Cranial Nerve Dysfunction After Flow Diversion Aneurysm Recurrence Flow Diversion in the Posterior Circulation Conclusion 434 - Endovascular Hunterian Ligation History Endovascular Hunterian Ligation Indications Approaches to the Occlusion of Specific Cerebral Vessels The Anterior Circulation The Posterior Circulation The Distal Circulation Endovascular Tools For Vessel Sacrifice Cerebral Reserve Testing Complications Case Examples Case 1: Internal Carotid Artery Occlusion for Tumor Case 2: Ruptured Fusiform Vertebral Artery Aneurysm Case 3: Ruptured Fusiform PICA Aneurysm Conclusion 435 - Surgical Approaches to Intracranial Aneurysms Basic Tenets of Cerebrovascular Surgery Brain Retraction and Relaxation Proximal and Distal Control Common Surgical Approaches to Intracranial Aneurysms Pterional (Frontotemporal) Craniotomy Positioning Skin and Soft Tissue Dissection Myocutaneous Flap. The temporalis fascia may be incised inferior to the superior temporal line and at the posterior aspect of th... Submuscular Dissection. The scalp may be dissected free of the temporalis fascia/pericranium to the level of the suprafascial/su... Subfascial Dissection. The temporalis fascia is incised at the posteriormost aspect of the incision, and the temporalis fascia (... Interfascial Dissection. In a technique popularized by Yaşargil,4 the scalp is dissected free of the temporalis fascia as in the... Craniotomy and Bone Dissection Dural Opening and Intracranial Dissection Orbitozygomatic Craniotomy Positioning Skin and Soft Tissue Dissection Craniotomy and Bone Dissection Dural Opening and Intracranial Dissection Anterior Interhemispheric Craniotomy Positioning Skin and Soft Tissue Dissection Craniotomy and Bone Dissection Dural Opening and Intracranial Dissection Subtemporal Craniotomy Positioning Skin and Soft Tissue Dissection Craniotomy and Bone Dissection Dural Opening and Intracranial Dissection Modifications Far Lateral Craniotomy Positioning Skin and Soft Tissue Dissection Craniotomy and Bone Dissection Dural Opening and Intracranial Dissection Transpetrous Approach Positioning Skin and Soft Tissue Dissection Craniotomy and Bone Dissection Dural Opening and Intracranial Dissection 436 - Microsurgery of Paraclinoid Aneurysms Anatomy and Embryology Osseous Structures and Relationships Dural Structures and Relationships Neural Structures and Relationships Vascular Structures and Relationships Arterial Segments Arterial Bends and Branches Aneurysm Classification Clinoidal Segment Aneurysms Anterolateral Variant Medial Variant Ophthalmic Segment Aneurysms Ophthalmic Artery Aneurysms Superior Hypophyseal Artery Aneurysms Dorsal Variant Aneurysms Indication for Treatment Preoperative Evaluation Operative Procedure Positioning and Draping Scalp Flap and Craniotomy Removing the Anterior Clinoid Process Aneurysm Dissection and Clipping Techniques Clinoidal Segment Aneurysms Ophthalmic Segment Aneurysms Surgical Complications and Outcome Conclusion 437 - Intracranial Internal Carotid Artery Aneurysms Surgical Approach to Internal Carotid Artery Aneurysms Pterional Craniotomy Intracranial Internal Carotid Artery Aneurysms Lateral Supraorbital Approach Operative Adjuncts Endovascular Versus Surgical Approach Treatment of Aneurysm by Location Posterior Communicating Artery Aneurysm Anatomy and Presentation Endovascular Versus Surgical Treatment Surgical Techniques Endovascular Techniques Anterior Choroidal Artery Aneurysm Anatomy and Presentation Endovascular Versus Surgical Treatment Surgical Techniques Endovascular Techniques Internal Carotid Artery Bifurcation Aneurysm Anatomy and Presentation Endovascular Versus Surgical Treatment Surgical Techniques Endovascular Techniques Internal Carotid Artery Trunk Aneurysm (Blister Aneurysm) Conclusion 438 - Microsurgery of Anterior Communicating Artery Aneurysms Operative Technique for Anterior Communicating Artery and Proximal Anterior Cerebral Artery Aneurysms Choice of Side of Craniotomy Head Position Incision Dissection of Temporalis Muscle Microsurgery of Anterior Communicating Artery Aneurysms History of Surgical Approaches for Anterior Communicating Artery Aneurysms Embryology of the Anterior Communicating Artery Region Microsurgery Anatomy of the A1 Segment–Anterior Communicating Artery–A2 Segment Nomenclature A1 Segment Anterior Communicating Artery A2 Segment Perforators of the A1 Segment and Anterior Communicating Artery Medial Striate Artery (Recurrent Artery of Heubner) Branches of the A2 Segment Arachnoid Cisterns of the A1 Segment–Anterior Communicating Artery–A2 Segment Region Clinical and Radiographic Presentation of Anterior Communicating Artery Aneurysm Surgical Adjuncts Frontosphenotemporal (Pterional) Craniotomy andDrilling Greater and Lesser Sphenoid Wings Dural Opening Sylvian Fissure Dissection Exposure of Optic Nerve and Internal Carotid Artery Exposure of Ipsilateral and Contralateral A1 Segments Gyrus Rectus Resection Identification of the A1-ACoA-A2 Complex Vessels Dissection of the Aneurysm Neck Clip Selection and Application Assessment of Clipping Papaverine or Nicardipine Application Arterial Bypass Outcomes of Anterior Communicating Artery Aneurysms Endovascular Versus Microsurgical Treatment 439 - Microsurgery of Distal Anterior Cerebral Artery Aneurysms Introduction Surgical Anatomy Clinical Presentation and Preoperative Imaging Advantages of Microsurgery Craniotomy Options Interhemispheric Approach Position Skin Incision and Craniotomy Microsurgical Maneuvers Microsurgical Alternatives Clinical Series Conclusion 440 - Surgical Management of Middle Cerebral Artery Aneurysms Middle Cerebral Artery Anatomy Classification of Middle Cerebral Artery Aneurysms Classification by Morphology Classification by Location Classification by Etiology Saccular Aneurysms Fusiform Aneurysms Infectious Aneurysms Dissecting Aneurysms Traumatic Aneurysms Classification by Size Presentation and Evaluation of Middle Cerebral Artery Aneurysms Treatment of Middle Cerebral Artery Aneurysms Surgical Treatment of Middle Cerebral Artery Aneurysms Preparation Pterional Craniotomy Extended Craniotomy for Possible Craniectomy Fissure Dissection Transcortical Approach Intraoperative Ventriculostomy Aneurysm Dissection and Clipping Temporary Clipping Indocyanine Green Videoangiography Intraoperative Angiography Use of Adenosine Aneurysmorrhaphy Bypass Conclusion 441 - Microsurgery of Vertebral Artery and Posterior Inferior Cerebellar Artery Aneurysms Introduction Anatomy Epidemiology Clinical Presentation Preoperative Evaluation Surgical Technique Vertebral Artery and Proximal Posterior Inferior Cerebellar Artery Aneurysms Far Lateral Suboccipital Approach Transfacial Transclival Approach Other Approaches Peripheral or Distal Posterior Inferior Cerebellar Artery Aneurysms Combined Lateral and Medial Suboccipital Approach Midline Suboccipital Approach Treatment Decision Making Conclusions 442 - Microsurgery of Basilar Apex Aneurysms Basilar Apex Aneurysm Surgery: Clinical Experience Microsurgical Clipping Versus Endovascular Options Microsurgical Anatomy of the Interpeduncular Cistern Surgical Strategies Pure Transsylvian Approach Positioning Scalp Incision Craniotomy Subarachnoid Exposure Clip Application Orbitozygomatic Exposure Pretemporal Transzygomatic Transcavernous Approach Subtemporal Approach Pterional Approach Through the Extended Lateral Corridor Dural Opening Cerebrospinal Fluid Drainage, Hyperventilation, and Diuresis Microdissection Timing of Treatment Temporary Occlusion Complication Avoidance Future of Basilar Apex Aneurysm Surgery Conclusion 443 - Microsurgical Management of Giant Intracranial Aneurysms Historical Considerations Microsurgical Management of Giant Intracranial Aneurysms Epidemiology and Incidence Pathophysiology Clinical Presentation Diagnosis Management Anterior Circulation Approaches Orbitozygomatic-Pterional Approach Bifrontal Interhemispheric Approach Posterior Circulation Approaches Orbitozygomatic-Pterional Approach Transpetrosal Approaches Far Lateral Approach Combined Approaches Subtemporal Approach Operative Techniques Vascular Control Surgical Techniques for Clipping Alternative Occlusion Techniques Bypass Techniques Endovascular Treatment Recent Advances Summary 444 - Medical, Microsurgical, and Interventional Treatment of Infectious Aneurysms Epidemiology Pathophysiology Microbiology Clinical Findings Natural History Diagnostic Evaluation Treatment Medical Treatment Nonmedical Treatment: Surgical and Endovascular Treatment Outcomes Conclusion 446 - Multimodality Treatments of Cerebrovascular Disorders Introduction Multimodal Treatment of Parenchymal Brain Arteriovenous Malformations Endovascular Embolization and Microneurosurgery Endovascular Embolization and Stereotactic Radiosurgery Stereotactic Radiosurgery and Microneurosurgery Multimodal Treatment Algorithm for Parenchymal Arteriovenous Malformations Multimodality Treatment of Dural Arteriovenous Fistulas Multimodality Treatment of Intracranial Aneurysms 447 - Traumatic Cerebral Aneurysms Secondary to Penetrating Intracranial Injuries Traumatic Cerebral Aneurysms Secondary to Penetrating Intracranial Injuries Clinical Findings Diagnosis Treatment Conclusion 448 - Medical Management of Cerebral Vasospasm Introduction Vasospasm in Conditions Other Than Aneurysm Rupture Epidemiology of Vasospasm Prediction of Vasospasm Pathogenesis Smooth Muscle Contraction Endothelial Injury, Nitric Oxide, and Endothelin-1 Inflammation, Vessel Remodeling, and Vasospasm Clinical Features and Investigation Symptoms, Signs, and Differential Diagnosis Diagnosis Transcranial Doppler Vascular Imaging Cerebral Blood Flow and Perfusion Near-Infrared Spectroscopy Brain Tissue Oxygen Microdialysis Monitoring Continuous Electroencephalography Prevention of Vasospasm and Cerebral Protection General Measures: Fluid Management and Medical Treatment Investigational Preventive Treatments Prophylactic Balloon Angioplasty Clot Clearance Intrathecal Vasodilators Magnesium Endothelin Receptor Antagonists Statins Tirilazad Mesylate Other Pharmacologic Intervention Exercise Reversal of Vasospasm and Cerebral Ischemia: Rescue Treatments Triple-H Therapy: Hypervolemia, Hypertension, and Hemodilution Endovascular Reversal of Vasospasm Other Reversal Therapies Cardiac Output Augmentation Hemoglobin Optimization Hypertonic Saline Therapeutic Hypothermia Intrathecal/Intraventricular Vasodilators Intra-aortic Balloon Counterpulsation and Aortic Flow Diversion Suggested Approach to Prevention and Treatment of Cerebral Vasospasm 449 - Endovascular Management of Cerebral Vasospasm Endovascular Management of Cerebral Vasospasm Clinical Indications and Efficacy Techniques and Devices Diagnostic Angiography of the Symptomatic Territory Considerations for Balloon Choice Optimizing Balloon Inflation Complication Avoidance and Management Conclusion 450 - Pathobiology of True Arteriovenous Malformations Introduction Arteriovenous Malformations Pathology, Pathogenesis, and Pathophysiology Etiology Staging, Grading, or Classification Criteria Venous Angioma Cavernous Malformation Pathology, Pathogenesis, and Pathophysiology Capillary Telangiectasia Pathology, Pathogenesis, and Pathophysiology Mixed Lesions: True Arteriovenous Malformations with Other Vascular Malformations Arteriovenous Malformations and Capillary Telangiectasia Arteriovenous Malformations and Developmental Venous Anomalies Arteriovenous Malformations and Cavernous Malformations Genetics of Arteriovenous Malformations Hereditary Syndromes Featuring Cerebral Arteriovenous Malformations Familial Cerebral Arteriovenous Malformations Congenital Syndromes Featuring Arteriovenous Malformations Biology of Vasculogenesis and Angiogenesis Hemodynamic Effects of Arteriovenous Malformations Active Vascular Remodeling and Angiogenesis in Arteriovenous Malformations Vascular Endothelial Cell Growth Factor Angiopoietin and Tie-2 Matrix Metalloproteinases Concerted Effects of Angiogenic Factors Hypothetical Events Leading to Vascular Malformation Development Recent Developments Conclusion 451 - Epidemiology and Natural History of Cerebral Vascular Malformations Introduction Arteriovenous Malformation Definition Epidemiology Clinical Presentation Natural History of Arteriovenous Malformation Dural Arteriovenous Fistula Definition Epidemiology Clinical Presentation Natural History Cavernous Malformation Definition Epidemiology Clinical Presentation Natural History Developmental Venous Anomaly Definition Epidemiology Clinical Presentation Natural History Capillary Telangiectasia Definition Epidemiology Clinical Presentation Natural History Biases and Caution in Interpreting Epidemiology and Natural History Studies 452 - Therapeutic Decision Making in the Management of Arteriovenous Malformations of the Brain Therapeutic Decision Making in the Management of Arteriovenous Malformations of the Brain Introduction Management Pathway Conservative Management Focused Irradiation Embolization Surgery Combined Treatments Other Factors Considered in Management Decisions Epilepsy Timing of Early Postoperative Radiologic Imaging Intensive Care Unit Management of Patients With Arteriovenous Malformation of the Brain After Surgical Resection Surveillance Radiology Pregnancy and Arteriovenous Malformation of the Brain Acute Intracranial Hemorrhage and Arteriovenous Malformation of the Brain Concomitant Aneurysm Unruptured Arteriovenous Malformation of the Brain and Unruptured Aneurysm Aneurysmal Subarachnoid Hemorrhage and Arteriovenous Malformation of the Brain Ruptured Arteriovenous Malformation of the Brain and Unruptured Aneurysm Unruptured Arteriovenous Malformation of the Brain and Ruptured Aneurysm Delayed Investigation for Aneurysms After Resection for Arteriovenous Malformation of the Brain Summary of Management Recommendations (See Fig. 452.6) Spetzler-Ponce Class A Spetzler-Ponce Class B Spetzler-Ponce Class C 453 - Adjuvant Endovascular Management of Brain Arteriovenous Malformations Historical Overview Treatment Goals Angioarchitecture Embolic Agents Liquid Nonliquid Embolization Before Microsurgery Embolization Before Radiosurgery Newer Techniques of Endovascular Embolization Safety and Efficacy of Endovascular Embolization Complications of Endovascular Treatment Conclusion 454 - Endovascular Management of Arteriovenous Malformations for Cure Aruba and the Debate About Unruptured Arteriovenous Malformations Goals of Endovascular Embolization Factors Associated With Endovascular Management as Cure Size Location Morphologic Features Spetzler-Martin Grade Patient-Specific Factors Efficacy of Endovascular Management for Cure Complications Associated With Endovascular Management for Cure Technical Details Facilitating Endovascular Management for Cure Embolic Materials Onyx Precipitating Hydrophobic Injectable Liquid (PHIL) Squid Polyvinyl Alcohol n-Butyl Cyanoacrylate Techniques Conclusion 455 - Microsurgery of Arteriovenous Malformations Epidemiology and Relationships to Other Vascular Malformations and Congenital Syndromes (see also Chapters 450 and 451) Microsurgery of Arteriovenous Malformations Clinical Presentation and Pathophysiology Hemorrhage Seizures Progressive Neurological Deficit Headaches Asymptomatic Lesions Natural History (see also Chapter 451) Imaging Computed Tomography Angiography Magnetic Resonance Imaging Functional Evaluation Grading of Arteriovenous Malformations Size of the Arteriovenous Malformation Eloquence of Adjacent Brain Pattern of Venous Drainage Decision Making (see also Chapter 452) Arteriovenous Malformation−Related Factors Size of the Arteriovenous Malformation Location Pattern of Venous Drainage Association With Aneurysms Management of Aneurysms Associated With Arteriovenous Malformations Patient-Related Factors Surgeon-Related Factors Treatment Microsurgical Resection Timing of Surgery General Surgical Technique Surgical Considerations for Arteriovenous Malformations in Specific Locations Convexity Arteriovenous Malformations Perisylvian Arteriovenous Malformations Medial Temporal Arteriovenous Malformations Trigonal Arteriovenous Malformations Parasagittal Arteriovenous Malformations Anterior Corpus Callosal Arteriovenous Malformations Splenial Arteriovenous Malformations Intraventricular Arteriovenous Malformations Thalamus and Basal Ganglia Arteriovenous Malformations Cerebellar Arteriovenous Malformations Brainstem Arteriovenous Malformations Surgical Outcomes Complications Intraoperative Complications Postoperative Complications Hemorrhage. The most immediate and morbid postoperative complication is hemorrhage. This is the result of either a residual nidu... Seizures. Of patients presenting with seizures, 55% have significant improvement, 35% remain unchanged, and 12% worsen. Of patie... Normal Perfusion Pressure Breakthrough. Hemodynamic changes following AVM resection can lead to cerebral edema, hemorrhage, or b... Retrograde Feeding Artery Thrombosis. Following AVM resection, angiographic feeding artery stasis is a common finding that can l... Retrograde Venous Thrombosis. After surgery, retrograde venous thrombosis can occur as a manifestation of venous stasis in large... Vasospasm. Yasargil104 described 2 of 414 patients in his series with postoperative vasospasm, an extraordinarily rare complicat... Radiosurgery (see also Chapter 300) Endovascular Therapy (see also Chapters 453 and 454) Preoperative Embolization Embolization Before Radiosurgery Palliative Embolization Curative Embolization ARUBA Trial Conclusion 456 - Surgical and Radiosurgical Management of Grade IV and V Arteriovenous Malformations Surgical and Radiosurgical Management of Grade IV and V Arteriovenous Malformations Clinical Findings and Preoperative Evaluation Symptoms Indications for and Contraindications to Surgery Hemodynamics Evaluation Angiography Magnetic Resonance Imaging Perfusion Studies Treatment Embolization Stereotactic Radiosurgery Microsurgery Multimodality Treatment Special Perioperative Equipment and Techniques Intraoperative Monitoring Frameless Image-Guided Navigation Mild Hypothermia Intraoperative Angiography Intraoperative Blood Flow Measurements With Ultrasound Surgical Outcome Complications Hemorrhage Venous Thrombosis Hydrocephalus Radiosurgical Complications Ischemia Conclusion 457 - Carotid-Cavernous Fistulas Introduction Anatomy Direct or True Carotid-Cavernous Fistulas Clinical Presentation Diagnosis Treatment Indirect Carotid-Cavernous Fistulas Clinical Presentation Diagnosis Treatment Conclusion 458 - Treatment of Other Intracranial Dural Arteriovenous Fistulas Classification Treatment of Other Intracranial Dural Arteriovenous Fistulas Natural History Diagnostic Imaging Treatment Indications and Options Observation and Compression Therapy Endovascular Embolization Transarterial Embolization Transvenous Embolization Stereotactic Radiosurgery Surgery Dural Arteriovenous Fistula by Location Transverse-Sigmoid Sinus Superior Sagittal Sinus Tentorial Anterior Fossa Outcomes Conclusion 459 - Natural History of Cavernous Malformations Epidemiology Natural History of Cavernous Malformations Clinical Presentation Hemispheric Lesions Brainstem Lesions Spinal Cord Lesions Natural History Brainstem Cavernous Malformations Spinal Cord Cavernous Malformations Familial Cavernous Malformations Radiation-Induced Cavernous Malformations Pregnancy and Sex Treatment Considerations Conclusion 460 - Genetics of Cerebral Cavernous Malformations Introduction Genetics of Cerebral Cavernous Malformations Clinical Genetics Molecular Biology of the Cerebral Cavernous Malformation Genes CCM1 CCM2 CCM3 Cerebral Cavernous Malformation Protein Expression Cellular Integration of Cerebral Cavernous Malformation Protein Functions Mechanisms of Disease Pathogenesis Development of Therapeutic Approaches Inhibition of RhoA-ROCK Signaling Targeting Other Pathways Unbiased Screens of Approved Drugs That Can Be Repurposed Clinical Trials Conclusion and Future Directions 461 - Microsurgery for Cerebral Cavernous Malformations Microsurgery for Cerebral Cavernous Malformations Surgical Indications Microsurgical Considerations, Approaches, and Techniques Goals of Surgery and Patient Counseling Preoperative Imaging Intraoperative Monitoring Microsurgical Technique Surgical Approaches Retrosigmoid Approach Far-Lateral Approach Supracerebellar Infratentorial Approach Interhemispheric Transcallosal Approach Clinical Outcomes Conclusion 462 - Classification of Spinal Arteriovenous Lesions Introduction Historical Classification Systems Spetzler Classification System Extradural Arteriovenous Fistulas Intradural Dorsal Arteriovenous Fistulas Intradural Ventral Arteriovenous Fistulas Extradural-Intradural Arteriovenous Malformations Intramedullary Arteriovenous Malformations Conus Medullaris Arteriovenous Malformations Conclusion 463 - Endovascular Treatment of Spinal Vascular Malformations Introduction Vascular Anatomy Diagnostic Imaging of Spinal Vascular Malformations Magnetic Resonance Imaging Computed Tomography Digital Subtraction Angiography Classification of Spinal Vascular Malformations Principles of Endovascular Therapy Techniques Monitoring Postprocedure Care Materials Endovascular Treatment of Spinal Arteriovenous Malformations Extradural-Intradural Arteriovenous Malformation Intradural Arteriovenous Malformation Conus Medullaris Arteriovenous Malformation Radiation Therapy and Radiosurgery for Spinal Cord Arteriovenous Malformations Endovascular Treatment of Spinal Arteriovenous Fistulas Extradural Arteriovenous Fistulas Intradural Dorsal Arteriovenous Fistula Intradural Ventral Arteriovenous Fistula Endovascular Treatment of Spinal Cord Aneurysms Complications Conclusions 464 - Microsurgical Treatment of Spinal Vascular Malformations Microsurgical Treatment of Spinal Vascular Malformations Anatomy Normal Vascular Anatomy of the Spinal Cord Arterial Anatomy Venous Anatomy Anatomy of Spinal Vascular Malformations Dural Arteriovenous Fistulas Juvenile (Extradural-Intradural) Type. Juvenile AVMs are complex lesions fed by multiple enlarged medullary arteries that fill a... Perimedullary (Pial) Type. These lesions are defined by an arteriovenous shunt in the pia that is a direct communication between... Classification Dural and Extradural Arteriovenous Fistulas Extradural Lesions Dural Lesions Intradural Lesions Arteriovenous Malformations Juvenile Type. These lesions are analogous to cerebral AVMs. They often are found in children and young adults, have multiple fe... Perimedullary (Pial) Arteriovenous Fistulas Etiology, Pathophysiology, Clinical Presentation, and Natural History Dural Arteriovenous Fistulas Foix-Alajouanine Syndrome Natural History Intradural Arteriovenous Malformations Cavernous Angiomas Diagnostic Imaging Magnetic Resonance Imaging and Magnetic Resonance Angiography Dural Arteriovenous Fistulas Intradural Arteriovenous Malformations Cavernous Angiomas Computed Tomographic Angiography Myelography Selective Spinal Arteriography Dural Arteriovenous Fistulas Intradural Arteriovenous Malformations Microsurgical Management Dural Arteriovenous Fistulas Surgical Technique Outcomes Glomus Arteriovenous Malformations Surgical Technique Outcomes Perimedullary Arteriovenous Fistulas Cavernous Angiomas Surgical Technique Outcomes Adjuncts to Surgery Preoperative Embolization Indocyanine Green Videoangiography Intraoperative Arteriography Intraoperative Neurophysiologic Monitoring Conclusion