Modern neurosurgical practice

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This lecture was presented the the Osteopathic students at Pacific Northwest University of Health Sciences. At the very beginning you will find operative videos that I recorded from some of my cases.

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Modern neurosurgical practice

  1. 1. MICHAEL THOMAS D.O.
  2. 2. EDUCATIONAL REQUIREMENTS FUNCTIONAL NEUROANATOMY  NEUROPHYSIOLOGY  NEUROPATHOLOGY  NEUROPHARMACOLOGY  NEUROANESTHESIOLOGY  NEURORADIOLOGY  NEUROONOCOLOGY  NEUROTRAUMA  PEDIATRIC NEUROSURGERY 
  3. 3. TERMINOLOGY      CRANIOTOMY- REMOVAL AND REPLACEMENT OF PART OF CRANIUM CRANIECTOMY- REMOVAL W/O REPLACEMENT OF PART OF CRANIUM LAMINOTOMY- REMOVAL OF PART OF LAMINA LAMINECTOMY- COMPLETE REMOVAL OF LAMINA BONE FLAP- THAT REGION OF CRANIUM REMOVED
  4. 4. SURGICAL MICROSCOPE LEICA OH3
  5. 5. MICROSCOPE TECHNOLOGY FLORESCENCE TECHNOLOGY FOR NEUROVASCULAR SURGERY
  6. 6. FLORESCENCE TECHNOLOGY
  7. 7. BRAIN LAB NEURONAVIGATION
  8. 8. MICROSCOPE TECHNOLOGY INTEGRATION WITH STEREOTACTIC NAVIGATION
  9. 9. TENSOR FIBER TRACT IMAGE
  10. 10. BRAIN LAB INTRAOPERATIVE MRI
  11. 11. BRAIN LAB WITH FUNCTIONAL MRI MAPPING
  12. 12. BRAIN LAB MAPPING AND FIBER TRACKING
  13. 13. FUNCTIONAL MRI
  14. 14. BRAIN LAB 3D RECONSTRUCTED IMAGE
  15. 15. NEUROENDOSCOPY    VENTRICULAR ENDOSCOPY – PRIMARILY USED TO TREAT INTRAVENTRICULAR TUMORS AND HYDROCEPHALUS MAY BE USED TO ASSIST WITH DIFFICULT AND LIMITED OPERATIVE EXPOSURES -IE; ANEUYSM SURGERY, PITUITARY SURGERY ASSISTANCE WITH SPINAL SURGERY
  16. 16. ENDOSCOPE USED WITH NEURONAVIGATION
  17. 17. HYDROCEPHALUS OBSTRUCTIVE-BLOCKAGE WITHIN VENTRICULAR CSF PATHWAYS  COMMUNICATING- BLOCKAGE OF ABSORBTION AT ARACHNOID VILLI 
  18. 18. OBSTRUCTIVE HYDROCEPHALUS AQUEDUCTAL STENOSIS  INTAVENTRICULAR TUMORS-IE; COLLOID CYSTS,DERMOIDS, SUBEPYNDYMOMAS. PINEAL TUMORS, CERREBELLAR MASSES, CEREBELLAR STROKES/HEMORRHAGE, BRAINSTEM TUMORS  4th VENTRICLE IS USUALLY NORMAL SIZE OR SMALL 
  19. 19. HYDROCEPHALUS - CLINICAL PRESENTATION  GAIT DISTURBANCE  HEAD ACHE  MEMORY DISTURBANCE  LETHARGY  URINARY INCONTINANCE
  20. 20. AQUEDUCTAL STENOSIS SUPRACEREBELLAR ARACHNOID CYST AQUEDUCT OF SYLVIUS 4th VENTRICLE (NORMAL SIZE)
  21. 21. AQUEDUCTAL STENOSIS CORONAL MRIOBSTRUCTIVE HYDROCEPHALUS
  22. 22. PINEAL TUMOR
  23. 23. BRAINSTEM GLIOMA ASTROCYTOMA
  24. 24. COLLOID CYST
  25. 25. 3rd VENTRICULAR COLLOID CYST  colloid
  26. 26. TREATMENT OF HYDROCEPHALUS    CSF DIVERSION – NORMAL SIZE VENTRICLES HAS 25 CC’s OF CSF – TOTAL PRODUCTION OF CSF IS 500 -750 CC’s PER DAY OBSTRUCTIVE HYDRO-ENDOSCOPIC 3RD VENTRICULOSTOMY OR AQUEDUCTAL DILATATION AND STENTING. IF THIS FAILS THEN VP SHUNT COMMUNICATING HYDROCEPHALUSVENTRICULOPERITONEAL SHUNT (VENTRICULOATRIAL , VENTRICULOPLEURAL)
  27. 27. ENDOSCOPIC VIEW OF 3RD VENTRICULOSTOMY FORMATION
  28. 28. ENDOSCOPIC VIEW OF OSTOMY AND PREPONTINE CISTERN
  29. 29. 3rd VENTRICAL EXPLORATION
  30. 30. BRAIN TUMORS MULTIPLE TYPES DEPENDING ON EMBRYOLOGICAL ORIGIN -ie; Astrocytoma derived from glial tissue origin  METASTASTATIC(secondary) BRAIN TUMORS MOST COMMON  ASTROCYTOMA MOST COMMON PRIMARY BRAIN TUMOR 
  31. 31. BRAIN TUMOR CLINICAL PRESENTATION HEAD ACHES SEIZURES NAUSEA/VOMITING MENTAL STATUS CHANGES GAIT DISTURBANCE VISUAL DISTURBANCE NEUROLOGICAL DEFICIT DEPENDING ON LOCATION  CEREBRAL HEMORRHAGE  BRAIN HERNIATION       
  32. 32. BRAIN TUMOR DIFFERENCIAL DIAGNOSIS CEREBRAL ABCESS  STROKE  PSEUDOTUMOR CEREBRI  CEREBRITIS (PRE-ABCESS STAGE)  ARTERIAL-VENOUS MALFORMATION  MS  HYDROCEPHALUS 
  33. 33. BRAIN TUMOR WORK UP AND INITIAL TREATMENT     DEXAMETHASONE- INITIAL 10 MG IV X 1 THEN FOLLOWED WITH 4-6 MG IV/PO q 6 hrs OBTAIN CT OR MRI WITH AND WITH OUT CONTRAST IF MASS IS PRESENT THEN RULE OUT ABCESS vs METASTATIC DISEASE IF ORIGIN OF TUMOR CANT BE DISCOVERED THEN CEREBRAL BIOPSY AND POSSIBLY RESECTION IS INDICATED
  34. 34. FALX MENINGIOMA
  35. 35. MENINGIOMA
  36. 36. ASTROCYTOMA
  37. 37. ANAPLASTIC ASTROCYTOMA
  38. 38. ANAPLASTIC ASTROCYTOMA HISTOPATHOLOGY
  39. 39. PILOCYTIC ASTROCYTOMA
  40. 40. GLIOBLASTOMA MULTIFORME
  41. 41. GLIOBLASTOMA MULTIFORME
  42. 42. GBM HISTOPATHOLOGY
  43. 43. SUBEPENDYMAL GIANT CELL ASTROCYTOMA
  44. 44. FRONTAL CRANIOTOMY
  45. 45. EXPOSURE OF RIGHT FRONTAL LOBE
  46. 46. PARTIAL FRONTAL LOBECTOMY FALX SUPERIOR SAGITAL SINUS PREMOTOR CORTEX
  47. 47. LATERAL VIEW ANTERIOR FRONTAL LOBECTOMY FALX CEREBRI CORONAL SUTRE TEMPORALIS MUSCLE
  48. 48. TRANSVENTRICULAR COLLOID CYST REMOVAL
  49. 49. SKULL BASE MENINGIOMA SAGITAL CORONAL AXIAL
  50. 50. SKULL BASE MENINGIOMA – POST OP MRI
  51. 51. STRUCTURES OF THE CAVERNOUS SINUS PITUITARY P SPHENOID SINUS S
  52. 52. PITUITARY MACROADENOMA
  53. 53. PITUITARY ADENOMA CLINICAL PRESENTATION HEADACHE  BITEMPERAL HEMIANOPSIA  APOPLEXY(RARE)  SECRETING vs NON-SECRETING  ENDOCRENOPATHIES –Cushings(ACTH) ACROMEGALY(GH),PANHYPOPITUITARY  FREQUENTLY HAVE ELEVATED PROLACTIN LEVELS-(STALK EFFECT vs PROLACTINOMA SECRETING ADENOMA 
  54. 54. PITUITARY SURGERY MOST COMMON APPROACH IS TRANSSPHENOIDAL  GOALS OF SURGERY 1) PRESERVE VISION 2) CORRECT ENDOCRENOPATHY  CAVERNOUS SINUS INVASION WILL REQUIRE POST OPERATIVE STEREOTACTIC RADIOSURGERY ,CONTINUED MEDICAL MANAGEMENT, OR BOTH  CRANIOTOMY IS RARELY INDICATED 
  55. 55. TRIGEMINAL NEUARALGIA ETIOLOGY REDUNDANT SUPERIOR CEREBELLAR ARTERY COMPRESSION  SUPERIOR PETROSAL VEIN COMPRESSION  POSTERIOR FOSSA TUMOR  MULTIPLE SCLEROSIS (bilateral TN) 
  56. 56. TRIGEMINAL NEURALGIA(AKA tic douloureux) PATHOPHYSIOLOGY    SEVERE PAROXYSMAL LANCINATING PAIN LASTING ONLY A FEW SECONDS OFTEN TRIGGERED BY SENSORY STIMULI CONFINED TO THE DISTRIBUTION OF ONE OR MORE DIVISIONS OF THE TRIGEMINAL NERVE ON ONE SIDE OF THE FACE DUE TO EPHAPTIC TRANSMISSION IN TRIGEMINAL NERVE FROM LARGE DIAMETER MYLENATED A FIBERS TO POORLY MYLENATED A-DELTA AND C NOCICEPTIVE FIBERS EPHAPTIC - conduction of nerve impulse across point of lateral contact rather than at synapse
  57. 57. VENTRAL BRAIN/POSTERIOR FOSSA
  58. 58. RIGHT CEREBELLOPONTINE ANGLE
  59. 59. TRIGENINAL NEURALGIA - TX OPTIONS       MEDICAL- TEGRETOL, NEURONTIN, DILANTIN PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY PERCUTANEOUS GLYCEROL INJECTION PERCUTANEOUS TRIGEMINAL BALLON COMPRESSION MICROVASCULAR TRIGEMINAL DECOMPRESSION STEREOTACTIC RADIOSURGERY
  60. 60. TRIGEMINAL NEURALGIA MICROVASCULAR DECOMPRESSION
  61. 61. CN VII+VIII A.I.C.A. SUP. PET. V. CN V S.C.A. CEREBELLUM FLOCCULUS PONS CN IV
  62. 62. PONTOMEDULLAY JUNCTION DURA CEREBELLUM
  63. 63. SPINALCORD TUMORS: CLASSIFICATION EXTRADURAL-arise outside cord in vertebral body and epidural tissue(metastatic tumors most common)  INTRADURAL EXTRAMEDULLARY-arise from leptomeninges or nerve roots. ie; meningiomas and neurofibromas  INTRAMEDULLARY- primary and secondary tumors that destroy tracts and grey matter 
  64. 64. INTRADURAL EXTRAMEDULLARY TUMOR CONUS TUMOR
  65. 65. CAUDAEQUINA EPENDYMOMA
  66. 66. CERVICAL MEDULLARY ANGIOMA
  67. 67. SYRINGOMYELIA ETIOLOGIES     ARNOLD CHIARI MALFORMATION INTRAMEDULLARY MASS IDIOPATHIC HYDROCEPHALUS
  68. 68. INTRAMEDULLARY ASTROCYTOMA
  69. 69. MEDULLOBASTOMA
  70. 70. MEDULLOBLASTOMA HISTOPATHOLOGY
  71. 71. INTRADURAL EXTRAMEDULLARY T-1 WEIGHTED SAGITAL IMAGE OF A NEUROFIBROMA
  72. 72. CONTRAST ENHANCED T1 WEIGHTED AXIAL IMAGE OF NEUROFIBROMA SPINAL CORD
  73. 73. C-6 SCHWANNOMA RESECTION
  74. 74. C-6 NEUROFIBROMA RESECTION
  75. 75. SUBDURAL HEMATOMA
  76. 76. POST OP CRANIOTOMY
  77. 77. SUBARACHNOID HEMORRHAGE
  78. 78. ANEURYSMAL SUBARACHNOID HEMORRAGE SEVERE SUDDEN ONSET HEAD ACHE MAY CAUSE ACUTE HYDROCEPHALUS  HUNT HESS GRADING SCALE 0-5  HIGH GRADE PTS REQUIRE VENTRICULOSTOMY  4 PERCENT RERUPTURE RATE WITHIN 24 HR  REQUIRES ANGIOGRAM  MAY PRESENT WITH NO NEURO DEFICIT TO FOCAL DEFICIT TO COMA  3rd OF PATIENTS DON’T EVEN MAKE IT TO HOSPITAL  VASOSPASM CLINICALLY EFFECTS 30% NO SOONER THAN DAY 3 ,USUALLY AROUND DAY6-8  ICP MANAGEMENT  
  79. 79. MANAGEMENT OF ANEURYSMS        ANGIOGRAM TO DEFINE ANEURYSM ANATOMY IF GRADE 3 OR LOWER SURGICALLY CLIP OR COIL VENTRICULOSTOMY FOR HYDROCEPHALUS CALCIUM CHANNEL BLOCKER (NIMODIPINE)HELPS PREVENT VASOSPASM STEROIDS (DEXAMETHASONE) ANALGESIA TRIPLE “H” THERAPY
  80. 80. VASOSPASM TREATMENT EARLY SURGERY CANT TREAT SAFELY WITHOUT SECURING ANEURYSM TRIPLE “H” THERAPY  HYPER VOLEMIA  HYPERTENSION  HEMODILUTION
  81. 81. CAROTID BIFERCATION ANEURYSM CT ANGIOGRAM
  82. 82. BASILAR ANEURYSM POSTERIOR CEREBRAL ARTERY
  83. 83. CTA BASILAR ANEURYSM
  84. 84. OCCIPITAL AVM
  85. 85. NEUROSURGICAL HORIZONS GENE THERAPY  STEM CELL IMPLANTS  IMMUNOTHERAPY  NANOTECHNOLOGY  ROBOTICS  MOORE’S LAW  NEURO - CYBERTECHNOLOGY 

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