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.

1. MICHAEL THOMAS D.O.

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

4. TERMINOLOGY
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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

5. SURGICAL MICROSCOPE
LEICA OH3

6. MICROSCOPE TECHNOLOGY
FLORESCENCE
TECHNOLOGY FOR
NEUROVASCULAR
SURGERY

7. FLORESCENCE TECHNOLOGY

8. BRAIN LAB NEURONAVIGATION

9. MICROSCOPE TECHNOLOGY
INTEGRATION WITH STEREOTACTIC NAVIGATION

10. TENSOR FIBER TRACT IMAGE

11. BRAIN LAB INTRAOPERATIVE MRI

12. BRAIN LAB WITH FUNCTIONAL MRI MAPPING

13. BRAIN LAB MAPPING AND FIBER TRACKING

14. FUNCTIONAL MRI

15. BRAIN LAB 3D RECONSTRUCTED IMAGE

16. 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

17. ENDOSCOPE USED WITH
NEURONAVIGATION

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

19. 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


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

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

22. AQUEDUCTAL STENOSIS
CORONAL MRIOBSTRUCTIVE
HYDROCEPHALUS

23. PINEAL TUMOR

24. BRAINSTEM GLIOMA
ASTROCYTOMA

25. COLLOID CYST

26. 3rd VENTRICULAR COLLOID CYST

colloid

27. 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)

28. ENDOSCOPIC VIEW OF 3RD
VENTRICULOSTOMY FORMATION

29. ENDOSCOPIC VIEW OF OSTOMY AND PREPONTINE CISTERN

30. 3rd VENTRICAL EXPLORATION

32. 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


33. 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
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34. BRAIN TUMOR DIFFERENCIAL DIAGNOSIS
CEREBRAL ABCESS
 STROKE
 PSEUDOTUMOR CEREBRI
 CEREBRITIS (PRE-ABCESS STAGE)
 ARTERIAL-VENOUS MALFORMATION
 MS
 HYDROCEPHALUS


35. BRAIN TUMOR WORK UP AND INITIAL TREATMENT
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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

36. FALX MENINGIOMA

37. MENINGIOMA

38. ASTROCYTOMA

39. ANAPLASTIC ASTROCYTOMA

40. ANAPLASTIC ASTROCYTOMA HISTOPATHOLOGY

41. PILOCYTIC ASTROCYTOMA

42. GLIOBLASTOMA MULTIFORME

43. GLIOBLASTOMA MULTIFORME

44. GBM HISTOPATHOLOGY

45. SUBEPENDYMAL GIANT CELL ASTROCYTOMA

46. FRONTAL CRANIOTOMY

47. EXPOSURE OF RIGHT FRONTAL LOBE

48. PARTIAL FRONTAL LOBECTOMY
FALX
SUPERIOR
SAGITAL
SINUS
PREMOTOR
CORTEX

49. LATERAL VIEW ANTERIOR
FRONTAL LOBECTOMY
FALX
CEREBRI
CORONAL
SUTRE
TEMPORALIS
MUSCLE

50. TRANSVENTRICULAR COLLOID CYST REMOVAL

51. SKULL BASE MENINGIOMA
SAGITAL
CORONAL
AXIAL

52. SKULL BASE MENINGIOMA – POST OP MRI

53. STRUCTURES OF THE CAVERNOUS SINUS
PITUITARY
P
SPHENOID
SINUS
S

54. PITUITARY MACROADENOMA

55. 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


56. 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


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

60. TRIGEMINAL NEURALGIA(AKA tic
douloureux) PATHOPHYSIOLOGY
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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

61. VENTRAL BRAIN/POSTERIOR FOSSA

62. RIGHT CEREBELLOPONTINE ANGLE

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

64. TRIGEMINAL NEURALGIA
MICROVASCULAR DECOMPRESSION

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

66. PONTOMEDULLAY JUNCTION
DURA
CEREBELLUM

67. 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


68. INTRADURAL EXTRAMEDULLARY
TUMOR
CONUS
TUMOR

69. CAUDAEQUINA EPENDYMOMA

70. CERVICAL MEDULLARY ANGIOMA

71. SYRINGOMYELIA
ETIOLOGIES
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ARNOLD CHIARI
MALFORMATION
INTRAMEDULLARY MASS
IDIOPATHIC
HYDROCEPHALUS

72. INTRAMEDULLARY ASTROCYTOMA

73. MEDULLOBASTOMA

74. MEDULLOBLASTOMA HISTOPATHOLOGY

75. INTRADURAL EXTRAMEDULLARY
T-1 WEIGHTED
SAGITAL IMAGE OF A
NEUROFIBROMA

76. CONTRAST ENHANCED T1 WEIGHTED AXIAL
IMAGE OF NEUROFIBROMA
SPINAL CORD

77. C-6 SCHWANNOMA RESECTION

78. C-6 NEUROFIBROMA RESECTION

79. SUBDURAL HEMATOMA

80. POST OP CRANIOTOMY

81. SUBARACHNOID HEMORRHAGE

82. 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
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83. MANAGEMENT OF ANEURYSMS
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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

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

85. CAROTID BIFERCATION ANEURYSM
CT ANGIOGRAM

86. BASILAR ANEURYSM
POSTERIOR
CEREBRAL
ARTERY

87. CTA BASILAR ANEURYSM

88. OCCIPITAL AVM

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