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Temporal Lobe Operations in Intractable Epilepsy

Epilepsy affects 1% of the world’s population and incurs an enormous burden of disease. One-third of patients with epilepsy fail to achieve adequate seizure control with antiepileptic drugs or cannot tolerate their side effects. In temporal lobe epilepsy, patients may experience dyscognitive or complex partial seizures, with auras, and possibly tonic-clonic seizures. Auras are generally characteristic in semiology, including epigastric sensation, automatisms, and taste or smell…

Multidisciplinary Presurgical Evaluation for Epilepsy Surgery

Introduction When we decide that surgery is an option for treating epilepsy, there are a number of considerations we have to make. First and most important, the decision of operating on a patient with seizures does not reside in one person, it is the result of a multidisciplinary team: epileptologist, neurophysiologist, neuropsychologist, neuroradiologist, and neurosurgeons play an important role in selecting, studying, and, above all, tailoring…

Laser Interstitial Thermal Therapy for Epilepsy

Introduction Laser interstitial thermal therapy (LITT) is a minimally invasive percutaneous procedure that involves the stereotactic insertion of a fiberoptic catheter and delivery of non-ionized photons into a predetermined intracranial location to thermally ablate specific anatomical structures or lesions. Laser technology for intracranial ablation has been available since 1960, with the use of ruby and CO 2 lasers for the treatment of malignant gliomas. , This…

Radiosurgery for Functional Disorders and Epilepsy

Trigeminal Neuralgia Introduction Trigeminal neuralgia (TN) is currently the most common among functional indications (approximately 90%) in the radiosurgical field, as stated by the Leksell Gamma Knife Society statistics. It has been named “tic douloureux” by Nicholas André, a French neurosurgeon. The prevalence is rare, 12.6 per 100,000 persons, and remains a serious health problem. The most accepted pathophysiological theory for TN appearance is the one…

Radiosurgery for Arteriovenous Malformations

Introduction Brain arteriovenous malformations (AVMs) are rare, congenital anomalies of blood vessels with an estimated incidence and prevalence of 1.12 to 1.34 and 10 to 50 cases per 100,000, respectively. They are typically a tangle of dysplastic vessels within the brain parenchyma, composed of a central nidus that is fed by arteries and drained by veins without an intervening capillary bed. Hemodynamically, there is a high-flow,…

Stereotactic Radiosurgery Meningiomas

Introduction/Background The average annual incidence of intracranial meningiomas (MNs) is five to six new cases per 100,000 person/years, with the age-related risk drastically increasing from the pediatric population to a peak during the sixth and seventh decades. , In adults (age 24 to 84 years), they occur in 2.4 per 100,000 person The female/male ratio is approximately 2:1 to 3:1, , and this prevalence is presumably…

Vestibular Schwannomas: The Role of Stereotactic Radiosurgery

Vestibular schwannomas (acoustic neuromas) are tumors arising from the Schwann cells of the eighth cranial nerve. They are typically slow-growing, benign tumors and malignant degeneration is rare. They are most commonly unilateral, resulting from a somatic mutation in a gene that encodes for the merlin protein on Chromosome 22, which is responsible for Schwann cell replication. In cases of bilateral vestibular schwannomas, the cause is almost…

Radiation Treatments in the Management of Craniopharyngiomas

Acknowledgments Steven D. Chang, MD, is supported in part by a research gift from Robert C. and Jeannette Powell. Introduction Craniopharyngiomas are benign extra-axial epithelial tumors that arise from squamous epithelial remnants of Rathke pouch near the pituitary gland. These cells may extend from the nasopharynx to the tuber cinereum and may arise within the sphenoid bone, the sella, or the suprasellar region. Although craniopharyngiomas are…

Stereotactic Radiosurgery for Cavernous Sinus Tumors

Introduction The cavernous sinus (CS) is a dural venous sinus that extends from the apex of the orbit to the apex of the petrous temporal bone and houses many critical neurovascular structures, including the carotid artery, the oculomotor nerve, the trochlear nerve, the first and second division of the trigeminal nerve, and the abducens nerve. Neoplastic, inflammatory, infectious, granulomatous, and vascular pathology can occur within the…

Stereotactic Radiosurgery for Pituitary Adenomas

Introduction This chapter discusses the use of stereotactic radiosurgery (SRS) in the treatment of secretory and nonfunctional pituitary adenomas (NFPAs). SRS refers to several modalities that deliver precisely targeted, high-energy photons or protons to target tissue. This energy is delivered as conformal radiation therapy in one or very few fractions with strict control over dosing of adjacent tissue. The main technologies used include Gamma Knife (GK),…

Stereotactic Body Radiotherapy for Spinal Metastases

Rationale for Spine Stereotactic Body Radiotherapy The term radiosurgery has been reserved for ablative doses of radiation directed to intracranial tumors with stereotactic localization and delivered typically in a single fraction. Thanks to the development of high-precision linear accelerators equipped with image guidance and robotics, radiosurgery can now be delivered to extracranial tumors in one to five fractions, a process termed stereotactic body radiotherapy (SBRT). For…

Stereotactic Radiosurgery for Trigeminal Neuralgia

Trigeminal neuralgia (TN) is characterized by unilateral paroxysmal stabbing pain in one or more branch distributions of the fifth cranial nerve. Classical TN typically occurs as a result of neurovascular compression from branches of the superior cerebellar artery or other nearby vasculature. Patients can often identify triggers for facial pain, including chewing, talking, washing, shaving, smoking, or toothbrushing. The pain can be debilitating and have serious…

Radiosurgery for Metastatic Brain Tumors

Introduction Stereotactic radiosurgery (SRS) is a minimally invasive treatment modality that delivers a large and typically single dose of radiation to a specific intracranial target while sparing surrounding tissue. Unlike conventional fractionated radiotherapy, SRS does not totally rely on the higher radiosensitivity of neoplastic lesions relative to normal brain (therapeutic ratio). Its selective destruction is dependent mainly on sharply focused high-dose radiation and a steep dose…

A Multidisciplinary Treatment Approach for Idiopathic Intracranial Hypertension

Acknowledgments We would like to thank Dr. Hitoshi Ganaha and Dr. Tabiko Ganaha for critically reviewing this manuscript. Introduction Idiopathic intracranial hypertension (IIH) is a complex disease whose incidence has been increasing since 1990. , It is highly correlated with an increase in obesity, and is associated with headaches, papilledema, and raised cerebral spinal fluid (CSF) pressure in the absence of an intracranial lesion, which can…

Management of Cerebrospinal Fluid Leaks

Conventions and Definitions CSF leaks are classified based on the location of observed fluid, rather than the location of fistula, such as rhinorrhea (from the nose) and otorrhea (from the ear). Transcranial CSF leaks fall into two major categories: traumatic and spontaneous (nontraumatic) leaks. The traumatic group is subdivided into acute or delayed; acute leaks present within 1 week of injury and delayed leaks occur months…

Management of Shunt Infections

Introduction Hydrocephalus is currently one of the most common conditions in neurosurgical practice. Hydrocephalus prevalence in childhood ranges from 0.5 to 1 per 1000 children. , In the adult population, the initial diagnosis is rather uncommon and incidence is approximately 3.4 per 100,000. Since the introduction of cerebrospinal fluid (CSF) shunts in the 1940s, morbidity and mortality rates associated with shunt implantation have decreased significantly, from…

Surgical Management of Cysts: Intraventricular Cysts, Intraventricular Septations, and Extraventricular Arachnoid Cysts

Most of the intracranial cystic lesions are related to neoplasms, bacterial or parasitic infections, or loss of tissue due to malformation, infarction, or injury, including that resulting from surgical resection of brain tissue. These topics are discussed in other chapters of this book; however, an additional group of cystic intracranial lesions is encountered in neurosurgical practice, and in this chapter we discuss intraventricular cysts, intraventricular septations,…

Endoscopic Third Ventriculostomy, Cerebral Aqueductoplasty, and Septum Pellucidotomy

Introduction Neuroendoscopy for cerebrospinal fluid (CSF) pathology has experienced a resurgence in popularity over the past 30 years. It is an alternative to open transcortical approaches to access intraventricular and periventricular pathology. In cases of hydrocephalus, it can be an excellent alternative to shunt placement. In fact, endoscopic third ventriculostomy (ETV) is a commonly performed neuroendoscopic procedure, and it is a safe and effective procedure that…

Cerebrospinal Fluid Diversion Procedures: Ventriculo-Atrial, Ventriculo-Peritoneal, Ventriculo-Pleural, and Lumbo-Peritoneal Shunts

Hydrocephalus is a medical condition characterized by a pathologic dilatation of the ventricular system and the subarachnoid space due to an abnormal increment of the cerebrospinal fluid (CSF volume). This condition can be secondary to a blockage in the regular transit between the ventricles, blockage of the outlet of the ventricular system (non-communicating hydrocephalus), or secondary to an imbalance in the production/reabsorption of CSF (communicating hydrocephalus).…

Surgical Management of Hydrocephalus in the Adult

Hydrocephalus, from the Greek word meaning “water in the head,” is a general term used to describe many conditions of fluid collected in the intracranial space. For the purposes of this chapter, we define hydrocephalus as an inappropriate amount of cerebrospinal fluid (CSF) within the intracranial space at an inappropriate pressure. In this way, we can include a variety of both childhood and adult syndromes of…