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Injuries to the Cervical Spine

Clinical Pearls The cervical spine is mobile and highly prone to traumatic injury. Early immobilization of the cervical spine and its thorough evaluation with imaging allow identification of a cervical injury and minimize the risk of further injuries. The clinician should always search for clinical and imaging signs of mechanical spinal instability. Injury mechanism, patient age, and the segments of the cervical spine result in different…

Traumatic Skull and Facial Fractures

Clinical Pearls Linear skull fractures require no stabilization or exploration when the scalp is closed and when there is no evidence of an underlying mass lesion. Management of comminuted fractures is the same as for linear skull fractures if the skin is closed and no depression of bone fragments is seen on computed tomography. Closed depressed skull fractures with a greater than 1-cm depression, or a…

Penetrating Brain Injury

Clinical Pearls In the presence of penetrating brain injury, the first step is to initiate advanced trauma life support resuscitation with early transportation for definitive care. The major principles of management of penetrating brain injuries include early decompression with conservative débridement of the brain. Surgeons should avoid disrupting functional eloquent cortex when chasing deep-seated fragments. In addition, it is important to identify and remove superficial expanding…

Critical Care Management of Neurosurgical Patients

Clinical Pearls The predominant aim in managing critically ill neurosurgical patients is to prevent cerebral ischaemia and exacerbation of neurological injury. This is achieved by manipulation of a variety of neurophysiological parameters including intracranial pressure (ICP), cerebral perfusion pressure (CPP) and cerebral blood flow (CBF). Knowledge of the aforementioned neurophysiological principles is important in understanding the mechanism of action and application of therapeutic interventions in a…

Closed Head Injury

Clinical Pearls As with all trauma patients, traumatic brain injury (TBI) patients must be promptly resuscitated and surveyed. A focus on oxygenation, ventilation, blood pressure, and determination of the Glasgow Coma Scale should be the immediate priority followed by a neurologic exam, which is the basis of all TBI treatment. Even single episodes of hypoxia or hypotension are associated with increased morbidity and mortality after a…

Endovascular Treatment of Intracranial Aneurysms

Clinical Pearls Endovascular neurosurgery is quickly emerging as a first-line treatment for many intracranial aneurysms. Aneurysm coils (with or without stents) and flow-diverting stents are the primary devices used for the endovascular neurosurgical treatment of an intracranial aneurysm. Treatment considerations include aneurysm location, aneurysm morphology, and risk of rupture. If an endovascular approach is not preferable, surgical clipping of the aneurysm remains the primary alternative treatment.…

Endovascular Treatment of Acute Stroke and Occlusive Cerebrovascular Disease

Clinical Pearls Stroke has been one of the leading causes of mortality and serious long-term disability. Timely treatment of patients with acute ischemic stroke can drastically change the outcomes. Endovascular treatment has become an important treatment modality for acute ischemic strokes. Noninvasive imaging prior to endovascular treatment provides the means to identify patients who are amenable to endovascular treatment and who would have the greatest benefit.…

Spontaneous Intracerebral Hemorrhage

Clinical Pearls Hemorrhagic stroke accounts for 10% of all strokes. Strokes are the third leading cause of death and the main cause of long-term disability in the United States. Spontaneous intracerebral hemorrhage (ICH) is most commonly caused by chronic hypertension and occurs in penetrating arteries in the basal ganglia, thalamus, pons, and cerebellum. However, other etiologies, such as vascular malformations, tumors, and amyloid angiopathy, should always…

Cavernous Malformations of the Brain and Spinal Cord

Clinical Pearls Cerebral cavernous malformations (CCMs) are vascular lesions that contain a compact bundle of pathologic capillary vessels without intervening brain parenchyma. CCMs are relatively common, affecting approximately 1 in every 200 individuals and accounting for 8% to 15% of all vascular malformations of the central nervous system (CNS). The majority of lesions occur in the brain, with most being located in the supratentorial compartment and…

Vascular Malformations (Arteriovenous Malformations and Dural Arteriovenous Fistulas)

Clinical Pearls Cerebral arteriovenous malformations (AVMs) are high-flow, high-pressure vascular anomalies that cause neurologic morbidity, resulting in seizures, ischemic or steal symptoms, or hemorrhage. Cerebral AVMs are classified on the basis of treatment risk, including nidus size, location within eloquent or noneloquent tissue, and pattern of venous drainage (superficial versus deep). Complete obliteration of AVMs is necessary to reduce the risk of bleeding and to mitigate…

Complex Aneurysms and Cerebral Bypass

Clinical Pearls Cerebral revascularization is a critical tool used to treat complex cerebral aneurysms. Careful preoperative planning and selection of the donor, recipient, and graft vessels are key to a successful outcome. Appropriate selection of low-flow or high-flow bypass is important to provide adequate revascularization and avoid hypoperfusion. Experienced intraoperative neuroanesthesia care and meticulous postoperative monitoring are key to successful outcomes. Indications for Bypass The natural…

Surgery for Posterior Circulation Aneurysms

Clinical Pearls Superior cerebellar artery aneurysms are often favorable for clipping because they tend to project laterally off of the midline, which places them directly in the well-visualized carotid-oculomotor triangle. They are associated with less morbidity than basilar apex aneurysms mainly because thalamoperforating vessels are often not involved. Basilar apex aneurysms can be approached from many angles. If working through the Sylvian fissure, a full dissection…

Anterior Circulation Aneurysms

Clinical Pearls Although endovascular intervention is an important part of the treatment of aneurysms, expertise and proficiency in open surgical management of cerebral aneurysms are essential requirements. Each aneurysm location requires its own unique set of nuances and methods, which are essential for proper and safe clip ligation. Cotton (in addition to patties) is an important adjunct to aneurysm repair and allows for retractorless surgery in…

General Principles for the Management of Ruptured and Unruptured Intracranial Aneurysms

Clinical Pearls The incidence of intracranial aneurysms is variable throughout the world and is approximately 6% in the international population, with higher rates in Asian/Finnish populations and those with a high-risk profile. In patients without any risk factors, the incidence is approximately 2%. Once the aneurysm has ruptured, one-third will die, whereas 50% of survivors will lead independent lives. The majority of intracranial aneurysms arise at…

Medical and Surgical Treatment of Cerebrovascular Occlusive Disease

Clinical Pearls Normal cerebral autoregulation maintains stable cerebral blood flow over a range of systemic perfusion pressures and metabolic demands. Atherosclerosis is an inflammatory disease characterized by the progressive deposition of atheromatous plaques that narrow affected arteries. The prevalence of moderate to severe carotid stenosis is common, and duplex ultrasonography is the most common initial screening method. Antihypertensive, statin, and antiplatelet medications are recommended for the…

Nontraumatic Stroke in Children

Clinical Pearls Treatment decision making for arteriovenous malformations should take into account the lifetime risk associated with the aggressive natural history of these lesions. Whenever surgically feasible (specifically for grades I through III lesions), microsurgical resection with multimodality therapy (endovascular embolization) should be considered as the primary treatment modality in these patients. Presentation of stroke in children will vary by age and etiology, with younger children…

All Other Brain Tumors in Pediatrics

Clinical Pearls The most common solid tumor in pediatrics is a central nervous system tumor, accounting for 20% to 25% of all childhood neoplasms. In childhood, 75% of congenital brain tumors are supratentorial. Initial presenting symptoms can include hydrocephalus, palpable skull mass, focal neurologic deficit, vision change, and endocrinopathies. Upon initial presentation, tumors are diagnosed through cranial imaging with computed tomography or magnetic resonance imaging. Endocrinologic…

Craniopharyngiomas

Clinical Pearls Craniopharyngioma is a histologically benign tumor, which presents special challenges to the neurosurgeon due to a combination of its highly eloquent location and locally recurrent nature. Craniopharyngioma can present with visual, neurologic, or endocrine symptoms. Neurosurgeons managing craniopharyngioma are strongly advised to work within a multidisciplinary team that includes neuro-ophthalmologists, endocrinologists, and oncologists. The “traditional” strategy for surgical management of craniopharyngioma was radical resection.…

Posterior Fossa and Brainstem Tumors in Children

Clinical Pearls Posterior Fossa Tumors Due to the location of posterior fossa tumors, they share common presenting features related to the development of hydrocephalus. They are histologically diverse, with different underlying genetic mutations and prognoses. Magnetic resonance imaging (MRI) of the brain and whole spine should be performed following presentation to identify evidence of disease dissemination. The midline suboccipital approach is most commonly used for tumor…

Chiari Malformations and Syringohydromyelia

Clinical Pearls Chiari malformations are pathologic herniations of the hindbrain through the foramen magnum and into the cervical spinal canal. Chiari malformations are being recognized with increasing frequency because of the increased availability of magnetic resonance imaging (MRI). Chiari I malformation (CIM) represents downward herniation of the cerebellar tonsils into the cervical canal at least 3 to 5 mm on sagittal MRI. The impaction of the tonsils…