Features of the Month

Unruptured right middle cerebral artery bifurcation aneurysm
by Juha Hernesniemi, MD, PhD

Figure 1: Cerebral aneurysms associated with segmental dilative arteriopathy of the circle of Willis

Figure 1: Microsurgical clipping for the true posterior communicating artery aneurysm in the distal portion of the posterior communicating artery

Figure 2: Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms

Dear Colleague,

This is the first newsletter since we launched the new SNI Web site at the end of May. I would really like to know what you all think about it. Please write me your suggestions on how we can make it better at jamesausman@mac.com


In order for you to keep up with what is going on in the other journals published in many disciplines, we developed "Neurosurgery Concepts," which summarizes the key articles in the literature with comments by specialists in the field. It is written to be easy to read. In the last month, there have been three Neurosurgery Concepts articles published, and should continue to appear once every six weeks. The Co-Editors are Zach Smith and Isaac Yang, with a group of reviewers each of whom is identified with their reviewed article.

The most recently-published article covers:

  • "Key perspectives on quality of life in children with spina bifida." Be sure to read the results
  • "Cilengitide for the treatment of newly diagnosed glioblastoma." Does it make a difference? No.
  • "Surgery, and stereotactic radio surgery in the management of intracranial metastasis" It is better than either treatment alone.
  • "Gamma Knife radio surgery in patients with meningiomas and with Neurofibromatosis Type 2."
  • "Patient misconceptions on the diagnosis and treatment of lumbar spondylosis." There are significant misconceptions; this is a must-read.

In the previous article, you will find summaries of:

  • "Key perspectives on C2 nerve root transection following C1 lateral mass screw fixation." This produces a better QOL
  • "Choroid plexus cauterization in infants with  hydrocephalus." Is it better than shunting, particularly in the developing world? Read the abstract and discussion.
  • "Quality of life following treatment of vestibular schwannoma."
  • "Dynamic magnetic resonance imaging for glioblastoma pseudo-progression compared with actual progression." It is made more accurate using relative cerebral blood volume measurement through ferumoxytol MRI.
  • "The value of interspinous devices vs standard decompression." There is none.

In last month's article, you will find short summaries of

  • "Key perspectives on Traumatic Brain Injury." The author shows that youthful, minimal TBI patients preserved their accuracy on cognitive measures, but show slower psychomotor speeds and longer reaction times.
  • "New Treatments for Glioblastoma." The multimodal strategy with resection plus carmustine wafers plus systemic therapy with fotemustine in patients with recurrent GBM showed an improved survival benefit; a second study showed the addition of bevacizumab to radiotherapy–temozolomide did not improve survival in patients with newly diagnosed GBM.
  • "Hemicraniectomy for Extensive Middle-Cerebral-Artery Stroke."
  • "Minimally Invasive Spine Surgery for Spinal Stenosis." It is better than open surgery in multiple ways
  • "Lumbar Epidural Injections for Radiculopathy." They are of no value. 

As you can see, a wide range of topics are covered from many journals. These important Neurosurgery Concepts pieces are placed in a new supplement, SNI: Neurosurgery Concepts, which you can find listed under "Supplements" on our Web site's toolbar, making them easy for you to access. Lots of information in a short read.


Sandquist et al from the United States write about "Preventing proximal junctional failure in long segmental instrumented cases of adult degenerative scoliosis using a multilevel stabilization screw technique." The authors comment that these problems "are well-recognized suboptimal outcomes of long-segmental fusions of the thoracolumbar spine that can lead to significant neurological morbidity and costly revision surgeries. With no known proximal junction failures to date, the MLSS technique has shown promising results in preventing adverse proximal junctional conditions and can be safely performed under fluoroscopy guidance."

Al-Khouja et al, also from the United States, studied the "Economics of image guidance and navigation in spine surgery." They concluded, "there is currently an insufficient amount of studies reporting on the economics of spinal navigation to accurately conclude on its cost-effectiveness in clinical practice. Although a few of these studies showed less costs associated with intraoperative imaging, none were able to establish a statistically significant difference." This is an excellent study.

Epstein reported in her paper "Preliminary study showing safety/efficacy of nanoss bioactive versus vitoss as bone graft expanders for lumbar non instrumented fusions" that "in patients undergoing multilevel lumbar laminectomies with posterolateral non instrumented fusions, results were nearly comparable utilizing Vitoss or NanOss as bone graft expanders."

Epstein also conducted a survey of the SNI: Spine Editorial Board on whether spine surgeons (or all surgeons or doctors for that matter) should read their patients studies rather than rely on radiologic reports. She presents a case of a patient with a cervical tumor that was missed for 2.5 years. Read the interesting and supportive answers of her Editorial Board.

Younoki et al from Japan report a rare case of a dumbbell-shaped epidural cavernous angioma in the lumbar spine. The lesion did not dilate the intervertebral foramen.


Revuelta-Gutierrez from Mexico reports in his 20-year surgical experience, lessons learned in treating Hemifacial spasm. He states, "The anterior inferior cerebellar artery is involved in most cases of hemifacial spasm. Failure to improve post surgically after 1 week warrants reoperation."

Yamamoto et al from Japan report on the use of Superficial Temporal Artery to Middle Cerebral Artery anastomosis for neovascular glaucoma due to common carotid artery occlusion. In the 1970s and 80s there were many reports of using STA-MCA bypasses to treat ocular ischemia related to carotid occlusion and poor collateral flow to the eye. This experience has been discarded with the EC-IC bypass studies. The bypass studies never examined this clinical problem, and, thus, this treatment stands as valid as this report describes.

Horta et al from Japan report two cases of cerebral aneurysms associated with segmental dilative arteriopathy of the circle of Willis. See Figure 1 in the featured images above.

In another rare case, Takeda et al from Japan report on the Microsurgical clipping for the true posterior communicating artery aneurysm in the distal portion of the posterior communicating artery." See Figure 1 in the featured images above.

Goehre et al from Finland describe a Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms that are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. See Figure 2 in the featured images above.

da Silva Martins from Brazil reviewed the management of Pial AV Fistulas. "Pial arteriovenous fistula (PAVF) is a rare vascular condition comprising of one or more arterial vessels that are in direct communication with the draining veins. The condition is also characterized by the absence of a nidus. Due to high blood flows, varicose systems adjacent to the fistula appear. The key characteristic of the arteriovenous direct transition is that it offers a treatment option in which interruption of the blood flow can occur without removing the entire lesion." These lesions can be successfully treated endovscularly or by surgery.


Russell Blaylock, who is an SNI Associate Editor-in-Chief and expert in natural supplemental molecular agents and inflammation, and whose papers in SNI have been read by thousands across the world, has written two major papers on cancer. One covers the fallacies in methodological studies on cancer treatment, and the second proposes a hypothesis for a new treatment paradigm in cancer control. His paper on immunoexcitotoxicity, written in 2011 as an explanation for the cascade of events leading from head injury to Alzheimer’s and Parkinson’s, has become a standard in the field for explaining the problems following head injury and other injuries to the CNS. Both of these papers take time to read. I advise downloading them and reading them at your leisure. The essence of each paper is in my introduction in the first paper and in the second in the summary below. These papers will change our way of thinking about cancer and its treatment. 

Papacci et al from Italy report on the use of Digital Subtraction Angiography for Meningiomas,and present two cases with associated AVMs that would not be seen on the detail of just MRA. The report raises some interesting questions. I remember Len Malis, one of the founders of microsurgery and an excellent neurosurgeon who said, "I want to know all that I can about a lesion before I operate."  In the present era of MR, DSA has been mostly abandoned because of ease of use and avoidance of risk. I rarely embolize meningiomas because it does not usually help and does have a higher risk, in my experience. To me it is the same for aneurysms. Why is an MRA or CTA used unless the quality is good, and surpasses a DSA? The inverventionalists want a DSA and would not use anything else. For me, I am partial to angiography, which has better resolution of the vessels I need to see, the deep perforators, veins and arteries and the angiographic anatomy. 

da Silva et al from Brazil have written an excellent paper on the removal of giant meningiomas of the skull base. They did have a 5% mortality, 18% cranial nerve deficit, and 14% CSF leak, but if you look at the size of these lessons at 3cm or larger, they did an admirable job. Their discussion is excellent and worth reading. They opted for total removal in mostly young patients (averaging 50 years of age) and discuss subtotal removal in the discussion. The argument was to delay recurrence. This is obviously an experienced team of surgeons dealing with a difficult problem. 


Moraes et al from Brazil reviewed their experience in re-irradiating patients with AVMs with a linear accelerator Of 37 patients, 27 had reangiography after re-treatment and 55% had angiographic obliteration. In three patients without obliteration, surgical removal was successful in 2/3. Nidus reduction of more than 50% at initial radiation with a dose >15.5 Gy was predictive of cure. These results are similar to those treated with a Gamma Knife. Read the Discussion for an excellent review of the studies on this subject. This is a superb paper. My question is what happens to those 25% of the initial group of AVM patients who failed to obtain obliteration?  In our experience, we see few back for surgery or surgical consideration. Of interest in this paper 2 of 3 patients with a reduction in AVM volume were treated successfully with surgery. Are we missing some patients here who could benefit from additional surgical treatment after failed radio surgery?

Eppinger et al from the United States report of the successful use of selective dorsal rhizotomy for spastic diplegia secondary to stroke in an adult patient. "Spastic diplegia in adult patients can be due to stroke, brain or spinal cord injury from trauma, infection, toxic-metabolic disorders, and other causes." The appropriate rootlets to cut are identified electrophysiologically. 


In a unique observation, Lai et al describe an arteriovenous malformation within an isocitrate dehydrogenase 1 mutated anaplastic oligodendroglioma. "The co-occurrence of an IDH1 mutated neoplasm and AVM supports the hypothesis that IDH1 mutations may contribute to aberrant angiogenesis and vascular malformation." Read the discussion on this interesting observation and what it implies.

There were other unique case reports this month, but we did not have room for them in this newsletter. Ather Enam, from Pakistan, who suggested the idea of a supplement devoted to unique case observations, is assuming the editorship of this supplement with his new board. 


Mona Stecker, Editor of SNI: Neurosurgical Nursing, wrote about Disruptive Behavior and what to do about it. Please let your nurses know that there is a free nursing journal for them in SNI. We welcome contributions from all over the world. Everyone needs to know what you are doing in your country with the resources you have, from the nursing perspective.


Faria has reviewed the rare three volumes of the History of Medicine by medical historian and classical scholar Plinio Prioreschi, MD, PhD (Volume 1, Volume 2, Volume 3). Faria states, "Among the many conclusions drawn from this reading is that medical history and ethics should not be left up to laymen with little knowledge of medicine, and sometimes with ideological agendas. All physicians including neurosurgeons should be interested in medical history, so that they know where they came from and where they are headed."


As our civilization evolves, there is a belief held by some in Secular Humanism.  As defined by Wikipedia, "Secular Humanism posits that human beings are capable of being ethical and moral without religion or a god." Yet, throughout history religions of all types have been closely aligned with ethical and moral behavior. Recently, an important letter to the editor was published in SNI in response to Miguel Faria’s editorial, "The road being paved to neuroethics: A path leading to bioethics or to neuroscience medical ethics?in which government-sponsored panels would make neuro-medical-ethical decisions for patients. Faria reviews the history of the connection between religious beliefs and moral behavior. 

Read Faria’s scholarly article on this subject, as well as his recently-published followup editorial. The issue of centrally dictated beliefs vs individual freedom is becoming the centerpiece of many of today’s national and international disputes. It will take some time to read Faria’s work. This is an outstanding review of this subject, regardless of your beliefs or where you live. These papers and their subject covers the major personal, social and political issues facing civilization in the 21st century. It is important to understand these concepts as they will affect everything you do. I suggest that you download the papers and read them at your leisure. SNI is open to ALL opinions and will publish them on subjects related to our patients and to the practice of medicine.


This journal represents CHANGE. SNI welcomes CHANGE. That is the 21st century. You need wisdom and judgment to deal with CHANGE. Technology is data and information. You need wisdom and judgment to use technology which has no wisdom and judgment. You do. Use it. Do not be intimidated by technology. It is a tool. Use it wisely. 


The Video Journal of Neurosurgery from Professor Hernesniemi scheduled to begin in June was delayed for technical reasons and will start in December. But, look at the new videos from the 2014 Helsinki Live Video Course just added to Videos.

There is a volume of new, growing information in SNI, with expert commentary and a chance for you to comment on anything we publish. Tell your friends to read SNI. Subscribe to this free newsletter on our home page. Google: Surgical Neurology International (or Bing: Surgical Neurology International or enter www.sni.global to reach our site directly. Tell us if you have any trouble accessing the Web site. All of SNI’s contents are free to people everywhere in the world. 

Please let me know what we can do to make our Web site and journals better for you at jamesausman@mac.com

James I. Ausman, MD, PhD,
Editor in Chief,
Surgical Neurology International

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