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Neurosurgeons needed?
Surg Neurol 1985;23:201-4
201
Letters to the Editor
Giant Aneurysms of the Cavernous Carotid Artery
Treatment of Chronic Cerebral Ischemia
To the Editor:
To the Editor:
The recent article by Dr. Alex Berenstein et al (SURGICAL NEUROLOGY 1984;21:3--12) is another step forward in the treatment of cerebrovascular disease. The problems of inserting a detachable balloon into a large aneurysm and then obliterating the aneurysm while preserving the parent artery are well known. Such may be accomplished routinely in the future, but at present these neuroradiologists are demonstrating impressive results with transvascular selective balloon occlusion of the parent artery just above and below the neck of the aneurysm. I would like to suggest one more advantage to their technique of occlusion, an advantage that one does not get with the classical surgical trapping procedure. With the latter, the ophthalmic artery origin usually is compromised. In the transvascular method the external carotid artery and the ophthalmic artery are preserved. As the external-carotid-to-ophthalmic arterial pathway is capable of providing fairly large amounts of blood to the intracranial internal carotid system [1], there will be a much improved tolerance to occlusion of the internal carotid artery in the cavernous sinus. An additional benefit to simple cervical carotid artery occlusion may be a reduced incidence of embolic phenomena from an internal carotid artery stump [2]. Recently we reported two cases of intracavernous carotid artery aneurysm treated by surgical insertion of Ivalon sponge directly into the giant aneurysm itself [ 1]. We are disappointed that the adjacent internal carotid arteries thrombosed (asymptomatically) in both cases; but, as in the patients of Berenstein et al, the aneurysms were successfully obliterated with excellent distal internal carotid flow from blood coursing retrograde through the ophthalmic artery and from anastomotic pathways of the circle of Willis. There was no need for an intracranial-extracranial arterial bypass. In both cases the entry and exit openings of the internal carotid artery were clearly seen from within the cavity of the aneurysm. These openings were separated by a considerable distance. In such cases the preservation of internal carotid flow perhaps requires some reconstructive procedure that would improve upon the balloon or Ivalon sponge insertion techniques.
The "new surgical technique for the treatment of cerebral ischemia" reported by F. Lesoin et al [1] is not so new. We reported this procedure in 1980 [2]. We agree with the authors that it is indeed a worthwhile alternative revascularization procedure to the superficial temporal artery-middle cerebral artery bypass, although we prefer the latter in the majority of patients.
J O H N L. FOX, M.D. Riyadh, Saudi Arabia 1. Fox,JL. Intracranialaneurysms.Vol 2. New York: Springer-Verlag,1983; 991,99'-)-1011. 2. Heros RC. Thromboemboliccomplicationsafter combinedinternalcarotid ligationand extra-to-intracranialbypass. Surg Neurol 1984;21:75-9. © 1985 by Elsevier Science Publishing Co., Inc.
ROBERT F. SPETZLER, M.D. Phoenix, Arizona 1. Lesoin F, Jomin M, Viaud C, et al. Encephaloarteriosynangiosis in the treatment of chronic cerebral ischemia: preliminary report based on 30 cases. Surg Neurol 1983;20:318-22. 2. Spetzler RF, Roski RA, Kopaniky DR. Alternative superficial temporal artery to middle cerebral artery revascularization procedure. Neurosurgery 1980;7,
Neurosurgeons Needed? To the Editor: I read with interest the letter by Berkley L. Risch, M.D. of Norfolk, Virginia in the May 1984 issue of SURGICAL NEUROLOGY. He points out the dilution of neurosurgical material created by the increase in the number of neurosurgeons practicing in the Norfolk area. He wonders whether this is a national problem and suggests one answer to the problem would be the reduction in neurosurgeons trained in order to reduce the dilution of the surgical case pool by neurosurgeons. However, he makes a substantial case for considerable dilution of neurosurgical material by the entrance of vascular surgeons, orthopedic surgeons, and plastic surgeons into the practice arena. The question that is never answered by individuals who call for a reduction of neurosurgeons is how does one reduce the number of nonneurosurgeons who are doing work traditionally performed by neurosurgeons? I am concerned that if we reverse the trend and decrease the number of neurosurgeons per population we will encourage more and more the care of patients with surgical diseases of the nervous system by nonneurosurgeons. It seems to me that if an individual is concerned that his skills are becoming rusty because of a decreasing number of a particular type of surgical procedure that he is doing, he has three options. First, he can go to the nearest university and ask for time to practice those skills in the laboratory. In some 0090-3I)19/85/$3.3I)
202
Surg Neurol 1985;23:201-4
areas, depending upon local politics, this may be rather naive, or it may be an excellent approach to maintenance of skills, especially in the microsurgical arena. Secondly, he can give up certain types of operations and limit his practice. Thirdly, he might reexamine his relationship with his referring physicians to find out if there is a reason why these patients are not being referred. I wonder if it is possible for a successful surgeon, being rather secure in his referral patterns, to eventually emanate a certain insensitivity to the needs of those referring physicians, who then look elsewhere.
Letters to the Editor
pericranium beneath the cyst and overlying the dent in the outer table of the skull is always intact. I am left with the inescapable conclusion that Pannell et al have described cranial dermoids rather than congenital inclusion cysts of the subgaleal space. Cranial dermoids or dermoids in general have been known since the times of Cruveilhier (1829) and Boestroem (1897). Their tendency to grow in the midline or at the lines of embryonal fusion has been a wellknown feature, and their racial prevalence has never been disputed.
CLARK WATTS, M.D.
A. BASIT C H A U D H A R I , M.D., F.R.C.S.
Co/umbia, Missouri
New Rochelle, Neu, York
Dermoid Cysts
Moyamoya Disease and Subarachnoid Hemorrhage To the Editor:
To the Editor: The article by A.B. Chaudhari in SURGICAL NEUROLOGY ( 1984 ;21:61--6) regarding dermoids of the subgaleal space begins erroneously by stating that "there is no series in the literature" reporting these cysts in whites. I would draw your attention to the series from the Hospital for Sick Children (HSC) in Toronto in which 25 cysts are reported over the anterior fontanelle [ 1]. Twenty-three of the 25 children were white. In Table 1 of that report, the entire group of 94 dermoids of the skull treated by the neurosurgical staff at HSC is displayed, demonstrating that every suture of the cranium can house an inclusion cyst. However, we showed that the anterior fontanelle is the most common site. We did not include epidermoids in our series, as those of the pterion and elsewhere are quite common. BEVERLY C. (PANNELL) WALTERS, M.D. Toronto, Ontario, Canada
Recently a paper appeared in SURGICALNEUROLOGY (Walsh JW, et al 1984,21:30-4) concerning a case of a 12-year-old girl with subarachnoid hemorrhage secondary to occlusion of the middle cerebral artery and moyamoya phenomenon. This communication is very interesting to me, but seems to have one question to be answered. Because only one slice of a computed tomography (CT) scan is presented in this article, it is not definite whether the hematoma is located in the quadrigeminal plate (intracerebral hematoma) or in the quadrigeminal plate cistern (subarachnoid hemorrhage). If the hematoma is confined to the subarachnoid space, this paper becomes exceedingly invaluable, because, since the advent of the CT scan, there has been no report that moyamoya disease per se caused subarachnoid hemorrhage [1]. In addition, although the authors show that intracranial hemorrhage in children with moyamoya phenomenon is rare, statistics from the Ministry of Public Welfare in Japan (1979) show that 33.3% of those between the ages of 10 and 12 years develop intracranial hemorrhage.
l. Pannell BW, Hendrick EB, Hoffman HJ, Humphreys RP. Dermoid cysts of the anterior fontanelle. Neurosurgery 1982;10:317-23.
Reply. The single most important criterion for including any congenital cyst (dermoid or epidermoid) in the category of congenital inclusion cyst of the subgaleal space is its very anatomic location at a particular stratum of the scalp, that is, subgaleal space. Any cyst that is congenitally located beyond the confines of this space and has deeper extensions and connections is no longer a subgaleal cyst, no matter where it is situated--anterior fontanelle, coronal suture, nasion, or inion. Because of this precise anatomic location, a classical subgaleal inclusion cyst does not warrant an extensive surgical procedure as the authors have described in their paper. A classical subgaleal inclusion cyst can be excised in toto quite easily by extracapsular, extracranial enucleation without going beyond the confines of the subgaleal space in 99% of the cases. In the others, one may have to improve the cosmetic result by using the bone chips from the edge of the dent in the outer table of the skull in somewhat older children, but here, too, the
N O B U H I K O AOKI, M.D. Tokyo, Japan 1. Aoki N, Mizutani H. Does moyamoya disease cause subarachnoid hemorrhage? Review of 54 cases with intracranial hemorrhage confirmed by computerized tomography. J Neurosurg 1984;60:348-53.
Reply: Dr. Aoki expresses concern about whether the hematoma we found on CT scan in our 12-year-old girl with moyamoya was located in the quadrigeminal plate (intracerebral) or in the quadrigeminal plate cistern (subarachnoid). We have reviewed our CT scan in full and find that the hematoma is probably primarily intracerebral and only secondarily subarachnoid. We base our conclusion on the fact that the quadrigeminal plate cistern is not dilated, and that at least some of the hematoma appears to be within the brainstem itself. Certainly she had blood in her spinal fluid so that a component of subarachnoid hemorrhage is clear.
201
Letters to the Editor
Giant Aneurysms of the Cavernous Carotid Artery
Treatment of Chronic Cerebral Ischemia
To the Editor:
To the Editor:
The recent article by Dr. Alex Berenstein et al (SURGICAL NEUROLOGY 1984;21:3--12) is another step forward in the treatment of cerebrovascular disease. The problems of inserting a detachable balloon into a large aneurysm and then obliterating the aneurysm while preserving the parent artery are well known. Such may be accomplished routinely in the future, but at present these neuroradiologists are demonstrating impressive results with transvascular selective balloon occlusion of the parent artery just above and below the neck of the aneurysm. I would like to suggest one more advantage to their technique of occlusion, an advantage that one does not get with the classical surgical trapping procedure. With the latter, the ophthalmic artery origin usually is compromised. In the transvascular method the external carotid artery and the ophthalmic artery are preserved. As the external-carotid-to-ophthalmic arterial pathway is capable of providing fairly large amounts of blood to the intracranial internal carotid system [1], there will be a much improved tolerance to occlusion of the internal carotid artery in the cavernous sinus. An additional benefit to simple cervical carotid artery occlusion may be a reduced incidence of embolic phenomena from an internal carotid artery stump [2]. Recently we reported two cases of intracavernous carotid artery aneurysm treated by surgical insertion of Ivalon sponge directly into the giant aneurysm itself [ 1]. We are disappointed that the adjacent internal carotid arteries thrombosed (asymptomatically) in both cases; but, as in the patients of Berenstein et al, the aneurysms were successfully obliterated with excellent distal internal carotid flow from blood coursing retrograde through the ophthalmic artery and from anastomotic pathways of the circle of Willis. There was no need for an intracranial-extracranial arterial bypass. In both cases the entry and exit openings of the internal carotid artery were clearly seen from within the cavity of the aneurysm. These openings were separated by a considerable distance. In such cases the preservation of internal carotid flow perhaps requires some reconstructive procedure that would improve upon the balloon or Ivalon sponge insertion techniques.
The "new surgical technique for the treatment of cerebral ischemia" reported by F. Lesoin et al [1] is not so new. We reported this procedure in 1980 [2]. We agree with the authors that it is indeed a worthwhile alternative revascularization procedure to the superficial temporal artery-middle cerebral artery bypass, although we prefer the latter in the majority of patients.
J O H N L. FOX, M.D. Riyadh, Saudi Arabia 1. Fox,JL. Intracranialaneurysms.Vol 2. New York: Springer-Verlag,1983; 991,99'-)-1011. 2. Heros RC. Thromboemboliccomplicationsafter combinedinternalcarotid ligationand extra-to-intracranialbypass. Surg Neurol 1984;21:75-9. © 1985 by Elsevier Science Publishing Co., Inc.
ROBERT F. SPETZLER, M.D. Phoenix, Arizona 1. Lesoin F, Jomin M, Viaud C, et al. Encephaloarteriosynangiosis in the treatment of chronic cerebral ischemia: preliminary report based on 30 cases. Surg Neurol 1983;20:318-22. 2. Spetzler RF, Roski RA, Kopaniky DR. Alternative superficial temporal artery to middle cerebral artery revascularization procedure. Neurosurgery 1980;7,
Neurosurgeons Needed? To the Editor: I read with interest the letter by Berkley L. Risch, M.D. of Norfolk, Virginia in the May 1984 issue of SURGICAL NEUROLOGY. He points out the dilution of neurosurgical material created by the increase in the number of neurosurgeons practicing in the Norfolk area. He wonders whether this is a national problem and suggests one answer to the problem would be the reduction in neurosurgeons trained in order to reduce the dilution of the surgical case pool by neurosurgeons. However, he makes a substantial case for considerable dilution of neurosurgical material by the entrance of vascular surgeons, orthopedic surgeons, and plastic surgeons into the practice arena. The question that is never answered by individuals who call for a reduction of neurosurgeons is how does one reduce the number of nonneurosurgeons who are doing work traditionally performed by neurosurgeons? I am concerned that if we reverse the trend and decrease the number of neurosurgeons per population we will encourage more and more the care of patients with surgical diseases of the nervous system by nonneurosurgeons. It seems to me that if an individual is concerned that his skills are becoming rusty because of a decreasing number of a particular type of surgical procedure that he is doing, he has three options. First, he can go to the nearest university and ask for time to practice those skills in the laboratory. In some 0090-3I)19/85/$3.3I)
202
Surg Neurol 1985;23:201-4
areas, depending upon local politics, this may be rather naive, or it may be an excellent approach to maintenance of skills, especially in the microsurgical arena. Secondly, he can give up certain types of operations and limit his practice. Thirdly, he might reexamine his relationship with his referring physicians to find out if there is a reason why these patients are not being referred. I wonder if it is possible for a successful surgeon, being rather secure in his referral patterns, to eventually emanate a certain insensitivity to the needs of those referring physicians, who then look elsewhere.
Letters to the Editor
pericranium beneath the cyst and overlying the dent in the outer table of the skull is always intact. I am left with the inescapable conclusion that Pannell et al have described cranial dermoids rather than congenital inclusion cysts of the subgaleal space. Cranial dermoids or dermoids in general have been known since the times of Cruveilhier (1829) and Boestroem (1897). Their tendency to grow in the midline or at the lines of embryonal fusion has been a wellknown feature, and their racial prevalence has never been disputed.
CLARK WATTS, M.D.
A. BASIT C H A U D H A R I , M.D., F.R.C.S.
Co/umbia, Missouri
New Rochelle, Neu, York
Dermoid Cysts
Moyamoya Disease and Subarachnoid Hemorrhage To the Editor:
To the Editor: The article by A.B. Chaudhari in SURGICAL NEUROLOGY ( 1984 ;21:61--6) regarding dermoids of the subgaleal space begins erroneously by stating that "there is no series in the literature" reporting these cysts in whites. I would draw your attention to the series from the Hospital for Sick Children (HSC) in Toronto in which 25 cysts are reported over the anterior fontanelle [ 1]. Twenty-three of the 25 children were white. In Table 1 of that report, the entire group of 94 dermoids of the skull treated by the neurosurgical staff at HSC is displayed, demonstrating that every suture of the cranium can house an inclusion cyst. However, we showed that the anterior fontanelle is the most common site. We did not include epidermoids in our series, as those of the pterion and elsewhere are quite common. BEVERLY C. (PANNELL) WALTERS, M.D. Toronto, Ontario, Canada
Recently a paper appeared in SURGICALNEUROLOGY (Walsh JW, et al 1984,21:30-4) concerning a case of a 12-year-old girl with subarachnoid hemorrhage secondary to occlusion of the middle cerebral artery and moyamoya phenomenon. This communication is very interesting to me, but seems to have one question to be answered. Because only one slice of a computed tomography (CT) scan is presented in this article, it is not definite whether the hematoma is located in the quadrigeminal plate (intracerebral hematoma) or in the quadrigeminal plate cistern (subarachnoid hemorrhage). If the hematoma is confined to the subarachnoid space, this paper becomes exceedingly invaluable, because, since the advent of the CT scan, there has been no report that moyamoya disease per se caused subarachnoid hemorrhage [1]. In addition, although the authors show that intracranial hemorrhage in children with moyamoya phenomenon is rare, statistics from the Ministry of Public Welfare in Japan (1979) show that 33.3% of those between the ages of 10 and 12 years develop intracranial hemorrhage.
l. Pannell BW, Hendrick EB, Hoffman HJ, Humphreys RP. Dermoid cysts of the anterior fontanelle. Neurosurgery 1982;10:317-23.
Reply. The single most important criterion for including any congenital cyst (dermoid or epidermoid) in the category of congenital inclusion cyst of the subgaleal space is its very anatomic location at a particular stratum of the scalp, that is, subgaleal space. Any cyst that is congenitally located beyond the confines of this space and has deeper extensions and connections is no longer a subgaleal cyst, no matter where it is situated--anterior fontanelle, coronal suture, nasion, or inion. Because of this precise anatomic location, a classical subgaleal inclusion cyst does not warrant an extensive surgical procedure as the authors have described in their paper. A classical subgaleal inclusion cyst can be excised in toto quite easily by extracapsular, extracranial enucleation without going beyond the confines of the subgaleal space in 99% of the cases. In the others, one may have to improve the cosmetic result by using the bone chips from the edge of the dent in the outer table of the skull in somewhat older children, but here, too, the
N O B U H I K O AOKI, M.D. Tokyo, Japan 1. Aoki N, Mizutani H. Does moyamoya disease cause subarachnoid hemorrhage? Review of 54 cases with intracranial hemorrhage confirmed by computerized tomography. J Neurosurg 1984;60:348-53.
Reply: Dr. Aoki expresses concern about whether the hematoma we found on CT scan in our 12-year-old girl with moyamoya was located in the quadrigeminal plate (intracerebral) or in the quadrigeminal plate cistern (subarachnoid). We have reviewed our CT scan in full and find that the hematoma is probably primarily intracerebral and only secondarily subarachnoid. We base our conclusion on the fact that the quadrigeminal plate cistern is not dilated, and that at least some of the hematoma appears to be within the brainstem itself. Certainly she had blood in her spinal fluid so that a component of subarachnoid hemorrhage is clear.