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Re: The keys to the future of healthcare everywhere. Surg Neurol 2004;61:499–500
Readers’ Comments
Surg Neurol 471 2004;62:470 – 472
ing the endovascular treatment of basilar artery aneurysms associated with fenestration in the literature. Dr. Islak also pointed out that we should have mentioned the main limiting factors for endovascular treatment of intracranial aneurysms associated with fenestrations, for example, the shape of the aneurysmal sac, especially the neck and sac ratio, the use of remodeling techniques, and preservation of the fenestration loops. In broad based aneurysms, it is difficult to form a stable coil nest, maintain the coil within the aneurysm, and obtain a dense coil packing without the risk of sacrificing the parent artery. The balloon remodeling technique was developed to overcome the difficulties and limitations of the endovascular therapeutic approach in broad based aneurysms. This technique offers the possibility of achieving a stable initial basket formation and a denser packing of the aneurysmal sac in such aneurysms, while maintaining the patency of the parent artery. Recently, the newly developed Neuroform stent enables a stable dense coil pacing in patients with geographically difficult aneurysms, including broad based aneurysms. However, neck remodeling techniques using balloon or stent may also increase the risks of thromboembolic complications as well as the risk of intaprocedural aneurysm rupture. Because of this, we seldom use this kind of technique. Even though we did not use the balloon remodeling technique in the cases of our study, we were able to occlude the aneurysmal sac successfully and spare the fenestration limb in all but one case, in which the fenestration limb was very small (patient 3). Conversely, Dr. Islak used the balloon remodeling technique in more than half of their patients of that study, but he also was unable to preserve the fenestration limb in 1 patient whose aneurysmal geometry was complex and the fenestration loop was small. The sacrifice of the fenestration loops should be avoided. However, if the arterial branches do not originate from the portion of the fenestration limb to be occluded, and if the fenestration limb plays a nondominant role in the blood flow to the basilar artery, it can be sacrificed with low risk of ischemic complications because the blood flow to it can be maintained through the distal junction of the fenestration in retrograde fashion. Seok Mann Yoon, M.D. Department of Neurosurgery Soonchunhyang University Hospital Chonan City, South Korea doi:10.1016/j.surneu.2004.08.075
RE: The Keys to the Future of Healthcare Everywhere. Surg Neurol 2004;61:499 –500 To the Editor: I recently read your editorial in Surgical Neurology and it was very refreshing to read your ideas. In addressing your points from a slightly different and, I believe, complementary direction, I would like to suggest you and the Surgical Neurology audience take a quick look at the Website describing my new company, Lynx Collaborative Care Network http://www.lynxcare.net. I conceived of this network of services as the parent of a child with a complex medical condition requiring numerous specialists. Over many years, I became aware of the types of gaps in the healthcare system that you describe and was amazed to discover, for example, that if in depth research into a particularly unusual medical presentation was needed, there was no one available to do that research and that the treating physicians were literally unable to bill anyone for the additional time required. I was also stunned to find that I was required to be the chief engineer of the train of specialists that guide and provide healthcare for my child, even though his pediatrician amazingly devotes scores of unpaid hours annually to just this 1 patient’s needs. This is an awesome burden with potentially dire consequences. Based on my communications with you, Dr. Ausman, I’ve included some information quoted from Surgical Neurology and the articles you have written as well as those you sent from the U.K. in the “Why Lynx” segment of the Lynx Website. Those jewels of information are part of the growing support for Lynx services. I agree with you that the future of medicine requires change and interdisciplinary cooperation. Sharon Feder, Director Lynx Collaborative Care Network, Inc. Denver, Colorado doi:10.1016/j.surneu.2004.06.025
RE: Biomechanical models to guide the surgical approach in atlantoaxial instability. Surg Neurol 2004;62:3. To the Editor: We read the above mentioned review with interest. The reviewer has analyzed two papers about the biomechanical strengths of atlantoaxial [10] and
Surg Neurol 471 2004;62:470 – 472
ing the endovascular treatment of basilar artery aneurysms associated with fenestration in the literature. Dr. Islak also pointed out that we should have mentioned the main limiting factors for endovascular treatment of intracranial aneurysms associated with fenestrations, for example, the shape of the aneurysmal sac, especially the neck and sac ratio, the use of remodeling techniques, and preservation of the fenestration loops. In broad based aneurysms, it is difficult to form a stable coil nest, maintain the coil within the aneurysm, and obtain a dense coil packing without the risk of sacrificing the parent artery. The balloon remodeling technique was developed to overcome the difficulties and limitations of the endovascular therapeutic approach in broad based aneurysms. This technique offers the possibility of achieving a stable initial basket formation and a denser packing of the aneurysmal sac in such aneurysms, while maintaining the patency of the parent artery. Recently, the newly developed Neuroform stent enables a stable dense coil pacing in patients with geographically difficult aneurysms, including broad based aneurysms. However, neck remodeling techniques using balloon or stent may also increase the risks of thromboembolic complications as well as the risk of intaprocedural aneurysm rupture. Because of this, we seldom use this kind of technique. Even though we did not use the balloon remodeling technique in the cases of our study, we were able to occlude the aneurysmal sac successfully and spare the fenestration limb in all but one case, in which the fenestration limb was very small (patient 3). Conversely, Dr. Islak used the balloon remodeling technique in more than half of their patients of that study, but he also was unable to preserve the fenestration limb in 1 patient whose aneurysmal geometry was complex and the fenestration loop was small. The sacrifice of the fenestration loops should be avoided. However, if the arterial branches do not originate from the portion of the fenestration limb to be occluded, and if the fenestration limb plays a nondominant role in the blood flow to the basilar artery, it can be sacrificed with low risk of ischemic complications because the blood flow to it can be maintained through the distal junction of the fenestration in retrograde fashion. Seok Mann Yoon, M.D. Department of Neurosurgery Soonchunhyang University Hospital Chonan City, South Korea doi:10.1016/j.surneu.2004.08.075
RE: The Keys to the Future of Healthcare Everywhere. Surg Neurol 2004;61:499 –500 To the Editor: I recently read your editorial in Surgical Neurology and it was very refreshing to read your ideas. In addressing your points from a slightly different and, I believe, complementary direction, I would like to suggest you and the Surgical Neurology audience take a quick look at the Website describing my new company, Lynx Collaborative Care Network http://www.lynxcare.net. I conceived of this network of services as the parent of a child with a complex medical condition requiring numerous specialists. Over many years, I became aware of the types of gaps in the healthcare system that you describe and was amazed to discover, for example, that if in depth research into a particularly unusual medical presentation was needed, there was no one available to do that research and that the treating physicians were literally unable to bill anyone for the additional time required. I was also stunned to find that I was required to be the chief engineer of the train of specialists that guide and provide healthcare for my child, even though his pediatrician amazingly devotes scores of unpaid hours annually to just this 1 patient’s needs. This is an awesome burden with potentially dire consequences. Based on my communications with you, Dr. Ausman, I’ve included some information quoted from Surgical Neurology and the articles you have written as well as those you sent from the U.K. in the “Why Lynx” segment of the Lynx Website. Those jewels of information are part of the growing support for Lynx services. I agree with you that the future of medicine requires change and interdisciplinary cooperation. Sharon Feder, Director Lynx Collaborative Care Network, Inc. Denver, Colorado doi:10.1016/j.surneu.2004.06.025
RE: Biomechanical models to guide the surgical approach in atlantoaxial instability. Surg Neurol 2004;62:3. To the Editor: We read the above mentioned review with interest. The reviewer has analyzed two papers about the biomechanical strengths of atlantoaxial [10] and