- Email: [email protected]
Response to an article entitled “Fellowship training in the United States and Europe”
CORRESPONDENCE REFERENCES 1. Accreditation Council for Graduate Academic Year 2010-2011. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsBooks/20102011_ACGME_DATA_RESOURCE_BOOK.pdf. Accessed June 27, 2014.
22. Metro DG, Talarico JF, Patel RM, Wetmore AL: The resident application process and its correlation to future performance as a resident. Anesth Analg 100: 502-505, 2005. 23. Neitzschman HR, Neitzschman LH, Dowling A: Key component of resident selection: the semi-structured conversation. Acad Radiol 9:1423-1429, 2002.
2. Bandiera G, Regehr G: Reliability of a structured interview scoring instrument for a Canadian postgraduate emergency medicine training program. Acad Emerg Med 11:27-32, 2004.
24. Pevehouse BC, Colenbrander A: The United States Neurological Surgery Residency Matching Program. Neurosurgery 35:1172-1175, 1994: discussion 1175-1182.
3. Bell JG, Kanellitsas I, Shaffer L: Selection of obstetrics and gynecology residents on the basis of medical school performance. Am J Obstet Gynecol 186:1091-1094, 2002.
25. Poole A, Catano VM, Cunningham DP: Prediction performance in Canadian dental schools: the new CDA structured interview, a new personality assessment, and the DAT. J Dent Educ 71(5):664-676, 2007.
4. Berner ES, Brooks CM, Erdmann JV: Use of the USMLE to select residents. Acad Med 68:753-755, 1993.
26. Powis DA, Neame RLB, Bristow T, Murphy LB: The objective structured interview for medical student selection. Br Med J 296:765-768, 1988.
5. Borowitz SM, Saulsbury FR, Wilson WG: Information collected during the residency match process does not predict clinical performance. Arch Pediatr Adolesc Med 154:256-260, 2000. 6. Boyse TD, Patterson SK, Cohan RH, Korobkin M, Fitzgerald JT, Oh MS, Gross BH, Quint DJ: Does medical school performance predict radiology resident performance? Acad Radiol 9:437-445, 2002. 7. Dirschl DR, Campion ER, Gilliam K: Resident selection and predictors of performance. Clin Orthop Relat Res 449:44-49, 2006. 8. Dirschl DR, Dahners LE, Adams GL, Crouch JH, Wilson FC: Correlating selection criteria with subsequent performance as residents. Clin Orthop Relat Res 399:265-271, 2002. 9. Dubovsky SL, Gendel MH, Dubovsky AN, Levin R, Rosse J, House R: Can admissions interviews predict performance in residency? Acad Pysch 32(6):498-503, 2008.
27. Prager JD, Myer CM 4th, Myer CM 3rd: Attrition in otolaryngology residency. Otolaryngol Head Neck Surg 145:753-754, 2001. 28. Reeve PE, Vickers MD, Hortorn JN: Selecting anaesthetists: the use of psychological tests and structured interviews. J R Soc Med 86:400-403, 1993. 29. Rhoton MF, Barnes A, Flashburg M, Ronai A, Springman S: Influence of anesthesiology residents’ noncognitive skills on the occurrence of critical incidents and the residents’ overall clinical performance. Acad Med 66:359-361, 1991. 30. Schell RM, Dilorenzo AN, Li HF, Fragneto RY, Bowe EA, Hessel EA: Anesthesiology resident personality type correlates with faculty assessment of resident performance. J Clin Anesth 2012:566-572, 2012. 31. Sloan DA, Donnelly MB, Schwartz RW, Felts JK, Blue AV, Strodel WE: The use of objective structured clinical examination (OSCE) for evaluation and instruction in graduate medical education. J Surg Res 63:225-230, 1996. 32. Smilen SW, Funai EF, Bianco AT: Residency selection: should interviewers be given applicants’ board scores. Am J Obstet Gynecol 184:508-513, 2001.
10. Harfmann K, Zirwas J: Can performance in medical school predict performance in residency? A compilation and review of correlative studies. J Am Acad Dermatol 65:1010-1022.e2, 2011.
33. Strand EA, Moore E, Laube DW: Can a structured, behavior-based interview predict future resident success? Am J Obstet Gynecol 204:446.e1-446.e13, 2011.
11. Hunt DD, Maclaren CF, Scott CS, Chu J, Leiden LL: Characteristics of dean’s letters in 1981 and 1992. Acad Med 68:905-911, 1993.
34. Takayama H, Grinsell R, Brock D, Foy H, Pellegrini C, Horvath K: Is it appropriate to use core clerkship grades in the selection of residents? Curr Surg 63: 391-396, 2006.
12. Kahn MJ, Merrill WW, Anderson DS, Szerlip HM: Residency program director evaluations do not correlate with performance on a required 4th-year objective structured clinical examination. Teach Learn Med 13:9-12, 2001.
35. Talarico JF, Metro DG, Patel RM, Carney P, Wetmore AL: Emotional intelligence and its correlation to performance as a resident: a preliminary study. J Clin Anesth 20:84-89, 2008.
13. Keck JW, Arnold L, Willoughby L, Calkins V: Efficacy of cognitive/noncognitive measures in predicting resident physician performance. J Med Educ 54:759-765, 1979.
36. Talarico JF, Varon AJ, Banks SE, Berger JS, Pivalizza EG, Medina-Rivera G: Emotional intelligence and the relationship to resident performance: a multiinstitutional study. J Clin Anesth 25:181-187, 2013.
14. Kilpatrick CC, Doyle PD, Reichman EF, Chohan L, Uthman MO, Orejuela FJ: Emotional intelligence and selection to administrative chief residency. Acad Psychiatry 36:388-390, 2012.
37. Tarico VS, Altmaier EM, Smith WL, Franken EA Jr, Berbaum KS: Development and validation of an accomplishment interview for radiology residents. J Med Educ 61:845-847, 1986.
15. Komives E, St Weiss, Rosa RM: The applicant interview as a predictor of resident performance. J Med Educ 59:425-426, 1984.
38. Volle RL: Using national board of medical examiners scores in selection of residents. JAMA 68:753-755, 1988.
16. Kwakwa F, Jonasson O: Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical. J Am Coll Surg 189:602-610, 1999.
39. Wallenstein J, Heron S, Santen S, Shayne P, Ander D: A core competency-based objective structure clinical examination (OSCE) can predict future resident performance. Acad Emerg Med 2:S67-S71, 2010.
17. Manriquez Gilpin M: Residency attrition rate in obstetrics and gynecology: are we losing more postgraduates today? Am J Obstet Gynecol 193:1804-1806, 2005.
40. Yindra KJ, Rosenfeld PS, Donnelly MB: Medical school achievement as predictors of residency performance. J Med Educ 63:356-363, 1998.
18. Market RJ: The relationship of academic measures in medical school to performance after graduation. Acad Med 68:S31-S34, 1993. 19. Matveevskii AS, Loyden JJ, Merlo LJ: Testing program to improve anesthesia resident selection. Anesthesiology 107:A995, 2007. 20. McDonald JS, Lingam RP, Gupta B, Jacoby J, Gough HG, Bradley P: Psychologic testing as an aid to selection of residents in anesthesiology. Anesth Analg 78: 542-547, 1994. 21. Merlo LJ, Matveevkii AS: Personality testing may improve resident selection in anesthesiology programs. Med Teach 31:e551-e554, 2009.
e554
www.SCIENCEDIRECT.com
IN REPLY: When talking about Europe but still including only the United Kingdom, one is talking about only less than a tenth of the population of more than 700 million people in Europe. There are many historical differences in training, health care systems, and
82 [3/4]: e553-e577, SEPTEMBER/OCTOBER 2014 WORLD NEUROSURGERY
CORRESPONDENCE
clinical working hours in general between the old and the new continent. Fellowship programs have a long history in the United States, whereas in Europe, formal clinical ones are more of a rarity and also usually with different content.
fellowship in the United States. This process is highly unmotivating and makes fellowships in the United States practically impossible, thereby preventing shared learning experiences and exchange of thoughts in clinical practice.
In Europe, there are a few centers of excellence to which visitors will travel either to observe surgery for a few days/weeks/months or longer periods of time to scrub, and then we are talking about real fellowships. In Europe the fellowships are more observational, even if the fellows scrub and close the wounds, whereas in the United States, they are more active in that fellows actually perform most parts of the surgeries.
We have good experience in having fellows who challenge us and from whom we also learn. We should establish formal fellowship programs at academic centers in Europe because, in the field of neurosurgery, the days are over of the “general neurosurgeon.” Patients should be centralized in dedicated centers of excellence with all subspecialties of neurosurgery available for better care of our patients.
There are neurosurgical centers such as International Neuroscience Institute (i.e., INI) in Hannover, Karolinska Hospital in Stockholm, Charité in Berlin, and University Hospitals in Utrecht and Zurich that have attracted many visitors and fellows, not to mention our center in Helsinki. Since 1997, we have had the privilege to have more than 2000 visiting neurosurgeons and 200 fellows from all over the world but only very few from the United Kingdom. In Helsinki, we have clinical fellowships for foreign neurosurgeons that range from 6 months to 3 years. We have an open-door policy so every visitor and fellow can enter any of our 4 operating rooms, with 3300 cases a year, to observe and learn. Real fellowships with professor Hernesniemi mean observing and assisting in 400 500 operations a year. After finishing our residency training program, young neurosurgeons do a 1-year fellowship with him. In addition, he has 5 8 foreign fellows and 5 10 visiting neurosurgeons. All operations are recorded and edited for clinical, teaching, and publishing purposes by the fellows. Performing a clinical fellowship should not be considered a real academic merit because it does not guarantee the production of any scientific papers during a relatively hectic 1-year period. In Helsinki, academic merits mean scientific papers in international journals and ultimately a PhD thesis where one includes 3 5 papers under the same topic into a book. Of our own staff of close to 20 fully trained neurosurgeons, all except one (in progress) have an MD PhD degree, which can be on either clinical or basic research or both combined. Despite our very busy clinical practice and the fact that English is not our native language, we still publish around 50 papers in major neurosurgical and other journals of high impact. It typically takes 5 years during/after the residency program to complete a PhD thesis, giving the students skills to write and really analyze scientific papers. We encourage also our foreign fellows also to start the PhD program, which then necessitates a longer stay, and some have taken the opportunity. One should note that a 1-year formal fellowship is just the beginning of a life-long learning process and as such does not guarantee mastering a subspecialty. In Europe, after or even during the 6-year residency program, neurosurgeons choose a subspecialty of their interest to be trained by those already having an “informal” subspecialty in the field. So, the end result of both the American and European systems is similar in the long run. Unfortunately, the American health care system is well-protected from outside practitioners, including Europeans, by forcing already fully trained neurosurgeons to again study basic preclinical and medical studies to pass tests and only thereafter have a
Mika Niemela¨ and Juha Hernesniemi Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland To whom correspondence should be addressed: Mika Niemelä, M.D., Ph.D. [E-mail: [email protected]] Published online 21 June, 2014; http://dx.doi.org/10.1016/j.wneu.2014.06.027.
Accurate Craniopharyngioma Topography for Patient Outcome Improvement LETTER: read with great interest the editorial by S.H. Raza and W eT.H.haveSchwartz (25), focused on the surgical management of retroinfundibular craniopharyngiomas (CPs). This topographic category of CPs includes lesions that involve the infundibulum and the tuber cinereum, the basal areas of the hypothalamus, which integrate the hormonal responses of the pituitary gland. We fully agree with the investigators that treatment of this subtype of CPs is particularly challenging and neurosurgeons have to consider the risks of aggressive resection against those of tumor recurrence. Surgery of CPs involving the infundibulotuberal area of the hypothalamus continues to swing between radical and conservative strategies. Actually, the final decision about the degree of tumor removal for CPs involving the third ventricle is chiefly based on the surgeons’ personal preferences and experience. The possibility of a radical removal for such lesions was strongly advocated by William Sweet (29), who considered that the layer of peritumoral gliosis is a reliable and safety margin between the tumor and the adjacent functioning hypothalamus. However, knowledge and skills attained by experts like Sweet can hardly be conveyed to novice specialists. For the latter, other sources of more tangible knowledge warn against heroic attempts of complete tumor excision. For instance, several pathologic studies performed on autopsy specimens have proven the impossibility for a safe complete removal of some infundibulotuberal CPs because of the extreme thinness or even absence of an intervening layer of gliosis around the tumor (8). In the present letter we would like to emphasize that surgical treatment of CPs should be individualized according to the morphologic and topographic features displayed by the tumor on preoperative high resolution magnetic resonance imaging (MRI) studies. In addition, our aim is to draw the attention to the anatomic, functional, and prognostic importance associated to the terms retrochiasmatic, retroinfundibular, and infundibulotuberal when they are used to define the CP topography.
WORLD NEUROSURGERY 82 [3/4]: e553-e577, SEPTEMBER/OCTOBER 2014
www.WORLDNEUROSURGERY.org
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22. Metro DG, Talarico JF, Patel RM, Wetmore AL: The resident application process and its correlation to future performance as a resident. Anesth Analg 100: 502-505, 2005. 23. Neitzschman HR, Neitzschman LH, Dowling A: Key component of resident selection: the semi-structured conversation. Acad Radiol 9:1423-1429, 2002.
2. Bandiera G, Regehr G: Reliability of a structured interview scoring instrument for a Canadian postgraduate emergency medicine training program. Acad Emerg Med 11:27-32, 2004.
24. Pevehouse BC, Colenbrander A: The United States Neurological Surgery Residency Matching Program. Neurosurgery 35:1172-1175, 1994: discussion 1175-1182.
3. Bell JG, Kanellitsas I, Shaffer L: Selection of obstetrics and gynecology residents on the basis of medical school performance. Am J Obstet Gynecol 186:1091-1094, 2002.
25. Poole A, Catano VM, Cunningham DP: Prediction performance in Canadian dental schools: the new CDA structured interview, a new personality assessment, and the DAT. J Dent Educ 71(5):664-676, 2007.
4. Berner ES, Brooks CM, Erdmann JV: Use of the USMLE to select residents. Acad Med 68:753-755, 1993.
26. Powis DA, Neame RLB, Bristow T, Murphy LB: The objective structured interview for medical student selection. Br Med J 296:765-768, 1988.
5. Borowitz SM, Saulsbury FR, Wilson WG: Information collected during the residency match process does not predict clinical performance. Arch Pediatr Adolesc Med 154:256-260, 2000. 6. Boyse TD, Patterson SK, Cohan RH, Korobkin M, Fitzgerald JT, Oh MS, Gross BH, Quint DJ: Does medical school performance predict radiology resident performance? Acad Radiol 9:437-445, 2002. 7. Dirschl DR, Campion ER, Gilliam K: Resident selection and predictors of performance. Clin Orthop Relat Res 449:44-49, 2006. 8. Dirschl DR, Dahners LE, Adams GL, Crouch JH, Wilson FC: Correlating selection criteria with subsequent performance as residents. Clin Orthop Relat Res 399:265-271, 2002. 9. Dubovsky SL, Gendel MH, Dubovsky AN, Levin R, Rosse J, House R: Can admissions interviews predict performance in residency? Acad Pysch 32(6):498-503, 2008.
27. Prager JD, Myer CM 4th, Myer CM 3rd: Attrition in otolaryngology residency. Otolaryngol Head Neck Surg 145:753-754, 2001. 28. Reeve PE, Vickers MD, Hortorn JN: Selecting anaesthetists: the use of psychological tests and structured interviews. J R Soc Med 86:400-403, 1993. 29. Rhoton MF, Barnes A, Flashburg M, Ronai A, Springman S: Influence of anesthesiology residents’ noncognitive skills on the occurrence of critical incidents and the residents’ overall clinical performance. Acad Med 66:359-361, 1991. 30. Schell RM, Dilorenzo AN, Li HF, Fragneto RY, Bowe EA, Hessel EA: Anesthesiology resident personality type correlates with faculty assessment of resident performance. J Clin Anesth 2012:566-572, 2012. 31. Sloan DA, Donnelly MB, Schwartz RW, Felts JK, Blue AV, Strodel WE: The use of objective structured clinical examination (OSCE) for evaluation and instruction in graduate medical education. J Surg Res 63:225-230, 1996. 32. Smilen SW, Funai EF, Bianco AT: Residency selection: should interviewers be given applicants’ board scores. Am J Obstet Gynecol 184:508-513, 2001.
10. Harfmann K, Zirwas J: Can performance in medical school predict performance in residency? A compilation and review of correlative studies. J Am Acad Dermatol 65:1010-1022.e2, 2011.
33. Strand EA, Moore E, Laube DW: Can a structured, behavior-based interview predict future resident success? Am J Obstet Gynecol 204:446.e1-446.e13, 2011.
11. Hunt DD, Maclaren CF, Scott CS, Chu J, Leiden LL: Characteristics of dean’s letters in 1981 and 1992. Acad Med 68:905-911, 1993.
34. Takayama H, Grinsell R, Brock D, Foy H, Pellegrini C, Horvath K: Is it appropriate to use core clerkship grades in the selection of residents? Curr Surg 63: 391-396, 2006.
12. Kahn MJ, Merrill WW, Anderson DS, Szerlip HM: Residency program director evaluations do not correlate with performance on a required 4th-year objective structured clinical examination. Teach Learn Med 13:9-12, 2001.
35. Talarico JF, Metro DG, Patel RM, Carney P, Wetmore AL: Emotional intelligence and its correlation to performance as a resident: a preliminary study. J Clin Anesth 20:84-89, 2008.
13. Keck JW, Arnold L, Willoughby L, Calkins V: Efficacy of cognitive/noncognitive measures in predicting resident physician performance. J Med Educ 54:759-765, 1979.
36. Talarico JF, Varon AJ, Banks SE, Berger JS, Pivalizza EG, Medina-Rivera G: Emotional intelligence and the relationship to resident performance: a multiinstitutional study. J Clin Anesth 25:181-187, 2013.
14. Kilpatrick CC, Doyle PD, Reichman EF, Chohan L, Uthman MO, Orejuela FJ: Emotional intelligence and selection to administrative chief residency. Acad Psychiatry 36:388-390, 2012.
37. Tarico VS, Altmaier EM, Smith WL, Franken EA Jr, Berbaum KS: Development and validation of an accomplishment interview for radiology residents. J Med Educ 61:845-847, 1986.
15. Komives E, St Weiss, Rosa RM: The applicant interview as a predictor of resident performance. J Med Educ 59:425-426, 1984.
38. Volle RL: Using national board of medical examiners scores in selection of residents. JAMA 68:753-755, 1988.
16. Kwakwa F, Jonasson O: Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical. J Am Coll Surg 189:602-610, 1999.
39. Wallenstein J, Heron S, Santen S, Shayne P, Ander D: A core competency-based objective structure clinical examination (OSCE) can predict future resident performance. Acad Emerg Med 2:S67-S71, 2010.
17. Manriquez Gilpin M: Residency attrition rate in obstetrics and gynecology: are we losing more postgraduates today? Am J Obstet Gynecol 193:1804-1806, 2005.
40. Yindra KJ, Rosenfeld PS, Donnelly MB: Medical school achievement as predictors of residency performance. J Med Educ 63:356-363, 1998.
18. Market RJ: The relationship of academic measures in medical school to performance after graduation. Acad Med 68:S31-S34, 1993. 19. Matveevskii AS, Loyden JJ, Merlo LJ: Testing program to improve anesthesia resident selection. Anesthesiology 107:A995, 2007. 20. McDonald JS, Lingam RP, Gupta B, Jacoby J, Gough HG, Bradley P: Psychologic testing as an aid to selection of residents in anesthesiology. Anesth Analg 78: 542-547, 1994. 21. Merlo LJ, Matveevkii AS: Personality testing may improve resident selection in anesthesiology programs. Med Teach 31:e551-e554, 2009.
e554
www.SCIENCEDIRECT.com
IN REPLY: When talking about Europe but still including only the United Kingdom, one is talking about only less than a tenth of the population of more than 700 million people in Europe. There are many historical differences in training, health care systems, and
82 [3/4]: e553-e577, SEPTEMBER/OCTOBER 2014 WORLD NEUROSURGERY
CORRESPONDENCE
clinical working hours in general between the old and the new continent. Fellowship programs have a long history in the United States, whereas in Europe, formal clinical ones are more of a rarity and also usually with different content.
fellowship in the United States. This process is highly unmotivating and makes fellowships in the United States practically impossible, thereby preventing shared learning experiences and exchange of thoughts in clinical practice.
In Europe, there are a few centers of excellence to which visitors will travel either to observe surgery for a few days/weeks/months or longer periods of time to scrub, and then we are talking about real fellowships. In Europe the fellowships are more observational, even if the fellows scrub and close the wounds, whereas in the United States, they are more active in that fellows actually perform most parts of the surgeries.
We have good experience in having fellows who challenge us and from whom we also learn. We should establish formal fellowship programs at academic centers in Europe because, in the field of neurosurgery, the days are over of the “general neurosurgeon.” Patients should be centralized in dedicated centers of excellence with all subspecialties of neurosurgery available for better care of our patients.
There are neurosurgical centers such as International Neuroscience Institute (i.e., INI) in Hannover, Karolinska Hospital in Stockholm, Charité in Berlin, and University Hospitals in Utrecht and Zurich that have attracted many visitors and fellows, not to mention our center in Helsinki. Since 1997, we have had the privilege to have more than 2000 visiting neurosurgeons and 200 fellows from all over the world but only very few from the United Kingdom. In Helsinki, we have clinical fellowships for foreign neurosurgeons that range from 6 months to 3 years. We have an open-door policy so every visitor and fellow can enter any of our 4 operating rooms, with 3300 cases a year, to observe and learn. Real fellowships with professor Hernesniemi mean observing and assisting in 400 500 operations a year. After finishing our residency training program, young neurosurgeons do a 1-year fellowship with him. In addition, he has 5 8 foreign fellows and 5 10 visiting neurosurgeons. All operations are recorded and edited for clinical, teaching, and publishing purposes by the fellows. Performing a clinical fellowship should not be considered a real academic merit because it does not guarantee the production of any scientific papers during a relatively hectic 1-year period. In Helsinki, academic merits mean scientific papers in international journals and ultimately a PhD thesis where one includes 3 5 papers under the same topic into a book. Of our own staff of close to 20 fully trained neurosurgeons, all except one (in progress) have an MD PhD degree, which can be on either clinical or basic research or both combined. Despite our very busy clinical practice and the fact that English is not our native language, we still publish around 50 papers in major neurosurgical and other journals of high impact. It typically takes 5 years during/after the residency program to complete a PhD thesis, giving the students skills to write and really analyze scientific papers. We encourage also our foreign fellows also to start the PhD program, which then necessitates a longer stay, and some have taken the opportunity. One should note that a 1-year formal fellowship is just the beginning of a life-long learning process and as such does not guarantee mastering a subspecialty. In Europe, after or even during the 6-year residency program, neurosurgeons choose a subspecialty of their interest to be trained by those already having an “informal” subspecialty in the field. So, the end result of both the American and European systems is similar in the long run. Unfortunately, the American health care system is well-protected from outside practitioners, including Europeans, by forcing already fully trained neurosurgeons to again study basic preclinical and medical studies to pass tests and only thereafter have a
Mika Niemela¨ and Juha Hernesniemi Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland To whom correspondence should be addressed: Mika Niemelä, M.D., Ph.D. [E-mail: [email protected]] Published online 21 June, 2014; http://dx.doi.org/10.1016/j.wneu.2014.06.027.
Accurate Craniopharyngioma Topography for Patient Outcome Improvement LETTER: read with great interest the editorial by S.H. Raza and W eT.H.haveSchwartz (25), focused on the surgical management of retroinfundibular craniopharyngiomas (CPs). This topographic category of CPs includes lesions that involve the infundibulum and the tuber cinereum, the basal areas of the hypothalamus, which integrate the hormonal responses of the pituitary gland. We fully agree with the investigators that treatment of this subtype of CPs is particularly challenging and neurosurgeons have to consider the risks of aggressive resection against those of tumor recurrence. Surgery of CPs involving the infundibulotuberal area of the hypothalamus continues to swing between radical and conservative strategies. Actually, the final decision about the degree of tumor removal for CPs involving the third ventricle is chiefly based on the surgeons’ personal preferences and experience. The possibility of a radical removal for such lesions was strongly advocated by William Sweet (29), who considered that the layer of peritumoral gliosis is a reliable and safety margin between the tumor and the adjacent functioning hypothalamus. However, knowledge and skills attained by experts like Sweet can hardly be conveyed to novice specialists. For the latter, other sources of more tangible knowledge warn against heroic attempts of complete tumor excision. For instance, several pathologic studies performed on autopsy specimens have proven the impossibility for a safe complete removal of some infundibulotuberal CPs because of the extreme thinness or even absence of an intervening layer of gliosis around the tumor (8). In the present letter we would like to emphasize that surgical treatment of CPs should be individualized according to the morphologic and topographic features displayed by the tumor on preoperative high resolution magnetic resonance imaging (MRI) studies. In addition, our aim is to draw the attention to the anatomic, functional, and prognostic importance associated to the terms retrochiasmatic, retroinfundibular, and infundibulotuberal when they are used to define the CP topography.
WORLD NEUROSURGERY 82 [3/4]: e553-e577, SEPTEMBER/OCTOBER 2014
www.WORLDNEUROSURGERY.org
e555