Some more pics ... Neurocon '08

Focal cellular hyperplasia matters... but how do I convince the sheep?... Manish

find the rest at yahoo group site.

At the Taj Mahal ... Neurocon 08

Most of it was infra-red... Neurocon 08, Agra

Liquid metal in neurosurgery

“Liquid metal” is the trade name of amorphous metal alloys which have dramatically different properties compared to ordinary metals that exists in crystalline state. The amorphous non crystalline nature of this product gives it a moldable plastic nature when heated, allowing it to be cast into complex shapes – like glass – they really never solidify (crystallize). In fact they are called metallic glass.

They are twice as strong as ordinary titanium, highly resistant to corrosion and have great elasticity. They are already being used for many applications, commercially, including prosthetic joints. Possible uses in neurosurgery would be spinal implants and may be aneurysm clips that can be opened any number of times without losing strength and free from risk of in situ ‘stress corrosion failure’.

The material is the culmination of many decades of research at California institute of technology.

Video>>

Journal club in neurosurgery training

An interesting survey of 113 residents on the impact of journal club in neurosurgery training. Most residents felt JCs are of good educational value with 'the perceived primary goal of keeping current with the literature and dissemination of information.'

Time we shifted ours to TGIF.

Source: Neurosurgery 61:397–403, 2007
Click below to read the full questionaire.

At Matrimandir, Auroville, Pondicherry.

Arivazhagan and Priya - marriage reception, 1st sept 07, Pondicherry

L>R Hari VS, Praful Maste , myself, Kiran Khanagpure, Mithun G Sattur, Pooja, Anirudh TJ, Anand B, Urmila, Nupur, Chandramouli BA, Anilkumar, Santanam, Roopeshkumar VR, Shankar Ganesh

Priya and Arivazhagan. Congrats!

The Ice pick leucotome - Ice pick lobotomy

Dr. Walter Jackson Freeman II (1895 –1972) designed what he called a orbitoclast which he used to do transorbital prefrontal lobotomy – once a popular form of psychosurgery.

Initially, he actually used an icepick from his kitchen. Although he had no formal surgical training, he perfected the technique of transorbital lobotomy which was “fast and less invasive” and required no burr holes. This essentially consisted of thrusting an icepick behind the supraorbital ridge and sweeping it within the brain to sever the connections of the prefrontal lobe as an office procedure which could be completed within a few minutes with little or no sterile precautions under local anesthesia. He, along with James W Watt [neurosurgeon, who later distanced himself from this procedure], popularized lobotomy as the “Freeman-Watt procedure” in the US and did more than three thousand cases often traveling in his “lobotomobile”!


Interestingly, the famous portugese neurologist Egas Moniz had applied Fulton’s animal research findings to human patients to initially perfect the technique of lobotomy [leucotomy] for which he received the Nobel prize for medicine in 1949.


With the advent of the antipsychotic drug thorazine in the 1950s, lobotomy fell into disrepute. By that time more than forty thousand people had been lobotomized in the US alone, many for trivial indications.

Rosemary Kennedy, sister of John F kennedy is the most famous victim of this notorious procedure. She was rendered incapacitated at the age of 23 after undergoing this procedure to control her “mood swings”. Lobotomy reduced Rosemary to an infantile mentality that left her incontinent and staring blankly at walls for hours. Her verbal skills were reduced to unintelligible babble.


May be one day, they might look back in horror that neurosurgeons used to resect gliomas ...

Whats this? Answer in three days!

Can this be Gammaknifed?

Can this 45 year old with grade 4/5 hemiparesis be offered gammaknife treatment? [I dont think so, considering proximity to brainstem, but just to be sure...]

Lesion measures 3.0X2.9X2.2 cms.

Question resolved:
As many of you suggested, the lesion is not suitable for gammaknife radiosurgery primarily because of mass effect on the brainstem which may even be aggravated by tumor swelling after radiosurgery. In fact, microsurgical excision is the primary option.
Outcome:
I could excise the lesion completely without new deficits [Subtemporal approach]. Hemiparesis is improving. Interestingly the fourth nerve comes from underneath the tent rather than between its leaves as they commonly describe.

Are we against the elderly? High grade glioma in the elderly – Do we condescend to sub-optimal therapy?

86-year-old man, developed recent onset of memory disturbance, general fatiguability and visual disturbance initially attributed to cataract. CT scan is suggestive of high grade glioma with mass effect in the right temporal lobe. Other than for mild attention span deficit and hemianopia, he has no deficits. He has good insight and judgment. Comorbid illnesses are unstable angina and well controlled diabetes. He and his relatives are afraid of surgery (who isnt?), risks of GA and ask “I am 86 yr old… can you give some medicines and manage this for one or two years?”

What do you do?

The options range from

1. Operative decompression [as total and safe as possible], ‘full’ radiation, chemotherapy.
2. Biopsy [open/STB] and adjuvant therapy [may be - palliative and less than full RT]
3. Do nothing definitive. Symptomatically treat with steroids, anticonvulsants, counselling for the terminal event.

Consider this ...

Substitute the 86 year old with a 30 year old young man.

The surgeon immediately offers option number one. Most of the time we do not offer or even consider options two and three. Why is that?

Is it because we are prejudiced against the elderly?

“He is 86 year old. Why take the effort and risk of resecting the tumor, subjecting him to the ‘stresses’ of surgery and GA at this advanced age? He could very well develop post op life threatening post op complications."
"Hasn’t he lived enough?"

Life expectancy statistics_____________________________

Life expectancy at birth in India is 64.35

Life expectancy for an 86 year old will be 87.30 [calculated from life table analysis, considering various risk factors]. Upper quartile being 87.85. That is around one and a half years of life left.

-With aggressive treatment of GBM, median survival is 8 months to one year.
-With no treatment it is 1-2 months
-With “suboptimal treatment” [like option two] it is 3-4 months.


That is, with optimal treatment, you are giving him 50-75% of the rest of his life back.

On the other hand, consider the case of the 30 year old man with life expectancy of 72 years, [42 years left]:
Even with aggressive treatment, you are only giving 2.4% of the rest of his life back. Even if he is a long term survivor of GBM [3% of GBM patients survive 3 years or more], that gives him back only 7% of the expected life span

So isn’t it in keeping with sound logic to offer aggressive treatment for the elderly with good KPS? Even eight months of quality life would mean so much for an 86 year old man.

Nobody has lived enough.

Alien technological artifact unearthed... MHT stereotactic frame.Can you help?

These are pictures of the "MHT stereotactic frame. "

Really have no idea how this 13 yr old instrument is used. can you help?

S i l v e r B u l l e t

This may sound paradoxical. But I can’t help saying this. Isn’t radiosurgery the elusive magic bullet we are seeking for? Painless, swift, targeted. Almost magic…

Yes. But surgery is irreplaceable and no radiosurgery can ever completely replace it.

But as surgeons, isn’t it one’s duty to find evermore less invasive ways to treat and if possible eliminate the need for surgery altogether.

Call it endovascular surgery, radiosurgery or nanosurgery – but it all points to the need for incision less, painless procedures to effect treatment on structural lesions. And hopefully surgeons remain in the forefront to create advances in those fields.

Oops! I did it again! Medical Errors.

And on the eighth day, He couldn’t believe what He had just done…

We ought to learn more from our mistakes than from what we would qualify as successes. In fact it’s not a bad idea to carefully maintain a dairy of complications that one encounters in addition to the ubiquitous logbook. Complications, unexpected adverse events, errors in judgment and technique, logically analyzed, anonymised and recorded over the years should be a great personal treasure to any surgeon. When compiled and edited – may be for all.

A good analysis is not a blame-game. There are no accusations, no confessions, no names, no apologies- just cold, logical assessment of the sequence of events that lead to an undesirable event and the actions that could have prevented it at each step, but didn’t.

Medical care review meets [mortality meets] suffer from accusatory overtones, compulsion to pass judgement, ‘us-against-you theatrics’ and hence, the defensive dilution of candid declaration of errors. It serves very little purpose in its present form. What happens is an unnecessary detailed presentation of clinical findings, investigations and procedures, all smoothened out to paint a picture of inevitable, apparently uncontrollable cascade of events leading to death of the patient. And is death the only undesirable outcome? Isn’t morbidity a more living problem? Is anything learned? Nothing is more volatile than memory of the last mortality meet. And a few weeks later - déjà vu!

Sometimes one wonders – may be physicians should have interaction with business management guys – failure analysis, root cause analysis, Ishikawa’s fishbone…The result of any failure analysis should be solid recommendations that do result in change in practice. Not the usual knee jerk response to an event in recent memory that dwarfs better judgement formed over years of clinical practice and trials.

Tons have been written on good techniques. Terabytes of operative videos. But what is transparent (invisible) to the onlooker are the hundreds of possible steps that the expert surgeon hasn’t taken each time, which avoided a future complication. For every ‘!!’ move there are a million ‘??’ moves that would have got you checkmated…

And not for a moment let us think that we have the greatest responsibility. A bus driver taking fifty sleeping passengers on a dark highway or the pilot flying through a thunderstorm has more at stake. He better have a good breakfast and sound sleep.

"Bridge Too Far"

Prof Charles Warlow had come to India to give a talk on pit falls in clinical trials. Errors in journals as reputed as NEJM …

He said he doesn’t encounter neurocysticercosis, or CVTs like we see here. HIV cases are rare out there! He continued …

“You have got 1.1 billion people in India. Every patient you treat should be in a randomized trial which should give you answers that are directly applicable to your population rather than importing data generated in the west.”

- Charles Warlow
Professor of Medical Neurology, Western General Infirmary, Crewe Road, Edinburgh

May be we should have a central body that can coordinate very large multi-institutional clinical trials in India – funding, monitoring and analysis. Because trials done by an individual or an institute are such a waste of time [other than an exercise in systematic fabrication of data.]

Ok. Now let’s take a look at this –

Decompressive Surgery After MCA Stroke Reduces Death, Improves Functional Outcome - Pooled analysis of 3 trials of randomized patients.
http://mp.medscape.com/cgi-bin1/DM/y/hBI6k0NQNoE0D2H0ILWY0E2

Hope too many neurologist don’t read this! Because I’m sure not too many neurosurgeons like the idea.

Do they still keep that stroke ward bed ready or is it NPOW?
May be I’ll ask visiting-Prof Venky!

This way please...

Slick and Black

Sometimes words aren’t enough.
Because it’s a tight neurovascular space out there. And there’s lots and lots of it on the way.
Is it science? Is it art? Or is it plain cold meticulous logic?

Let’s find out!