Intercontinental Neurosurgery Society of University Neurosurgeons
June 21-27, 2011 Athens, Greece; Istanbul & Izmir, Turkey
Hotel & Scientific Program Locations: Divani Caravel
Conrad Istanbul
Hilton Izmir
2, Vas. Alexandrou Avenue 16121 Athens - Greece
Cihannuma Mah Saray Cd No5 Besiktas, Istanbul, 34353, Turkey
Gazi Osmanpasa Bulvari No 7 Izmir, Turkey 35210
Tel. +30 210 7207000
Tel: +90 212 310 2525
Tel: +90 232 497 6060
Intercontinental Neurosurgery Society of University Neurosurgeons
June 21-27, 2011 Athens, Greece; Istanbul & Izmir, Turkey
TURKEY LOCAL HOST
Y端cel Kanpolat, MD
I am enthusiastically delighted to host all SUN members in Istanbul. Thank you all for joining us in the cultural capital of Europe. As you will see during your travels, Istanbul, geographically being in the center of the world, is a fascinating mixture of the past and present, old and new, modern and traditional. Over its ten millennia, Istanbul has been home to many civilizations and the capital of three empires - the Roman, Byzantine and Ottoman... And as a center for three major religions - Judaism, Christianity and Islam... Being the only city in the world bridging two continents, Istanbul, in all its guises, has always been a crossroad of cultures... With its unique historical and cultural background and innumerable attractions, modern convention centers and hotels, exclusive restaurants, nightclubs, cabarets, festivals, bazaars and shops, Istanbul is one of the most popular destinations of the world. I hope you enjoy the beautiful Bosphorus atmosphere. It is a great opportunity for the distinguished members of the world neurosurgery to have a super scientific meeting but also have unforgettable social programs with pleasant surprises in the bridge of Asia and Europe continents. I am delighted to welcome you and your families to Istanbul, Izmir, and Ephesus. Y端cel Kanpolat, MD President of the Turkish Academy of Sciences
GREECE LOCAL HOSTS
Vassilis G. Varsos, MD, PhD Local Host and Neurosurgeon in Chief, Department of Neurosurgery Red Cross Hospital, Athens,Greece
Kostas Fountas, MD Local Host and Hellenic Neurosurgical Society Member University of Thessaly, School of Medicine, Athens, Greece
Anil Nanda, MD, FACS
PRESIDENT’S MESSAGE
I am delighted to welcome you to the 45th Society of University Neurosurgeons meeting being held in Greece and Turkey. In the shadows of the Ottoman Empire and among the Byzantine Ruins, we will be immersed in the only city that is home to two continents and is a literal crossroads between Europe and Asia. On a historical note, Julius Caesar first proclaimed his celebrated words, ‘Veni, Vidi, Vici,’ – ‘I came, I saw, I conquered,’ in Turkey when he defeated Pontus in the Black Sea region of Turkey. Homer was born in the city of Izmir, and Alexander the Great cut the famous Gordion Knot in the Phrygian capital, not far from Ankara. The theme of this meeting will be Intercontinental Neurosurgery, and will serve as a colloquium for intellectual discourse between distant neurosurgical centers. This is a true international gathering with presentations from Sydney, Australia, Málaga, Spain, Recife, Brazil and Matsumoto, Japan! We have an archaeologist, geologist, and a Capuchin monk giving us distinct views on history, academia, and spirituality. Be it the dashing leadership of Mustafa Kemal Atatürk at Gallipoli or the poetry of Rumi’s whirling dervishes, it is a trip through history, with an after-meeting tour to Ephesus. Our local host, Dr. Yücel Kanpolat, who is also the President of the Turkish Academy of Sciences, has set up a delightful program with participation from the talented schools of neurosurgery in Turkey and our secretary, Dr. Sander Connolly, is helping us with the planning of what promises to be a grand neurosurgical odyssey. Additionally, we are delighted that the Hellenic Neurosurgical Society in Athens is hosting us with Professors Vassilis Varsos and Kostas Fountas in Athens for a day. Visiting the city of the cradle of ancient Greek civilization along with the new Acropolis museum will be a wonderful addition. As they say in Louisiana, “laissez le bon temp rouler!” and so we welcome you to Istanbul, the capital of three great empires – Roman, Byzantine, and Ottoman – as well as Athens and Ephesus. Laura and I are delighted you have joined us with your families. Anil Nanda, MD, FACS SUN President, 2010 - 2011 Department of Neurosurgery LSUHSC - Shreveport
E. Sander Connolly, Jr, MD
SECRETARY/TREASURER’S MESSAGE
It gives me great pleasure to welcome you to the 45th annual SUN Meeting which promises to be our best yet! Anil and I promise world-class science, unbeatable hospitality, and lively intimate interchange with leading academic neurosurgeons from all over the world. A spectacular program has been organized throughout Greece and Turkey that will truly have something special for everyone. In Greece, our expert guides will take you throughout Athens to experience the “changing of the guards” at the Prime Minister’s residence, to the memorial of the Unknown Solider, and of course to the Acropolis. In Turkey, you will visit the Blue Mosque in Istanbul and the ancient ruins in Ephesus. This event will serve as another opportunity to enhance the friendship and scientific learning amongst SUN attendees. E. Sander Connolly, Jr, MD SUN Secretary/Treasurer, 2010 - 2011 Department of Neurological Surgery Columbia University
GUEST LECTURERS
Simeon Gallagher, OFMCap Simeon Gallagher, OFMCap holds advanced degrees in Religious Education, Ascetical Theology, Liberal Arts, and l9th century British Literature. His literature degree has earned him a reputation as a scholar in the works of John Henry Cardinal Newman. He is a graduate of the Great Books Program at St. John’s College (Annapolis/Santa Fe). Fr. Gallagher was born in Philadelphia and is a member of the Mid-America Province of the Capuchin Order. He was ordained a priest in l971, and his ministerial background is diverse. He was Campus Minister at Fort Hays State University in Kansas from l972-78 and held faculty positions at both Marian High-School and Marymount College both in Kansas. He was Chairman of the Religious Education Board for the Salina Diocese. In l978, he was appointed Co-Pastor of Good Shepherd Parish in Shawnee, Kansas and was a faculty member of Notre Dame de Sion Academy in Kansas City, Missouri. In l980, he assumed a Pastorate at Holy Cross Church in Thornton, Colorado. While there, Fr. Gallagher conducted a highly successful parish development program in conjunction with the national Metropolitan Organization of Peoples. Fr. Gallagher is currently Director of the Preaching Ministry Office of the Mid-America Province of the Capuchin Order. He conducts retreats, parish development programs, parish missions, and religious educational workshops. His association with the Emmaus Spirituality Program for Priests has gained him an international reputation in conducting retreats for priests throughout Central America, Great Britain, and Europe. For the past several years he has worked closely with the US Armed Forces at military bases around the world. He recently returned from engagements in Asia and Australia. Athens “Subtexts on the Areopagus: Paul and Religious Diversity” In a contemporary world marked by conflicts often generated in the crucible of religion, St. Paul’s famous speech at Athens might provide insights ( Acts 17: 16-34). Raphael immortalized the event in a powerful painting done in 1515 A.D. (Albert and Victoria Museum, London). This reflection will offer an exegesis of the speech and an appreciation of inter-religious dialogue today. Istanbul “The Ascetical Triad: Henri Nouwen and the Integrated Life” From ancient times the “ascetics” in all religious traditions have attempted personal integration. Anthony of Egypt (c252-365) offered the earliest advice but Henri Nourwen (1932-1996) has achieved a remarkable contemporary expression. Nouwen, a Dutch Catholic priest, psychologist and theologian, published over 40 books before his untimely death. This presentation will situate the “ascetical triad” historically and offer an appreciation of Nouwen’s work. Ephesus “A Bridge Quite Near: Mary and East-West Dialogue” Traditionally, Mary the Mother of Jesus was brought to Ephesus by John the Divine after the Crucifixion. She lived here and was cared for by John until the end of her life. All three great religious traditions (Judaism, Christianity, and Islam) esteem and honor her. Could she be a “bridge” for East-West dialogue? This reflection will assess Mary’s impact.
Mehmet Özdoğan, PhD Professor Özdoğan received his undergraduate degree from Robert College in 1963. He then received his doctorate degree in Archeology with honors from Istanbul University in 1969. His academic career has led him to complete over 12 scientific research projects, and he has served on the editorial board for eight scientific journals. Professor Özdoğan’s research interests include the beginning of village life based on agriculture and animal husbandry, the farming way of life based on the transfer to Europe, and archeology and cultural heritage management models. Professor Özdoğan has been a visiting scholar at numerous universities including Brown University and Cambridge University. He is an active member of 12 scientific institutions throughout Europe and Central Asia. Most recently, Professor Özdoğan was invited by the Council of Young Scientists of Institute of Archaeology and Ethnography at the National History Museum of ANAS, where he spoke on “Archaeological cultures of Anatolia reflecting initial civilizations.” Presently, Professor Özdoğan serves as the head of the Department of Prehistory at Istanbul University.
Yücel Yilmaz, PhD Professor Yilmaz completed his undergraduate degree in 1964 at Istanbul University Faculty of Science. Upon graduation he worked as a geologist at MTA Institute in Ankara, Turkey which was followed by his doctorate in Geology at University College, London University. Professor Yilmaz has conducted research at numerous institutions, including University of London, Leicester University, State University at Albany, NY, and Cambridge University. He has completed over 14 geological studies in his early career. Some of his more recent professional activities include serving as an Exxon Mobil Oil Corporation consultant since 2000 and as Kadir Has University President from 2002 – 2010.
DISTINGUISHED SERVICE AWARD 2011
Kim J. Burchiel, MD, FACS
Kim J. Burchiel, MD, FACS, is the John Raaf Professor and Chairman of the Department of Neurological Surgery at Oregon Health Sciences University. Dr. Burchiel completed his residency in Neurological Surgery at the University of Washington. Dr. Burchiel’s academic career began in 1982, when he remained on faculty at the University of Washington until 1988. He then moved to OHSU in Portland to head up, what was at that time, the Division of Neurosurgery. Dr. Burchiel currently directs the Functional and Stereotactic Neurosurgery fellowship program at OHSU that encompasses the surgical treatment of pain, movement disorders, and epilepsy. His research interests are concerned with the physiology of nociception and neuropathic pains, including trigeminal neuralgia, the neurosurgical treatment of movement disorders, and imageguided neurosurgery. He has published over 300 peer-reviewed articles and chapters, and his published textbooks include the Surgical Management of Pain, Spinal Cord Injury Pain: Assessment, Mechanisms, Management, and Microelectrode Recording in Movement Disorder Surgery. In addition to his academic activities, Dr. Burchiel is very involved and has been active in numerous neurosurgical organizations, serving as past Chairman of the AANS/CNS Joint Section on Pain, past-President of the American Board of Pain Medicine, past-President the Society of University Neurosurgeons, and past-President of the Western Neurosurgical Society. He has been a Director and Vice-Chairman of the American Board of Neurological Surgery and Secretary of the Society of Neurological Surgeons. Currently he is a member of the ACGME Residency Review Committee for Neurological Surgery and the Co-Chairman of the Editorial Board of the Journal of Neurosurgery. Dr. Burchiel and his wife, Debra, have four children, and live in Portland, Oregon.
Previous Award Recipients 2008 Kenneth R. Smith, Jr, MD
2009 Michael L.J. Apuzzo, MD
2010 Jon H. Robertson, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to: 1. Discuss the recent scientific and clinical developments in the field of cerebrovascular disease research and medicine. This includes the management of acute stroke, endovascular therapies, and the results of recently conducted clinical trials and outcomes. 2. Discuss the recent scientific and clinical developments in the field of brain tumor and spinal cord injury basic science research and medicine. This includes management, surgical intervention, and rehabilitation of this patient population. 3. Discuss the recent scientific and clinical developments in the field of spinal degenerative disease. This includes the indications and application of contemporary spinal fixation, fusion, and decompression, as well as, clinical trials and recent outcomes data.
ACCREDITATION STATEMENT
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Association of Neurological Surgeons (AANS) and Society of University Neurosurgeons. The AANS is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
DESIGNATION STATEMENT
The AANS designates this live educational activity for a maximum of 14.25 AMA PRA Category 1Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
2011 MEETING ATTENDEES Saleem Abdulrauf, MD, FACS * Feridun Acar, MD Felipe C. Albuquerque, MD * Arun Paul Amar, MD * Mario Ammirati, MD, MBA Richard C.E. Anderson, MD Alexandros Andreou, MD Michael L. J. Apuzzo, MD * Miguel Angel Arraez Sanchez, MD, PhD Hildo RC Azevedo-Filho, MD, PhD, MSc, FRCS SN Lissa Baird, MD Daniel L. Barrow, MD * Mustafa K. Baskaya, MD Peter Black, MD * Nicholas M. Boulis, MD Ricardo H. Brau, MD, FACS * Ruth E. Bristol, MD Jeffrey A. Brown, MD Jeffrey Bruce, MD * Kim Burchiel, MD, FACS * Paul Camarata, MD Martin Camins, MD Raul Cardenas, MD Luis Casanova Caicedo, MD James Chandler, MD Prashant Chittiboina, MD David Choi, FRCS, PhD * E. Sander Connolly, Jr, MD * William T. Couldwell, MD, PhD Reza Dashti, MD Franco DeMonte, MD, FRCSC, FACS * Robert J. Dempsey , MD Aclan Dogan, MD Richard G. Ellenbogen, MD * Uygur Er, MD Kadir Erkmen, MD Paul Fagan, MD Hamad Farhat, MD Patricia Farrell, MD Venko Filipce, MD Konstantinos Fountas, MD Simeon Gallagher, OFMCap
Francis Gamache, Jr., MD * Fred Gentili, MD, FRCSC, FACS * Thomas Germasimidis, MD Christopher C. Getch, MD * Zoher Ghogawala, MD Steven Giannotta, MD, FACS Steven Steuer Glazier, MD, FACS * Joan Grieve, MD, FRCS * Costas Hadjipanayis, MD David Hasan, MD Takatoshi Hasegawa, MD Carl Heilman, MD * Daniel Hoh, MD Kazuhiro Hongo, MD Ali Kafadar, MD Michael G. Kaiser, MD, FACS * Yukinari Kakizawa, MD Iain H. Kalfas, MD Yucel Kanpolat, MD Evren Keleş, MD Türker Kılıç, MD Neil Kitchen, MD, FRCS * Neville Knuckey, MD * Hasan Kocaeli, MD Sean LaVine, MD * Joung H. Lee, MD Michael L. Levy, MD, PhD, FACS * Stephen Lewis, MD, FRCS * Charles Y. Liu, MD, PhD * Russell R. Lonser, MD * James Markert, Jr., MD * Aristeidis Masmanidis, MD Junko Matsuyama, MD, PhD Georgios K. Matis, MD, MSc, PhD Ian E. McCutcheon, MD John E. McGillicuddy, MD * Jacques Morcos, MD * Melike Mut, MD Anil Nanda, MD, FACS * Naoki Ogihara, MD Mehmet Ozerk Okutan, MD Edward H. Oldfield, MD, FACS Thomas Origitano, MD, PhD *
Mehmet Ozdogan, PhD Nelson M.Oyesiku, MD, PhD, FACS * M Necmettin Pamir, MD Selçuk Peker, MD Konstantinos Polyzoidis, MD Donald O. Quest, MD Hans-Peter Richter, MD, PhD * David W. Roberts, MD * Jon H.Robertson, MD * Charles L. Rosen, MD, PhD Burak Sade, MD Mary Louise Sanderson, MD Michael Schulder, MD, FAANS Panagiotis Selviaridis, MD Mitesh Shah, MD Richard H. Simon, MD Anthony Sin, MD Michael B. Sisti, MD Donald Smith, MD Kenneth R. Smith, Jr., MD * Ihsan Solaroğlu, MD Robert Solomon, MD * Jeffrey Sorenson, MD Stephen Bradley Tatter, MD, PhD* Nicholas Theodore, MD, FACS Phillip Theodosopoulos, MD B. Gregory Thompson, Jr., MD PhillipTibbs, MD Volker M. Tronnier, MD, PhD * Uğur Türe, MD Hasan Çağlar Uğur, MD Vassilis G. Varsos, MD, PhD Erol Veznedaroglu, MD, FACS, FAHA Toshihiko Wakabayashi, MD, PhD Michael Wang, MD * Clarence Watridge, MD Yucel Yilmaz, PhD Daniel Yoshor, MD Gelareh Zadeh, MD Vasilios A. Zerris, MD, MPH, MSc Mehmet Zileli, MD *SUN Member
SOCIAL EVENTS
T uesday, June 21
Athens
10:00 AM - 2:00 PM
Registration
Divani Caravel Hotel Lobby
2:00 PM – 6:30 PM
Tour: Temple of Poseidon
Meet in Divani Caravel Lobby
W ednesday, June 22
Athens
11:00 AM – 11:30 AM Divani Caravel Hotel 11:30 AM – 12:20 PM Divani Caravel Hotel
Subtext on the Areopagus: Paul and Religious Diversity
Fr. Simeon Gallagher, OFMCap
Lunch Presentation: Death of Alexander the Great
Thomas Gerasimidis, MD, Aristotle University of Thessaloniki
1:00 PM – 5:00 PM
Tour: Athens City and Acropolis New Museum
Meet in Divani Caravel Lobby
8:00 PM
Joint Dinner with Hellenic Neurosurgical Society
T hursday, June 23 10:00 AM – 6:30 PM
Registration
6:45 PM
Transportation from Conrad Istanbul Lobby
7:00 PM – 10:00 PM
Welcome Reception
F riday, June 24 9:15 AM – 9:30 AM 11:10 AM – 11:40 AM Conrad Istanbul
Athens/Istanbul Conrad Istanbul Lobby – Floor L
Ciragan Palace Kempinski East Garden
Istanbul
Distinguished Service Award Kim Burchiel, MD, FACS
Conrad Istanbul
Archaeology of Istanbul in between Europe and the Near East
Mehmet Özdoğan, PhD, Archaeologist, Istanbul University
11:40 AM – 12:10 PM Conrad Istanbul 12:10 PM - 1:00 PM
The Ascetical Triad: Henri Nouwen and the Integrated Life
Fr. Simeon Gallagher, OFMCap
Lunch
Conrad Istanbul
1:30 PM – 6:30 PM
Tour: Topkapi Palace, Blue Mosque, and Basilica Cistern
Meet in Conrad Istanbul Lobby
7:30 PM
Transportation from Conrad Istanbul Lobby to the port
8:00 PM – 11:30 PM
Dinner Cruise on the Bosphorus
“I am not an Athenian or a Greek, but a citizen of the world.”
- D iogenes
S aturday, June 25
Istanbul
11:30 AM – 12:15 PM Conrad Istanbul 12:15 PM – 1:00 PM
Presidential Address Anil Nanda, MD, FACS Gallipoli: Intercontinental leadership through the prism of Atatürk, Churchill, and Gandhi Lunch
Conrad Istanbul
1:30 PM – 6:30 PM
Tour: Hagia Sophia, Archeological Museum, and Grand Covered Bazaar
Meet in Conrad Istanbul Lobby
8:00 PM
Gala Dinner
Conrad Istanbul Manzara Restaurant
S unday, June 26
Istanbul/Izmir
11:25 AM – 11:45 AM Conrad Istanbul 12:00 PM
Sea Connections between the Black Sea and Bosphorus and its Bearing on the Ancient Settlements
1:00 PM
Transportation from Conrad Istanbul to the airport (for the flight at 4:00 PM to Izmir)
4:05 PM and 5:05 PM
Transportation from Airport to Izmir Hilton
8:00 PM
Transportation from Izmir Hilton to Dinner
8:15 PM
Dinner Deniz Restaurant
Yücel Yilmaz, PhD, Geologist, President, Kadir Has University
Transportation from Conrad Istanbul to the airport (for the flight at 3:00 PM to Izmir)
M onday, June 27
Izmir/Ephesus
8:30 AM – 7:00 PM
Tour: Ancient Ruins of Ephesus, House of Mary, Museum in Selcuk, Temple of Artemis, Lunch
On Location 8:00 PM
A Bridge Quite Near: Mary and East-West Dialogue
Fr. Simeon Gallagher, OFMCap
Dinner Party Hosted by Feridun Acar
Seaside Izmir
SCIENTIFIC MEETING SCHEDULE
W ednesday, June 22
Divani Caravel
Greece
7:30 AM - 9:30 AM
Scientific Presentation Moderator, Carl Heilman, MD
7:30 AM - 7:40 AM
Welcome, Vassilis G. Varsos, MD, PhD
7:40 AM - 7:50 AM
Endoscopic Extracapsular Dissection for Resection of Pituitary Macroadenomas Daniel Yoshor, MD
7:50 AM - 8:00 AM
Novel Treatment Modalities in the Management of Medically Refractory Epilepsy Kostas Fountas, MD
8:00 AM - 8:10 AM
Cerebral Metastases of Unknown Primary Konstantinos Polyzoidis, MD
8:10 AM - 8:20 AM
Role of fMRI and DTI incorporated into an Intraoperative 3D Dimensional Ultrasound Based Neuronavigation System for Brain Lesions Resection Panagiotis Selviaridis, MD
8:20 AM - 8:30 AM
Acoustic Neuroinomas: Multimodality Management Vassilis G. Varsos, MD, PhD
8:30 AM - 8:40 AM
Artificial Neural Network Versus Apache II System in Predicting Mortality in Head Injury After Falls - A Preliminary Study Georgios K. Matis MD, MSc, PhD
8:40 AM - 8:50 AM
Application of Image Guided Spinal Navigation to Decompression and Internal Fixation of the Upper Cervical Spine Iain H. Kalfas, MD
8:50 AM - 9:00 AM
Cerebral Aneurysms: Coiling or Clipping Alexandros Andreou, MD
9:00 AM - 9:10 AM
In Vitro Engineering of Nucleus Pulposus Using Adult Disc Stem Cells Raul Cardenas, MD
9:10 AM - 9:20 AM
Robust Motor Neuron Transduction Following Intrathecal Delivery of AAV9.GFP to Pigs Nicholas M. Boulis, MD
9:20 AM - 9:30 AM 9:30 AM - 10:00 AM
Calcified Thoracic Disks: Minimally Invasive, Transthoracic, Vertebral Body Sparing Approach Vasilios A. Zerris, MD, MPH, MSc
10:00 AM - 12:20 PM
Scientific Presentation Moderator, B. Gregory Thompson, Jr, MD
10:00 AM - 10:10 AM
Pain Relief Patterns Following Treatment of Trigeminal Neuralgia with Gamma Knife Radiosurgery or Microvascular Decompression Lissa Baird, MD
10:10 AM - 10:20 AM
Subtotal Resection of Large Acoustic Neuromas Philip Theodosopoulos, MD
10:20 AM - 10:30 AM
Spinal Cord Vascular Physiology in Normal and Pathological States Nicholas Theodore, MD, FACS
10:30 AM - 10:40 AM
Canine Model of Convection-Enhanced Delivery of Cetumimab Conjugated Iron-Oxide Nanoparticles Monitored with Magnetic Resonance Imaging Costas Hadjipanayis, MD
10:40 AM - 10:50 AM
Saving Face Michael B. Sisti, MD
10:50 AM - 11:00 AM
Neurosurgical Aristeia and Peak Performance Anil Nanda, MD, FACS
11:00 AM - 11:30 AM
Subtexts on the Areopagus: Paul and Religious Diversity Fr. Simeon Gallagher, OFMCap
11:30 AM - 12:20 PM
Lunch Presentation: The Death of Alexander the Great Thomas Gerasimidis, MD
Break
T hursday, June 23 4:00 PM - 5:00 PM
Conrad Istanbul
Turkey
Executive Committee Meeting
F riday, June 24
Conrad Istanbul
Turkey
6:30 AM - 7:15 AM
Business Meeting
7:30 AM - 9:30 AM
Scientific Presentation Moderator, E. Sander Connolly, Jr, MD
7:30 AM - 7:35 AM
Welcome, Y端cel Kanpolat, MD
7:35 AM - 7:45 AM
Cystic Vestibular Schwannomas Steven Giannotta, MD, FACS
7:45 AM - 7:55 AM
Acoustic Tumor Treatment: An Evolution and Personal Experience Paul Fagan, MD
7:55 AM - 8:05 AM
Surgery for the Pontine Cavernous Angioma Kazuhiro Hongo, MD
SCIENTIFIC MEETING SCHEDULE
F riday, June 24
Conrad Istanbul
Turkey
8:05 AM - 8:15 AM
Language and Cognitive Disturbances After Aneurismal SAH: The Impact of Treatment Hildo RC Azevedo-Filho, MD, PhD, MSC, FRCS SN
8:15 AM - 8:25 AM
Identification of Altered Genes and Protein Expression Profile in Bone Invasive Versus Non-Invasive Meningiomas Gelareh Zadeh, MD
8:25 AM - 8:35 AM
Occipital Lobe Epilepsy and Its Surgical Treatment David W. Roberts, MD
8:35 AM - 8:45 AM
Pedunculopontine Stimulation, A New Frontier in Deep Brain Stimulation Feridun Acar, MD
8:45 AM - 8:55 AM
High Grade Gliomas Melike Mut, MD
8:55 AM - 9:05 AM
Edothelial Cellular Attachment, Proliferation, and Differentiation on Platinum Based Coils Erol Veznedaroglu, MD, FACS, FAHA
9:05 AM - 9:15 AM
CNS: Presidential Update Christopher Getch, MD
9:15 AM - 9:30 AM
Distinguished Service Award Kim Burchiel, MD, FACS
9:30 AM - 10:00 AM
Break
10:00 AM - 12:00 PM
Scientific Presentations Moderator, Jeffrey Bruce, MD
10:00 AM - 10:10 AM
WFNS- World Neurosurgery Peter Black, MD
10:10 AM - 10:20 AM
Neurosurgery Journal and the SUN Meeting in Atlanta Nelson Oyesiku, MD, PhD, FACS
10:20 AM - 10:30 AM
Surgical Resection of Endolymphatic Sac Tumors in Von Hippel-Lindau Disease: Findings, Results and Indications Russell R. Lonser, MD
10:30 AM - 10:40 AM
Regenerative Cerebrovascular Neurosurgery: Lessons Learned from Our Neuro-Oncology Colleagues Robert J. Dempsey, MD
10:40 AM - 10:50 AM
Motion Preservation and Clinical Outcome of PCM 速 Cervical Arthroplasty David Choi, FRCS, PhD
10:50 AM - 11:00 AM
Neuroanatomy-Based Microneurosurgery Mustafa Baskaya, MD
11:00 AM - 11:10 AM 11:10 AM - 11:40 AM
iPad application for learning anatomy of the CNS Yukinari Kakizawa, MD
11:40 AM - 12:10 PM
The Ascetical Triad: Henri Nouwen and the Integrated Life Fr. Simeon Gallagher, OFMCap
Archaeology of Istanbul in between Europe and the Near East Mehmet Özdoğan, PhD
S aturday, June 25
Conrad Istanbul
Turkey
7:30 AM - 9:30 AM
Scientific Presentation Moderator, Neil Kitchen, MD, FRCS
7:30 AM - 7:40 AM
Management of Craniopharyngiomas: Open vs Endoscopic Techniques Fred Gentili, MD, FRCSC, FACS
7:40 AM - 7:50 AM
Assessment of Magnesium and Mild Hypothermia in Rat Focal and Global Cerebral Ischaemia Models Neville Knuckey, MD
7:50 AM - 8:00 AM
Advanced Multimodal Treatment Strategies for Malignant Glioma by Means of Nano-Medicine Toshihiko Wakabayashi, MD, PhD
8:00 AM - 8:10 AM
Concussions James Chandler, MD
8:10 AM - 8:20 AM
Asprin as a Promised Agent for Decreasing Incidence of Cerebral Aneurysm Rupture David Hasan, MD
8:20 AM - 8:30 AM
Assessment of the Corticospinal Tract Alterations Before and After Resection of Brainstem Lesions Using Diffusion Tensor Imaging (DTI) and Tractography at 3-Tesla MRI Uğur Türe, MD
8:30 AM - 8:40 AM
The Subfrontal-Interhemispheric Approach to the Parasellar Region Miguel A. Arraez, MD, PhD
8:40 AM - 8:50 AM
The Rhoton Collection - Creation of an Interactive Steropscopic Neuroanatomy Database Jeffrey Sorenson, MD
8:50 AM - 9:00 AM
The Socio-Economics of Excellence: Can Academic Medical Centers Compete Thomas Origitano, MD, PhD
9:00 AM - 9:10 AM
A Newly Described Ligament Lying Between the Dural Sac and the Ligamentum Flavum at the L5 Level; The ATA and Its Surgical Importance Ihsan Solaroğlu, MD
SCIENTIFIC MEETING SCHEDULE
S aturday, June 25
Conrad Istanbul
Turkey
9:10 AM - 9:20 AM
Phase I Clinical Trial of Intralesional Reovirus Infusion for Tx of Recurrent Malignant Gliomas James Markert, Jr, MD
9:20 AM - 9:30 AM
Surgical Management of Pituitary Adenomas in Pediatric Cushing’s Disease Edward H. Oldfield, MD, FACS
9:30 AM - 10:00 AM
Break
10:00 AM - 12:00 PM
Scientific Presentation Moderator, Thomas Origitano, MD, PhD
10:00 AM - 10:10 AM
Cotton Clipping Technique to Repair Intraoperative Aneurysm Neck Tear Daniel L. Barrow, MD
10:10 AM - 10:20 AM
Cranio-Cervical Arterial Dissections as Sequelae of Chiropractic Manipulation: Patterns of Injury and Management Felipe C. Albuquerque, MD
10:20 AM - 10:30 AM
Effects of Hormone Replacement Therapy in an Aged Animal Model of Stroke Charles L. Rosen, MD, PhD
10:30 AM - 10:40 AM
10-year Experience of Radiosurgery Treatment for Cerebral Arteriovenous Malformations: Puerto Rico Experience Ricardo H. Brau, MD, FACS
10:40 AM - 10:50 AM
Operative Outcome, Risk Factors & Complications in Meningioma Surgery: A Review of 800 Consecutive Cases Joung H. Lee, MD
10:50 AM - 11:00 AM
Evolution of Parasellar Approaches & AANS Update William T. Couldwell, MD, PhD
11:00 AM - 11:10 AM
The 1933 Turkish University Reform and Its Impact on the Turkish Academic Life M Necmettin Pamir, MD
11:10 AM - 11:30 AM
A Nuclear Powered Submarine Journey Through the Bosphorus and the Reinvention of Neurosurgery Michael L.J. Apuzzo, MD
11:30 AM - 12:15 PM
Presidential Address, Introduction by Thomas Origitano, MD, PhD Gallipoli: Intercontinental leadership through the prism of Atatürk, Churchill, and Gandhi Anil Nanda, MD, FACS
S unday, June 26
Conrad Istanbul
Turkey
7:30 AM - 9:30 AM
Scientific Presentation Moderator, Jacques Morcos, MD
7:30 AM - 7:40 AM
Flow Diverters in the Management of Complex Aneurysms: Ready for Prime Time? No way! Jacques Morcos, MD
7:40 AM - 7:50 AM
Lumbar Spinal Fusion Reduces Risk of Re-operation after Laminectomy for Lumbar Spinal Stenosis associated with Grade I Degenerative Spondylolisthesis: Initial Results from the SLIP trial. Zoher Ghogawala, MD
7:50 AM - 8:00 AM
Molecular Understanding of Angiogenesis in AVM’s: From Lab to Clinic Türker Kiliç, MD
8:00 AM - 8:10 AM
Punch Drunk Michael L. Levy, MD, PhD, FACS
8:10 AM - 8:20 AM
Surgery of the Craniovertebral Junction & Upper Cervical Spine: Our Experience Uygur Er, MD
8:20 AM - 8:30 AM
Intraoperative MRI Guidance for Laser Interstitial Thermal Therapy Michael Schulder, MD, FAANS
8:30 AM - 8:40 AM
Placement of thoraco-lumbar pedicle screws using O arm based navigation: technical note on screws placement and on controlling the operational accuracy of the navigation system Mario Ammirati, MD, MBA
8:40 AM - 8:50 AM
Working Under Basic Conditions in Foreign Cultures Hans-Peter Richter, MD, PhD
8:50 AM - 9:00 AM
Non-surgical Exogenous Crossline Therapy: Can Disc Degeneration Be Reversed? Phillip A. Tibbs, MD
9:00 AM - 9:10 AM
Symptomatic Outcome After Decompression Surgery for the Treatment of Chiari Type I Malformation: Evaluation of operative procedures Ruth E. Bristol, MD
9:10 AM - 9:20 AM
Difficult Lessons I Learned in the Treatment of Giant Aneurysms: When to Clip, Coil, Stent, Bypass, or Leave Well Enough Alone? Saleem I. Abdulrauf, MD, FACS
9:20 AM - 9:45 AM
Break
“If one had but a single glance to give the world, one should gaze on Istanbul.”
ALPHONSE DE LAMARTINE
SCIENTIFIC MEETING SCHEDULE
S unday, June 26
Conrad Istanbul
Turkey
9:45 AM - 11:30 AM
Scientific Presentation Moderator, Michael Wang, MD
9:45 AM - 9:55 AM
Management of Hydrocephalus in Pediatric Posterior Fossa Tumors Ali Kafadar, MD
9:55 AM - 10:05 AM
Scalp Tumors with Intracranial Extension in 60 Patients; Multidisciplinary Surgical Strategies and Outcomes Ian E. McCutcheon, MD
10:05 AM - 10:15 AM
Defining the Optimal Neurostimulation/Neuromodulation Paradigm for Treatment of Epilepsy: An Engineering Approach Charles Y. Liu, MD, PhD
10:15 AM - 10:25 AM
Treatment of Pseudotumor Cerebri Due to Venous Obstruction by Stent Placement in the Dural Sinuses Aclan Dogan, MD
10:25 AM - 10:35 AM
Current Concepts in Metabolic and Functional Imaging of Hemispheric Low Grade Gliomas in Adults Evren Keleş, MD
10:35 AM - 10:45 AM
Selective Targeting of Phosphoinositide 3-kinase (PI3K) Gamma is a Promising Novel Approach for the Treatment of Ischemic Stroke Prashant Chittiboina, MD
10:45 AM - 10:55 AM
Hypothalamic Perforating Artery Variations in Patients with Posteriorly and Inferiorly Projecting Anterior Communicating Artery Aneurysms Hasan Kocaeli, MD
10:55 AM - 11:05 AM
Characterization of Lower Urinary Tract Function and Correlative Neuroanatomy in a Novel Translational Model of Experimental Cervical Contusion Spinal Cord Injury Daniel J. Hoh, MD
11:05 AM - 11:15 AM
Quantitative and Qualitative Analysis of the Working Area Obtained by Endoscope and Microscope in Various Approaches to the Anterior Communicating and Basilar Artery Complex Using CT Based Frameless Stereotaxy: A Cadaver Study Venko Filipce, MD
11:15 AM - 11:25 AM
Extension of Research from Anatomy Laboratory to Neurosurgery Practice Hasan Çağlar Uğur, MD
11:25 AM - 11:45 AM
Sea Connections Between the Black Sea and Bosphorus and Its Bearing on the Ancient Settlements (Geology, History, and Mythology) Yücel Yilmaz, PhD
M onday, June 27
Hilton Izmir
Turkey
7:00 AM - 8:00 AM
Scientific Presentation Moderator, Franco DeMonte, MD, FRCSC, FACS
7:00 AM - 7:10 AM
The Role of Surgery in the Management of Skull Base Metastases Franco DeMonte, MD, FRCSC, FACS
7:10 AM - 7:20 AM
Subgroups of Stem Cell-Like Human Glioma Cells Respond Differently to TMZ Volker M. Tronnier, MD, PhD
7:20 AM - 7:30 AM
Intra-operative Indocyanine Green (ICG) Angiography Decreases the Risk of Perforator Vessel Stroke During Cerebral Aneurysm Surgery Kadir Erkmen, MD
7:30 AM - 7:40 AM
Management of Pituitary Adenomas with Cavernous Sinus Invasion and Prognostic Value of MIB-1 Labeling Index Junko Matsuyama, MD, PhD
7:40 AM - 7:50 AM
Laporoscopic Triple Neurectomy for Intractable Groin Pain After Mesh Repair of Hernias John E. McGillicuddy, MD
7:50 AM - 8:00 AM
Surgery for Kyphosis Mehmet Zileli, MD
On Location
A Bridge Quite Near: Mary and East-West Dialogue Fr. Simeon Gallagher, OFMCap
“The world is a book and those who do not travel read only one page.” –
ST. AUGUSTINE
PAST MEETINGS & PRESIDENTS 1965
James T. Robertson, MD Montreal Neurological Institute Montreal, QUE
1966
George T. Tindall, MD Duke University Durham, NC
1967
Robert G. Ojemann, MD University of Minnesota Minneapolis, MN
1968
Charles L. Branch, MD Upstate Medical Center Syracuse, NY
1969
Jim Story, MD Massachusetts General Hospital Boston, MA
1970
Herbert Lourie, MD Baptist Memorial Hospital Memphis, TN
1971
Byron Pevehouse, MD Albert Einstein College of Medicine Bronx, NY
1972
Kenneth Shulmann, MD University of British Columbia Vancouver, BC
1973
Darton Brown, MD Emory University Atlanta, GA
1974
Ellis Kenner, MD University of Texas Medical School San Antonio, TX
1975
Robert Hardy, MD Mayo Clinic Rochester, MN
1976
1981
Stewart Dunsker, MD University of Western Ontario London, ONT
1982
Marshall Allen, MD University of Mississippi Jackson, MS
1983
Ian Turnbull, MD Duke University/University of NC Durham/Chapel Hill, NC
1984
Henry Garretson, MD University of Washington Seattle, WA
1985
Harold F. Young, MD University of Colorado Denver/Vail, CO
1986
Robert Smith, MD University of Louisville Louisville, KY
1987
Kenneth R. Smith, Jr, MD Medical College of Virginia Richmond, VA
1997
Ronald F. Young, MD University of Michigan Ann Arbor, MI
1998
David W. Roberts, MD University of Tennessee Memphis, TN
1999
Charles S. Hodge, Jr, MD University of Melbourne Melbourne, Australia
2000
John E. McGillicuddy, MD Havard Medical School/ Brigham & Women’s Boston, MA
2001
H. Hunt Batjer, MD Oregon Health Sciences University Portland, OR
2002
Philip Stieg, PhD, MD Northwestern University/ Chicago Evanston, IL
2003
1988
Robert Rosenwasser, MD Columbia Presby. Med Center/ NY Presby. Hospital New York, NY
1989
Robert Breeze, MD Karolinska Institute Stockholm, Sweden
Willis Brown, MD University of Tubingen Tubingen, FRG Glenn W. Kindt, MD University of Toronto Toronto, ONT
2004
2005
1990
Kim Burchiel, MD, FACS Wake Forest University School of Medicine Winston-Salem, NC
1991
Jon Robertson, MD University of California – San Diego Del Mar, CA
Salvador Gonzales-Cornejo, MD Louisiana State Univ. Medical Center New Orleans, LA Michael L.J. Apuzzo, MD Tufts New England Medical School Boston, MA
1992
2006
2007
Carl Heilman, MD National Hospital for Neurology and Neurosurgery London, England
Phanor Perot, MD Jefferson Medical College Philadelphia, PA
William A. Buchheit, MD Dartmouth Medical School Woodstock, VT
1977
Gordon Thompson, MD Mayfield Neurological Institute Cincinnati, OH
1993
Alan R. Hudson, MD St. Louis University Medical School St. Louis, MO
Robert Solomon, MD University of California San Francisco, CA
1978
Lucien R. Hodges, MD Medical College of Georgia Augusta, GA
1994
Robert Maxwell, MD, PhD University of Lyon Lyon, France
Jeffrey Bruce, MD Sapienza University Rome, Naples & Capri, Italy
1979
Robert White, MD University of Guadalajara Guadalajara, MX
1995
Peter L. Black, MD Thomas Jefferson Medical School Philadelphia, PA
John Wilson, Jr, MD University of Miami Miami, FL
1980
1996
Current President: Anil Nanda, MD, FACS University of Thessaly & Turkish Academy of Sciences Athens, Greece; Istanbul, Turkey
Robert Grossman, MD University of Florida Gainesville, FL
William Shucart, MD University of Southern California Los Angeles, CA
2008
2009
2010
2011
FUTURE MEETING
ACTIVE MEMBERS SALEEM I. ABDULRAUF, MD, FACS ST. LOUIS UNIV. SCHOOL OF MED., 3635 VISTA AVE., PO BOX 15250 ST LOUIS, MO 63110
DENNIS E. BULLARD, MD TRIANGLE NEUROSURGERY PA 1540 SUNDAY DRIVE, SUITE 214 RALEIGH, NC 27607-5163
DAVID FRIM, MD UNIV. OF CHICAGO MC/NEURO 5841 S. MARYLAND AVE., MC-4066 CHICAGO, IL 60637-1463
P. DAVID ADELSON, MD 1919 E. THOMAS RD. BLDG. B 4TH FL. PHOENIX CHILDREN’S HOSPITAL PHOENIX, AZ 85016-0000
KIM J. BURCHIEL, MD, FACS OREGON HEALTH SCIENCE UNIV. 3181 SW SAM JACKSON PARK RD PORTLAND, OR 97201
FRANCIS W. GAMACHE, JR, MD NEUROSCIENCE INSTITUTE 523 E. 72ND ST., 7TH FLOOR NEW YORK, NY 10021
ARUN P. AMAR, MD 1200 N. STATE ST. STE. 3300 LOS ANGELES CA 90033-0000
WILLIAM F. CHANDLER, MD UNIV. OF MICHIGAN MEDICAL CTR, TAUBMAN HEALTH CARE CENTER 1500 E MEDICAL CENTER DRIVE ANN ARBOR, MI 48109
FRED GENTILI, MD, FRCSC, FACS TORONTO HOSPITAL RM 445 4TH FLOOR WEST WING 399 BATHHURST STREET TORONTO, ON M4T 1B6
DAVID CHOI, FRCS, PHD INSTITUTE OF NEUROSURGERY QUEEN SQUARE, LONDON WC1N 3BG, U.K.
CHRISTOPHER C. GETCH, MD DEPT OF NEUROSURGERY 675 N. ST.CLAIR, GALTER 20-250 CHICAGO, IL 60611
FELIPE C. ALBUQUERQUE, MD BARROW NEUROLOGICAL INSTITUTE 2910 N. THIRD AVE. PHOENIX, AZ 85013 DAVID W. ANDREWS, MD THOMAS JEFFERSON UNIV. HOSPITAL 834 WALNUT STREET, SUITE 650 PHILADELPHIA, PA 19107
ENNIO ANTONIO CHIOCCA, MD, PHD OHIO STATE MEDICAL CENTER DEPARTMENT OF NEUROSURGERY N1017 DOAN HALL COLUMBUS, OH 43210
MICHAEL L.J. APUZZO, MD USC SCHOOL OF MEDICINE 1200 N. STATE ST., SUITE 5046 LOS ANGELES, CA 90033
E. SANDER CONNOLLY, JR, MD 710 W. 168TH ST. RM. 435 NEW YORK, NY 10032-2603
NICHOLAS BARBARO, MD UNIVERSITY OF CALIFORNIA-SF BOX 0112 NEUROSURGERY SAN FRANCISCO, CA 94143
CARLOS A. DAVID, MD LAHEY CLINIC 41 MALL ROAD BURLINGTON, MA 01805
DANIEL L. BARROW, MD THE EMORY CLINIC 1365 B CLIFTON ROAD ATLANTA, GA 30322
JOHNNY DELASHAW, MD DEPT OF NEUROLOGICAL SURGERY L472, OREGON HEALTH SCIENCES 3181 SW SAM JACKSON PK RD PORTLAND, OR 97201
DAVID S. BASKIN, MD BAYLOR COLLEGE OF MED 6560 FANNIN ST., SUITE #944 HOUSTON, TX 77030
FRANCO DE MONTE, MD, FRCSC, FACS MD ANDERSON CANCER CENTER 1515 HOLCOMBE BLVD, BOX 442 HOUSTON, TX 77030-4009
H. HUNT BATJER, MD 676 N. ST. CLAIR ST. SUITE 2210 CHICAGO, IL 60611
RICHARD G. ELLENBOGEN, MD CHILDREN’S HOSPITAL AND REG. MED. CTR P.O. BOX 5371 SEATTLE, WA 98105
RICARDO H. BRAU, MD, FACS CLINICA LAS AMERICAS 400 F. D. ROOSEVELT AVE. #511 SAN JUAN, PR 00918 ROBERT E. BREEZE, MD UNIV OF COLORADO DENVER 1945 WHEELING ST AURORA, CO 80045-2539 JEFFREY N. BRUCE, MD NEUROLOGICAL INSTITUTE, RM 434, 710 W 168TH ST. NEW YORK, NY 10032
KEVIN T. FOLEY, MD SEMMES MURPHEY CLINIC 1211 UNION AVE., SUITE 200 MEMPHIS, TN 38104
EDMUND H. FRANK, M.D. OREGON HEALTH SCIENCES UNIV. 3181 SW SAM JACKSON PARK RD PORTLAND, OR 97201
STEVEN S. GLAZIER, MD, FACS MEDICAL UNIV. SOUTH CAROLINA/ NEUROSURGERY 428CSB PO BOX 250616 CHARLESTON, SC 29425-0100 JOHN G. GOLFINOS, MD NEW YORK UNIV. MED. CTR. 530 1ST AVE, STE 8R NEW YORK, NY 10016-6497 LILIANNA GOUMNEROVA, MD CHILDREN’S HOSPITAL/BADER 3 300 LONGWOOD AVE. BOSTON, MA 02115-5724 JOAN GRIEVE, MD, FRCS UNIV COLLEGE LONDON HOSPITALS QUEEN SQUARE, LONDON WC1 N 3 BG, U.K ROBERT G. GROSSMAN, MD METHODISTHOSPITAL/ NEUROSURGERY 6560 FANNIN STREET, SUITE 944 HOUSTON, TX 77030 ROBERT HARBAUGH, MD PSU-HMC DEPT. OF NEUROSURGERY 30 HOPE DRIVE, EC 110 HERSHEY, PA 17033 CARL B. HEILMAN, MD TUFTS NEW ENGLAND MED. CTR 750 WASHINGTON ST., BOX 178 BOSTON, MA 02111 CHARLES J. HODGE, MD UNIVERSITY OF MARYLAND DEPT. OF NEUROSURGERY 22 S. GREENE ST./#S12D BALTIMORE, MD 21201-1734
DAVID JIMENEZ, MD UNIV. OF TEXAS/ NEUROSURGERY 7703 FLOYD CURL DR, BOX 7843 SAN ANTONIO, TX 78207-0843 MICHAEL G. KAISER, MD, FACS NY NEUROLOGICAL INSTITUTE 710 W. 168TH ST. RM. 504 NEW YORK, NY 10032 GLENN KINDT, MD UNIV OF COLORADO DENVER 1945 WHEELING ST AURORA, CO 80045-2539 NEIL KITCHEN, MD, FRCS THE NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY QUEENS SQUARE, LONDON WC1N 3BG ENGLAND DOUGLAS S. KONDZIOLKA, MD PRESBYTERIAN-UNIV. HOSPITAL 200 LOTHROP STREET, STE B-400 PITTSBURGH, PA 15213 SATISH KRISHNAMURTHY, MD SUNY UPSTATE MED UNIVERSITY 750 E ADAMS ST. SYRACUSE, NY 13210-2306 SEAN D. LAVINE, MD NY NEUROLOGICAL INSTITUTE 710 W. 168TH ST. NEW YORK, NY 10032 PETER LE ROUX, MD, FACS UNIVERSITY OF PENNSYLVANIA 330 S. 9TH ST. 4TH FL., ROOM 424 PHILADELPHIA, PA 19107 MICHAEL L. LEVY, MD, PHD, FACS UNIV. OF CA - SAN DIEGO 8010 FROST ST., SUITE #300 SAN DIEGO, CA 92123 ROBERT M LEVY, MD, PHD DEPT. OF NEUROLOGICAL SURGERY NORTHWESTERN UNIVERSITY CHICAGO, IL 60611 STEPHEN B. LEWIS, MD, FRCS UNIVERSITY OF FLORIDA DEPARTMENT OF NEUROSURGERY P.O. BOX 100265 GAINESVILLE, FL 32610 MICHAEL LINK, MD MAYO CLINIC 200 1ST ST S.W., 233 E ERIE STE 614 ROCHESTER, MN 55905 MARK E. LINSKEY, MD UCI MEDICAL CENTER 101 CITY DRIVE SOUTH BLDG 3 ROOM 313, ROUTE 81 ORANGE, CA 92868-3298
CHARLES LIU, MD, PHD LAC/USC MEDICAL CENTER/NEUROSURGERY 1200 N. STATE ST. RM. 5046 LOS ANGELES, CA 90033
STEPHEN L. ONDRA, MD DEPT. OF NEUROLOGICAL SURGERY NORTHWESTERN UNIVERSITY 675 N. ST. CLAIR ST. SUITE 250 CHICAGO, IL 60611
RUSSELL R. LONSER, MD NINDS - 10 CENTER DRIVE BUILDING 10, ROOM 3D20 BETHESDA, MD 20892
THOMAS ORIGITANO, MD, PHD LOYOLA UNIVERSITY MED CTR 2160 SOUTH 1ST AVE STE 1900 MAYWOOD, IL 60153
JAMES M. MARKERT, JR., MD FOT 1060 510 20TH ST. S. BIRMINGHAM, AL 35294-3410
NELSON OYESIKU, MD, PHD, FACS EMORY UNIVERSITY DEPT. OF NEUROSURGERY 1365-B CLIFTON ROAD NE #2200 2160 S. 1ST AVE./BLDG 105 RM 1900 ATLANTA, GA 30322
PAUL G. MCCORMICK, MD NEUROLOGICAL INSTITUTE 710 W. 168TH STREET NEW YORK, NY 10032 JOHN E. MCGILLICUDDY, MD UNIVERSITY OF MICHIGAN 2128 TAUBMAN CTR BOX 0330 1500 E MEDICAL CENTER ANN ARBOR, MI 48109 GUY MCKHANN, MD NY NEUROLOGICAL INSTITUTE 710 W. 168TH ST., NI 42 NEW YORK, NY 10032-2603 J. MICHAEL MCWHORTER, MD CAROLINA NEUROSURGICAL ASSOCIATES 2810 N. MAPLEWOOD AVE WINSTON-SALEM, NC 27103 JACQUES MORCOS, MD LOIS POPE LIFE CENTER 1095 N.W. 14th TER. D4-6 MIAMI, FL 33136 ANIL NANDA, MD, FACS LOUISIANA STATE UNIVERSITY HSC 1501 KINGS HIGHWAY, BOX 33932 SHREVEPORT, LA 71130 RAJ K. NARAYAN, M.D. PROFESSOR AND CHAIRMAN DEPARTMENT OF NEUROSURGERY NORTH SHORE UNIV. HOSPITAL 300 COMMUNITY DRIVE, 9 TOWER MANHASSET. NY 11030 CHRISTOPHER S. OGILVY, MD MASSACHUSETTS GEN. HOSPITAL 55 FRUIT ST., VBK710 BOSTON, MA 02114 GEORGE A. OJEMANN, MD UNIVERSITY OF WASHINGTON ROOM RR744, BOX 35 6470 SEATTLE, WA 98195
ANDREW PARENT, MD UNIV. OF MISSISSIPPI MED. CTR. 2500 N. STATE STREET JACKSON, MS 99216 AMAN B. PATEL, MD MOUNT SINAI 1 GUSTAVE L. LEVY PO BOX 1136 NEW YORK, NY 10029 CHARLES PRESTIGIACOMO, MD NEUROLOGICAL SURGERY DOCTOR’S OFFICE CENTER 90 BERGEN STREET, STE. 8100 NEWARK, NJ 07101 ALI R. REZAI, MD OHIO STATE UNIVERSITY NEUROSURGERY DEPT 410 W. 10TH AVE. N- DOAN HALL COLUMBUS, OH 43210 DAVID W. ROBERTS, MD DARTMOUTH-HITCHOCK MED CTR ONE MEDICAL CENTER DRIVE LEBANON, NH 03756 JON H. ROBERTSON, MD UNIV. OF TENNESSEE MEMPHIS 847 MONROE AVE., SUITE #427 MEMPHIS, TN 38163 ROBERT H. ROSENWASSER, MD THOMAS JEFFERSON UNIV. HOSPITAL 909 WALNUT ST., 3RD FLOOR STE PHILADELPHIA, PA 19107 OREN SAGHER, MD UNIV. OF MICHIGAN HEALTH SYSTEM NEUROSURGERY 1500 E MEDICAL CTR DR 3470 TAUBMAN CTR ANN ARBOR, MI 48109-0338 MICHAEL SALCMAN, MD 9101 FRANKLIN SQUARE, STE #310 BALTIMORE, MD 21237
ROBERT A. SANFORD, MD SEMMES-MURPHY CLINIC 6325 HUMPHREYS BLVD. MEMPHIS, TN 38120 ROBERT A. SOLOMON, MD NEUROLOGICAL INSTITUTE 710 W. 168TH STREET NEW YORK, NY 10032
PHILIP E. STIEG, PHD, MD NY PRESBYTERIAN HOSPITAL 520 EAST 70TH ST., STARR 651 NEW YORK, NY 10021 STEPHEN TATTER, MD, PhD WAKE FOREST UNIV BLVD./NEUROSURGERY WINSTON-SALEM, NC 27157
MARK SOUWEIDANE, MD NY PRESBY/WEILL MED. CORNELL UNIV. DIV. OF NEUROSURGERY 520 E. 70TH ST. BOX 99 NEW YORK, NY 10021
MICHAEL WANG, MD UNIVERSITY OF MIAMI 1095 N.W. 14TH TER./D4-6 MIAMI, FL 33136
JOHN A. WILSON, JR., MD WAKE FOREST SCHOOL OF MED MEDICAL CENTER BLVD. WINSTON-SALEM, NC 27157-1029
CORRESPONDING MEMBERS PAOLO CAPPABIANCA, MD FEDERICO II UNIV. VIA CHIATAMONE 57 NAPLES 80121 ITALY
NEVILLE KNUCKEY, MD 13 FAULKNER ST WEMBLEY DOWNS, PERTH, AUSTRALIA
NICOLAS DE TRIBOLET, MD RUE MICHELI-DU-CREST 24 GENEVA 12205 SWITZERLAND
IVER A. LANGMOEN, MD ULLEVAL UNIV. HOSP O407 OSLO NORWAY, SWEDEN
SALVADO GONZALEZ-CORNEJO, MD BUENOS AIRES #2691 COLNIA PROVIDENCIA GUADALAJARA, MEXICO 44630 ERNST GROTE , MD HOPPE SEYLER ST 3, TUBINGEN BADEN-WURTTEMBERG 72076 NOBUO HASHIMOTO, MD, PHD DEPT. OF NEUROSURGERY, KYOTO UNIV. 54 KAWAHARA-CHO SHOGOIN, SAKYA-KU KYOTO 606-8507 JAPAN YÜCEL KANPOLAT, MD ANKARA UNIVERSITY INKLAP SOK 2412 KISILAY ANKARA, TURKEY 6650 ANDREW H. KAYE, MD ROYAL MELBOURNE HOSPITAL PARKVILLE 3050 MELBOURNE, VICTORIA, AUSTRALIA
MARC LEVIVIER, MD U.L.B. - HOSPITAL ERASME 808 ROUTE DE LENNIK BRUSSELS B-1070 BELGIUM PAUL J. MULLER, MD 38 SHUTER STREET TORONTO ONT M5B 1A6 CANADA JOHN D. PICKARD, MD ADDENBROOKE’S HOSPITAL BOX 167 A BLOCK LEVEL 4 CAMBRIDGE CB2 2QQ ENGLAND HANS-PETER RICHTER, MD UNIVERSITY OF ULM. LUDWIG-HEILMEYER-STRASSE 2 C-8870 GUENZBURG 89312 GERMANY MARC SINDOU, MD HOSPITAL P. WERTHEIMER 59 BOULEVARD PINEL B.P. LYON MONTCHAT, 69394 LYON, CEDEX 3 FRANCE
PETER J. TEDDY, MD DEPT OF NEUROSURGERY THE RADCLIFFE INFIRMARY NHS TRUST WOODSTOCK RD GERMANY GORDON B THOMPSON, MD 1358 GABRIOLA DRIVE PARKSVILLE BC V9P2T5 CANADA VOLKER TRONNIER, MD, PHD NEUROCHIRURGISCHE UNIVERSITATSKLINIK LUBECK UNIVERSITATSKLINIKUM SCHLESWIG-HOLSTEIN RATZEBURGER ALLEE 160 23538 LUBECK GERMANY JAVIER VERDURA, MD INSURGENTES SUR 549-402 MEXICO CITY, MEXICO
SENIOR MEMBERS MARSHALL B. ALLEN, MD MEDICAL COLLEGE OF GEORGIA 1120 15TH STREET, ROOM #348W AUGUSTA, GA 30912
PETER BLACK, MD BRIGHAM & WOMEN’S HOSPITAL 75 FRANCIS ST BOSTON, MA 02115 CHARLES L. BRANCH, MD 3709 HUNDRED OAKS DRIVE SAN ANTONIO, TX 783217 WILLIS BROWN, MD 7523 SHADYLANE DR. SAN ANTONIO TX 78209-0000
WILLIAM A. BUCHHEIT, MD 6014 CRICKET ROAD FLOURTOWN, PA 19031 MICHAEL E. CAREY, MD 900 AMETHYST ST. NEW ORLEANS LA 70124-0000 STEWART B. DUNSKER, MD MAYFIELD NEURO INSTITUTE 2123 AUBURN AVENUE, SUITE 441 CINCINNATI, OH 45219 PHILIP I. GILDENBERG, MD 2260 W. HOLCOMB BLVD, #309 HOUSTON, TX 77030 SALVADO GONZALEZ-CORNEJO, MD UNIVERSIDAD DE GUADALAJARA AV. CHAPULTEPEC SUR 1300-204 GUADALAJARA, JALISCO, MEXICO ALAN R. HUDSON, MD CANCER CARE ONTARIO 620 UNIVERSITY AVENUE TORONTO CANADA M5G2L7
ELLIS B. KEENER, MD 915 EAST LAKE DRIVE, N.W. GAINESVILLE, GA 30506
JAMES C.H. SIMMONS, MD 190 GROVE PARK ROAD MEMPHIS, TN 38117
DAVID G. KLINE, MD LOUISIANA STATE UNIV. HSC 1542 TULANE AVE. BOX T7-3 NEW ORLEANS LA 70112-2822
JIM L. STORY, MD LONE STAR NEUROSURGERY 2.25 315 NORTH SAN SABA, SUITE 1240 SAN ANTONIO, TX 78207
ROBERT MAXWELL, MD, PHD UNIV. OF MINNESOTA/S.E. MMC 96 420 E. DELAWARE ST. MINNEAPOLIS MN 55455-0374
GORDON B. THOMPSON, MD 1358 BARIOLA DRIVE PARKSVILLE, BC, CANADA V9P2T5
PAUL MYERS, MD 2608 JOHN D. RYAN BLVD. SAN ANTONIO TX 78245-0000
GEORGE T. TINDALL, MD 227 ROSE HILL ROAD MEANSVILLE, GA 30256
SKIP J. PEERLESS, MD MERCY NEUROSCIENCE INSTITUTE 3661 S. MIAMI AVENUE, SUITE #209 MIAMI, FL 33133
JAVIER VERDURA, MD INURGENTS SUR 549-402 MEXICO CITY, MEXICO
ALBERT L. RHOTON, MD UNIVERSITY OF FLORIDA HSC 1600 S.W. ARCHER ROAD, RM M-219 GAINESVILLE, FL 32610 JAMES T. ROBERTSON, MD UNIV. OF TENNESSEE, MEMPHIS 847 MONROE AVENUE, SUITE #427 MEMPHIS, TN 38163 WILLIAM SHUCART, MD TUFTS NEW ENGLAND MED CTR 750 WASHINGTON STREET, BOX 178 BOSTON, MA 02111 KENNETH R. SMITH, JR, MD ST. LOUIS UNIVERSITY HOSPITAL 6365 VISSTA, BOX 15250 ST LOUIS, MO 63110
“Painting is the silence o f thought and the music o f sight.”
ORHAN PAMUK
ROBERT H. WILKINS, MD DUKE UNIV MED. CTR, BOX 3807 DURHAM, NC 27710 ERICH WISIOL, MD 800 E. 28TH STREET MINNEAPOLIS, MN 55407 JULIAN R. YOUMANS, MD 44124 GREENVIEW DRIVE EL MACERO, CA 95618
ABSTRACTS
W ednesday, June 22
Divani Caravel
Daniel Yoshor, MD Endoscopic Extracapsular Dissection for Resection of Pituitary Macroadenomas Background. With the increasing use of the endoscope in neurosurgery, transphenoidal surgery has undergone a considerable technical evolution. However, most recently reported advances relate to the approach to the sella turcica or to extended transphenoidal approaches, while the dissection technique for pituitary tumor removal itself has received more limited attention. A notable exception is Oldfield’s elegant description of an extracapsular dissection of functional pituitary microadenomas. Methods. Influenced by this work, we have gradually adopted an endoscopic extracapsular dissection for resection of pituitary macroadenomas. After initially defining the edges of the tumor pseudocapsule, a central intracapsular tumor debulking is carried out to enable a more extensive peripheral extracapsular dissection. The enhanced exposure of the tumor periphery afforded by the endoscope makes identification and extensive surgical dissection of the pseudocapsule at the margins of a macroadenoma possible in the majority of cases. The pseudocapsule is then used to define a plane between tumor and normal gland, and between tumor and diaphragma sella. Results. The endoscopic extracapsular dissection appears to improve the ease and completeness of macroadenoma resection. It may also enable the surgeon to more easily identify and anatomically preserve the normal gland, and it does not appear to cause a significant increase in CSF leaks. Operative videos illustrate our current technique. We also discuss the pros and cons of extracapsular dissection, and review the relevant literature on the topic. Conclusion. In agreement with the limited existing literature, we find that endoscopic extracapsular dissection of pituitary macroadenomas may facilitate a more complete maroadenoma resection, with better anatomic preservation of the gland and without an apparent increase in complications. Further studies are needed to confirm these early findings. Kostas Fountas, MD Novel Treatment Modalities in the Management of Medically Refractory Epilepsy Konstantinos Polyzoidis, MD Cerebral Metastases of Unknown Primary Panagiotis Selviaridis, MD Role of fMRI and DTI incorporated into an Intraoperative 3D Dimensional Ultrasound Based Neuronavigation System for Brain Lesions Resection
Greece
Vassilis G. Varsos, MD, PhD Acoustic Neuroinomas: Multimodality Management Georgios K. Matis MD, MSc, PhD Artificial Neural Network Versus Apache II System in Predicting Mortality in Head Injury After Falls A Preliminary Study Aim. To compare the performance of APACHE II system and an ANN model in predicting outcome in ICU head-injured patients after falls. Patients and Methods. Retrospective data collection on 15 consecutive head injured patients. The APACHE-II risk of death equation was employed for calculating the predicted risk of death. An ANN was constructed using NeuralWorks Predict® (NeuralWare, PA). The receiver operating characteristic curves (ROCs) and the Lemeshow-Hosmer goodness of fit test were employed. Results. Twelve patients were males (80%) and 3 were females (20%). Eight of them survived (53%) and 7 died (47%). The mean age was 53.33±5.493 years, the mean GCS was 6.93±1.329 and the mean APACHE-II was 14.07±2.067. A four-layer feedforward backpropagation ANN was constructed and trained. The R value for the training, the testing and our data sets was 96.8%, 87.77%, and 83.64% respectively. The corresponding correct classification rates were 86.3%, 79.3%, and 83%. The APACHE II system for a cut off value of 18 demonstrated sensitivity (Se) 51.5%, specificity (Sp) 89.4%, correct classification (CC) 70.4%, positive predictive value (PPV) 84.44%, negative predictive value (NPV) 57.65. The ANN achieved Se 89.7%, Sp 73.4%, CC 84%, PPV 85.3%, and NPV 84.5%. The area under the curve (AUC) for the APACHE II system was 0.732±0.059 (95% CI 0.612 – 0.859, p=0.003), while for the ANN model was 0.845±0.04 (95% CI 0.741 – 0.962, p=0.000). The Hosmer-Lemeshow goodness-of-fit statistic was calculated to be χ2 = 4.225 (p=0.644) for the APACHE II system and χ2 = 5.322 (p=0.592) for the ANN model. Conclusion. The AAN seemed to exhibit better discrimination and similar calibration compared to the APACHE-II system. Moreover, the AAN used fewer variables. Iain Kalfas, MD Application of Image-Guided Spinal Nav to Decompression and Internal Fixation of the Upper Cervical Spine Introduction. Surgery for decompression and fixation in the upper cervical region can be technically challenging due to the anatomic complexity of this region. It requires the surgeon to have a high degree of spatial orientation to the surrounding neural, vascular and bony structures during the
procedure in order to optimize the outcome of surgery. While intraoperative fluoroscopy can help facilitate intra-operative anatomic orientation, it has several technical limitations. Computed tomography-based image-guided spinal navigational technology has proven useful for lumbar fixation procedures. Unlike, fluoroscopy, it provides the surgeon with multiplanar images through the surgical field. These images can be manipulated intraoperatively to provide enhanced orientation to the non-visualized surgical anatomy. The use of image-guided technology in the upper cervical spine will be reviewed. Methods. Forty patients underwent surgery for decompression and internal fixation of the upper cervical spine using CT-based image-guided navigation. Thirty-two patients underwent posterior C1-2 screw fixation, 5 patients underwent transoral surgery with posterior C1-2 screw fixation and 3 patients underwent anterior odontoid screw fixation. Fluoroscopy was also used on a limited basis during each case to validate the navigational information. All patients were assessed postoperatively with plain radiographs. Results. The level of intra-operative image information provided by navigational technology exceeded that provided by fluoroscopy in all cases. Satisfactory screw placement was achieved in all patients. There were no incidences of neural of vascular injury due to incorrect screw placement. There were no cases of fixation failure or incomplete decompression. Conclusion. Image-guided navigation is a safe and reliable technology for facilitating surgery in the upper cervical region. It provides the surgeon with a greater degree of anatomic orientation than can be provided by fluoroscopy alone. Alexandros Andreou, MD Cerebral Aneurysms: Coiling or Clipping Raul Cardenas, MD In Vitro Engineering of Nucleus Pulposus Using Adult Disc Stem Cells Cardenas RJ, Akbar U, Shah HM, Foley KT, Duntsch CD
Degenerative disc disease (DDD) is a chronic degeneration of the disc tissue that occurs with aging and may be symptomatic. We have recently developed a stem culture platform that efficiently isolates disc stem cells (DSCs) from healthy adult disc tissue. Adult DSC potential, when combined with tissue engineering principles, has significant potential for the treatment of DDD. The aim of this study was to investigate the in vitro tissue engineering potential of adult DSCs derived from healthy adult disc tissue. The ability of DSCs to generate functional nucleus pulposus cells and fabricate tissue in vitro was assessed. Tissue engineering assays were used to characterize the rate of cell growth and several cell biology parameters. Novel three-dimensional (3D) tissue engineering models were created to characterize the ability of DSCs to grow in scaffolds, fill defects, and secrete extracellular matrix (ECM). Finally, denucleated rabbit annulus with thin bony
endplates were prepared and used as a scaffold into which DSCs were injected to assess their ability to grow into disc tissue in vitro. The rate of development of disc cell progeny was characterized, as well as their ability to migrate, the velocity of motility, differentiation events, and the degree of proliferation. Novel 3D tissue engineering models were used to determine the ability of adult DSCs to fill spatial defects seeded with scaffolds allowing cell migration in all directions. The ability of DSCs and seeded scaffolds to lead to tissue fabrication and secrete ECM was determined with histologic stains and light microscopy. In both models, histology and immunohistochemistry for disc biomarkers were used to verify and further characterize nucleus pulposus cell progeny. DSCs readily attached to ECM coated culture plates. Progenitor-like cells in contact with the coated surface migrated from the outside in, and spread across the available culture area in 96 hours. Migration was followed by proliferation and the combination resulted in large surface areas surrounding the stem cell cluster being covered with nucleus pulposus cells. Using a 3D tissue engineering assay, DSCs were able to seed scaffolds effectively, migrate multidirectionally, and proliferate to fill structural defects. Post-culture gross inspection revealed a disc-like structure resembling nucleus pulposus. The neoengineered tissue was sectioned and histologic analysis revealed tissue fabrication histology that was moderately cell dense with extensive ECM. Stem cell cluster remnants were easily located. A variation of this model was used to observe in real time the morphology and migration of DSCs as they emerged from DSC clusters. Finally, using a disc with endplate model, neoengineered was shown to effectively grow and the result was disc-like tissue with biomechanical properties similar to and cell biology very similar to disc. In summary, we have characterized activity of adult human DSCs in tissue engineering assays. These studies demonstrated the ability of DSCs to effectively populate tissue engineering assays in a relevant and functional manner. The use of adult DSCs for tissue engineering of the disc to treat DDD holds great potential. Nicholas M. Boulis, MD Robust Motor Neuron Transduction Following Intrathecal Delivery of AAV9.GFP to Pigs Thais Federici PhD’, Jason S. Taub, MD’, Steven S. Gray PhD², Stacey Foti², Josh Grieger², Chalonda R Handy’, Eleanor M. Donnelly’, R. Jude Samulski PhD², and Nicholas M. Boulis, MD’ ‘Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA; ²Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
Introduction. AAV9 has recently been shown to penetrate the blood-brain barrier via intravascular administration, making it a good candidate for diffuse gene delivery. However, the potential side effects of systemic delivery are unknown. Intrathecal vector administration may be more invasive than intravenous injections, but it requires far less vector and it can be performed on an outpatient basis, making it an ideal route of delivery for clinical translation.
ABSTRACTS Methods. Twelve domestic farm pigs (< 15 kg) underwent a single level lumbar laminectomy with intrathecal catheter placement for vector delivery. Animals received either a local lumbar 1.5 ml vector injection, or three 0.5 ml injections at the cervical, thoracic, and lumbar regions of the spinal cord. A total of 1.5 ml of two concentrations of AAV9.Cbh.GFP (7.5 x 10E11 vg â&#x20AC;&#x201C; 3 x 10E12 vg) was locally or diffusely delivered (n = 3/group). Animals were perfused and the tissue was harvested thirty days after treatment. Gene expression was assessed by anti-GFP immunohistochemistry along with diaminobenzidine (DAB) staining. Results. There was no observed morbidity associated with the laminectomy or intrathecal catheter placement required for subarachnoid vector delivery. AAV9.Cbh.GFP was capable of penetrating the pia, reaching motor neurons of the ventral horn and exiting motor rootlets, with limited off-target transduction. While a single lumbar injection resulted in gene expression limited to the lumbar segment of the spinal cord, three consecutive boluses via a temporary catheter resulted in diffuse transduction of motor neurons throughout the cervical, thoracic, and lumbar spinal cords. Analysis is ongoing to assess for toxicity and appropriate dosaging. Conclusions. We now present the first successful robust transduction of motor neurons in the spinal cord of a large animal via intrathecal gene delivery using an AAV serotype 9. Similarity in size and morphology between the swine and human spines and spinal cords renders the pig optimal for biodistribution studies. However, while intrathecal delivery in pigs requires a laminectomy, this procedure would be performed percutaneously in humans. These promising results can be translated to many neurologic disease processes requiring diffuse gene delivery. Funding. Hannahâ&#x20AC;&#x2122;s Hope Fund. Vasilios A Zerris MD MPH MSc Calcified Thoracic Disks: Minimally Invasive, Transthoracic, Vertebral Body Sparing Approach Calcified thoracic discs are rare but surgically challenging lesions. Depending on the location, several surgical corridors have been employed. Postero-lateral approaches such as the costotransversectomy have gained increasing popularity. Occasionally, the anatomic location of the calcified disc mandates an anterior trajectory and thus a thoracotomy. This frequently requires a single or multilevel corpectomy along with an instrumented spinal reconstruction. These approaches lead to extended hospitalization and significant post-operative pain. I present a new approach, which allows the transthoracic removal of central calcified discs via a twoinch incision, while maintaining the structural integrity of the spine and avoiding the need for instrumentation.
Lissa Baird, MD Pain Relief Patterns Following Treatment of Trigeminal Neuralgia with Gamma Knife Radiosurgery or Microvascular Decompression Lissa C. Baird, MD; Vijayakumar Javalkar MD; Shihao Zhang, MD; Osama Ahmed, MD, Anil Nanda, MD LSUHSC Shreveport
Introduction. Microvascular decompression and gamma knife radiosurgery are both accepted modalities of treatment for intractable trigeminal neuralgia. The aim of our study was to evaluate the pain relief patterns after treatment for trigeminal neuralgia following gamma knife radiosurgery and micro vascular decompression. Materials and methods. We excluded those patients no longer living at time of the survey, those who had a prior intervention and those requiring an additional intervention following initial treatment. 122 patients met the criteria. Telephone interview was conducted to assess the pain status. Pain status was assessed using the Barrow Neurological Institute (BNI) pain scale. 61 patients responded to the interview. Pain relief patterns were categorized as follows: no pain relief, pain relief-improvement of one grade, pain relief-improvement of two grades, pain relief-improvement of three grades, total pain relief, initial pain relief-recurrence-total pain relief, initial pain relief-recurrence-partial improvement, initial pain relief-recurrence-total pain relief. Results. The median follow up was 5.2 years. A total of 61 patients met inclusion criteria (GKR 45, MVD 16). No pain relief was noted in 8 cases (GKR 17.8%, MVD 0%). Pain relief improvement of one grade was noted in 2 cases (GKR 4.4%, MVD 0%). Pain relief improvement of two grades was noted in 3 cases (GKR 4.4%, MVD 6.3%). Total pain relief (without initial recurrence) was noted in 27 cases (GKR 33.3%, MVD 75%). 21 patients developed pain recurrence at some point of time (GKR 40%, MVD 18.8%). Initial pain relief-recurrence-total pain relief pattern was noted in 5 cases (GKR 8.9%, MVD 6.3%). Initial pain relief-recurrence- partial improvement pattern was noted in 12 cases (GKR 22.2%, MVD 12.5%). Initial pain relief-recurrence-no improvement pattern was noted in 4 cases (GKR 8.9%, MVD 0%). Conclusion. From our study microvascular decompression offers total pain relief in significantly higher number of patients than those treated with gamma knife radiosurgery. Philip Theodosopoulos, MD Subtotal Resection of Large Acoustic Neuromas Nicholas Theodore, MD, FACS Spinal Cord Vascular Physiology in Normal and Pathological States Nicholas Theodore, MD, FACS and Nikolay Martirosyan, MD Division of Neurological Surgery; Barrow Neurological Institute, Phoenix, Arizona, USA
Current concepts regarding the physiology of spinal cord perfusion in normal and pathological states will be presented.
This will include the results of an animal model of spinal cord injury with the effects of lumbar drainage and oxygen concentration as well as perfusion measurements. Novel human data related to longstanding hypertension and its effects on myelopathy will also be presented. Costas G. Hadjipanayis, MD Canine Model of Convection-Enhanced Delivery of Cetuximab Conjugated Iron-Oxide Nanoparticles Monitored with Magnetic Resonance Imaging Simon Platt, Edjah Nduom, Marc Kent, Courtenay Freeman, Revaz Machaidze, and Costas G. Hadjipanayis
Introduction. Visualizing distribution of infused therapeutic agents into the brain by convection-enhanced delivery (CED) is necessary to ensure accurate delivery into target sites. Recently, bioconjugated magnetic iron-oxide nanoparticles (IONPs) have been shown to produce a magnetic resonance imaging (MRI) T2 signal drop in the rodent brain after CED permitting direct visualization of nanoparticle distribution and dispersion days later. We have now studied the CED of IONPs in the larger, more clinically relevant, canine brain for distribution, dispersion, toxicity, and clearance studies. Methods. Eight healthy laboratory dogs were infused with either free IONPs (n=4) or Cetuximab-conjugated IONPs (Cetuximab-IONPs; n=4) at different infusion rates (0.5, 1.0, 3.0, and 5.0 microliters/min) and volumes (180, 300, 360, and 720 microliters). IONP CED was monitored by sequential MRIs (preop, 12 h, 5 d, 7 d, and 30 d) and volumes of distribution and dispersion were calculated from MR images. Toxicity assessment was based on MRI, clinical, hematologic/ CSF analysis, and histopathological evaluation. Results. Robust IONP distribution in the grey and white matter of the canine brain was achieved by CED and direct IONP imaging was possible. Accurate calculation of volumes and pathways of IONP distribution was achieved by MRI. Distribution volumes were linearly proportional to infusion volumes and dispersion of IONPs occurred 5 d after CED. Leakback of IONPs along the catheter track was prevalent at the higher infusion rates. Use of the slower infusion rates provided for more uniform initial distribution of IONPs and low infusate leakback. No signs of toxicity were found in any animals based on physical examination, hematologic and CSF analysis. MRI and histopathologic analysis of brains 30 d after CED revealed near complete clearance of IONPs. Uptake of IONPs by astrocytes and microglia was found adjacent to catheter sites. Conclusions. CED of bioconjugated IONPs in the canine brain is safe and represents an effective delivery method in a large animal model. Direct imaging of IONPs is possible with MRI and volumes of distribution and dispersion can be easily calculated. Future studies involving CED of bioconjugated IONPs in canines with spontaneous gliomas may provide a unique animal model for targeting infiltrative cancer cells responsible for tumor recurrence.
Michael B. Sisti, MD Saving Face The results of a ten year single neurosurgeon and single radiosurgeon at a single institution(Columbia University Medical Center, New York, NY) in the primary surgical or radiosurgical treatment of 383 acoustic neuromas is presented. The focus of this hybrid treatment paradigm is to protect facial nerve function and minimize treatment morbidity. A total of 151 patients underwent total(55) or near total surgical(96) resection of tumors over 2.2 cm in size with an average tumor size of 3.6 cm with good facial nerve function(HB1or 2)in 96% of patients. In the subtotally resected group 20 patients had tumor regrowth requiring radiosurgery with facial function the same or better post radiosurgery in 80% of patients. Patient age and tumor size was found to be significant in predicting total versus subtotal(> 90%) of tumor resection with respect to good facial nerve outcome. Patients with tumors less than 2. 2 cm in size( 232) underwent Gamma Knife radiosurgery all with good facial nerve function and with 3 patients requiring follow up microsurgery due to progressive tumor growth after radiation. There were no patients deaths in the series and the 14 patients with post operative complications (CSF leak(11), hyrdrocephalus(2), and meningitis(1)) recovered. Four patients in the surgical group underwent gold weight tarsorraphies for facial weakness and no patients treated with Gamma Knife required this procedure. The logic and technique of this hybrid method( surgery, radiosurgery, or both) of a single neurosurgeon treatment paradigm to maximize patient outcome with respect to facial preservation will be presented in detail. Anil Nanda, MD, FACS Neurosurgical Aristeia and Peak Performance Thomas Gerasimidis, MD The Death of Alexander the Great
â&#x20AC;&#x153;Athens, the eye of Greece, mother of arts and eloquence.â&#x20AC;?
JOHN MILTON
ABSTRACTS
F riday, June 24
Conrad Istanbul
Steven Giannotta, MD, FACS Cystic Vestibular Schwannomas
Turkey
The authors present their experience with 22 cases of vestibular schwannomas with cystic degeneration. Results suggested less likelihood of total removal, poorer HB facial nerve scores, and more control failures with radiosurgery. A multirecurrent case will be presented that dramatically illustrates the adage: ”Once a cystic tumor, always a cystic tumor.” Current hypotheses as to the biological nature of the cystic degenerative process will be discussed.
surgeries (7 patients) for the posterior lesion, anterior petrosal approach in 2 patients for the anterior lesion, lateral suboccipital transhorizontal fissure approach in 2 patients for the ventrolateral lesion, supra- and transcerebellar infratentorial approach in one for the lesion from the pons to the cerebellar peduncle. For one patient of kissing pontine cavernous angiomas, staged trans-fourth ventricular floor approaches were carried out intentionally. For the trans-fourth ventricular floor approach, brainstem mapping/monitoring was utilized especially for preserving the facial nerve function. All the lesions were totally removed, neurological conditions improved in all patients after surgery. No recurrence, no postoperative hemorrhage occurred. In patients operated on via the trans-fourth ventricular floor approach, facial palsy worsened in one patient, abducens nerve palsy worsened in one patient, both transiently. Surgical strategy and tactics with selecting an appropriate surgical approach and operative results will be shown with operative videos of illustrative cases.
Paul Fagan, MD Acoustic Tumor Treatment: An Evolution and Personal Experience
Hildo RC Azevedo-Filho, MD, PhD, MSC, FRCS SN Language and Cognitive Disturbances After Aneurismal SAH: The Impact of Treatment
The Author was first involved, as a very junior member of a Neurosurgical team, in the management of a huge acoustic tumour in 1963. A disastrous outcome led eventually to a life-long interest in this condition with further experience, as a senior member of a team beginning in 1974. In this paper, a review is made of the natural history of acoustic tumours and the early attempts to treat them. Some aspects of the Author’s experience are reviewed, including the role of the extended Trans-labyrinthine approach in large tumours, the near abandonment of hearing preservation surgery in small tumours and a review of the conservative management of over 400 small tumours.
Blood in the SAH space is responsible most of times for severe disturbances of brain functions.
While vestibular schwannomas are typically solid, approximately 4-20% are cystic. This term should be reserved for those lesions that exhibit intrinsic cysts, not those associated with arachnoid cysts. Cystic schwannomas tend to be larger at presentation, exhibit capricious growth rates, cause more pretreatment cranial nerve symptoms, and generate more treatment complications than their solid counterparts.
Kazuhiro Hongo, MD Surgery for the Pontine Cavernous Angioma: Surgical Approach and Surgical Outcome Kazuhiro Hongo, Yukinari Kakizawa, Kunihiko Kodama, Kohei Kanaya, Nunung Nur Rahman Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
Direct surgery for pontine cavernous angioma is indicated when the lesion causes repeated hemorrhage resulting in symptoms. Between January 2006 and March 2011, 13 surgeries were performed in 12 patients (4 men and 8 women, age ranged between 3 and 62 years, average age of 33.6 years, follow-up period of 19.4 months) were surgically treated. Trans-fourth ventricular floor approach was taken in 8
Nowadays, when analyzing post-operative results is no longer sufficient to gauge according to the Glasgow Outcome Scale (GOS) when good results are considered to be achieved when patients pass on the test ‘walk and talk’. Certainly, language and cognitive impairment represent a serious burden to patients (and relatives) who survive the whole procedure, including the treatment. However, due to clipping or coiling being performed within a few days after the bleeding, it is almost impossible to determine which phenomenon is the main cause of the disturbances, either the SAH or the treatment. On the other hand, it is essential to try to detect eventual differences between the two types of aneurysms’ occlusion. Unfortunately, as in most of our patients we cannot treat them on an early stage after the hemorrhage, we were able to perform several neuropsychological tests on the second week following the SAH and recheck them between eight and 14 days after the clipping or coiling. Therefore, we compared the changes arising from the various aneurysms sites, before and after treatment. In the immediate post-operative screen there was a favorable trend towards coiling against clipping, which tended to equalize in the 3-month follow-up.
1 – Azevedo-Filho HRC et al.; Language and cognitive disturbances following aneurismal subarachnoid hemorrhage. In Essential Practice of Neurosurgery, Eds. Kalangu K and Kato Y, 2010 2 – Chan A, Ho S, Poon W; Neuropsychological sequelae of patients treated with microsurgical clipping or endovascular embolization for anterior communicating artery aneurysm. Eur Neurol. 2002, 47:37-44 3 – Hutter B, Gilsbach JM, Kreitschmann I; Quality of life and cognitive deficits after subarachnoid hemorrhage. Br J Neurosurg. 1995, 9:465–75 4 – Powell M, Kitchen N, Heslin J, Greenwood R; Psychosocial outcomes at three and nine months after good neurological recovery from aneurismal subarachnoid hemorrhage: predictors and prognosis. J Neurol Neurosurg Psychaitry. 2002, 72(6):772-81
130 genes under expressed), amongst which we can refer to over expression of PDGFRα, MMP16, MMP19, Matrilin4 and ADAMTS4 in bone-invasive relative to non-invasive meningiomas. Upregulation of these genes were verified using quantitative real-time PCR (RT-qPCR) analysis in both tumor specimens and meningioma cell lines.
Gelareh Zadeh, MD Identification of Altered Genes and Protein Expression Profile in Bone Invasive Versus Non-invasive Meningiomas
David W. Roberts, MD Occipital Lobe Epilepsy and Its Surgical Treatment
Introduction. Though majority of meningiomas grow intradurally, a subset of meningiomas invade the underlying bone causing hyperostosis and invasion into associated neuronal tissue. The surgical resection of such bone-invading tumors is challenging and repeat surgery is often required, resulting in significant patient morbidity. To date there has been very limited studies focused on the molecular pathophysiology of bone invading meningiomas. Therefore the aim of our study is to use an integrative analysis approach, performing RNA microarray and tissue microarray analysis to identify differentially expressed protein and genes involved in bone tropism of meningioma cells. Methods. We chose radiological features to define two distinct bone invading meningioma population and their control counterpart. 1) spheno-orbital meningioma and their control non-bone invading sphenoid wing meningioma and 2) transbasal meningioma and their control counterpart anterior skull base meningioma with no bone invasion. Review of our prospectively collected database identified 57 patients in the last ten years. For microarray studies, RNA was extracted from paraffin-embedded tissue sections of invasive and non-invasive meningiomas and processed on Illumina Whole Genome DASL assay. Data were analyzed using Multi Expression Viewer Software (MEV). Quantitative real-time PCR (RT-qPCR) was used to verify micro-array data. Three different meningioma cell lines, with different invasive characteristics (IOMMA-Lee, CH157-MN and F5 cells) were used to study molecular and signaling mechanisms of invasion in vitro and in vivo functional xenograft studies. We further verified our data using Tissue microarray (TMA) and examined commercially available antibodies involved in bone invasion (osteopontin, MMP2 and integrin-β1). TMA scoring was carried out with two independent observers using percentage and intensity staining. Results. TMA analysis identified increased expression of both MMP2 and integrin-β1 expression in tumor cells of non-invasive meningiomas, with an increase of vascular MMP2 expression in non-invasive compared to invasive meningiomas. RNA microarray data analysis identified 222 differentially expressed genes (92 genes over-expressed and
Conclusions. Our results identify novel differentially expressed proteins and genes in bone-invading meningiomas compared to non-invasive meningiomas. Our baseline in-vivo mechanistic results will help design new therapeutic strategies that can control bone-invading meningioma progression and provide the basis for translation to clinical studies.
David W. Roberts, MD, Barbara C. Jobst, MD, Vijay M. Thadani, MD, Karen Gilbert, ARNP, Richard P. Morse, MD, Krysztof A. Bujarski, MD, Terrance M. Darcey, PhD, Ann-Christine Duhaime, MD, Gregory L. Holmes, MD Dartmouth Medical School and Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756
Introduction. Occipital lobe epilepsy presents both diagnostic and surgical challenges but in many patients may be amenable to surgical treatment. This study examines the clinical presentation, evaluation findings, and surgical outcomes associated with this condition. Methods. A retrospective review of the Dartmouth Surgical Epilepsy Program database was performed for identification and analysis of patients with occipital lobe epilepsy. Data were collected for clinical seizure expression, video-EEG monitoring, MRI findings, ictal SPECT, visual field testing, intracranial electrode investigation, and seizure outcome after resective surgery. Results. In this series of 14 patients, 7 (50%) experienced visual auras; in 4 of these patients, visual auras were elementary. Only eight patients (57%) had posterior scalp EEG changes. Ictal SPECT corrected localized seizure onset in only 3 of 10 patients. Twelve patients underwent resective surgery, and Engel Class I outcome was achieved in 6. New, expected visual field deficits were present in 4 patients. Two patients with complete hemianopsia preoperatively complained of worsening of their vision for motion detection. More extensive coverage of the occipital lobe (i.e., coverage of all three occipital surfaces) was associated with better seizure outcome. The presence of a lesion on MRI, EEG findings, and ictal SPECT were not correlated with seizure outcome. Conclusions. Ictal spread patterns may confound the diagnosis of occipital epilepsy. Intracranial electrode investigation, especially if providing more complete coverage of the occipital lobe, may enable successful surgical intervention.
ABSTRACTS Feridun Acar, MD Pedunculopontine Stimulation, A New Frontier in Deep Brain Stimulation Melike Mut, MD High Grade Gliomas High grade gliomas (HGG) are the most common intrinsic brain tumors in adults. The term malignant or high-grade glioma refers to tumors that are classified as WHO Grade III (anaplastic astrocytoma, anaplastic oligodendroglioma, anaplastic oligoastrocytoma, anaplastic ependymoma) and Grade IV (glioblastoma). HGGs were presumed to arise from glial cells residing within the brain parenchyma. However, recent evidence in human and animal studies suggests neural stem cells as an alternate cellular origin of gliomas. Studies on molecular biology and genetics of HGG delineate that HGGs can be classified as proneural, proliferative and mesenchymal according to the dominant feature of the gene list and each represents a markedly different prognostic subclass. Major molecular and genetic changes associated with high grade gliomas include disorders of epithelial growth factor receptor and its downstream signal transduction pathways; isocitrate dehydrogenase mutations; p53 mutations; disorders of vascular endothelial growth factor and angiogenesis; deletion of chromosomal arms 1p and 19q, hypermethylation/gene silencing of specific promoters, notably the MGMT gene promoter and abnormal cell cycle regulatory events. These malignant tumors may present in a number of ways, depending on growth rate and anatomic location. Headache, seizure, cognitive dysfunction or focal neurological deficits are the most common presenting symptoms. Diagnosis is usually made by magnetic resonance imaging. Newer modalities of MRI may help as surgical adjunct and in preoperative planning. Surgical intervention for HGG is important for definitive diagnosis, reduction of neurological symptoms and mass effect. Surgery effectively and rapidly decreases the tumor burden. Maximal and safe surgical resection is established to have role in improving the overall survival and the quality of life. Current surgical armamentarium including microneurosurgery, preoperative planning with DTI, MRS, functional MRI, intraoperative real-time neuroimaging, neuronavigation, neuromonitoring, awake craniotomies, 5-ALA guided resection as well as intraoperative administration of chemotherapy help to achieve the goal of maximal safe resection. Surgical resection for tumor recurrence still remains an option to improve both quality of life and overall survival. External beam radiotherapy is the single most effective therapy in the treatment of high grade gliomas and recently, the standard therapy is the radiotherapy and concomitant temozolomide following surgical resection. Adjuvant temozolomide is the most frequently applied chemotherapy regimen and second line therapies; particularly antiangiogenetic agents and mo-
lecular targeted therapies are also commonly used. Recent developments in treatment and better understanding the nature of HGGs improved significantly the survival of patients suffering from these devastating tumors. Erol Veznedaroglu MD FACS FAHA Endothelial Cellular Attachment, Proliferation, and Differentiation on Platinum Based Coils Background and Purpose. Subarachnoid hemorrhage is a neurologically devastating condition leading to 50% of patients becoming deceased or disabled. The availability of Guglielmi Detachable Coils (GDC) in 1995 allowed for endovascular treatment of cerebral aneurysms[1]. Coiling is efficacious and safe but durability needs to improve as nearly 20% of patients will need further invasive follow up or intervention secondary to recurrence of the aneurysm [2]. To understand the pathophysiology of recurrence it is essential to elucidate the mechanism of aneurismal healing post coiling. We aim to understand the cellular and molecular mechanisms of endothelial cellular interaction with platinum coils and to determine which coil surfaces support the optimal endothelial cellular proliferation. Methods. Human umbilical vein endothelial cells (HUVEC) were grown on segments of platinum coils in an in-vitro model. Endothelial cell growth rates were assessed as a function of coil type. Differentiation markers of attached versus unattached endothelial cells was determined using immunohistochemistry and gene array analysis. Results. Endothelial cells showed rapid and robust attachment to segments of platinum coils. Over a 24-48 hour period detachment of cellular clusters occurred. Significant growth occurred over the next week allowing for a confluence of cells on the platinum coils as well as within the grooves. Immunostaining and gene array analysis revealed differentiation markers of the attached cells to be similar to non-attached monolayer. Conclusion. We have developed an in-vitro model for evaluating endothelialization of platinum coils toward the goal of optimizing conditions for EC proliferation on platinum coils. Differentiated endothelial cells proliferate on platinum surface as well as within coil grooves and tend to favor proliferating on polyglycolic acid surface (PGLA) as opposed to platinum surface. Russell R. Lonser, MD Surgical Resection of Endolymphatic Sac Tumors in von Hippel-Lindau Disease: Findings, Results and Indications
Russell R. Lonser, M.D., 1Marygrace Hagan, M.D.,2John A. Butman, M.D., Ph.D., 1Martin Baggenstos, M.D.,3Carmen Brewer, Ph.D., 3Christopher Zalewski, M.A., 3,4H. Jeffrey Kim, M.D. 1
Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health Bethesda, Maryland; 2Diagnostic Radiology Department, Clinical Center of the National Institutes of Health, National Institutes of Health, Bethesda, 1
Maryland; 3Otolaryngology Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland; 4Department of Otolaryngology-Head and Neck Surgery, Georgetown University Medical Center, Washington, District of Columbia
Objective. Endolymphatic sac tumors (ELSTs) cause significant audiovestibular morbidity, including hearing loss, in von Hippel-Lindau disease (VHL). To define surgical management and outcomes of VHL-associated ELSTs, we analyzed audiologic, clinical and operative findings in VHL patients that underwent ELST resection. Methods. Analysis of consecutive VHL patients who underwent resection of ELSTs at the National Institutes of Health. Serial clinical examinations, audiograms, imaging and operative records were analyzed. Results. Thirty-one consecutive patients (15 males, 16 females) underwent resection of 33 ELSTs (mean follow-up, 111.8+77.9 months; range 5.0 to 239.0 months). One patient had bilateral ELSTs resected and 1 patient underwent re-operation for recurrence. Mean age at surgery was 38.2+10.2 years (range, 12 to 67 years). While 29 ears (88%) had direct radiographic evidence of an ELST, 4 ears (12%) did not. Mean tumor size was 1.3+1.1 cm (range, 0.2 to 5.2 cm). While 2 patients (2 ears, 6% of ears) were asymptomatic, 29 patients (31 ears, 94% of ears) had associated audiovestibular symptoms including sensorineural hearing loss (SNHL) (26 ears; 79% of ears), tinnitus (24 ears, 73%) and vertigo (21 ears, 64% of patients). Postoperatively, hearing was stabilized or improved in 30 ears (97% of 31 ears with post-operative audiometry). Complete tumor resection was achieved in 31 ears (94%). Complications included cerebrospinal fluid leak in 2 ears (6%). Histopathology was consistent with ELST in all cases. Conclusions. Surgical resection of ELSTs can be performed with hearing preservation and reduce audiovestibular dysfunction. Early surgical resection can prevent or decrease disabling audiovestibular symptoms, enhance the opportunity for complete resection and preserve hearing. Robert J. Dempsey, MD Regenerative Cerebrovascular Neurosurgery: Lessons Learned from Our Neuro-oncology Colleagues Introduction. Cerebrovascular neurosurgery must move from an emphasis on surgical arresting of disease, hemorrhage, vascular blockage, etc., to surgical repair of degenerative disorders to be relevant in 21st century medicine. The potential strategies for regenerative neurosurgery include brain computer interface, transplantation, and neurogenesis. It is neurogenesis that recapitulates normal mechanisms of development and repair. The components of this process: proliferation of new cells, differentiation of cells, migration to the injury site, incorporation into the damaged area, and angiogenesis to develop neurovascular units are exactly the components that our neuro-oncology colleagues attempt to control.
If they are unchecked, they are the very mechanisms of neuroplasia and metastasis. Collaborative research, therefore, should focus on the mechanisms which stimulate and regulate these processes. We studied in-vitro and in-vivo models of tumor growth and augmented brain repair to determine common features which may be regulated in both. We utilized in vitro cell cultures of neuro precursor cells after ischemia as well as neuroblastoma cell culture, RNA interference and pharmacological inhibition. Protease effect was studied in vitro in a xenograft mouse model. From the field of ischemia we studied a variety of growth factors and cytokines upregulated in injured ischemic cortex including the migratory cytokines MCP1 and SDF1. We present information that suggests that the process of progenitor cell proliferation is regulated by differentiating the new cells under the influence of TGFβ1. Our further studies show that IGFB may be used to turn off proliferation of progenitor cells by inhibiting the necessary growth factor IGF, suggesting this process of differentiating proliferating cells may be a potential therapeutic target in brain neoplasms. Working from the neuroplasia side, we studied neuroblastoma cells as a neoplasm of neural origin whose virulence depends on migration, metastases, and angiogenesis. In these, we found the pro-angiogenic and migratory chemokine SDF1 upregulated due to a loss of its regulatory protease DPP4. Stimulation of SDF1 after cerebral ischemia transiently improves outcome after ischemia. Expression of DPP4 in neuroblastoma cells inhibited in vitro migration and angiogenesis. Inhibition of DPP4 increased SDF and bFGF which are migratory and angiogenic chemokines. Understanding that DPP4 can regulate SDF, means that timely regulation of DPP4 couldstimulate progenitor migration and angiogenesis after stroke and turn off the process in neuro-oncology. Conclusion: An understanding of the commonality of the research questions of regenerative neurosurgery with that of neuro-oncology will lead to safe regulation of new cells be they progenitors or transplants to avoid neoplasm formation and translate these lessons to the control of intrinsic CNS tumors. David Choi, FRCS, PhD Motion Preservation and Clinical Outcome of PCM ® Cervical Arthroplasty Objective. Assessment of motion preservation and clinical outcome after Porous Coated Motion (Cervitech PCM®) artificial cervical disc replacement. Design. Prospective observational study. Subjects. 80 PCM® artificial discs (C3/4 - 6, C4/5 - 11, C5/6 - 37, C6/7 - 26) were implanted in 53 patients (24 females, average age ± STDEV, 48.8 ± 9.2 years) assessed by postoperative flexion/extension X rays and clinical outcome. Median follow up was 15 months, range 1-35 months. Methods. Motion was assessed by measuring changes in angulation at the level of the disc replacement, increase in the
ABSTRACTS interspinous process distance with cervical flexion, and horizontal shift of implant plates. Clinical outcome was assessed by pre-operative and follow-up Neck Disability Index (NDI), Neck and Arm Pain Visual Analogue Score (VAS) and SF-36. Results. Forty four implants were considered to have little functional movement defined by angular changes of less than 3°. Nineteen implants moved between 3° and 5° and 17 implants more than 5°. Angular movement correlated well with other methods of radiological assessment of movement (p < 0.01) such as changes in interspinous process distance (r = 0.74) and horizontal shift of implant plates (r = 0.49). Post-operatively there was a 21% average improvement in NDI, 31% improvement in neck and 40% in arm VAS, and 12% and 18% improvements in physical and mental components of SF-36 respectively. The outcome, however, was not correlated with the degree of movement (ANOVA, p>0.05). One patient required re-operation for migration of the implant. Conclusions. Only 21% of implants maintained movement of more than 5°. Although clinical outcome suggested better results with higher degrees of motion preservation the results in our cohort were not statistically significant. References. Pimenta L et al.: Clinical experience with the new artificial cervical PCM (Cervitech) disc. Spine J. 2004, Nov-Dec:4(6 Suppl):315S-321S.
Mustafa Baskaya, MD Neuroanatomy-Based Microneurosurgery
To achieve proficiency in current state of the art neurosurgical techniques requires microsurgical anatomical laboratory training. The most basic principle of medicine throughout the ages, “primum non nocere” (first, do no harm), cannot be achieved in contemporary neurosurgery without having micro-neurosurgical skills and a proper knowledge of neuroanatomy and skull base anatomy. The brain is distinguished from the other vital organs of the human body by unique anatomical features. Sulci and gyri maximize the available cortical surface of the cerebrum in the limited volume of the skull. Most pathologies, whether neoplastic or vascular, are located beneath the cortical surface, sometimes as deep as ventricles or in the white matter surrounding the ventricles. Other pathologies, like aneurysms of the anterior or posterior circulation, again lie beneath the whole mass of the cerebrum. Approaches to these deeply seated cerebral pathologies necessitate advanced techniques, such as the dissection of cisterns, which is only achievable by employing micro-neurosurgical skills or skull base approaches. These microneurosurgical techniques based on thorough neuroanatomical knowledge may result in better outcome in patients with complex lesions. This presentation will demonstrate diverse advanced micro-neurosurgical approaches based on neuroanatomy in various complex neoplastic and vascular cases.
Yukinari Kakizawa, MD iPad Application for Learning Anatomy of the Central Nervous System Yukinari Kakizawa, Kazuhiro Hongo Department of Neurosurgery; Shinshu University School of Medicine, Matsumoto, Japan
Objective. The goal was to develop an interactive iPad application of three-dimensional (3-D) computerized anatomical model of the central nervous system for learning microneurosurgical anatomy, operative planning, and using for informed consent. Methods. The 3-D model was constructed using commercially available software Maya 2011 Unlimited (Alias Systems Corp., Delaware, US), a personal computer, cadaver specimens, CT images, and anatomical book for reconstruction of brainstem fiber and nuclei. Skull bone model was reconstructed using CT images at first. Then, photos from the superior and lateral views, from at least 2 angles of cadaver specimen, were imported to the 3-D software. Many photos were needed for making the model in anatomically complex areas. Careful dissection was needed to expose important structures in the two views. Landmarks, which can be foramen, bone, dura mater and so on, were utilized as reference points. Results. The 3-D model of the skull base and related structures were constructed utilizing more than 280,000 remodeled polygons. The model was imported to iPad application, developed by company. The model can be viewed from any angle. It can be rotated through 360 degrees in any plane utilizing any structure as the focal point of rotation. The model can be reduced or enlargement utilizing the zoomfunction. Variable transparencies could be assigned to any structures so that the structures at any level can be seen. Conclusion. This iPad application of computer-generated 3-D model can be utilized and studied repeatedly, and used for informed consent. This software will be available on iPad with reasonable cost at App Store. Mehmet Ozdogan, PhD Archaeology of Istanbul in between Europe and the Near East
“In many ways we are all sons and daughters of ancient Greece” N ia Vardalos
S aturday, June 25
Conrad Istanbul
Fred Gentili, MD, FRCSC, FACS Management of Craniopharyngiomas: Open vs Endoscopic Techniques The development of pure extended endoscopic transphenoidal (EETS) techniques has added another surgical option for accessing suprasellar craniopharyngiomas. However, the reported experience is still too limited to consider EETS as a standard surgical procedure for these lesions. Likewise the role of EETS in primary versus recurrent lesions remains undefined. We report our initial experience with 19 patients who underwent EETS for the removal of suprasellar craniopharyngiomas. We provide an analysis of the surgical outcomes, including visual and endocrinological results in this patient series. We will also discuss the indications and limitations of the technique and examine its possible integration in the overall management of craniopharyngiomas. Conclusion. Based on our experience, with careful patient selection, the expanded endoscopic transphenoidal approach can be integrated in the overall management of both primary and recurrent craniopharyngiomas with good results. Neville Knuckey, MD Assessment of Magnesium and Mild Hypothermia in Rat Focal and Global Cerebral Ischaemia Models *Knuckey, N.W.,., Campbell K., Li L-X. Meloni B.P Australian Neuromuscular Research Institute, Department of Neurosurgery, Sir Charles Gairdner Hospital, Western Australia, Centre for Neuromuscular and Neurological Disorders, University of Western Australia
There are, at present, few neuroprotective treatments available following stroke and cerebral ischaemia. To address this, we have assessed the neuroprotective efficacy of magnesium and mild hypothermia (35°C) alone and in combination in experimental stroke/cerebral ischaemia rat models. Methods. Permanent and transient (90min) intraluminal thread middle cerebral artery occlusion (MCAO) was used to model focal ischaemia (SD or SH rats). Transient carotid occlusion (8min) with hypotension was used to model global ischemia (SD rats). Mg treatment: IV bolus 360µmol/kg + infusion 120µmol/kg/h for 24h (focal) or 48h (global); hypothermia treatment: core body temperature of 35°C or 33°C for 24h. Results. Combined Mg and mild hypothermia was effective when commenced 2h or 4h after permanent MCAO, but ineffective at 6h. Combined treatment was ineffective when administered 2h or 3h after transient MCAO. Following global ischaemia, treatment was effective when commenced 2h after ischaemia, but ineffective at 3h or 4h. Mg alone was ineffective. Mild hypothermia was effective following global ischaemia, and reducing the level of hypothermia to 33°C did
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not improve outcomes following either focal or global ischaemia. Conclusions. Mg and mild hypothermia can reduce ischaemic brain injury when administered early, however to further improve the therapeutic window and efficacy it may be necessary to combine the treatment with other neuroprotective agents. Toshihiko Wakabayashi, MD, PhD Advanced Multimodal Treatment Strategies for Malignant Glioma by Means of Nano-Medicine Nowadays, major interests of brain tumor research member of neuro-oncology group lie in translational research for malignant brain tumors. There are several reasons why, in particular, the prognosis for patients with glioblastoma multiforme (GBM) is still very poor and median survival is generally less than one year. As for the treatment methods, besides radiotherapy, Temozolomide (TMZ), an oral alkylating chemotherapeutic agent, is demonstrated anti-tumor activity with minimal additional toxicity in the treatment of GBM and median survival time is prolonged significantly in the previous study. However, its clinical outcomes depend on O6-methylguanine-DNA methyltransferase (MGMT) status and modification of MGMT is one of the key factors to get more significant clinical benefits in the future. As for the candidate, MGMT siRNA capsulated with nano-particle has a possibility to deplete MGMT levels in the cell and it is shown that MGMT siRNA acted as a controller for MGMT when added with Temozolomide in the preclinical studies. That is why newly established nano-leveled particle treatment strategies with MGMT siRNA against GBM should be required as a possible candidate for clinical trial for the next step. In our department, nowadays, it runs three advanced clinical trials; nano-leveled liposome-mediated interferon-beta gene therapy for malignant gliomas, dendritic cell vaccination with Interleukin13-Receptor (IL-13R) alpha 2 peptide, and molecular-targeting chemotherapy using a combination of temozolomide and interferon-beta (INTEGRA study). As a co-director of Advanced clinical research center, We play an important role in the management of Bio-Material Producing Facility in Nagoya University Hospital, which allows for Human Gene Therapy Non-viral Vector (nano-particle liposome) Production, as well as Cell Processing under the managing system of the International Organization for Standardization (ISO) 9001:2000 and 13485:2003, as well as Good Manufacturing Practice (GMP). Besides advanced medicine, as a skillful neurosurgeon, we are also interested in the image-assisted surgical treatment, which is in collaboration with Department of Engineering. We utilize an intraoperative MR imaging (iMRI) operating unit at Nagoya University Hospital. The iMRI unit is connected to a network which enables us to share not only real time usual operative images and planning, but also advanced 3D
ABSTRACTS imaging and dynamic fusion images. Using with this technology, we can inject nano-capsuled medicine at the accurate targeted point for the treatment of brain tumors. In addition, the experience gathered in the developmental and review processes of these clinical trials may contribute to the development of other advanced medicines. Furthermore, the understanding of the anti-tumor mechanism facilitates the identification of candidate target molecules for new approaches. In conclusion, newly established neuro-radiological images are very useful for invasive non-circumscribed brain tumors such as malignant glioma and, in combination with such highly technological progress, newly developed neurosurgical procedures with nano-medicine will be possible for the improvement of prognosis for such a fetal diseases. 1. J Yoshida, Mizuno M, Fujii M, Kajita Y, Nakahara N, Hatano M, Saito R, Nobayashi M, T Wakabayashi: Human gene therapy for malignant gliomas (Glioblastoma multiforme and anaplastic astrocytoma) by in vivo transduction with human interferon beta gene using cationic liposomes. Human gene therapy 15: 77-86, 2004. 2. J Yoshida, Mizuno M, T Wakabayashi: Interferon-beta gene therapy for cancer: basic research to clinical application. Cancer Sci 95(11), 858-865, 2004. 3. T Wakabayashi, A natsume, Y hashizume, M Fujii, M Mizuno, J Yoshida: A phase I clinical trial of interferon-beta gene therapy for high-grade glioma: novel findings from gene expression profiling and autopsy. J Gene Medicine, 10, 329-339, 2008 4. S Shimato, A Natsume, T Wakabayashi, M Fujii, M Ito, J Yoshida: Identification of an HLA-A24-restricted T-cell epitope derived from a glioma-associated antigen, interleukin 13 receptor alpha 2 chain. J Neurosurg., 109 (1), 117-122, 2008. 5. T Wakabayashi, A Natsume, T Kayama, R Nishikawa, H Takahashi, T Yoshimine, N Hashimoto, T Aoki, K Kurisu, M Ogura, J Yoshida. A Multicenter phase I trial of interferon-beta and temozolomide combination therapy for high-grade gliomas (INTEGRA study). JJCO, 38(10), 715-718, 2008 6. A Natsume, S Kinjo, K Yuki, T Kato, M Ohno, K Motomura, K Iwami, T Wakabayashi. Glioma-initiating cells and molecular pathology: Implications for therapy. Brain Tumor Pathol. 28,1-28, 2011
James Chandler, MD Concussions David Hasan, MD Aspirin as a Promising Agent for Decreasing Incidence of Cerebral Aneurysm Rupture Background and Purpose. Chronic inflammation is postulated as an important phenomenon in intracranial aneurysm (IA) wall pathophysiology. This study was conducted to determine if aspirin use impacts the occurrence of IA rupture. Methods. Subjects enrolled in the International Study of Unruptured Intracranial Aneurysms (ISUIA) were selected from the prospective untreated cohort (n=1691) in a nested case-control study. Cases were subjects who subsequently suffered a proven aneurysmal SAH during a 5-year follow-up period. Four controls were matched to each case by site and size of aneurysm (58 cases, 213 controls). Frequency of
aspirin use was determined at baseline interview. Aspirin frequency groups were analyzed for risk of aneurysmal hemorrhage. Bivariable and multivariable analyses were performed using conditional logistic regression. Results. A trend of a protective effect for risk of UIA rupture was observed. Patients who used aspirin 3x weekly - daily had an odds ratio (OR) for hemorrhage of 0.40 [95% CI=0.18-0.87, reference group = no use of aspirin], patients in the “< once a month” group had an OR of 0.80 (95% CI=0.31-2.05) and patients in the “> once a month – 2x/ week” group had an OR of 0.87 (95% CI=0.27-2.81) (p= 0.025). In multivariable risk factor analyses, patients who used aspirin three times weekly to daily had a significantly lower odds of hemorrhage (Adjusted OR=0.67, 95% CI 0.110.67, p=0.03) compared to those who never take aspirin. Conclusions. Frequent aspirin use may confer a protective effect for risk of IA rupture. Future investigation in animal models and clinical studies is needed. Ugur Ture, MD Assessment of the Corticospinal Tract Alterations Before and After Resection of Brainstem Lesions Using Diffusion Tensor Imaging (DTI) and Tractography at 3-Tesla MRI Miguel A. Arraez, MD, PhD The Subfrontal-Interhemispheric Approach to the Parasellar Region Background. Many differents approaches have been devised for the surgical treatment to the lesions at the anterior fossa and parasellar area: transcraneal (transfrontal, pterional, transglabellar-subfrontal, orbito-frontal, orbito-pterional), transphenoidal microsurgical and, more recently, transesphenoidal endoscopic approach. Many of the lesions in and around the parasellar area have extension to the III ventricle. Due to this fact, some other approaches should be taken into account, as the transcallosal route and endoscopic transventricular transforaminal approach. In this presentation we will deal with the subfrontal interhemispheric approach, a surgical procedure to get access to the anterior fossa, the suprasellar area and the anterior III ventricle. Surgical Technique. The surgical technique based in the philosophy of the japanese neurosurgeon Zentaro Ito, who used to interhemispheric approach to clip the anterior communicating artery aneurysms through this route. It is also noteworthy the work from Shibuya, describing and using this approach for resection of complex craniopharyngiomas. The patient is placed in supine position, with the head in neutral position with slight hyperextension. The use of lumbar drainage can ease the intradural retraction and dissection. A bicoronal incisión is done behind the hairline. A bifrontal craniotomy is carried out, with anterior and medial burr hole that penetrates the frontal sinus. The craniotomy is transecting the frontal sinus lateral to lateral. The duramater is opened anteriorly, bilaterally and parallel to orbital rims, transecting the superior sagital sinus at its anterior edge, as well as the falx until reaching the crista galli. In this moment,
the interhemispheric dissection starts after pulling back the falx and sagital sinus. Both frontal lobes are spared with the aid of some traction with spatula. The dissection must start at the anterior callosal cistern if the III ventricle is going to be approached. Both anterior cerebral arteries are identified in front of the genu, being followed down. The interhemispheric fissure unlike the silvian fissure doesn’t have CSF and both frontal lobes are sometimes very difficult to be spared. The most anterior and basal aspects of the frontal lobes are spared and pulled away. To avoid any olfactoty damage, the frontal and basal arachnoid is cut to free both olfactory tracts. The parasellar area is exposed, allowing for a very good and upper midline view of both optic nerves. The anterior comunicating artery can be divided to improve the exposition of the anterior III ventricle. The lamina terminalis can be oponed, giving access to the III ventricle chamber. The approach is offering a very good corridor along the anterior fossa, suprasellar/parasellar area and III ventricle. After tumor resection, the frontal sinus is cranialized. The duramater is closed in a watertight fashion. Bone is replaced and fixed. A subgaleal drainage is placed. Complications and Avoidance. The most frequent complication derives from the frontal lobe management. The probability of venous infractation is very low, as all cortical veins can be preserved. Olfactory damage is another complication derived from this approach. Epidural infection and all the other complications related to the “transcanial morbidity” when accessing the anterior fossa must be taken into consideration. Jeffrey M. Sorenson, MD The Rhoton Collection - Creation of an Interactive Stereoscopic Neuroanatomy Database Jeff Sorenson, MD and Jon Robertson, MD
Of all of the areas within the neurosurgical curriculum, neuroanatomy is perhaps the most difficult to learn, yet fundamental to everything a neurosurgeon does. Few surgeons complete their training having achieved mastery. Although anatomy and surgery have always been intrinsically three dimensional endeavors, the supporting technologies and teaching materials have largely been confined to two dimensions. These two dimensional figures, drawings, photographs and movies do not optimally prepare surgeons for their three dimensional tasks in the operating room. Recent developments in technology have finally brought us to a tipping point at which it is practical to prepare comprehensive teaching materials using three dimensional resources. Dr. Albert Rhoton has been creating stereoscopic photographs of meticulously prepared neuroanatomical dissections for nearly two decades. In this presentation, we describe the development of an online database of neurosurgical teaching materials which contains the Rhoton Collection. This new kind of educational resource supports a variety of devices ranging from phones and tablets to televisions and projectors. The interactive and stereoscopic features should make the study of neuroanatomy more efficient. Advanced searching capabilities put high quality reference materials at your fingertips. In short, we believe that this type of media-rich
database with stereoscopic capabilities is a logical evolution beyond the anatomy textbook. Thomas Origitano, MD, PhD The Socio-Economics of Excellence: Can Academic Medical Centers Compete The University Health Consortium defines 2 distinct case types that contribute to the financial impact to university hospitals: Core and Commodity. The Core cases are those which are of a complexity, acuity, and requiring significant talent, technology and facility to be 3 times more likely to be performed in a university setting (i.e. subarachnoid hemorrhage). These Core cases constitute @5% of all cases but 90% of revenue. The commodity cases are those classically done at community based hospitals. These cases are generally at best break even in the university setting and profitable in a lower cost community center. The average profit margin for university medical centers ranges from 1-6% (usually 1-3) with successful community counterparts 6-12%. These economic realities affect the facility, technology and talent compensation. This is especially true when it comes to “risk” related technologies whom are avant-garde but not necessarily scientifically proven (i.e. intra operative mri, Robotics, computer assisted surgical therapeutics). The economic realities of university based medical centers often must sacrifice excellence in any particular specialty to balance mission. This has caused significant changes in faculty compensation, allocation of support resources (nursing, secretarial, research), facilities (private vs. semi-private rooms) and technology. The full implementation of work hours restriction has had several unintended effects. The graduating senior resident experiences @20% less operative case experience than his/ her pre-work restriction counter part. Clinic experience is sacrificed for surgical case experience. Exposure to critical surgical judgment experience is reduced. There is a “shift work” environment reducing continuity of care for patients. These economic and culture changes are leading to an exodus of talented senior academic neurosurgical leaders to community based hospitals that can provide the economic base, facilities, technology and compensation for excellence. They often have clinical neurosurgical fellowships (non ACGME) which provide a teaching environment. As this occurs Core cases are migrating away from their traditional university setting and vesting at community based Neurological Institutes. These facilities have a responsive, facile administrative environment which facilitates programmatic implementation of patient care services. This leads to transfer of Core cases to the community setting further reducing resident training opportunities. Over the recent 7 years this exodus has been seen in 10 major training centers, in major US cities. As regionalization of specialty services evolves it maybe that the future of neurological surgery will not be in the traditional university setting but rather highly efficient, economically progressive regional medical centers.
Russell R. Lonser, M.D., 1Joshua J. Wind, M.D., 2Lynnette K. Nieman, M.D., 3Robert J. Weil, M.D., 1Hetty L. DeVroom, R.N., 4 Meg F. Keil, R.N., 4Constantine A. Stratakis, M.D., 1,5Edward H. Oldfield, M.D. 1
ABSTRACTS Ihsan Solaroglu, MD A Newly Described Ligament Lying Between the Dural Sac and the Ligamentum Flavum at the L5 Level; The ATA and Its Surgical Importance James Markert, MD Phase I Clinical Trial of Intralesional Reovirus Infusion for Treatment of Recurrent Malignant Gliomas KP Kicieliski, JM Markert
Introduction. Reovirus is an RNA virus shown to have in vivo activity in malignant gliomas (MG) in preclinical studies. A single Phase I trial of one-time intratumoral reovirus inoculation in patients with MG showed the virus to be well-tolerated, without dose-limiting toxicity (DLT). The goal of this multicenter Phase I study was to determine the DLT and maximum tolerated dose (MTD), as well as the antitumor effect of intratumoral reovirus infusion in patients with recurrent MG. The response rate of the targeted lesions was also evaluated. Methods: Patients were adults with a first through third recurrence of a histologically-confirmed supratentorial MG with a Karnofsky Performance score (KPS) of ≥60, and had received prior surgery and radiation. A total of 15 patients were enrolled in a classic 3x3 dose escalation scheme with three patients treated at each of the following tissue culture infectious dose 50 (TCID50) doses: 1 x 108, 3 x 108, 1 x 109, 3 x 109, 1 x 1010. Each patient received a 72 hour infusion via one to four catheters implanted intraoperatively at the enhancing border of target lesions. Patients underwent examinations of neurological and functional performance as well as MRI scans at baseline, the time of discharge from infusion, and at 4, 8, 12, 16, and 24 weeks post infusion. Results. The patients featured a median age of 51.5 years, a median enrollment KPS of 90, 10 males, and 14 Caucasians. There was one grade III adverse event (AEs), confusion, felt to be probably related to treatment, but no grade IV AEs graded probably or definitely related to treatment. Twelve patients had tumor progression, two had stable disease, and one had a partial response. Median survival was 140 days (range, 97 – 989), and one patient is still alive 1 year post treatment. Median time to progression (TTP) was 61 days (range, 29 – 140 days). DLTs were not identified and a MTD was not reached. Conclusions. A 72 hour intratumoral infusion of genetically unmodified reovirus was well-tolerated at the above doses in patients with recurrent MG, and may offer some antitumor effect in certain patients. Edward H. Oldfield, MD, FACS Surgical Management of Pituitary Adenomas in Pediatric Cushing’s Disease
Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health,Bethesda, Maryland, 2Reproductive and Adult Endocrinology, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; 3Department of Neurosurgery, The Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio; 4Pediatric Endocrinology Program, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; 5Department of Neurological Surgery, University of Virginia Health Science Center, University of Virginia, Charlottesville, Virginia 1
Despite the long-ranging effects of pediatric Cushing’s disease (CD), factors that influence the outcome of surgical treatment have not been determined. We examined consecutive pediatric CD patients treated at the National Institute of Health from 1982 through 2010. Clinical findings, laboratory results, imaging findings and operative outcomes were analyzed. Two hundred pediatric CD patients (106 female, 94 males) were included. Mean age at first symptom was 10.6±3.6 years (range, 4.0 to 19.0 years) and age at surgery was 13.7±3.7 years (range, 4.5 to 20.8 years). One hundred seventy-three patients (87%) had no prior surgery and twenty-seven patients (13%) had undergone prior surgery. Magnetic resonance (MR)-imaging identified adenomas in 97 patients (50%). Overall, 195 of the 200 patients (98%) achieved remission following surgery. One hundred ninety-two patients (98%) achieving remission were hypocortisolemic and 3 patients (2%) were eucortisolemic postoperatively. Factors associated with initial biochemical remission (P<0.05) included identification of an adenoma at surgery, immunohistochemical confirmation of ACTH adenoma and non-invasive ACTH adenoma. Younger age at surgery, smaller adenoma size, and lack of cavernous sinus or other dural invasion were associated with longterm remission (P<0.05). A postoperative serum morning cortisol nadir of less than 1 g/dl was most predictive of lasting remission (positive predictive value, 96%). Surgical resection of pituitary adenomas in pediatric CD is a safe, effective and durable treatment. The presentation will emphasize factors that underlie surgical success and early postoperative endocrine tests that can be used to predict lasting remission. Daniel L. Barrow, MD Cotton Clipping Technique to Repair Intraoperative Aneurysm Neck Tear Daniel L. Barrow, M.D., Robert F. Spetzler, M.D. This talk will describe a surgical technique the authors have used to successfully repair a tear at the neck of an intracranial aneurysm. The technique and alternative options for managing this intraoperative complication are addressed. The tear on the neck of the aneurysm is covered with a
small piece of free cotton and held in place with a suction device to clear the field of blood. The cotton is then clipped onto the tear with an aneurysm clip using the cotton as a bolster to obliterate the tear. The cotton increases the surface area allowing the clip to be placed more distally on the neck to preserve patency of the parent artery. Case examples will be used to illustrate the technique. Intraoperative rupture of an intracranial aneurysm is a potentially devastating complication, particularly if a tear occurs in the neck. This simple yet effective method has been very useful in repairing a partial avulsion or tear of the neck of an aneurysm. Felipe Albuquerque, MD Cranio-Cervical Arterial Dissections as Sequelae of Chiropractic Manipulation: Patterns of Injury and Management Objective. Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. We describe the patterns of arterial injury and their management in the modern endovascular era. Methods. We reviewed our prospectively maintained endovascular database to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up. Results. Thirteen patients (8 women and 5 men, mean age 44 years, range 30 to 73 years), presented with neurological deficits, head and neck pain, or both typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V4 segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): one involved the cervical ICA and one involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in one case. Three patients underwent emergent cerebellar decompression because of impending herniation. Six patients were managed with medication alone, including either anticoagulation or antiplatelet therapy. Clinical followup was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and one died from a massive cerebellar stroke. The remaining 9 recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but one of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up. Conclusion. Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In our series, a significant percentage (31% or 4 of 13) was left permanently disabled or died as a result of their arterial injuries.
Charles Rosen, MD Hormone Replacement Therapy for Stroke Prevention The Womenâ&#x20AC;&#x2122;s Health Initiative (WHI) showed for the first time in a large-scale clinical trial that hormone replacement therapy (HRT) was linked to higher incidence of stroke (Wassertheil-Smoller, Hendrix et al. 2003). Meta-analyses of the WHI and other smaller clinical trials have shown that women taking estrogen experience greater stroke severity (Bath and Gray 2005; Sare, Gray et al. 2008). These findings contradict data from prior animal studies indicating a neuroprotective role of estrogen and raise concerns regarding the safe and appropriate use of HRT. Age may be a contributing factor accounting for the contrast between animal studies and clinical trial findings. The vast majority of research in stroke, including studies on the effects of HRT, utilizes young animal models, despite statistics from the Centers for Disease Control and Prevention indicating that 72% of people who suffer a stroke are over age 65. Previous reports demonstrate that aged rats experience increased infarct size and worsened functional outcome following experimental stroke compared to young adult rats [Rosen et al., 2005; DiNapoli etal., 2006; DiNapoli et al., 2008]. Ischemic strokes in aged rats are characterized by earlier disruptions of the blood-brain barrier, exacerbated neuronal degeneration, and higher mortality [Rosen et al., 2005; DiNapoli et al., 2006; DiNapoli et al., 2008]. These studies underscore the importance of creating clinically relevant models of disease, including the use of aged animals. In the present study, we examined the effects of estrogen administration on infarct size and functional recovery following experimental stroke in both young adult and aged female rats. We confirmed the results of previous studies showing that young adult rats treated with estrogen have reduced infarct size and improved functional recovery compared to ovariectomized rats. Then, for the first time, we showed that chronic estrogen administration led to increased infarct size (both cortical and total) following experimental stroke in aged female rats. The results presented here replicate the findings of the WHI in a clinically relevant animal model and suggest a potential age-related difference in the effects of estrogen on stroke, as well as the effect of chronicity for administration of HRT. Ricardo H. Brau, MD, FACS 10-year Experience of Radiosurgery Treatment for Cerebral Arteriovenous Malformations: Puerto Rico Experience Ricardo H. Brau, M.D., Gisela Murray, M.D. Section of Neurosurgery, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
1
Object. The purpose of this study is to describe a 10 year experience in the use of radiosurgery (RS) for patients with Arteriovenous Malformations (AVMs) in Puerto Rico.
ABSTRACTS Methods. Retrospective analysis was performed of all the patients with AVMs treated with RS by senior author (RHB) in Puerto Rico. Between February of 1999 and December of 2009, a total of 83 patients underwent the procedure. All charts were reviewed for recollection of demographic data, AVM and treatment characteristics. Clinical and radiographical follow up information was collected retrospectively. Results. A total of 83 patients and 86 procedures of radiosurgery for AVMs were performed during a 10 year period. Eight patients were lost to follow up. The remaining 75 patients include 36 males and 39 females. The average age was 34. Hemorrhage was the initial presentation in 40% of patients. Fifty five (72%) patients were treated previously with endovascular neurosurgery without success. The median volume of the malformation was 17.7 ml. Nearly 65% of the malformations were considered large (greater than 10 ml) in volume. Forty patients (52.6%) had AVMs with largest diameter greater than 3.5 cm. The overall obliteration rate was 56.4% and the median time for obliteration was 33 months. The AVMs of diameter larger than 3.5 cm had greater latency period than smaller than 3.5 cm (31 months vs. 46 months, p =0.01). In addition, AVM obliteration was inversely associated with AVMs volume, especially in large AVMs (p=0.037). In bivariate analysis, patients achieving obliteration had lower Spetzler grading scores as compared to patients not achieving obliteration (p=0.009). Post radiosurgery hemorrhages were seen in 9 cases. Eleven patients underwent surgery after RS. Major neurological deficits found in 9 patients and 17 patients developed only minor deficits. The upcoming of neurological deficit was significantly associated to lesions with volume >10 ml. Conclusion. Radiosurgery is a useful treatment for AVMs in the majority of the cases in spite of the large difficult-to-treat arteriovenous malformations. Joung H. Lee, MD Operative Outcome, Risk Factors & Complications in Meningioma Surgery: A Review of 800 Consecutive Cases
Joung H. Lee, M.D., Burak Sade, M.D., Soichi Oya, M.D., Ph.D. Brain Tumor and Neuro-Oncology Center/Department of Neurosurgery, Cleveland Clinic Neurological Institute
Introduction. A comprehensive review of a personal experience in meningioma surgery was conducted. Main goals of the study were (1) to determine the overall outcome and identify the factors influencing outcome in meningioma surgery, (2) to elucidate as to what complications led to poor outcome, and (3) to see if there is a “learning curve” in meningioma surgery. Methods. 800 consecutive operative cases of meningioma performed by a single surgeon (JHL) between July 1993 and March 2010 at the Cleveland Clinic were retrospectively
analyzed. Outcome at 6 weeks was assessed using the Glasgow Outcome Score. To assess the influence of the learning curve on outcome, 800 operative cases were then divided into 4 groups of 200 cases each (Groups I, II, III & IV). To identify the factors influencing outcome, the followings were assessed: Co-morbidity, patient’s age, tumor location, tumor size, preoperative symptoms/signs, prior surgery, prior radiation, presence of peritumoral edema. Results. Overall, 95.8% (766) had good outcome (GOS IVV): 91% of Group IV patients had GOS 5, as compared to 83.5% of Group I and 85.5% of Group II and 88.0% of Group III patients (p=0.02). The overall mortality in this series was 0.6%. The incidence of major neurological complications was 11.5% in Group I, 9.5% in Group II, 5.5% in Group III and 3% in Group IV. In reviewing the types of complications, 3 types were identified: Type I (result of surgeon’s inexperience or ignorance), Type II (chance occurrence) and Type III (result of surgeon’s greed). Additional review showed strongly positive influence on outcome by the following factors: Co-morbidity (C), Location (L), Age (A), Size (S), Symptoms (S), in addition to a history of prior surgery and prior radiation. Conclusion. Operative complications occur as a result of 3 broad categories of causes, namely, surgeon’s inexperience/ ignorance (Type I), chance occurrence (Type II) and surgeon’s greed (Type III). There is clearly a learning curve in meningioma surgery, which resulted in a statistically significant improvement in the incidence of surgical complications and the incidence of excellent outcome group (GOS 5) after the first 600 cases. Additionally, co-morbidity, location, age, size, symptoms (collectively termed ‘CLASS’) and prior surgery and radiation are found to be important factors determining outcome following meningioma surgery. William T. Couldwell, MD, PhD Evolution of Parasellar Approaches & AANS Update Parasellar anatomical approaches have a several thousand year history, initially starting with Egyptian decerebration techniques. The past century has seen advances in instrumentation and illumination, as well as a greater understanding of skull base anatomy to facilitate a wide variety of surgical approaches to the parasellar region. The transnasal approach, the transmaxillary and infratemporal approaches may be utilized to offer a wide exposure to the anterior, middle and posterior skull base parasellar regions. Finally, the lateral transorbital approach will be described and demonstrated in anatomical and clinical detail. M Necmettin Pamir, MD The 1933 Turkish University reform and its impact on the Turkish Academic Life Michael L.J. Apuzzo, MD A Nuclear Powered Submarine Journey Through the Bosphorus and the Reinvention of Neurosurgery The Bosphorus, also known as the Istanbul Strait, forms a boundary between Europe and Asia. The world narrowest strait used for international navigation, it connects the Black
Sea with the Sea of Marmara. The strait measures 17 nautical miles with a minimum width of 0.380 nautical miles. Its depth averages 213 feet. The shores are heavily populated and there is considerable surface maritime traffic. The challenges of clandestine subsurface navigation employing a 7-story 400-foot nuclear powered submarine are considerable. Preparation for such an epic journey and the introduction of attendant technologies allowing this possibility proved to be seminal in creating ideas, translations and subsequent multiple practical fruitions in the reinvention of neurosurgery
S unday, June 26
over a subsequent three-decade period. Topics of concepts and technologies and their introduction and catalytic effect to the field of neurosurgery will be elucidated. Anil Nanda, MD, FACS Presidential Address - Gallipoli: Intercontinental leadership through the prism of Ataturk, Churchill, and Gandhi
Conrad Istanbul
Jacques Morcos, MD Flow Diverters in the Management of Complex Aneurysms: Ready for Prime Time? No way! Large, giant and complex aneurysms continue to pose serious management challenges. There have been recent advances in stent technology and great hope is being pinned on â&#x20AC;&#x153;Flow Divertersâ&#x20AC;?. One such device (Pipeline) has just obtained FDA approval. I reviewed the basic science, technology, clinical experience and reported outcomes pertaining to stents and particularly flow diverters in the treatment of aneurysms. I particularly emphasized complications and hemodynamic analysis of poor outcomes. I concluded that the evidence is very clear. While the endovascular advances are promising, the technology is far from mature, and concerns exist with respect to delayed complications. We should be extremely cautious in advocating widespread usage of flow diverters, and open surgical clip reconstruction and bypass techniques remain the preferred option in the majority of perforator bearing aneurysmal segments. Zoher Ghogawala, MD Lumbar Spinal Fusion Reduces Risk of Re-operation after Laminectomy for Lumbar Spinal Stenosis Associated with Grade I Degenerative Spondylolisthesis: Initial Results from the SLIP trial Zoher Ghogawala, MD, Edward C. Benzel, MD, Subu N. Magge, MD, Jean-Valery CE Coumans, MD, J Fred Harrington, MD, and Fred G. Barker, MD
Turkey
Objective: To compare laminectomy with fusion to laminectomy alone in terms of re-operation rates after surgery for lumbar spinal stenosis with grade I spondylolisthesis. Methods: A prospective, 5-center randomized clinical trial was conducted from 2002-2009. Patients aged 50-80 with degenerative spondylolisthesis (3-14 mm) with symptomatic lumbar spinal stenosis were eligible. Patients with mechanical instability or gross motion (> 3mm) on flexion-extension lumbar radiographs were excluded. Patients were randomized to either laminectomy alone or laminectomy with posterolateral instrumented fusion with autograft. Follow-up outcome assessments were done in the clinic at 1 month, 3 months, 6 months, 12 months, and then annually for 5 years by phone from an independent study coordinator. All re-operations in the lumbar spine were recorded. Results: 130 patients were screened, 106 were enrolled, and 66 randomized to receive either lumbar decompression alone versus lumbar decompression with posterolateral instrumented fusion with autograft. Accrual goal has been reached in this RCT. Mean age was 66.8 years. Two-year follow-up rate is 88%. Average follow-up is currently 34 months. For patients treated with laminectomy alone, the re-operation rate was 10/34 (29.4%). When fusion was added to laminectomy, the re-operation rate was considerably lower 3/31 (9.7%) (P=0.05). Actuarial rate of re-operation for both cohorts is depicted in Figure 1. All re-operations in the laminectomy cohort consisted of fusion performed at the index level for instability. Re-operations in the fusion cohort were at an adjacent level in all cases. Mean SF-36 and Oswestry (ODI) scores were substantially lower at 1 year in patients who ultimately underwent re-operation. These outcomes scores improved
ABSTRACTS [SF-36: 34.2 to 45.3 (P=0.001); ODI – 29.3 to 17.3(P=0.01)] significantly 6 months after re-operation. Conclusions: Performing a lumbar fusion when decompressing the spine in the context of a degenerative grade I spondylolisthesis significantly reduces the risk of re-operation within 3 years of the initial procedure. Turker Kilic, MD Molecular Understanding of Angiogenesis in AVM’s: From Lab to Clinic Michael L. Levy, MD, PhD, FACS Punch Drunk Lissa C. Baird, MD; James L.O. Toney The coining of the term “punch drunk” occurred in 1928 when Harrison Martland initially described the syndrome in the Journal of the American Medical Association. He estimated that half of all professional boxers eventually became symptomatic. There is no doubt that the relationship between repetitive head injury and neurologic compromise, such as dementia, is absolute. The question remains as to the other variables involved which catalyze the progression from repetitive head injury to dementia. Joe Louis was born on May 13, 1914 on Bell Chapel Road, six miles north of Lafayette, Alabama. He was the son of Munroe Barrow and Lillie (Reese) Barrow, the seventh of eight children. His parents were the children of former slaves. Two years after his birth, his father was confined to the Searcy State Hospital for the Colored Insane. Despite the fact that his family was informed that he died; he lived for another twenty years. His family resettled in Detroit, where at age 12, Louis started boxing. Louis’ professional boxing career began in 1934. He won his first 27 fights, all but four by knockout. He became the World Heavyweight Champion by defeating Jim Braddock (the Cinderella Man) on June 22, 1937. Louis held the world heavyweight title 11 consecutive years (from 1937 – 49) which is the longest reign in boxing history. He successfully defended his title a record 25 consecutive times with a career record of 68-3. In 2003, Ring Magazine named Louis the Greatest Puncher of All-Time. In 2005, the IBRO named Joe Louis as the greatest heavyweight champion of all-time. “I had the feeling that I was in the room with a wild animal…. He lives like an animal, fights like an animal, has all the cruelty and ferocity of a wild thing…. I see in this colored man something so cold, so hard, so cruel that I wonder as to his bravery. Courage in the animal is desperation.” New York Daily News. Paul Gallico Louis eventually became addicted to cocaine and developed signs of paranoid schizophrenia. In 1969, he was hospitalized
after collapsing on a New York City street which he admitted was the result of cocaine abuse and paranoid delusions. The following year, he spent an additional five months hospitalized in a Colorado state mental institution. He had surgery to correct an aortic aneurysm (abnormal widening of a blood vessel) in 1977 and was thereafter confined to a wheelchair. On April 12, 1981, he sat ringside at the Larry Holmes and Trevor Berbick heavyweight championship bout at Caesar’s Palace. After the fight, Louis died of cardiac arrest at the age of sixty-six. In evaluating available footage of his boxing matches in addition to a significant literature of interviews and commentaries, by and about him, we are able to suggest that despite repeated exposure to head injury, it is unlikely that Louis suffered from a pugilistacally induced dementia, as many are willing to suggest. Michael Schulder, MD Intraoperative MRI Guidance for Laser Interstitial Thermal Therapy Introduction. Laser interstitial thermal therapy (LITT) has been described as a treatment for patients with refractory brain tumors. Low-field intraoperative MRI (iMRI) was assessed as a tool to guide laser placement. Methods. Five patients were treated with iMRI-guided LITT. Two patients had tumors in the brainstem, one had a prolactinoma, and two had cerebral metastatic tumors. Each patient had progressive symptoms from tumor growth, despite maximal attempts at prior surgery, radiation therapy or radiosurgery, and chemotherapy. Laser fibers (Visualase, Houston, TX) were stereotactically placed in the operating room under guidance with a 0.15 Tesla (T) intraoperative MRI. Patients were transferred to a 1.5T MRI for LITT. Laser therapy was administered until ablation zones reached desired sizes or critical structures exceeded preset safety limit temperatures. Contrast-enhanced T1 weighted MRI was then done to confirm the volume of treatment. Results. IMRI ultimately confirmed accurate laser placement in the operating room before transfer to diagnostic MRI for LITT in all patients. In 1 patient with a medial parietal metastatic tumor, surgical navigation without intraoperative imaging resulted in laser misplacement; this patient underwent a successful 2nd procedure with iMRI guidance. In another patient who had had 2 prior craniectomies and irradiation for an ependymoma of the medulla, laser test doses did not yield satisfactory zones of ablation, and full therapeutic doses therefore were not applied. Conclusions. Successful completion of LITT is facilitated by the use of iMRI guidance. This ensures accurate laser insertion into the tumor and subsequent technically successful tumor ablation. Surgical navigation alone can result in fiber misplacment and an aborted procedure.
Mario Ammirati, MD, MBA Placement of thoraco-lumbar pedicle screws using O arm based navigation: technical note on screws placement and on controlling the operational accuracy of the navigation system
the changes implemented in the Congo hospital after their discussion with the local co-workers have survived even for some months after my departure. Usually, such changes are connected to the person who initiated them and disappear when the person has left.
Background. Suboptimal placements of pedicle screws may lead to neurological and vascular complications, potentially requiring reoperation. Computer-assisted image guidance has been shown to improve accuracy in spinal instrumentation. We describe a novel technique of using O-arm based neuronavigation to place pedicle screws in the thoraco-lumbar region in a minimally invasive fashion highlighting steps to continuously maintain the operational accuracy of the navigation system. Methods. A total of 62 pedicle screws were inserted in 10 patients using a stepwise algorithmic combination of O-armstealth navigation. All patients underwent post-operative thin slices control CT scan of the instrumented area. Follow-up ranged from 4 months to 24 months (mean and median 20 months). The Mirza evaluation system was used to evaluate the accuracy of the position of the inserted screws.
Aid under the described circumstances shouldn’t be limited to the purely humanitarian aspect and can usually not be extended to what is generally called “development”. I am convinced that the gap between those countries which have access to modern technology and those countries which do not have this access or do have it only on a much inferior level, will increase in the future - as well as the need for humanitarian assistance in conflict areas of this world.
Results. We placed 26 thoracic and 36 lumbar screws in 10 patients. No patient experienced any complication related to pedicle screws placement. None of the screws needed to be repositioned after surgery. The post-op thin slices CT show that the accuracy of the screws placement, according to the Mirza’s system, was 100%. Conclusion. Our algorithmic step wise technique of O-arm based Stealth navigation, is associated with extreme accuracy of screw placement and with practical elimination of the need to bring a patient back to the operating room to reposition a pedicle screw as well as with absence of neurological injuries. Hans-Peter Richter, MD, PhD Working Under Basic Conditions in Foreign Cultures In the middle of the installation of our BrainSuite, I retired from active service in Germany (August 2008). A long time before, I had decided to serve from now on only in humanitarian missions for a limited period of the year. Except from neurosurgical teaching in Nepal (2008), I have worked in the meantime as general surgeon for Doctors without Borders in the war area of North Kivu, Democratic Republic of Congo (2009), and as neurosurgeon in Taiz, Yemen and Bishkek, Kirgistan (2010). The April 2011 appointment in Taiz, Yemen has just been cancelled due to the recent political turmoil. Working in such locations means to adjust yourself to a very basic level of technical equipment, to occasionally unstable environments, and always to an entirely different culture. This has been tribal in Congo, islami(sti)c in Yemen, and mixed central asian and post-soviet in Kirgistan. It is amazing, however, what can be achieved with very limited material. The only hospital which asked for assistance in organizational matters besides the medical work was that in Congo. The hospitals in Yemen and in Kirgistan were just happy with their performance. I do not know, however, if
Phillip A. Tibbs, MD Non-surgical Exogenous Crossline Therapy: Can Disc Degeneration Be Reversed? The unique biochemical composition and structure of the intervertebral disc allows it to support load, permit rotation and dissipate energy. Disc degeneration is a major cause of pain, disability, surgery and loss of work time in our society costing billions of dollars each year. The pathophysiology of disc degeneration includes loss of collagen matrix crosslinking which, combined with disc dehydration and mechanical stress causes loss of functional integrity of the disc. Genipin is a crosslinking reagent that augments and/or restores the crosslinking in natural collagen matrix. In our laboratories, we have analyzed the cytochemical and biomechanical effects of Genipin injection therapy into intervertebral discs. Materials and Methods. Genipin was injected into bovine and human degenerated intervertebral discs in vitro. Biomechanical evaluation indicated improved mechanical stability and fatigue resistance versus buffered saline-injected controls. Net fluid inflow into treated specimens of nucleus pulposus increased 103%. Conclusion. We conclude that Genipin crosslinking improves collagen matrix permeability and proteoglycan retention. These in turn enhance hydration levels and fluid flow in the intervertebral disc, enhancing tissue permeability, nutritional reflow and waste product outflow. Non-surgical exogenous crosslink therapy is a promising approach to minimize progression of symptomatic disc degeneration in vulnerable human populations. The laboratory data will be outlined in detail and the rationale for a pending human trial described. Ruth E. Bristol, MD Symptomatic Outcome after Decompression Surgery for the Treatment of Chiari Type I Malformation: Evaluation of operative procedures Samuel Kalb MD, Ruth E. Bristol MD; Barrow Neurological Institute
Objective. The decompression of Chiari I malformations is one of the more controversial procedures in neurosurgery. Cerebellar tonsillar descent greater than 1cm, syringomyelia, and symptoms of brainstem compression are generally agreed-upon indications for intervention. But, patients who
ABSTRACTS harbor Chiari I malformations present with a wide spectrum of symptoms and radiographic findings, making the decision to proceed with intervention, at times controversial. Similarly, the surgical procedure itself can be performed in a variety of ways. Our goal was to evaluate the symptomatic outcomes from a large group of surgeons who use diverse surgical techniques. Methods. Of 137 patients who underwent decompression, 104 had records for review and follow up. 101 patients underwent durotomy with or without subsequent patch duraplasty. The other 3 patients had bony decompression alone. Results. Symptomatic improvement was evident in the majority of the cases. Patients who initially presented with syringomyelia showed fewer symptomatic improvements, however, symptomatic worsening was not associated with the presence of syrinx. Durotomy was performed in 97.1%, arachnoid opening in 60.6% with visualization of the fourth ventricle in 51.9 % of the patients. Neither arachnoid opening nor fourth ventricle visualization affected symptomatic outcome. Duroplasty was performed in 94.2% of the cases, and Chiari plate was used in 13.4% cases resulting in favorable symptomatic outcome. The use of post-operative steroid or muscle relaxant medications did not change the course of symptom outcome. Follow-up MRI of patients who initially presented with syringomyelia showed a 62.5% improvement rate. Conclusion. We conclude that bony decompression and durotomy are the most important steps in Chiari I surgery. Whether or not syringomyelia responds better to opening of the outlet of the fourth ventricle, will require a larger study population. Even with the variety of surgical techniques in a large group of surgeons, symptomatic improvement can be achieved in the majority of patients. Saleem I. Abdulrauf, MD, FACS Difficult Lessons I Learned in the Treatment of Giant Aneurysms: When to Clip, Coil, Stent, Bypass, or Leave Well Enough Alone? Introduction. The treatment of giant aneurysms continues to be a challenge and is associated with morbidity and mortality. In this presentation, I will review my own learning curve in handling these challenging and at times formidable lesions. Methods. We retrospectively reviewed our treatment of giant intracerebral aneurysms over a 10 year period (July 2000June 2010) at a single institution (Saint Louis University Hospital). For this specific presentation, we identified specific cases that will be used to illustrate certain decisions that affected the patient positively or negatively. Conclusion. The treatment of giant cerebral aneurysms is associated with a steep learning curve and, in this presentation, I will share some of the decisions that resulted in nega-
tive outcomes and will elaborate on paradigms that may help avoid potential negative outcomes. Ali Kafadar, MD Management of Hydrocephalus in Pediatric Posterior Fossa Tumors Ian E. McCutcheon, MD Scalp Tumors with Intracranial Extension in 60 Patients; Multidisciplinary Surgical Strategies and Outcomes Introduction. Malignant skin cancers of the scalp can present with calvarial invasion, dural extension, and rarely intraparenchymal involvement. Typically such lesions involve a multi-disciplinary approach involving head and neck surgery, neurosurgery and plastic surgery for optimal resection and reconstruction. We present a prospective analysis of patients with scalp malignancies who underwent resection and reconstruction. Methods. Patients presenting with scalp malignancies (19932010, n=60) who required neurosurgical assistance for tumor resection were identified prospectively. We classified the extent of neurosurgical resection into four levels of involvement: scalp (level I), calvarial (level II), dural (level III), or intraparenchymal (level IV). Complications and evidence of local, locoregional, or regional recurrence were documented. Results. Patients underwent resection to level I (n=60), level II (n=50), level III (n=9, all with duraplasty), and level IV (n=2). At a mean follow-up of 28 months, patients had local recurrence (29%), locoregionalrecurrence (12%), regional metastases (29%), and 58% required no further interventions. Scalp-based reconstruction involving plastic surgery was performed in 38 patients. All cases underwent craniectomy and 26% demonstrated dural invasion. The most commonly used free flap was latissimus dorsi (n=38). Complications occurred in 18% of all patients; the most common was wound dehiscence (n=5). Our analysis demonstrates that more aggressive resection (level III or IV) was associated with decreased incidence of local and regional recurrence (p <0.05) when compared to level I and II resections. Importantly, more extensive levels of resection were not associated with an increased incidence of complications. Conclusions. Our study is the first attempt to classify the extent of neurosurgical resection for malignant scalp tumors and the largest series describing treatment of scalp malignancies with intracranial extension. Despite aggressive resection, the incidence of complications is low. This study demonstrates the efficacy of neurosurgical intervention, which should include the entire area of calvarial/dural involvement to prevent recurrence of these tumors. Charles Y. Liu, MD, PhD Defining the Optimal Neurostimulation/Neuromodulation Paradigm for Treatment of Epilepsy - An Engineering Approach Liu, Charles Y., MD, PhD, Heck, 2Christie N., MD, and 3Berger, Theodore, PhD
1
1
Department of Neurological Surgery, USC Keck School of Medicine, 2Department of Neurology, USC Keck School of Medicine, 3 Department of Biomedical Engineering, USC Viterbi School of Engineering
suggest that dural venous sinus stenting in properly selected patients with IIH dural venous sinus stenosis represents a promising alternative to traditional surgical modalities (LPS, VPS, and ONSF)
Despite advances in both the medical and surgical management of epilepsy, a large number of patients continue to be “intractable”. For the past two decades, vagus nerve stimulation (VNS) has become standard in most modern epilepsy centers. Although long-term experience clearly demonstrate that a large number of patients achieve reductions in seizure burden with VNS, critics point out that only a few patients achieve seizure freedom. Recently, new neurostimulation strategies are being evaluated, including deep brain stimulation (DBS) and responsive neurostimulation (RNS). The results of clinical trials have been promising. However, these new strategies suffer from the same criticisms as that for VNS, that patients do not benefit “enough” to warrant cost and risks of surgery. While our experience with both closed and open-loop stimulation strategies clearly demonstrates a positive effect, the challenge is to optimize the positive effect to tip risk/benefit considerations toward surgery. In this paper, we describe an approach that utilizes an in-vitro slice model for temporal lobe epilepsy and mathematical modeling that may serve as a platform to identify the optimal neurostimulation/neuromodulation paradigm.
Evren Keles, MD Current Concepts in Metabolic and Functional Imaging of Hemispheric Low Grade Gliomas in Adults
Aclan Dogan, MD Treatment of Pseudotumor Cerebri Due to Venous Obstruction by Stent Placement in the Dural Sinuses
Aclan Dogan, Parisa Javedani, Jeremy D. Fields, Julie Falardeau, Erek Helseth, Stanley L. Barnwell, Bryan D. Petersen.
Purpose. To evaluate the use of self expanding nitinol stents for the treatment of dural sinus stenosis causing elevated venous pressures associated with peusdotumor cerebri. Material and Methods. Consecutive patients undergoing venous sinus stenting for IIH were identified. Patients were considered eligible for stenting if they were diagnosed with IIH with papilledema by a neuro-ophthalmologist and the mean pressure gradient across the stenosis exceeded 10 mmHg. Results. A total of 13 patients were treated; all were refractory to medical therapy, and 5/13 (38%) had undergone VPS, LPS, ONSF (or a combination of these procedures) prior to stenting. No procedural complications occurred and the technical success rate was 100%. The mean gradient across the venous sinus stenosis 23 mmHg (range 12-40) prior to stenting and 4 (1-9) mmHg afterward. All patients presented with papilledema and headache; papilledema resolved or improved in 100% and headache resolved or improved in 76%; Visual acuity stabilized or improved in 100%. Conclusion. In this small series, dural venous sinus stenting for IIH was performed with a high degree of technical success and without complications, resulting in improvement or stabilization of vision and papilledema in all patients and improvement or resolution of headache in 76%. These results
Prashant Chittiboina, MD Selective Targeting of Phosphoinositide 3-kinase (PI3K) Gamma is a Promising Novel Approach for the Treatment of Ischemic Stroke Hasan Kocaeli, MD Hypothalamic Perforating Artery Variations in Patients with Posteriorly and Inferiorly Projecting Anterior Communicating Artery Aneurysms Daniel J. Hoh, MD Characterization of lower urinary tract function and correlative neuroanatomy in a novel translational model of experimental cervical contusion spinal cord injury Daniel J. Hoh, MD1,2, Teresa Martin – Carreras, BS1, Michael A. Lane, PhD2, Paul J. Reier, PhD2, University of Florida, Department of Neurosurgery1, Department of Neuroscience2
Background. Traumatic spinal cord injury (SCI) can impair ascending and descending pathways of the spinal cord resulting in potentially devastating loss of motor and sensory function. Lower urinary tract (LUT) function, which is normally mediated by both local spinal cord circuitry as well as spinal – supraspinal pathways, can also be compromised by SCI. It has been previously shown in a rodent model of thoracic spinal cord transection that animals demonstrate impaired voiding similar to that seen clinically, characterized by urinary retention and bladder - external urethral sphincter (EUS) dyssynergy. Bladder – EUS dyssynergy occurs presumably secondary to loss of poorly-defined supraspinal white matter projections through the spinal cord lesion, resulting in tonic EUS activity during bladder contraction, and thereby incomplete bladder emptying. Developing successful therapies for improving neurologic recovery after SCI is dependent on translational models that examine clinically relevant injury mechanisms with well-defined correlative neurophysiology and anatomy. Therefore, we introduce a novel preclinical model that to the best of our knowledge is the first of its kind. The objective of this study is to characterize changes in LUT function as demonstrated by impaired bladder emptying and bladder – EUS dyssynergy, and to correlate these changes with appropriate neuroanatomy in the setting of rodent cervical spinal cord contusion injury. Methods. Six naïve Sprague – Dawley rats underwent urodynamic testing with continuous transurethral cystometry (7.5 ml/hr) and EUS electromyography (EUS – EMG) to demonstrate normal bladder emptying and coordinated bladder – EUS activity. Another twelve animals were subjected to either unilateral (n=6) or bilateral (n=6) moderate cervical contusion
ABSTRACTS injury (C4-5). Bladder – EUS dyssynergy was assessed by urodynamic testing on postinjury day 7 or 14. Impaired bladder emptying was assessed behaviorally by daily manual bladder expression to record post void residual urine volume. Animals were then sacrificed and the spinal cords sectioned for neuroanatomic analysis. Results. Naïve rats demonstrated normal spontaneous urinary voiding behavior, whereas animals with unilateral contusion injuries had minimal impairment in voiding, and those with bilateral injuries had significant urinary retention (Figure 1). On urodynamic testing and EUS - EMG, naïve animals demonstrated synchronous EUS bursting activity coordinated with initiation of bladder emptying (Figure 2). Animals with unilateral cervical contusion injury (Figure 3) demonstrated presence of synchronous EUS bursting activity with initiation of bladder emptying, albeit diminished compare to naïve animals at both 7 and 14 days post injury. Animals with bilateral contusion injuries (Figure 4) demonstrated bladder - EUS dyssynergy, characterized by continuous tonic EUS activity throughout bladder contraction at both 7 and 14 days post injury. Conclusion: Using a novel translational SCI model, we demonstrated the ability to effectively characterize LUT dysfunction after cervical contusion SCI. Further, we validated that urodynamic assessment for bladder – EUS dyssynergy serves as a sensitive indicator of both neuroanatomic spinal cord lesion involvement and degree of urinary voiding impairment. Venko Filipce, MD Quantitative and Qualitative Analysis of the Working Area Obtained by Endoscope and Microscope in Various Approaches to the Anterior Communicating and Basilar Artery Complex Using CT Based Frameless Stereotaxy: A Cadaver Study Objective. Surgical treatment of aneurysms of the anterior communicating artery (ACom) and basilar artery (BA) complex is challenging due to their intricate vascular anatomy. Endoscopy is a recently rediscovered neurosurgical technique that could lend itself well to overcome some of the vascular visualization challenges associated with this procedure.
The purpose of this study was to quantify and compare the working areas afforded by the microscope and the endoscope to the ACom and BA complex in different surgical approaches and using image guidance. Methods. We performed a total of 9 dissections including mini supraorbital (SO), pterional (PT) and orbitozygomatic (OZ) approaches bilaterally in five whole, fresh cadaver heads. We used CT based image guidance for intraoperative navigation as well as for quantitative measurements. We estimated the working area of the ACom and BA complex region, using both a rigid endoscope (4.0 mm in diameter and 18 cm long with 0° and 30° lenses) and an operating microscope. Operability was qualitatively assessed by the senior authors. Results. For ACom, in microscopic exposure, the orbitozygomatic approach provided the greatest working area (204.5±33.9mm²) compared to the mini-supraorbital (114.8±26.9mm²) and to the pterional approach (170±20.4mm²;p value <0.05). Evaluation of the endoscopic working area showed that the SO approach, using both 0°and 30° endoscopes, provided a working area greater than a conventional PT approach (p < 0.05) and an area comparable to an OZ approach (p>0.05). For BA, in microscopic exposure, the orbitozygomatic approach provided greater working area (160±34.3mm²) compared to the pterional approach (129.8±37.6mm²) (p value >0.05). The working area in both pterional and orbitozygomatic approaches using 0°and 30° endoscopes was larger than the one available using the microscope alone (p value <0.05). In the pterional approach, both 0°and 30° endoscopes provided a working area greater than a microscopic orbitozygomatic approach (p < 0.05) and an area comparable to the orbitozygomatic endoscopic approach (p>0 .05). Conclusion. In our model, use of the endoscope, in an assistive manner to microscopic surgery, provided a working area advantage without loss of microneurosurgical techniques of dissection or of depth perception in the surgical field. This advantage was most prominent when smaller craniotomies were used. Hasan Caglar Ugur, MD Extension of Research from Anatomy Laboratory to Neurosurgery Practice Yücel Yilmaz, PhD Sea Connections Between the Black Sea and Bosphorus and Its Bearing on the Ancient Settlements
M onday, June 27
Hilton Izmir
Franco DeMonte, MD, FRCSC, FACS The Role of Surgery in the Management of Skull Base Metastases Introduction. Skull base metastases (SBM) are rare and have received limited attention in the medical literature. Questions remain regarding the role of surgery, if any, in the management of these tumors. The purposes of this presentation are to report surgical outcomes in a consecutive series of patients with metastases to the skull base, and to better define the role of surgery in the management of SBM. Methods and Materials. 27 patients with SBM underwent surgery between 1996 and 2009 at MD Anderson Cancer Center. A retrospective review of their prospectively collected data was performed after obtaining institutional review board (IRB) approval. Median patient age was 52 years. The most common pathology was renal cell carcinoma (6 patients). Surgical indications were worsening neurologic deficit, mass and need for diagnosis. Results. A gross total resection was achieved in 59% of the cases. Median survival was 11.4 months. Median progression-free survival was 5.8 months. A Karnofsky performance score less than 90, dural invasion and brain invasion were associated with a shorter survival. 7 patients were neurologically intact pre-op; all of them remained intact after surgery. Among all patients with pre-operative neurologic deficit, 11 remained stable, 7 improved and 2 had worsening of their deficit post-operatively. Conclusion. The goal of surgery for skull base metastatic disease is to provide symptom relief and to preserve functional status in well selected cases. Patient selection is critical since the surgery is usually palliative and only a minority of patients are surgical candidates. Radiation therapy remains the management option of choice for the majority of patients with metastases to the skull base. Volker Tronnier, MD, PhD Subgroups of Stem Cell-Like Human Glioma Cells Respond Differently to TMZ Volker Tronnier , Christina Zechel Department of Neurosurgery, University of Lübeck, Germany Klinik für Neurochirurgie, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Ratzeburger Allee 160, D-23538 Lübeck
Objective. Malignant gliomas are amongst the most lethal solid tumors. They grow invasively, develop resistance to radiation and chemotherapy, and frequently recur. The gold standard in malignant glioma therapy is concurrent radiochemotherapy, using the alkylating compound temozolomide (TMZ). It has been proposed that stem cell-like tumor cells mediate resistance to TMZ and regrowth. Methods. Glioma cells with stem cell-like properties (SCLC)
Turkey
were isolated from glioblastoma, gliosarcoma and other highly malignant gliomas. The cells were grown in serumfree medium containing the growth factors bFGF and EGF. Tumorigenicity was analyzed in SCID mice. We determined the responsiveness of SCLC to TMZ by several approaches (BrdU-ELISA, growth curves, MTT- and TUNEL-assay, propidium iodide and Annexin staining) and related it to the expression of MGMT and proteins associated with the stem-like phenotype. Marker expression and changes in expression levels were assessed by Western blot and real-time PCR, as well as by immunocytochemistry and FACS. Results. Primary cultures of SCLC exhibited self-renewal, although growth behaviour and proliferation rate differed largely. Based on their intrinsic growth properties and the expression of the intermediary filaments Nestin and GFAP, we classified several SCLC subgroups. Nestin expression was found in all SCLC subtypes, whereas GFAP expression levels varied largely between the different populations. In a few cases, Nestin+/GFAP- and Nestin+/GFAP+ cells stably co-existed within the same population. Sox2 was expressed to different levels in the various populations. Finally, for all SCLC subgroups CD133- and CD133+ cells coexisted in the cultures in certain, mostly stable ratios. Confirming previously published results, responsiveness to TMZ was related to the methylation status of the MGMT promoter, as was revealed by methylation-dependent PCR and real-time PCR. TMZ responsiveness amongst the MGMT+ and the MGMTgroup of SCLC, however, was not identical. It appeared that differences in the coexpression of Nestin, GFAP, CD133 and Sox2 define the differentiation status of the respective SCLC populations, which in turn affects their responsiveness to TMZ. Conclusions. Our data indicate that the stemness and differentiation states of SCLC populations contribute to their responsiveness to TMZ treatment. Kadir Erkmen, MD Intra-operative Indocyanine Green (ICG) Angiography Decreases the Risk of Perforator Vessel Stroke During Cerebral Aneurysm Surgery Kadir Erkmen (presenter), Kimon Bekelis, Symeon Missios, Matthew Ippolito, Clifford J. Eskey, and David W. Roberts
Introduction. Increasing use of endovascular techniques for the treatment of cerebral aneurysms has resulted in a higher complexity of cerebral aneurysms treated with surgical clipping. Aneurysms that are considered inappropriate for endovascular treatment are often more complex surgically due to large or giant size, presence of wide-necks, or incorporation of parent vessels in the dome. Inherent with increasing complexity of surgically treated aneurysms is a potential increase in risk, specifically in ischemic complications related to perforator or parent-vessel occlusion. Intra-operative ICG angiography is a technique that allows real time visualization
ABSTRACTS of flow in cerebral vessels using fluorescence imaging. Rapid identification of perforator or parent vessel occlusion allows for timely clip repositioning during aneurysm surgery, and may decrease the risk of stroke. Methods. A retrospective analysis was performed on data from cerebral aneurysm surgery at a single institution. From July 2008 to September 2009 ICG was used in all patients (n=50) undergoing cerebral aneurysm surgery. The control group consisted of the prior 50 patients who had aneurysm clipping by the same surgeon before the introduction of ICG, where conventional digital subtraction angiography (DSA) was the standard intra-operative imaging technique. All patients were imaged 24 hours post-operatively with noncontrast head CT according to our standard protocol. Postoperative stroke (symptomatic and asymptomatic), vasospasm, need for intra-operative DSA, and Glasgow performance score at discharge and three months postoperatively were compared in the two groups. Results. There were no complications in the study group specifically related to the use of the ICG dye. Patients who had intraoperative ICG angiography demonstrated a decreased rate of postoperative stroke (0% with ICG versus 8.1% without, p = 0.03) and decreased need for intra-operative conventional angiography to confirm aneurysm occlusion and vessel patency (9.5% with ICG versus 100% without, p<0.0001). The use of ICG did not affect the rate of vasospasm (18% with ICG versus 14% without, p=0.3) and the GOS of the patients at discharge (mean GOS was 3.71 with ICG versus 3.57 without, p=0.27) and three months post-operatively (mean GOS was 4.58 with ICG versus 4.58 without p=0.99). Conclusions. Intra-operative ICG angiography is safe and beneficial in reducing inadvertent vessel occlusion and stroke during aneurysm clipping surgery. Routine use of ICG may decrease the need for conventional DSA; possibly reducing the associated time, risks, and costs. Further prospective studies are necessary to confirm the improved safety of aneurysm surgery performed with this technique. Junko Matsuyama, MD Management of Pituitary Adenomas with Cavernous Sinus Invasion and Prognostic Value of MIB-1 Labeling Index Junko Matsuyama, MD, Masato Abe MD, Mitsuhiro Hasegawa MD, Yuichi Hirose MD, Yoko Kato MD
Objective. In residual invasive pituitary adenomas after surgery, reliable prognostic parameters indicating tumor recurrence is necessary. The authors also tried to determine predictors of progression of tumor after surgery. Subjects and Methods. We retrospectively analyzed 37 cases of patients with pituitary adenomas that were surgically treated between January 2001 and January 2010 at Fujita Health
University. Among those cases, 23 cases were pituitary adenomas with cavernous sinus invasion and 14 cases were adenomas without cavernous sinus invasion. The patients with cavernous sinus invasion were aged from 31 to 75 years old with the mean age of 51 years old, 6 women and 17 men. We evaluated the extent of the cavernous sinus invasion by Knosp grading, and MIB-1 index in tumor specimen, and retrospectively analyzed the tumor growth or recurrence rate as treatment results. Results. Non-functioning adenomas were found in 16 cases, Growth hormone secreting adenomas were found in 2 cases, and Prolactinomas were found in 5 cases. Initial surgeries were performed via transsphenoidal route in 19 cases, craniotomy was performed in 2 cases. Visual and visual field defect, the most frequent symptom showed improvement in 90%. MIB-1 index of the cases with cavernous sinus invasion was 2.66±2.00% (mean±standard deviation). On the other hand, in 14 cases of pituitary adenomas without cavernous sinus invasion, MIB-1 index was 1.14±0.39% (mean±standard deviation). MIB-1 index was significantly higher in the cases with cavernous sinus invasion (P<0.05). In 7 cases among the 23 cases with cavernous sinus invasion, we found tumor regrowth and recurrence. Conclusions. The result of the statistical analysis indicated that MIB-1 index in pituitary adenomas is clinically useful prognostic parameters indicating of tumor invasiveness into the cavernous sinus, and adenomas with MIB-1>3% tended to cause poor recurrence free survival rate. Cavernous sinus invasion may be a predictor as associated with increased recurrence rate. Transsphenoidal approach is safe and effective procedure even in large or invasive pituitary adenomas, and improving the gross total removal rate by introducing endoscopic approach will contribute to better prognosis. John E. McGillicuddy, MD Laporoscopic Triple Neurectomy for Intractable Groin Pain After Mesh Repair of Hernias Severe, persistent groin pain following hernia repair and other lower abdominal incisions has been a vexing problem for many years. Determination of which of the three possible nerves - iliohypogastric, ilioinguinal, or genitofemoral - is involved is very difficult and past efforts to relieve the pain have been unpredictable. In the past, local re-exploration of the wound was performed, but clear dissection through the scar and identification of the lesion, despite a number of strategies, was only occasionally successful. Consequently, attempts were made to identify and transect all three nerves. Even these procedures were inadequate and required two separate approaches for a local retroperitoneal identification and transection. The problem has become even more difficult with the widespread use of mesh repairs and the consequent addition of more widespread scarring and a foreign body. After our general surgeons wisely advised against any local procedures when initial conservative measures had failed, we determined to resect the nerves through a retroperitoneal approach in the upper abdomen where the nerves could be identified through
clear anatomical landmarks. An open approach was used on four patients with successful relief of pain, but it did require a considerable incision and dissection. We are reporting similar success with a one-stage laparoscopic retroperitoneal approach to this are for a triple neurectomy in an area devoid of scar. Proximal interruption of all three nerves is preferred because there are distal communications among the nerves and overlap of their sensory fields in the groin and genitalia. Eight patients have now been treated with gratifying results. Significant pain relief has persisted for 10 months to 3 years. There was only one complication, an inadequate transection of the genitofemoral nerve which was corrected. Operative time was 2 hours and all patients were discharged the following day. Recent surgeries have been done as an outpatient procedure. The procedure, performed under general anesthesia in the lateral decubitus position, will be described and illustrated. Four ports are required; only the port for the dissecting balloon is large. It is essential that the kidney be reflected anteriorly, and a urologist assists with the approach and exposure. We believe that this technique is reliable, effective, and ideal for the treatment of chronic, intractable groin pain following lower abdominal surgery and trauma.
AANS DISCLAIMER STATEMENT The material presented at the Society of University Neurosurgeons (SUN) Annual Meeting has been made available by the Society of University Neurosurgeons and the AANS for educational purposes only. The material is not intended to represent the only, nor necessarily the best, method or procedure appropriate for the medical situations discussed, but rather it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. Neither the content (whether written or oral) of any course, seminar or other presentation in the program, nor the use of a specific product in conjunction therewith, nor the exhibition of any materials by any parties coincident with the program, should be construed as indicating endorsement or approval of the views presented, the products used, or the materials exhibited by the Society of University Neurosurgeons and jointly sponsored by the AANS, or its Committees, Commissions, or Affiliates. Neither the AANS nor the Society of University Neurosurgeons makes any statements, representations or warranties (whether written or oral) regarding the Food and Drug Administration (FDA) status of any product used or referred to in conjunction with any course, seminar or other presentation being made available as part of SUN Annual Meeting. Faculty members shall have sole responsibility to inform attendees of the FDA status of each product that is used in conjunction with any course, seminar or presentation and whether such use of the product is in compliance with FDA regulations. DISCLOSURES In accordance with the Standards for Commercial Support established by the Accreditation Council for Continuing Medical Education (ACCME), anyone in a position to control the content of the educational activity (speakers, paper presenters/ authors, co-authors, staff, and the significant others of those mentioned), are required to disclose any relationship they have with commercial interests which may be related to the content of their lecture. Failure or refusal to disclose or the inability to satisfactorily resolve the identified conflict may result in the withdrawal of the invitation to participate in any AANS education activities. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. The ACCME defines a “commercial interest” as any entity producing marketing, re-selling, or distributing healthcare goods or services consumed by, or used on patients. Any potential conflicts of interest have been reviewed to ensure the content is valid and aligned with the interest of the activity audience. All disclosures are noted on the enclosed handout provided with your program book.
BYLAWS ARTICLE I: NAME AND OBJECT Section 1. This organization shall be known as “The Society of University Neurosurgeons, Incorporated”. Section 2. The objectives of this society shall be: to promote scientific and social discourse among its members, to encourage investigative work in the neurological sciences, to improve teaching methods and techniques in neurological surgery, and to inspire its members to acquire humanistic ideals and to achieve clinical excellence in the practice of medicine. Section 3. No part of the income or property of this Society shall inure to the benefit of any individual. ARTICLE II: MEMBERSHIP QUALIFICATIONS Section 1. The membership of the Society shall be divided into five classifications: (a) Active (b) Senior (c) Corresponding (d) Honorary (e) Inactive A member shall be elected as provided in Article V – CANIDATES FOR MEMBERSHIP. Section 2. Classification of Membership: (a) ACTIVE. Active members shall be neurological surgeons who have been certified by the American Board of Neurological Surgery, Inc., or are certificates of the Royal College of Physicians and Surgeons (Neurosurgery) of Canada and who are engaged on the practice of Neurological Surgery. (b) SENIOR. An active member may, upon request to and approval of the Executive Council, transfer to Senior membership upon attaining the age of sixty (60) years or upon retirement from practice of neurological surgery. Senior members may not vote or hold office but may serve on Committees; and are not required to pay dues or regularly attend annual meetings. (c) CORRESPONDING. Corresponding members shall be individuals who reside outside of North America, chosen because of their devotion and contribution to neurological sciences as well as their interest in the Society. They shall not exceed fifteen percent of the Active membership at the time of election. They shall pay an initiation fee and reduced annual dues to be determined by the Executive Council. They are not required to attend annual meetings. They shall not vote or hold office but may serve on Committees. (d) HONORARY. Honorary members shall be chosen as recognized leaders in the field of neurological sciences. They shall not exceed five in number. They shall not be required to pay dues or attend annual meetings. They shall not vote or hold office but may serve on Committees. (e) INACTIVE. Inactive members shall be former Active members who by virtue of illness or other reasons can no longer maintain Active membership and are not eligible for any other classification of membership. An Active member may, upon request to and approval of the Executive Council, transfer to Inactive status. An Inactive member may be restored to Active status by request to and approval of the Executive Council. Inactive members shall not vote, hold office or serve on Committees. They shall not be required to pay dues or attend annual meetings. Section 3. Qualifications for Membership: The Membership Committee shall be cognizant of the objectives of the Society and shall recommend for membership individuals who are affiliated with a medical school or outstanding clinic. If an Active member ceases to comply with the membership requirements as provided in Section 2(a), he/she must resign from the Society or be transferred to a different membership classification. Individual exception to this requires recommendation by the Executive Council and approval by majority vote of the Active membership. Section 4. Limitation of Membership: The number of Active members in the Society may be limited upon recommendation of the Executive Council and approval by a majority vote of the Active membership. Honorary members shall not exceed five in number at any time. ARTICLE III: OFFICERS Section 1. The officers of the Society shall be President, President Elect, Vice-President, and Secretary/Treasurer. The Executive Council shall be composed of the officers, an Active Member-at-Large appointed by the President, and the Immediate Past-President of the Society.
Section 2. The Nominating Committee shall present a slate of proposed officers to be elected for the succeeding year at each annual meeting. Additional nominations may be made by Active members present at the meeting. Election of officers shall be by ballot; the member receiving the largest number of votes cast for that office shall be elected. Officers so elected shall take office at the close of that annual meeting. Section 3. Vacancy of an office shall be filled by an appointee of the Executive Council. Section 4. The President shall serve for a term of one (1) year. He/She shall preside at all meetings and decide all questions of order, appoint committees and cast the deciding votes in ties. Section 5. The President Elect shall be elected at each annual meeting. He/She shall become President of the Society at the close of the subsequent annual meeting. Section 6. The Vice-President shall assist the President. He/She shall preside at functions and meetings in the absence of the President. Section 7. The Secretary/Treasurer shall serve for a term of at least two (2) years but not more than (3) years. The Executive Council shall determine at which year the election for Secretary/Treasurer will be held. He/She shall keep records of attendance and minutes of each meeting, read all correspondence to the Society, handle all notices and correspondence of the Society. He/She shall account for the finances of the Society, collect dues and notify members of delinquent standing. He/ She shall receive all applications for membership or guest attendance and forward this information to the Membership Committee at least one month prior to the annual meeting. Section 8. The Executive Council shall be the governing body of the Society and have charge of activities of the Society not otherwise provided in these Bylaws. The Executive Council shall work in close coordination with the Membership Committee concerning the proposal of candidates for membership in the Society. Section 9. The Historian of the Society shall maintain and update the Society of University yearbooks, which should document the scientific and social programs of the yearly meeting. ARTICLE IV :MEETINGS Section 1. The Society shall meet annually in the Spring of the year, preferably before May 15th, at a site determined by a majority vote of the membership at a preceding meeting. Section 2. The annual meeting shall be a three-day scientific program preceded or followed by a weekend as determined by the Program Committee. The scientific presentations shall be balanced between clinical and investigative topics. Section 3. The Chairman of the Program Committee shall serve as Host for the annual meeting, assisted by his/her Committee and responsible for arrangements of both social and scientific activities during the meeting. Section 4. Robert’s Rules of Order (Revised) Shall govern the conduct of the business meetings of the Society and the duties of its officers. The order of business shall consist of a roll call, reading of the minutes, reading of correspondence, old business, new business, election of new members, reports of committees, the Secretary/Treasurer’s report, election of officers, appointment of committees, and adjournment. Section 5. Members of any class shall be assessed a pro rata share of the expenses of the annual meetings which they attend. ARTICLE V: CANDIDATES FOR MEMBERSHIP Section 1. Candidates for membership shall have the qualifications as provided in Articles 1, 2 & 3. Section 2. No candidate shall be elected to Active membership who has not attended at least one annual meeting as a guest. Section 3. Each candidate shall be nominated in writing to the Secretary/Treasurer at least two (2) months prior to the next annual meeting. The nomination shall include the candidate’s curriculum vitae and a statement of his/her present academic and professional status. The completed proposal for membership shall be forwarded to the Membership Committee for consideration. The Membership Committee shall present to the Executive Council their recommendations for new members. On
BYLAWS approval of Executive Council, candidates shall be proposed to the Active Membership for written secret ballot at the annual meeting of the Society. Election of a member requires affirmative vote of three-fourths (3/4) of the Active members present and voting at the annual meeting. Section 4. The Membership Committee shall present no more than five (5) candidates for Active membership each year with no requirement of a minimal number to be presented. Section 5. The Secretary/Treasurer shall notify each candidate elected to membership not earlier than two (2) weeks following the date of his/her election and collect a membership initiation and certificate fee, the amount to be determined each year by the Executive Council. Section 6. A candidate who has failed to be elected may be reconsidered at a subsequent annual meeting upon written request of three (3) Active members to the Executive Council. ARTICLE VI: DUES Section 1. All Active members of the Society shall be accessed annual dues, the amount to be determined each year by the Executive Council. Section 2. Dues are payable in advance for the succeeding year at the time of or immediately following the annual meeting, at the discretion of the Secretary/Treasurer. ARTICLE VII: STATUS OF MEMBERS Section 1. All members shall be in good standing when abiding by the Bylaws of the Society. Section 2. An Active member shall be suspended when dues or assessments have not been paid for the previous two (2) years. If he/she fails to attend two (2) consecutive annual meetings and does not present an excuse acceptable to the Executive Council, a warning letter will be sent. If an active member fails to attend three consecutive meetings, then his/her membership will be terminated. Section 3. A member may be suspended or dropped from any class of membership in the Society by an affirmative vote of three-fourths (3/4) of the Active membership. Section 4. In cases of exceptional service to the society, an associate international member, can be voted on as office bearer and president; effective June 13, 2009 ARTICLE VIII: COMMITTEES Section 1. The Society may have standing and adhoc committees as determined by the President and the Executive Council. There shall be at least four standing committees: Membership Committee, Nominating Committee, Future Sites Committee, and Program Committee. Section 2. The Membership Committee shall be composed of three (3) members, one to be elected at large each year to serve a term of three (3) years. The senior member of the Committee shall serve as Chairman. This Committee shall review nominations for new members and present the applications of the most worthy and desirable candidates to the Executive Council. The names of the candidates approved by the Executive Council shall be submitted to vote by the Active membership at the next annual meeting of the Society. Section 3. The Executive Council shall serve as the Nominating Committee, with the Immediate Past- President of the Society as Chairman. Section 4. The Program Committee shall be appointed each year by the President taking office at the close of the annual meeting. The Chairman of the Committee shall be the Host for the next annual meeting. The Program committee may invite guests to complement the scientific program of the meeting.
Section 5. The Future Sites Committee shall be composed of three (3) members, one to be elected at large each year to serve a term of three (3) years. The senior member of the Committee shall serve as Chairman. This Committee shall recommend the site of future meetings, at least three years in advance. Section 6. A distinguished service committee will be formed headed by the President and consisting of the Secretary/Treasurer and immediate past two Presidents to decide on the distinguished service award; effective June 13, 2009 ARTICLE IX: GUESTS Section 1. The Society shall encourage the presence of guests at its annual meeting. Section 2. Certain invited guests of the Society shall not pay a registration fee or be charged for a share of the group expenses of the meeting. Such guests shall include: individuals invited by the Program Committee to give us a scientific presentation, candidates proposed for Active membership invited under special circumstances by the Membership Committee, other individuals approved by the Executive Council. Section 3. Individual guests to the annual meeting may be invited by members. The member shall notify the Secretary/Treasurer of the name and address of his/her proposed guest, and the Secretary/Treasurer shall officially invite the guest to the meeting. The inviting member shall be responsible for the guestâ&#x20AC;&#x2122;s behavior, expenses of registration and participation in all scientific and social activities. ARTICLE X: AMENDMENTS Section 1. Amendments to these Bylaws may be made by a proposal in writing from a member of the Executive Council at any time. The amendment shall be voted on at the subsequent annual meeting. The Secretary/Treasurer shall notify all Active members in writing of the proposed amendment prior to the annual meeting, and such amendment shall require for adoption and affirmative vote of three-fourths (3/4) of the Active members present and voting. RULES AND REGULATIONS MEMBERSHIP Section 1. Candidate Profile (a) Candidates should be less then 48 years of age. (b) Candidates should be committed to an academic career. (c) Candidates should have sufficient publications that the quality of their academic activity can be evaluated. (d) Candidates should have attended a SUN meeting, presented a paper before the Society, and expressed an interest in the Society. (e) Candidates should have potential hosting a future SUN meeting. Section 2. Membership Process (a) Candidates must have attended at least one SUN meeting and presented at least one paper to the Society before being recommended for membership. (b) No voting for membership will occur at the meeting where the candidate is a guest and presents a paper to the Society (c) The membership process would be initiated by obtaining the membership application form from the Secretary of the Society. (d) The form would be returned to the Secretary who, following documentation of its completeness, would forward it to the Chair of the Membership Committee. (e) The candidate is proposed for membership to the Membership Committee and a recommendation is made to the Executive Committee based on the candidateâ&#x20AC;&#x2122;s profile. (f) At the next regular meeting, the candidate is brought forward for membership during the first business session (g) If elected by the membership, the candidate will be invited to membership and upon joining the Society, is then eligible to attend the next regular meeting.
This conference was made possible by generous donations from:
Gold: Synthes Anspach Zeiss Silver: Harvest Technologies Depuy Codman Codman Nuvasive Medtronic Stealth Bronze: Elekta Leica
Information for Confirmation StealthStation® Navigation, StealthViz™, and Polestar® Intraoperative MR combine for enhanced planning and visualization in the OR. www.medtronicnavigation.com
Innovating for life. MED_SUN_AD_FINAL.indd 1
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