Acquisition of Basic Microsurgical Skills Using Low-Cost, Readily Available Models: The Orange Model.

Background: Attainment of basic microsurgical skills in neurosurgery presents a departmental challenge worldwide. Models for teaching are either not readily available or expensive and are incompatible with a resident's busy schedule, requiring lengthy and proper setup. We present a model and a set of measurable tasks, based on a fruit (orange) that is cheap, easy to set up instantly when desired, and useful for training of basic microsurgical skills.

Rescue Craniectomy with Subsequent Cranioplasty for Recurrent Symptomatic Subdural Hematoma in Elderly Patients.

Objective: Recurrent subdural hematoma (SDH) is commonly encountered in clinical practice. Multiple surgical techniques have been reported for management of recurrent SDH with variable success and complication rates. We report an alternative technique to halt SDH reaccumulation in elderly patients with multiple recurrences despite multiple surgical evacuations via rescue craniectomy and subsequent cranioplasty.

Primary Low-Grade B-Cell Lymphoma of Skull With Translocation Between Immunoglobulin and Interferon Regulatory Factor 4 Genes.

Low-grade B-cell lymphoma with immunoglobulin () and interferon regulatory factor 4 () gene rearrangement is extremely rare, with only 4 cases being previously reported. In this article, we report one additional case that arises from the skull and review the literature. The patient was a 69-year-old man who presented with recurrent and disabling vertigo and was found to have a 5.

Unilateral Venous Approach to Contralateral or Bilateral Carotid Cavernous Shunts.

Background: Cavernous carotid fistulas (CCF) are anatomically complex vascular lesions. Treatment via the venous approach has been previously described and is highly dependent on the patency of the drainage pathways. The use of a unilateral approach to contralateral or bilateral shunts is technically challenging and not commonly described.

Metastatic Subdural Hematoma with Dural Metastasis Secondary to Poorly Differentiated Adenocarcinoma of Unknown Origin.

Background: Metastatic subdural hematoma with dural metastasis in the setting of an underlying malignancy is a rare condition that is difficult to diagnose and associated with a poor prognosis. Knowledge of this rare entity is of a paramount importance to neurosurgeons, as its diagnosis may affect the management plan and overall survival. Here, we report a rare case of atraumatic subdural hematoma with dural metastasis in a patient with poorly differentiated adenocarcinoma of unknown origin.

Trapping and resection of cortical MCA mycotic aneurysm in eloquent area.

Background: Mycotic aneurysms, although well recognized, are relatively rare intracranial vascular pathology. These aneurysms are typically located in distal cortical vessels. When these aneurysms are located in eloquent cerebral territories, they may become challenging to treat.

Intraoperative Angiography for Arteriovenous Malformation Resection in the Prone and Lateral Positions, Using Upper Extremity Arterial Access.

Background: Intraoperative angiography is routinely utilized for aneurysms and arteriovenous malformations (AVMs) to verify complete occlusion and resection. Surgery for spinal and posterior fossa neurovascular lesions is usually performed in prone position. Intraoperative angiography in the prone position is challenging and there is no standardized protocol for this procedure.

Treatment of distal anterior cerebral artery aneurysms with the Pipeline Embolization Device.

Aneurysms of the anterior cerebral artery (ACA) located distal to the anterior communicating artery complex (ACOM) remain challenging to treat with surgical clip reconstruction as well as with endovascular coil-embolization strategies. We have treated five complex geometry distal ACA aneurysms with endoluminal reconstruction using the Pipeline Embolization Device (PED). Two aneurysms were of the dysplastic fusiform type.

Forearm Cephalic Vein Graft for Short, "Middle"-Flow, Internal Maxillary Artery to Middle Cerebral Artery Bypass.

Background: The cervical carotid system has been used as a source of donor vessels for radial artery or saphenous vein grafts in cerebral bypass. Recently, internal maxillary artery to middle cerebral artery bypass has been described as an alternative, with reduction of graft length potentially correlating with improved patency.

Objective: To describe our experience using the forearm cephalic vein grafts for short segment internal maxillary artery to middle cerebral artery bypasses.

Angiographic Evidence of a Purely Pial Bihemispheric Intracranial Hemangiopericytoma.

Background. Classification of hemangiopericytoma (HPC) has evolved to a mesenchymal, nonmeningothelial grade two or three neoplasm according to the World Health Organization; however its blood supply has always been defined by dual origin, pial and dural contribution. Case Description.

Analysis of superiorly projecting anterior communicating artery aneurysms: anatomy, techniques, and outcome. A proposed classification system.

Superiorly projecting (SP) anterior communicating artery (AComA) aneurysms are typically described as a homogenous group. Clinically and microsurgically, these aneurysms vary in multiple important characteristics. We propose a microsurgical classification system for these complex aneurysms and review its implications regarding presentation, microsurgical techniques, and outcome.

Ventriculoperitoneal Shunt Infection with Mycobacterium abscessus: A Rare Cause of Ventriculitis.

Background: Mycobacterium abscessus is a rapidly growing atypical mycobacterium implicated in chronic lung disease, otitis media, surgical site infections, and disseminated cutaneous diseases. It is typically seen in patients with some degree of immunosuppression. Only 1 previous case has been reported in the setting of ventriculoperitoneal (VP) shunt infection.

Awake Craniotomy in Arteriovenous Malformation Surgery: The Usefulness of Cortical and Subcortical Mapping of Language Function in Selected Patients.

Objective: Awake craniotomy for removal of intra-axial lesions is a well-established procedure. Few studies, however, have investigated the usefulness of this approach for resection of arteriovenous malformations adjacent to eloquent language areas. We demonstrate our experience by using cortical stimulation mapping and report for the first time on the usefulness of subcortical stimulation with interrogation of language function during resection of arteriovenous malformations (AVMs) located near language zones.

Concurrent use of the Pipeline Embolization Device and coils for intracranial aneurysms: technique, safety, and efficacy.

Object: The use of the Pipeline Embolization Device (PED) as a sole endovascular modality has been described for the treatment of brain aneurysms. The benefit of using coils concurrently with a limited number of PEDs is not well documented. The authors describe their experience with this technique as well as their midterm clinical and angiographic results.

The art of cerebral aneurysms-3 decades of postoperative drawings: review, classification, and efficacy for training.

Objective: To focus on postoperative drawings of aneurysms, which serve as visual records and teaching tools for neurosurgeons and reinforce three-dimensional vascular configurations that are specific for different cerebral aneurysms, and examine experience with this technique, particularly in regard to the training of neurosurgical residents.

Methods: After performing craniotomy for aneurysm treatment, formal postoperative drawings were created and reviewed. Microsurgical issues graphically highlighted included the totality of aneurysmal dome anatomy, position of visible and hidden branch vessels, rupture points, clipping techniques, and location of adjacent cranial nerves.

Anterior petroclinoid fold fenestration: an adjunct to clipping of postero-laterally projecting posterior communicating aneurysms.

Proximally located posterior communicating artery (PCoA) aneurysms, projecting postero-laterally in proximity to the tentorium, may pose a technical challenge for microsurgical clipping due to obscuration of the proximal aneurysmal neck by the anterior petroclinoid fold. We describe an efficacious technique utilizing fenestration of the anterior petroclinoid fold to facilitate visualization and clipping of PCoA aneurysms abutting this aspect of the tentorium. Of 86 cases of PCoA aneurysms treated between 2003 and 2013, the technique was used in nine (10.

Modifying flow in the ACA-ACoA complex: endovascular treatment option for wide-neck internal carotid artery bifurcation aneurysms.

Background: Treatment of selected wide-neck internal carotid artery (ICA) bifurcation aneurysms remains challenging for clip reconstruction and for endovascular options.

Objective: To describe a new endovascular treatment technique for wide-neck ICA bifurcation (ICAb) aneurysms.

Methods: We have employed a treatment approach that uses both complete proximal occlusion and reversal of flow in the ipsilateral A1 segment, using different endovascular modalities such as coils, stent-assisted coiling, or flow diverters (FDs) plus coiling concomitantly.

Internal maxillary artery-middle cerebral artery bypass: infratemporal approach for subcranial-intracranial (SC-IC) bypass.

Background: Internal maxillary artery (IMax)-middle cerebral artery (MCA) bypass has been recently described as an alternative to cervical extracranial-intracranial bypass. This technique uses a "keyhole" craniectomy in the temporal fossa that requires a technically challenging end-to-side anastomosis.

Objective: To describe a lateral subtemporal craniectomy of the middle cranial fossa floor to facilitate wide exposure of the IMax to facilitate bypass.

How I do it: occipital artery to posterior inferior cerebellar artery bypass.

Background: Aneurysms located at the proximal posterior inferior cerebellar artery (PICA) may need to be addressed by trapping and concomitant bypass. An anastomosis of the Occipital Artery (OA) to PICA is one bypass option in these cases. This bypass is highly challenging and its technical description is seldom cited in the literature.

Flow-based evaluation of cerebral revascularization using near-infrared indocyanine green videoangiography.

Object: Indocyanine green (ICG) videoangiography has been established as a noninvasive technique to gauge the patency of a bypass graft; however, intraoperative graft patency may not always correlate with graft flow. Altered flow through the bypass graft may directly cause delayed graft occlusion. Here, the authors report on 3 types of flow that were observed through cerebral revascularization procedures.

Iatrogenic dural arteriovenous fistula and aneurysmal subarachnoid hemorrhage.

The authors present the case of a patient who presented acutely with aneurysmal subarachnoid hemorrhage (SAH) and a contralateral iatrogenic dural arteriovenous fistula (DAVF). Diagnostic angiography was performed, revealing a right-sided middle cerebral artery (MCA) aneurysm and a left-sided DAVF immediately adjacent to the entry of the ventriculostomy and bur hole site. A craniotomy was performed for clipping of the ruptured MCA aneurysm, and the patient subsequently underwent endovascular obliteration of the DAVF 3 days later.

Orthogonal interlocking tandem clipping technique for the reconstruction of complex middle cerebral artery aneurysms.

Objective: Complex aneurysms arising at the middle cerebral artery (MCA) bifurcation frequently present a microsurgical challenge to effectively obliterate while maintaining patency of the distal MCA branches. These aneurysms are often multilobed, with their long axis aligned with the long axis of the M1 trunk, placing the dome of the aneurysm in the surgeons' line of sight, preventing an unobstructed view of the entire bifurcation and proximal M1 segment. MCA aneurysms often have a broad neck, splaying the bifurcation.

The Portrait of Gertrude Stein at 100.

ONE HUNDRED YEARS ago, the 24-year-old Pablo Picasso painted the masterpiece Portrait of Gertrude Stein. The portrait was a landmark and a turning point for both artist and model. The painting, completed in 1906 in Paris, marked a radical stylistic change for Picasso and was a transitional work signaling the beginnings of Cubism.

The pipes of pan.

The pipes of pan is the crowning achievement of Pablo Picasso's neoclassical period of the 1920s. This monumental canvas depicts a mythological Mediterranean scene in which two sculpted classical giants stare out, seemingly across the centuries, toward a distant and lost Arcadia. Picasso was influenced by Greco-Roman art during his travels in Italy, and his neoclassical works typically portray massive, immobile, and pensive figures.