The Current Procedural Terminology and the Medicare Resource Based Relative Value Scale in neurosurgical practice.

Changes in healthcare have made it increasingly more important for neurosurgeons to understand the economic pressures that effect their reimbursement. Two fundamental concepts that are of the greatest importance are the Current Procedural Terminology coding and the Medicare Resource Based Relative Value Scale. The impact of these two entities on neurosurgical reimbursement in analyzed in this review.

The winds of change.

Redirecting physician incentives, providing universal coverage, improving access to meaningful information, and providing innovation are the key components to solving this crisis. Those changes must focus on true competition and innovative ideas, which we must provide. In the past, the innovation in health care has come from physicians, and physicians must provide it in the future.

Extradural meningeal cyst. Case report and review of the literature.

Extradural meningeal cysts are rare spinal lesions. The clinical presentation is most often characterized by a slowly progressive spastic paraparesis, frequently associated with pain. Adequate drainage of the cyst with obliteration of the neck of the cyst or complete removal of the cyst can bring about a permanent resolution of the symptoms.

Middle cerebral artery perfusion pressure in cerebrovascular occlusive disease.

We measured the MCAP (middle cerebral artery pressure)/MSBP (mean systemic blood pressure) ratio in 76 patients who underwent an EIAB (extracranial-intracranial arterial bypass). Patients were divided into groups on the basis of angiographic findings. We found a definite correlation between increasing angiographic cerebral vascular occlusive disease and lower MCAP/MSBP ratios.

Ineffectiveness of DMSO in treating experimental brain ischemia.

A beneficial effect of dimethyl sulfoxide (DMSO) in the treatment of acute focal cerebral ischemia has not been proven. In the present study, two established experimental models of acute focal cerebral ischemia were treated with DMSO. Twenty adult cats lightly anesthetized with ketamine hydrochloride underwent right middle cerebral artery (MCA) occlusion for 6 hours.

Barbiturate coma in focal cerebral ischemia. Relationship of protection to timing of therapy.

The therapeutic application of barbiturate-induced coma was evaluated in a primate model of focal cerebral ischemia. A standardized regimen of pentobarbital was used, and the times of initiation of administration were varied following a 6-hour middle cerebral artery occlusion in baboons. Three groups of five animals were treated at 30, 120, and 240 minutes after occlusion, while one group of five animals received no barbiturate therapy.

Middle meningeal artery trauma.

We present the case of a patient who had the symptoms of a subarachnoid hemorrhage but was subsequently found to have an unusual combination of a separate traumatic pseudoaneurysm and a traumatic arteriovenous fistula of the middle meningeal artery. A review of the literature revealed a difference in the clinical course of patients with traumatic pseudoaneurysms compared to that of patients with arteriovenous fistulas. Patients who were found to have traumatic pseudoaneurysms of the middle meningeal artery frequently manifested signs of delayed hemorrhage.

Atypical trigeminal neuralgia in a 6-year-old boy. Case report.

This boy first contracted atypical trigeminal neuralgia at the age of 6 years. Four years later, he underwent a microvascular decompression of a venous loop from his trigeminal nerve. He remains asymptomatic 2 years after surgery.

Cerebral revascularization during barbiturate coma in primates and humans.

Extracranial-intracranial arterial bypass was performed in five baboons to assess the effectiveness of the procedure in preventing acute cerebral ischemia following middle cerebral artery occlusion in our primate model. Thirty minutes following middle cerebral artery occlusion, the animals were placed in barbiturate coma while the extracranial-intracranial artery bypass was being completed. In the three animals with patent extracranial-intracranial arterial bypasses, infarction was prevented.

Occipital artery to posterior inferior cerebellar artery bypass for vertebrobasilar ischemia.

Fourteen patients who underwent occipital to posterior inferior cerebellar arterial bypass are reviewed. All of the patients were treated for severe vertebrobasilar ischemia secondary to lesions of the distal vertebral artery. There was no operative death or permanent postoperative morbidity.

Improved neurologic function after cerebrovascular accident with extracranial-intracranial arterial bypass.

This study, by use of direct measurement, sought to investigate the role of diminished cerebral blood flow on neurologic function after cerebrovascular accident (CVA). Twenty-seven patients had mean middle cerebral artery pressure (MCAP) measured intraoperatively prior to a superficial temporal artery to middle cerebral artery bypass. The ratio of MCAP to mean systemic blood pressure (BP) was less than 0.

Clinical and pathological study of dysplastic gangliocytoma. Case report.

A case of dysplastic gangliocytoma of the cerebellum (Lhermitte-Duclos disease) is reported. Computerized tomography revealed a nonenhancing mass lesion surrounded by areas of calcification. Surgical excision resulted in complete resolution of the patient's symptoms.

Barbiturate resuscitation from focal cerebral ischemia--A review.

Barbiturate therapy has been shown to be of benefit in certain instances for focal cerebral ischemia. This therapy can, however, result in a deleterious outcome. Early institution in combination with revascularization appears to be important for successful barbiturate application.

Late complications of carotid ligation in the treatment of intracranial aneurysms.

The results in 57 consecutive patients treated with carotid ligation for an intracranial aneurysm were analyzed to define the risks of late complications. The average age for the group was 46 years. Eighty percent of the aneurysms were located on the internal carotid artery (ICA).

Intrachiasmatic arteriovenous malformation. Case report.

A patient presented with an abrupt monocular decrease in visual acuity and a bitemporal hemianopsia. At surgery, a totally intrachiasmatic arteriovenous malformation was removed, with subsequent resolution of the visual deficit.

Alternative superficial temporal artery to middle cerebral artery revascularization procedure.

The intact superficial temporal artery was sutured to the cortical arachnoid in a patient in whom no adequate cortical recipient vessel could be found. Subsequent arteriography demonstrated good revascularization of the middle cerebral distribution fed through the superficial temporal artery. The patient was relieved of this symptoms and remained neurologically intact postoperatively.

The "bonnet bypass". Case report.

A saphenous vein bypass graft from the contralateral superficial temporal artery to the ipsilateral middle cerebral artery was performed in a patient who required occlusion of his left common carotid artery. This procedure was used because of the unavailability of an ipsilateral donor artery. The bypass is working well 8 months postoperatively.

Subclavian to middle cerebral artery saphenous vein bypass graft.

A variation of an extracranial-intracranial arterial bypass is presented. The subclavian artery is used as the donor vessel and the saphenous vein as the graft; thus, a bypass to a cortical branch of the middle cerebral artery can be accomplished. The advantage of this modification is that the saphenous vein, when tunneled subcutaneously behind the ear, is positioned in a straight line from the donor to the recipient vessel.

Elective extracranial-intracranial arterial bypass in the treatment of inoperable giant aneurysms of the internal carotid artery.

Thirteen patients with giant aneurysms of the internal carotid artery (ICA) were treated with ICA ligation and an extracranial-intracranial arterial bypass. A method for establishing a proper superficial temporal artery to middle cerebral artery pressure gradient while maintaining partial flow through the ICA is presented. This procedure allows the anastomosis to become established before full occlusion of the cervical ICA.

The role of EC-IC in the treatment of giant intracranial aneurysms.

Extracranial to intracranial bypass surgery was used in 27 cases of intracranial giant aneurysm to prevent ischemic complications. In 19 of 21 patients the aneurysm was considered unfit for a direct clipping or ligation, and an EC-IC bypass was done in conjunction with staged clipping of the internal carotid artery or occlusion of the middle cerebral artery. All bypass grafts have remained patent postoperatively.

Vermian hematoma in a four-year-old child.

An unusual case of a vermian hematoma from the rupture of an angioma in a four-year-old child is presented. The lesion was treated successfully with complete recovery.