Category Archives: Operative Neurosurgery

Book: Anticoagulation and Hemostasis in Neurosurgery

Anticoagulation and Hemostasis in Neurosurgery

Anticoagulation and Hemostasis in Neurosurgery

Price: $199.00


This book is an up-to-date reference on all aspects of anticoagulation and hemostasis in neurosurgery.  After an opening section on basic principles and drug classes in current use, detailed consideration is given to coagulation issues relevant to all patients, not just neurosurgical ones. The coverage includes, for example, deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation. A variety of important issues specific to neurosurgical practice are then addressed, and a summary of current guidelines and best practices is provided. By bringing together the latest knowledge from across the discipline, this book will serve as a sound basis for informed decision making in surgical practice. It will be of daily value for neurosurgeons and trainees worldwide and will also be of interest to emergency room physicians, surgeons in general, critical care physicians, neurologists, and hospital medicine specialists.

Product Details

  • Published on: 2016-05-16
  • Original language: English
  • Binding: Hardcover
  • 376 pages

Editorial Reviews

From the Back Cover

As the population ages and prophylactic anticoagulation for different cardiac disorders is validated by cooperative trials, it is becoming ever more important that practicing neurosurgeons have the requisite knowledge to manage optimally the opposing processes of anticoagulation and hemostasis. Nevertheless, only a modest amount of structured information is at present available on the subject, with the consequence that decision making is too often insufficiently informed. This book, written by recognized experts, is designed to rectify this situation by bringing together the latest knowledge from across the entire discipline. It will be of daily value for neurosurgeons and trainees worldwide and will also be of interest to emergency room physicians, surgeons in general, critical care physicians, neurologists, and hospital medicine specialists.

About the Author
Christopher M. Loftus, MD, Dr.h.c., FACS, is Professor and Chairman, Department of Neurosurgery, and Professor of Neurology at Loyola University Stritch School of Medicine, Maywood, IL, USA. His previous appointments include Professor and Chairman, Department of Neurosurgery, Temple University School of Medicine, Philadelphia, PA; The Harry Wilkins Professor and Chairman and The Esther and Ted Greenberg Professor and Chairman, Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK; and Professor of Surgery (Neurosurgery), The University of Iowa College of Medicine, Iowa City, IA. Dr. Loftus is a Diplomate of the National Board of Medical Examiners and the American Board of Neurological Surgery. He has held many offices in leading professional bodies, including Vice Presidency of the American Association of Neurological Surgeons, and he is currently Treasurer of the World Federation of Neurosurgical Societies. His research interests include intracranial collateral circulation, extracranial carotid occlusive disease, and responses of cerebral blood flow to cerebral revascularization. He is participating in the IHAST cooperative trial for hypothermia in aneurysm surgery and the ISUIA – unruptured aneurysm trial. Dr. Loftus has been a member of the editorial boards of many prestigious journals and is the author of more than 200 articles and book chapters in peer-reviewed publications. He has edited or authored over twenty previous books, including, most recently, Intraoperative Neuromonitoring (McGraw-Hill, New York, 2013; co-editors Biller J and Baron EF).

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(To see the three-dimensional image you need anaglyph glasses)

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AC: anterior clinoid process; ICA: internal carotid artery; LT: lamina terminalis; ON: optic nerve; OlN; olfactory nerve; SW: sphenoid wing; TS: tuberculum sellae; A1: A1 segment of the Anterior Cerebral Artery; A2: A2 segment of the Anterior Cerebral Artery; M1: M1 segment of the Middle Cerebral Artery.

The anterior clinoid, which represents the terminal portion of the lesser wing of sphenoid bone, forms the anterior aspect of the lateral wall of the optic canal.

see Anterior clinoidectomy

The olfactory nerve (Latin: Nervus olfactorius), known as the first cranial nerve, or simply CN I, carries the sensory information for the sense of smell. Derived from the embryonic nasal placode, the olfactory nerve is capable of regeneration. The olfactory nerve is sensory in nature and originates on the olfactory mucosa in the anterosuperior nasal cavity.

From the olfactory mucosa, the nerve travels down the olfactory tract until it reaches the olfactory bulb, where the fascicles of the olfactory nerve pass through foramina on the cribriform plate, which resides on the roof of the nasal cavity. These fascicles are not visible on a cadaver brain because they are severed upon removal.

Sacrifice of the olfactory nerves is often required during a transbasal approach or subfrontal approach.

In the sphenoid bone, behind the chiasmatic groove is an elevation, the tuberculum sellae (or the tubercle of sella turcica). A variable slight to prominent median elevation forming the posterior boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.

A challenging area in skull base surgery is microsurgery of the tuberculum sellae and sphene-orbital lesions.

see Tuberculum sellae meningioma

Book: Atlas of Neurosurgical Techniques: Brain

Atlas of Neurosurgical Techniques: Brain

Atlas of Neurosurgical Techniques: Brain

List Price: $449.99

This thoroughly revised and expanded atlas is the ideal reference for residents, fellows, and clinicians to review surgical procedures before entering the OR. The authors provide step-by-step descriptions of techniques, clearly delineating indications and contraindications, goals, operative preparation and anesthesia, and postoperative management.  The main focus of this book is on teaching neurosurgical techniques at the most detailed level.

Features of the second edition:

  • A new chapter on proton therapy
  • An expanded section covering the latest radiosurgery techniques
  • Nearly 3,000 high-quality images aid rapid comprehension of surgical procedures
  • Online access to more than 100 surgical technique videos

This book should be read cover to cover by young practitioners several times during their residency and it will keep more experienced neurosurgeons up-to-date on the latest surgical techniques in the field.

Product Details

  • Original language: English
  • Number of items: 1
  • Dimensions: .0″ h x .0″ w x .0″ l, .0 pounds
  • Binding: Hardcover
  • 1566 pages

The December 2015 Issue of Operative Neurosurgery is Now Online!

The December 2015 issue of Operative Neurosurgery is now online and full-text access is available for print subscribers. Non-subscribers may access all article abstracts and the full-text of selected articles.

December 2015 Table of Contents:

Operative Technique

Endoscopic and Gravity-Assisted Resection of Medial Temporo-occipital Lesions Through a Supracerebellar Transtentorial Approach: Technical Notes With Case Illustrations
Villanueva, Pablo; Louis, Robert G.; Cutler, Aaron R.; Wei, Hua; Sale, Danjuma; Duong, Huy T.; Barkhoudarian, Garni; Kelly, Daniel F.

Simultaneous Image-Guided Skull Bone Tumor Resection and Reconstruction With a Preconstructed Prosthesis Based on an OsiriX Virtual Resection
Bruneau, Michaël; Kamouni, Rachid; Schoovaerts, Frédéric; Pouleau, Henri-Benjamin; De Witte, Olivier

Thoracoscopic-Assisted Ventriculo-Azygous Shunt Placement for the Treatment of Hydrocephalus
Pace, Jonathan; Smith, Gabriel A.; Pannunzio, Andrea; Rothstein, Brian D.; Markowitz, Alan; Hoffer, Alan

Operative Nuances

The Subtemporal Approach to Retroinfundibular Craniopharyngiomas: A New Look at an Old Approach
Wong, Ricky H.; De Los Reyes, Kenneth; Alikhani, Puya; Sivakanthan, Sananthan; van Gompel, Jamie; van Loveren, Harry; Agazzi, Siviero

Technique Assessment

Video-Assisted Navigation for Adjustment of Image-Guidance Accuracy to Slight Brain Shift
Kantelhardt, Sven R.; Gutenberg, Angelika; Neulen, Axel; Keric, Naureen; Renovanz, Mirjam; Giese, Alf

The Use of an Aspirating/Resecting Device to Reduce Stoma Closure Following Endoscopic Third Ventriculostomy for Aqueductal Stenosis
Goodwin, C. Rory; Sankey, Eric W.; Jusué-Torres, Ignacio; Elder, Benjamin D.; Kosztowski, Thomas A.; Liu, Ann; Hoffberger, Jamie; Lu, Jennifer; Blitz, Ari M.; Rigamonti, Daniele

Microsurgical Pontine Descending Tractotomy in Cases of Intractable Trigeminal Neuralgia
Ibrahim, Tarik F.; Garst, Jonathan R.; Burkett, Daniel J.; Toia, Giuseppe V.; Braca, John A. III; Hill, Jacquelyn P.; Anderson, Douglas E.

Percutaneous Minimally Invasive (MIS) Guide Wire-less Self-Tapping Pedicle Screw Placement in the Thoracic and Lumbar Spine: Safety and Initial Clinical Experience: Technical…
Beckman, Joshua M.; Murray, Gisela; Bach, Konrad; Deukmedjian, Armen; Uribe, Juan S.

Prospective Evaluation of a Low-Dose Radiation Fluoroscopy Protocol for Minimally Invasive Transforaminal Lumbar Interbody Fusion
Tumialán, Luis M.; Clark, Justin C.; Snyder, Laura A.; Jasmer, Gary; Marciano, Frederick F.

Use of a Dermal Regeneration Template in Complicated Craniotomy Wounds: Review of a Series
LoGiudice, John A.; Thayer, Jacob; Hoyt, Alistair T.; Mueller, Wade M.

Accuracy of Laser Placement With Frameless Stereotaxy in Magnetic Resonance-Guided Laser-Induced Thermal Therapy
Attaar, Sakina J.; Patel, Nitesh V.; Hargreaves, Eric; Keller, Irwin A.; Danish, Shabbar F.

Surgical Anatomy and Technique

Dual Origin of Extradural Posterior Inferior Cerebellar Artery From Vertebral and Occipital Arteries: Anatomic Case Report
Tayebi Meybodi, Ali; Lawton, Michael T.; Benet, Arnau


Alternative Detachment Technique for Electrically Detachable Coils: Rescue From an Unintended Complication
Kim, Young Soo; Lee, Sang Won; Yeom, Jeong A.; Yoon, Chang Hyo; Baik, Seung Kug

3-D Video

Aneurysm Transection and Intra-aneurysmal Clipping of a Giant Ophthalmic Artery Aneurysm: 3-Dimensional Operative Video
Benet, Arnau; Lawton, Michael T.

Microsurgical Treatment of Thalamic Cavernous Malformation: 3-Dimensional Operative Video
Yilmaz, Tevfik; Cikla, Ulas; Baskaya, Mustafa K.

Awake Craniotomy and Intraoperative MRI for Maximal Safe Resection in a Case of an Extensive Left Frontal and Insular Low-grade Glioma: 3-Dimensional Operative Video
Abolfotoh, Mohammad; Horowitz, Peleg M.; Chiocca, E. Antonio

Technical Case Report

An Unusual Case of an Ethmoidal Arteriovenous Fistula Draining Into the Superior Ophthalmic Vein: Technical Case Report
Daou, Badih; Chalouhi, Nohra; Williams, Kim; Polifka, Adam; Jabbour, Pascal; Rosenwasser, Robert H.; Tjoumakaris, Stavropoula I.

Single-Staged Multilevel Spondylectomy for En Bloc Resection of an Epithelioid Sarcoma With Intradural Extension in the Cervical Spine: Technical Case Report
Bydon, Mohamad; De la Garza-Ramos, Rafael; Suk, Ian; McCarthy, Edward; Yamada, Yoshiya; Wolinsky, Jean-Paul; Gokaslan, Ziya L.

Update: Delayed postoperative spinal epidural hematoma

Delayed postoperative spinal epidural hematoma

J. Sales-Llopis

Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

Uribe et al. defined delayed postoperative spinal epidural hematoma as an occurrence more than three days after operation 1).

Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves 2).


Awad et al. 3) divided potential risk factors into two categories, preoperative and intraoperative factors. Significant preoperative risk factors included nonsteroidal antiinflammatory drug use and patient age more than 60 years; significant intraoperative risk factors included multiple-level operation, anemia, and large blood loss. Sokolowski et al. 4) reported that age greater than 60 years, multilevel procedures, and preoperative international normalized ratio (INR) correlated with postoperative hematoma volumes.

Parthibian and Majeed described a case which developed following an episode of violent twisting movement 5).

Clinical features

Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 6).

Only one rare case of delayed onset of epidural hematoma after lumbar spine surgery whose only presenting symptom was vesicorectal disturbance is reported by Kamoda et al. 7).


Surgical evacuation if symptomatic.

The administration of prothrombin complex concentrate (PCC) facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation 8).

Case series


Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 9).


Uribe et al. report a series of delayed epidural hematomas in a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after their index procedure.

They reviewed the database of six spine surgeons over a 4-year period, looking for presence of epidural hematomas as a cause of clinical deterioration after an asymptomatic postoperative period of at least 3 days, and identified a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after spinal surgery.

Of 4,018 patients, they identified seven with spinal epidural hematoma who presented more than 3 days after their index procedure. The initial presenting symptom, which heralded the subsequent onset of neurological deterioration, consisted of severe sharp pain with radiation to the extremities. The average time to neurological deterioration was 5.3 days. Fifty-seven percent of the patients had multiple previous spinal surgeries at the site of the epidural hematoma. Surgical evacuation of the epidural hematomas resulted in neurological improvement in five patients. Persistent neurological deficits were observed in two patients.

Delayed spinal epidural hematomas are an uncommon cause of delayed deterioration after spinal surgery. Previous surgery with attendant scarring that results in impairment of clot resorption may be a contributing factor in the development of the condition 10).

Case reports


A 64-year-old woman underwent an uneventful total knee arthroplasty operation under a spinal anesthetic. A lumbar puncture was performed in the L2-L3 interspace, that was atraumatic and successful on the first attempt. The operation was uneventful. On the third postoperative day, the patient developed a SEH that expanded from C2 to T3 levels. She was presented with bilateral shoulder pain, muscle weakness of the upper extremities with normal sensation, followed by paraparesis. The magnetic resonance imaging (MRI) revealed a large vascular malformation, partially ruptured forming a hematoma compressing the spinal cord toward the vertebral bodies The patient was treated conservatively and full recovery was achieved 11).

An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered 12).


A rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered 13).


Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesia 14).


A patient 9 days after he underwent laminoplasty. The authors draw attention to the possibility of delayed PSEH and its triggering mechanism. In this case, a 59-year-old man with no history of bleeding disorder underwent cervical laminoplasty for mild myelopathy. On the 7th postoperative day computed tomography demonstrated no abnormal findings in the operative field. On the 9th postoperative day, while straining to defecate, the patient suddenly felt neck and shoulder pain, and tetraplegia rapidly developed. Magnetic resonance imaging demonstrated a huge epidural hematoma. The clot was evacuated during emergency revision surgery, during which the arterial bleeding from a split muscle wall was confirmed. The postoperative course after the revision surgery was uneventful and the patient had none of the previous symptoms 1 year later. A PSEH causing paralysis can occur even more than a week after surgery. The possibility of a delayed-onset PSEH should be kept in mind, and prompt diagnosis should be made when a patient presents with paresis or paralysis after an operation. The authors recommend advising patients that for a while after surgery they avoid strenuous activity 15)


Treatment of thromboembolic disease in the postoperative lumbar spine patient is controversial. This case report describes an epidural hematoma with neurologic sequelae in an elderly patient who received intravenous heparin therapy over 2 weeks after lumbar decompression 16)

1) , 10) Uribe J, Moza K, Jimenez O, Green B, Levi AD. Delayed postoperative spinal epidural hematomas. Spine J. 2003 Mar-Apr;3(2):125-9. PubMed PMID: 14589226.
2) , 7) , 13) Kamoda H, Ishikawa T, Miyagi M, Eguchi Y, Orita S, Suzuki M, Sakuma Y, Oikawa Y, Yamauchi K, Inoue G, Takahashi K, Ohtori S. Delayed postoperative epidural hematoma presenting only with vesicorectal disturbance. Case Rep Orthop. 2013;2013:861961. doi: 10.1155/2013/861961. Epub 2013 Sep 1. PubMed PMID: 24073350; PubMed Central PMCID: PMC3773434.
3) Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. Journal of Bone and Joint Surgery B. 2005;87(9):1248–1252.
4) Sokolowski MJ, Garvey TA, Perl J, et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine. 2008;33(1):108–113.
5) Parthiban CJ, Majeed SA. Delayed spinal extradural hematoma following thoracic spine surgery and resulting in paraplegia: a case report. Journal of Medical Case Reports. 2008;2, article 141
6) , 9) Sokolowski MJ, Dolan M, Aminian A, Haak MH, Schafer MF. Delayed epidural hematoma after spinal surgery: a report of 4 cases. Journal of Spinal Disorders and Techniques. 2006;19(8):603–606.
8) Beynon C, Potzy A, Unterberg AW, Sakowitz OW. Prothrombin complex concentrate facilitates emergency spinal surgery in anticoagulated patients. Acta Neurochir (Wien). 2014 Apr;156(4):741-7. doi: 10.1007/s00701-014-2032-x. Epub 2014 Feb 26. PubMed PMID: 24570188.
11) Makris A, Gkliatis E, Diakomi M, Karmaniolou I, Mela A. Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site. Spinal Cord. 2014 Jun;52 Suppl 1:S14-6. doi: 10.1038/sc.2013.174. Epub 2014 Jan 21. PubMed PMID: 24445973.
12) Kin H, Mukaida M, Koizumi J, Kamada T, Mitsunaga Y, Iwase T, Ikai A, Okabayashi H. Spontaneous spinal epidural hematoma presenting as paraplegia after cardiac surgery. Gen Thorac Cardiovasc Surg. 2014 Apr 11. [Epub ahead of print] PubMed PMID: 24722959.
14) Yao W, Wang X, Xu H, Luo A, Zhang C. Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesia. J Anesth. 2012 Dec;26(6):949-50. doi: 10.1007/s00540-012-1444-0. Epub 2012 Jul 13. PubMed PMID: 22790515.
15) Neo M, Sakamoto T, Fujibayashi S, Nakamura T. Delayed postoperative spinal epidural hematoma causing tetraplegia. Case report. J Neurosurg Spine. 2006 Sep;5(3):251-3. PubMed PMID: 16961087.
16) Spanier DE, Stambough JL. Delayed postoperative epidural hematoma formation after heparinization in lumbar spinal surgery. J Spinal Disord. 2000 Feb;13(1):46-9. PubMed PMID: 10710150.

Hospital Quirón Barcelona incorpora el primer escáner intraoperatorio O-arm® 2 en España

hospital quiroacuten

Disminuye un 50% la dosis de radiación utilizada y mejora la calidad de las imágenes aportadas. Al mismo tiempo, ofrece una cirugía menos invasiva y más precisa.

Hospital Quirón Barcelona, de la mano del Instituto Clavel, acaba de incorporar el primer escáner intraoperatorio de última generación O-arm® 2 y de navegación intraoperatoria  stealth station S7  en España. Este nuevo sistema, de la marca Medtronic, se utilizará para lasintervenciones de neurocirugía y columna vertebral del equipo dirigido por el doctor Pablo Clavel. Este pionero sistema permite navegar con datos de alta precisión, imágenes bidimensionales y tridimensionales durante las intervenciones en quirófano y en tiempo real, incrementando la seguridad del paciente, así como los rendimientos y eficiencia de la actividad quirúrgica.

Con el equipo de nueva generación O-arm® 2, primero de sus características que se instala en España y noveno en Europa, el equipo médico del Instituto Clavel gana en precisión en cada cirugía, mejora la eficacia mecánica de los implantes utilizados en el tratamiento de la patología vertebral, evita reintervenciones y pruebas radiológicas postoperatorias. Durante cada intervención, los cirujanos disponen de imágenes instantáneas multi-dimensionales e imágenes fluoroscópicas que les permiten ver la anatomía del paciente en la posición operativa, supervisar el estado de la cirugía  y verificar los cambios quirúrgicos con una imagen volumétrica 3D antes de que el paciente salga del quirófano. Con este sistema revolucionario, utilizado para pacientes de neurocirugía de Hospital Quirón Barcelona, los pacientes se benefician de una cirugía menos invasiva, una operación más corta, una recuperación más rápida y un mejor resultado final.

Este nuevo modelo de alta tecnología reduce a la mitad la dosis de radiación en la toma de las imágenes y permite adquirir un volumen tridimensional mucho mayor. El equipo instalado en Hospital Quirón Barcelona cuenta con un pórtico similar al de un TAC pero con apertura y cierre alrededor del paciente de modo que se mantiene estéril dentro del campo quirúrgico, siendo más seguro.

Con la incorporación de esta tecnología de última generación, el Instituto Clavel -fundado por el Dr. Pablo Clavel, neurocirujano especialista en cirugía de columna-  se consolida como centro de referencia en técnicas de neurocirugía no invasiva.

Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH)

The only randomised trial of ETV for iNPH compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH.

Tudor KI, Tudor M, McCleery J, Car J. Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH). Cochrane Database Syst Rev.
2015 Jul 29;7:CD010033. doi: 0.1002/14651858.CD010033.pub2. Review. PubMed PMID: 26222251.