CNS Tumors: Surgical Anatomy, Neuropathology, Neuroradiology, Neurophysiology, Clinical Considerations, Operability, Treatment Options
E-Book, Englisch, 416 Seiten, ePub
ISBN: 978-3-13-258011-4
Verlag: Thieme
Format: EPUB
Kopierschutz: Wasserzeichen (»Systemvoraussetzungen)
Zielgruppe
Ärzte
Autoren/Hrsg.
Fachgebiete
Weitere Infos & Material
1 Anatomy
2 Neuropathology
3 Neuroradiology
4 Neurophysiology
5 Clinical Considerations – Operability
Preface The purpose of Volumes IV A and B is to discuss the reliability of the present basic neuroscientific investigations and to present clinical observations, management strategies, microsurgical approaches, and operative results in over 3400 patients with CNS tumors. The decision-making process in the treatment of CNS tumors involves the application of knowledge from several associated disciplines. Precision in determining the diagnosis, localization, treatment options, and prognosis of each lesion requires accurate neuroanatomical, neurophysiological, neuropathological, neuroinvestigational, and newoclinical knowledge. Those involved in the care of CNS tumor patients must be familiar with the important role each of these fields plays in the final determination of a treatment strategy. In addition, we must be aware of the remarkable recent advances being made in these areas. Neuropathologists, using immunocytochemistry and allied techniques, have been able to offer us an increasingly precise classification of tumors. However, the understanding of fundamental tumor biology is still elusive. In addition, they have not yet provided an accurate method of anticipating the growth and growth pattern, spread, migration, or penetration of an individual tumor, the factors which are most helpful in the determination of tumor operability and intensity of treatment. Clinical observations, on the other hand, indicate that the invasive potentials of benign and malignant extrinsic and intrinsic tumors are limited by anatomical and biological barriers, at least in the initial and intermediate phases of tumor growth. This important fact indicates great changes concerning the therapeutic options (see Chapter 2, Neuropathology). During the initial period of microsurgery in Zurich (between 1967 and 1975), the diagnosis and the indications for surgery of CNS tumors were based in the classic manner on the complete history, physical examination, and adjuvant studies, including EEG, pneumoencephalography, angiography, and myelography. Within the past 17 years, significant diagnostic advances have been achieved: the visualization techniques of CT scan, functional and dynamic MRI, MR spectroscopy, and other techniques (PET, SPECT, Doppler) have proved to be great innovations in the immediate recognition of CNS tumors and peritumoral changes in both the pre- and postoperative phases. These modalities, combined with microtechniques, have greatly improved the surgical treatment of CNS tumors. Along with these advances, however, there are new problems in diagnosis, indications for treatment, and decisions on the treatment options of these lesions, which are presented and discussed in Neuroradiology (Chapter 3) and Operability (Chapter 5). The century-old neurophysiological concepts concerning the balance of intracranial and intraspinal volumes (parenchymal mass, blood, cerebrospinal fluid, and tumor) were based only on mechanical forces. Clinical observations, however, combined with modern neuroimaging techniques, demand a more complex concept. This new dynamic concept should not only account for mechanical factors but must allude to the complex biochemical, biological, and immunological interactions between normal tissue and pathological tissue. An understanding of this dynamic normal tissue-lesion imbalance may then explain the changes seen in pathological situations and their resultant consequences (see Chapter 4, Neurophysiology). Surgical anatomy is another essential issue; it is not only the summary of available knowledge gained from macroscopical, microscopical, and ultramicroscopical investigations of the anatomist or from observations and studies of the neuroradiologist, neurophysiologist, and neurosurgeon. Although three-dimensional morphological and functional anatomical models of the brain are very instructive, they remain segregated models of reality. The individual variations of “morphology-pathomorphology” and “physiology-pathophysiology” are other dimensions, which provoke and challenge the surgeon to continuous imagination and projection of adequate dynamic concepts. Additionally, the reality of a surgical exploration involves a gross amount of still undiscovered, therefore unknown, morphological and functional facts. It would be ideal to have the assistance of the clinical neuroanatomist, neurophysiologist, and computer engineer during the whole perioperative phase. Personally, I am convinced that this will be the case in the near future in the modern, computerized operating room, where the combined morphological and functional anatomical 3-D dynamic models can be examined and checked according to the needs of the given situation with respect to the desires of the surgeon. The ongoing technical developments (i. e., frameless stereotactic localization system with the help of infrared LED devices) require from us accurate anatomical knowledge and new surgical anatomical concepts. The unique construction and functions of the brain require, topographically, a more differentiated concept according to the functional anatomy and sophisticated predilection site of the lesions; to provide the reader with an adequate and systematic picture of the complex brain anatomy, the gyral convolutions, the gyral segments, the sectorial and peduncular organization of the white matter, the topography of the basal ganglia and central nuclei, the pattern of arterial and venous vascularization, pathways of neuronal migration, and pathways of neurotransmitters, I have used not only my own material of sectional specimens and those of the Anatomical Institute of the University of Zurich, but also related, essential, well-known pictures of other authors. It is my intention to give interested colleagues my personal surgical anatomical concepts, which I need and use for my surgical decisions and actions. To facilitate the transformation of surgical anatomical images and their memorization, the figures have often been colored as in Chapter 1, Neuroanatomy. Our ability to continue to rely on the old paradigms of neuroanatomy, neuropathology, neuroradiology, and neurophysiology is questionable. Therefore, conceptually innovative ideas relating to individual surgical anatomy, neuroimaging, neuropathology, and neurophysiology are presented here. A new definition and approach to operability is examined, perhaps giving life to a new paradigm for the treatment of CNS tumors. Advances and limitations in neuroanatomy, neuropathology, neuroimaging, and neurophysiology and their relation to clinical neurosurgery, especially regarding the operability of CNS tumors and the treatment options, are presented and discussed in Chapter 5, Clinical Considerations. Noninvasive explorations and pure tumorectomies have been performed along the transcisternal, transsulcal, and transfissural pathways without lobectomy or gyrectomy, fully respecting the brain and other vital structures. These microsurgical techniques of “nontraumatization” of the brain or with “very minimal traumatization,” are documented in numerous cases with pre- and postoperative three-planar MR images, at the end of Chapters 2, 3, 4, and 5. I have been asked from visiting colleagues to write this volume and describe the applied microsurgical techniques with perioperative surgical-anatomical perspectives and concepts of the surgeon. Each surgical action comprises not only science, experience, knowledge, and techniques, but also artistic, philosophical, and religious attitudes from a neurosurgeon. We respect that eros is the cohesive power which holds the multimodal potentials of the human brain together with its continuous stimulation and drives. The artistic masters of the Renaissance discovered the perspective of three-dimensionality and immediately began to study the impact of functionality in exact measurement techniques. Up until the twentieth century, orientation depended on the topology of a pictorially ordered world of objects in which relationships are expressed by spatial metaphors. Cubism broke down these forms of perception, dismantling the identity of the figurative into non-identical aspects that could be projected upon each other. Constructive and concrete art entered into deeper dimensions, searching the elements of functionality. These trends culminated in mathematized art and philosophy, and computerized science and techniques. The masterpieces of constructive and concrete art deal scientifically with modern modular, serial and parallel processes, some relating to the philosophy of monads from G. W. Leibniz (1646–1716), whose genius had already developed an early computer. The neurophysiologist introduced the concept of a modular and columnar cortical organization of the brain (V. B. Mount-castle, 1957; D. Hubel, T. Wiesel, 1977): computational neurobiology has arrived. The convergence of science, technology, art, and philosophy is obvious. The displayed masterpieces of constructive and concrete art in this volume should be seen symbolically as a prelude to the related topics of the different chapters. It is hoped that the combination of pure art with the art of scientific illustration will enhance the interest of the reader. We should remember that the fortunate cooperation between H. Cushing and W. E. Dandy with the gifted illustrator Max Brödel at Johns Hopkins, Baltimore, opened new perspectives for scientific medicine at the beginning of 20th century. The presented experiences, observations, ideas, perspectives, and concepts are intended to stimulate open discussions, which will subsequently further advances throughout the entire field of neurosurgery. Volume IV B...
