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List of Contributors XV


Depolarisation Phenomena in Traumatic and Ischaemic Brain Injury. A. J. Strong and R. Dardis, Section of Neurosurgery, Department of Clinical Neurosciences, King's College, London, UK

Abbreviation List 4

History, Definitions and Introduction 5

Cortical Spreading Depression 7

The "Onset" Phase of CSD 7

Initiation of CSD 7

The DC Potential Transient 8

Mass Neuronal Activity: Grafstein - 1956 8

Changes in Extracellular Ion Concentrations [K+]e, [Na+]e, [Cl ]e,

Changes in Membrane Potential and Conductance During CSD 10

Redistribution of Water: Tissue Impedance 10

Mode of Propagation of CSD 10

Propagation of CSD via Glial and/or Neuronal Gap Junctions 11

The Recovery Phase of CSD, and the Responses of Cerebral Metabolism and Blood Flow to CSD 12

Glucose Utilisation During Recovery from CSD 13

Haemodynamic Response 15

Histology of the Cortex Following CSD 15

Molecular Responses to CSD 15

CSD as an Initiator of Inflammation 16

Pre-Ischaemic Conditioning with CSD as Protection in Experimental

Stroke 16

Factors Determining Ease of Induction of CSD 17

Species Differences and Cytoarchitecture 17

Drugs and Anaesthetic Agents 18

Factors Precipitating Migraine with Aura 18

Genotype 18

Haemodynamic and Metabolic Conditions in the Cortex 18

Peri-Infarct Depolarisations (PIDS) 19

Historical 19

Detection with Electrodes, and Characteristics of PIDs in Experimental in Vivo Models 19

The Response of CBF to a Peri-Infarct Depolarisation 20

Detection and Tracking of PIDs with Imaging 20

Initiation of PIDs 23

Terminal Depolarisation 23

Evolution of PID Patterns with Time, Pathogenic Potential, and

Recruitment of Penumbra into Core Territory 24

Species Variations in PID Frequency 25

Effects of Drugs and Anaesthetic Agents on PID Frequency 25

Relationship of Cortical Glucose Availability with PID Frequency 25

The Metabolic "Signature" of PIDs 26

The Role of Depolarisations in Pathophysiology of CNS Disorders in

Humans 27

Migraine 29

Transient Global Amnesia 29

Trauma 30

Depolarisation and Concussion 30

Recurrent Depolarisations Following Experimental Traumatic Brain

Injury (TBI) 30

Direct Detection and Characterisation of Depolarisations in Humans, and Their Role in Human Traumatic Brain Injury 31

Cerebrovascular Disease 33

Occlusive Stroke 33

Intracerebral Haemorrhage 34

Subarachnoid Haemorrhage (SAH) 34

Non-Invasive Detection of Depolarisations in Ischaemic and Traumatic

Brain Injury 35

Characterisation of Depolarisation Events in the Injured Human Brain 35

The Biological Significance of CSD 37

Summary 38

Acknowledgements 39

Key Original Papers and Reviews 39

References 40

What is Magnetoencephalography and why it is Relevant to Neurosurgery? F. H.

Lopes da Silva, Section Neurobiology, Swammerdam Institute for Life Sciences, University of Amsterdam, Amsterdam, The Netherlands

Abstract 51

Introduction 52

Some Basic Notions: From Applied Physics to Biophysics 53

Clinical Applications of MEG in a Neurosurgical Setting 54

Magnetic Functional Source Imaging of the Sensorimotor Strip 55

Functional Localization of Somatosensory Cortex 55

Functional Localization of Motor Cortex 57

Comparison Between MEG and fMRI Regarding the Functional Localization of Somatomotor Cortex 57

MEG in Epilepsy: Identification of Epileptiform Inter-Ictal Foci 59

Functional Localization of Speech Relevant Brain Areas 61

Discussion and Future Developments 63

References 64

Basic and Clinical Aspects of Olfaction. B. N. Landis1,2, T. Hümmel2, and J.-S. Lacroix1, i Unité de Rhinologie-Olfactologie, Service d' Oto-Rhinologie-Laryngologie, Hopitaux Universitaires de Geneve, Geneve, Switzerland, 2 Smell and Taste Clinic, Department of Otolaryngology, University of Dresden Medical School, Dresden, Germany

Abstract 70

Anatomy 70

Main Olfactory System 70

Trigeminal System 71

Gustatory System 72

Vomeronasal System 73

Olfactory Coding 73

Measurement of Olfactory Function 75

Psychophysical Methods of Olfactory Testing 75

Electrophysiological/Imaging Techniques Used to Test Olfactory

Testing 77

Causes and Symptoms of Smell Disorders 79

Most Common Causes 80

Olfactory Loss Following Infections of the Upper Respiratory Tract

Posttraumatic Olfactory Loss 81

Sinunasal Causes 82

Neurodegenerative Causes 82

Idiopathic 83

Less Frequent Causes 83

Endocrine Diseases 83

Epilepsy 83

General Pathologies 84

Post-Surgery/Anesthesia 84

Drug-Induced/Toxic 84

Congenital 85

Symptoms 85

Quantitative Olfactory Disorders 85

Qualitative Olfactory Disorders 85

Surgical Risks to the Olfactory System 86

Endoscopic Sinus/Transnasal Surgery 86

Craniotomy 87

Recovery of Smell Disorders 88

Treatment of Olfactory Disorders 89

Surgical 89

Conservative/Medication 89

Acknowledgements 91

References 91

Cranial Venous Outflow Obstruction and Pseudotumor Cerebri Syndrome. B. K.

OwLER1,2, G. Parker3, G. M. Halmagyi1, I. H. Johnston1, M. Besser1,2, J. D. Pickard4, and J. N. Higgins5, 1T. Y. Nelson Departments of Neurosurgery and Neurology, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia, 2 Department of Surgery, University of Sydney, Sydney, Australia, 3 Department of Radiology, Royal Prince Alfred Hospital, Sydney, Australia, 4 Department of Neurosurgery, Academic Neurosurgical Unit, University of Cambridge, Addenbrookes Hospital, Cambridge, UK, 5 Department of Neuroradiology, Addenbrookes Hospital, Cambridge, UK,

Abstract 108

Introduction 109

Historical Perspective 109

Prevalence of Cranial Venous Outflow Obstruction in PTS 112

Interaction Between Venous Sinus Hypertension and CSF Pressure 114

Effects of Raised Venous Pressure in Adults and Children 115

Effects of Raised Venous Pressures in Infants 120

Effects of Raised CSF Pressure 124

Venous Sinus Obstruction in PTS: Cause or Effect? 128

Non-Obstructive Venous Hypertension 138

Cerebrospinal Fluid Dynamics in Pseudotumor Cerebri Syndrome 140

Investigation of Venous Aetiology in Pseudotumor Cerebri Syndrome________142

Treatment of Venous Sinus Obstruction 146

Direct Surgical Treatment 147

Endovascular Treatment 147

Venous Sinus Angioplasty 148

Venous Sinus Stenting 149

Technical Consideration 156

Related Disorders 157

Dural AV Fistulas 157

Other Headache Disorders 158

Conclusions 160

References 160

Technical Standards

Sacral Neuromodulation in Lower Urinary Tract Dysfunction. J. R. Vignes1, M. De Seze2, E. Dobremez3, P. A. Joseph2, and J. Guerin1, 1 Department of Neuro-

surgery, Medical School Hospital, Hopital Pellegrin, Bordeaux, France, 2 Neuro-rehabilitation Unit, Medical School Hospital, Hopital Pellegrin, Bordeaux, France, 3 Department of Pediatric Urology, Medical School Hospital, Hopital Pellegrin, Bordeaux, France

Abstract 179

Introduction 179

Anatomy and Physiology of the Lower Urinary Tract 180

Spinal Levels 180

Efferent Pathway 180

Afferent Pathway 182

Spinal Centers 182

Pontine Centers 183

Suprapontine Controls 183

Reflex Mechanisms Controlling Micturition 184

Storage Reflexes 184

Voiding Reflexes 184

Historical Evolution of Functional Therapy for Lower Urinary Tract

Dysfunction 185

Spinal Cord Stimulation 185

Intravesical Stimulation 185

Pelvic Nerve Stimulation 186

Stimulation of Pelvic Floor Muscles 186

Stimulation of Sacral Never Roots 186

Sacral Nerve Deafferentation 187

Sacral Neuromodulation 187

Methods and Techniques for Sacral Nerve Stimulation 188

Sacrum Anatomy 188

Posterior Sacrum 188

Sacral Foramen 189

Anterior Sacrum 189

Localization of Sacral Foramen 189

Anatomical Landmarks 189

Radiological Landmarks 191

Surgical Approach 191

Peripheral Nerve Evaluation 192

Implantation of Neurostimulator 194

Clinical Application of Sacral Neuromodulation 195

Indications 195

Evaluation 196

Pediatric Setting 197

The Overactive Bladder 198

Definition 198

Diagnosis of Overactive Bladder 199

Clinical Parameters 199

Urodynamic Parameters [60] 199

Classification of Overactive Bladder 199

Etiology 200

Results of Sacral Neuromodulation 201

Urge Incontinence 201

Chronic Urinary Retention 202

Pain 203

Long-Term Effectiveness 203

Impact on Quality of Life 204

Results for Neurogenic Bladder 204

Predictive Factors for Sacral Neuromodulation 204

Complications of Sacral Neuromodulation 205

Complications of Peripheral Nerve Evaluation 205

Complications of Sacral Nerve Neuromodulation 205

Pain 205

Infection 206

Problem of Nerve Injury 206

Technical Problems and Device-Related Complications 207

Surgical Revision 207

Conclusion 207

Therapeutic Alternatives and Developing Treatments in Overactive

Bladder 208

Medical Therapeutics 208

Surgical Alternatives 209

Perspectives in Electric Stimulation 210

Cost of Sacral Neuromodulation 211

General Issues in Urge Incontinence Costs 211

Expected Cost per Patient of Sacral Nerve Stimulator Implant

Treatment 211

Conclusion 213

Acknowledgements 213

References 213

Prevention and Treatment of Postoperative Pain with Particular Reference to Children. A. Chiaretti and A. Langer, Paediatric Intensive Care Unit, Catholic University Medical School, Rome, Italy

Abstract 226

Introduction 226

Acute Pain Assessment in Paediatric Age 229

Specific Aspects of Post-Operative Pain 234

Post-Operative Pain Management 237

By the Patient 239

By the Ladder 241

Step 1 242

Step 2 242

Step 3 242

Non-Opioid Analgesics 243

a. NSAIDs With Low Potency and Short Elimination Halflife 244

b. NSAIDs With High Potency and Short Elimination Halflife 245

c. NSAIDs With Intermediate Potency and Elimination Halflife 245

d. NSAIDs With High Potency and Long Elimination Halflife 245

Opioid Analgesics 246

Opioid Classification 248

'Weak' Versus 'Strong' Opioids 249

Factors in Opioid Selection 251

Pain Intensity 251

Co-Existing Disease 252

Selecting the Appropriate Route of Systemic Opioid Administration 253

Non-Invasive Routes 253

Invasive Routes 254

Scheduling of Opioid Administration 255

'Around the Clock' Dosing 255

'As Needed' Dosing 256

Patient-Controlled Analgesia 256

Management of Opioid Adverse Effects 259

Respiratory Depression 259

Nausea and Vomiting 260

Urinary Retention 261

Physical Dependence 261

Adjuvant Analgesics 262

Corticosteroids 262

Topical and Local Anaesthetics 263

Neuroleptics 265

Benzodiazepines 265

Conclusions 265

References 266

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