[Guide to correct clinical practice in neurosurgery. World Federation of Societies of Neurosurgery. European Association of Societies of Neurosurgery].
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The field of human stereotactic neurosurgery has just passed the half-century mark. Soon after its inception, the pioneers in the field began to meet to exchange information and ideas, which led to an international forum for stereotactic surgery. In 1973, the organization was expanded to form both the World Society for Stereotactic and Functional Neurosurgery, as well as the European and American Societies for Stereotactic and Functional Neurosurgery. Reviewing the programs of the meetings of those Societies permits one to review the nature of the information that was exchanged through the years, and, in doing so, to monitor the pulse of the field as it has developed. The first independent meeting of the American Society for Stereotactic and Functional Neurosurgery took place in Houston in 1980, at which there were 27 papers, 40% of which were on the newly emerging field of image-guided neurosurgery and the rest on classical functional neurosurgery. The five meetings since, occurring at approximately 4-year intervals, have documented the progress in epilepsy surgery, the reemergence of stereotactic surgery for movement disorders, the growth of stereotactic radiosurgery, and the genesis of frameless stereotactic techniques which have now become widespread.
The avenues of development, successes and failures of modern neurosurgery taking into account the factors of its humanisation and dehumanisation are analysed. A new model of humanisation of neurosurgery to give it a human face for the future is outlined. Suggestions are made to prepare the neurosurgeons for 21st century. The main pre-condition for the humanisation of neurosurgery in the 21st century are that neurosurgeon must not only be Homo Sapiens, but also Homo Moralis.
The author, who is currently a member of the Editorial Board of the Journal of Neurosurgery, examines the development of the specialty of neurosurgery and the timing of first publication of the Journal. He describes the role played by the Journal in the constantly advancing specialty and its importance to neurosurgery as a whole.
The author describes the history of neurosurgery in Manitoba, with particular emphasis on events that occurred after his arrival there in 1950. Highlights of global neurosurgery are spliced into the author's reminiscences to anchor the local history with that of neurosurgery as a whole.
Stereotactic and functional operations represent, altogether, about 20% of all surgeries in a large number of Neurological Institutions, and this percentage is steadily increasing. To a large extent, stereotactic surgery has essentially merged with general neurosurgery. Therefore stereotactic techniques, at least to perform biopsies, should be available to any well-trained neurosurgeon. Functional neurosurgery is increasingly dependent upon clinical neurophysiology, not only for guidance of the procedure, but also for better selection of patients and objective assessment of results. Therefore, the concept of interventional neurophysiology must be recognized and acknowledged.
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The outcome after a specific treatment (clipping or coiling) of ruptured intracranial aneurysms is determined by both the periprocedural complication rate and the success of preventing re-bleeding from the treated aneurysm. The latter is associated with a cumulative risk over many years, particularly in incompletely treated aneurysms. Incomplete occlusion of the aneurysm is not infrequently seen after endovascular coiling, even in cases with a perfect anatomical configuration. Therefore, we believe that the 1-year outcome as reported in the ISAT is not an appropriate endpoint for the comparison of both methods. There has also been a tendency to apply the 1-year ISAT data to all patients harbouring intracranial aneurysms. It is inappropriate and dangerous to be less critical when selecting the endovascular approach as the method of choice for treating an aneurysm. This will ultimately result in a higher complication rate of coiling. Another striking finding is the poor surgical outcome in the ISAT. This good-grade patient population (94 % were WFNS grade 1-3 and 89 % were WFNS grade 1-2) had an almost 10 % higher rate of poor outcome compared to other good-grade patients in large prospective surgical studies or the same outcome as trials that included up to 20 % poor-grade patients.[nl]Neurosurgeons should acknowledge that endovascular coiling is a safe method associated with less complications than clipping in experienced hands (Fig. ). Endovascular radiologists should acknowledge that the success of complete obliteration is higher after surgery, that incompletely occluded aneurysms have a higher rate of re-rupture and that the definitive long-term re-rupture rate still remains unknown. Therefore, we await with interest the angiographic and clinical follow-up data that will provide evidence about the final patient outcome.
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