In the previous volume, "Differential Approaches in - if approach is hindered through such variants, or - if the lesion itself has a close relationship to impor- Microsurgery of the Brain", the particularly prob lematical operations in the depth of the brain around tant vessels, for example, if arteries penetrate or the brainstem were covered. Even more than in other are just adjacent to a meningioma. operations on the brain, it was important here to decide before the operation which from several pos On the basis of this method, it was obvious to first sible approaches would be chosen. Therefore in this present the description of the veins and then to con present volume, it was obvious to try to describe sider the arteries and not to choose the direction of microsurgical operations of the brain primarily under the blood flow in the image analysis, as is usually the aspect of preoperative planning. This is done by done. Only then can one judge which problems might presenting the usual daily preliminary discussions be encountered. Certainly only a part of the suspected which have taken place in the Freiburg Clinic for the problems will show up during the operation. How last ten years. On the day before surgery, these ever, in view of the great number of possible difficul discussions are always carried out according to the ties, one should also be prepared for rare complica same principle: tions.

Preface matic depiction of the NMR slices in three levels. The Supported by NMR it has become possible to carry out operations in socalled inoperable regions of basal book is completed with selected technical tricks in ganglia, brainstem and problematic areas of the cor problematic operation cases. tex as well as in the areas of limbic system. Special appreciation is due to Prof. Dr. B. Volk, Thus the planning of an operation has become widely Director of the Institute of Neuropathology of the extended. A widening of the knowledge of the ana University of Freiburg, for his advice and help. tomical fundamentals is therefore indispensable and For nearly all MRI-findings I have to thank the should be conveyed by means of this book. colleagues of the Institute of Radiology (Director: The last two volumes "Anatomical Dissections for Prof. Dr. W. Wenz), especially Dr. Dorothea Ott, Use in Neurosurgery Vol. 1 and 2" supply the mor Dr. T. Adam and Dr. B. Wimmer. I also have to phological base for this book. The book itself is a thank Dr. R. Fiirmaier (neuroradiologist in Freiburg) continuation of "Planning Strategies of Intracranial for several MRI- and CT-findings. Microsurgery" . Most of the CTs were made in the stereotactic depart Some very problematic operations were carried out ment (Director: Prof. Dr. F. Mundinger) of our cli by my co-worker, Priv.-Doz. Dr. Eggert, who is now nic. I want to thank in particular Dr. M. Mohadjer.

Preoperative Magnetic Resonance Imaging allows now a better analysis of the relationship between intracranial tumors and the surrounding brain tissue. Even very small deepseated tumors can be identified during the operation by intraoperative ultrasound. These technological advances have had a great influence on indications, planning strategies and microsurgical techniques. The author shows the functional anatomy of the brain with the eye and the mind of a microsurgeon and demonstrates well known topographical relationships under the aspect of an utmost gentle operative approach.

A rich source of information about human voluntary movement in health and disease can be found in this book. The most esteemed researchers in their respective fields bring you up-to-date articles. Their collected work combines fundamental research in the life sciences with clinical neuroscience in a unique overview. The interdisciplinary aspects of motor physiology uncover a wealth of information for researchers from neighboring disciplines. For example, oculomotor research, vestibular research, equilibrium, sensory research and cognition, evolution, synaptic and elementary processes and the neurological sciences can be discovered.

Preface Drawings and scripts were selected from those tion of the operative routes and their alternatives which were produced by the author in the last for well-defined anatomical target areas alone. This three years to help educate young neurosurgeons viewpoint becomes more and more important, be in Freiburg and in other clinics. cause today there is no anatomical structure of the This programm for education may be managed in 2 brain which cannot be approached with a minimal steps: risk for surviving the operation. But more and more - Learning techniques for performing of trepana the risk for neurologicalor psychological postopera tions from opening of the skin onto dura incision tive complications will rise if the anatomical and (step 1) neurophysiological knowledge is insufficient. These - Learning of techniques for routine operations viewpoints are most important in operations at the (e. g. , for extirpation of gliomas of cerebral lobes) cranial base and operations transcrossing midline (step 2) structures of the brain. An intensive anatomical - Learning of techniques for operative approach es training helps to understand MRI before opera in problematic areas of the cranial and cerebral tion. Often the modern MRI demonstrates more base and of the midline, especially for the often anatomical details than the unexperienced neurosur performed operations, e. g. for basal meningeo geon has understood.

This is the first of four volumes that together elaborate on an advanced minimally invasive neurosurgery (MIN) technique for cerebral hemorrhages, which makes it possible to prevent secondary injury by the hematoma and to preserve neurological function and accelerate neuropsychological recovery after the evacuation. It describes in detail the theoretical, technical and training procedures necessary to carry out successful intracerebral hemorrhage evacuations using MIN techniques. A combination of mouth-tracked microsurgery, neuro-sonography, neuro-endoscopy, LASER and sealing makes highly effective, minimally invasive evacuation of all types of hematomas possible. The MIN Key Concept, an advanced new model based on the Keyhole Concept and MIN techniques is also presented. Lastly, the scientific basics of MIN are discussed and summarized. A historical curriculum vitae is included in memory of the main pioneer of innovative MIN techniques, Prof. Axel Perneczky, to whom this book is dedicated.

Modern diagnostic imaging and operative approaches have witnessed significant improvements in our times. Computerassisted methods are in use in all microsurgical fields. Neuronavigation, novel stereotactic methods, endoscopic procedures, magnetic resonance imaging, ultrasound and the progress in pre- and intraoperative epilepsy diagnostics must be mentioned in particular in this connection. However, the insights of neuroanatomy and neurophysiology have not become obsolete thereby, on the contrary: such knowledge is imperative and a prerequisite for all neurosurgeons, nowadays more than ever before. Otherwise, excellent modern approaches are liable to fall into discredit if microanatomical aspects are neglected. The goal of this book is two-fold: first, to guide the resident towards a fruitful application of anatomical basics in visualizing and operative techniques. Second, to draw attention to as many anatomical norm variants as possible to forestall complications during surgery. Standard methods, such as the pterional approach, often confront the surgeon with a range of anatomical variants.

First multi-year cumulation covers six years: 1965-70.

Thisbookispublishedintwovolumes. Velum medullare posterior in the area of the 4th Inthisfirstvolume, anattemptismadetogiveyoung ventricle, including the choroidpoint ofthe PICA, neurosurgeons methodical instruction in the dissec canbestudiedexactly. Theseexampleswerechosen tion of formaldehyde-preserved brains. This book, becauseexacttopographicalknowledgeoftheseves however, isnotintendedtobetakenasatextbookon sel-richstructuresisofteninadequate;andwhenusing modernoperativetechniques, increasingly more op anatomy. Conventionalpresentationsoftheanatomy ofthebrainmustpresent, stepbystep, theindividual erationsareperformedinjusttheseparticularareas. systemsoftheorganaccordingto itsdevelopmental These dissections compose the content of the first and functional aspects, e. g. cortex, limbic system, volume. basal ganglia, brainstem, and cerebellum. Because The second volume is intended for experienced duringasingleoperationtheneurosurgeon issome neurosurgeonswhoperformcomplexoperationsdeep times confronted with all the various systems, it is insidethebrain. Someoftheseoperations have be necessarytoperformbraindissectionsfromtheview come standardized, e. g. theopeningofthesylvian point of operative approaches. Therefore, in this fissure withoperations intheareaofthe Insulaand worktheattemptismadetokeepcertainindividual cranial base. Other complex operations are per surfacestructures, e. g. theGyruspraecentralisintact formed seldom eventoday, e. g. approaches to the until the end of the dissection so that the relative 3rdventricle, Velum interpositum, lateralventricle, topographicalpositionsofsurfaceanddeepstructures Cisterna tecti, Lobulus quadrangularis cerebelli, to can be made discernable. For these reasons, it is namejustafew. Beforesuchoperations, itis advis advisabletoviewthesurfacestructuresofthebrainin able(theauthorstilldoessooccasionally)toorientate relationship to the skull, but then to start with re oneself on a formaldehyde-preserved brain. It is movingthebloodvesselsandleptomeningessothatin shownhowonaformaldehyde-preservedbrain, even this waythe skeletonizedorgan is dissected step by thoughitdoesnotprovidetherealconditionsofalive step, because in the preserved vascular system, the brainunderthe operative microscope, the most im structures are only partially recognizable and thus portant topographical relationships can be recog confusing. Forthisdissectiontwoorgansareneeded. nized. Inthe first dissection, thecerebrum andcerebellum Bothvolumesaretheresultofaone-yeardissection are studied. These the young neurosurgeon should course for colleagues meeting twice a week in our havebecomefamiliarduringhisinitialtraininginthe clinic.