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2015v1.0
100 Case Reviews
in Neurosurgery
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100 Case Reviews
in Neurosurgery
RAHUL JANDIAL, MD, PhD
Associate Professor
Division of Neurosurgery, Department of Surgery
City of Hope Cancer Center & Beckman Research Institure
Los Angeles, CA, USA
MICHELE R. AIZENBERG, MD
Associate Professor of Neurological Surgery and Oncology,
Director, Brain and Spine Cancer Center
University of Nebraska Medical Center
Omaha, NE, USA
MIKE Y. CHEN, MD, PhD

Associate Professor
Division of Neurosurgery, Department of Surgery
City of Hope Cancer Center & Beckman Research Institure
SECTION EDITORS
Henry E. Aryan, MD
Ramsis Benjamin, MD
Justin Brown, MD
Joseph D. Ciacci, MD
Griffith R. Harsh IV, MD
Adam S. Kanter, MD
Aasim S. Kazmi, MD
Alexander A. Khalessi, MD
Paul S. Larson, MD
Michael L. Levy, MD, PhD
Neal Prakash, MD, PhD
J. Dawn Waters, MD
For additional online content visit http://expertconsult.inkling.com
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2017
© 2017, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
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broaden our understanding, changes in research methods, professional practices, or medical treatment
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Practitioners and researchers must always rely on their own experience and knowledge in evaluating
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and contraindications. It is the responsibility of practitioners, relying on their own experience and
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individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
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contained in the material herein.
ISBN: 978-0-323-35637-4
Content Strategist: Charlotta Kryhl

Content Development Specialist: Alexandra Mortimer
Content Coordinator: Devika Ponnambalam
Project Manager: Louisa Talbott
Design: Christian Bilbow
Illustration Manager: Amy Naylor
Marketing Manager: Rachael Pignotti
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contents
Preface xii
List of Contributors xiii
Acknowledgments xxii
Dedication xxiii
SECTION I
Vascular Neurosurgery
Section Editor: Alexander A. Khalessi, MD
1 Cerebral Arteriovenous Malformation 1

Jason W. Signorelli • J. Scott Pannell, MD •
2 Cavernous Malformation 9
Jeffrey A. Steinberg, MD • J. Scott Pannell, MD •
3 Ruptured Middle Cerebral Artery Aneurysm 15

Vincent J. Cheung, MD • Jayson A. Sack, MD •
J. Scott Pannell, MD • Alexander A. Khalessi, MD
4 Unruptured Anterior Communicating Artery Aneurysm 21

Vincent J. Cheung, MD • Jayson A. Sack, MD •
5 Intradural Internal Carotid Artery Fusiform Aneurysm 25

Gunjan Goel, MD • J. Scott Pannell, MD •
6 Spinal Arteriovenous Malformations 31

7 Cranial Dural Arteriovenous Fistula 37

Reid Hoside, MD • J. Scott Pannell, MD •
8 Spinal Dural Arteriovenous Fistulas 43

David R. Santiago-Dieppa, MD • J. Scott Pannell, MD •
Scott E. Olson, MD • Alexander A. Khalessi, MD
9 Vertebral Artery Dissection 47

Robert C. Rennert, MD • Jayson A. Sack, MD •
10 Basilar Tip Aneurysm 53

Robert C. Rennert, MD • Jayson A. Sack, MD •
11 Endovascular Treatment of Unruptured Aneurysms 61

v
vi Contents
12 Dominant Hemisphere Hemorrhagic Stroke 69

J. Scott Pannell, MD • Robert C. Rennert, MD •
13 Hypertensive Thalamic Hemorrhage 73

Jason W. Signorelli • J. Scott Pannell, MD •
14 Cerebellar Hemorrhage 81
Reid Hoside, MD • J. Scott Pannell, MD •
15 Moyamoya Disease 85
Brandon C. Gabel, MD • J. Scott Pannell, MD •
16 Venous Sinus Thrombosis 89

Brandon C. Gabel, MD • J. Scott Pannell, MD •
17 Carotid Stenosis 93
Jeffrey A. Steinberg, MD • J. Scott Pannell, MD •
18 Ischemic Stroke Management 101

Joel R. Martin, MD • J. Scott Pannell, MD •
SECTION II
Nontraumatic Cranial Lesions
Section Editor: Griffith R. Harsh IV, MD • J. Dawn Waters, MD
19 Vestibular Schwannoma 109

Robert M. Lober, MD, PhD • Abdulrazag Ajlan, MD
20 Sphenoid Wing Meningioma 115

Omar Choudhri, MD
21 Cerebellar Cystic Hemangioblastoma 121

J. Dawn Waters, MD • Griffith R. Harsh IV, MD
22 Pituitary Apoplexy 127

James Wright, MD • Christina Huang Wright, MD
23 Cushing’s Microadenoma 131

J. Dawn Waters, MD
24 Pituitary Macroadenoma – Prolactinoma 137

Melanie G. Hayden Gephart, MD • YouRong Sophie Su
25 Craniopharyngioma 141
Matthew G. MacDougall, MD • David D. Gonda, MD •
26 Glioblastoma 147
Kevin K.H. Chow, MD, PhD
27 Anaplastic Oligodendroglioma 151

Christine K. Lee, MD, PhD •
Melanie G. Hayden Gephart, MD
28 Low-Grade Glioma 155

Christina Huang Wright, MD • James Wright, MD
Contents vii
29 Radiation Necrosis versus Tumor Recurrence 159

Derek Yecies, MD • J. Dawn Waters, MD
30 CNS Lymphoma 163

Zachary Medress • Kai Miller, MD • Li Gordon, MD
31 Brain Metastases 167

Kevin K.H. Chow, MD, PhD
32 Intraventricular Colloid Cyst 171

Arjun V. Pendharkar, MD • Melanie G. Hayden Gephart, MD
33 Cerebral Abscess 175

Aatman Shah • Henry Jung, MD
34 Chiari I Malformation 179

Henry Jung, MD • Aatman Shah
35 Ependymoma 183
Zachary Medress • Melanie G. Hayden Gephart, MD
36 Normal Pressure Hydrocephalus 187

Robert C. Rennert, MD • Vincent J. Cheung, MD •
J. Dawn Waters, MD
37 Arachnoid Cyst 191

J. Dawn Waters, MD
SECTION III
Neurosurgical Trauma
Section Editor: Joseph D. Ciacci, MD
38 Penetrating Head Injuries 195

Vincent J. Cheung, MD • Brandon C. Gabel, MD •
39 Intractable Intracranial Hypertension 201

Vincent J. Cheung, MD • David R. Santiago-Dieppa, MD •
Brandon C. Gabel, MD • Joseph D. Ciacci, MD
40 Epidural Hematoma 205

Vincent J. Cheung, MD • Brandon C. Gabel, MD •
41 Chronic Subdural Hematoma 209

Erik I. Curtis, MD • Brandon C. Gabel, MD •
42 Subaxial Cervical Fracture 213

Erik I. Curtis, MD • Brandon C. Gabel, MD •
Nicholas Fain • Joseph D. Ciacci, MD
43 Odontoid Fractures 219

Brandon C. Gabel, MD • Erik I. Curtis, MD •
44 Hangman’s Fracture 225

Brandon C. Gabel, MD • Vincent J. Cheung, MD •
45 Thoracolumbar Burst Fractures 231

Brandon C. Gabel, MD • Erik I. Curtis, MD •
viii Contents
46 Chance Fractures 237

47 Jumped Cervical Facets 241

SECTION IV
Spinal Neurosurgery
Section Editor: Adam S. Kanter, MD
48 Atlanto-Axial Dislocation 247

Gurpreet S. Gandhoke, MD • Adam S. Kanter, MD
49 Basilar Invagination - Rheumatoid Pannus 253

Zachary J. Tempel, MD • Robert A. Miller, MD •
Adam S. Kanter, MD
50 Cervical Spondylotic Myelopathy 261

Christian B. Ricks, MD • Nathan T. Zwagerman, MD •
Adam S. Kanter, MD
51 Cauda Equina Syndrome 265

Gurpreet S. Gandhoke, MD • Adam S. Kanter, MD
52 Foot Drop and Far Lateral Disc Herniation 269

Christian B. Ricks, MD • Adam S. Kanter, MD
53 Thoracic Disc Herniation 273

Zachary J. Tempel, MD • Adam S. Kanter, MD
54 Spinal Epidural Abscess 279

Christian B. Ricks, MD • Adam S. Kanter, MD
55 Spinal Metastases 283

Todd Harshbarger, MD • Mike Y. Chen, MD, PhD
56 Spinal Intradural Extramedullary Mass 289

Hazem Mashaly, MD • Zachary J. Tempel, MD •
Adam S. Kanter, MD
57 Intradural Intramedullary Mass 293

Hazem Mashaly, MD • Zachary J. Tempel, MD • Adam S. Kanter MD
58 Cervical Ossified Posterior Longitudinal Ligament 299

Hazem Mashaly, MD • Adam S. Kanter, MD
59 Ankylosing Spondylitis 307

Michael M. McDowell, MD • Zachary J. Tempel, MD •
Adam S. Kanter
60 Chordoma 313
Michael M. McDowell, MD • Zachary J. Tempel, MD •
Adam S. Kanter, MD
SECTION V
Pediatric Neurosurgery
Section Editor: Michael L. Levy, MD, PhD
61 Pineal Tumor 319

Bond Nguyen • Melanie G. Hayden Gephart, MD •
Alexa Smith, MD • Michael L. Levy, MD, PhD
Contents ix
62 Myelomeningocele 327
Alexa Smith, MD • Bond Nguyen •
63 Cerebellar Medulloblastoma 331

Michael L. Levy, MD, PhD • John R. Crawford, MD, PhD •
Alexa Smith, MD
64 Brainstem Glioma 337

Alexa Smith, MD • Salman Abbasifard, MD
65 Hypothalamic Hamartoma 341

66 Endoscopic Third Ventriculostomy 345

Alexa Smith, MD • Salman Abbasifard, MD •
Ali H. A. Muhammad Altameemi, MD
67 Slit Ventricle Syndrome 353

David S. Hong, MD • Alexa Smith, MD
68 Neural Tube Defect-Tethered Cord Syndrome 357

Hal S. Meltzer, MD • Michael L. Levy, MD, PhD •
69 Craniosynostosis – Plagiocephaly 361

Hal S. Meltzer, MD • Michael L. Levy, MD, PhD •
Alexa Smith, MD • Dillon Levy • Salman Abbasifard, MD
70 Vein of Galen Malformations 367

Brandon C. Gabel MD • Jeffrey A. Steinberg, MD •
71 Pilocytic Astrocytoma 371

Alexa Smith, MD • Ali H. A. Muhammad Altameemi, MD
SECTION VI
Stereotactic and Functional Neurosurgery
Section Editor: Paul S. Larson, MD
72 Trigeminal Neuralgia 377

Andrew L. Ko, MD • Kim J. Burchiel, MD
73 Hemifacial Spasm 381

Thomas J. Gianaris, MD • Aaron Cohen-Gadol, MD •
Nicholas Barbaro, MD
74 Parkinson’s Disease 385

Doris D. Wang, MD, PhD • Philip A. Starr, MD, PhD
75 Progressive Spastic Paraparesis and Decreased Mobility in a Young

Patient 391
Tsinsue Chen, MD • Andrew Shetter, MD • Peter Nakaji, MD
76 Mesial Temporal Sclerosis 397

Nathan C. Rowland, MD, PhD • Edward F. Chang, MD
x Contents
77 Corpus Callosotomy 403

Thomas L. Beaumont, MD, PhD • Matthew D. Smyth, MD
78 Normal Pressure Hydrocephalus 411

Michael Bohl, MD • David S. Xu, MD • Peter Nakaji, MD
79 Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) 415

Benjamin D. Elder, MD, PhD • C. Rory Goodwin, MD, PhD •
Thomas A. Kosztowski, MD • Daniele Rigamonti, MD
80 Intractable Oncologic Pain 423

Nelson Moussazadeh, MD • Michael G. Kaplitt, MD, PhD
81 Spinal Cord Stimulation 429

Daniel M. Birk, MD • Konstantin V. Slavin, MD
SECTION VII
Peripheral Nerve Neurosurgery
Section Editor: Justin Brown, MD
82 Thoracic Outlet Syndrome 435

Justin Brown, MD • Mark A. Mahan, MD
83 Peroneal Neuropathy 439

Mark A. Mahan, MD • Justin Brown, MD
84 Nerve Sheath Tumor 443

85 Cubital Tunnel Syndrome 447

86 Carpal Tunnel Syndrome 453

87 Brachial Plexus Injury 459

88 Parsonage-Turner Syndrome 467

89 Radial Nerve Injury 471

Justin Brown, MD • Geehan D’Souza, MD •
Mark A. Mahan, MD
90 Ulnar Nerve Injury 477

91 Median Nerve Injury 481

Mark A. Mahan, MD • Justin Brown, MD
SECTION VIII
Neurology
Section Editors: Neal Prakash, MD, PhD • Ramsis Benjamin, MD
92 Multiple Sclerosis 489

Audrey Kohar, DO • Neal Prakash, MD, PhD
93 Amyotrophic Lateral Sclerosis 495

Ramsis Benjamin, MD
Contents xi
94 Guillain-Barré Syndrome 501

Ramsis Benjamin, MD
95 Devic’s Syndrome 507

Audrey Kohar, DO • Noriko Salamon, MD •
96 Human Immunodeficiency Virus 511

Ramsis Benjamin, MD
97 Status Epilepticus 517

98 Neurosarcoidosis 521
Ramsis Benjamin, MD
99 Transverse Myelitis 525

Audrey Kohar, DO • Neal Prakash, MD, PhD
100 Giant Cell Arteritis 529

Ramsis Benjamin, MD
Glossary 533
APPENDICES
Section Editors: Henry E. Aryan, MD • Aasim S. Kazmi, MD
Appendix A Neuropathology 541

Appendix B Neurology 549
Appendix C Neuroradiology 557
Appendix D Spinal Fracture Grading 563
Appendix E Peripheral Nerve Exam 571
Appendix F Neurocutaneous Disorders 573
Appendix G Positioning 575
Index 579
Preface
As the most challenging discipline, Neurosurgery rebuffs any single text’s attempt at reveal-
ing its intricacies and complexities. Accordingly, this text and its individual chapters aim
for a more humble goal. Together, they aspire to serve as a primer of essential material
often reviewed during certification examinations and a framework into which deeper
knowledge can be contextualized.
From the perspective of didactic utility, the standard, time-tested neurosurgical text-
books offer a distillation of the most useful art and schemata. Therefore, figures from these
familiar texts have been incorporated into this book, along with new art and imaging, in
the hope that the aggregate will constitute a robust visual fabric within 100 Case Reviews
in Neurosurgery.
The book is divided into intuitive sections. The information provided and the questions
posed follow the experience of a neurosurgeon being consulted in the hospital or seeing
a new patient in clinic that has come to them for care. The vascular section covers surgical
and nonsurgical elements that are key elements of essential vascular cases. The peripheral
nerve section is particularly detailed since this is a specialized field most general neuro-
surgeons have limited exposure to in daily practice. The appendices provide information
that is vital yet cumbersome to include in the flow of the chapters. The layout and pre-
sentation of information follows the formats of common grand rounds and examinations
most readers have experienced from the beginning of their neurosurgical training through
their current continuing education.
The most challenging part of constructing the book you now read has been to find that
elusive balance invaluable to the modern pedagogical text between comprehensiveness
and concision, between textual explanation and visual illustration, between esoteric speci-
ficity and simple intelligibility. My hope is that the content presented here has been
insightfully and incisively curated for your purposes.
Rahul Jandial
xii
List of Contributors
Salman Abbasifard, MD Nicholas Barbaro, MD

International Pediatric Neurosurgery Chairman
Fellow Department of Neurosurgery
Rady Children’s Hospital Indiana University School of Medicine
University of California – San Diego Indianapolis, IN, USA
San Diego, CA, USA Case 73: Hemifacial Spasm
Case 64: Brainstem Glioma
Case 65: Hypothalamic Hamartoma Thomas L. Beaumont, MD, PhD
Case 66: Endoscopic Third Senior Resident
Ventriculostomy Department of Neurological Surgery
Case 68: Neural Tube Defect–Tethered Washington University School of
Cord Syndrome Medicine
Case 69: Craniosynostosis St. Louis, MO, USA
– Plagiocephaly Case 77: Corpus Callosotomy
Michele R. Aizenberg, MD Ramsis Benjamin, MD

Associate Professor of Neurological City of Hope National Medical Center
Surgery and Oncology Duarte, CA, USA
Director, Brain and Spine Cancer Center Section Editor for Section 8
University of Nebraska Medical Center Neurology
Omaha, NE, USA Case 93: Amyotrophic Lateral
Sclerosis
Abdulrazag Ajlan, MD Case 94: Guillain-Barré Syndrome
Clinical Instructor Case 96: Human Immunodeficiency
Department of Neurosurgery Virus
Stanford Hospitals and Clinics Case 98: Neurosarcoidosis
Stanford, CA, USA Case 100: Giant Cell Arteritis
Case 19: Vestibular Schwannoma
Daniel M. Birk, MD
Ali H. A. Muhammad Altameemi, MD Resident
International Fellow of Neurosurgery Department of Neurosurgery
Rady Children’s Hospital San Diego University of Illinois at Chicago
Division of Pediatric Neurosurgery Chicago, IL, USA
University of California – San Diego Case 81: Spinal Cord Stimulation
San Diego, CA, USA
Case 66: Endoscopic Third Michael Bohl, MD
Ventriculostomy Resident Physician
Case 71: Pilocytic Astrocytoma Division of Neurological Surgery
Barrow Neurological Institute
Henry E. Aryan, MD St. Joseph’s Hospital and Medical Center
Clinical Professor of Neurosurgery, UC Phoenix, AZ, USA
San Francisco Case 78: Normal Pressure
Chief, Spine Center Hydrocephalus
Sierra Pacific Orthopedic & Spine Center
Fresno, CA, USA
Section Editor for Appendices
xiii
xiv List of Contributors
Justin Brown, MD Vincent J. Cheung, MD

Associate Professor Neurosurgical Resident
Department of Neurosurgery Division of Neurosurgery
University of California University of California – San Diego
San Diego School of Medicine San Diego, CA, USA
San Diego, CA, USA Case 3: Ruptured Middle Cerebral
Section Editor for Section 7 Artery Aneurysm
Peripheral Nerve Neurosurgery Case 4: Unruptured Anterior
Case 82: Thoracic Outlet Syndrome Communicating Artery Aneurysm
Case 83: Peroneal Neuropathy Case 36: Normal Pressure
Case 84: Nerve Sheath Tumor Hydrocephalus
Case 85: Cubital Tunnel Syndrome Case 38: Penetrating Head Injury
Case 86: Carpal Tunnel Syndrome Case 39: Intractable Intracranial
Case 87: Brachial Plexus Injury Hypertension
Case 88: Parsonage-Turner Syndrome Case 40: Epidural Hematoma
Case 89: Radial Nerve Injury Case 44: Hangman’s Fracture
Case 90: Ulnar Nerve Injury
Case 91: Median Nerve Injury Omar Choudhri, MD
Neurosurgery Chief Resident
Kim J. Burchiel, MD Stanford University School of Medicine
John Raaf Professor and Chairman Stanford, CA, USA
Department of Neurological Surgery Case 20: Sphenoid Wing Meningioma
Oregon Health and Science University
Portland, OR, USA Kevin K.H. Chow, MD, PhD
Case 72: Trigeminal Neuralgia Neurosurgery Resident
Department of Neurosurgery
Edward F. Chang, MD Stanford University School of Medicine
Associate Professor Palo Alto, CA, USA
Department of Neurological Surgery Case 26: Glioblastoma
University of California – San Francisco Case 31: Brain Metastases
San Francisco, CA, USA
Case 76: Mesial Temporal Sclerosis Joseph D. Ciacci, MD
Program Director UCSD Neurosurgery
Mike Y. Chen, MD, PhD Residency
Associate Professor Academic Community Director
Division of Neurosurgery, Department of UCSD School of Medicine
Surgery Chief of Neurosurgery VASDHS
City of Hope Cancer Center & Beckman Professor, Division of Neurosurgery
Research Institure University of California, San Diego
Los Angeles, CA, USA School of Medicine
Case 55: Spinal Metastases San Diego, CA, USA
Section Editor for Section 3
Tsinsue Chen, MD Neurosurgical Trauma
Neurosurgery Resident Case 38: Penetrating Head Injury
Division of Neurological Surgery Case 39: Intractable Intracranial
Barrow Neurological Institute Pressure
St. Joseph’s Hospital and Medical Center Case 40: Epidural Hematoma
Phoenix, AZ, USA Case 41: Chronic Subdural Hematoma
Case 75: Progressive Spastic Case 42: Subaxial Cervical Fracture
Paraparesis and Decreased Mobility in Case 43: Odontoid Fractures
a Young Patient Case 44: Hangman’s Fracture
Case 45: Thoracolumbar Burst
Fractures
Case 46: Chance Fractures
Case 47: Jumped Cervical Facets
List of Contributors xv
Aaron Cohen-Gadol, MD Brandon C. Gabel, MD

Associate Professor Neurosurgical Resident
Department of Neurosurgery Division of Neurosurgery
Indiana University School of Medicine University of California, San Diego
Indianapolis, IN, USA School of Medicine
Case 73: Hemifacial Spasm San Diego, CA, USA
Case 15: Moyamoya Disease
John R. Crawford, MD, PhD Case 16: Venous Sinus Thrombosis
Associate Professor of Clinical Case 38: Penetrating Head Injury
Neurosciences and Pediatrics Case 39: Intractable Intracranial
University of California – San Diego Hypertension
Director Neuro-Oncology Rady Children’s Case 40: Epidural Hematoma
Hospital Case 41: Chronic Subdural Hematoma
San Diego, CA, USA Case 42: Subaxial Cervical Fracture
Case 63: Cerebellar Medulloblastoma Case 43: Odontoid Fractures
Case 64: Brainstem Glioma Case 44: Hangman’s Fracture
Case 65: Hypothalamic Hamartoma Case 45: Thoracolumbar Burst
Case 66: Endoscopic Third Fractures
Ventriculostomy Case 46: Chance Fractures
Case 67: Slit Ventricle Syndrome Case 47: Jumped Cervical Facets
Case 71: Pilocytic Astrocytoma Case 70: Vein of Galen Malformations
Erik I. Curtis, MD Gurpreet S. Gandhoke, MD

Neurosurgical Resident Department of Neurological Surgery
Division of Neurosurgery University of Pittsburgh Medical Center
University of California, San Diego Pittsburgh, PA, USA
School of Medicine Case 48: Atlanto-Axial Dislocation
San Diego, CA, USA Case 51: Cauda Equina Syndrome
Case 41: Chronic Subdural Hematoma
Case 42: Subaxial Cervical Fracture Melanie G. Hayden Gephart, MD
Case 43: Odontoid Fractures Assistant Professor
Case 45: Thoracolumbar Burst Department of Neurosurgery
Fractures Stanford University School of Medicine
Stanford, CA, USA
Gehaan D’Souza, MD Case 24: Pituitary Macroadenoma
Fellow in Plastic Surgery – Prolactinoma
Department of Plastic Surgery Case 27: Anaplastic
University of California Oligodendroglioma
San Diego School of Medicine Case 32: Intraventricular Colloid Cyst
San Diego, CA, USA Case 35: Ependymoma
Case 89: Radial Nerve Injury Case 61: Pineal Tumor
Benjamin D. Elder, MD, PhD Thomas J. Gianaris, MD

Resident Resident
Department of Neurosurgery Department of Neurosurgery
The Johns Hopkins University School of Indiana University School of Medicine
Medicine Indianapolis, IN, USA
Baltimore, MD, USA Case 73: Hemifacial Spasm
Case 79: Idiopathic Intracranial
Hypertension (Pseudotumor Cerebri) Gunjan Goel, MD
Neurosurgical Resident
Nicholas Fain, MD Division of Neurosurgery
Resident Physician University of California – San Diego
Department of Radiology San Diego, CA, USA
University of Iowa Case 5: Intradural Internal Carotid
Iowa City, IA, USA Artery Fusiform Aneurysm
Case 42: Subaxial Cervical Fracture
xvi List of Contributors
David D. Gonda, MD Rahul Jandial, MD, PhD

Neurosurgery Chief Resident Associate Professor
Division of Neurosurgery Division of Neurosurgery, Department of
University of California – San Diego Surgery
San Diego, CA, USA City of Hope Cancer Center & Beckman
Case 25: Craniopharyngioma Research Institure
C. Rory Goodwin, MD, PhD
Resident Henry Jung, MD
Department of Neurosurgery Neurosurgery Resident
The Johns Hopkins University School of Department of Neurosurgery
Medicine Stanford Hospital and Clinics
Baltimore, MD, USA Stanford, CA, USA
Case 79: Idiopathic Intracranial Case 33: Cerebral Abscess
Hypertension (Pseudotumor Cerebri) Case 34: Chiari I Malformation
Li Gordon, MD Adam S. Kanter, MD

Assistant Professor, Department of Associate Professor
Neurosurgery Department of Neurological Surgery
Stanford University School of Medicine University of Pittsburgh Medical Center
Stanford, CA, USA Pittsburgh, PA, USA
Case 30: CNS Lymphoma Section Editor for Section 4 Spinal
Neurosurgery
Griffith R. Harsh IV, MD Case 48: Atlanto-Axial Dislocation
Professor Case 49: Basilar Invagination –
Department of Neurosurgery Rheumatoid Pannus
Stanford Hospital and Clinics Case 50: Cervical Spondylotic
Stanford, CA, USA Myelopathy
Section Editor for Section 2 Non- Case 51: Cauda Equina Syndrome
traumatic Cranial Lesions Case 52: Foot Drop and Far Lateral
Case 21: Cerebellar Cystic Disc Herniation
Hemangioblastoma Case 53: Thoracic Disc Herniation
Case 54: Spinal Epidural Abscess
Todd Harshbarger, MD Case 56: Spinal Intradural
Neurosurgery Division, City of Hope Extramedullary Mass
Duarte, CA, USA Case 57: Intradural Intramedullary
Case 55: Spinal Metastases Mass
Case 58: Cervical Ossified Posterior
David S. Hong, MD Longitudinal Ligament
Pediatric Neurosurgery Fellow Case 59: Ankylosing Spondylitis
Division of Pediatric Neurosurgery Case 60: Chordoma
Rady Children’s Hospital San Diego
University of California – San Diego Michael G. Kaplitt, MD, PhD
San Diego, CA, USA Residency Director and Vice Chairman
Case 67: Slit Ventricle Syndrome for Research
Department of Neurological Surgery
Reid Hoside, MD Weill Cornell Medical College
Neurosurgical Resident New York Presbyterian Hospital
Division of Neurosurgery New York, NY, USA
University of California – San Diego Case 80: Intractable Oncologic Pain
San Diego, CA, USA
Case 7: Cranial Dural Arteriovenous Aasim S. Kazmi, MD
Fistula Section of Neurosurgery
Case 14: Cerebellar Hemorrhage Meridian Health
Wall, NJ, USA
Section Editor for Appendices
List of Contributors xvii
Alexander A. Khalessi, MD Thomas A. Kosztowski, MD

Director of Endovascular Neurosurgery Resident
Surgical Director of Neurocritical Care Department of Neurosurgery
Assistant Professor of Surgery and The Johns Hopkins University School of
Neurosciences Medicine
University of California – San Diego Baltimore, MD, USA
San Diego, CA, USA Case 79: Idiopathic Intracranial
Section Editor for Section 1 Vascular Hypertension (Pseudotumor Cerebri)
Neurosurgery
Case 1: Cerebral Arteriovenous Christine K. Lee, MD, PhD
Malformation MD/PhD Student
Case 2: Cavernous Malformation Stanford University School of Medicine
Case 3: Ruptured Middle Cerebral Stanford, CA, USA
Artery Aneurysm Case 27: Anaplastic
Case 4: Unruptured Anterior Oligodendroglioma
Communicating Artery Aneurysm
Case 5: Intradural Internal Carotid Paul S. Larson, MD
Artery Fusiform Aneurysm Professor and Vice Chair
Case 6: Spinal Arteriovenous Department of Neurological Surgery
Malformations University of California – San Francisco
Case 7: Cranial Dural Arteriovenous San Francisco, CA, USA
Fistula Section Editor for Section 6
Case 8: Spinal Dural Arteriovenous Stereotactic and Functional
Fistulas Neurosurgery
Case 9: Vertebral Artery Dissection
Case 10: Basilar Tip Aneurysm Dillon Levy
Case 11: Endovascular Treatment of Pre-Medical Student
Unruptured Aneurysms University of San Diego
Case 12: Dominant Hemisphere San Diego, CA. USA
Hemorrhagic Stroke Case 69: Craniosynostosis
Case 13: Hypertensive Thalamic – Plagiocephaly
Hemorrhage
Case 14: Cerebellar Hemorrhage Michael L. Levy, MD, PhD
Case 15: Moyamoya Disease Professor and Chief
Case 16: Venous Sinus Thrombosis Division of Pediatric Neurosurgery
Case 17: Carotid Stenosis Rady Children’s Hospital – San Diego
Case 18: Ischemic Stroke San Diego, CA, USA
Management Section Editor for Section 5 Pediatric
Neurosurgery
Andrew L. Ko, MD Case 25: Craniopharyngioma
Fellow, Stereotactic and Functional Case 61: Pineal Tumor
Neurosurgery Case 62: Myelomeningocele
Department of Neurological Surgery Case 63: Cerebellar Medulloblastoma
Oregon Health and Science University Case 64: Brainstem Glioma
Portland, OR, USA Case 65: Hypothalamic Hamartoma
Case 72: Trigeminal Neuralgia Case 66: Endoscopic Third
Ventriculostomy
Audrey Kohar, DO Case 67: Slit Ventricle Syndrome
Physical Medicine and Rehabilitation Case 68: Neural Tube Defect–Tethered
University of California Cord Syndrome
Irvine, CA, USA Case 69: Craniosynostosis
Case 92: Multiple Sclerosis – Plagiocephaly
Case 95: Devic’s Syndrome Case 70: Vein of Galen Malformations
Case 99: Transverse Myelitis Case 71: Pilocytic Astrocytoma
xviii List of Contributors
Robert M. Lober, MD, PhD Zachary Medress

Chief Resident Medical Student
Department of Neurosurgery Stanford University School of Medicine
Stanford Hospitals and Clinics Stanford, CA, USA
Stanford, CA, USA Case 30: CNS Lymphoma
Case 19: Vestibular Schwannoma Case 35: Ependymoma
Matthew G. MacDougall, MD Hal S. Meltzer, MD

Neurosurgery Resident Neurosurgical Director of Craniofacial
Division of Neurosurgery Program
University of California – San Diego Rady Children’s Hospital San Diego
San Diego, CA, USA Professor of Neurosurgery
Case 25: Craniopharyngioma University of California, San Diego
San Diego, CA, USA
Mark A. Mahan, MD Case 68: Neural Tube Defect–Tethered
Assistant Professor Cord Syndrome
Department of Neurosurgery Case 69: Craniosynostosis
Clinical Neurosciences Center – Plagiocephaly
University of Utah
Salt Lake City, UT, USA Kai Miller, MD
Case 82: Thoracic Outlet Syndrome Resident, Department of Neurosurgery
Case 83: Peroneal Neuropathy Stanford University School of Medicine
Case 84: Nerve Sheath Tumor Stanford, CA, USA
Case 85: Cubital Tunnel Syndrome Case 30: CNS Lymphoma
Case 86: Carpal Tunnel Syndrome
Case 87: Brachial Plexus Injury Robert A. Miller, MD
Case 88: Parsonage-Turner Syndrome Department of Neurological Surgery
Case 89: Radial Nerve Injury University of Pittsburgh Medical Center
Case 90: Ulnar Nerve Injury Pittsburgh, PA, USA
Case 91: Median Nerve Injury Case 49: Basilar Invagination –
Rheumatoid Pannus
Joel R. Martin, MD
Neurosurgical Resident Nelson Moussazadeh, MD
Division of Neurosurgery Resident in Neurological Surgery
University of California-San Diego Weill Cornell Medical College
San Diego, CA, USA New York Presbyterian Hospital
Case 18: Ischemic Stroke New York, NY, USA
Management Case 80: Intractable Oncologic Pain
Hazem Mashaly, MD Peter Nakaji, MD

University of Pittsburgh Medical Center Residency Program Director
Pittsburgh, PA, USA Division of Neurological Surgery
Case 56: Spinal Intradural Barrow Neurological Institute
Extramedullary Mass St. Joseph’s Hospital and Medical Center
Case 57: Spinal Intramedullary Mass Phoenix, AZ, USA
Case 58: Cervical Ossified Posterior Case 75: Progressive Spastic
Longitudinal Ligament Paraparesis and Decreased Mobility in
a Young Patient
Michael M. McDowell, MD Case 78: Normal Pressure
Department of Neurological Surgery Hydrocephalus
University of Pittsburgh Medical Center
Pittsburgh, PA, USA Bond Nguyen
Case 59: Ankylosing Spondylitis University of California – Irvine
Case 60: Chordoma Irvine, CA, USA
Case 61: Pineal Tumor
Case 62: Myelomeningocele
List of Contributors xix
Scott E. Olson, MD Neal Prakash, MD, PhD

Assistant Professor of Surgery and City of Hope National Medical Center
Neurosciences Chief of Neurology
Division of Neurosurgery Associate Clinical Professor of Neurology
University of California – San Diego Director of Neurological Optical Imaging
San Diego, CA, USA Duarte, CA, USA
Case 8: Spinal Dural Arteriovenous Section Editor for Section 8
Fistulas Neurology
Case 12: Dominant Hemisphere Case 92: Multiple Sclerosis
Hemorrhagic Stroke Case 95: Devic’s Syndrome
Case 18: Ischemic Stroke Case 97: Status Epilepticus
Management Case 99: Transverse Myelitis
J. Scott Pannell, MD Robert C. Rennert, MD

Endovascular Neurosurgery Fellow Neurosurgical Resident
Division of Neurosurgery Division of Neurosurgery
University of California – San Diego University of California – San Diego
San Diego, CA, USA San Diego, CA, USA
Case 1: Cerebral Arteriovenous Case 9: Vertebral Artery Dissection
Malformation Case 10: Basilar Tip Aneurysm
Case 2: Cavernous Malformation Case 12: Dominant Hemisphere
Case 3: Ruptured Middle Cerebral Hemorrhagic Stroke
Artery Aneurysm Case 36: Normal Pressure
Case 4: Unruptured Anterior Hydrocephalus
Communicating Artery Aneurysm
Case 5: Intradural Internal Carotid Christian B. Ricks, MD
Artery Fusiform Aneurysm Department of Neurological Surgery
Case 6: Spinal Arteriovenous University of Pittsburgh Medical Center
Malformations Pittsburgh, PA, USA
Case 7: Cranial Dural Arteriovenous Case 50: Cervical Spondylotic
Fistula Myelopathy
Case 8: Spinal Dural Arteriovenous Case 52: Foot Drop and Far Lateral
Fistulas Disc Herniation
Case 9: Vertebral Artery Dissection Case 54: Spinal Epidural Abscess
Case 10: Basilar Tip Aneurysm
Case 11: Endovascular Treatment of Daniele Rigamonti, MD
Unruptured Aneurysms Professor
Case 12: Dominant Hemisphere Department of Neurosurgery
Hemorrhagic Stroke The Johns Hopkins University School of
Case 13: Hypertensive Thalamic Medicine
Hemorrhage Baltimore, MD
Case 14: Cerebellar Hemorrhage Case 79: Idiopathic Intracranial
Case 15: Moyamoya Disease Hypertension (Pseudotumor Cerebri)
Case 16: Venous Sinus Thrombosis
Case 17: Carotid Stenosis Nathan C. Rowland, MD, PhD
Case 18: Ischemic Stroke Chief Resident
Management Department of Neurological Surgery
University of California – San Francisco
Arjun V. Pendharkar, MD San Francisco, CA, USA
Department of Neurosurgery Case 76: Mesial Temporal Sclerosis
Stanford University School of Medicine
Palo Alto, CA, USA
Case 32: Intraventricular Colloid Cyst
xx List of Contributors
Jayson A. Sack, MD Jason W. Signorelli

Neurosurgical Resident Medical Student
Division of Neurosurgery Division of Neurosurgery
University of California – San Diego University of California – San Diego
San Diego, CA, USA San Diego, CA, USA
Case 3: Ruptured Middle Cerebral Case 1: Cerebral Arteriovenous
Artery Aneurysm Malformation
Case 4: Unruptured Anterior Case 13: Hypertensive Thalamic
Communicating Artery Aneurysm Hemorrhage
Case 9: Vertebral Artery Dissection
Case 10: Basilar Tip Aneurysm Konstantin V. Slavin, MD
Professor
Noriko Salamon, MD, PhD Department of Neurosurgery
Professor of Radiology University of Illinois at Chicago
Chief of Neuroradiology Chicago, IL, USA
Section of Neuroradiology Case 81: Spinal Cord Stimulation
Department of Radiological Sciences
David Geffen School of Medicine at Alexa Smith, MD
UCLA Pediatric Neurosurgery Fellow
Ronald Reagan Medical Center Rady Children’s Hospital – San Diego
Los Angeles, CA, USA Division of Pediatric Neurosurgery
Case 95: Devic’s Syndrome University of California, San Diego
San Diego, CA, USA
David R. Santiago-Dieppa, MD Case 61: Pineal Tumor
Neurosurgical Resident Case 62: Myelomeningocele
Division of Neurosurgery Case 63: Cerebellar Medulloblastoma
University of California – San Diego Case 64: Brainstem Glioma
San Diego, CA, USA Case 65: Hypothalamic Hamartoma
Case 8: Spinal Dural Arteriovenous Case 66: Endoscopic Third
Fistulas Ventriculostomy
Case 39: Intractable Intracranial Case 67: Slit Ventricle Syndrome
Hypertension Case 68: Neural Tube Defect–Tethered
Cord Syndrome
Aatman Shah, BS Case 69: Craniosynostosis
Medical Student – Plagiocephaly
Department of Neurosurgery Case 71: Pilocytic Astrocytoma
Stanford Hospital and Clinics
Stanford, CA, USA Matthew D. Smyth, MD
Case 33: Cerebral Abscess Associate Professor of Neurosurgery and
Case 34: Chiari I Malformation Pediatrics
Director, Pediatric Epilepsy Program
Andrew Shetter, MD Department of Neurological Surgery
Chair, Section of Functional Stereotactic Washington University School of
Neurosurgery Medicine
Division of Neurological Surgery St. Louis, MO, USA
Barrow Neurological Institute Case 77: Corpus Callosotomy
St. Joseph’s Hospital and Medical Center
Phoenix, AZ, USA Philip A. Starr, MD, PhD
Case 75: Progressive Spastic Professor and Co-Director, Functional
Paraparesis and Decreased Mobility in Neurosurgery Program
a Young Patient Department of Neurological Surgery
University of California – San Francisco
San Francisco, CA, USA
Case 74: Parkinson’s Disease
List of Contributors xxi
Jeffrey A. Steinberg, MD Christina Huang Wright, MD

Division of Neurosurgery Resident Physician
University of California – San Diego Department of Neurological Surgery
San Diego, CA, USA University of Southern California School
Case 2: Cavernous Malformation of Medicine
Case 17: Carotid Stenosis Los Angeles, CA, USA
Case 70: Vein of Galen Malformations Case 22: Pituitary Apoplexy
Case 28: Low-Grade Glioma
YouRong Sophie Su
Medical Student James Wright, MD
Stanford University School of Medicine Resident Physician
Stanford, CA, USA Department of Neurological Surgery
Case 24: Pituitary Macroadenoma Case Western Reserve University School
– Prolactinoma of Medicine
Cleveland, OH, USA
Zachary J. Tempel, MD Case 22: Pituitary Apoplexy
Department of Neurological Surgery Case 28: Low-Grade Glioma
University of Pittsburgh Medical Center
Pittsburgh, PA, USA David S. Xu, MD
Case 49: Basilar Invagination – Resident Physician
Rheumatoid Pannus Division of Neurological Surgery
Case 53: Thoracic Disc Herniation Barrow Neurological Institute
Case 56: Spinal Intradural St. Joseph’s Hospital and Medical Center
Extramedullary Mass Phoenix, AZ, USA
Case 57: Intradural Intramedullary Case 78: Normal Pressure
Mass Hydrocephalus
Case 59: Ankylosing Spondylitis
Case 60: Chordoma Derek Yecies, MD
Resident
Doris D. Wang, MD, PhD Department of Neurosurgery
Resident Physician Stanford Hospitals and Clinics
Department of Neurological Surgery Stanford, CA, USA
University of California – San Francisco Case 29: Radiation Necrosis versus
San Francisco, CA, USA Tumor Recurrence
Case 74: Parkinson’s Disease
Nathan T. Zwagerman, MD
J. Dawn Waters, MD Department of Neurological Surgery
Clinical Instructor University of Pittsburgh Medical Center
Department of Neurosurgery Pittsburgh, PA, USA
Stanford Hospital and Clinics Case 50: Cervical Spondylotic
Stanford, CA, USA Myelopathy
Section Editor for Section 2 Non-
traumatic Cranial Lesions
Case 21: Cerebellar Cystic
Hemangioblastoma
Case 23: Cushing’s Microadenoma
Case 29: Radiation Necrosis versus
Tumor Recurrence
Case 36: Normal Pressure
Hydrocephalus
Case 37: Arachnoid Cyst
Acknowledgements
For those that have not had the opportunity to assemble a text, the immense collaborative
effort can be lost behind the bold, large font names on the cover. Yes, the editors are key
to the process. Equally important is the publishing team. Alexandra Mortimer, Louisa
Talbott and Andrew Riley have been thoughtful and attentive companions in making this
book. The book would be porous and flawed without them. Most importantly Charlotta
Kryhl has helped shepherd us through the original idea, its need in the neurosurgical
community and ultimately the spirit of this textbook. Thank you for your support and
leadership.
xxii
For boundless love
For unwavering support
For my mother, Sushma Jandial
Rahul Jandial
Chen, Ph.D, for gifting me his disdain of the conventional-and
to my mother, Professor S.J. Chen,
for my brutal endurance and voice of reason.
Mike Y. Chen
I am grateful to all of my colleagues for their collaboration,

expertise, and friendship. I am appreciative of our residents
who motivate us to be even better. Also, my patients,
who inspire me to persevere.
I dedicate this book to family: My mother, Lenore, for her endless

commitment to our happiness. My father, Stephen, who is missed
beyond words. My in-laws, Shari and Ali, for their undying love
and support. My husband, Shervin, for his sacrifices for my
dedication to my profession. My children, Ava and Cyrus,
who have enriched my life in ways I never thought possible,
making me a better person and surgeon.
Michele R. Aizenberg
Section I Vascular
Neurosurgery
Case 1
Cerebral Arteriovenous
Malformation
Jason W. Signorelli •Alexander
J. Scott Pannell, MD •
A. Khalessi, MD
Presentation
An 18-year-old female presents to the ED with severe headaches, nausea, vomiting, and
complex partial seizure beginning on the right side of the body. She has no history of prior
seizures. She has had headaches in the past, but this headache is worse than usual.
• PMH: otherwise unremarkable; no recent trauma
• Exam: mild left-sided weakness
Differential Diagnosis
• Vascular
• Ischemic/embolic stroke
• Arteriovenous malformation (AVM)
• Cavernous hemangioma
• Aneurysm rupture
• Moyamoya disease
• Infectious
• CNS infection (herpes simplex encephalitis)
• Neoplastic
• Primary cerebral tumor
• Metastasis (most commonly lung, renal cell carcinoma, melanoma, breast)
• Metabolic/toxic/nutritional
• Alcohol withdrawal
• Drug intoxication
• Electrolyte abnormalities
• Hypoglycemia
• Congenital/developmental
• Osler-Weber-Rendu disease
• Sturge-Weber syndrome
• Wyburn-Mason syndrome (“Bonnet–Dechaume–Blanc syndrome”)
1
2 SECTION I Vascular Neurosurgery
Initial Imaging
FIGURE 1-1
FIGURE 1-2
Imaging Description and Differential

• Axial noncontrast head CT demonstrates serpiginous calcified structures in the left
parieto-occipital region, concerning for vascular malformation.
• Axial T2-weighted MRI demonstrates cortical AVM and numerous flow voids in the left
parieto-occipital region.
Further Imaging
Anterior parietal
artery
Posterior parietal
artery
Angular artery
Temporo-occipital
artery
Superior division
of left MCA
Anterior choroidal Inferior division

artery of left MCA
Left ICA Anterior temporal

artery
M1 segment of
the left MCA
Fetal PCA
FIGURE 1-3 PA and lateral left anterior circulation digital subtraction angiogram.
Anterior parietal
artery
Posterior parietal
branch of left MCA
Angular artery
Parieto-occipital Temporo-occipital
branch of left PCA artery
Inferior division
Calcarine branch of left MCA
of left PCA
Superior division
of left MCA
Anterior choroidal
artery
Fetal posterior
cerebral artery
Internal carotid
artery
FIGURE 1-4 PA and lateral left anterior circulation digital subtraction angiogram.
Superior
anastomotic
vein of Trolard
Superior
sagittal sinus
Parietal cortical
bridging veins
Superficial middle
temporal vein
Straight sinus
Torcula Inferior
anastamotic
vein of Labbe
Transverse sinus
Sigmoid sinus
FIGURE 1-5 Lateral venous phase digital subtraction angiogram.
• Figures 1-3 and 1-4 are digital subtraction angiograms of PA and lateral left anterior
circulation performed by left ICA injection. They depict a large 6 cm AVM nidus sup-
plied by multiple MCA and foetal variant PCA pedicles.
• Figure 1-5 is a lateral venous phase digital subtraction angiogram performed by left ICA
injection and demonstrates superficial and deep venous drainage from the AVM.
• Findings are consistent with Spetzler-Martin (SM) scale grade 5 AVM.
Further Workup
• Imaging
• ECG
• Grading
• SM or supplemented SM grading (SM-supp)
• Laboratory
• CMP, CBC, ESR, and CRP
• Consultants
• Cardiology (ECHO)
Pathophysiology
Cerebral AVM is a rare disorder with an estimated prevalence of 0.01% to 0.5% that com-
monly presents with intracranial hemorrhage or seizures. It is the most common cause of
spontaneous intraparenchymal hemorrhage in adults <40 years old. The majority of lesions
(~88%) are superficially located, with approximately 20% having associated aneurysms.
The natural history is heterogeneous, with an approximate 2.2% annual risk of rupture
for previously unruptured AVMs and 4.5% for ruptured. This risk is significantly altered
by several factors including prior hemorrhage, venous drainage, and associated aneurysms;
increasing the annual risk of hemorrhage to as high as 34% in patients having all three
risk factors. Furthermore, the cumulative risk of rupture increases with age. Ruptured
AVMs result in major mortality and morbidity; the associated death rate is as high as 29%
and only 55% of survivors are capable of independent living (mRS ≤2). A majority of
patients will be diagnosed with an AVM before the age of 40, and there is substantial risk
of at least one hemorrhage during their lifetime; therefore these lesions should be treated.
Of note, the recently published ARUBA trial argued for the superiority of medical manage-
ment versus interventional therapy for unruptured AVMs; however, methodological flaws
within the trial and other more recent studies cast significant doubt on those findings.
Treatment Options
Treatment of AVMs is often multimodal, tailored to the specifics of the lesion, and com-
monly assessed by the SM grading scale.
• Surgery
• Resection is the most definitive treatment, resulting in complete obliteration of the
AVM in nearly all patients
• Appropriate for lesions with SM grade ≤5 or SM-supp grade ≤6
• May be combined with embolization for larger AVMs
• Stereotactic radiosurgery
• Appropriate for lesions ≤3cm in diameter with a compact nidus or location in an
eloquent area where resection would result in significant neurologic deficits
• Long latency to lesion obliteration period (1–3 years) and does not completely elimi-
nate the risk of hemorrhage
• May be combined with embolization
• Embolization
• Facilitates both surgery and stereotactic radiosurgery
• May be appropriate for complete AVM obliteration in select cases
Surgical Technique
The approach must be tailored to the AVM location and key associated vascular structures,
including arterial feeders, draining veins, and boundaries of the nidus. Extranidal aneu-
rysms should also be accounted for when planning an approach. Intraoperative monitoring
is important when the AVM is located in or near an eloquent cortex; electrophysiological
monitoring with continuous bilateral upper and lower somatosensory and motor evoked
potentials may aid in the resection. Preoperative staging for embolizations may be per-
formed if deemed appropriate. The significant majority of AVMs are located in the cerebral
convexity, and this surgical approach is outlined next.
Surgical Resection: Cerebral Convexity (85% of AVMs)

The head is placed in rigid fixation with the cortical surface of the AVM parallel to the
floor. The skin is incised in standard fashion and a wide craniotomy/durotomy is per-
formed to ensure adequate access and visualization of all key vascular structures.
FIGURE 1-6 Skin is incised in standard fashion. Extra

precaution should be taken if arterial feeders emanating
from the external carotid arteries feed the AVM nidus
since this can lead to significant bleeding. When the skull
is exposed, the AVM is mapped out using a neuronaviga-
tion system for bone flap planning. To avoid unnecessary
bleeding, care should be exercised when crossing loca-
tions of draining veins with a craniotomy. (Reprinted
with permission. Jandial R, McCormick P, Black PM. Core
Techniques in Operative Neurosurgery. Philadelphia:
Philadelphia: Elsevier/Saunders; 2011, ©2011.)
FIGURE 1-7 When the bone flap has been removed,

the dura should be tacked up to the surrounding bone
taking care not to penetrate vessels underlying the
dura. The dural opening should adequately expose the
entire AVM nidus, feeding arteries, and draining veins
of the cortical surface. The dura should be reflected
very gently because vessels associated with the AVM
can be adherent to the dura, and tearing could result
in AVM bleeding. (Reprinted with permission. Jandial
R, McCormick P, Black PM. Core Techniques in Oper-
ative Neurosurgery. Philadelphia: Philadelphia:
Elsevier/Saunders; 2011, ©2011.)
Next, surface feeding arteries are identified and occluded. The dissection of the nidus
may then begin in a circumferential pattern. Deep feeding arteries should be coagulated
and cut or clipped as needed. Upon completion of the nidus dissection, the deep arterial
pedicles must be identified and dissected.
FIGURE 1-8 When all components of the AVM are

identified on the cortical surface, the parenchymal phase
of the dissection can begin, dissecting around the AVM
in a spiral fashion. A gliotic tissue plane frequently exists
because of chronic ischemic changes that facilitate iden-
tification of such a plane. Retraction during dissection
should always be on the AVM nidus and not on the sur-
rounding brain parenchyma. (Reprinted with permission.
Jandial R, McCormick P, Black PM. Core Techniques in
Operative Neurosurgery. Philadelphia: Philadelphia:
Elsevier/Saunders; 2011, ©2011.)
FIGURE 1-9 When the dissection plane has led to the

apex of the nidus, special attention must be paid to the
deep arterial supply. Often these arterial feeders are small
and high flow, making their control difficult with electro-
cautery. Small AVM clips are useful. If the bleeding cannot
be controlled, it may be necessary to remove the bulk of
the AVM nidus so that the remaining AVM deep in the
resection bed can be better controlled. (Reprinted with
permission. Jandial R, McCormick P, Black PM. Core Tech-
niques in Operative Neurosurgery. Philadelphia: Philadel-
phia: Elsevier/Saunders; 2011, ©2011.)
Deep venous drainage is approached last. Major draining veins must first be occluded
with a temporary aneurysm clip and the AVM observed to identify indications of intact
arterial pedicles, such as increased distension of the AVM. Following control of these veins,
the AVM is removed en bloc and blood pressure may be transiently elevated to confirm
adequate hemostasis.
FIGURE 1-10 After the AVM nidus has been removed, the resection bed must be examined for residual
nidi and areas of bleeding. Continuous bleeding often means residual nidi and should be examined closely.
Intraoperative imaging may consist of digital subtraction angiography, with or without supplementary indo-
cyanine green dye video angiography. The resection bed must be completely dry because increases in
systolic blood pressure can easily lead to re-bleeds, necessitating evacuation. Systolic blood pressure can
be increased temporarily to high-normal levels to check for areas of potential bleeding. (Reprinted with
permission. Jandial R, McCormick P, Black PM. Core Techniques in Operative Neurosurgery. Philadelphia:
Philadelphia: Elsevier/Saunders; 2011, ©2011.)
Once confirmed, an EVD or ICP monitor is placed if deemed appropriate. The dura is
then closed, bone flap replaced, and skin closed.
Surgical Resection: Deep Brain

For AVMs with a nidus in the deep brain, preoperative staged embolizations should be
incorporated and an anatomically suitable approach used including options such as:
• Interhemispheric transcallosal (frontal, parietal, or occipital)
• Transsylvian
• Occipital transtentorial infrasplenial
• Infratentorial supracerebellar
Complication Avoidance and Management

• Craniotomy must be wide enough to visualize all surface vascular structures and mini-
mize brain retraction.
• The AVM must be resected as a whole; partial resection is likely to lead to severe
hemorrhage.
• Venous drainage should always be addressed last. Early elimination of venous drainage
increases the risk of rupture and bleeding into the parenchyma or ventricles.
• A noncontrast head CT should be obtained postoperatively to monitor for hematoma
formation.
• Normotensive or hypotensive blood pressure should be targeted postoperatively to
reduce the risk of hematoma formation in the residual cavity.
KEY PAPERS
Al-Shahi R, Bhattacharya JJ, Currie DG, et al. Prospective, population-based detection of intracranial vascular
malformations in adults the Scottish intracranial vascular malformation study (SIVMS). Stroke.
2003;34(5):1163-1169.
Brown RD, Wiebers DO, Forbes G, et al. The natural history of unruptured intracranial arteriovenous malforma-
tions. J Neurosurg. 1988;68(3):352-357.
Friedlander RM. Arteriovenous malformations of the brain. N Engl J Med. 2007;356(26):2704-2712.
Gross BA, Du R. Natural history of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg.
2013;118(2):437-443.
Kim H, Abla AA, Nelson J, et al. Validation of the supplemented Spetzler-Martin grading system for brain arte-
riovenous malformations in a multicenter cohort of 1009 surgical patients. Neurosurgery. 2015;25-31.
Korja M, Bervini D, Assaad N, et al. Role of surgery in the management of brain arteriovenous malformations
prospective cohort study. Stroke. 2014;45(12):3549-3555.
Mohr JP, Parides MK, Stapf C, et al. Medical management with or without interventional therapy for unruptured
brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet.
2014;383(9917):614-621.
Potts MB, Zumofen DW, Raz E, et al. Curing arteriovenous malformations using embolization. Neurosurg Focus.
2014;37(3):E19.
Stapf C, Mast H, Sciacca RR, et al. Predictors of hemorrhage in patients with untreated brain arteriovenous
malformation. Neurology. 2006;66(9):1350-1355.
van Beijnum J, van der Worp H, Buis DR, et al. Treatment of brain arteriovenous malformations: a systematic
review and meta-analysis. JAMA. 2011;306(18):2011-2019.
Case 2
Cavernous Malformation
Jeffrey A. Steinberg, MD •Alexander
J. Scott Pannell, MD •
A. Khalessi, MD
Presentation
A healthy 45-year-old female presents to the emergency room with seizure.
• PMH: otherwise unremarkable
• Exam: mildly slowed cognition
• Pupils equal and reactive
• Moves all extremities with full strength
• Face/smile symmetric
• No drift
• Vascular
• Stroke/TIA
• Hemorrhage of vascular malformation
• Neurologic
• Seizure
• Neoplastic
• Brain tumor
• Infectious
• Meningitis, abscess
• Other
• MS
• Systemic/metabolic
9
Initial Imaging
FIGURE 2-1
FIGURE 2-2
FIGURE 2-3
Imaging Description and Differential

• MRI of the brain depicts typical representation of cavernous malformation, evident by
the popcorn/mulberry shape and surrounding rim of signal loss, secondary to hemo-
siderin deposit, with increased signal on T2 compared with T1. Gradient echo sequences
are most sensitive in picking up these lesions because of the increased susceptibility
effect.
FIGURE 2-4 Brainstem cavernous malformations are often removed through a parenchymal incision much
smaller than the malformation itself. In contrast to many supratentorial cavernous malformations, the prin-
ciples of piecemeal resection are applied here. After incision the lesion is emptied, internally targeting cavi-
ties with liquefied old blood. (Reprinted with permission. Jandial R, McCormick P, Black PM. Core
Techniques in Operative Neurosurgery. Philadelphia: Elsevier/Saunders, ©2011.)
A B
FIGURE 2-5 When the malformation has been partially internally decompressed, a cleavage plane between the lesion and
the surrounding gliotic hemosiderin-stained parenchyma is developed beginning in the portion of the capsule and surface of
the malformation closest to the entry point. Specifically designed round dissectors (A) or gentle spread of the bipolar forceps
(B) can be used for this maneuver. During this maneuver, gentle traction is applied to the cavernous malformation with the
suction in the surgeon’s left hand, minimizing the mechanical trauma to the surrounding parenchyma. (Reprinted with permis-
sion. Jandial R, McCormick P, Black PM. Core Techniques in Operative Neurosurgery. Philadelphia: Elsevier/Saunders,
©2011.)
FIGURE 2-6 After further internal emptying of the malformation, the cleavage plane is dissected further with a round dis-
sector. Because of the depth of the field and the limited size of the entry incision, this portion of the operation is done more
by “feel” than by direct vision. Extreme caution and gentle touch must be exercised to avoid any damage to portions of
parenchyma not in direct vision. (Reprinted with permission. Jandial R, McCormick P, Black PM. Core Techniques in Opera-
tive Neurosurgery. Philadelphia: Elsevier/Saunders, ©2011.)
FIGURE 2-7 After the bulk of the cavernous malformation has been released from the surrounding paren-
chyma, gentle traction with pituitary forceps is applied to the edges of the most superficial portion of the
lesion. If the cavernous malformation has been properly separated, very gentle but steady traction at this
point often leads to the malformation eventually “giving in.” (Reprinted with permission. Jandial R, McCor-
mick P, Black PM. Core Techniques in Operative Neurosurgery. Philadelphia: Elsevier/Saunders, ©2011.)
• Differential: cerebral amyloid angiography, diffuse axonal injury, hemorrhagic metasta-

ses, capillary telangiectasia, or arteriovenous malformation
Further Workup
• Laboratory
• Routine labs
• Imaging
• MRI brain including gradient echo sequences
• Cerebral angiography generally not necessary for classically appearing lesions, but
may be useful in atypical lesions to rule out other vascular anomalies
Pathophysiology
Cavernoma is defined as a vascular malformation composed of dilated capillary-like vessels
without intervening neuronal parenchyma. Cavernomas may occur in the brain or spinal
cord; they can range in size from a few millimeters to several centimeters, are often associ-
ated with venous lesions, and may be congenital or acquired. Grossly they appear as
purple-blue multilobulated “mulberry” lesions, often with gliotic, yellow-stained sur-
rounding tissue from repeated small hemorrhages. Microscopically cavernomas are thin-
walled vessels that lack smooth muscle and elastin and are composed of a single cell layer
of endothelial cells that can contain areas of thrombosis.
Treatment Options
• Observation
• Serial imaging in patients with asymptomatic lesions, lesions in deep locations, or
eloquent regions
• Monitor for hemorrhage or secondary growth/changes in recurrent hemorrhage.
• Medical management
• Focus on symptom management of headaches and seizures.
• Surgery
• Surgical resection is the only treatment that is curative for cavernomas. Complete
resection eliminates the risk of hemorrhage and improves seizures and headaches.
• Stereotactic radiosurgery
• Controversial in the treatment of cavernomas, generally only considered for inoper-
able lesions with progressive symptoms. Results and evidence vary.
Surgical Technique
The goal of surgery is complete removal of the cavernoma. As with many other neurosur-
gical pathologies, the approach is critical in facilitating resection without injury to normal
parenchyma. Intraoperative navigation and ultrasound may be beneficial for localization.
Because these lesions are not highly vascularized, piecemeal removal is possible (Figure
2-4, cavernoma dissection). Dissection between the lesion and the surrounding gliotic
hemosiderin-stained parenchyma is achieved. Decompression of the cavernoma may facili-
tate dissection by allowing folding in of the lesion from the normal tissue (Figures 2-4,
2-5, 2-6, Cavernoma dissection). Once the lesion is completely removed, hemostasis of
the cavity should be achieved with irrigation and a hemostatic agent, as opposed to bipolar
cautery, to decrease risk of injury to parenchymal tissue.
Complication Avoidance and Management

• Cavernoma Resection
• Resection 2 to 4 weeks after hemorrhage allows for liquefaction of the hematoma,
aiding in decompression and delivery of the lesion. Monitoring of tissue color changes
from shades of brown to yellow typically demarcates the plane between cavernoma
and normal tissue. Deep-seated lesions should be approached with minimal disrup-
tion of parenchymal tissue, specifically avoiding eloquent brain regions, and targeting
the most superficial aspect of the cavernoma. Dissection through tissue should occur
parallel to neuronal tracts to better preserve these structures. Co-occurring venous
malformations should be preserved. Hemostasis should be achieved with irrigation
and hemostatic agents, as opposed to bipolar cautery, to decrease the risk of injuring
normal tissue.
KEY PAPERS
Brown RD Jr, Flemming KD, Meyer FB, et al. Natural history, evaluation, and management of intracranial vascular
malformations. Mayo Clin Proc. 2005;80:269-281.
Lanzino G, Spetzler RF. Cavernous Malformations of the Brain and Spinal Cord. New York: Thieme; 2008.
Porter RW, Detwiler PW, Spetzler RF, et al. Cavernous malformations of the brainstem: experience with 100
patients. J Neurosurg. 1999;90:50-58.
Case 3
Ruptured Middle Cerebral
Artery Aneurysm
Vincent J. Cheung, MD
J. Scott Pannell, MD •• Jayson A. Sack, MD •
Presentation
A 47-year-old woman with no significant past medical history presents to the emergency
department with acute onset headache, nausea, and vomiting. Upon presentation, she is
lethargic but able to answer orientation questions and briskly follow commands in all
extremities. Cranial nerves and motor strength are all grossly intact.
• Vascular
• Ruptured aneurysm
• Ruptured dural arteriovenous fistula
• Ruptured arteriovenous malformation
• Hypertensive hemorrhage
• Infectious
• Rupture of mycotic cerebral aneurysm (in setting of IV drug use)
• Meningitis
• Other
• Traumatic hemorrhage
• Cocaine-induced intracerebral hemorrhage
• Migraine
Initial Imaging
15
FIGURE 3-1
FIGURE 3-2
Imaging Description
• Figure 3-1: Noncontrast CT scan of the head. Dense subarachnoid hemorrhage is
present in the right sylvian fissure.
• Figure 3-2: AP projection digital subtraction angiography, right internal carotid injec-
tion. An elongated M1 segment MCA aneurysm is shown.
Further Workup
Following a subarachnoid hemorrhage, the first priority should be given to “ABCs” (airway,
breathing, circulation). If there is significant intraventricular hemorrhage, or the patient
must be intubated and sedated for airway protection or poor neurologic status, an external
ventricular drain should be placed. Strict blood pressure control is critical.
Following subarachnoid hemorrhage, patients are at risk for vasospasm. Vasospasm is
a pathologic constriction of blood vessels that can result in ischemic stroke and is a major
cause of morbidity and mortality after aneurysmal rupture. After securing a ruptured
aneurysm through endovascular embolization or craniotomy for clip ligation, patients are
typically observed for at least 2 weeks. Vasospasm risk peaks from 3 to 14 days after
rupture. During this time, efforts are made to monitor for and mitigate the effects of
vasospasm.
Pathophysiology
Aneurysms are pathologic dilatations in the wall of a blood vessel. When the aneurysm
weakens to the point of rupture, blood extravasates into the subarachnoid space. The
development of a cerebral aneurysm is multifactorial and includes focal structural defects
in the vessel wall, hemodynamic stress from turbulent blood flow or branch point, and
familial factors. Hereditary syndromes associated with cerebral aneurysms include Ehlers-
Danlos syndrome, fibromuscular dysplasia, Osler-Weber-Rendu syndrome, and polycystic
kidney disease. Aneurysms may also form from trauma or infection. Traumatic aneurysms
differ from true aneurysms in that they typically result from dissection between layers of
a vessel wall. In contrast, saccular aneurysms involve all layers of the vessel wall. Infectious
aneurysms (also known as mycotic aneurysms) typically occur in distal cortical branches
and can form in response to focal weakening of the vessel wall due to septic emboli from
bacterial endocarditis, meningitis, or fungal infection.
3 Ruptured Middle Cerebral Artery Aneurysm 17
Anterior communicating artery

A1 segment
Ophthalmic artery
A2 segment Posterior
communicating
artery
Anterior
choroidal
artery
Orbitofrontal Middle cerebral
artery artery (M1 segment)
Medial striate artery
of Heubner
Medial lenticulostriate
arteries Lateral
lenticulostriate
arteries M2 segments
FIGURE 3-3 Anatomy of anterior circulation with the major branches and perforators of the internal
carotid artery, of the M1 segment of the middle cerebral artery, of the A1 and A2 segments of the anterior
cerebral artery, and of the anterior communicating artery. (Reprinted with permission. Winn HR. Youmans
Neurological Surgery. 6th ed. Elsevier; 2011.)
Treatment Options
• Craniotomy for clip ligation
• Endovascular embolization
Surgical Technique
The patient is positioned supine in a head holder, and the head is maintained in a 15- to
20 degree rotation away from the side of the aneurysm. Additionally, the head is extended
roughly 20 degree to allow gravity to retract the frontal lobe from the anterior cranial fossa.
A curvilinear skin incision is performed inferiorly from the zygomatic arch (<1 cm from
tragus) and superiorly to the midline, staying just behind the hairline. The skin and tem-
poralis muscle are elevated together and retracted forward with skin hooks. A standard
frontotemporal craniotomy is performed. Additional bone of the pterion and lesser wing
of the sphenoid are drilled down and/or rongeured until the lateral edge of the superior
orbital fissure is reached. The dura is then opened with a semicircular incision.
FIGURE 3-4 Positioning of the patient for the right-sided
lateral supraorbital approach. (Reprinted with permission.
Quiñones-Hinojosa A. Schmidek and Sweet Operative
Neurosurgical Techniques. 6th ed. Elsevier; 2012.)
20° 20°
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“And first I put it upon the Profession of Divinity to deny one word of
the fact as I have repeated it. Next I challenge the Science of the
Law to shew such another Title as this is. And then I defy the
Logicians to deny my Argument: of which this is the abstract: That
the Law delivered to Adam before the Fall is the original cause of
Death in the World: That this Law is taken away by the Death of
Christ: That therefore the legal power of death is gone. And I am so
far from thinking this Covenant of Eternal Life to be an allusion to the
forms of Title amongst men, that I rather adore it as the precedent for
them all; believing with that great Apostle that the things on Earth are
but the patterns of things in the Heavens where the Originals are
kept.” This he says because he has before made it appear that in the
Covenant of Eternal Life all things requisite to constitute a legal
instrument are found, to wit, the date, the parties, the contents, and
consideration, the sealing, and execution, the witnesses, and the
Ceremony required of Man, whereby to execute it on his part and
take the advantage of it.
By the sacrifice which our Lord offered of himself, this technical but
sincere and serious enthusiast argues, more than an atonement was
made. “And that this superabundancy might not run to waste, God
declared that Man should have Eternal Life absolute as Christ
himself had it; and hence Eternal Life is called the Gift of God
through our Lord and Saviour Jesus Christ, over and above our
redemption. Why then,” he asks, “doth Death remain in the World?
Why because Man knows not the Way of Life—‘the way of Life they
have not known.’ Because our faith is not yet come to us—‘when the
Son of Man comes shall he find faith upon the earth?’ Because Man
is a beast of burden that knows not his own strength in the virtue of
the Death and the power of the Resurrection of Christ. Unbelief goes
not by reason or dint of argument, but is a sort of melancholy
madness, by which if we once fancy ourselves bound, it hath the
same effect upon us as if we really were so. Death is like Satan, who
appears to none but those who are afraid of him: Resist the Devil
and he will flee from you. Because Death had once dominion over
us, we think it hath and must have it still. And this I find within myself,
that though I can't deny one word I have said in fact or argument, yet
I can't maintain my belief of it without making it more familiar to my
understanding, by turning it up and down in my thoughts and
ruminating upon some proceedings already made upon it in the
World.
“The Motto of the Religion of the World is Mors Janua Vitæ; if we

mean by this the Death of Christ, we are in the right; but if we mean
our own Death then we are in the wrong. Far be it from me to say
that Man may not attain to Eternal Life, though he should die; for the
Text runs double. ‘I am the Resurrection and the Life; he that liveth
and believeth on me, shall never die; and though he were dead he
shall live.’ This very Text shows that there is a nearer way of entering
into Eternal Life than by the way of Death and Resurrection.
Whatever circumstances a man is under at the time of his death,
God is bound to make good this Text to him, according to which part
of it he builds his faith upon; if he be dead there's a necessity for a
resurrection; but if he be alive there's no occasion for Death or
Resurrection either. This text doth not maintain two religions, but two
articles of faith in the same religion, and the article of faith for a
present life without dying is the higher of the two.
“No man can comprehend the heights and depths of the Gospel at
his first entrance into it; and in point of order, ‘the last enemy to be
destroyed is Death.’ The first essay of Faith is against Hell, that
though we die we may not be damned; and the full assurance of this
is more than most men attain to before Death overtakes them, which
makes Death a terror to men. But they who attain it can sing a
requiem ‘Lord now lettest thou thy Servant depart in peace!’ and if
God takes them at their word, they lie down in the faith of the
Resurrection of the Just. But whenever he pleases to continue them,
after that attainment, much longer above ground, that time seems to
them an interval of perfect leisure, till at last espying Death itself,
they fall upon it as an enemy that must be conquered, one time or
other, through faith in Christ. This is the reason why it seems
intended that a respite of time should be allotted to believers after
the first Resurrection and before the dissolution of the World, for
perfecting that faith which they began before their death but could
not attain to in the first reach of life: for Death being but a
discontinuance of Life, wherever men leave off at their death, they
must begin at their resurrection. Nor shall they ascend after their
resurrection, till they have attained to this faith of translation, and by
that very faith they shall be then convinced that they need not have
died.
“When Elijah courted death under the juniper tree in the wilderness,
and ‘said—now Lord, take away my life, for I am not better than my
fathers,’ that request shews that he was not educated in this faith of
translation, but attained it afterwards by study. Paul tells ‘we shall not
all die but we shall all be changed;’ yet though he delivered this to be
his faith in general, he did not attain to such a particular knowledge
of the way and manner of it as to prevent his own death: he tells us
he had not yet attained the Resurrection of the dead, but was
pressing after it. He had but a late conversion, and was detained in
the study of another part of divinity, the confirming the New
Testament by the Old and making them answer one another,—a
point previous to the faith of translation, and which must be learned
before it—in order to it. But this his pressing (though he did not
attain,) hath much encouraged me,” says Asgill, “to make this
enquiry, being well assured that he would not have thus pursued it,
had he not apprehended more in it than the vulgar opinion.
“We don't think ourselves fit to deal with one another in human
affairs till our age of one and twenty. But to deal with our offended
Maker, to counterplot the malice of fallen Angels, and to rescue
ourselves from eternal ruin, we are generally as well qualified before
we can speak plain, as all our life-time after. Children can say over
their religion at four or five years old, and their parents that taught
them can do no more at four or five and fifty. The common Creed of
the Christian religion may be learned in an hour: and one days
philosophy will teach a man to die. But to know the virtue of the
Death and Power of the Resurrection of Christ, is a science
calculated for the study of Men and Angels for ever.
“But if man may be thus changed without death, and that it is of no
use to him in order to Eternal Life; what then is Death? Or,
whereunto serveth it? What is it? Why 'tis a misfortune fallen upon
man from the beginning, and from which he has not yet dared to
attempt his recovery: and it serves as a Spectre to fright us into a
little better life (perhaps) than we should lead without it. Though God
hath formed this Covenant of Eternal Life, Men have made an
agreement with Death and Hell, by way of composition to submit to
Death, in hope of escaping Hell by that obedience; and under this
allegiance we think ourselves bound never to rebel against it! The
study of Philosophy is to teach men to die, from the observations of
Nature; the profession of Divinity is to enforce the doctrine from
Revelation: and the science of the Law is to settle our civil affairs
pursuant to these resolutions. The old men are making their last
Wills and Testaments; and the young are expecting the execution of
them by the death of the testators; and thus
Mortis ad exemplum totus componitur orbis.
I was under this Law of Death once; and while I lay under it, I felt the
terror of it, till I had delivered myself from it by those thoughts which
must convince them that have them. And in this thing only, I wish, for
their sakes, that all men were as I am. The reason why I believe that
this doctrine is true, is, because God hath said it: yet I could not thus
assert it by argument, if I did not conceive it with more self-conviction
than I have from any maxims or positions in human science. The
Covenant of Eternal Life is a Law of itself and a science of itself,
which can never be known by the study of any other science. It is a
science out of Man's way, being a pure invention of God. Man knows
no more how to save himself than he did to create himself; but to
raise his ambition for learning this, God graduates him upon his
degree of knowledge in it, and gives him badges of honour as
belonging to that degree, upon the attainment whereof a man gains
the title of a Child of the Resurrection: to which title belongs this
badge of honour, to die no more but make our exit by translation, as
Christ, who was the first of this Order, did before us. And this world
being the academy to educate Man for Heaven, none shall ever
enter there till they have taken this degree here.
“Let the Dead bury the Dead! and the Dead lie with the Dead! And
the rest of the Living go lie with them! I'll follow him that was dead,
and is alive, and living for ever. And though I am now single, yet I
believe that this belief will be general before the general change, of
which Paul speaks, shall come; and that then, and not before, shall
be the Resurrection of the Just, which is called the first Resurrection;
and after that the Dead so arisen, with the Living, then alive, shall
have learned this faith, which shall qualify them to be caught up
together in the air, then shall be the General Resurrection, after
which Time shall be no more.
“The beginning of this faith, like all other parts of the Kingdom of
Heaven will be like a grain of mustard seed, spreading itself by
degrees till it overshadow the whole earth. And since ‘the things
concerning Him must have an end,’ in order to this they must have a
beginning. But whoever leads the van will make the world start, and
must expect for himself to walk up and down, like Cain, with a mark
on his forehead, and run the gauntlet for an Ishmaelite, having every
man's hand against him because his hand is against every man;
than which nothing is more averse to my temper. This makes me
think of publishing with as much regret as he that ran way from his
errand when sent to Niniveh: but being just going to cross the water
—(he was going to Ireland,—) I dared not leave this behind me
undone, lest a Tempest send me back again to do it. And to shelter
myself a little, (though I knew my speech would betray me) I left the
Title page anonymous. Nor do I think that any thing would now extort
my name from me but the dread of the sentence, ‘he that is
ashamed of me and of my words, of him will I be ashamed before my
Father and his Angels:’ for fear of which I dare not but subscribe my
argument, though with a trembling hand; having felt two powers
within me all the while I have been about it, one bids me write, and
the other bobs my elbow. But since I have wrote this, as Pilate did
his inscription, without consulting any one, I'll be absolute as he was;
‘what I have written, I have written.’
“Having pursued that command, ‘Seek first the Kingdom of God,’ I
yet expect the performance of that promise, ‘to receive in this life an
hundred fold, and in the world to come life everlasting.’ I have a
great deal of business yet in this world, without doing of which
Heaven itself would be uneasy to me: but when that is done I know
no business I have with the dead, and therefore do depend that I
shall not go hence by ‘returning to the dust,’ which is the sentence of
that law from which I claim a discharge: but that I shall make my exit
by way of translation, which I claim as a dignity belonging to that
Degree in the Science of Eternal Life of which I profess myself a
graduate. And if after this I die like other men, I declare myself to die
of no religion. Let no one be concerned for me as a desperade: I am
not going to renounce the other part of our religion, but to add
another article of faith to it, without which I cannot understand the
rest. And if it be possible to believe too much in God, I desire to be
guilty of that sin.
“Behold ye despisers and wonder! Wonder to see Paradise lost, with

the Tree of Life in the midst of it! Wonder and curse at Adam for an
original fool, who in the length of one day never so much as thought
to put forth his hand, for him and us, and pull and eat and live for
ever! Wonder at and damn ourselves for fools of the last impression,
that in the space of seventeen hundred years never so much as
thought to put forth our hands, every one for himself, and seal and
execute the Covenant of Eternal Life.
“To be even with the World at once, he that wonders at my faith, I

wonder at his unbelief. The Blood of Christ hath an incident quality
which cleaneth from sin; and he that understands this never makes
any use of his own personal virtues as an argument for his own
salvation, lest God should overbalance against him with his sins; nor
doth God ever object a man's sins to him in the day of his faith;
therefore till I am more sinful than He was holy, my sins are no
objection against my faith. And because in Him is all my hope, I care
not (almost) what I am myself.
“It is observed in the mathematics that the practice doth not always
answer the theory; and that therefore there is no dependence upon
the mere notions of it as they lie in the brain, without putting them
together in the form of a tool or instrument, to see how all things fit.
This made me distrust my own thoughts till I had put them together,
to see how they would look in the form of an argument. But in doing
this, I thank God I have found every joint and article to come into its
own place and fall in with and suit one another to a hair's breadth,
beyond my expectation: or else I could not have had the confidence
to produce this as an engine in Divinity to convey man from Earth to
Heaven. I am not making myself wings to fly to Heaven with, but only
making myself ready for that conveyance which shall be sent me.
And if I should lose myself in this untrodden path of Life, I can still
find out the beaten Road of Death blindfold. If therefore, after this, ‘I
go the way of my fathers’ I freely waive that haughty epitaph, magnis
tamen excidit ausis, and instead knock under table that Satan hath
beguiled me to play the fool with myself, in which however he hath
shewed his masterpiece; for I defy the whole clan of Hell to produce
another lye so like to truth as this is. But if I act my motto, and go the
way of an Eagle in the air, then have I played a trump upon Death
and shewn myself a match for the Devil.
“And while I am thus fighting with Death and Hell, it looks a little like
foul play for Flesh and Blood to interpose themselves against me.
But if any one hath spite enough to give me a polt, thinking to falsify
my faith by taking away my life, I only desire them first to qualify
themselves for my executioners, by taking this short test in their own
consciences: whoever thinks that any thing herein contained is not
fair dealing with God and Man, let him—or her—burn this book, and
cast a stone at him that wrote it.”
CHAPTER CLXXIII.
MORE CONCERNING ASGILL. HIS DEFENCE IN THE HOUSE OF COMMONS,
HIS EXPULSION, FARTHER SPECULATIONS AND DEATH.
Let not that ugly Skeleton appear!

Sure Destiny mistakes; this Death's not mine!
DRYDEN.
The substance of Asgill's argument has been given in his own

words, but by thus abstracting and condensing it his peculiar manner
is lost. This though it consisted more perhaps in appearance than in
reality, is characteristic of the author, and may be well exemplified in
the concluding passage of one of his political pamphlets:
“But I shall raise more choler by this way of writing,

For writing and reading are in themselves commendable things,
But 'tis the way of writing at which offence is taken,
And this is the misfortune of an Author,
That unless some are angry with him, none are pleased.
Which puts him under this dilemma,
That he must either ruin himself or his Printer.
“But to prevent either, as far as I can, I would rather turn

Trimmer and compound too. And to end all quarrels with my
readers (if they please to accept the proposal,
And to shew withal that I am no dogmatical Author,)
I now say to them all, in print, what I once did to one of them, by
word of mouth. Whoever meets with any thing in what I publish,
which they don't like,
Let 'em strike it out.
But to take off part of the Odium from me,
They say others write like me,
In short paragraphs:
(An easy part of a mimick,)
But with all my heart!
I don't care who writes like me,
So I do'nt write like them.”
Many a book has originated in the misfortunes of its Author. Want,

imprisonment, and disablement by bodily infirmity from active
occupation, have produced almost as many works in prose or rhyme,
as leisure, voluntary exertion, and strong desire. Asgill's harmless
heresy began in an involuntary confinement to which he was
reduced in consequence of an unsuccessful speculation; he had
engaged in this adventure (by which better word our forefathers
designated what the Americans call a spec,) with the hope of
increasing his fortune, instead of which he incurred so great a loss
that he found it necessary to keep his chamber in the Temple for
some years. There he fell to examining that “Book of Law and
Gospel,” both which we call the Bible; and examining it as he would
have perused an old deed with the hope of discovering in it some
clause upon which to ground a claim at law, this thought, he says,
first came into his head; but it was a great while coming out. He was
afraid of his own thoughts, lest they were his own only, and as such
a delusion. And when he had tried them with pen, ink and paper, and
they seemed to him plainer and plainer every time he went over
them, and he had formed them into an Argument, “to see how they
would bear upon the proof,” even then he had no intention of making
them public.
“But writing an ill hand,” says he, “I resolved to see how it would look
in print. On this I gave the Printer my Copy, with money for his own
labour, to print off some few for myself, and keep the press secret.
But I remember before he got half way through, he told me his men
fancied I was a little crazed, in which I also fancied he spoke one
word for them and two for himself. However I bid him go on; and at
last it had so raised his fancy that he desired my leave to print off
one edition at the risque of his own charge, saying he thought some
of the Anabaptists would believe it first. I being just then going for
Ireland, admitted him, with this injunction, he should not publish them
'till I was got clear out of Middlesex; which I believe he might
observe; though by what I heard afterwards, they were all about
town by that time I got to St. Albans: and the book was in Ireland
almost as soon as I was, (for a man's works will follow him,) with a
noise after me that I was gone away mad.”
Asgill was told in Ireland that the cry which followed him would
prevent his practice; it had a contrary effect, for “people went into
Court to see him as a Monster and heard him talk like a man.” In the
course of two years he gained enough by his profession to purchase
Lord Kenmure's forfeited estate, and to procure a seat in the Irish
House of Commons. The purchase made him enemies; as he was
on the way to Dublin he met the news that his book had been burnt
by Order of the House. He proceeded however, took the oaths and
his seat, and the Book having been condemned and executed
without hearing the author in its defence, nothing more was
necessary than to prove him the Author and expel him forthwith, and
this was done in the course of four days. After this he returned to
England and obtained a seat for Bramber, apparently for the mere
sake of securing himself against his creditors. This borough he
represented for two years; but in the first Parliament after the Union
some of the Scotch Members are said to have looked upon it as a
disgrace to the House of Commons that a man who enjoyed his
liberty only under privilege should sit there, and instead of attempting
to remedy a scandal by straight forward means, they took the easier
course of moving for a Committee to examine his book. Their report
was that it was profane and blasphemous, highly reflecting upon the
Christian Religion. He was allowed however to make his defence,
which he thus began.
“Mr. Speaker, this day calls me to something I am both unapt and

averse to—Preaching. For though, as you see, I have vented some
of my thoughts in religion, yet I appeal to my conversation, whether I
use to make that the subject of my discourse. However that I may
not let this accusation go against me by a Nihil dicit, I stand up to
make my defence. I have heard it from without doors that I intended
to withdraw myself from this day's test and be gone; which would
have given them that said it an opportunity to boast that they had
once spoken truth. But quo me fata trahunt, I'll give no man occasion
to write fugam fecit upon my grave-stone.”
He then gave the history of his book and of his expulsion in Ireland,
and thanked the House for admitting him to a defence before they
proceeded to judgement. “I find,” said he, “the Report of the
Committee is not levelled at the argument itself which I have
advanced, nor yet against the treatise I have published to prove it,
but against some expressions in that proof, and which I intend to
give particular answers to. But there is something else laid to my
charge as my design in publishing that argument, of higher concern
to me than any expressions in the treatise, or any censure that can
fall on me for it; as if I had wrote it with a malicious intention to
expose the scriptures as false, because they seemed to contain
what I asserted; and that therefore if that assertion did not hold true,
the Scripture must be false. Now whether this was my intention or
no, there is but one Witness in Heaven or Earth can prove, and that
is He that made me, and in whose presence I now stand, and Who is
able to strike me dead in my place; and to Him I now appeal for the
truth of what I protest against: that I never did write or publish that
argument with any intention to expose the Scriptures; but on the
contrary, (though I was aware that I might be liable to that censure,
which I knew not how to avoid) I did both write and publish it, under a
firm belief of the truth of the Scriptures: and with a belief, (under that)
that what I have asserted in that argument is within that truth. And if
it be not, then I am mistaken in my argument and the Scripture
remains true. Let God be true and every man a lyar. And having
made this protestation, I am not much concerned whether I am
believed in it or not; I had rather tell a truth than be believed in a lie
at any time.”
He then justified the particular passage which had been selected for
condemnation, resting his defence upon this ground, that he had
used familiar expressions with the intent of being sooner read and
more readily understood. There was indeed but a single word which
savoured of irreverence, and certainly no irreverence was intended
in its use: no one who fairly perused his argument but must have
perceived that the levity of his manner in no degree detracted from
the seriousness of his belief. “Yet,” said he, “if by any of those
expressions I have really given offence to any well-meaning
Christian, I am sorry for it, though I had no ill intention in it: but if any
man be captious to take exceptions for exception sake, I am not
concerned. I esteem my own case plain and short. I was expelled
one House for having too much land; and I am going to be expelled
another for having too little money. But if I may yet ask one question
more; pray what is this blasphemous crime I here stand charged
with? A belief of what we all profess, or at least what no one can
deny. If the death of the body be included in the Fall, why is not the
life of the body included in the Resurrection? And what if I have a
firmer belief of this than some others have? Am I therefore a
blasphemer? Or would they that believe less take it well of me to call
them so. Our Saviour in his day took notice of some of little faith and
some of great faith, without stigmatizing either of them with
blasphemy for it. But I do not know how 'tis, we are fallen into such a
sort of uniformity that we would fain have Religion into a Tyrant's
bed, torturing one another into our own size of it only. But it grows
late, and I ask but one saying more to take leave of my friends with. I
do believe that had I turned this Defence into a Recantation, I had
prevented my Expulsion: but I have reserved my last words as my
ultimate reason against that Recantation. He that durst write that
book, dares not deny it!”
“And what then?” said this eccentric writer, when five years
afterwards he published his Defence. “Why then they called for
candles; and I went away by the light of 'em: and after the previous
question and other usual ceremonies, (as I suppose) I was expelled
the House. And from thence I retired to a Chamber I once had in the
Temple; and from thence I afterwards surrendered myself in
discharge of my bail, and have since continued under confinement.
And under that confinement God hath been pleased to take away,
‘the Desire of mine Eyes with a stroke,’ which hath however drowned
all my other troubles at once; for the less are merged in the greater;
Qui venit hic fluctus, fluctus supereminet omnes.
And since I have mentioned her, I'll relate this of her. She having
been educated a Protestant of the Church of England, by a Lady her
Grandmother, her immediate parents and other relations being
Roman Catholics, an honest Gentleman of the Romish persuasion,
who knew her family, presented her, while she was my fellow-
prisoner, with a large folio volume, being the history of the Saints
canonized in that Church, for her reading; with intention, as I found,
to incline her that way. With which, delighting in reading, she
entertained herself 'till she shad gone through it; and some time after
that she told me that she had before some thoughts towards that
religion, but that the reading that history had confirmed her against it.
“And yet she would never read the book I was expelled for 'till after
my last expulsion; but then reading it through, told me she was
reconciled to the reasons of it, though she could not say she
believed it. However she said something of her own thoughts with it,
that hath given me the satisfaction that she is ‘dead in Christ,’ and
thereby sure of her part in the first Resurrection: the Dead in Christ
shall arise first. And this pars decessa mei leaving me half dead
while she remains in the grave, hath since drawn me, in diving after
her, into a nearer view and more familiar though more unusual
thoughts of that first Resurrection than ever I had before. From
whence I now find that nothing less than this fluctus decumanus
would have cast me upon, or qualified me for, this theme, if yet I am
so qualified. And from hence I am advancing that common Article in
our Creed, the Resurrection of the Dead, into a professed study;
from the result of which study I have already advanced an assertion,
which (should I vent alone) perhaps would find no better quarter in
the world than what I have advanced already. And yet, though I say it
that perhaps should not, it hath one quality we are all fond of,—it is
News; and another we all should be fond of, it is good News: or at
least, good to them that are so, ‘for to the froward all things are
froward.’
“Having made this Discovery, or rather collected it from the Word of

Life; I am advancing it into a Treatise whereby to prove it in special
form, not by arguments of wit or sophistry, but from the evidence and
demonstration of the truth as it is in Jesus: which should I
accomplish I would not be prevented from publishing that edition to
gain more than I lost by my former; nor for more than Balak ever
intended to give, or than Balaam could expect to receive, for cursing
the people of Israel, if God had not spoilt that bargain. I find it as old
as the New Testament, ‘if by any means I may attain the
Resurrection of the Dead.’ And though Paul did not then so attain,
(not as if I had already attained,) yet he died in his calling, and will
stand so much nearer that mark at his Resurrection. But if Paul, with
that effusion of the Spirit upon him in common with the other
Apostles, and that superabundant revelation given him above them
all, by that rapture unto things unutterable, did not so attain in that
his day; whence should I a mere Lay, (and that none of the best
neither) without any function upon me, expect to perfect what he left
so undone?—In pursuit of this study I have found, (what I had not
before observed) that there are some means since left us towards
this attainment, which Paul had not in his day; for there now remain
extant unto the world, bound up with that now one entire record of
the Bible, two famous Records of the Resurrection that never came
to Paul's hands; and for want whereof, perhaps, he might not then so
attain. But having now this intelligence of them, and fearing that in
the day of Account I may have a special surcharge made upon me
for these additional Talents and further Revelations; and bearing in
mind the dreadful fate of that cautious insuring servant who took so
much care to redeliver what he had received in statu quo as he had
it that it might not be said to be the worse for his keeping, I have
rather adventured to defile those Sacred Records with my own study
and thoughts upon them, than to think of returning them wrapt up in
a napkin clean and untouched.
“Whether ever I shall accomplish to my own satisfaction what I am
now so engaged in, I do not yet know; but 'till I do, I'll please myself
to be laughed at by this cautious insuring world, as tainted with a
frenzy of dealing in Reversions of Contingencies. However in the
mean time I would not be thought to be spending this interval of my
days by myself in beating the air, under a dry expectancy only of a
thing so seemingly remote as the Resurrection of the Dead: like
Courtiers-Extraordinary fretting out their soles with attendances in
ante-rooms for things or places no more intended to be given them
than perhaps they are fit to have them. For though I should fall short
of the attainment I am attempting, the attempt itself hath translated
my Prison into a Paradise; treating me with food and enamouring me
with pleasures that man knows not of: from whence, I hope, I may
without vanity say,
Deus nobis hæc otia fecit.”
What the farther reversion might be to which Asgill fancied he had

discovered a title in the Gospels, is not known. Perhaps he failed in
satisfying himself when he attempted to arrange his notions in logical
and legal form, and possibly that failure may have weakened his
persuasion of the former heresy: for though he lived twenty years
after the publication of his Defence and the announcement of this
second discovery in the Scriptures, the promised argument never
appeared. His subsequent writings consist of a few pamphlets in
favour of the Hanoverian succession. They were too inconsiderable
to contribute much towards eking out his means of support, for which
he was probably chiefly indebted to his professional knowledge. The
remainder of his life was past within the Rules of the King's Bench
Prison, where he died in 1738 at a very advanced age, retaining his
vivacity and his remarkable powers of conversation to the last. If it be
true that he nearly attained the age of an hundred (as one statement
represents) and with these happy faculties unimpaired, he may have
been tempted to imagine that he was giving the best and only
convincing proof of his own argument. Death undeceived him, and
Time has done him justice at last. For though it stands recorded that
he was expelled the House of Commons as being the Author of a
Book in which are contained many profane and blasphemous
expressions, highly reflecting upon the Christian Religion! nothing
can be more certain than that this censure was undeserved, and that
his expulsion upon that ground was as indefensible as it would have
been becoming, if, in pursuance of the real motives by which the
House was actuated, an Act had been past disqualifying from that
time forward any person in a state of insolvency from taking or
retaining a seat there.
In the year 1760 I find him mentioned as “the celebrated gentleman

commonly called ‘translated Asgill.’” His name is now seen only in
catalogues, and his history known only to the curious:—“Mais, c'est
assez parlé de luy, et encore trop, ce diront aucuns, qui pourront
m'en blasmer, et dire que j'estois bien de loisir quand j'escrivis cecy;
mais ils seront bien plus de loisir de la lire, pour me reprendre.”1
1 BRANTOME.
CHAPTER CLXXIV.
THE DOCTOR INDULGES IN THE WAY OF FANTASTIC AND TYPICAL

SPECULATION ON HIS OWN NAME, AND ON THE POWERS OF THE LETTER D.,
WHETHER AS REGARDS DEGREES AND DISTINCTIONS, GODS AND
DEMIGODS, PRINCES AND KINGS, PHILOSOPHERS, GENERALS OR
TRAVELLERS.
My mouth's no dictionary; it only serves as the needful interpreter of my heart.
QUARLES.
There were few things in the way of fantastic and typical speculation
which delighted the Doctor so much as the contemplation of his own
name:
DANIEL DOVE.
D. D. it was upon his linen and his seal. D. D. he used to say,

designated the highest degree in the highest of the sciences, and he
was D. D. not by the forms of a University, but by Nature or Destiny.
Besides, he maintained, that the letter D was the richest, the most
powerful, the most fortunate letter in the alphabet, and contained in
its form and origin more mysteries than any other.
It was a potential letter under which all powerful things were

arranged; Dictators, Despots, Dynasties, Diplomas, Doctors,
Dominations; Deeds and Donations and Decrees; Dioptrics and
Dynamics; Dialectics and Demonstrations.
Diaphragm, Diathesis, Diet, Digestion, Disorder, Disease, Diagnosis;

Diabrosis, Diaphragmatis, Diaphthora, Desudation, Defluxions,
Dejection, Delirium, Delivery, Dyspepsy, Dysmenorrhœa, Dysorœxia,
Dyspnœa, Dysuria, Dentition, Dropsy, Diabetes, Diarrhœa,
Dysentery; then passing almost in unconscious but beautiful order
from diseases to remedies and their consequences, he proceeded
with Dispensation, Diluents, Discutients, Deobstruents, Demulcents,
Detergents, Desiccatives, Depurantia, Diaphoretics, Dietetics,
Diachylon, Diacodium, Diagrydium, Deligations, Decoctions, Doses,
Draughts, Drops, Dressings, Drastics, Dissolution, Dissection. What
indeed he would say, should we do in our profession without the Ds?
Or what would the Divines do without it—Danger, Despair, Death,

Devil, Doomsday, Damnation; look to the brighter side, there is the
Doxology, and you ascend to Διὸς, and Deus and Deity.
What would become of the farmer without Dung, or of the Musician

without the Diapason? Think also of Duets in music and Doublets at
Backgammon. And the soldier's toast in the old Play, “the two Ds
Drink and your Duty.”1
1 Shirley, Honoria and Mammon.
Look at the moral evils which are ranged under its banners,
Dissentions, Discord, Duels, Dissimulation, Deceit, Dissipation,
Demands, Debts, Damages, Divorce, Distress, Drunkenness, Dram-
drinking, Distraction, Destruction.
When the Poet would describe things mournful and calamitous,

whither doth he go for epithets of alliterative significance? where but
to the letter D? there he hath Dim, Dusky, Drear, Dark, Damp, Dank,
Dismal, Doleful, Dolorous, Disastrous, Dreadful, Desperate,
Deplorable.
Would we sum up the virtues and praise of a perfect Woman, how

should we do it but by saying that she was devout in religion,
decorous in conduct, domestic in habits, dextrous in business, dutiful
as a wife, diligent as a mother, discreet as a mistress, in manner
debonnaire, in mind delicate, in person delicious, in disposition
docile, in all things delightful. Then he would smile at Mrs. Dove and
say, I love my love with a D. and her name is Deborah.
For degrees and distinctions, omitting those which have before been
incidentally enumerated, are there not Dauphin and Dey, Dux, Duke,
Doge. Dominus, with its derivatives Don, the Dom of the French and
Portugueze, and the Dan of our own early language; Dame, Damsel,
and Damoisel in the untranslated masculine. Deacons and Deans,
those of the Christian Church, and of Madagascar whose title the
French write Dian, and we should write Deen not to confound them
with the dignitaries of our Establishment. Druids and Dervises,
Dryads, Demigods and Divinities.
Regard the Mappa Mundi. You have Denmark and Dalecarlia,

Dalmatia and the fertile Delta, Damascus, Delos, Delphi and
Dodona, the Isles of Domingo and Dominica, Dublin and Durham
and Dorchester and Dumfries, the shires of Devon, Dorset and
Derby and the adjoining Bishoprick. Dantzic and Drontheim, the
Dutchy of Deux Ponts; Delhi the seat of the Great Mogul, and that
great city yet unspoiled, which
Geryon's sons
Call El Dorado,—
the Lakes Dembea and Derwentwater, the rivers Dwina, Danube and
Delawar, Duero or Douro call it which you will, the Doubs and all the
Dons, and our own wizard Dee,—which may be said to belong
wholly to this letter, the vowels being rather for appearance than use.
Think also, he would say of the worthies, heroes and sages in D.

David, and his namesake of Wales. Diogenes, Dædalus, Diomede,
and Queen Dido, Decebalus the Dacian King, Deucalion, Datames
the Carian whom Nepos hath immortalized, and Marshal Daun who
so often kept the King of Prussia in check, and sometimes defeated
him. Nay if I speak of men eminent for the rank which they held, or
for their exploits in war, might I not name the Kings of Persia who
bore the name of Darius, Demaratus of Sparta, whom the author of
Leonidas hath well pourtrayed as retaining in exile a reverential
feeling toward the country which had wronged him: and Deodatus, a
name assumed by, or given to Lewis the 14th, the greatest actor of
greatness that ever existed. Dion who lives for ever in the page of
Plutarch; the Demetrii, the Roman Decii, Diocletian, and Devereux
Earl of Essex, he by whom Cadiz was taken, and whose execution
occasioned the death of the repentant Elizabeth by whom it was
decreed. If of those who have triumphed upon the ocean shall we
not find Dragat the far-famed corsair, and our own more famous and
more dreadful Drake. Dandolo the Doge who at the age of 2
triumphed over the perfidious Greeks, and was first chosen by the
victorious Latins to be the Emperor of Constantinople: Doria of whom
the Genoese still boast. Davis who has left his name so near the
Arctic Pole. Dampier of all travellers the most observant and most
faithful.3 Diaz who first attained that Stormy Cape, to which from his
time the happier name of Good Hope hath been given; and Van
Diemen the Dutchman. If we look to the learned, are there not Duns
Scotus and Descartes. Madame Dacier and her husband. Damo the
not-degenerate daughter of Pythagoras, and though a woman
renowned for secrecy and silence; Dante and Davila, Dugdale and
Dupin; Demosthenes, Doctor Dee, (he also like the wizard stream all
our own) and Bishop Duppa to whom the Εικὼν Βασιλικὴ whether
truly or not, hath been ascribed: Sir Kenelm Digby by whom it hath
been proved that Dogs make syllogisms; and Daniel Defoe. Here the
Doctor always pronounced the christian name with peculiar
emphasis, and here I think it necessary to stop, that the Reader may
take breath.
2 The blank is in the original MS. Quære, ninety-five?
3 “One of the most faithful, as well as exact and excellent of all voyage writers.”
Vindiciæ Eccl. Angl. p. 115. Unhappily Southey's wish to continue this work was not
responded to. The continuation would have proved invaluable now; for who, so well
as he, knew the wiles of the Romish Church, and the subtilties of the Jesuit?
CHAPTER CLXXV.
THE DOCTOR FOLLOWS UP HIS MEDITATIONS ON THE LETTER D. AND

EXPECTS THAT THE READER WILL BE CONVINCED THAT IT IS A DYNAMIC
LETTER, AND THAT THE HEBREWS DID NOT WITHOUT REASON CALL IT
DALETH—THE DOOR—AS THOUGH IT WERE THE DOOR OF SPEECH.—THE
MYSTIC TRIANGLE.
More authority dear boy, name more; and sweet my child let them be men of good
repute and carriage.—
LOVE'S LABOUR LOST.

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Last digit is the print number: 9 8 7 6 5 4 3 2 1

1 Cerebral Arteriovenous Malformation 1

3 Ruptured Middle Cerebral Artery Aneurysm 15

4 Unruptured Anterior Communicating Artery Aneurysm 21

5 Intradural Internal Carotid Artery Fusiform Aneurysm 25

6 Spinal Arteriovenous Malformations 31

7 Cranial Dural Arteriovenous Fistula 37

8 Spinal Dural Arteriovenous Fistulas 43

9 Vertebral Artery Dissection 47

10 Basilar Tip Aneurysm 53

11 Endovascular Treatment of Unruptured Aneurysms 61

12 Dominant Hemisphere Hemorrhagic Stroke 69

13 Hypertensive Thalamic Hemorrhage 73

16 Venous Sinus Thrombosis 89

18 Ischemic Stroke Management 101

19 Vestibular Schwannoma 109

20 Sphenoid Wing Meningioma 115

21 Cerebellar Cystic Hemangioblastoma 121

22 Pituitary Apoplexy 127

23 Cushing’s Microadenoma 131

24 Pituitary Macroadenoma – Prolactinoma 137

27 Anaplastic Oligodendroglioma 151

28 Low-Grade Glioma 155

29 Radiation Necrosis versus Tumor Recurrence 159

30 CNS Lymphoma 163

31 Brain Metastases 167

32 Intraventricular Colloid Cyst 171

33 Cerebral Abscess 175

34 Chiari I Malformation 179

36 Normal Pressure Hydrocephalus 187

37 Arachnoid Cyst 191

38 Penetrating Head Injuries 195

39 Intractable Intracranial Hypertension 201

40 Epidural Hematoma 205

41 Chronic Subdural Hematoma 209

42 Subaxial Cervical Fracture 213

43 Odontoid Fractures 219

44 Hangman’s Fracture 225

45 Thoracolumbar Burst Fractures 231

46 Chance Fractures 237

47 Jumped Cervical Facets 241

48 Atlanto-Axial Dislocation 247

49 Basilar Invagination - Rheumatoid Pannus 253

50 Cervical Spondylotic Myelopathy 261

51 Cauda Equina Syndrome 265

52 Foot Drop and Far Lateral Disc Herniation 269

53 Thoracic Disc Herniation 273

54 Spinal Epidural Abscess 279