Dr Jacob Chandy- Father of Modern Neurosurgery in India

Prior to 1949, Neurosurgery in India was being practised by General Surgeons.
Dr.Jacob Chandy, after obtaining  his medical degree from Madras Medical College, worked in the Gulf state of Bahrain. He received his neurosurgical training at the Montreal Neurological Institute with Wilder Penfield and in Chicago with Theodore Rasmussen. Dr. Chandy returned to India after completing his training to work at the Christian Medical College in Vellore. Thus, it was in 1949 that Chandy established the first neurosurgery department in India. He is regarded as Father of Indian Neurosurgery. He initiated the first neurosurgical training program in India at the Christian Medical College, Vellore, Tamilnadu.

The Department of Neurological Sciences at Christian Medical College ( CMC), Vellore,  was started to function in early 1949 under the leadership of Dr. Jacob Chandy who then had the vision to develop the neural sciences as an integration of the clinical and the basic sciences, for the first time in India. This resulted in establishing a department with Neurology, Neurosurgery, Neurochemisty, Neurophysiology, Neuroanatomy and Neuropathology under one roof.

In 1958, formal training in Neurosurgery ( M.S. Neurosurgery) was started at CMC, Vellore. Dr. K.V. Mathai joined as first trainee at CMC, Velore in 1958 and completed formal Neurosurgery training  in 1961.

As Founder President of Neurological Society of India (NSI) in 1951

. On 8^th  December, 1951 Neurological Society of India ( NSI) was constituted by Dr Jacob Chandy as Founder President , Dr. B Ramamurthy, Founder Secretary and Founder Treasurer: Dr Baldev Singh ( Father of Modern Neurology in India), S T Narasimhan.
As the Principal (Dean) of the Christian Medical College,Dr. Chandy displayed his skills as a medical educator and administrator. He was source of inspiration for many neurosurgeons even after his retirement from the medical college  Dr. Jacob Chandy passed away in 2007 at the age of 97,  

His son, Dr. Mathew Chandy is also a famous neurosurgeon. Dr.Mathew Chandy was Professor and also the Head of Department of neurosurgery at CMC Vellore, the same Department founded by his great father. He is presently working as senior consultant Neurosurgeon at Apollo Hospital, Dhaka.

Neurosurgery department of CMC, Vellore is among the best neurosurgical center in India. It is a reputed neurosurgical training center. The associated hospital is one of the most respected center and provides services to the patients not only from South India but patients from other states and other countries. Charity, devotion to serve, ability to compete with the most technologically advanced centers make this medical college and hospital a pilgrimage for anyone who aspires to be an ethical Neurosurgeon. 



Sources:

Abraham J, Mathai KV, Rajshekhar V, Narayan RK. Jacob Chandy: pioneering neurosurgeon of India. Neurosurgery. 2010 Sep;67(3):567-75.
http://www.cmch-vellore.edu/static/neuro
Karapurkar AP, Pandya SK.Neurosurgery in India.Neurosurg Rev. 1983;6(3):85-92.
http://www.mni.mcgill.ca/media/stories/sept_2007_chandy/

Emil Theodor Kocher (1841-1917) - Pioneer Swiss Neurosurgeon

Emil Theodor Kocher (1841-1917) was elected as head of the university clinic for surgery in Berne, Switzerland at the age of 31 years. During the 45 years of his professorship he became one of the outstanding surgeons of Europe by using surgical techniques based predominately on physiological and biological ideas. He published 249 scholarly articles and books, trained numerous medical doctors and treated thousands of patients.Kocher received the Nobel Prize in Physiology or Medicine in 1909 because he devoted himself to intense research and development in the pathophysiology and surgical treatment of diseases of the thyroid gland. His particular neurosurgical interests were in cerebral and spinal trauma, operative treatment of epilepsy and the pathophysiology of elevated intracranial pressure.

He implemented of antiseptic wound treatment which prevented infection and later death of the patients . He used special masks , monitored anesthesia and later used local anesthesia for goiter surgery which removed the dangers of anesthesia.  He achieved minimal blood loss during surgery by controlling the smallest bleeding source and thus decreased the post operative infection. Kocher first attained international recognition with his method to reset a dislocated shoulder published in 1870. The new procedure was much less painful and safer than the traditionally used procedure and could be performed by a single physician. Kocher also studied the phenomena of bullet wounds.

Kocher also contributed significantly to the field of neurology and  neurosurgery.  Furthermore, he investigated the surgical treatment of epilepsy and spinal and cranial trauma. He found that in some cases, the epilepsy patients had a brain tumor which could be surgically removed. He hypothesized that epilepsy was caused by an increase in ICP and believed that drainage of cerebrospinal fluid could cure epilepsy.
The founder of American Neurosurgery, Dr. Harvey Cushing spent several month in the lab of Kocher in 1900, performing cerebral surgery and first encountering the Cushing Reflex which describes the relationship between blood pressure and intracranial pressure.  Kocher later also found that decompressive craniotomy was an effective method to lower ICP.
In his surgery textbook Chirurgische Operationslehre, Kocher dedicated 141 pages of 1060 pages to surgery of the nervous system. It included methods of exploration and decompression of the brain.
Kocher was a surgical pioneer and in 1909 was awarded the Nobel Prize in Physiology or Medicine for his contributions to the understanding and treatment of the thyroid gland. What is lesser known are his contributions to neurosurgery. He published articles on traumatic epilepsy, brain damage and trepanation. Together with Harvey Cushing, they pioneered and expanded on research of the physiology of intracranial pressure, which led to the advent of the Cushing–Kocher theory. 

References: 

Hildebrandt G, Surbeck W, Stienen MN. Emil Theodor Kocher: the first Swiss neurosurgeon.Acta Neurochir (Wien). 2012 Jun;154(6):1105-15 

Wikipedia 

ScienceDirect 

Cheryl Choong^, , Andrew H. Kaye. Emil Theodor Kocher (1841–1917)  Journal of Clinical Neuroscience, Volume 16, Issue 12, December 2009, Pages 1552–1554

 

Founders of Neurosurgery in France

Contribution of France in the development of Neurosurgery as a subspeciality of surgery had been exemplary and French Neurosurgeons had been the Pioneers.


Dr. Clovis Vincent

THIERRY DE MARTEL  (1875-1940) and CLOVIS VINCENT ( 1879-1947) developed neurosurgery as a discipline in France.
Thierry De Martel, as a student in a school for training engineers, had interest in neurosurgical instruments. Together with Vincent they developed neurosurgery as a discipline in France.In World War I De Martel was a medical officer and received many decorations for his services and his bravery.
Vincent Clovis began his carrier as a neurologist and finally became neurosurgeon at an advanced age. He was mainly interested in pituitary tumors and his work on oncologic neurosurgery remains valuable.
In 1914, when the First World War broke out, he served as a doctor. He received the Legion of Honor as a soldier and the Military Medal in 1915. He was appointed chief physician of the neurological center of the ninth French military region and there, he fostered a new treatment to get soldiers with psychic disease symptomes back to the front.

Clovis Vincent founded the French school of neurosurgery.

Dr. Martel

                                                                      

Jean Talairach (January 15, 1911 – March 15, 2007) was a neurosurgeon who practiced at the Centre Hospitalier Ste. Anne in Paris, and who is noted for his work in stereotaxy : the Talairach coordinates.

Pierre Wertheimer ( 1892-1982): Neurosurgical innovations in Lyon

Gerard Guiot ( 1912-1996): Pituitary Surgery

Living Legend Dr Maurice Choux contributed significantly in the development of Pediatric neurosurgery in France and encouraged many neurosurgeons worldwide to devote their practice to pediatric neurosurgery.

Sources:
Wikipedia,
PubMed
http://www.uic.edu/depts/mcne/founders
www.neurosar.ru
www.google.co


 

Clinical and practical knowledge of Intracranial Pressure (ICP) & Cerebral Perfusion Pressure (CPP)

 Quincke in 1891 first reported the measurement of intracranial pressure through lumbar route.

Quickenstedt  established the range of normal ICP and demonstrated the effect of changes in body position and respiration .
Lundberg, in 1960, described the 3 ICP waveforms.
Cranium is like a rigid bony sphere with a constant intracranial volume and it contains three components

1. Brain    1400 mL

2. CSF       150 mL

3. Blood    150 mL

Therefore, any change in the volume of the brain causes a reciprocal change in the volume of other intracranial components,i.e., either blood or CSF.  This is the basis of Monro-Kellie hypothesis introduced in neurosurgery by Cushing.

There is a relationship between  intracarnial volume and intracranial pressure.  Because cranium  is  a rigid and non-distensible structure, any increase in the volume of a component would be accompanied by a reciprocal decrease in the volume of the other two components. Once the volume buffering capacity is exhausted, the ICP would begin to rise.

During gradual expansion of a mass lesion, the volume displaced may be CSF, intravascular blood or brain tissue water. Of the three components, CSF appears to be the main buffer and is the first to be displaced as evident  by compressed ventricles  and obliterarted subarachnoid spaces.

The rate of expansion of an intracranial mass is also important. A rapidly growing intracranial mass lesion may outpace the compensatory shift of CSF and even the smallest increase in mass could produce a life threatening increase in ICP. Thus, a large hematoma could be accommodated within a few hours without dangerous rise in ICP.

Intracranial hypertension can lead to secondary changes by interfering with the cerebral blood flow ( CBF). The normal  cerebral blood flow ( CBF) is about 50 mL/100 g/min.

Cerebral Perfusion Pressure ( CPP) is defined as the difference between mean arterial pressure

( MAP) and intranial pressure (ICP).

CPP= MAP-ICP

Normal range of ICP in an adult is less than 10-15 mmHg.

Cerebral perfusion pressure is normal till the autoregulation mechanism of brain is intact. But there is a range upto which level body is able to maintain CPP.  Between 60 to 160 mmHg of mean arterial pressure brain will be able to receive blood with normal perfusion. But, if MAP falls blow 50 mmHg, features of cerebral ischemia will appear.
Mean Arterial Pressure ( MAP)= Diastolic Pressure+1/3rd of Pulse Pressure 
Pulse pressure= Systolic blood pressure - Diastolic pressure
So, in a normal person MAP = 80 mmHg+ (120mmHg-80mmHg)/3
MAP= 80+40/3
So on average, roughly MAP is about 90-95.

A rise in ICP would lead to a fall in CPP unless buffered by a compensatory rise in blood pressure ( Cushing response). Raised ICP can cause hypertension, bradycardia and respiratory changes. Therefore any patient who is suspected as a case of intracranial space occupying lesion ( ICSOL), like brain tumor or hematoma or granuloma or abscess and complaining of headache, vomiting, blurring of vision then blood pressure and pulse rate should always be monitored. In clinical setting bradycardia is a reliable indicator of rise in ICP in a patient who was otherwise allright sometimes back. Bradycardia is a sign of raised ICP and can precede and ppears before deterioration of conscious level ( Drowsinees, disorientation or poor Glasgow Coma Scale) and papillary asymmetry.

Lundberg described three pressure waves namely A waves, B waves and  C waves .

A waves
A waves are pathological  and indicate rapid rise in ICP  for variable period and then rapid fall to the baseline.
The A waves that persist for longer periods( usually 5-20 minutes) are called plateau waves.
Smaller A waves termed “ atypical” or “ truncated” A waves , that often do not exceed an elevation of 50 mm Hg, are also clinically important early indicators of neurological deterioration.

The A waves are accompanied by clinical features  of raised ICP, like headache, vomiting, decerebrate posturing, papillary changes, bradycardia and hypertension and respond to CSF drainage, hyperventilation and osmotic diuretics.

B waves

Occur at the rate of 0.2-2 per minute and are related to respiration.

B waves may be vasomotor in origin. Lundberg initially described them in patients with intracranial hypertension, though they can occur in normal individuals.
B waves are said to be one of the best predictors of outcome after surgery for normal pressure hydrocephalus.

C waves

C waves are low amplitude with afrequency of 4-8 per minute. These waves are thought to be related to Traube-Hering- Mayer waves.
C waves are of little clinical significance.

There is pressure equilibrium in the skull  but if pressure rises then a part of brain herniates. The herniations are subfalcine, tentorial, and tonsillar. In subfalcine herniation, a part of the frontal lobe herniates below the falx to the opposite side . In tentorial herniation ( Uncal herniation) a part of the medial temporal lobe herniated below through an opening in the tent and compresses over the midbrain. In tonsillar herniation, a part of cerebellum,i.e, Cerebellar Tonsil herniates down through the Foramen Magnum and compresses the medulla oblongata ( Coning). Brain Herniation is life threatening as it causes  brain stem compression which contains vasomotor center. Patient presents with drowsiness, deceerbrate posturing, papillary asymmetry, bradycardia, hypertension and respiratory irregularities.

Increased ICP is indicated by a sustained elevation in pressure above 15 mmHg or when intermittent A or B waves are recorded.

The normal CSF pressure measured through the lumbar route ranges from 50 to 200 mm H₂O in the lateral decubitus position.

ICP and CPP monitoring are important in the management of head injury patients, especially in whom the decision to operate is equivocal. Surgery may be required if ICP is progressively rising and not responding to conservative treatment with cerebral decongestants. ICP monitoring may also be required in patients of spontaneous subarachnoid hemorrhage (SAH) to assess the effect of cerebral vasospasm and in patients of arrested hydrocephalus and  normal pressure hydrocephalus to take decision about CSF diversion procedure.

Various methods of monitoring the ICP

1.       Intraventricular catheters like External Ventricular Drainage ( EVD): Most accurate, lower cost, also allows therapeutic drainage of CSF

2.       Intraparenchymal catheters (eg. Camino labsor Honeywell/Phillips)

3.       Epidural catheters ( e.g. Fibreoptic tipped catheter: Ladd fireoptic)

4.       Subarachnoid bolt (screw)

5.       Subdural ( eg. Cordis Cup catheter)

Monitoring Systems can broadly be divided into Fluid coupled system and Non-fluid cupled system

In fluid-coupled system a fluid filled catheter or a hollow bolt placed in the ventricle, subarachnoid space or the subdural space connected to a pressure transducer through a fluid-filled line. The transducer converts the hydraulic pressure into an electrical signal which can be displayed  digitally or an oscilloscope.

In Non-fluid coupled systems, the transducer is mounted on the monitoring device itself.

In infants and in children below 18 months of age , the anterior fontanelle is open. Tense anterior fontanelle indicates raised ICP and intraventricular pressure. CSF drainage can be done from the right side lateral angle of the diamond shaped anterior fontanelle.

In clinical setting  cerebral edema is one of the important causes of raised ICP.  if a patient presents with clinical features of raised intracranial pressure, then following steps may be helpful:

Bed rest  reduces the cerebral  metaboloic  rate of oxygen consumption and decreased blood supply

Oxygenation

Elevation of head end of the bed to 30^o

Acetazolamide ( Diamox tablet) is a carbonic anhydrase inhibitor and is available in tablet form . In an adult 250 mg tablet can be given orally three times a day( tds)

Frusemide or Furusemide ( Lasix) is a loop diuretic and is available in both oral and injectable form. A dose of 40 mg twice a day reduces the cerebral edema ICP. But Frusemide use may cause  potassium  loss leading to hypokalemia so serum electrolyte monitoring should also be done. To avoid hypokalemia , potassium supplement is advised for example syp Potklor  1 TSF twice a day or Injection KCL  in Intravenous  infusion may be given. Another drug can be prescribed is Spiroolactone( Lasilactone), a potassium sparing diuretic and then potassium supplementation is not required.

Injection Mannitol 100 ml stat or 100 ml 8 hourly ( 1 -1.5 Gm/ kg body weight in divided doses in an adult) for three days and then Syp Glycerol 6 TSF three times a day for about 2 weeks.

Dexamethasone 4 mg 6 hourly in injectabe or oral form. Ranitidine or other antacid should be prescribed alog with steroid to avoid gastritis. Dexamethasone is diabetogenic and raises blood sugar level. Prolong  use is associated with fluid retention and swelling over face and body.

CSF drainage is another way to reduce ICP. Ventricular tap is done usually through the point just anterior to the coronal suture on right side , about 3 cm lateral to the sagittal suture . This is a ethod of reducing ICP in a patient with post meningitic hydrocephalus and at the time of surgery. And if CSF pressure is persistently high then External ventricular drainage system can be used.

Elective hyperventilation is a mode or reducing ICP. Hyperventilation leads to CO₂ wash out which  causes vasoconstriction and decreased blood supply to the brain leading to decreased ICP. In this procedure patient is intubated after giving muscle relaxant and put on ventilation for about 48 hours. The ventilator mode is Controlled Mechanical Ventilation ( CMV) the respiratory rate is low,i.e., about 16/minute and monitoring of the patient is done with arterial blood gases(ABG) in which the pCO₂ is about 25mm Hg ( Normal range of arterial partial pressure of Carbon Dioxide ranges from 25mm Hg to 42 mmHg). Elective hyperventilation is often advise in patients with severe head injury, diffuse axonal injury, in a patient of spontaneous subarachnoid hemorhhage ( SAH) presenting with features of vasospasm, after a prolonged surgery with brain swelling during surgery.

Some surgical ways of reducing ICP are CSF diversion procedures ,  decompressive craniectomy or excision of the intracranial space occupying lesion( ICSOL) like hematoma, tumor or abscess.

Sources: 

Chapter 6. Intra-operative monitoring written by Babu KS, Rajsekhar VRamamurthy & Tandon’s manual of Neurosurgery ,  Editors:  PN Tandon, Ravi Ramamurthy, Pradeep Kumar Jain N, first edition: 2014 ISBN 978-93-5152-192-1

Handbook of Neurosurgery, Mark S Greenberg, 7^th edition ( Thieme Publishers)