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Member since Jun-04-08 · Last seen Aug-30-15
Good Day to All! Ma-ayong adlaw sa tanan. And my thanks to for this excellent website. Salamat Opinions:

1. World Chess Championship

The true Chess World Champions are the holders of the Traditional Title that originated with Steinitz & passed on in faithful succession to Lasker, Capablanca, Alekhine, Euwe, Botvinnik, Smyslov, Tal, Petrosian, Spassky, Fischer, Karpov, Kasparov, Kramnik, Anand, and Carlsen. The sacredness of this Title is what makes it so valuable.

And how does one become the true Chess World Champion? In general, by beating the previous Titleholder one on one in a Match! Matches are preferred over Tournaments because of the Tradition of the WC Succession & because the chance for pre-arranging a Tournament result is more likely. The only exceptions to this rule:

A. In case where the Candidates and World Champion participate in an event that all the participants agree to be a World Championship event because of extraordinary circumstances.

Thus, the 1948 World Championship Tournament was justifiable because of the death of the Title holder Alekhine.

Likewise, the 2007 WC Tournament was justifiable under the extraordinary circumstances of the Chessworld trying to heal its internal rift over the 1993 Kasparov Schism. Anand himself became the World Champion in this 2007 Tournament & not in 2000 when he won a knock-out FIDE Tournament. Caveat: Some chess fans deem the 2007 WC Tournament as illegitimate, considering that Anand became the World Champion only in 2008, when he beat the previous Titleholder Kramnik in a WC match. From this perspective Anand only became the Undisputed World Champion in 2008.

Karpov lost his Title to Kasparov in 1985, & never regained it in the 1990s events that FIDE labeled as 'world championships'. All solely FIDE Champions that emerged outside WC Traditional Succession elaborated on above, strong as they were, were not true World Champions (eg., Bogolyubov 1928, Khalifman 1999, Ponomariov 2002, Kasimdzhanov 2004, Topalov 2005).//

B. In case the previous Titleholder defaults an event that the Chessworld largely deems as a World Championship event in the Tradition of the World Championship Succession. Thus, Karpov was the true successor to Fischer who defaulted their WC Match in 1975.

2. The strongest chess events in different eras of chess history?

Because of the brain's limitations explained below, the best professional (amateurs don't matter much in top level chess) chess players of each generation beginning in the Lasker era have always played at a similar level - near the maximum allowed by human standards. Now there are larger cohorts of chess professionals post WW2 than preWW2 thanks to government state funding in the Soviet era and presently corporate funding. The result is that large preWW2 tournaments had numerous 'bunnies', relatively weak players. By the Kasparov era, super-tournaments that featured most of the top ten, and no bunnies, had became more common. However, the top 4 or 5 since Lasker's time have always been very strong.

Consequently the smaller the top-player-only tournament, the stronger it gets. For any era. If there was a double round robin tournament in 1914 featuring Lasker, Capablanca, Alekhine, and Rubinstein, and no other, it would be as strong as any present day super-tournament.

Now weed out everyone except the two strongest players in the world. What we (usually) get is the chess World Championship match.

There has been talk of elite tournaments, composed only of the strongest top masters and no weaker bunnies replacing the World Championship match in prestige, probably because of the assumption that they would be the strongest chess events possible. False assumption. The strongest chess events in chess history generally have been World Championship matches. Even the strongest masters in each generation usually do not match the world champion and challenger in chess strength. In a World Championship match, the contestant has to meet the monster champion or challenger over and over again, with no weaker master in between. Capablanca vs Lasker 1921 was just as strong a chess event as the recent Carlsen vs Anand 2013, and far stronger than Zurich 2014. (Imagine having to play 14 straight games with a computer-like errorless Capablanca at his peak.)

3. The strongest chess players in chess history?

IMO the 1919 version of Capablanca & the 1971 version of Fischer, both of whom played practically error-free chess, are it; updated in opening theory, they should beat anyone in a match.

If computers were self-aware, I have no doubt that they would unanimously choose the 1916 to 1924 Capablanca as the strongest chess player in history. And please no red herring remark that Capa played only 'simple' chess. This young Capablanca played some of the most complicated, sharp, double edged, and bizarre positions possible; and played them without making a single losing error (and by all accounts with unsurpassed quickness), something that has always befuddled my mind when I got to peruse through his games.

We have to take this question in the context of the limits of the human Anatomy and Physiology. A concrete example would be the one hundred meter dash. The human body is designed such that the limit it can run is about 9 seconds. In order for a human being to run faster, we would have to redesign the human anatomy into that of say a cheetah. One can rev up the human Anatomy and Physiology, say with steroids, but this regimen would hit an eventual Stonewall too; the same way that we could rev up human proficiency to learn openings with computer assistance.

Since the Nervous System has physiological limits (example of a limit- neuronal action potential speed don't go up much more than 100 m/s) and so limits the human chess playing ability, increasing the number human chess players, thus expanding the normal curve of players, simply creates more possibilities of players playing like a Fischer in his prime, but will not create a mental superman who plays chess at computer levels. This explains why human and computer analysis indicate that Lasker was playing on a qualitatively similar level as more recent WCs.

'Worse' in chess, any computer assistance ends once the opening is over. After a computer-assisted opening prep, every GM today has to play the game the way Lasker did a hundred years ago, relying on himself alone, with the same fundamental chess rules and chess clock. An Encyclopedic opening repertoire is not a necessity to be a top player. In fact, there are World Champions who did not do deep opening prep; they just played quiet but sound openings that got them into playable middlegames and then beat their opponents in the midlegame or endgame. Just look at Capablanca, Spassky, Karpov, and now Carlsen.

Because of subconscious adherence to the narcissistic generation syndrome, the belief that everything that is the best can only exist in the here and now, many kibitzers would not agree to the above theses. While it is true that there have been more active chess professionals and consequently larger cohorts of top chess masters on a yearly basis since WW2 thanks to Soviet state funding and present corporate funding, the very top chess masters since Lasker's time have always played at a similar level- within the limits imposed by the human brain. There is no physical law that bars a pre-WW2 chess master from playing chess as well as today's generation. The human brain has not changed in any fundamental manner in the past tens of thousands of years.

4. The greatest chess players in history?

A related question is who is the greatest chess player in history. The answer depends on the criteria one uses. Since I place great emphasis on the ability to play world class chess for the longest period of time, Lasker would be it. He was playing at peak form from 1890 age 22 (when he began a remarkable run of match victories over Bird, Mieses, Blackburne, Showalter, and culminating in his two massacres of Steinitz) until 1925 at age 57 (when he nearly won Moscow after winning new York 1924). Kasparov (high plateau from 1980 to 2005) and Karpov (high plateau from 1972 to 1996) would follow. (At their very peak though, I believe that Kasparov was stronger than Karpov, and both were stronger than Lasker; and the peak Capablanca and Fischer were stronger than any of them.)

5. Computers vs Humans, who is stronger?

Another related question is how history's top masters would fare against computers. It's obvious from Kasparov's time that computers would totally crush them all. Opening knowledge would not matter much. Computers swamp human opponents in the middle game, simply by calculating more variations more rapidly by several orders of magnitude. Peak Capablanca probably would have the best score among humans. Talk about another level of playing is fans' subjective and IMO wrong words for their favorite players, unless one talks about chess computers. Chess computers do play at a higher level.

6. On the game and chess players young and old, past and present:

The proposition that an older player would not be able to adjust to the openings and methods of a younger generation is false, as evidenced by the observation of strong masters whose careers happened to span generations beating the tar out of weaker masters of the next generations. Lasker provides a classic example; he was beating Mieses, Blackburne, and Steinitz in the 1890s, and crushing masters versed in the hyper-modern teaching of controlling the center indirectly- Reti, Bogolyubov, and Euwe in the 1920s. In more recent times, we have Victor the Terrible, who learned most of his chess in the 1940s and 1950s, whom we have seen competing successfully with the so-called computer generation even at an advanced age.

The notion that computers are more advantageous to younger players IMO is not quite right. Younger players should have more energy and stamina in studying chess openings and endgames for long hours everyday compared to older players without computers, but the use of computers would tend to make the learning process easier for every one including the older ones.

As a corollary, computers also make it easier today for very young players in their early teens to peak at a younger age than in past eras, although they tend to level off in their early 20s to their high plateau, defined by their inborn talents and determination.

In brief. computers tend to level chess learning for everyone, young and old.

This is not a rigid rule. The best games I have ever seen played by a 12-13 year old are Capablanca's; and Tal, Karpov, and Kasparov reached their high plateau in their early 20s in a computer-less era, similar to computer age Carlsen. However let it be noted that Carlsen reached his peak sidestepping intensive computer-prepped tactical openings and beating his competitors in the old fashioned way in the middlegame and endgame. These masters peaked early not because of computers by because of their immense chess talent. Perhaps normal rules do not apply to these geniuses.

Another false notion is that the nature of the middlegame today is somehow different from the middlegame in the past. The easiest way to prove the wrongness of this proposition is by observing CG's daily puzzles. Do not peek at the names of the players that played these puzzles, and don't look at the dates. Can you glean from the middlegame play and combinations in the puzzles the date they were played? You can't. You would not know if it was played in 2014, 2000, 1950, or 1900. Chess combinations don't just suddenly change their stripes just because a hundred years have passed.

Another observation is that when the best masters of the past, Lasker and Capablanca met the occasional 'modern' structures of the Sicilian Scheveningen and Dragon, KID, Modern Benoni, Benko Gambit, they played strategically perfectly, in just the way these opening structures should be played. So how did these masters play openings and the resulting middlegame structures that are deemed incomprehensible to them by some of today's dogmatically 'modern' kibitzers? The answer is that chess rules and principles have not changed. Center, rapid development, open files and diagonals, holes, weak pawns, piece activity, initiative and attack, positional sacrifices and all types of combinations were as familiar to them as to us.

Instead, it is the frequencies of a few middlegame pawn structures have changed since WW2. Not the Ruy Lopez or QGD, but obviously Sicilians and KIDs are much more common post-WW2. Since so many games nowadays begin with the Sicilian and KID, people associate these with being 'modern' (which is a rather vague undefined term IMO). But certainly Lasker and Capablanca understood the middlegame principles behind them and when they did get these positions they played them excellently, like the top masters they are.

Moreover, Keres is a smoking gun, bomb proof evidence of the fallacy of Watson's speculation that pre-WW2 masters would not be able to learn 'modern' chess, and Larsen's assertion that he would crush everyone in the 1930s. The glaring fact is that Keres is a 1930s pre-WW2 master whose career extended up to the 1970s, and he did learn (and contributed) to the newer opening variations (the most famous of which is the Keres attack which he invented in 1943). Tellingly enough Keres beat both Watson and Larsen.

7. On ratings:

Elo ratings reflect relative and not absolute chess strength.

Chessplayers are naturally arranged in populations partitioned by geopolitical regions & time periods that have infrequent contacts with one another. Within such a population, players get to play each other more frequently, thus forming a quasi-equilibrium group wherein individual ratings would tend to equilibrate quickly; but not with outside groups. With caveats & in the proper context, FIDE/Elo ratings are simply fallible descriptors & predictors of an active player's near-past & near-future performances against other rated players, & only within the same quasi-equilibrium group.

As corollaries: the best way to evaluate a player's strength is to analyze his games & not his ratings; one cannot use ratings to accurately compare the quality of play of players from the past and present, or even the same player say a decade ago and today; & care should be taken in the use of ratings as a criterion in choosing which players to seed into the upper levels of the WC cycle. All the above often entail comparisons between players from different quasi-equilibrium groups separated by space and/or time.

Regarding inflation deniers, they imply that Elo ratings reflect absolute and not relative chess strength. Professor Elo himself would condemn their view. If the top 20 players were to suffer a serious brain injury and begin playing like patzers, but play no one else for the next decade, they would more or less retain their 2700s ratings, although they would be playing terrible patzerish chess.

8. Best Qualifiers?

The credible, fair, tried & tested Zonals - Interzonals - Candidates (with known strong players directly seeded into the Interzonals & Candidates; & here ratings may be used with caveats) over the random World Cup and the elitist Grand Prix. If possible long Candidate matches and 16 to 24 game World Championship matches. However, with the passing of the state-funded chess era of Soviet times, I begin to doubt if the strict money guzzling qualification process above can be re-installed.

9. The 1993 Chess Rift and Kramnik:

Regarding the Rift in the chessworld after Kasparov split in 1993, I believe that Kramnik has done more than any other individual in helping heal it by concrete actions - agreeing to a WC Match with Topalov in 2006 & not walking out when he could have done so with the support of most of the world's top GMs after getting accused of cheating; & agreeing to Defend his Title in a WC Tournament in 2007, the first time a living Titleholder has agreed to do so in chess history. My eternal gratitude to him.

10. Finances of a would-be Challenger:

Regarding all kinds of problems chessplayers outside of Europe & the USA face in their quest for the Title, Capablanca & Anand have proven it's possible for a non-European non-USA chessplayer to be World Champion; but apparently only if you have the chess talent of a Capablanca or Anand! For others, I guess they would have to try to get monetary support & good seconds somewhere to have some hope for a Title shot.

11. Ducking a World Championship re-match:

Alekhine vs. Capablanca - Not definitively resolved. If pushed, I would tend to favor Capablanca given that pre-WW 2, there was no definitive cycle to choose the Challenger &, after all is said and done, it was the Champion who set the conditions & who chose his Challenger. AAA could & should have chosen Capa; & there was ample time, more than a decade, to do so before WW2. On the other hand, Capa's pride may have caused him to behave arrogantly & thus offend AAA. The issue is very much debatable. //

Kramnik vs. Kasparov - For me, it's resolved. Kudos to Kramnik for trying his best to install a decent Qualifying Event. Kasparov for his reasons clearly did not want to go through the Qualifying Event that he himself had pledged before losing his Title; & did not even seem serious in playing the solely FIDE champions. Why? I can only speculate that Kasparov would rather retire than risk a loss in a Qualifier or a match to either a FIDE champion or to Kramnik. If he regained his Title, he would be the greatest Champion in history, but there was risk involved. If he retired, he would still be the greatest Champion in history, but there would be no risk involved. Kasparov chose the latter & no one should blame him for that decision; & more so don't blame Kramnik!

12. Predictions for Hypothetical World Championship Matches:

Lasker vs. Pillsbury, Rubinstein, Maroczy - Lasker wins 2, loses 1 match //

Lasker vs. Capablanca (inexperienced) 1914 - Lasker close win //

Capablanca (not overconfident & not having TIAs) 1929 to 1937 vs. Alekhine or any other master - Capa win //

Alekhine (sober & prepared) vs. Capablanca (w/ severe HPN & numerous past strokes), Botvinnik, Keres, Fine, Reshevsky, Flohr 1939 - Alekhine win //

Alekhine (alcoholic, ill, & depressed) vs. Botvinnik 1946 - Botvinnik win //

Fischer (inactive for 3 years) vs. Karpov 1975 - Karpov win//

Kasparov vs. Shirov 2000 - Kasparov win. (But GKK should still have given it to Shirov. And don't blame Kramnik. Had Kramnik declined, GKK would have chosen another; & Shirov would still be frustrated.)


I have opened a <'multi-experimental' forum> below. Its nature is that of several secret social and psychological experiments, whose objectives and parameters, and the rules that follow, are strictly defined and which I may or may not reveal. Readers of this forum might be able to deduce some of these rules. Accordingly messages shall be retained or removed with or without explanation, even those from my dear friends here in CG, although I am making it clear here that absolutely no offense is intended to any one in this experiment. I may or may not respond to certain questions and messages, also according to the rules. To my friends: Please bear with me in this matter. There can be a certain amount of disinformation and propaganda in the messages that are retained.

The title of this <'multi-experimental' forum> is:

Biased Journal of a Fourth World Brain Operator

Some abbreviations

CiH = the public City Hospital

PrvH = Private Hospital. There are three main ones. So PrvH 1, PrvH 2, PrvH 3.

ProvH = the public Provincial Hospital

SOL = Space Occupying Lesion

SQ = Subcutaneous tissue layer of the skin or scalp

CVA = Cerebrovascular accident = stroke

EDH = Epidural Hematoma, blood above the dura mater, the outer covering of the brain, and beneath the skull.

SDH = Subdural Hematoma, blood beneath the dura mater.

ASDH = Acute Subdural Hematoma, SDH incurred recently, usually less than a week

CSDH = Chronic Subdural Hematoma, SDH that is more than two weeks old

HCP = Hydrocephalus, too much CSF in the brain's ventricular system

CSF = Cerebrospinal Fluid

CNS = Central Nervous System

CAB = Continuous ambubagging

ETT = Endotracheal tube (for airway purposes)

NGT = Nasogastric tube (for feeding purposes)

NOD = Nurse on duty

The Oracle = personification of the CT (computed tomography) scan.

Magic mirror = the computer monitor where one can see CT scan images.

Witching Hour Admissions or Referrals = 12 midnight to 5am

MF = Motorcycle Fall

Craniectomy = neurosurgical procedure that involves removing a portion of the skull

Tracheostomy = a surgical procedure to create an opening through the neck into the trachea (windpipe)

INTUBATE: To put a tube in, commonly used to refer to the insertion of a breathing tube into the trachea for mechanical ventilation

EXTUBATION: the removal of a tube especially from the larynx after intubationócalled also detubation.

Uneventful day = Most likely still a busy day, making daily rounds in the hospitals, following up post-op patients, seeing patients in the OPD, answering referrals, admitting all kinds of patients in the hospitals; nevertheless a day in which nothing interesting has caught my attention.

>> Click here to see visayanbraindoctor's game collections. Full Member

   visayanbraindoctor has kibitzed 7399 times to chessgames   [more...]
   Aug-30-15 twinlark chessforum
   Aug-25-15 Sinquefield Cup (2015) (replies)
visayanbraindoctor: <Is Fischer the same player if he gets teleported to 2015? Can he change his basic principles, enough to play at a high enough level to challenge a new generation?> Of course he would. Basic chess principles have been well understood since the Lasker era. Anyone ...
   Aug-12-15 visayanbraindoctor chessforum
visayanbraindoctor: 12 August 2015. <4 July 2015. <57M hypertensive basal ganglia hemorrhage patient. (Right temporo-parietal craniectomy, superior temporal gyrus cortisectomy, evacuation of basal ganglia hemorrhage, bone transplant to left hemi-abdomen SQ layer 6/28/15 2:30 pm to ...
   Jul-06-15 Alekhine vs B Gregory, 1909
visayanbraindoctor: <ForeverYoung: This is quite a brilliant combination by the great man beginning with 17 exf5.> Astonishing. The 16 year old Alekhine sacs a rook based on two themes. Shifting his Queen in a sudden twist via the back rank to directly attack his opponent's King on the
   Jul-06-15 Alekhine vs V Rozanov, 1908 (replies)
visayanbraindoctor: <perfidious> Speaking for myself, I would have easily seen and considered the position at 13. h4. But being the unimaginative dumbbell that I am, I probably would have thought that upon 13. h4, then Bxh4 ends my h-pawn's queening aspirations, and would most probably
   Jul-06-15 Wei Yi (replies)
visayanbraindoctor: <Whitemouse: thank you Visayabraindoctor great comments.> Appreciate it. I have began replaying those games myself. It turns out that Alekhine played more games in 1909, since his birthday is on the last quarter of 1892. He was still 16 I believe when he played in ...
   Jul-06-15 Kramnik vs I Nepomniachtchi, 2015
visayanbraindoctor: <Sokrates: Thanks, <visayanbraindoctor>, for your erudite analysis. After having defended so well, Nepo must have felt pretty disappointed about this outcome. Patiently and accurately played by Kramnik, though.> Appreciate it. Kramnik though isn't as ...
   Jul-04-15 Dortmund (2015) (replies)
visayanbraindoctor: <choosea: see "The Rating of Chessplayers" by Dr. Arpad Elo which discusses the development of the Elo rating system "Serious mathematicians have devoted hard work to the rating system trying to improve it, only to have their recommendations ignored." " For women's ...
   Jul-03-15 Wei Yi vs L Bruzon Batista, 2015 (replies)
visayanbraindoctor: A Kasparovian like win and an old fashioned king hunt. Beginning with 20. fg6 hg6 21. Nd5 Nd5 22. Rf7, Wei went all out for the Black King with successive tactical shots whose sole purpose was to expose the Black King and mate him. The young crop of top chess players born
   Jun-22-15 Norway Chess (2015) (replies)
visayanbraindoctor: <fallen angel> Good model game. Duras vs Capablanca, 1913 The comments on this game page on the particular ending that Carlsen and Naka are playing are also instructive, and teaches a little history on the the theory behind this rook ending. Note how the attacking
(replies) indicates a reply to the comment.

Kibitzer's Corner
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Premium Chessgames Member
  visayanbraindoctor: 10 June 2015.

Yesterday I had 7M, a head injured kid who fell off a jackfruit (langka) tree, brought to the OR. I found out his relatives had procured nothing at all for the operation, not even a cautery pen. His father was a disabled person lacking a lower limb, and his mother was said to be insane (buang) by his relatives. So I decided to postpone the operation. I was not unduly worried as he would occasionally still wake up and communicate.

This morning I had 7M was wheeled into the OR once again, but I found out that he was comatose (decorticate) with dilated fixed pupils. I immediately operated.

(Right fronto-parieto-temporal craniectomy, evacuation of epidural hematoma, 6/10/15 9:03 to 9:24 am. No BT.)

Too late. 7M never woke up and died in the afternoon.

Premium Chessgames Member
  visayanbraindoctor: 15 June 2015.

65F whom I operated on 5/2/15 was brought home against advise by the relatives, who could not stomach the hospital costs.

Premium Chessgames Member
  visayanbraindoctor: 17 June 2015.

In the afternoon a Neurologist called me. He has admitted a comatose 44M stroke patient in PrH1 ICU. This patient had suffered a hemorrhagic hypertensive left basal ganglia stroke 3 days prior to consult, but was admitted in a different hospital previously, where it was not suspected that he was in a potentially critical situation (this explains the delay).

Although still relatively young, 44M was obese and has had a long history of untreated hypertension. He is an engineer who eats a lot according to a niece who signs his consents forms (since his wife is a domestic helper abroad).

I went and examined the patient. He was GCS 6 but his pupils were still bilaterally small (2mm), indicating that his diencephalon (the thalamus) was being compressed. Next stage would be uncal herniation, wherein his mesencephalon would be compressed by a herniating uncus. His ipsilateral pupil (same side as the lesion) would then dilate. Generally, patients like that die, whether you operate on them or not.

I knew I have to operate before that happens.

(Left fronto-parieto-temporal craniectomy, frontal cortisectomy, evacuation of left basal ganglia hemorrhage, hemostasis, bone transplant to left hemi-abdomen SQ layer 6/17/15 9:10 to 10:42 pm. No BT.)

44M was also developing pneumonia, as typical in comatose patients. So I did an additional operation.

(Tracheostomy 6/17/15 10:50 to 11:05 pm.)

The scrub nurse assisting me complained that I was moving too quickly for them. But also told me they were happy that I was the surgeon, since I operate clean and fast, which makes things less tiring for them. They hate hours long surgical procedures, but I finish nearly all of my operations within 2 hours (cutting to closure, skin to skin), even hemorrhagic stroke and tumor cases.

Post-op I told the niece that if her uncle makes it past 3 days without further deteriorating, then he would have good chances for survival.

Premium Chessgames Member
  visayanbraindoctor: 19 June 2015.

Something that surgeons dread and hate, the late referral.

64F was walking by the roadside yesterday when she got hit by a trisikad (a foot powered pedicab). She arrived in PrH1 ER. Normally she would have been referred to me immediately. Because she was covered by a private insurance, she was referred to a doctor who was in the accredited list of the insurance, as a private patient. The admitting physician then referred her to a Neurologist who made the unfortunate but common mistake of trying to manage her on her own. Neurologists can do nothing if a patient that needs an operation deteriorates.

This is precisely what 64F did. From drowsy, she became comatose. Only then was she referred to me, at the ungodly hour of 4am. I dislike these witching hour stat referrals because they mean I won't be able to sleep and get discombobulated for the rest of the day. After a little delay as the daughter was still deciding to push through or not with the operation, I proceeded to operate stat on 64F. She was GCS 5 (decorticate coma), with pupils dilated to 6mm and 4mm.

(Left temporo-parietal craniectomy, cortisectomy, evacuation of intracerebral contusion-hematoma 6/19/15 7:25 am to 8:30 am. No BT.)

The delay in referral will probably prove fatal for 64F. She would have had better chances if I operated on her while she was still merely drowsy. Comatose decorticate patients carry very poor prognosis, whether one operates on them or not.

Premium Chessgames Member
  visayanbraindoctor: 20 June 2015. 64F died.
Premium Chessgames Member
  visayanbraindoctor: 22 June 2015.

Something new and rare. 5 days old neonate baby girl was born with a huge occipital mass jutting out of her posterior skull, which also happened to be microcephalic (a congenitally small head). Before and upon birth, she was referred to me by the OB, as the anomaly was already detected 6 months into the pregnancy by an ultrasound.

When I saw the baby, it confirmed my suspicion of an occipital encephalocoele. The skull does not develop properly, leaving a gap through which the brain herniates out in a sack-like structure. As is common among these cases, part of the skin covering the externally located brain was very thin and about to rupture. I recommended an immediate operation. However, I also told the family of the higher risks in neonatal operations.

Most of these encephalocoeles are located in the fronto-ethmoid area, in front of the skull. Most of the frontal lobes are considered to be 'silent' areas, but not the occipital areas. The location of the lesion and the CT scan even suggested that the cerebellum might be involved. From the CT scan I could see however that the brainstem was not.

So an operation was feasible. If the brainstem had also herniated out, it would have been inoperable, and fatal. However, the microcephaly would ensure that the patient would never develop normally even with a successful operation.

The family decided to transfer to the nearest big city, not trusting the medical facilities in our locality. Then yesterday they transferred back. Maybe the big city hospitals were too expensive for them. By this time the encephalocoele had ruptured. It had to be operated on or the open wound exposing the brain would result in meningitis and abscesses.

So I finally operated on the baby. The CSF that gushed out on opening the sack was yellow, indicating that infection had already set in. I found out on opening that the cerebellar vermis (the medial structure of the cerebellum) had herniated outside the skull along with parts of the occipital lobes. I had to excise all of these externally located brain. This is done by using bipolar cautery in order to cauterize the brain vessels, suctioning off the surrounding brain tissue, and cutting the vessels. I kept repeating this procedure until the entire encephalocoele base had been severed from the normal brain located at the level of the skull's outer table. I had preserved a lot of the dura, which I afterwards used to repair the defect. then I closed the galea and skin.

(Vermian cerebellectomy, partial bi-occipital lobectomy, repair of occipital encephalocoele. 6/22/15 3:18 pm to 4:30 pm. 60 cc BT.)

I had preserved a lot of dura and skin from the encephalocoele sac for closure purposes. This resulted in an empty sack of skin with enormous dog tags at the back of the baby's head, but this will eventually disappear as the baby grows up and her head stretches the rest of her scalp. Better an excess than a lack of skin in closing these things.

Now hopefully, 5 day old baby girl still has not developed meningitis. She is now in Pedia ICU in PrH1 and so far doing fine.

Premium Chessgames Member
  visayanbraindoctor: 23 June 2015. A table death.

5F is a hit and run victim of a motorcycle. Apart from an intracerebral hemorrhage, the child had multiple fractures of the left tibia-fibula and the mandible. She was comatose, anisocoric, and hypotensive. Hb only 96, presumably she had bled a lot from her scalp lacerations and fractures. I started BT pre-op in the CiH ICU, and proceeded to operate while BT was still ongoing.

(Right parietal-temporal craniectomy, cortisectomy, evacuation of basal ganglia intracerebral hemorrhage 6/23/15 2:41 pm to 3:50 pm.

Tracheostomy 6/23/15 4:06 to 4:22 pm. No further BT other than the ongoing pre-op one.)

As I was closing the tracheostomy operation, my Anesthesiologist announced that he could not detect any heart beat. Cardio-pulmonary arrest. (Most of these table deaths occur when a patient already has low BP, as in this case.) After a failed resuscitation, I pronounced 5F dead. Then I went out and told the mother. She was already prepared to receive the bad news as pre-op I had already explained that the young girl most likely would not live. She had insisted that I operate anyway, as the last chance for her child.

Premium Chessgames Member
  WannaBe: Very, very, sad.
Premium Chessgames Member
  visayanbraindoctor: <WannaBe: Very, very, sad.> It always is when a child dies in an accident.
Premium Chessgames Member
  visayanbraindoctor: 28 June 2015.

Since getting new bipolar cautery equipment (two bipolar forceps that the OR head nurse found in an old donated OR stock supply) in CiH last month, it has become easier for me to do operations that require a cortisectomy. In such an operation, the surgeon removes a small part of the cortex, the surface layer of the brain. The usual purpose is to make a little hole on the brain's surface in order to access an intra-cerebral hemorrhage or tumor inside the brain. Bipolar cautery forceps allows one to cauterize the brain vessels without them sticking, which happens when one uses monopolar cautery pens. Moreover, there is less adjacent heat damage and any possible electrical damage compared to monopolars.

In brief, for brain operations and hemostasis of brain blood vessels, bipolar cautery is better than monopolar.

I used the bipolar forceps for my next operation on a 57M hypertensive basal ganglia hemorrhage patient.

(Right temporo-parietal craniectomy, superior temporal gyrus cortisectomy, evacuation of basal ganglia hemorrhage, bone transplant to left hemi-abdomen SQ layer 6/28/15 2:30 pm to 3:51 pm. No BT.)

More confident in my ability to effect hemostasis with the new bipolar forceps, I went for a superior temporal gyrus cortisectomy in order to access the hemorrhage. The temporal approach is quite dangerous if you only have a monopolar because there are lots of blood vessels in that area.

Now it remains to be seen if 57M will survive the usual pneumonia that develops in comatose patients.

Premium Chessgames Member
  visayanbraindoctor: 3 July 2015.

I had admitted 24F, a backrider motorcycle fall victim, two days ago and decided to observe her. She was drowsy on admission (GCS 14) and had a small right frontal hemorrhagic contusion. She did not get better but instead lapsed into stupor. I scheduled her for an emergency operation in PrH1.

Along the way to the OR, I had a repeat CT scan done in order to confirm my suspicion. And there it was; the Oracle showed an increase in the volume of the hemorrhage and the contusion.

(Right frontal craniectomy, frontal cortisectomy, evacuation of intra cerebral hemorrhage, bone transplant to left hemi-abdomen SQ layer. 7/3/15 11:42 am to 1:05 pm. No BT.)

Premium Chessgames Member
  visayanbraindoctor: 4 July 2015.

<57M hypertensive basal ganglia hemorrhage patient.

(Right temporo-parietal craniectomy, superior temporal gyrus cortisectomy, evacuation of basal ganglia hemorrhage, bone transplant to left hemi-abdomen SQ layer 6/28/15 2:30 pm to 3:51 pm. No BT.)>

57M's pneumonia progressed and I had to do a tracheostomy on him. he is now on the pneumonia-sepsis ride.

(Tracheostomy 7/4/15 10:53 am to 11:10 am.)

Premium Chessgames Member
  visayanbraindoctor: 6 July 2015.

Entry 1. A failed case due to a series of bad luck incidents.

21M is a MF victim. He was drunk and backriding on a motorcycle driven by another drunk friend just before midnight. A insane man was meandering in the middle of the highway and they hit him.

(In my area, insane persons can sometimes be seen walking around in the streets, always malnourished and thin, dirty, smelly and often naked. They usually don't bother anyone but they are a traffic hazard. The Department of Social Welfare is supposed to 'arrest' and confine them, but somehow they always manage to escape and begin wandering around the city again.)

I saw 21M yesterday and scheduled him for an operation next morning 8am. The relatives did not buy any of the OR needs. So I rescheduled him 9pm. When I showed up, I got bumped off by an emergency Caesarian section, which always takes OR priority because two lives are involved (mother and child). The OB still had not showed up.

If I had to wait in the hospital for the OB to arrive and begin operating, I estimated that I would be able to operate perhaps at 2am or 3am. Do nothing but wait for the next several hours and not getting an iota of sleep, which sometimes leads to mistakes in my operating.

21M was still able to follow commands. So I rescheduled him again, at 8am on the morrow.

At 5am, the NOD texted me. 21M had suddenly died.

Entry 2. <3 July 2015. I had admitted 24F, a backrider motorcycle fall victim>

The pulmonologist with whom I co-managed 24F did not want to extubate her for two days post-op even though she was already awake and I wanted to extubate her. So it's only now that she got extubated. If you co-manage with an internist in private hospitals, you have to respect their decisions.

Premium Chessgames Member
  visayanbraindoctor: 12 July 2015.

I made a mistake. There was no bipolar available, as gassing in PrH2 had not yet taken place. Rather than wait for a week to a month, depending on when the gassing would take place, I operated on 50F (a patient with a one and a half year history of headache and seizure) in CiH without a bipolar cautery. CT scan showed a huge hypodense right frontal lesion. I thought it was cystic and non bloody. I have no trouble in excising these lesions solely with a monopolar cautery.

(Right frontal craniectomy, excision of right frontal brain tumor, bone transplant to left hemi-abdomen SQ layer. 7/12/15 3:41 pm to 5:21 pm. BT 1 unit.)

It turned out to be a very bloody brain tumor, probably a malignancy. With only a monopolar cautery available, I had extreme difficulty in controlling the bleeding. I finally packed the tumor cavity with absorbable gel sponge in order to effect hemostasis. This is a riskier procedure; I usually cauterize all bleeding points with a bipolar in these cases.

Now I would have to wait if rebleeding would occur post-op.

Premium Chessgames Member
  visayanbraindoctor: 15 July 2015. My fears for 50F came true. One day post-op she became drowsy. Two days post-op, she deteriorated fast and became brain dead. I had to reintubate her. She died today.
Premium Chessgames Member
  visayanbraindoctor: 16 July 2015.

I returned the craniectomized skull bone of 12F whom I had operated on 3/4/15 for an EDH. She recovered well after the first operation, with no neuro deficits at all, as commonly happens in EDH cases. She had been hit by a car.

(Replacement of bone right temporo-parietal. 7/16/15 10:02 am to 10:50 am.)

12F had huge keloid scarring on her left abdominal area where I had stored her skull bone. This is pretty common. I did my SOP, which is to excise the keloid and close the wound by a subcuticular absorbable (Vicryl) suture. Since the suture is below the skin, the resulting wound, and any subsequent scar, would look like one white line.

For females, minimizing scarring is particularly important. A huge keloid formation on a girl's left abdomen is quite visible if she ever wears a bikini to the beach.

Premium Chessgames Member
  visayanbraindoctor: 17 July 2015.

Why do teenage girls love to backride on motorcycles without helmets?

14F did it with her likewise 14 year old male classmate driving, and fell off. After admission in CiH, she became comatose.

Luckily for her, her panicky parents secured OR needs quickly; and I managed to operate before she could become brain dead.

(Left parietal temporal frontal craniectomy, evacuation of ASDH, bone transplant to left hemi-abdomen SQ layer. 7/17/15 10:54 am to 12:37 pm. No BT.)

Premium Chessgames Member
  visayanbraindoctor: 19 July 2015.

Another motorcycle fall, 22M, driver, hit a Forward truck. He was comatose pre-op, with pinpoint pupils (sign of diencephalic phase of central herniation, as the diencephalon or thalamus and adjacent structures become compressed).

(Right frontal parietal craniectomy, evacuation of ASDH, left frontal craniectomy, evacuation of ASDH, bones transplant to left hemi-abdomen SQ layer. 7/19/15 10:20 pm to 12:35 am. I unit BT.)

The patient is in a bad way. Since there were two large ASDHs on top of both hemispheres, I had to do two operations, right and left of the skull's midline. I don't open the midline of the skull because below it is the sagittal sinus, the main venous drainage of the cerebral hemispheres, and it could bleed like red spring.

After the removal of the ASDHs, both of 22M's hemispheres began to swell right out of his skull, above the outer table. They were non-pulsatile. An indication of a severely ischemic or dead brain.

Moreover, the skull's diploe and the scalp's subcutaneous layer also began to bleed profusely. Venous drainage of the skull and scalp mostly enter the dural veins and sinuses, where they compete with brain venous drainage. If the brain is dead and severely swollen, the skull and scalp veins can't drain normally and tend to bleed out into the open. I spent quite some time controlling 22M's diploe and fracture bleeding with bone wax, and individually suturing each bleeding point on his scalp.

I don't think 22M will survive.

Premium Chessgames Member
  visayanbraindoctor: 20 July 2015.

Entry 1. Patient that I operated on yesterday 22M is brain dead.

Entry 2. Another motorcycle fall, 35M, backrider.

(Left and right frontal craniectomies, evacuation of EDHs and ASDHs. 7/20/15 9:45 to 10:45 pm. No BT.)

The case of 35M resembles that of 22M closely. There were ASDHs on both sides of the midline, prompting me to do two operations, left and right. 35M was also comatose pre-op with pinpoint pupils. His brain was also non-pulsatile and swelled above the skull's outer table. The only difference if that his skull's diploe and scalp were not bleeding during closure.

Nevertheless I don't think 35M will likewise survive. I threw away the craniectomized bones.

Premium Chessgames Member
  visayanbraindoctor: 22 July 2015.

Entry 1. Routine return of bone on 51M, a MF victim whom I had operated on last January.

(Replacement of bone right temporo-parietal. 7/22/15 9:29 am to 10:05 am.)

Entry 2. Surprise. 35M is still alive.

Premium Chessgames Member
  visayanbraindoctor: 25 July 2015.

Entry 1. I now regret having thrown away the skull bones of 35M, whom I expected to have died by now. Not only is he alive, his sensorium is increasing. He is now exhibiting volitional movements.

He has acquired the pneumonia that all comatose patients develop after 3 days of lying down in a hospital bed. I decided to be aggressive and do tracheostomy.

The PrH1 Anesthesiologist for this case was out of town and so I did it under local anesthesia (LA) by my own, rather than get another Anesthesiologist. I admix lidocaine, epinephrine, and NSS in these cases and inject it into the operative site. I keep on injecting as I dig deeper and deeper (using blunt dissection) until I reach the pre-tracheal fascia. I then inject into this fascia and do a cross shaped incision on the trachea, the horizontal arm between two tracheal cartilages.

(Tracheostomy 7/25/15 11:34 am to 11:52 am. LA.)

Entry 2. 14F whom I had operated on a week ago (Left parietal temporal frontal craniectomy, evacuation of ASDH, bone transplant to left hemi-abdomen SQ layer. 7/17/15 10:54 am to 12:37 pm. No BT.) has developed post-traumatic seizures.

She is now wide awake, GCS 15, and so I am not too worried. Post-traumatic seizures occasionally occur among my patients, and I just do my SOP for them. I place them on IV Phenytoin.

Premium Chessgames Member
  visayanbraindoctor: 29 July 2015. Backrider motorcycle fall case. Comatose pre-op, beginning to decorticate. 19M's brain was also swelling slightly above the outer table when I opened it, but not too much.

(Right fronto-parieto-temporal craniectomy, evacuation of ASDH, bone transplant to left hemi-abdomen SQ layer. 7/29/15 3:02 to 4:36 pm. No BT.)

A swollen brain rising above the skull's outer table is indicative of a very ischemic brain or an infarct. If infarcted, the patient's sensorium usually deteriorates further post-op. We'll have to see if 19M wakes up tomorrow. I refrained from extubating him.

His brain isn't as swollen as the case of (35M, left and right frontal craniectomies, evacuation of EDHs and ASDHs. 7/20/15 9:45 to 10:45 pm.), whom I had thought would die. So I am hopeful 19M will likewise survive.

Premium Chessgames Member
  visayanbraindoctor: 30 July 2015.

Entry 1.

They come in pairs. Another backrider motorcycle fall case, 27M. This one occurred two weeks ago. Instead of recovering, he has remained drowsy all throughout the post accident period, and recently has experienced increased sleeping time.

A repeat CT scan shows increasing hypodensity of his subdural hematoma. The hyperdense more whitish blood from the first picture has become darker. This indicates that instead of being absorbed, the blood has liquified into a chronic subdural hematoma. More common in the elderly, this phenomenon also occurs in young patients with a history of alcoholism, such as 27M. CSDHs do not resolve spontaneously, but keep on increasing in size until they kill the patient. Weird tumor-like behavior for a blood clot.

(Left parieto-frontal craniectomy, evacuation of CSDH, bone transplant to left hemi-abdomen SQ layer. 7/30/15 11:22 am to 12:37 pm. No BT.)

If you have a relative that is elderly, or an alcoholic, or both, with a history of head trauma, and progressively becomes drowsier and weaker in the next few weeks, it's best to have a CT scan done. He just might have a growing chronic subdural hematoma.

Entry 2. 19M whom I had operated on yesterday is now more awake and attempting to self-extubate. Good. I extubated him.

Premium Chessgames Member
  visayanbraindoctor: 10 August 2015. Two weeks ago 73M was hit by a motorcycle while riding on a bicycle. In the first few days, he seemed fine, but in the past week he began to present with increased sleeping time and motor weakness. The delay in signs and symptoms is typical of a progressively enlarging chronic subdural hematoma.

CT scan showed more than 150cc of the CSDH. The skull's CSF compartment holds only about 75cc of CSF, which is the usual amount displaced by a space occupying lesion before the brain herniates. However, a larger amount is possible in the elderly and alcoholics since their brains are often atrophied. Amazingly enough, 73M was merely drowsy (GCS 14) before the operation.

(Right fronto-parietal-temporal craniectomy, evacuation of chronic subdural hematoma, bone transplant to left hemi-abdomen SQ layer 8/10/15 5:38 pm to 6:30 pm. No BT.)

Premium Chessgames Member
  visayanbraindoctor: 12 August 2015.

<4 July 2015.

<57M hypertensive basal ganglia hemorrhage patient.

(Right temporo-parietal craniectomy, superior temporal gyrus cortisectomy, evacuation of basal ganglia hemorrhage, bone transplant to left hemi-abdomen SQ layer 6/28/15 2:30 pm to 3:51 pm. No BT.)>

57M's pneumonia progressed and I had to do a tracheostomy on him. he is now on the pneumonia-sepsis ride.

(Tracheostomy 7/4/15 10:53 am to 11:10 am.)>

57M has survived the pneumonia sepsis roller coaster ride. He can now communicate. I am discharging him today.

<25 July 2015.

Entry 1. I now regret having thrown away the skull bones of 35M, whom I expected to have died by now. Not only is he alive, his sensorium is increasing. He is now exhibiting volitional movements.>

I have already discharged 35M last week.

I expected the two patients above to die, yet they survived.

You just can't predict with total accuracy who will live or die.

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